RU2345773C2 - Minimal flow inhalational anesthesia method - Google Patents

Abstract

FIELD: medicine; traumatology and orthopaedics.

SUBSTANCE: minimal flow anaesthesia based on application of Sevoflurane and fast restoration recovery of vital functions within near-term postoperative period includes as followed. Minimal flow inhalation anaesthesia 0.5 l/min is based on application of Sevoflurane of MAC 0.5-1.0 in oxygen-air mixture. Anaesthesia is deepened with Suprastine premedication in dosage 0.25 mg/kg. 15 minutes prior to be induced to anaesthesia, Ringer's solution is intravenously injected in dosage 7-8 ml/kg. For initial narcosis, Atropine dosed 0.012 mg/kg and Fentanyl dosed 1.32 mkg/kg are used. Induction is represented with Propovan 1% introduction in dosage 2.6-3.2 mg/kg followed with Esmeron dosed 0.65 mg/kg. After myoplegia is ensued in 90 seconds, laryngoscopy and intubation of trachea follow. Myoplegia is maintained with infused Esmeron dosed 0.26-0.37 mg/kg/h. Artificial pulmonary ventilation is carried out through endotracheal tube in IPPV reverse-circuit mode with respiratory volume 7-8 ml/kg and respiratory minute volume 80-90 ml/kg, FiO₂=35-40% with controlled SpO₂ and EtCO₂. High-calcium lime is used as a sorbent. Spondylosyndesis operation in open pneumothorax at pneumothorax application stage implies infusion of balanced potassium magnesium aspartate in amount 3-3.5 ml/kg. 2 minutes prior to collaber lung is straightened, anaesthesia is deepened by Fentanyl introduction in dosage 1.25-1.5 mkg/kg. Additionally Ingitril 30 UNITS is introduced to the patients suffering from complicated spine injury.

EFFECT: managed adequate anaesthetic protection with minimal pharmacological effect on patient's homeostasis.

4 cl, 2 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 the homeostasis of the body.

Known methods of anesthetic protection:

I group. General anesthesia with the use of antipsychotics (NLA) and artificial lung ventilation (IVL), (Andrianov VL et al. Diseases and injuries of the spine in children and adolescents. - 1985. - L., "Medicine"). The above methods have several disadvantages:

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

- depletion of the reserves of adaptation of the patient;

- the development of complications from the cardiovascular system, respiration, homeostasis.

II group. General anesthesia with the use of NLA drugs in combination with ketamine in mechanical ventilation on the background of controlled arterial hypotension or without it (Menyailov N.V. Traumatology and orthopedics // Handbook of anesthesiology and intensive care. - Moscow. - 1982). 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 neuro-vegetative blockade.

III group. General anesthesia using inhaled anesthetics in combination with drugs for NLA and mechanical ventilation (Steven HR Anesthesia, positioning and postoperative pain management for spine surgery // In: Steven HR, Elliot BA, Horloker TT eds. The Adult Spine: Principles and Practice, 2 ^nd edition. Philadelphia / 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 gas anesthetics of the past generation;

- air pollution in the operating room during high-flow inhalation anesthesia;

- the very high cost of modern gas anesthetics, only when conducting high-flow inhalation anesthesia.

The above methods cannot be used for anesthetic protection at the stages of surgical correction of the spine, including the stage of expansion of a collapsed lung.

Closest to the claimed one is the method "Anesthetic support of operations of ventral spinal fusion in conditions of open pneumothorax for spinal fractures" (dissertation for the degree of candidate of medical sciences, A. Smorodnikov, Novosibirsk, 2004), developed at the Novosibirsk Scientific Research Institute of Traumatology and Orthopedics Ministry of Health of the Russian Federation.

10 minutes before induction in anesthesia, the patient is injected intravenously for 2 minutes with a solution of clonidine at a dose of 0.34-0.486 μg / kg and a continuous infusion of clonidine solution through a DShV-1 dispenser is started at a rate of 0.486 μg / kg / hour. Preparation for the induction of anesthesia ends with an intravenous infusion of an atropine solution in a dose that does not cause pronounced tachycardia (0.004 ± 0.02 mg / kg), then sodium thiopental (2.5-1% solution depending on the patient's age) is administered at a dose of 6.5 ± 0.5 mg / kg, fentanyl at a dose of 1.42 ± 0.01 μg / kg. After reaching a sufficient depth of drug sleep, arduan is administered at a dose of 0.12 mg / kg and after 4-5 minutes the trachea is intubated. The patient is laid in the necessary operating position.

