RU2296562C2 - Method for treatment of acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine, gastroenterology, pancreatology, reanimation.

SUBSTANCE: method involves carrying out epidural anesthesia at the level Th_IX - Th_XI with 0.2% ropivacaine solution that is administrated at the rate 4-5 ml/h for 72 h. Epidural infusion is combined with intravenous administration of the preparation "Essentiale" in the dose 10 ml of solution in 200 ml of 0.9% NaCl, 2 times per 24 h. Invention provides adequate anti-stress protection and analgesic effect and with retention of motor activity of patient. Invention can be used in treatment of acute destructive pancreatitis in early period.

EFFECT: improved and enhanced effectiveness of treatment.

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Description

The invention relates to medicine, in particular to anesthesiology-resuscitation, and can be used in the treatment of pancreatic necrosis.

A known method of antistress protection and analgesia in the early period of acute destructive pancreatitis through the use of complex drug analgesic therapy. Mandatory components of this anesthesia technique are:

1. Dalargin - a synthetic analogue of leukenkephalin, is administered intravenously dropwise at a dose of 50 mg / kg in a dilution of 400 ml of physiological solution of sodium chloride or 5% glucose solution;

2. Non-narcotic analgesics - Baralginum 5 ml intravenously every 6 hours, regardless of the severity of the pain syndrome. It is possible to use other analgesics, in particular those belonging to the class of non-steroidal anti-inflammatory drugs (NSAIDs) - ketrodol (ketorol, toradol, etc.), diclofenac, xefocam;

3. Weak opiates - tramal intramuscularly or intravenously at a dose of 50-100 mg 4-6 times a day, depending on the severity of the pain syndrome. It is advisable to combine tramal with NSAIDs or other non-narcotic analgesics;

4. Strong opiates - morphine hydrochloride, promedol, are administered parenterally with the ineffectiveness of non-narcotic analgesia regimens.

(A.P. Chadayev, A.Ts. Butkevich, S.V. Sviridov et al. Surgical treatment of pancreatic necrosis. / Russian Medical Journal No. 1, 2002, pp.21-24-24).

The disadvantages of this method of analgesia are not always an adequate analgesic effect of the drugs, the impossibility of their intravenous administration (diclofenac, ketoprofen), increased bleeding from postoperative wounds, cases of gastrointestinal bleeding and nephrotoxic effects (ketorolac), in the case of the use of narcotic analgesics, the possibility of spasm of the sphincter of Oddi and aggravation of intraductal hypertension in the pancreas.

A known method of antistress protection and analgesia in the early period of acute destructive pancreatitis by regional blockade of the pancreas by local anesthetics - lumbar block according to L.I. Roman: simultaneous administration of 80-120 ml of 0.25% novocaine solution or drip of the treatment mixture (200 ml of 0.25% novocaine solution, 500,000 units of penicillin or another antibiotic, 25 mg of hydrocortisone, 10,000 units of contracal or trasilol) at a rate of 20- 30 drops per minute through a vinyl chloride tube into the retroperitoneal cellular space. This method of analgesia is carried out for 2-4 days. (Acute destructive pancreatitis. / Y. B. Martov, V. V. Kirkovsky, V. Yu. Martov; under the editorship of Prof. Yu. B. Martov. - M .: Med. Lit., 2001. - 80 p. : ill.).

The disadvantages of this method of analgesia are the high risk of allergic reactions, with the simultaneous administration of a local anesthetic, a short-term effect, and with prolonged drip, the occurrence of the tachyphylaxis phenomenon.

A known method of pain relief in the postoperative period by epidural infusion of 0.2% ropivacaine at a rate of 6-10 ml / h (with inefficiency - 12-14 ml / h) for up to 72 hours. In this case, the first dose of anesthetic is administered bolus. (V.V. Nikoda, A.V. Bondarenko, V.I. Brusin, E.Yu. et al. Continuous epidural infusion of ropivacaine in the postoperative period. / Anesthesiology and intensive care №5, 2000 p. 76-79).

The disadvantages of this method of analgesia are a high risk of hypotensive reactions, and therefore this method is not used in the early treatment of acute destructive pancreatitis due to uncorrected hypovolemia.

A known method of antistress protection and analgesia in the early period of acute destructive pancreatitis by prolonged epidural blockade with local anesthetics at the level of Th _VII -Th _VIII with catheterization of the epidural space and the systematic (every 2 hours) administration of a 2% solution of lidocaine at a dose of 5-7 ml (B. I.Filin, A.L. Kostyuchenko Emergency Pancreatology. - St. Petersburg; Peter, 1994. - 416 p.).

The disadvantages of this method of analgesia are a high risk of hypotensive reactions with uncorrected hypovolemia, the frequent occurrence of general intoxication and tachyphylaxis, the development of undesirable motor blockade of the lower extremities with limited patient activity.

