RU2319514C2 - Method for anesthesia at surgical interferences in oncological patients - Google Patents

Abstract

FIELD: medicine, anesthesiology.

SUBSTANCE: the present innovation could be applied as an anesthesiological assistance during vast and highly traumatic surgical interferences in oncological patients. So, it is necessary to carry out anesthesia with xenon-oxygen mixture at the ratio of 60%-40% along closed respiration contour. Moreover, before the onset of endotracheal narcosis it is important to fulfill epidural anesthesia with naropin at the dosage of 75 mg or about 3-5 min before the onset of traumatic stage of operation one should intravenously inject fentanyl at the dosage ranged 2-2.5 mcg/kg. The innovation provides reliable level of anesthesiological protection at minimal pharmacological loading upon the body in patients being weakened after chemiradiation therapy due to matching optimal combination of anesthetics and the modes of their injection.

EFFECT: higher efficiency.

2 ex

Description

The invention relates to medicine, anesthesiology, and specifically to a method for xenon (Xe) anesthesia in a closed breathing circuit during surgical interventions in cancer patients.

A known method of conducting Xe anesthesia in a closed circuit, including premedication, induction of anesthesia, intubation, artificial ventilation of the lungs (mechanical ventilation) on a half-open circuit with 100% oxygen (O ₂ ) for 4-5 minutes in order to denitrogenation with the subsequent transition to a closed breathing circuit and supplying a xenon-oxygen mixture to the patient’s body at a xenon to oxygen ratio of 70:30 under the control of the concentration of O ₂ in the respiratory circuit (FiO ₂ ). This method was used mainly when performing cholecystectomy [1].

The aforementioned method has the following disadvantages - during anesthesia, conducting mechanical ventilation along a closed breathing circuit, maintaining a concentration of Xe at a given level of 70% is a rather difficult task, even with modern gas monitoring. In addition, the accumulation of Xe in the patient’s body and in the respiratory circuit of the anesthesia apparatus in a closed circuit conditions necessitates an increase in O ₂ flux, which, in turn, makes it possible to decrease the concentration of Xe as the main narcotic agent. All this can cause instability in the course of general anesthesia due to inadequate responses of the sympathoadrenal system due to a changing quantitative ratio of Xe and O ₂ , which negatively affects the course of the surgical period. Due to its large specific gravity and high fat solubility coefficient, Xe can accumulate rapidly in the body, especially in adipose tissue cells. Therefore, the use of a ratio of Xe and O ₂ at a concentration of 70% and 30% to maintain anesthesia leads to its accumulation in the respiratory circuit, which, in turn, does not exclude the possibility of developing intraoperative hypoxia and undesirable complications associated with it.

Also known method Xe-anesthesia closed loop breathing during surgery comprising premedication, intubation followed denitrogenation and supplying xenon-oxygen mixture in a closed breathing circuit under the control of FiO _2, wherein in the saturation period the gas flow is set in a volume ratio of: O ₂ - 0.3 l / min; Xe - 1.0 l / min; after 4-6 minutes, after reaching the surgical stage of anesthesia and at the beginning of the operation, the volumetric ratio of the gas flow is changed, while the total volume of the respiratory mixture is adjusted to 1 l / min with a ratio of O ₂ and Xe of 0.4 and 0.6 l / min accordingly, to reduce FiO ₂ not lower than 96%, hemostasis and sealing of hollow organs are performed, after which Xe is stopped in the respiratory circuit, and the lungs are ventilated with pure oxygen in a closed circuit in a volume of 0.3-0.4 l until the FiO ₂ value is normalized not lower than 99-100%. When performing non-cavity surgical interventions, accompanied by a blood loss of more than 300 ml, the duration of a complete shutdown of xenon supply to the circuit is 40% of the total duration of anesthesia, and when performing surgery on an open lumen of the gastrointestinal tract (GIT), the supply of xenon to the respiratory circuit is disabled periodically under the control of FiO ₂ , as the duration of work in the open lumen of the gastrointestinal tract increases, and makes up 40% of the total duration of anesthesia [2].

The main disadvantage of this method is the conduct of general anesthesia in mononarcosis mode. This does not allow to achieve a reliable level of anesthetic protection when performing extensive and highly traumatic operations. Anesthesia for such interventions should be proactive and multi-level, with an emphasis on the preventive blockade of pathological afferent impulse from the surgical wound.