Prevention of purulent postoperative complications is carried out by intravenous administration of cephalosporins of the 2nd and 3rd generation, in particular, aksetin at a dose of 750 mg before surgery and 750 mg after 2 hours.

Maintenance of anesthesia is carried out against a background of continuous infusion of clonidine solution, which ensures the maintenance of an effective concentration of the drug in the blood. The introduction of hypamine anesthetics of ketamine through DSA at a dose of 2.85 ± 0.04 mg / kg / h. Immediately before the skin incision, fentanyl is administered at a dose of 5-6 μg / kg, and then bolus every 20 minutes with fentanyl at a dose of 1.42 ± 0.01 μg / kg (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. Neurovegetative protection is achieved by the introduction of droperidol at a dose of 0.03 ± 0.005 mg / kg / h.

Mechanical ventilation is carried out with TITUS, EVITA-2-DURA, PO-6H devices, an oxygen-air mixture with 35% FiO ₂ . Norm ventilation with EtCO ₂ exhaled air 34-36 mm RT.art.

However, when using this method, it is necessary to prepare the patient. 10 minutes before induction into anesthesia, the patient is injected intravenously for 2 minutes with a solution of clonidine at a dose of 0.34-0.486 μg / kg and a continuous infusion of clonidine solution through a DShV-1 dispenser is started at a rate of 0.486 μg / kg / h. In patients with complicated spinal injury, an anesthesiological aid uses antikininogen ingitrile in a dose of 90 units. In addition, fentanyl at a dose of 6-7 μg / kg should be bolus administered 1.5-2 minutes before the collapsed lung is spread. The method provides protection against factors of surgical aggression at all stages of surgical intervention, however, it has several disadvantages:

- the use of "high doses" of the central analgesic of fentanyl, especially at the stage of expansion of the collapsed lung, leads to postoperative respiratory depression and requires mechanical ventilation;

- it is necessary to strictly observe the dose and rate of administration of the drugs used, while these drugs are not highly controlled;

- mechanical ventilation using high-flow anesthesia (5.8-8 l / min) leads to additional intraoperative cooling of the patient with an oxygen-air mixture;

- increased risk of microbial contamination of the respiratory tract of the patient and staff;

- the level of neurohumoral protection is insufficient to perform operations for traumatic injuries of the spine in adult patients.

Objective: to develop a method of anesthetic protection with minimal impact of the pharmacological load on the patient’s homeostasis during inhalation anesthesia with minimal gas flow based on sevoflurane.

In solving this problem, there is a positive therapeutic effect, which consists in the use of inhalation anesthesia with minimal gas flow and minimal impact on the patient’s homeostasis, a decrease in the pharmacological load on the patient, normalization of glycemia level, optimal oxygen utilization at all stages of the surgical intervention; vegetation stabilization at all stages of the surgical and immediate postoperative periods. In addition, psychoemotional stress in the perioperative period is excluded, the effect on the adaptive reserve of the body is minimal.

The proposed method allows you to:

- ensure the safety of operations of a high degree of anesthetic risk (ventral spinal fusion from transthoracic and thoracodiaphragmatic approaches, 2-stage surgical interventions on the ventral and dorsal spine, etc.);

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

- significantly reduce the pharmacological burden on the patient;

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

- eliminate the negative impact on the restoration of independent breathing through the endotracheal tube and the postoperative condition of the patient.

