RU2254131C2 - Method for anesthesiological protection against factors of surgical aggression - Google Patents

Abstract

FIELD: medicine, anesthesiology, traumatology, orthopedics, thoracic surgery.

SUBSTANCE: about 1.5-2 min before spreading the affected lung it is necessary to deepen anesthesia due to injecting phenthanyl at the dosage of 10-12 mcg/kg body weight. The present innovation provides safety of operations of ventral spondyledesis out of transthoracic and thoracodiaphragmatic accesses, stability of arterial pressure level and patient's heart rate, decreases stress loading upon a patient that, in its turn, favors the prophylaxis of intraoperative complications.

EFFECT: higher efficiency of anesthesiological protection.

2 cl, 1 ex

Description

The invention relates to medicine, namely to traumatology, orthopedics and thoracic surgery, and can be used to prevent the damaging effects of stress-induced biologically active substances on organs and systems of the body.

Known methods of anesthetic protection:

I group. General anesthesia with the use of antipsychotics (NLA) and mechanical ventilation (IVL) (Fischenko V.Ya., 1982; Andrianov V.A. et al., 1985; Soboleva N.S. et al., 1991; Hilgenberg JC, 1981; Malcolm-Smith NA, Master MJ, 1983; Lauri A. et al., 1989). The above methods have several disadvantages:

- the development of sharp cardiovascular, metabolic and hormonal reactions;

- depletion of the patient’s adaptation reserves, the development of complications from the cardiovascular system, respiration, hemeostasis.

II group. General anesthesia using inhaled anesthetics in combination with drugs for NLA and mechanical ventilation (Rose S. H. et al., 1997, Steven H.R, et. Al., 1997).

This method of anesthesia using inhaled anesthetics is more manageable than total intravenous anesthesia (TBA), and allows you to achieve quick and adequate recovery of consciousness and independent breathing. The disadvantages include:

- arrhythmogenic effect inherent in many gas anesthetics;

- expensive low-flow breathing apparatus and gas analyzers;

- air pollution in the operating room;

- very high cost of modern gas anesthetics.

III group. General anesthesia with the use of NLA drugs in combination with ketamine under mechanical ventilation on the background of controlled arterial hypotension or without it (Menyailov H.V., 1982; Maerova N.D. et al., 1990, 1996). These methods of general anesthesia with mechanical ventilation are not without clinically significant drawbacks. These include:

- multicomponent, in which it is difficult to avoid polypharmacy;

- the need to use large total doses of narcotic analgesics and sedatives;

- the manifestation of paranarcotic, undesirable effects and consequences of the drugs used;

- the slowed-down of patients from anesthesia and the rapid cessation of anesthetic protection in the immediate postoperative period;

- “breakthrough” of defense, inadequacy of the neuro-vegetative blockade (Dauphin A., 1997; Aliev O.M., 1990; Bromage P.R., 1967).

The above methods cannot be used for anesthetic protection at the stage of expansion of a collapsed lung.

Closest to the claimed is the method of Lebedeva M.N. - “Anesthetic management of simultaneous two-stage surgical correction of scoliosis” (dissertation for the degree of candidate of medical sciences), developed at the Novosibirsk Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation.