The objective of the invention is the improvement of the method of treatment and analgesia in the early period of acute destructive pancreatitis.

The problem is solved in that in the method of treating patients with acute destructive pancreatitis, including epidural infusion of a 0.2% ropivacaine solution, analgesia is carried out directly when a patient enters with a drug injection rate of 4-5 ml / h into the epidural space at the level of Th _IX -Th _XI within 72 hours in combination with intravenous administration of the essence of 10 ml of a solution in 200 ml of 0.9% NaCl 2 times / day.

As an anesthetic method, we used early low-flow extended infusion epidural analgesia with 0.2% ropivacaine solution. This drug has been widely used for the past 2 years for regional methods of pain relief in surgery. The choice of methodology was due to the fact that due to epidural analgesia at the level of Th _IX- Th _{XI, the} flow of nociceptive influences from the pancreatic destruction zone with the blockade of adverse autonomic reactions to hemodynamics and intestinal motility, the disorder of which complicates acute pancreatitis, is stopped. The choice of ropivacaine as an anesthetic was due to the fact that ropivacaine has both analgesic and anesthetic properties. In high doses (up to 200 mg), the drug causes surgical anesthesia, and in low doses (20-30 mg) - sensory blockade with or without limited or non-progressive motor blockade. In addition, with epidural infusion up to 72 hours, there are no signs of cumulation and the appearance of side or toxic effects and there is no occurrence of the tachyphylaxis phenomenon.

Description of the technique. When a patient with acute pancreatitis enters the intensive care and resuscitation department after central vein catheterization and in parallel with the start of corrective infusion-transfusion therapy under aseptic conditions after skin anesthesia with 0.5% novocaine solution, the epidural space is punctured with a Tuohy G-20 needle at the Th level _IX- Th _XI vertebrae. Identification of the epidural space by a “drop drop” breakdown. A test dose of anesthetic is injected into the epidural space: lidocaine 2% - 3 ml. After 5 min, with the stability of hemodynamics and the absence of signs of a spinal block, a standard epinid catheter is inserted into the epidural space and the cranial position is 2-3 cm. The Tuoha needle is removed. An aseptic dressing is glued to the place where the catheter enters the skin, the catheter is removed through the back and shoulder girdle to the front surface of the chest, fixing along the entire length with adhesive tape. They begin infusion into the epidural space of a 0.2% ropivacaine solution by means of the DShV-01 infusomat at a rate of 4-5 ml / hour for 72 hours.

The intensity of pain is evaluated in points on a scale of verbal assessments (SHVO): no pain - 0 points; mild pain - 1 point; moderate pain - 2 points; severe pain - 3 points; unbearable pain - 4 points.

Assessment of sensory blockade is carried out on a scale of "pin prick" (loss of pain sensitivity of the skin in response to irritation with a needle): preservation of pain sensitivity - 0 points; a dull touch in response to stimulation with a sharp needle - 1 point (analgesia); lack of sensation with needle stimulation - 2 points (anesthesia).

Assessment of motor blockade is carried out according to R. Bromage: complete block - if the patient is unable to bend the leg in the hip joint, unbend in the knee and perform plantar flexion of the big toe - 3 points; while maintaining plantar flexion of the foot - 2 points; if active movements in the knee joint are possible - 1 point; maintaining active mobility in all three joints - lack of motor blockade - 0 points.

Monitoring of central hemodynamic parameters is carried out by means of integral rheography.

In the complex of intensive care in the early period for the purpose of membrane stabilization, infusion of high doses of the drug Essential (10 ml of solution in 200 ml of 0.9% NaCl 2 times a day) is used.

Example. Patient D., 52 years old, was delivered to MSCh No. 4 at 12:00 on 08.03.2004 with a diagnosis of chronic cholecystopancreatitis, exacerbation; after 3 hours from the time of the disease with complaints of pain in the upper abdomen, repeated vomiting. The pains were permanent, radiating to the back. In the emergency room, the patient's condition is regarded as moderate. Consciousness is clear. The position is active. The skin is pale. The tongue is wet. Vesicular breathing, evenly carried out at all departments of the lungs. BH = 17-18 min ^-1 . Heart sounds are muffled, the rhythm is correct. HELL = 140/100 mm Hg Pulse 80 min ^-1 . The abdomen is soft, participates in the act of breathing, painful in the epigastrium and both hypochondria. The gall bladder is not palpable. Liver at the edge of the costal arch. There are no symptoms of peritoneal irritation. In laboratory tests, it was noted: in a detailed clinical blood test - red blood cells 5.0 · 10 ¹² / l, hemoglobin 166 g / l, white blood cells 8.0 · 10 ⁹ / l, ESR 7 mm / h, in the leukocyte formula - segmented neutrophils 78 %, stab 2%. In blood serum - total protein 80.9 g / l, sugar 10.8 mmol / l, urea 6.4 mmol / l, creatinine 77.8 mmol / l, total bilirubin 39.0 mmol / l, direct 14.1 μmol / L, indirect 21.9 μmol / L, AlAT activity 1.3 mmol / L, AcAT 0.75 mmol / L. Diastasuria at 12.00 512 units, at 18.00 2048 units. According to the ECG - sinus rhythm (65-75 min ^-1 .). The electrical axis of the heart is not deflected.