The objective of the invention is to obtain a reliable level of anesthetic protection when performing extensive and highly traumatic operations.

The problem is solved by applying Xe anesthesia on a closed breathing circuit with a xenon-oxygen mixture ratio of 60-40%, in combination with intravenous (iv) narcotic analgesic of fentanyl at a dose of 2-2.5 μg / kg 3-5 minutes before the beginning of the traumatic stage of the operation or epidural anesthesia with napropine at a dose of 75 mg.

The novelty of the invention lies in the fact that they additionally use a centrally acting narcotic analgesic fentanyl at a dose of 2-2.5 μg / kg 3-5 minutes before the start of the traumatic stage of the operation or epidural anesthesia with napropine at a dose of 75 mg is performed.

The essence of the invention lies in the fact that in the method of anesthesia with xenon according to the endotracheal type, including premedication with atropine, denitrogenation with pure oxygen, induction of anesthesia, myoplegia, intubation, re-denitrogenation by means of artificial ventilation of the lungs with subsequent transition to a closed circuit, supplying xenon to the system anesthesia apparatus and anesthesia at low gas flow and the ratio of xenon and oxygen of 0.6: 0.4. To potentiate iv, a short-acting narcotic analgesic fentanyl is administered at a dose of 2-2.5 mcg / kg 3-5 minutes before the start of the traumatic stage of the operation or epidural anesthesia with napropine at a dose of 75 mg is performed.

During denitrogenation, total iv anesthesia with propofol is performed.

The method is as follows: sedation, induction of anesthesia with propofol 2-2.5 mg / kg Intubation, denitrogenation for 6-8 minutes. 100% oxygen in a half-open circuit, after switching to a closed circuit, no more than 500 ml of oxygen is left in the breathing bag, the flow is reduced to zero. Then, the phase of rapid saturation of Xe (1.3-1.5) of the vital capacity of the lungs (VC) of this patient under the control of FiO _{2 is} carried out until the oxygen concentration in the respiratory circuit is 40%. When Xe reaches 60%, a flow of 250-400 ml per minute is established until a stable equilibrium is reached. Upon reaching a stable equilibrium in the Xe: O ₂ ratio (60:40), the Xe flow decreases to 0-160 ml / min, and oxygen begins to flow into the circuit at a dose equal to the physiological need of 4 ml / kg / min.

To potentiate iv, fentanyl is administered at a dose of 2-2.5 μg / kg 3-5 minutes before the start of the traumatic stage of the operation.

Or epidural anesthesia with napropine 75 mg is performed.

During denitrogenation, total iv anesthesia with propofol is performed at a dose of 4 mg / kg / h.

Example No. 1. Patient G. 91. The medical history No. 127961.

Diagnosis: Primary multiple malignant tumors. Cancer of the left breast III B century, T4N1M0. Synchronous cancer of the descending part of the colon of the second century, T3N0M0.

The first stage - March 29, 05 performed a radical mastectomy on the left. Under endotracheal anesthesia with xenon with the addition of fentanyl.

After performing the generally accepted preparation of the patient for surgery and anesthesia on the operating table, premedication was carried out by intravenous administration of atropine 1 mg. Through the face mask of the anesthesia apparatus, 100% oxygen was inhaled along a half-open circuit at a gas flow of 6 l / min for 5 minutes in order to dehydrogenate. Then, introductory anesthesia was carried out with propofol 2-2.5 mg / kg, myoplegia with ditilin 200 mg and arduan 3 mg. After this, the patient was intubated. A mechanical ventilation was performed with 100% oxygen along a half-open circuit using a Ruben valve at a gas flow of 8 l / min for 8-10 minutes. Then we switched to a closed circuit, leaving 500 ml of oxygen in the breathing bag, we remove the flow of fresh gas to zero. Through the xenon anesthesia prefix (KPP-01), xenon was supplied into the anesthesia system in an amount equal to 1.3 VC of the patient for 2 minutes. The oxygen concentration decreased to 40%, and xenon reached 60%. A flow of Xe of 250-400 ml per minute is established until a stable equilibrium is reached. Upon reaching a stable equilibrium in the ratio of Xe: O ₂ (60:40) Xe flow is reduced to 50-200 ml / min, and the circuit begins to supply oxygen at a dose of physiological needs of 4 ml / kg / min.