The method is as follows. Premedication is carried out 15-30 minutes before transporting the patient to the operating room. In the premedication scheme, relanium is used at a dose of 0.2 mg / kg and diphenhydramine at a dose of 0.4 mg / kg, which is administered intramuscularly. Direct preparation for the induction of anesthesia is completed by intravenous infusion of a solution of atropine in a dose that does not cause severe tachycardia (0.004-0.02 mg / kg). Induction in anesthesia is carried out by the introduction of fentanyl at a dose of 0.002 mg / kg, sodium thiopental (2.5-1% solution depending on the patient's age) at a dose of 10 mg / kg. After reaching a sufficient depth of anesthetic sleep, listenone is administered at a dose of 2.5-3 mg / kg and the trachea is intubated. Immediately after tracheal intubation (until the patient turns into the required operating position), clonidine 0.01% solution at a dose of 0.4-0.5 μg / kg is bolus. Next, carry out the laying of the patient in the necessary operating position. Two-lung ventilation was carried out with an air-oxygen mixture with an oxygen content of 50%. Maintenance of general anesthesia is carried out against a background of continuous infusion of clonidine solution with a dispenser at a rate of 0.42 ± 0.01 μg / kg / h; Hypnanesthetic calypsol is continuously administered at a rate of 2.25 ± 0.04 mg / kg / h against a background of a bolus of a central analgesic of fentanyl at a dose of 0.003 ± 0.001 mg / kg / h. The state of total myoplegia is supported by arduan at a dose of 0.03 ± 0.01 mg / kg / h. Mechanical ventilation is carried out by the EVITA-2-DURA apparatus, operating in a flow mode with a plateau on inspiration with FiО ₂ 40%. Moderate hyperventilation with ETCO _{2 of} exhaled air of 31-35 mm Hg is maintained. A feature of the proposed method of anesthetic management is the special preoperative preparation of patients (pyrogenal, vitamin E), as well as through the use of the clonidine stress protector in the anesthesia program while maintaining its constant concentration in the blood by continuous infusion.

However, when using this method, it is necessary to prepare the patient by administering three times the domestic polysaccharide preparation of pyrogenal according to the following scheme: 72 and 48 hours before surgery, pyrogenal is administered at a dose of 0.5 μg / kg intramuscularly, 24 hours before surgery, pyrogenal is administered at a dose of 1 μg / kg intramuscularly. In addition, antioxidant - vitamin E at a dose of 10 mg / kg intramuscularly is administered 24 hours before surgery. Within six hours after the injection of pyrogenal, the patient's body temperature is monitored. Method Lebedeva M.N. It provides protection against factors of surgical aggression at all stages of surgical intervention, however, it is not possible to use it for protection at the stage of expansion of a collapsed lung. Moreover:

- preoperative preparation for 72 hours requires monitoring of the patient;

- in the operational period, these doses of drugs do not allow for adequate and effective anesthesia;

- the level of neurohumoral protection is insufficient for operations with traumatic injuries of the spine in adult patients;

- lack of adequate and effective protection at the most traumatic stage of surgical intervention.

Objective: to develop a method for efficiently damping exo- and auto-aggression factors at the stage of expansion of a collapsed lung.

When solving this problem, there is a positive therapeutic effect, which consists in normalizing the level of glycemia, homeostasis of the body, vegetative stabilization using drugs at the stages of the surgical and the immediate postoperative periods.

Moreover:

- preliminary preoperative preparation of patients using the clonidine stress protector;

- deepening the level of anesthesia at the stage of expansion of the collapsed lung;

- the exception of the induction of psychoemotional stress;

- prevention of the inclusion of mechanisms of depletion of the adaptive reserve of the body.

Higher protective capabilities of the proposed method allow:

- to ensure the safety of ventral fusion operations from transthoracic and thoracodiaphragmatic approaches;

- maintain stable levels of blood pressure (blood pressure) and heart rate (heart rate) at the stages of the surgical period, even in patients with complicated spinal injury;

- reduce stress on the patient, which helps prevent intraoperative complications;

- eliminate the negative impact on the restoration of independent breathing through the endotracheal tube, the postoperative state of the patient;

- the use of dosed intravenous infusion of the drugs used increases the controllability of general anesthesia;

- the use of special preoperative preparation quite effectively increases the degree of protection of the patient from surgical aggression, which is reflected in a decrease in metabolic and inflammatory reactions of the body, helping to reduce the frequency of complications at the stages of the operation and in the postoperative period;

- the stability of the levels of tissue metabolism markers remains within the physiological norm, reflects the adequacy of anesthetic protection.

