RU2436603C1 - Method of anaesthesia care of operative delivery in women with severe gestosis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to anaesthesiology, and can be used as an anaesthesia care if a surgical delivery in women with severe gestosis is required. For this purpose, at the stage of preanesthetic medication, one of the components is cytoflavin 10 ml dissolved in physiologic saline 200 ml intravenously drop-by-drop for 5 minutes. It is followed by spinal anaesthesia by intrathecal introduction of Marcaine-spinal. After neuroaxial block developed and blood circulation stabilised at average blood pressure reduction by 20 % and less, magnesium sulphate 60 mg/kg is administered intravenously for 15 minutes. Then the operative intervention follows. ^ EFFECT: method allows providing adequate anaesthesia, with prevented potential CNS ischemia and lower development rate and intensity of postoperative arterial hypertension due to the effect on cellular structure metabolism. ^ 6 tbl, 2 ex

Description

The invention relates to medicine, namely to obstetrics and anesthesiology, and will find use as an anesthetic aid for surgical delivery in pregnant women with severe gestosis.

Gestosis is one of the most severe and common complications of pregnancy, it occupies the 3rd place among the causes of maternal mortality - 20-25%, which is 3-4 times higher than in healthy pregnant women (Repina M.A. Preeclampsia and maternal mortality. - St. Petersburg ., 2005. - 208 p.).

The progression of gestosis to a severe degree is accompanied by the activation of lipid peroxidation and a systemic inflammatory reaction, the development of generalized damage to endotheliocytes and increased arteriolospasm. These processes contribute to the violation of cerebrovascular autoregulation, with hypoxic-ischemic damage to the central nervous system. It should be noted that the degree of cerebral hemodynamic disorders and hypoxic-ischemic brain damage is directly proportional to the severity of gestosis (Khapiy Kh. Kh. On the mechanism of seizures in severe forms of gestosis. - Bulletin of intensive care. - 2005. - No. 5. - C .73-74).

A currently recognized option for reducing both maternal and perinatal mortality in severe gestosis is cesarean section.

Anesthesiological aid for surgical delivery of pregnant women with severe gestosis should be aimed not only at blocking nociceptive impulses, but also at preventing hypoxic-ischemic damage to the brain, as well as compensating for the bioenergetic needs of body cells.

An analysis of numerous domestic and foreign scientific and medical literature on the perioperative period and the prevention of brain damage in women with severe gestosis showed that many questions remain poorly understood and controversial. In particular, in such a situation, neuroprotective therapy is not sufficiently developed and far from the optimal solution, and the assessment of the effectiveness of using magnesium sulfate for this purpose is contradictory.

Conducted research on the medical-scientific and patent literature has revealed various methods of anesthetic management for surgical delivery and surgical interventions on the abdominal organs.

The well-known "Method of anesthesia for cesarean section" (RF patent No. 2111770, 1998.05.27), including induction of anesthesia, as well as the use of fentanyl and diazepam in reduced doses at the stage of postnatal anesthesia against the background of iv administration of tranexamic acid at a dose of 10-11 mg / kg The disadvantage of this method is the high anesthetic risk associated with hemodynamic instability in women in labor with gestosis, as well as a possible drug depression of the fetus.

The well-known "Method of birth management in patients suffering from bronchial asthma" (RF patent No. 2183974, 2003.11.20), including catheterization of the epidural space at the level of L2-L4 and fractional introduction of a 2% solution of lidocaine, characterized in that for 1-1 5 hours before delivery, an additional epidural block is performed with a catheter in the cranial direction at the level of Th6-Th8 with the introduction of a 0.125% solution of marcaine in 4-8 ml once during childbirth and delivery through the natural birth canal with epidural anesthesia at the level of L2- L4 2% Rust Oromo lidocaine during labor. However, this method does not provide for the prevention of hypoxic-ischemic brain damage in women with severe gestosis during surgical delivery.

The well-known "Method of spinal anesthesia according to N.A. Urakova" (RF patent No. 2192789, 11/20/2002.), Which can be used for pain relief during operations on the pelvic organs and abdominal cavity during obstetric care. The application of local anesthetic and ephedrine hydrochloride intrathecal is described. However, the use of ephedrine hydrochloride is contraindicated in arterial hypertension and late gestosis, because may cause an uncontrolled hypertensive reaction.

