RU2259201C2 - Method for giving anesthesia in carrying out surgical treatment of lumbosacral vertebral column segment diseases and injuries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying fractal introduction of 0.2 mg/kg MT calypsol and 0.4 mcg/kg MT fentanyl every 10 min during operation. Additional local spinal cord root irrigation with 2% lidocaine solution at maximum traumatic operation moment.

EFFECT: enhanced effectiveness of treatment; preserved spontaneous patient respiration.

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Description

The present invention relates to medicine, namely to anesthesiology, neurosurgery, traumatology and orthopedics, and can be used in the surgical treatment of diseases and injuries of the lumbosacral spine.

Known methods of analgesia in the surgical treatment of discogenic lumbosacral radiculitis, including the introduction of calculated doses of anesthetics into the epidural space. The most common among them is a method of prolonged epidural anesthesia with the installation of an epidural catheter and the use of local anesthetics (marcain, lidocaine) in its pure form and in combination with opioid analgesics (morphine, fentanyl) and adrenopositive drugs (adrenaline, clonidine). According to the authors, this method of anesthesia provides a high level of antinociceptive protection of patients when removing intervertebral hernias (1).

Closest to the proposed method is general anesthesia using intravenous administration of anesthetics and narcotic analgesics and controlled breathing against the background of total myoplegia, the essence of which is as follows: on the eve of surgery, patients receive intramuscularly tranquilizers, analgesics in calculated doses. 40 minutes before the start of the operation, premedication includes the necessary doses of tranquilizers, analgesics, antihistamines, antipsychotics, in the absence of contraindications atropine. All drugs are administered intramuscularly. Induction in anesthesia involves one or, more often, a combination of several general anesthetics and analgesics. Typically, drugs and their combinations such as sodium thiopental, sibazon, sodium hydroxybutyrate, diprivan, calypsol are used for induction. Among narcotic analgesics used as a component of induction, fentanyl, promedol are used. If necessary, antipsychotics, a subapnotic dose of a non-depolarizing muscle relaxant are included in the induction. Upon reaching the required level of anesthesia, after the introduction of the estimated doses of depolarizing relaxants, tracheal intubation is performed and artificial ventilation of the lungs begins. Mechanical ventilation is carried out in the mode of moderate hyperventilation by the breathing apparatus with an oxygen-air mixture. Ventilation parameters (tidal volume and minute ventilation) are calculated according to generally accepted formulas and nomograms. After this, the patient is laid on his side in the operating position and the operation begins. Maintenance of the surgical level of anesthesia and myoplegia necessary for adaptation with the ventilator is achieved by intravenous administration of maintenance doses of general anesthetics and narcotic analgesics (fentanyl, promedol, morphine), non-depolarizing relaxants. According to the literature, the described method is the most common among those used for the removal of intervertebral hernias (2).

However, the presented methods of anesthesia during operations for DPRK are not without significant drawbacks.

Assessing the method of prolonged epidural anesthesia using local anesthetics of opioid analgesics, the authors indicate that the particularities of performing this spinal operation (lateral position of the patient on the operating table, opening the spinal canal, washing the wound, applying aspiration) often interfere with the maintenance of epidural blockade by the additional administration of anesthetic through an epidural catheter. In addition, the anatomical features of the spinal structures characteristic of patients with duodenoscopy, such as a narrow spinal canal, commissural epiduritis of various origins, the presence of varicose veins of the epidural space, can cause difficulties in placing an epidural catheter, the development of incomplete blockade (mosaic, unilateral), perforation of veins with the development of bleeding. The risk of developing high spinal blockade in case of accidental damage to the dura mater both during puncture and catheter placement, and during surgery, as well as the likelihood of a systemic toxic effect of the used large doses of anesthetics (3, 4), is significant.

On the other hand, the method of general anesthesia with the use of anesthetics and narcotic analgesics in combination with controlled breathing on the background of total myoplegia is characterized by significant aggressiveness associated both with drug multicomponent and with the use of mechanical ventilation. According to published data, anesthetic manipulations associated with mechanical ventilation (laryngoscopy, tracheal intubation), characterized by pronounced reflexogenicity, often exceed the surgical intervention in terms of aggressiveness and can be a source of complications, primarily from the organs of the cardiovascular system. There is also a risk of traumatic complications (tooth breakage, dislocation and fracture of the lower jaw, tears and injuries of the mucous membrane of the oral cavity, tongue, epiglottis, vocal cords, etc.) and the development of hypoxia in the event of technical difficulties in tracheal intubation. Volumetric mechanical ventilation always leads to violations of ventilation-perfusion relationships, which are exacerbated by the patient’s side position. As a result of this, physiological dead space and blood shunting increase from right to left, the alveolar-arterial oxygen gradient increases. Monotonous tidal volume contributes to the flow of air into the same stretchable areas of the lungs. Under these conditions, the risk of barotrauma of the alveoli increases, and in less extensible areas there is a tendency to atelectasis. The need to introduce muscle relaxants to adapt a patient with a ventilator further increases the pharmacological load and can cause specific complications associated with their use (bradycardia, increased intraocular pressure during anesthesia; myalgia, prolonged or repeated apnea in the postoperative period). The authors also describe a large number of complications of tracheal extubation, which can worsen the course of the postoperative period (5, 6, 7).