In addition, the proposed method is simple in execution and can be used in specialized medical institutions. Its use is economically feasible due to a decrease in the frequency of postoperative complications and a reduction in the duration of a bed day.

The problem is solved due to the fact that 1.5-2 minutes before spreading the collapsed lung, anesthesia is deepened by the administration of fentanyl at a dose of 10-12 μg per kg of patient’s body weight. In patients with complicated spinal injury, additionally administered ingitrile - 45 units. Deepening of anesthesia is carried out against the background of sedation with diphenhydramine - 0.3 mg / kg, 10 minutes prior to induction, clonidine solution is administered intravenously for 2 minutes at a dose of 0.0034 μg / kg, continuous infusion of clonidine solution through DSL is started at a rate of 0.486 mcg / kg / h; induction of anesthesia is carried out with atropine 0.007-0.01 mg / kg and fentanyl 2 μg / kg; induction is carried out by the introduction of sodium thiopental at a dose of 6.5 mg / kg; Arduan is then administered at a dose of 0.115 μg / kg, after adequate myoplegia occurs, after 4.5 minutes laryngoscopy and tracheal intubation are performed; further sedation and myoplegia are intraoperatively achieved by continuous infusion of ketamine - 2.82 mg / kg / h and arduan - 0.033 mg / kg / h, artificial ventilation of the lungs through the endotracheal tube in IPPV mode with respiratory volume (DO) = 60-80 ml / kg and minute volume of respiration (MOD) = 80-100 ml / kg, FiО ₂ 35% under the control of SpО ₂ and EtCO ₂ .

The technical result is achieved due to the fact that during the expansion of a collapsed lung, specific prophylaxis is carried out aimed at eliminating operational stress, since during the most traumatic stage, acidic metabolic products (cyclic nucliatides, biologically) accumulate in the bloodstream due to a violation of the ventilation-perfusion relationship of the lungs active substances), which in turn stimulates the sympathetic-adrenal system and, consequently, the release of catecholamines. Respiratory acidosis leads to glycemia and a decrease in potassium. The loss of hormones is also stimulated by blood loss, the more traumatic the operation, the higher the level of antidiuretic hormone.

The method is as follows: in the ward 30 minutes before the operation is premedication. In the premedication scheme, intramuscular administration of diphenhydramine at a dose of 0.4 mg / kg of the patient’s body weight is used. The patient is transported to the operating room. Initially, two systems are installed in the peripheral veins on the operating table through catheters for infusion-transfusion therapy, and with a high degree of operational-anesthetic risk, the subclavian vein is punctured.

To assess the condition of the patient during surgery and in the immediate postoperative period, it is mandatory to monitor the vital functions and modes of mechanical ventilation.

For an extended version of intraoperative monitoring, monitors are used that enable visual monitoring of the ECG (electrocardiogram), non-invasive measurement of systolic, diastolic and mean arterial pressures, registration of oxygen saturation and registration of ETCO ₂ , peak pressure, compliance (lung tissue extensibility),% 02 on inhalation and exhalation, the level of oxygen utilization ("CARDIOCAP - ULTIMA", "Cardiocap-II - Datex - Finland). Monitoring of neuromuscular conduction with the apparatus" TOF - WATCH "(Netherlands).

An abbreviated monitoring option includes measuring the level of blood pressure according to the Korotkov method, recording heart rate and the level of blood oxygen saturation.

Clonidine anesthetic management program: 10 minutes before induction, clonidine solution is administered intravenously for 2 minutes at a dose of 0.0034 μg / kg and continuous infusion of clonidine solution through a DShV-1 dispenser is started at a rate of 0.486 μg / kg / hour .

Induction: intravenous infusion of atropine solution in a dose that does not cause pronounced tachycardia (0.004-0.02 mg / kg), then administration of sodium thiopental (2.5-1% solution depending on the patient's age) at a dose of 6.5 ± 0, 5 mg / kg, fentanyl at a dose of 0.002 mg / kg. After reaching a sufficient depth of drug sleep, arduan is administered at a dose of 0.115 mg / kg and after 4-5 minutes the trachea is intubated. The patient is laid in the necessary operating position.