Additional benefits are that:

- inhalation anesthesia with minimal gas flow is highly controllable;

- Sevoflurane has a low gas / blood solubility, which ensures quick wake up of the patient;

- while working with minimal fresh gas flows, indicators of oxygenation, gas exchange, respiratory function and hemodynamics remain stable and do not go beyond the physiological norm;

- the use of only calcium lime as an sorbent excludes the formation of toxic metabolic products;

- the use of calcium lime leads to moistening and warming of the gas mixture, which improves the microclimate in the respiratory tract;

- minimized heat loss through the respiratory circuit, and therefore, reduced the patient's cost of heat load in the operating room;

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

- during inhalation anesthesia during the transition from high flows of fresh gas to low and minimal controllability and controllability of anesthesia does not decrease, since the dosages and concentrations of inhalation anesthetics can be accurately quantified.

In addition, the proposed method is simple to implement and can be used in specialized medical institutions. Its use is economically feasible due to a decrease in the pharmacological load on the patient, early recovery of consciousness and neuromuscular conduction with the possibility of rapid extubation of the patient, a decrease in the burden on medical personnel and the frequency of postoperative complications, followed by a reduction in bed days.

The technical result is achieved due to the fact that inhalation anesthesia is used with a minimum gas flow based on a halogen-containing anesthetic sevoflurane, which can significantly reduce the pharmacological load on the patient’s homeostasis, and synergism with a central analgesic fentanyl and non-depolarizing muscle relaxant, Esmeron, reduces the use of surgical induction as a sorbent only calcium lime eliminates the formation of toxic metabolic products.

The problem is solved due to the fact that sedation with suprastin at a dose of 0.25 mg / kg is carried out, 15 minutes before induction, Ringer's solution of 7-8 ml / kg is administered intravenously, atropine is 0.012 mg / kg and fentanyl 1.32 μg / kg, then 1% propovine is introduced at a dose of 2.6-3.2 mg / kg, then esmeron is administered at a dose of 0.65 mg / kg, after adequate myoplegia occurs, laryngoscopy and tracheal intubation are performed after 90 s, an artificial trachea is carried out through the endotracheal tube lung ventilation in IPPV mode along the reverse circuit with a tidal volume of 7-8 ml / kg and minute bemsya breathing 80-90 ml / kg, FiO ₂ = 35-40% under the control of SpO ₂ and EtCO ₂ are used as a sorbent calcium lime, provide maintenance of anesthesia by inhalation anesthesia with minimal gazotokom 0.5 liters / min based on the sevoflurane with a minimum alveolar concentration of 0.5-1.0 in the oxygen-air mixture, myoplegia is supported by infusion of esmeron at a dose of 0.26-0.37 mg / kg / h; during the operation of ventral fusion in conditions of open pneumothorax at the stage of elimination of artificial pneumothorax, infusion of a solution of potassium-magnesium-asparaginate in the volume of 3-3.5 ml / kg is started, if the operation involves the expansion of a collapsed lung, then anesthesia is deepened 2 minutes before it is expanded fentanyl at a dose of 1.25-1.5 mcg / kg, if the operation is performed for patients with complicated spinal injury, an additional 30 units of ingitrile is administered.

The method is as follows: in the ward 30 minutes before the operation is premedication. Intramuscular administration of suprastin at a dose of 0.25 mg / kg of the patient’s body weight is used in the premedication regimen. The patient is transported to the operating room. Initially, the system is installed on the operating table into the peripheral vein through a catheter for infusion-transfusion therapy, and with a high degree of operational-anesthetic risk, the subclavian vein is punctured on the access side.

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) with the calculation of heart rate, non-invasive measurement of the values of ADsyst., ADdiast., ADsr. (with an interval of 5 min), SpO ₂ and registration EtCO ₂ - monitor «Cardiocap-II» (Datex - Finland); P _peak (peak pressure), C (compliance - lung tissue extensibility), FiO ₂ (oxygen by inhalation) and EtO ₂ (oxygen by exhalation), LO ₂ (utilization rate) in%, FiSevo (sevoflurane by inhalation) and EtSevo ( expiratory sevoflurane), MAK (minimal alveolar concentration) - with the Cardiocap-ULTIMA monitor (Datex, Finland). Determine pH, Hb, Ht, pO ₂ , pCO ₂ , sO ₂ , tCO ₂ , HCO ₃ ^- , ABE, SBC, SBE - gas analyzer "Radiometer ABL-5"(Denmark); levels of potassium, blood glucose, cortisol - with the analyzer "Electrolyte Analyzer AVL-9180" (Austria). Hemoglobin level, the number of red blood cells, white blood cells, platelets, color index, hematocrit - hematological analyzer Sysmeh KH-21N (Japan). Control of neuromuscular conduction with the TOF-WATCH apparatus (Netherlands). As the sorbent used calcium lime (Intersugical).