Describes the "Method of pain relief during obstetric care" (RF patent No. 2203654, 2003.05.10.), The essence of which is that drugs are introduced first into the subarachnoid space, and then into the epidural space in a total dose: clonidine 50-100 μg, fentanyl 100-200 mcg and lidocaine 40-120 mg. However, this method does not provide prophylaxis for hypoxic-ischemic brain damage in women with severe gestosis, and drug-induced depression of the fetus is also possible.

The well-known "Method of anesthesia during surgical interventions" (RF patent No. 2228192, 05/10/2004), including premedication, induction anesthesia and maintenance of anesthesia, characterized in that epithalamine is used as a component of sedation and maintenance of anesthesia, moreover, it is used as a component of sedation epithalamin is administered by the first drug intravenously at a dose of 0.20-0.25 mg / kg in 20.0 ml of 5% glucose solution, introductory anesthesia is performed 5-10 minutes after the end of sedation, as a component of maintaining anes ezii Epithalamin diluted in 5% glucose solution and drip infusion is administered during the entire surgical intervention at a dose of 0.05-0.10 mg / kg / hr. However, epithalamin is not currently being produced. It should be noted that epithalamin did not exhibit a clinically significant neuroprotective effect.

The well-known "Method of epidural anesthesia at the lumbar level of the spine" (2309773, 10.11.2007), including the introduction of local anesthetic, control of central hemodynamics and repeated administration of local anesthetic, characterized in that before the anesthesia and during epidural anesthesia, the amplitude of the pulsation is additionally determined microvessels of the hand and after reaching the amplitude value of the pulsation of the microvessels of the hand, approximately equal to or greater than the value of the specified amplitude, before olives re-administer the local anesthetic. However, this method does not provide for the prevention of hypoxic-ischemic brain damage in women with severe gestosis during surgical delivery.

The prototype of the invention, we have chosen "The method of anesthetic administration for the surgical delivery of pregnant women with moderate gestosis" (2286793, 04/10/2006). The essence of the prototype is that they perform conventional cerebrospinal anesthesia and additionally, after administration of marcain-spinal, intravenous administration of dexamethasone is carried out - 8 mg, and after the development of the regional block, an intravenous infusion of dalargin 40-50 μg / kgh is carried out, which is continued throughout during surgery.

The disadvantages of the prototype include the fact that in women with severe preeclampsia, such an anesthetic does not prevent the prophylaxis of hypoxic-ischemic brain damage, while for a long period after the operation, circulatory disorders (arteriolospasm and hypokinetic type of blood circulation) and arterial hypertension are preserved. This situation reflects the complicated course of the postoperative period and requires additional medical correction.

These disadvantages are eliminated in the claimed invention.

The task of the invention is the prevention of central nervous system damage in women with severe gestosis with surgical delivery and reducing the frequency and severity of arterial hypertension in the postoperative period.

The problem is solved by the use of cytoflavin - 10 ml in a dilution of 200 ml of physiological solution for 5 minutes in premedication. Then, spinal anesthesia is performed by intrathecal administration of marcaine-spinal, after the development of neuroaxial blockade (spinal anesthesia) and stabilization of hemodynamics (decrease in mean blood pressure not more than 20%), intravenous administration of magnesium sulfate at a dose of 60 mg / kg for 15 minutes is performed and the operation is performed.

A positive technical result of the application of the claimed method is a decrease in the frequency of the complicated course of the postoperative period in women with severe gestosis.

The following data served as the prerequisites for using the distinguishing features of the invention that we claimed.

Caesarean section on the background of severe gestosis causes pronounced endocrine, inflammatory and metabolic changes, activation of lipid peroxidation and systemic inflammatory response, while amplified discirculatory disorders and hypoxic-ischemic brain damage (Zhenilo V.M. Effect of operational stress on the level of neuron-specific enolases in women with preeclampsia - Collection of materials of the XI Congress of the Federation of Anesthesiologists and Resuscitators - St. Petersburg, 2008. - P.238-239). In such a situation, the frequency of intra- and postoperative complications increases (D. Elyutin. Perioperative period with gestosis: abstract of thesis: doctor of medical sciences. - Saratov, 2001. - 36 p.).

