RU2372106C1 - Hypotensive anesthetic technique in hip joint surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns anaesthesiology, and can be used as an anaesthesia care in hip joint surgeries. It is ensured by spinal anaesthesia to block roots of spinal marrow. During the whole operation, adrenaline solution is constantly infused at rate that ensures systolic arterial pressure at the level 80-85 mm Hg.

EFFECT: invention allows reducing considerably intraoperative haemorrhage owing to maintaining optimum arterial pressure.

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Description

The present invention relates to medicine, and specifically to methods that cause changes in the state of consciousness, and relates to a method of regional anesthesia for operations on the hip joint.

Closest to the proposed technical solution is a method consisting in performing epidural anesthesia at the level of Th ₁₂ -L ₁ , L ₁ -L ₂ with reaching a high block to the level of Th ₄ and monitoring the level of blood pressure by constant intravenous administration of low doses of adrenaline, the infusion rate of which depends on the level of blood pressure (Sharrock NE Hypotensive epidural anesthesia for total hip arthroplasty: a review / NESharrock, EASalvati // Acta Orthop.Scand. - 1996; 67. - No. 1. - P.91-107).

However, the known method requires puncture of the epidural space with a needle of a sufficiently large diameter (18G, 0.8 mm), followed by the placement of a catheter in it and fractional injection of a large volume of local anesthetic through it (20-25 ml of a 0.5-0.75% solution of bupivacaine hydrochloride ) In addition, epidural anesthesia takes a long time to complete, blockade develops slowly, incomplete blockade is possible, or it may be mosaic. Epidural anesthesia can also be accompanied by a number of undesirable complications: back pain, severe and prolonged headache after unintentional puncture of the dura mater with a thick needle, vascular damage with the development of epidural hematoma, total spinal block, infectious complications, damage to nerves and spinal cord with the development of irreversible neurological deficit.

The objective of the invention is to reduce the morbidity of the central segmental blockade and the risk of infectious, toxic and neurological complications.

The problem is solved due to the fact that in a method that includes blockade of the roots of the spinal cord and maintaining the necessary level of blood pressure, spinal anesthesia is performed to block the roots.

The method is as follows. Before surgery, the patient is spinal anesthetized with a solution of bupivacaine hydrochloride at the level of L ₃ -L ₄ . After blockade and throughout the operation, an intravenous infusion of an adrenaline solution is carried out in a dilution of 1: 200000 (1 ml of 0.1% solution per 200 ml of physiological solution) with an initial speed of 24 ml of solution per hour (2 μg per minute). The rate of administration of adrenaline is selected depending on the level of blood pressure in such a way as to maintain systolic blood pressure at a level of 80-85 mm Hg, and the average at a level of 55-60 mm Hg. Infusion therapy during the operation is carried out with crystalloid solutions at an average speed of 6-8 ml / kg / h, depending on the rate of blood loss and under the control of central venous pressure, blood pressure, heart rate and minute urine output. At the end of the operation, at the stage of suturing the wound, the rate of infusion therapy is increased, the rate of adrenaline is reduced, ephedrine is administered if necessary, and after stabilization of the systolic blood pressure at 100-110 mm Hg adrenaline infusion is stopped.

Clinical examples

Patient B., 51, No. I.B. 209118.

Diagnosis: Right-sided dysplastic coxarthrosis 3st.

Operation: Total endoprosthetics of the right hip joint with the Protec prosthesis with installation on bone cement.

Anesthesia: The patient was taken to the operating table after premedication with blood pressure 140/90 mm Hg, heart rate - 76 per minute. The left cubital vein was catheterized with a 16 G catheter, intravenous sedation of 10 mg of Relanium, local anesthesia was punctured and catheterized with an internal jugular catheter 16 G, control of central venous pressure (CVP) - 7 cm water column. Monitoring: ECG, non-invasive monitoring of blood pressure (BP), heart rate (HR), respiratory rate (BH), oxygen saturation of the arterial blood (SpO ₂ ), CVP.

In the position on the left side at the level of L ₃ -L ₄ with a 25 G needle, a puncture of the subarachnoid space was performed, 3 ml of isobaric 0.5% bupivacaine hydrochloride was introduced (markain spinal, AstraZeneca, Sweden). The block has evolved to level Th ₄ .