An abbreviated monitoring option includes non-invasive measurement of the levels of ADsyst., ADdiast., ADsr. with an interval of 5 minutes, registration of heart rate, SpO ₂ , EtCO ₂ (sampling the gas mixture every 15 minutes to reduce operating room contamination and leakage from the circuit), P _peak , FiO ₂ . The content of white blood cells in the blood.

Induction: 15 minutes before induction, a ring solution of 7-8 ml / kg is administered intravenously, then an intravenous infusion of atropine solution in a dose that does not cause pronounced tachycardia (0.012 mg / kg), then 1% at a dose of 2.75 ± 0.25 mg / kg, fentanyl at a dose of 1.32 mcg / kg. Mask ventilation of the patient is carried out with an oxygen-air mixture with FiO ₂ = 60%. After reaching a sufficient depth of drug sleep, Esmeron is administered at a dose of 0.65 mg / kg, after adequate myoplegia occurs, laryngoscopy and tracheal intubation are performed after 90 s. The patient is laid in the necessary operating position.

Prevention of purulent postoperative complications is carried out by the intravenous administration of antibacterial drugs (cephalosporins of the 2nd and 3rd generation, fluoroquinolones in the appropriate dosage, etc.).

Maintenance of anesthesia is ensured by the use of inhalation anesthesia with a minimum gas flow of 0.5 l / min in an oxygen-air mixture based on sevoflurane to maintain an effective concentration of the drug in the blood with MAK at a level of 0.5-1.0 (with an average flow rate of 5.2 ml / h). Immediately before the skin incision, fentanyl at a dose of 3.0-3.6 μg / kg, and then bolus every 25 minutes with fentanyl at a dose of 1.33 ± 0.03 μg / kg / h (in case of somatic diseases, dose adjustment is 15- twenty%). The state of total myoplegia is supported by Esmeron at a dose of 0.26-0.37 mg / kg / h. At the main stage of surgical intervention, in conditions of hyperextension, additional medical correction is not required.

At the stage of elimination of artificial pneumothorax (layer-by-layer suturing of the surgical wound) at the time of installation of thoracic drainage 4-6 minutes before spreading the collapsed lung, the flow of sevoflurane is turned off, while the ventilator works along a reverse circuit with a flow of oxygen-air mixture of 0.5 l / min and with FiO ₂ = 40%.

During rehabilitation of the thoracic cavity with physiological saline at 37 ° C (1.5-2 minutes before spreading of the collapsed lung on the access side), a bolus of fentanyl is administered at a dose of 0.75-1.33 μg / kg. The collapse of the collapsed lung is carried out with an oxygen-air mixture with FiO ₂ = 50% and a stream of oxygen-air mixture of 6 l / min when the ventilator is turned off. Further, the flow of the oxygen-air mixture is reduced to 0.5 l / min and ventilation is continued on the reverse circuit with sevoflurane with the same parameters. Prior to suturing the subcutaneous adipose tissue, the administration of muscle relaxant is stopped (on average for 15-20 minutes), before the end of the surgical procedure (for 10 minutes), the flow of inhalation anesthetic is switched off, while the gas flow is preserved. 5 minutes before the end of the intervention, the patient is transferred to ventilation with a high gas flow (6-8 l / min) FiO ₂ = 30%.