It is generally recognized that maternal arterial hypertension in gestosis is partly a compensatory reaction aimed at redistributing blood flow, increasing perfusion pressure in the placenta and, thus, eliminating oxygen and substrate debt to the fetus (Sadchikov D.V. Gestoz. - Saratov, 1999. - 228 p.). The development of arteriolospasm in pregnant women with gestosis occurs due to the restructuring of the hypothalamic centers of neurohumoral regulation of blood circulation. The new level of functioning that has formed in women with severe gestosis is characterized by a certain inertia, because against the background of selective damage to neurons and synapses caused by exposure to hypoxia, free radical and inflammatory factors of gestosis and surgical trauma, the restructuring of interneuronal relations occurs, which contributes to the development of persistent pathological changes in hypothalamic regulation of blood circulation. As a result, normalization of blood circulation is delayed in the postpartum period and arterial hypertension persists for a long period (Shapovalov OE. The reaction of hemodynamics and water sectors of the body during surgical delivery of women with gestosis. - Materials of the IV All-Russian Interdisciplinary Scientific and Practical Conference "Critical Conditions in Obstetrics and Neonatology" . - SPb., 2006. - S.769-777).

Thus, hypoxic (discirculatory) factors of surgical trauma and gestosis cause the progression of structural and functional disorders of the brain. As a result, for a long time after surgical delivery in women with severe gestosis, generalized arteriolospasm, hypokinetic blood circulation and arterial hypertension persist, the risk of chronic disorders and the development of hypertension increases, often leading to disability (Simakov I.V. Women's health after suffering preeclampsia: abstract of thesis: Candidate of Medical Sciences. - M., 2004. - 24 p.).

Cytoflavin is a balanced complex of two metabolites (succinic acid, riboxin) and two coenzymes of vitamins (riboflavin mononucleotide - vitamin B ₂ , nicotinamide - vitamin PP). All cytoflavin components are natural metabolites of the body, which are utilized by cellular structures and participate in redox reactions, reduce the production of free radicals and restore the activity of antioxidant defense enzymes. Cytoflavin has a positive effect on the processes of energy production in the cell under hypoxia, activates the compensatory metabolic processes of ATP formation, alternative to the NADH-oxidase oxidation pathway, which leads to the normalization of metabolic processes in the body. Cytoflavin improves microcirculation and cerebral blood flow, stimulates metabolic processes in the central nervous system and modulates the processes of oxygen and glucose utilization in tissues, activates intracellular protein synthesis and promotes the resynthesis of γ-aminobutyric acid in neurons. Cytoflavin has antihypoxic and antioxidant activity, which is determined by the pharmacological mutually potentiating properties of its constituent components. The introduction of cytoflavin is indicated for discirculatory (vascular) and hypoxic encephalopathy, it can be used intravenously during pregnancy (Instructions for the manufacturer NTFF Polisan LLC “Instructions for the medical use of the drug cytoflavin”, reg. No. 003135/01 of November 20, 2008).

Magnesium sulfate has a hypotensive, vasodilating, anticonvulsant, sedative and neuroprotective effect, in large doses inhibits neuromuscular transmission and relaxes smooth muscles. Magnesium sulfate improves cerebral blood flow in women with severe gestosis. Magnesium is a physiological calcium antagonist and is able to displace it from binding sites. The neuroprotective effect of magnesium ions is associated with the non-competitive blockade of NMDA receptors, which leads to the closure of calcium channels and prevents the entry of calcium into the neuron. It should be noted that free intracellular calcium is toxic to the neuron and leads to a series of neurochemical reactions, mitochondrial dysfunction, increased hypoergosis, impaired ion pump activity, membrane depolarization and subsequent cell death. The use of magnesium sulfate is indicated for encephalopathy, arterial hypertension, to prevent seizures with gestosis and eclampsia (Instructions for the manufacturer of JSC “Biosynthesis” “Instructions for the medical use of the preparation of magnesium sulfate”, reg. No. 001547/01 of 07/22/2008). The administration of magnesium sulfate to women with gestosis before delivery does not increase the incidence and mortality of newborns (The Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomized placebo-controlled trial. - Lancet . - 2002. - V.359 (9321). - P.1877-1890).

