RU2245173C1 - Method for correcting anesthetic therapy - Google Patents

Abstract

FIELD: medicine, anesthesiology, intensive therapy, surgery.

SUBSTANCE: the present innovation is suggested to correct anesthetic therapy in postoperational period. One should apply a modified visual-analog scale of pain on which patient should mark independently his (her) pain feelings by fixing them on vertical sections of the above-mentioned scale of pain every 2 h during the day, then doctor should plot an algogram of daily fluctuations of patient's pain feelings to analyze them for estimating the strength of pain feelings and adequacy of analgetic therapy conducted; and by taking into account the data obtained to conduct correction anesthetic program next day. The present innovation enables to adequately evaluate patient's pain feelings in postoperational period for subsequent performing adequate preventive analgetic therapy of pain syndrome, that, in its turn, enables to prevent pathological postoperational syndromocomplex.

EFFECT: higher efficiency of correction.

2 cl, 3 dwg, 1 ex

Description

The invention relates to medicine, namely to anesthesiology, intensive care and surgery, i.e. then, when it is necessary to assess the intensity of pain impulses after surgery.

The relevance of this method lies in the fact that an insufficient assessment of the pain of patients can lead to inadequate postoperative analgesia. Moreover, it is known that from 33 to 75% of patients complain of moderate and severe pain in the postoperative period (Ferrante P.M., VadeBoncouer T.R. 1998). Foreign multicenter studies have determined the state of postoperative analgesia to be catastrophic, since the adequacy of analgesia, according to subjective estimates of patients, did not exceed 50% (Owen H., McMillan V. and Rogowski D. Postoperative pain therapy: a survey of patients' expectations and their experiences. // Pain. - 1990. - V.41. - P.303-309).

Over the past decades, there has been a steady increase in the frequency of complex extended and simultaneous operations, in particular, on the abdominal organs. In this case, the majority of patients undergoing surgery have pronounced concomitant diseases from the internal organs. This requires a special anesthetic and resuscitation approach to the management of this category of patients, including in assessing the adequacy of relief of the pain component in the postoperative period.

It is known that pain is the root cause of the development of a pathological postoperative syndrome complex. Acute pain increases the rigidity of the muscles of the anterior abdominal wall and chest, which leads to a decrease in tidal volume, vital capacity of the lungs, functional residual capacity and alveolar ventilation. The consequence of this is collapse of the alveoli, hypoxemia and a decrease in blood oxygenation (Liu S, Carpenter R, Neal J. Epidural anesthesia and analgesia. Their role in postoperative outcome. // Anesthesiology. 1995. - V.82. - P.1474-1506) . The difficulty in coughing up against a background of a pain syndrome disrupts the evacuation of bronchial secretions, which contributes to the development of pulmonary infection.

The pain is accompanied by hyperactivity of the sympathetic nervous system, causing tachycardia, hypertension and increased peripheral vascular resistance. Sympathetic activation also causes postoperative hypercoagulation and increases the risk of thrombosis. Against this background, patients are more likely to sharply increase myocardial oxygen demand with the development of acute myocardial infarction (Breivik H. Postoperative pain management. // Bailliere's Clinical Anesthesiology. -1995. - V.9. - P.403-585).

Activation of the autonomic nervous system against a background of pain reduces peristaltic activity and can cause postoperative paresis.

Intense pain is one of the factors behind the realization of a catabolic hormonal response to trauma: water and sodium retention with increased secretion of ADH and aldosterone, as well as hyperglycemia due to hypersecretion of cortisol and adrenaline (Kehlet H., Dahl JB Postoperative pain. // World J. Surg. 1993. V.17. P.215-219), negative nitrogenous builds up due to inactivity, lack of appetite and violation of a normal diet; deterioration of the immune status and increased frequency of septic complications with inadequate relief of postoperative pain, especially in high-risk patients (Yeagcr M, Glass D, Neff R, Brick Johnsen f. Epidural anaesthesia and analgesia in high risk surgical patjents. // Anesthesiology. - 1988. - V.73. - P.729-736).

The result of insufficient pain relief is also the formation of chronic postoperative neuropathic pain syndromes (Kalso E, Perttunen K, Kaasinen S. Pain after thoracic surgery. // Acta Anaesth. Scand. 1992. V.36. P.96-100).

By the definition of the American organization for the study of pain (IASP Pain Terminology), pain is an unpleasant sensory or emotional sensation that occurs at the time or at the risk of tissue damage, or described in terms of such damage. Note: Pain is always subjective. Each person perceives and applies this word through their individual experience associated with earlier injuries (Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, © 1994 , pp. 209-214).

Thus, the complexity of the problem in assessing pain is that there are no precise physiological or clinical signs for measuring pain. An ideal tool for measuring pain should evaluate both its presence and its dynamics over time (But Kendall; Spence Julie; Murphy Michael F..Review of pain-measurement tools. Ann. Emergency Med. 1996. No.4. P.427 -432).