After performing spinal anesthesia, an intravenous infusion of an adrenaline solution was started at a dilution of 1: 200000 at a rate of 25-50 ml per hour (2-4 μg / min) depending on the level of blood pressure. HELL during the operation was maintained at 80/55 mm Hg, heart rate - 64-67 per minute. The level of sedation during surgery is superficial, achieved by the intravenous administration of thiopental at a rate of 200-400 mg per hour. The respiratory rate is 16-18 per minute with oxygen supplied through the nasal catheter at a speed of 4-5 l per minute, SpO ₂ during surgery - 98-99%. The level of CVP during the operation is 6.5-8 cm of water.

The duration of the operation is 100 minutes, the volume of intraoperative blood loss was 150 ml. During the operation, 600 ml of physiological solution was transfused, while the surgical wound was sutured, the rate of infusion therapy was increased, another 500 ml of Ringer's solution was transfused, after which at a blood pressure level of 110/70 mm Hg administration of an adrenaline solution is discontinued. In total, 1100 ml of crystalloid was transfused during the operation, diuresis was 120 ml.

After surgery, the patient was transferred to the intensive care unit, 350 ml of blood loss through drainage in the first day. The level of hemoglobin in the postoperative period did not decrease less than 100 g / l, transfusion of donor blood or plasma in the postoperative period was not required.

Patient M., 31, No. I.B. 208771.

Diagnosis: Aseptic necrosis of the head of the left femur.

Operation: Total endoprosthetics of the right hip joint with the Protec prosthesis.

Anesthesia: The patient was taken to the operating table after premedication with blood pressure of 120/80 mm Hg, heart rate - 76 per minute. The right cubital vein was catheterized with a 16 G catheter, sedation 10 mg of Relanium intravenously. Under local anesthesia, a puncture and catheterization of the internal jugular vein by Seldinger was performed using a 16 G catheter, the level of CVP was 9 cm of water. Monitoring: ECG, non-invasive monitoring of blood pressure, heart rate, SpO ₂ , CVP.

In the position on the right side at the level of L ₃ -L ₄ with a 25 G needle, a puncture of the subarachnoid space was performed, 3.5 ml of isobaric 0.5% bupivacaine hydrochloride was introduced (marcain spinal, AstraZeneca, Sweden).

After performing spinal anesthesia, intravenous administration of an adrenaline solution in a dilution of 1: 200000 at a rate of 25-35 ml per hour (2-3 μg per minute), depending on the level of blood pressure, was started. Blood pressure during the operation was maintained at 78 / 45-82 / 45 mm Hg, heart rate - 66-68 per minute, SpO ₂ - 98-100%. The level of CVP during surgery is 6.5-10.5 cm water column.

Sedation during surgery is superficial, achieved by intravenous administration of diprivan at an individual target concentration.

The duration of the operation is 90 minutes. Blood from the wound was collected by suction for subsequent reinfusion (cell saver C.A.T.S., Fresenius). In total, 100 ml of blood was processed during the operation, 30 ml of autoerythrocyte mass were obtained. During the operation, 700 ml of physiological saline solution was poured. When suturing the surgical wound, the rate of infusion therapy was increased, another 900 ml of physiological saline was transfused. With a blood pressure level of 100/70 mm Hg adrenaline infusion discontinued. In total, 1600 ml of physiological saline was transfused during the operation, diuresis was 150 ml.

After surgery with blood pressure 110/70 mm Hg the patient was transferred to the intensive care unit. Blood collection and reinfusion was continued for 4 hours after the operation; a total of 170 ml of autoerythrocyte mass was returned to the patient. After stopping the collection of drainage blood, blood loss through the drains in the first day amounted to 80 ml. Postoperative red blood control - hemoglobin level did not decrease less than 100 g / l. Transfusion of donated blood or plasma in the postoperative period was not required.

The method of antihypertensive anesthesia during operations on the hip joint requires a minimum time for its implementation, it has a fast onset of action, good analgesic and muscle relaxant effect when using a small dose of local anesthetic for blockade. The method is simpler and safer, reduces the risk of infectious, toxic and neurological complications, reduces the likelihood of injuries of the epidural veins, since the diameter of the needle used is quite small.

Claims (1)

A method of hypotensive anesthesia for operations on the hip joint, which consists in blocking the roots of the spinal cord by spinal anesthesia and infusion of an adrenaline solution, characterized in that the infusion is carried out continuously throughout the operation by selecting the injection rate, ensuring the maintenance of systolic blood pressure at 80 -85 mmHg