However, the available scientific literature and researchers did not find a description of the neuroprotective effect of magnesium sulfate during surgical delivery of women with severe gestosis against the background of spinal anesthesia. We also did not reveal data on the effect on the blood circulation of the combined use of magnesium sulfate and spinal anesthesia against the background of the existing bcc deficiency in women with severe gestosis (in this situation, the development of relative hypovolemia and severe arterial hypotension during the development of the sympathetic block of spinal anesthesia). The prophylactic use of cytoflavin was also not identified in order to reduce the damage to the central nervous system by hypoxic factors of gestosis and surgical trauma.

As a result of our studies, it was found that in women with severe gestosis with surgical delivery in order to realize the neuroprotective effect of magnesium sulfate, the introduction of cytoflavin is necessary.

The use of magnesium sulfate or cytoflavin alone (solo) does not give a significant neuroprotective effect, while the use of cytoflavin (an energetic antihypoxant), increasing the energy potential of neurons in the ischemic area of the brain, contributes to the implementation of the neuroprotective effect of magnesium sulfate. Thus, we found that the most rational is the combined use of cytoflavin and magnesium sulfate, because only when used together, the degree of damage to the central nervous system is significantly reduced.

The proposed mechanism of this effect (synergism) is as follows: the main direction of primary neuroprotection is the interruption of the rapid reactions of the glutamate-calcium cascade, the prevention of activation of NMDA receptors. The only safe and effective non-competitive antagonists of NMDA receptors, the use of which is allowed in pregnant women and puerperas, are magnesium preparations (Firulev L.V. Intensive therapy for severe late gestosis and its complications. - Izhevsk, 2003. - 176 p.). However, a distinctive feature of NMDA receptors is that they are blocked by magnesium ions by a voltage-dependent mechanism that works under physiological conditions, but decreases when the resting potential decreases under conditions of cerebral hypoxia (Meldrum BS Glutamate as a Neurotransmitter in the Brain: Review of Physiology and Pathology / BS Meldrum // Journal of Nutrition. - 2000. - V.130 - S.1007-1015). With surgical delivery in women with severe gestosis against the background of energy deficiency in ischemic brain tissue (under conditions of discirculatory disorders), even with high doses of magnesium sulfate, a full-fledged neuroprotective effect does not develop and hypoxic-ischemic damage to the central nervous system is enhanced.

The use of cytoflavin in pregnant women with severe gestosis is necessary in order to correct hypoxia and compensate for the bioenergetic needs of neurons. The introduction of cytoflavin must be carried out in sedation, because in a woman with severe preeclampsia, psychoemotional stress before the operation is often accompanied by a significant increase in arteriolospasm, in such a situation, circulatory disorders and hypoxic-ischemic brain damage may intensify.

The introduction of magnesium sulfate (taking into account its vasodilating and hypotensive effect) should be started only after the development of spinal anesthesia and stabilization of blood circulation with the help of infusion therapy. With this sequence, the risk of hemodynamic instability and aggravation of cerebral perfusion disorders is reduced.

It should be emphasized that the use of magnesium sulfate before performing the SMA causes a significant decrease in vascular tone and increases the anesthetic risk. Against the background of an initially reduced volume of circulating blood in pregnant women with severe gestosis and magnesium sulfate introduced into premedication during the development of cerebrospinal anesthesia, the frequency of complications in the form of acute hypovolemia and critical arterial hypotension in the mother increases and the risk of asphyxiation in the newborn increases (since a violation of central hemodynamics is manifested not only nausea and a feeling of "lack of air" on the part of the mother, but also a decrease in utero-placental blood flow with the development of fetal hypoxia).

A clear implementation of the sequence of stages of the proposed method of anesthesiological aid developed by us (using cytoflavin, performing spinal anesthesia, administering magnesium sulfate) reduces the anesthetic risk and prevents possible complications of the anesthetic aid (in the form of hemodynamic instability - a pronounced arterial hypotensive reaction). Thus, the achievement of a new technical result is possible only if the declared essential features.