Based on the known level of anesthesia technologies in the surgical treatment of diseases and injuries of the lumbar spine, elimination of existing deficiencies, the task was set: to increase the effectiveness of the anesthetic aid, to reduce its aggressiveness.

The problem is solved as follows:

Anesthesia during surgical treatment of diseases and injuries of the lumbar spine is carried out by intravenous administration of anesthetics, narcotic analgesics and sedatives. New in solving this problem is that general anesthesia is performed while maintaining spontaneous respiration of the patient by fractional administration of 0.2 mg / kg MT of calipsol and 0.4 μg / kg MT of fentanyl every 10 minutes against the background of deep sedation, while in the most traumatic at the time of surgery, an additional local irrigation of the spinal canal root with 2% lidocaine solution is carried out.

We explain the significant distinguishing features of the proposed method of analgesia:

Conducting general anesthesia against the background of preserved spontaneous breathing of the patient provides a significant reduction in pharmacological and reflexogenic aggressiveness, eliminates the risk of various complications associated with the use of mechanical ventilation.

Fractional administration of 0.2 mg / kg MT calypsol and 0.4 μg / kg MT fentanyl every 10 minutes during the operation allows for a continuous high level of analgesia.

Performing additional irrigation of the spinal canal root with a 2% lidocaine solution at the most traumatic time of the operation is necessary to enhance the analgesic effect of the anesthetic aid and maintain the depth of anesthesia at a level that does not inhibit the function of the respiratory system.

The essence of the proposed method of analgesia during operations for DKRR is as follows:

On the eve of night surgery, individual doses of tranquilizers and analgesics are prescribed. 40 minutes before surgery, sibazon (0.14 mg / kg), droperidol (0.06 mg / kg), promedol (0.3 ± 0.06 mg / kg) are intramuscularly administered. If the general condition of the patient is weighed down by hypertension, then to prevent pressor reactions, pre-medication includes clonidine in an individually selected dosage.

Anesthesia begins with the administration of sibazon and droperidol by titration until a pronounced sedative effect occurs, on average 0.3 mg / kg MT and 0.03 mg / kg MT, respectively. Immediately before the incision, a dose of fentanyl and calipsol is administered, twice the amount used in the future to maintain analgesia (0.8 μg / kg MT and 0.4 mg / kg MT, respectively). In order to prevent respiratory depression, all drugs are administered slowly. Also, thiopental sodium in a dose of 1-2 mg / kg MT is administered before the incision. Further, anesthesia is supported by fractional administration of sub-drug doses of fentanyl (0.4 μg / kg MT) and calypsol (0.2 mg / kg MT) after 10-15 minutes and by adding calculated doses of sibazon and thiopental - 0.1 mg / kg / hour and 3.3 ± 1.4 mg / kg / hour, respectively. At the most traumatic time of the operation (meningoradiculolysis), local irrigation of the root with a 2% lidocaine solution is carried out. In the postoperative period, there is a quick and smooth exit from anesthesia, on average 5-15 minutes after the end of the operation.

The effectiveness of anesthesia during operations is confirmed by the concentration of cortisol and glycemia, which reflect the functional state of the sympathoadrenal and hypothalamic-pituitary-adrenal systems, which did not exceed the physiological norm, the absence of a hyperdynamic blood circulation reaction, a decrease in the oxygen demand of the myocardium, and a moderate increase in the photoplethysmogram amplitude during the operation. The physiological level of hemoglobin oxygen saturation and a stable respiratory rate and depth were maintained at all stages of the operation. We have not registered a decrease in the level of initial proteinemia in the postoperative observation period. Mild depression of immunity indicators observed on the first day after surgery tends to recover quickly.

A comparison of some of the studied indicators of the effectiveness of antinociceptive protection when using combined endotracheal anesthesia with artificial lung ventilation and total intravenous anesthesia with preserved spontaneous breathing of patients and local irrigation of the roots of the spinal cord with a 2% lidocaine solution is presented in the table.

Table Indicator Type of anesthesia Operation stages I II III Glycemia (mmop × l ^-1 ), KEN (n = 25) 3.98 ± 0.65 4.79 ± 1.05 6.68 ± 3.6 * M ± m TVA (n = 25) 4.26 ± 0.56 4.67 ± 0.8 4.86 ± 0.79 Cortisolemia (nmol × L ^-1 ) P ₅₀ KEN (n = 25) 259.95 (137.5; 341.3) 379.21 (171.3; 488.2) 526.4 (281.3; 725.4) * (P ₂₅ ; P ₇₅ ) TVA (n = 25) 245.9 (131.2; 290.9) 184.5 (50.9; 182.6) * 149.6 (50.0; 156.3) * GARDEN × HR KEN (n = 25) 7603.2 ± 041.0 9172.7 ± 1725.3 * 8268.5 ± 1883.9 * TVA (n = 25) 8868.4 ± 1429.4 8638.5 ± 1307.2 7037.9 * 1089.3 * * - p <0.05 compared with the initial indicator