Mechanical ventilation is carried out using the Fabius apparatus (electric compressor, Drager) with a tidal volume (DO) = 7-8 ml / kg and a minute breathing volume (MOD) = 80-90 ml / kg, inspiratory concentration FiO ₂ = 35-40 %, EtCO ₂ support at 35 ± 1 mm RT.article

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, mainly Ringer (15-20 ml / kg, the next day 10-15 ml / kg) and colloids (Reftan 6% in a volume of 5-7 ml / kg ) When blood loss exceeds 10 ml / kg, BCC correction is carried out using FFP. In the postoperative period (with blood loss of more than 10%), an infusion of a solution of crystalline amino acids - “Infezol-40” is carried out in a volume of 4.5-6.5 ml / kg The volume of infusion therapy averages 10.0 ml / kg / h and as a result exceeds the total blood loss by 100-200%. When blood loss exceeds 20% of BCC, blood transfusion is performed using erythrocyte mass in a volume of up to 50% of the lost erythrocyte volume and plasma transfusion using FFP in an amount of 50-90% of the plasma loss volume. The adequacy of infusion therapy is evaluated on the basis of registration of hemodynamic parameters, blood cells, hemoglobin, potassium, glucose, albumin, hematocrit, leukocytosis and hourly urine output.

After the operation is completed, the patient is transferred to the intensive care unit, accompanied by an anesthesiology team in spontaneous breathing, they monitor and, if necessary, correct the volemic changes and the qualitative composition of the blood.

Example No. 1 clinical use of the method.

Patient B., born in 1978 (28 years old), was admitted to the clinic of traumatology and orthopedics with a diagnosis of Closed uncomplicated stable incomplete explosive fracture of the L1 body. Post-traumatic kyphosis 23 °.

Given the diagnosis at admission, the patient was scheduled to perform the operation: Ventral corrective monosegmental spinal fusion D12-L1 with an endofixer with autografts from the resected rib and vertebral body.

When examining and collecting the anamnesis, the patient revealed the concomitant diseases: Chronic catarrhal bronchitis (smoker), concussion, an extensive scalped wound of the frontoparietal region. There were no allergic reactions to drugs. The patient's body weight is 51 kg. Blood pressure (BP) 110/60 mm Hg On an ECG: unsharp changes in the myocardium. It is reasonable to conduct inhalation anesthesia based on sevoflurane in mechanical ventilation through an endotracheal tube. Anesthetic risk according to ASA (American Sosiety of Anesthesiologi) I degree. Risk classification Mallampati I degree.

The patient received the following anesthetic benefit:

The first stage is premedication 20 minutes before surgery, a solution of suprastin 20 mg intramuscularly.

The following monitoring was carried out in the operating room: ECG, heart rate, non-invasive measurement of ADsyst., ADdiast., ADsr., SpO ₂ , EtCO ₂ , rate of urine output. Laboratory diagnostics: analyzes of the level of cortisol, potassium, glucose, lactate and pyruvate, the level of blood leukocytes initially, intraoperatively every 30 minutes, at the main stage and 1 per day. Respiratory monitoring P _peak C (compliance), FiO ₂ and EtO ₂ , LO ₂ %, FiSevo and EtSevo, MAK.

HELL at admission of the patient to the operating room 107/65 mm Hg, blood pressure 79 mm Hg, heart rate 72 beats. in minutes Before introductory anesthesia, pre-infusion with Ringer crystalloid solution was carried out in a volume of 7 ml / kg and 2000 mg of cefotaxime antibiotic was administered.

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% - 0.012 mg / kg was administered, for anesthesia with laryngoscopy and intubation, a solution of fentanyl 1.32 μg / kg was administered.

Induction was carried out by the administration of 1% 2.96 mg / kg propovan. Upon achieving sufficient sedation, the administration of esmerone 0.65 mg was carried out, continued mechanical ventilation through the facial mask under the control of SpO ₂ and EtCO ₂ . After the onset of adequate myoplegia, laryngoscopy and tracheal intubation were performed after 80 s, mechanical ventilation was started through the endotracheal tube with DO = 8 ml / kg and MOD = 90 ml / kg, FiO ₂ = 40% under the control of SpO ₂ and EtCO ₂ .

The flow of the oxygen-air mixture was reduced to 2 l / min and the low-flow mechanical ventilation was continued along the reverse circuit with the supply of sevoflurane 3 vol.% (MAK 0.6) for 4 min, after which the flow of the oxygen-air mixture was reduced to 0.5 l / min

Further sedation and myoplegia were intraoperatively achieved by anesthesia with sevoflurane with MAK 0.8-0.6 (2.5-1.5 vol.%), In an oxygen-air mixture with FiO ₂ = 38% and a minimum gas flow of 0.5 l / min, maintenance of myoplegia was carried out by continuous infusion of esmeron at a dose of 0.36 mg / kg / h, anesthesia with fentanyl at a rate of 2.8 μg / kg / h.