The inventive method of anesthesia is recommended for women with severe gestosis, since they have a cesarean section against the background of conventional spinal anesthesia which causes surgical distress and significantly enhances the hypoxic-ischemic lesion of the central nervous system. Against this background, with severe gestosis, after surgical delivery for a long period, generalized arteriolospasm, hypokinetic type of blood circulation and arterial hypertension are determined. In women with moderate preeclampsia, surgical trauma is accompanied by moderate lesion of neurons, the postoperative period is relatively favorable, normalization of blood circulation and regression of arterial hypertension by the fifth day after surgery (Shapovalov O.E. Hemodynamics and water sectors of the body during surgical delivery women with preeclampsia - Materials of the IV All-Russian Interdisciplinary Scientific and Practical Conference "Critical Conditions in Obstetrics and Neonato ogii. "- SPb., 2006. - S.769-777). Therefore, in patients with moderate gestosis, conventional spinal anesthesia can be used.

The method is as follows.

In premedication, an intravenous infusion of cytoflavin is carried out - 10 ml in a dilution of 200 ml of saline for 5 minutes. Spinal anesthesia is technically performed according to generally accepted rules: under aseptic conditions, the spinal space is punctured with a sterile set for spinal anesthesia under L-3 or L-4, 0.5% markain-spinal is administered - 2.5-3.5 ml (depending on growth). With the development of bradycardia, iv atropine 0.1% - 1.0 ml is used. After intrathecal administration, marcain-spinal infusion therapy is carried out through a peripheral intravenous catheter G18 jet (400-800 ml of physical solution) until stabilization of blood circulation (decrease in mean blood pressure not more than 20%). Then the infusion rate is reduced (iv drip). Humidified oxygen is inhaled through a face mask - 6 l / min. After the development of neuroaxial blockade (cerebrospinal anesthesia) and the stabilization of hemodynamics, micro-jet iv administration of magnesium sulfate at a dose of 60 mg / kg is started for 15 minutes and the operation is performed.

The specific implementation of the claimed method is illustrated by examples from clinical practice.

Example 1

Pregnant C-ova, 26 years old, history of childbirth No. 1390, was admitted to the maternity hospital "Maternity Hospital No. 5" in Rostov-on-Don. Diagnosis: 37 weeks pregnancy, pelvic presentation of the fetus, severe late gestosis. Edema syndrome of the 3rd degree is noted, as well as severe arterial hypertension BP - 170/115 mm Hg, heart rate - 88 beats. in minutes In urine, protein is determined - 0.099 g / l. Edema and hypertension appeared from 32 weeks of gestation. No complaints. When conducting a rheomonitorial study, arteriolospasm and hypokinetic type of blood circulation were determined (SI - 1.66 l / min · m ² , OPSS - 3191 dyn · s / cm ⁵ ). The severity of gestosis is 12 points. (on the Goecke scale as modified by G. M. Savelyeva). Given the severity of gestosis and pelvic presentation of the fetus, an operative delivery is planned.

Premedication: iv cap. cytoflavin - 10 ml per 200 ml of physical solution within 5 minutes. Then, a puncture of the cerebrospinal space under L-3 was performed and marcain spinal (3.0 ml) was introduced. Jet infusion started. solution - 600 ml. Intravenous bolus was administered 0.1% atropine - 1.0 ml. During hemodynamic instability, blood pressure decreased to 115/80 mm Hg, heart rate - to 69 beats. in minutes At the 5th minute after the administration of marcain, blood circulation was stabilized (blood pressure - 140/90 mmHg, heart rate - 95 beats per minute). Started micro-jet intravenous injection of magnesium sulfate at a dose of 60 mg / kg for 15 minutes and the operation began. After 5 minutes, the fetus was removed, an intravenous infusion of oxytocin is carried out - 5 U / h. Hemodynamics remained stable, the woman did not show complaints of nausea and shortness of breath. A newborn in the 5th minute was rated at 8 points. on the Apgar scale.

The duration of the operation is 45 minutes.