Maintenance of anesthesia is ensured by continuous infusion of clonidine solution, which ensures the maintenance of an effective concentration of the drug in the blood. The administration of ketamine hypnanesthetic through the DShV-1 dispenser without a loading dose at a dose of 2.85 ± 0.04 mg / kg / h begins. Immediately before the skin incision, fentanyl at a dose of 9-10 μg / kg and then bolus every 20 minutes with fentanyl at a rate of 0.228 ± 0.001 μg / kg / h (in case of somatic diseases, the dose adjustment is 10-15%). The state of total myoplegia is supported by arduan at a dose of 0.033 ± 0.01 mg / kg / h. At the main stage of surgical intervention in conditions of hyperextension, additional medical correction is not required.

But 1.5-2 minutes before spreading the collapsed lung on the access side, fentanyl is infused at a dose of 10-12 μg / kg, after which the administration of the central analgesic and ketamine is stopped after 10 minutes (if there is no need for further surgical intervention).

Mechanical ventilation is carried out using a TITUS or EVITA-2-DURA device (Drager company), working in a stream, or with a volume respirator RO-6N in the mode of nomo ventilation, with a concentration _of 35% on the inspiration of FiО ₂ . EtCO _{2 is} maintained at 35 mmHg.

To assess the condition of the patient during surgery and in the immediate postoperative period, it is mandatory to monitor the vital functions and modes of mechanical ventilation.

The main principles of conducting infusion-transfusion therapy during surgery are the recovery of the circulating blood volume (BCC), the restoration of the gas transport capabilities of the blood, the stabilization of oncotic pressure, the restoration of the concentration of total protein and hemostatic potential of the blood. The volume and rate of infusion therapy are determined by the volume and rate of blood loss. When blood loss is up to 10 ml / kg, bcc is replenished with crystalloid solutions (15-20 ml / kg, the next day 10-15 ml / kg) and colloids ("Gemokhes" in the amount of 5-12.5 ml / kg; "Polyglukin", "Reopoliglyukin" 3-8 ml / kg). With blood loss exceeding 10 ml / kg, BCC correction is carried out using blood products (erythrocyte mass and FFP). The volume of infusion therapy averages 10.0 ml / kg / h and as a result exceeds the volume of total blood loss by 100-200%. When blood loss exceeds 30% of BCC, blood transfusion is carried out using erythrocyte mass in a volume of up to 75% of the lost red blood cell volume and plasma transfusion using SZP in the amount of 50-90% of the plasma loss volume (average Er-mass is 4.8-5.5 ml / kg , FFP 5.3-6.2 ml / kg). Replenishment of bcc crystalloid solutions (with a high potassium content of up to 1.6 g per 400 ml) 30-49 ml / kg, the next day 15-20 ml / kg; colloids: "Gemokhes" in a volume of 10-25 ml / kg; "Polyglukin", "Reopoliglyukin" 4-10 ml / kg. The adequacy of infusion therapy is evaluated on the basis of registration of hemodynamic parameters, blood cells, hemoglobin, potassium, glucose, albumin, hematocrit, control of neuromuscular conduction and hourly urine output.

After the operation is completed, the patient is transferred to the intensive care unit, accompanied by an anesthesiology team, where they perform mechanical ventilation (on average for 1.5 hours), monitor and carry out correction of volemic changes and high-quality blood composition.

An example of the clinical use of the method.

Patient E., born in 1948 (54 years old), was admitted to the clinic of traumatology and orthopedics with a diagnosis of Elderly uncomplicated compression wedge-shaped penetrating body fracture D12 n-ka. Post-traumatic kyphosis 18 °.

Given the diagnosis at admission, the patient was scheduled to perform the operation: 1. Ventral bisegmental spinal fusion D11-L1 with a bisegmental endofixer and an autograft from the resected rib, correction of kyphosis. 2. Transpedicular fixation of D11-L1 p-kov.