The surgical team installed thoracic drainage. During sanitation of the thoracic cavity with physiological saline at 37 ° C (2 minutes before the collapsed lung was spread on the access side), fentanyl was administered at a dose of 1.5 μg / kg bolus, the flow of sevoflurane was stopped, and anesthesia with an oxygen-air mixture (0.5 l / min) was continued. The collapsed lung was straightened with an exhalation bag (in the apparatus circuit) with an oxygen-air mixture with FiO ₂ = 40% with a flow of 7 l / min when the ventilator was turned off. Then, the flow of the oxygen-air mixture was reduced to 2 l / min and the low-flow mechanical ventilation was continued along the reverse circuit when feeding sevoflurane in 2 vol.% (MAK 0.7) for 3 min, after which the flow of the oxygen-air mixture was reduced to 0.5 l / min Esmeron infusion discontinued in 23 minutes. Layer wound closure. At the stage of suturing of subcutaneous fat, 8 min before the end of the intervention, the supply of sevoflurane to the circuit was stopped, mechanical ventilation with a flow of 0.5 l / min. When applying a “suture to the skin”, mechanical ventilation in the normal ventilation mode on a half-open (non-reversible) circuit with an oxygen-air mixture with FiO ₂ = 33% and a flow of 4.6 l / min.

At the stages of the surgical intervention, hemodynamic parameters were stable. Blood pressure ranged from 101/60 to 90/59 mm Hg, heart rate 72-84 beats / min, SpO ₂ 99-100%, EtCO ₂ 35 mm Hg. The total volume of infusion therapy in the intraoperative period was 1,500 ml of crystalloids, colloids (at the main stage of the surgical procedure, before the hyperextension, an infusion of Reftana-6% solution was carried out) in a volume of 350 ml. Intraoperative blood loss was 150 ml.

The intraoperative flow rate of sevoflurane was 4.1 ml / h, i.e. 141.5 rubles per 1 hour of anesthesiology benefits.

The duration of the operation of ventral spinal fusion was 2 hours, anesthetic benefits 2 hours 30 minutes.

Restored spontaneous breathing through the endotracheal tube after 20 seconds after surgery. After 5 minutes, against the background of restoration of consciousness and neuromuscular conduction, the patient was extubated. Monitoring of vital functions was carried out for 5 minutes, and then, accompanied by an anesthesiology team, the patient was transferred for observation to the intensive care unit and intensive care unit. 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 6.8% higher than the initial one, and a 1.5% decrease at the stage of expansion of the collapsed lung. The glycemia level is initially 5.0 mmol / L, at the stage of expansion of the collapsed lung 6.1 mmol / L. The initial level of leukocytosis is 15.9 * 10 ⁹ / l (2 days before the operation), after a skin incision, a decrease in leukocytosis to the level of 5.3 * 10 ⁹ / l, at the main stage of the surgical procedure 4.8 * 10 ⁹ / l. The ratio of pO ₂ / FiO ₂ = 210-290 mm Hg Oxygen utilization (LO ₂ ) averaged 10.87% (fluctuations from 9.1 to 12.7%), which is 60.1% higher than with similar interventions and the use of high-flux anesthesia in conditions of TBA with mechanical ventilation.

Example No. 2 clinical use of the method.

Patient Sh., Born in 1940 (66 years old), was admitted to the clinic of traumatology and orthopedics with a diagnosis of Closed, uncomplicated compression wedge-shaped penetrating fractures of D6-7 vertebrae, fracture of the spinous process of the D6 vertebra, fracture of the apices of the right superior articular process of D7, left upper articular processes D6-7. Fracture of the articular joints of the arches D6-7 on the left. Fracture of the sternal end of the right clavicle with a displacement of the lateral fragment. Multiple degenerative lesions of the cervicothoracic spine.