The degree of impaired function of organs and systems on the M-SAPS scale corresponded to 4 points.

The patient was hospitalized in the surgical department, where conservative basic therapy was started: infusion therapy, antispasmodics, kallikrein-kinin system inhibitors. March 9, 2004 in connection with the intensification of pain, an increase in endotoxemia, the lack of effect of the therapy, the patient was transferred to the intensive care unit and intensive care.

Upon admission to the intensive care unit, severe hypovolemia was noted: CVP = 1 cm of water. Art., according to integral rheography (IRG), stroke volume (UO) of 28 ml, minute volume of blood circulation (IOC) 2.6 l, cardiac index (SI) 1.3 l / min / m, total peripheral vascular resistance (OPSS) 2995 dyne · s · cm ^-5 , circulating blood volume (BCC) 2.1 l, endotoxemia (nuclear shift of neutrophils to the left up to 25% of stab neutrophils, acceleration of ESR up to 26 mm / h, increase of bilirubin in blood up to 43.3 mmol / l, diastasuria 32768 units), severe pain syndrome with a score of 3 points at rest according to SUR. Blood pressure at the level of 100 / 60-110 / 70 mm Hg, heart rate up to 120 min ^-1 . Comprehensive intensive therapy has begun with the inclusion in the treatment regimen of early low-flow extended infusion epidural analgesia with 0.2% ropivacaine solution according to the above method and the essential infusion of 10 ml of solution in 200 ml of 0.9% NaCl 2 times a day.

The epidural infusion rate of ropivacaine is 4-5 ml / hour. The duration of administration is 72 hours. SCW points: after 10 minutes - 2, after 30 minutes - 1, after 1 hour - 0, after 3 hours - 0, on day 2 - 0, on day 3 - 0. Assessment of sensory blockade on the "pin prick" scale: after 10 minutes - 1, after 30 minutes - 1, after 1 hour - 1, after 3 hours - 2, on 2 days - 1, on 3 days - 1. Assessment of motor blockade according to the R. Bromage scale: After 10 minutes - 0 , after 30 minutes - 0, after 1 hour - 0, after 3 hours - 0, on day 2 - 1, on day 3 - 1. Blood pressure remained at the level of 110 / 70-130 / 80 mm Hg. IRG indicators after 30 min - UO 32 ml, IOC 2.9 L, SI 1.45, OPSS 1988, BCC 2.9 L; after 3 hours - UO 40 ml, IOC 3.5 l, SI 1.75 l / min / m ² , OPSS 1889 dyn · s · cm ^-5 , BCC 3.08 l. There were no complications of epidural blockade.

Against the background of the treatment, the patient's condition stabilized, water-electrolyte and metabolic disorders, endotoxemia were stopped, and hyperfermentemia quickly regressed. The patient was discharged in satisfactory condition on the 16th day from the moment of admission to the hospital.

Clinical diagnosis: Acute necrotic pancreatitis. Fatty small focal pancreatic necrosis complicated by diffuse enzymatic peritonitis and obstructive jaundice. Chronic calculous cholecystitis.

This method of treatment was used in 12 patients with acute destructive pancreatitis. Using the proposed method reduced mortality in acute destructive pancreatitis from 16.7% to 14.2% and the average bed day from 12, 3 to 10.5.

Results. The proposed method of antistress protection and analgesia in the early period of acute destructive pancreatitis combines the rapid onset of analgesia (15-20 minutes) and maintaining an effective blockade of pain impulse during the entire period of use (up to 72 hours). Moreover, our proposed method is simple to use, does not require high material costs, is free from the disadvantages that are found in other methods of antistress protection and analgesia that we studied - the absence of a pronounced negative effect on central hemodynamics, the development of toxic effects and tachyphylaxis, the absence of significant motor block, which subjectively tolerated by patients much easier, and also allows you to maintain motor activity, which is important for the prevention of pulmonary and thromboembolic x complications.

Claims (1)

A method for the treatment of acute destructive pancreatitis, including epidural analgesia, characterized in that the analgesia is carried out directly when a patient enters with a 0.2% ropivacaine solution with a drug injection rate of 4-5 ml / h into the epidural space at the level of Th _IX -Th _XI for 72 hours in combination with intravenous administration of the essence of 10 ml of a solution in 200 ml of 0.9% NaCl 2 times a day.