5 minutes after the start of xenon inhalation, surgery began, the duration of the operation was 60 minutes. All subsequent anesthesia was performed at low gas flow with oxygen concentration control not lower than 40%. 3-5 minutes before the start of the traumatic stage of the on / in, a short-acting narcotic analgesic, fentanyl, is administered at a dose of 2-2.5 mcg / kg. 4 minutes after anesthesia, the patient was fully conscious, extubated. Hemodynamics during the operation is stable: blood pressure = 120/80, pulse 80, CO 2-4 vol.%. The adequacy of anesthesia was evaluated according to the following data: clinical picture, studies of the neuroendocrine system and the reactivity of the autonomic circuits of regulation of the rhythmic work of the heart according to the mathematical analysis of heart rate variability.

Subjective sensations of the patient after exit from anesthesia are pleasant. There were no complaints.

Example No. 2. Patient G. 91. The medical history No. 127961.

Diagnosis: Primary multiple malignant tumors. Cancer of the left breast III B century, T4N1M0. Synchronous cancer of the descending part of the colon of the second century, T3N0M0.

The second stage is 05/19/05 resection of the descending colon.

Under endotracheal anesthesia with xenon in combination with epidural anesthesia.

After performing the generally accepted preparation of the patient for surgery and premedication on the operating table, epidural space was catheterized at the level of L-3, 75 mg napropine was administered. Then, endotracheal anesthesia with xenon was performed. Through the face mask of the anesthesia machine, 100% oxygen was inhaled along a half-open circuit at a gas flow of 6 l / min for 5 minutes in order to denitrogenate. Then, introductory anesthesia was carried out with propofol 2-2.5 mg / kg, myoplegia with ditilin 200 mg and arduan 3 mg. After this, the patient was intubated. A mechanical ventilation was performed with 100% oxygen along a half-open circuit using a Ruben valve at a gas flow of 8 l / min for 8-10 minutes. Then we switched to a closed circuit, leaving 500 ml of oxygen in the breathing bag, we remove the flow of fresh gas to zero. Through the xenon anesthesia prefix (KNP-01), xenon was supplied into the anesthesia system in an amount equal to 1.3 VC of the patient for 2 minutes. The oxygen concentration decreased to 40%, and xenon reached 60%. A flow of Xe of 250-400 ml per minute is established until a stable equilibrium is reached. When a stable equilibrium is reached in the Xe: O ₂ ratio (60:40), the Xe flow decreases to 50-200 ml / min, and oxygen is supplied to the circuit at a dose equal to the physiological need of 4 ml / kg / min.

5 minutes after the start of xenon inhalation, surgery began, the duration of the operation was 150 minutes. All subsequent anesthesia was performed at low gas flow with oxygen concentration control not lower than 40%. 15 minutes after anesthesia, the patient was fully conscious, extubated. Hemodynamics during the operation is stable at all stages: blood pressure = 120 / 80-110 / 70, pulse 80-68, СО 2-4 vol.%. The adequacy of anesthesia was evaluated according to the following data: clinical picture, studies of the neuroendocrine system and the reactivity of the autonomic circuits of regulation of the rhythmic work of the heart according to the mathematical analysis of heart rate variability.

Subjective sensations of the patient after exit from anesthesia are pleasant. There were no complaints.

Using the invention allows to obtain the following positive therapeutic result.

Ensuring reliable blockade of afferent nociceptive impulses from the surgical wound with minimal pharmacological load on the patient's body.

The absence of metabolic effects on the parenchymal organs, myocardium, endocrine system of the patient’s body, which is important in oncology.

A unique opportunity to quickly wake up without pain and depression of breathing.

High controllability of anesthesia.

The proposed method operated on 20 patients, complications associated with anesthesia in the postoperative period was not observed.

Bibliography

1. RF patent No. 2102068, 1998.

2. RF patent No. 2195327, 2001.

Claims (1)

The method of anesthesia for extensive and highly traumatic surgical interventions in cancer patients by applying xenon anesthesia on a closed breathing circuit, characterized in that the anesthesia is performed at a ratio of xenon - oxygen mixture of 60-40%, and additionally 3-5 minutes before the start of the traumatic stage of the operation intravenously fentanyl is administered at a dose of 2-2.5 μg / kg or epidural anesthesia with napropine at a dose of 75 mg is performed before endotracheal anesthesia begins.