Given the diagnosis at admission, the patient was scheduled to undergo surgery in 2 stages: 1. Posterior internal fixation at the level of D4, 5, 8, 9 vertebrae with adapted NIIITO instruments. 2. Spoke-loop osteosynthesis of fragments of the sternal end of the right clavicle.

When examining and collecting the anamnesis, the patient revealed concomitant diseases: Bronchial asthma, endogenous, moderate, remission, respiratory failure 0-I. Peptic ulcer, remission? Cerebral atherosclerosis, dyscirculatory encephalopathy I. Coronary heart disease. Diverticulosis of the large intestine. Chronic hemorrhoids. Allergic history: reaction in the form of urticaria to sulvanamides. Body weight 76 kg. Blood pressure (BP) 110/70 mm Hg On an ECG: violation of intraventricular conduction on the right leg of the bundle of His, signs of left ventricular hypertrophy. It is reasonable to conduct inhalation anesthesia based on sevoflurane in mechanical ventilation through an endotracheal tube. Anesthetic risk according to ASA (American Society of Anesthesiology) III degree. Risk classification Mallampati II degree.

The patient received the following anesthetic benefit:

The first stage is premedication 20 minutes before surgery with a solution of suprastin - 0.25 mg / kg intramuscularly.

The following monitoring was carried out in the operating room: ECG, heart rate, non-invasive measurement of ADsyst., AD diast., ADsr., SpO ₂ , EtCO ₂ , rate of urine output. Laboratory diagnostics: analyzes of the level of cortisol, potassium, glucose, lactate and pyruvate, the level of blood leukocytes initially, intraoperatively every 30 minutes, at the main stage and 1 per day. Respiratory monitoring P _peak , C (compliance), FiO ₂ and EtO ₂ , LO ₂ %, FiSevo and EtSevo, IAC.

HELL at admission of the patient to the operating room 139/85 mm Hg Heart rate 60 beats / min. Before introductory anesthesia, pre-infusion was performed with Ringer crystalloid solution in a volume of 8 ml / kg and the administration of 2000 mg cefotaxime antibiotic.

The second stage is tracheal intubation, sedation and myoplegia. The patient was flipped and laid on the stomach with rollers under the chest and lower legs.

Induction anesthesia: in order to prevent excessive vagal effect on the myocardium, a solution of atropine 0.1% - 0.012 mg / kg was administered, for anesthesia with laryngoscopy and intubation - a solution of fentanyl 1.32 μg / kg.

Induction was carried out by the administration of 1% - 2.63 mg / kg. Upon achievement of sufficient sedation, the administration of esmerone 0.65 mg was carried out, continued mechanical ventilation through the facial mask under the control of SpO ₂ and EtCO ₂ . After adequate myoplegia occurred, laryngoscopy and tracheal intubation were performed after 90 s, mechanical ventilation was started through the endotracheal tube with DO = 7.8 ml / kg and MOD = 90 ml / kg, FiO ₂ = 40% under control of SpO ₂ and EtCO ₂ .

The flow of the oxygen-air mixture was reduced to 2 l / min and the low-flow mechanical ventilation was continued along the reverse circuit with the supply of sevoflurane 2.5 vol.% (MAK 0.5) for 3 min, after which the flow of the oxygen-air mixture was reduced to 0.5 l / min

Further sedation and myoplegia were intraoperatively achieved by anesthesia with sevoflurane with MAK 0.8-0.5 (2.2-1.5 vol.%), In an oxygen-air mixture with FiO ₂ = 40% with a minimum gas flow of 0.5 l / min, maintenance of myoplegia was carried out by continuous infusion of esmeron at a dose of 0.34 mg / kg / h, anesthesia with fentanyl at a rate of 2.8 μg / kg / h.

The surgical team installed the design on the dorsal spine. Remediation and installation of drains, layered wound closure. X-ray control. The patient is turned upside down and laid on his back, with rollers under the right scapular and gluteal region. Osteosynthesis was performed. Esmeron infusion discontinued in 15 minutes. Seams in layers. At the stage of suturing of subcutaneous fat, 10 minutes before the end of the intervention, the flow of sevoflurane, mechanical ventilation with a flow of 0.5 l / min was stopped. When applying a “suture to the skin”, mechanical ventilation in the normal ventilation mode on a half-open (non-reversible) circuit with an oxygen-air mixture with FiO ₂ = 35% and a flow of 6 l / min. X-ray control and plaster cast.