When examining and collecting the anamnesis, the patient revealed concomitant diseases: Chronic gastritis. Chronic cholecystitis. Urolithiasis, stone of the left kidney. Rheumatism? Arterial hypertension of the II degree. Aortic regurgitation of the I-II degree, mitral regurgitation of the I degree. Allergic reactions with the use of any drugs are not marked. The patient's body weight is 50 kg. Blood pressure (BP) - 140/90 mm Hg It is reasonable to conduct total intravenous anesthesia in conditions of mechanical ventilation through the endotracheal tube. Anesthetic risk according to ASA (American Sosiety of Anesthesiologi) IV degree.

The patient received the following anesthetic benefit:

The first stage is premedication 30 minutes before surgery, a solution of diphenhydramine 1% -2.0 intramuscularly.

The following monitoring was carried out in the operating room: ECG, heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure non-invasive method, SpO ₂ , EtCO ₂ . pace of diuresis. Laboratory diagnostics: analyzes of the level of cortisol, potassium, glucose, lactate and pyruvate, leukocytosis initially, at the main stage and 1 per day.

HELL at admission to the operating room 153/87 mm Hg Heart rate 88 beats. in minutes Before induction of anesthesia, preinfusion was carried out with crystalloid solutions in a volume of 600 ml with clonidine 0.01% -1.0 for 1.5 hours.

The second stage is tracheal intubation, sedation and myoplegia. The patient was laid on the left coat with rollers under the gluteal and shoulder regions.

Induction anesthesia: in order to prevent excessive vagal effect on the myocardium, a solution of atropine 0.1% - 0.7 was administered, for anesthesia with laryngoscopy and intubation - a solution of fentanyl 0.005% - 2.0.

Induction was carried out by the introduction of sodium thiopental 2.5% - 400 mg. After the administration of the arduan relaxant 6 mg, mechanical ventilation was performed through the face mask under the control of SpO ₂ . After the onset of adequate myoplegia, laryngoscopy and tracheal intubation were performed, mechanical ventilation was started through the endotracheal tube with D0 = 60-80 ml / kg and MOD = 80-100 ml / kg, FiO ₂ 50% under the control of SpO ₂ and EtCO ₂ .

Further sedation and myoplegia were intraoperatively achieved by continuous infusion of ketamine 2.85 ± 0.04 mg / kg / h, arduana 0.033 ± 0.01 mg / kg / h, anesthesia fentanyl at a rate of 0.228 ± 0.001 μg / kg / h. The duration of surgery was 5 hours 20 minutes, the operation of ventral fusion 2 hours 40 minutes.

To deepen the level of anesthesia, fentanyl was introduced at a dose of 11 μg / kg 1.5-2 minutes before the collapse of the collapsed lung.

At the stages of the surgical intervention, hemodynamic parameters were stable. The level of blood pressure ranged from 112/61 - 94/67 mm Hg, heart rate 68 - 74 beats. per minute, SpO ₂ - 99-100%, EtCO ₂ 34 - 35 mm Hg The total volume of infusion therapy during the intraoperative period was 2600 ml of crystalloid. Intraoperative blood loss was 650 ml. At the end of the surgery, the patient was transferred for observation to the intensive care unit and intensive care unit.

Against the background of restored spontaneous breathing, 1 hour 50 minutes after being transferred to the intensive care unit, extubation was performed against the background of spontaneous breathing, restored consciousness and muscle tone. No complications recorded.

The following markers of the severity of stress can serve as evidence of the adequacy of anesthetic protection: the level of cortisol at the main stage was 13.2% higher than the initial one, and at the stage of expansion of the collapsed lung, a decrease of 2.1%. Compared with statistical data, glycemia decreased by 43.2% at the stage of lung expansion and was at the level of 4.19 - 6.8 mmol / l.

