RU2252002C2 - Method for correcting respiratory disorders - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying auxiliary non-invasive lung ventilation with air-and-oxygen mixture in PSV mode with supporting pressure being equal to 8-12 cm of water column at inspiration phase, FiO₂ 0.25-0.3, positive pressure at expiration phase end equal to 2-4 cm of water column being applied. Inspiration trigger sensitivity being equal to 15-2 cm of water column relative to positive pressure at expiration phase end level to reach tidal respiratory volume not less than 6-7 ml/kg under SpO₂ and blood gases control.

EFFECT: prevented acute respiratory insufficiency; improved alveolar ventilation; reduced venous bypass.

Description

The invention relates to medicine, to the field of epidural and combined spinal-epidural anesthesia while maintaining spontaneous breathing of patients in abdominal surgery.

A known method of conducting epidural (EA) and combined spinal-epidural anesthesia (CSEA) in abdominal surgery while preserving the spontaneous breathing of patients [2, 3, 5, 8]. In EA, a calculated dose of local anesthetic is injected into the thoracic epidural space in order to spread sensory blockade of the spinal roots from L5 to Th 4 ± 1, as well as motor and sympathetic blocks. With the additional introduction of local anesthetic into the lumbar subarachnoid space, CSEA develops with improved antinociceptive qualities compared with isolated epidural anesthesia [2, 3]. At the same time, independent breathing of patients is maintained as physiologically preferable [6, 7, 8].

However, the conduct of EA and CSEA in conditions of independent breathing is associated with a risk of respiratory disorders in patients directly during surgery, which is associated with the following factors:

1. Mechanical limitations of excursion of the diaphragm by retractors used by surgeons during abdominal operations [9, 11].

2. If it is necessary to increase ventilation of the patient by the patient, the latter is impossible due to motor blockade of the external intercostal muscles due to blocking of the upper thoracic spinal segments; participation in the act of inspiration of unblocked additional respiratory muscles — the scalene and sternocleidomastoid muscles — leads to an increase in the patient’s energy consumption [10].

There are various methods for correcting respiratory distress during surgery. The most important of these is facial mask oxygen therapy [4]. This ensures an increase in the alveolar concentration of oxygen with an optimal flow of humidified oxygen in the inhaled mixture. However, this method of treating respiratory disorders is not effective enough, because with these violations of the mechanics of the patient’s breathing, inhalation of oxygen of high concentration (FiO ₂ 0.4-0.6 or more) is necessary, which can lead to a decrease in cardiac output and, accordingly, systemic oxygen delivery to tissues [12].

An alternative method of correcting respiratory disorders during surgery is the use of artificial ventilation, which is possible only with deep sedation of patients [1]. Thus, the main advantage of EA and CSEA is leveled - the possibility of anesthetic administration under the conditions of the patient's independent breathing, avoiding the depriving effect on the body of general anesthetics and the negative effects of mechanical ventilation and total muscle relaxation [4, 5].

The proposed method for the correction of respiratory disorders is characterized in that when performing abdominal operations under conditions of EA and CSEA with preservation of spontaneous breathing, patients use non-invasive assisted ventilation (NVVL) with an air-oxygen mixture in PSV mode with an inspiratory support pressure of 8-12 cm water ., FiO ₂ 0.25-0.3, positive pressure at the end of exhalation (PDKV) 2-4 cm water.article, the sensitivity of the trigger inspiration - 1.5-2 cm water. Art. from the level of PEEP, to achieve a tidal volume of at least 6-7 ml / kg under the control of SpO ₂ and blood gases.

The method is as follows:

After performing EA or CSEA, the patient is placed in a supine position. After making sure that the sensor unit reaches the required level of Th 4 ± 1, they begin carrying out the NVL, which is carried out using ventilators - "Servoventilator-C900"("Siemens", Sweden), "Erica" and "Elvira"("Gambro" Sweden ), Puritan-Bennet 7200, and Respironix Inc (USA). NVVL was performed through a face mask matched to the patient’s face. The mask was conveniently placed on the patient's face and fixed with special straps so as to avoid excessive pressure on the skin of the face and at the same time prevent leakage of the respiratory mixture. NVVL was carried out with an air-oxygen mixture in PSV mode with an inspiratory support pressure of 8-12 cm water column, FiO ₂ 0.25-0.3, PEEP 2-4 cm water column, inspiratory trigger sensitivity - 1.5 -2 cm water column from the level of PEEP, to achieve a tidal volume of at least 6-7 ml / kg. NVVL parameters were selected individually, as patient comfort was achieved in the absence of resistance to the fan under the control of SpO ₂ and blood gases. A prerequisite for conducting NVVL in EA and CSEA is the patient’s collaboration with the doctor, which is achieved by a preliminary explanatory conversation with obtaining informed consent for anesthesia and NVVL, as well as minimal patient sedation during anesthesia and surgery, which allows voice contact with the patient. According to the testimony, the mask can be removed at any time and reapplied.