Thus, when conducting total intravenous anesthesia according to the proposed method, there was no significant increase in the levels of glycemia and cortisolemia, in contrast to the compared method, which indicates the absence of activation of the sympathoadrenal and hypothalamic-pituitary-adrenal systems. Against the background of total intravenous anesthesia, there was a significant decrease in myocardial oxygen demand (GARDEN × HR), which confirms the absence of tension of the cardiovascular system. The data presented indicate a higher degree of antinociceptive protection of patients under the conditions of the proposed method of anesthesiological aid in operations for the removal of intervertebral hernias.

The essence of the proposed method is illustrated by a clinical example:

Patient M, 47 years old.

Diagnosis: DPCR, disc herniation L4-L5, severe pain. Concomitant diagnosis: hypertension, stage I. Chronic simple bronchitis, stage of remission. Varicose disease.

02.09.2001, the operation was performed hemilaminectomy L4, removal of a hernia of the disc L4-L5. The duration of the operation is 1 hour 10 minutes, the duration of anesthesia is 1 hour 25 minutes. For the purpose of sedation, 40 minutes before surgery, intramuscularly administered: sibazon 0.14 mg / kg MT, diphenhydramine 0.14 mg / kg MT, promedol 0.29 mg / kg MT, droperidol 0.04 mg / kg MT. Total intravenous anesthesia was performed, which included the administration of fentanyl 0.4 μg / kg and calipsol 0.2 mg / kg after 10 minutes during the operation, local irrigation of the exposed spinal root with a 2% lidocaine solution against the background of sedation with sibazon 0.1 mg / kg / hour and thiopental sodium 3 mg / kg / hour.

During anesthesia and surgery, stable hemodynamic parameters were observed, adequate spontaneous breathing with NPV: 18-14-15-16 per minute, which supported oxygen saturation of hemoglobin against the background of oxygen insufflation through the nasal cannula (V - 3 l / min) at the figures: 97 % -97% -99% -98%. The amplitude of the PPG had a significant tendency to increase towards the end of the operation.

The indicators of the analgesic effect were as follows: glycemia - 3.5-4.7-4.8 (mol / L), cortisolemia - 236.2-418.3-491.3 (nmol / L). The body resistance index, studied before the operation, changed on the first day and on the 10th day after the operation as follows: 0.29-0.16-0.75. The level of proteinemia by the 10th day of the postoperative period decreased compared with the initial one, but did not go beyond the normal values (83.9 and 68.8 g / l).

Blood loss during the operation was 320.0, diuresis - 190.0, intravenous induction - 800.0 (crystalloids). Awakening 12 minutes after the end of the operation. The postoperative period without features. The patient was discharged on the 21st day with recovery.

Thus, the proposed "Method of anesthesia in the surgical treatment of discogenic lumbosacral radiculitis" allows, in comparison with other known methods of anesthesia, to avoid the reflexogenic aggressiveness of anesthetic benefits while maintaining an effective level of antinociceptive protection of patients.

Sources of information

1. Solenkova A.V., Lubnin A.Yu. Tenedieva Yu.V. Epidural anesthesia for surgical interventions on the spine and spinal cord // Anesthesiol. and resuscitation. - 2000. - No. 4. S.27-37.

2. Guide to anesthesiology. Volume 1: Per. from English / Edited by A.R. Aitkenhead, G. Smith. - M .: Medicine, 1999. - S.416-432.

3. Arestov O. G., Solenkova A. V., Lubnin A. Yu. Features of epidural analgesia when removing hernias of the lumbar intervertebral discs // Questions of Neurosurgery named after A.L. Polenova. - 2000. - No. 1. - S.13-15.

4. J. Edward Morgan Jr., Magid S. Michael. Clinical Anesthesiology: Book 1 / Per, Eng. - M. - St. Petersburg: Publishing House BINOM-Nevsky Dialect, 1998.-S.311-314.

5. Lebedinsky K.M. Anesthesia and systemic hemodynamics. - St. Petersburg: Man, 2000. - S.65-90.

6. Kassil V.L. Mechanical ventilation in intensive care. - M .: Medicine, 1987. - P.32-47; 161-171.

7. Guide to anesthesiology. Volume 1: Per. from English / Edited by A.R. Aitkenhead, G. Smith. - M .: Medicine, 1999. - S. 424-429.

Claims (1)

A method of analgesia in the surgical treatment of diseases and injuries of the lumbosacral spine, including intravenous administration of anesthetics, narcotic analgesics and sedatives, characterized in that general anesthesia is performed against the background of saved spontaneous breathing of the patient by fractional administration of 0.2 mg / kg MT calipsol and 0 , 4 μg / kg MT of fentanyl every 10 min during the operation, while at the most traumatic moment of the operation, additional local irrigation of the spinal canal root with 2% lidocaine solution.