Pain is a subjective sensation, depending on the individual threshold of its perception. Pain is a multidimensional phenomenon, including nociception, sensation, experiencing pain and pain behavior (Hunfeld J.A.M .; Passchier J. Pain and assessment of the degree of pain in children. Rus. Med. Zh. 1997 No. 7. S.420-424).

The severity of pain can be analyzed subjectively by the patient himself, who is conscious. There are no adequate methods for assessing the severity of pain by other people in patients with loss of consciousness (Memran N .; Steib A .; Esteve M .; Servin F .; Vulser C .; Lassalle C .; Pipien I .; Cousin MT Prise en charge de la douleur postoperatoire chez le sujet age. Sem. hop. Paris. 1998. P.700-708. Vol. 15-16). Nociceptive impulses, regardless of their strength, become pain if and only when the central nervous system, upon receipt of this information, recognizes it as an “image of pain” (OV Petrov et al. Information Pain Theory. 2nd Congress of Russian Biophysicists, M. , Aug. 23-27, 1999. M., 1999. T. 2, p. 436). Finer pain assessment and control mechanisms may correlate with subjective pain assessment. (Danilov A.B .; Danilov Al.B .; Vane A.M. Nociceptive flexor reflex: a method for studying brain mechanisms of pain control. J. Neurol. And Psychiatry. 1996. No. 1. P.107-111).

Therefore, the development and study of methods for measuring pain, its strength, and the length of time by subjective visual-analogue methods is an urgent problem for modern anesthesiology, intensive care, surgery, and other related specialties involved in the treatment and management of postoperative patients.

One of the analogues of the invention is the method described in the source Fedorov V.V. et al: Evaluation of discomfort and pain after laparoscopic surgery. Mater. VI International conf. surgeon.-hepatol. CIS countries "Actual. prob. surgical hepatol.", Kiev, November 4-6, 1998. Annals surgeon, hepatol. 1998. No3. P.111, in which patients who underwent, in particular, laparoscopic surgery, were asked, using a questionnaire, to evaluate their condition after surgery using a 5-point system at fixed hours after surgery.

Using this method allows patients to subjectively assess their pain after surgery.

However, the above method only captures the pain of patients after surgery, but does not provide for the appropriate correction of pain therapy.

Another method is also known, in which the effectiveness of treatment and the intensity of the pain syndrome were determined on a scale of verbal ratings: 0 - no pain, 1 - mild pain, 2 - moderate, 3 - severe, 4 - very strong (G. Novikov and Chronic pain and assessment of the quality of life of cancer patients. Ros. medical journal. 1997. No. 2, p. 32-36).

The use of this method is limited only by a verbal assessment of the pain of the patient who underwent surgery for cancer.

Closest to the claimed method is the analogue, taken by us for the prototype described in the source Michael Ferrante. Postoperative pain. Per. with eng. M .: Medicine, 1998, p. 119. This source uses a visual-analogue pain scale, which is a straight line 10 cm long, the ends of which correspond to extreme degrees of pain intensity ("no pain" - at one end, "unbearable pain "- on the other), (see figure 1).

This prototype did not allow to evaluate pain in a long time period and is a criterion for evaluating only at the current moment; it also does not allow building a graphic image of the dynamics of changes in pain impulses per day, which, in turn, makes it difficult to assess the dynamics of pain, and building a program of adequate postoperative analgesia, which allows you to prevent, rather than treat, pain that has arisen.

The aim of the present invention is an adequate assessment of pain by visual analogue method in patients after surgery.

The technical result to which the present invention is directed is to adequately assess the patient's pain sensations by the visual-analogue method in the postoperative period to conduct sufficient preventive therapy for the pain syndrome.

To achieve the claimed technical result, we have developed a modified visual-analogue scale (MVASH) (see figure 2), on which the patient notes his pain at this point in time, every two hours, which he fixes on vertical segments of pre-prepared forms MVASHB. Moreover, the patient marks these marks on the vertical segments of the MBASH form in the form of a point corresponding, in his opinion, to the intensity of the pain, taking into account that the beginning of the segment, i.e. its lower part indicates the absence of pain (or absolute “0” in pain), and the end of the segment, i.e. its upper part is maximum pain (or intolerable pain). At night, the patient notes his feelings only during wakefulness. This pain analysis is performed within seven days after surgery.

Based on the indicated marks, the doctor draws an algogram, i.e. a pain intensity curve (CIB), which is a graphical display of the patient's pain during the past day and shows the adequacy or inadequacy of the ongoing analgesic therapy during this period.

Based on the algogram, an analgesic therapy is corrected. Which consists in either replacing one analgesic with another, or in a combination of analgesics, or in increasing the dose of the drug being administered, or in increasing the frequency of the drug being administered, or in conducting additional pain relief with other methods, for example, regional methods of pain relief.

The implementation of the proposed method is illustrated by the following clinical examples.