Example 1

Patient Ш, 65 years old, diagnosis: chronic calculous cholecystitis, the estimated scope of the operation is cholecystectomy, the chosen method of anesthesia is EA with preservation of spontaneous breathing and NVVL. In the position on the left side under local anesthesia, traditional puncture and catheterization of the epidural space at the level of Th 7-8 were performed. After fixing the catheter and transferring the patient to the back, a test dose of bupivacaine 0.5% 2.0 was introduced into the epidural catheter. After 5 minutes, in the absence of symptoms of spinal anesthesia, the main calculated dose of bupivacaine 0.5% - 16 ml was introduced. After 25 minutes, the upper boundary of the block was established at the level of Th 4. NVVL was started through the face mask in the pressure support breathing apparatus "Puritan-Bennet 7200". Maintaining verbal contact with the patient, we selected individual parameters of NVVL, focusing on achieving respiratory comfort of the patient. NVVL parameters: FiO ₂ 0.3, inspiratory support pressure 10 cm water column, PEEP - 2 cm water. Art., tidal volume - 480 ml. The patient was sedated with a bolus of 2.5 mg of diazepam before surgery, followed by continuous infusion of diazepam at a rate of 0.2 mg / kg / hour. SpO ₂ and capillary blood gases were monitored, which remained within the physiological parameters. After surgery, the patient was transferred to the intensive care unit for observation and treatment in the early postoperative period.

Example 2

Patient K, 65 years old, diagnosis: exacerbation of chronic calculous cholecystitis, the estimated scope of the operation is cholecystectomy, the chosen method of anesthesia is KSEA with preservation of spontaneous breathing and NVVL. In the position on the left side under local anesthesia, traditional puncture and catheterization of the epidural space at the level of Th 7-8 were performed. A test dose was introduced - bupivacaine 0.5% 2.0, after 5 minutes in the absence of spinal block phenomena, a subarachnoid space was punctured at the level of L3-4, bupivacaine 0.5% 2.5 ml was introduced. After fixing the epidural catheter and moving the patient to the supine position, the level of spinal anesthesia was assessed. Upon reaching the upper level of spinal anesthesia, Th 10 ± 1, we started fractional administration of 0.5% bupivacaine into the epidural catheter, achieving the upper level of the Th 4 sensory block. The total dose of 0.5% epidurally administered bupivacaine was 8 ml. 17 minutes after the first dose of bupivacaine was administered, the upper level of spinal-epidural anesthesia reached Th 4. NVVL was started through the face mask in the pressure support breathing apparatus "Puritan-Bennet 7200". NVVL parameters: FiO ₂ 0.3, inspiratory support pressure 12 cm water column, PEEP - 3 cm water column, tidal volume - 520 ml. The patient was sedated with a bolus of 2.5 mg of diazepam before surgery, followed by continuous infusion of diazepam at a rate of 0.2 mg / kg / hour. SpO ₂ and capillary blood gases were also monitored, which remained within physiological parameters. The patient experienced sufficient respiratory comfort during anesthesia and surgery. Transferred to the intensive care unit for observation and treatment in the early postoperative period.

Literature

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Claims (1)

A method for the correction of respiratory disorders under conditions of epidural and combined spinal-epidural anesthesia while maintaining patients' independent breathing in abdominal surgery, characterized in that they additionally use auxiliary non-invasive ventilation of the lungs with an air-oxygen mixture in PSV mode with an inspiratory support pressure of 8-12 cm of water. Art., FiO ₂ 0.25-0.3, positive pressure at the end of expiration (PDKV) 2-4 cm of water. Art., the sensitivity of the trigger inspiration - 15-2 cm of water. Art. from the level of PEEP, to achieve a tidal volume of at least 6-7 ml / kg under the control of Spo ₂ and blood gases.