At the stages of the surgical intervention, hemodynamic parameters were stable. Blood pressure ranged from 111 / 67-100 / 68 mm Hg, heart rate 60-70 beats / min, SpO ₂ 99-100%, EtCO ₂ 33 mm Hg The total volume of infusion therapy in the intraoperative period was 2500 ml of crystalloids, colloids (Reftana 6%) in a volume of 500 ml. Intraoperative blood loss was 450 ml. Diuresis 600 ml (100 ml / h).

The intraoperative flow rate of sevoflurane was 4.9 ml / h, i.e. 169 rubles for 1 hour of anesthesiology benefits.

The duration of the two-stage surgical intervention was 4 hours, anesthesiology benefits 5 hours 30 minutes.

At the end of the intervention, after 5 minutes, spontaneous respiration through the endotracheal tube was restored. For 15 minutes (X-ray and casting), vital functions were monitored, and the patient was transferred to the intensive care unit and intensive care unit, accompanied by an anesthesiology team. 20 minutes after surgery, against the background of restoration of consciousness and neuromuscular conduction, the patient was extubated. 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 15% higher than the initial one. The glycemia level was initially - 4.6 mmol / L; in the main stage, 6.0 mmol / L. There was no significant change in the level of leukocytosis and averaged 7.35 * 10 ⁹ / L. The ratio of pO ₂ / FiO ₂ = 205-275 mm Hg Oxygen utilization (LO ₂ ) averaged 7.2% (fluctuations from 7.3 to 8.7%), which is 30.5% higher than with similar interventions and the use of high-flow anesthesia in conditions of TBA with mechanical ventilation.

Thus, the use of inhalation anesthesia with minimal gas flow based on sevoflurane allowed us to ensure a safe course of the intraoperative and immediate postoperative periods, reduce the pharmacological load on the patient, eliminate possible hemodynamic disturbances, and achieve a quick exit from anesthesia with minimal impact on the body's homeostasis.

Claims (4)

1. A method of inhalation anesthesia with minimal gas flow during surgical correction of the spine by affecting the patient’s homeostasis, characterized in that they are premedicated with suprastin at a dose of 0.25 mg / kg, Ringer's solution of 7-8 ml / kg is administered intravenously 15 minutes before induction, induction is carried out with atropine at a dose of 0.012 mg / kg, fentanyl at a dose of 1.32 μg / kg, then 1% propovine is administered at a dose of 2.6-3.2 mg / kg, then esmeron is administered at a dose of 0.65 mg / kg, after the onset of adequate myoplegia, laryngoscopy and intubation of the trachea are performed after 90 s, through endotracheal th tube artificial lung ventilation is carried out in IPPV mode by reversing circuit with a tidal volume of 7-8 mL / kg and the respiratory minute 80-90 ml / kg, FiO ₂ = 35-40% under the control of SpO ₂ and EtCO ₂ as a sorbent use calcium lime, maintain anesthesia by inhalation anesthesia with a minimum gas flow of 0.5 l / min based on sevoflurane with a minimum alveolar concentration of 0.5-1.0 in an oxygen-air mixture, myoplegia is supported by infusion of esmeron at a dose of 0.26-0 , 37 mg / kg / h. 2. The method according to claim 1, characterized in that when performing the operation of ventral fusion in conditions of open pneumothorax at the stage of elimination of artificial pneumothorax, infusion of a solution of potassium-magnesium-asparaginate in a volume of 3-3.5 ml / kg is started. 3. The method according to claim 1, characterized in that if the operation involves expansion of the collapsed lung, then 2 minutes before the collapse of the collapsed lung, anesthesia is deepened by the administration of fentanyl at a dose of 1.25-1.5 μg / kg. 4. The method according to claim 1, characterized in that, if the operation is performed for patients with complicated spinal injury, then additionally injected with a dose of 30 units.