Example 1. Patient K., 63 years old, weight 75 kg, was admitted to the State Research Center for Coloproctology with a diagnosis of “Cancer of the lower ampullar rectum with transition to the anal canal T ₃ NxMo”, which underwent abdominal-perineal extirpation of the rectum with the formation of smooth muscle cuffs, pelvic colonic reservoir with their reduction into the pelvic cavity, extended aortic ileo-pelvic and lateral lymphadenectomy.

After the operation, the patient was routinely admitted to the intensive care unit (ICU), where he was anesthetized in the form of promedol 1% - 2.0 v / m according to indications.

On the next (2nd) day after surgery, the patient was asked to mark his pain on the MBASH scale according to the essence of the claimed method. Analgesic therapy was also prescribed to the patient in the form of a / m injection of promedol 1% - 2.0 according to the scheme: 12-18-24-6 hours.

Based on the obtained data for the expired 2nd day, the attending physician drew an algogram or CIB, from which it followed that the patient experienced maximum pain during the period from 13 hours to 24 hours, therefore, the analgesic therapy was inadequate during this period (see. Fig. Za). During this period, Ketorolac was additionally prescribed by the ward doctor at a dose of 2.0 ml IM at 18 hours and 20 hours. Based on the analysis of the algogram obtained on the second day, it follows that pain during this period of time required the strengthening of the analgesic therapy regimen with the introduction of Ketorolac that was taken into account when drawing up the anesthesia program for the 3rd day of the postoperative period.

On the 3rd day after the operation, the patient was also asked to mark his pain on the MBASH scale according to the essence of the claimed method, after which the CIB was also drawn (see fig.3b). Analgesic therapy was prescribed to the patient, taking into account changes in the CIB for the 2nd day in the form of a / m injection of promedol 1% - 2.0 according to the scheme: 12-18-24-6 hours, while at 13-00 and 21-00 an additional injection of Ketorolac 2.0 ml / m was prescribed. Based on the analysis of CIB for the past 3rd day, it can be seen that the most algogenic period had a less pronounced intensity, which gave reason to keep this scheme for pain relief on the 4th day, which the patient transferred smoothly - without pronounced pain. This fact made it possible to conduct a preliminary correction of the anesthesia scheme for the 5th day.

On the 5th day after the operation, the patient was also asked to mark their pain on the MBASH scale according to the essence of the claimed method, after which the CIB was also drawn (see Fig. 3c). Analgesic therapy was prescribed to the patient, taking into account changes in CIB on the 3rd day and the nature of subjective sensations on the 4th day. And it was presented as a / m injection of promedol 1% - 2.0 according to the scheme at 18-00 and 24-00, while at 12-00 and 6-00 the injection of promedol was replaced by an injection of Ketorolac 2.0 ml / m . On the basis of the algogram for the 5th day, an increase in pain was noted in the period from 15-00 to 17-00, in connection with which the ward doctor during this period introduced an additional injection of baralgin 5.0 ml v / m, which adequately stopped the increase in pain component. On the sixth day, the scheme of the fifth postoperative day was decided to be maintained, which provided adequate analgesic support to the patient.

On the 7th day after the operation, the patient was also asked to mark their pain on the MBASH scale according to the essence of the claimed method and plotted CIB (see Fig. 3d). Analgesic therapy was prescribed to the patient taking into account changes in the CIB for the previous days and was presented as a / m injection of only Ketorolac 2.0 ml / m according to the scheme at 10-00, 17-00, 24-00. The assessment of CIB on the seventh day showed that the pain syndrome practically does not cause unpleasant subjective sensations in the patient, and therefore it was proposed to continue the therapy in the same dose and the same frequency until the pain is completely stopped.

Thus, the claimed method allows you to adequately assess the pain in patients in the postoperative period and adjust the analgesic therapy so that the patient does not experience severe discomfort associated with pain. At the same time, the correction of the ongoing analgesic therapy avoids the increase in the post-operative narcotic potential, i.e. reduce the dose, the frequency of use of narcotic analgesics, expand the indications for the use of non-narcotic analgesics; expand the indications for the use of regional methods of pain relief and other official methods aimed at relieving pain in the postoperative period. This method also allows you to reduce the number of postoperative complications associated with the problem of inadequate pain relief in the postoperative period.

The claimed method can be recommended for an adequate assessment of pain in clinical practice.

Claims (3)

1. A method for the correction of analgesic therapy in patients in the first days after surgery, including the assessment of pain using a visual-analogue pain scale, characterized in that they use a modified visual-analogue pain scale, consisting of a horizontally located segment of a straight line to which are restored vertical straight line segments at regular intervals corresponding to 2 hours; the patient independently notes his pain, fixing them on vertical sections of the scale for every 2 hours during the day, after which the doctor draws an algorithm for the daily fluctuations in the pain of the patient; carries out their analysis in terms of assessing the strength of pain and the adequacy of the ongoing analgesic therapy and, taking into account the data obtained, carries out the correction of the pain program the next day. 2. The method according to claim 1, characterized in that at night the patient fixes his pain only during wakefulness. 3. The method according to claim 1, characterized in that the algorithm is plotted for the next seven days after the operation.

Images