Thus, the resolving possibilities of the proposed method of anesthetic protection made it possible to ensure the safety of the course of the operating period, to exclude possible hemodynamic disturbances, to achieve an adequate exit from anesthesia, which contributed to the uncomplicated course of the postoperative period.

Literature

1. Andrianov V.L., Bairov G.A., Sadofieva V.I., Raye R.E. Diseases and injuries of the spine in children and adolescents. - 1985. - L., Medicine. 256 s.

2. Maerova N.D., Kirilina S.I., Krivoshapkin A.L., Lebedeva M.N., Smorodnikova A.P., Kovalenko A.I. Anesthesia in operative vertebrology // Abstracts of the All-Russian Scientific and Practical Conference: "Problems of spinal cord and spinal cord surgery." - 1996. - Novosibirsk. - S.121-122.

3. Menyailov N.V. Traumatology and orthopedics // Handbook of Anesthesiology and Intensive Care. - 1982. - Moscow. - S.204-207.

4. Soboleva N.S., Doletsky A.S., Onuchina N.B., Stroganov I.A. Continuous intravenous administration of fentanyl with multicomponent anesthesia in children // Anest. and reanim. - 1991. - No. 1. - S. 58-59.

5. Fischenko V.Ya. Blood loss, its prevention and compensation for operations on the spine with scoliosis // Ortop.traumat. prosthetics. - 1982. - No. 2. - S.5-7.

6. Hilgenberg J.S. Intraoperative awareness during high-dose fentanyl-oxygen anesthesia // Anesthesiology. - 1981. - Vol. 54. - P.341-343.

7. Lauri A., Corbari M., Galli C., Marri M. Use of neuroleptoanesthesia for carrying out a Harrington intervention in a patient probably susceptible to malignant hyperthermia // Minerva-Anestesiol. - 1989 .-- Sep. 55 (9). - P.331-335.

8. Malcolm-Smith Nigel A., Mc Master Michael J. The use of induced hypotension to control bleeding during posterior fusion for scoliosis // J-Bone-Joint-Surg-Br. - 1983. - Vol. 65-B. - N.3. - P.255-258.

9. Steven HR, Elliot BA, Horioker TT Anesthesia, positioning and postoperative pain management for spine surgery // The adult spine: principles and practice, 2 ^nd edition. - 1997. - Philadelphia. - P.703-718.

Claims (3)

1. A method of anesthetic protection against factors of surgical aggression by acting on the body's homeostasis, characterized in that 1.5-2 minutes before the collapsed lung is expanded, anesthesia is administered by the administration of fentanyl at a dose of 10-12 μg per kg of patient body weight. 2. The method according to claim 1, characterized in that in patients with complicated spinal cord injury, they additionally administer 45 UNITRIL. 3. The method according to claim 1, characterized in that the deepening of anesthesia is carried out against the background of sedation with diphenhydramine - 0.3 mg / kg; 10 minutes before induction, a clonidine solution is administered intravenously for 2 minutes at a dose of 0.0034 mcg / kg; start a continuous infusion of clonidine solution through a DShV-1 dispenser at a rate of administration of 0.486 mcg / kg / h; induction of anesthesia is carried out with atropine 0.007-0.01 mg / kg and fentanyl 2 μg / kg; induction is carried out by the introduction of sodium thiopental at a dose of 6.5 mg / kg; Arduan is then administered at a dose of 0.115 mcg / kg; after adequate myoplegia occurs, after 4.5 minutes laryngoscopy and tracheal intubation are performed; further sedation and myoplegia are intraoperatively achieved by continuous infusion of ketamine - 2.82 mg / kg / h and arduana - 0.033 mg / kg / h; artificial lung ventilation through the endotracheal tube in IPPV mode, with a tidal volume (D0) = 60-80 ml / kg and a minute respiratory volume (MOD) = 80-100 ml / kg, FiO ₂ 35% under the control of SpO ₂ and EtCO ₂ .