AD - 155 / 100-115 / 80-140 / 90-160 / 105-140 / 90-135 / 90-150 / 95-140 / 90 mm Hg,

Heart rate - 84-69-95-100-88-81-87-83 beats. in minutes

Blood loss - 600 ml. Infusion - 1450 ml. Diuresis - 50 ml.

During the operational period, when applying the claimed method of anesthetic administration, the hemodynamics were stable with moderate arterial hypertension, respiratory comfort, normal blood loss and adequate diuresis, normal contractility of the uterus (administration of oxytocin magnesium sulfate does not inhibit myometrial contractility), that is, a smooth course of the surgical period was observed; .

The dynamics of the concentration of NSE (μg / l), SI (l / min · m ² ) and OPSS (dyn · s / cm ⁵ ) before, on the 1st and 5th day after cesarean section:

Table 1 Stages one 2 3 Nse 11.9 15.6 5.1 SI 1.66 1.49 2,53 OPSS 3191 3354 2134

The postoperative period was uneventful, without infectious and inflammatory complications and hyperthermia. Normalization of NSE concentration was noted on the 5th day after the operation, arteriolospasm significantly decreased and a rational transition to the eukinetic type of blood circulation was recorded. The woman was discharged from the maternity hospital on the seventh day after surgical delivery in a satisfactory condition with normalization of blood pressure.

Example 2

Pregnant L-eva, 24 years old, history of childbirth No. 3287, was admitted to the maternity hospital "Maternity Hospital No. 5" in Rostov-on-Don. Diagnosis: 38 weeks pregnancy, lateral position of the fetus, severe late gestosis. Edema syndrome of the 3rd degree is noted, as well as severe arterial hypertension BP - 160/100 mm Hg, heart rate - 83 beats. in minutes In the urine, protein is determined - 1.32 g / l. Edema appeared from 35 weeks, arterial hypertension - from 36 weeks of pregnancy. In the last 5 days, the pregnant woman notes periodic headaches, sleep disturbance, emotional lability. When conducting a rheomonitorial study, arteriolospasm and hypokinetic type of blood circulation were determined (SI - 1.85 l / min · m ² , OPSS - 2858 dyn · s / cm ⁵ ). The severity of gestosis is 14 points. (on the Goecke scale as modified by G. M. Savelyeva). Given the severity of gestosis and the transverse position of the fetus, an operative delivery is planned.

Premedication: iv cap. cytoflavin - 10 ml per 200 ml of physical solution within 5 minutes. Then, a puncture of the cerebrospinal space under L-3 was performed and marcain spinal (2.8 ml) was introduced. Jet infusion started. solution - 600 ml. Intravenous bolus was administered 0.1% atropine - 1.0 ml. During hemodynamic instability, blood pressure decreased to 125/80 mmHg, heart rate to 74 beats. in minutes At the 5th minute after the administration of marcaine, blood circulation was stabilized (blood pressure - 135/85 mm Hg, heart rate - 98 beats per minute). Started micro-jet intravenous injection of magnesium sulfate at a dose of 60 mg / kg for 15 minutes and the operation began. After 6 minutes, the fetus was removed, an intravenous infusion of oxytocin is carried out - 5 U / h. Hemodynamics remained stable, the woman did not show complaints of nausea and shortness of breath. A newborn in the 5th minute was rated at 8 points. on the Apgar scale.

The duration of the operation is 35 minutes.

AD - 165 / 100-155 / 105-125 / 80-135 / 85-130 / 75-140 / 85-145 / 90-130 / 80 mm Hg,

Heart rate - 81-92-74-98-89-85-81-84 beats. in minutes

Blood loss - 600 ml. Infusion - 1400 ml. Diuresis - 100 ml.

During the operating period, when applying the claimed method of anesthetic administration, it was characterized by hemodynamic stability, respiratory comfort and a sense of “rest”, normal blood loss and adequate diuresis, normal contractility of the uterus (with the administration of magnesium oxytocin sulfate does not inhibit contractility of the myometrium), that is, a smooth course of the surgical period was observed .

The dynamics of the concentration of NSE (μg / l), SI (l / min · m ² ) and OPSS (dyn · s / cm ⁵ ) before, on the 1st and 5th day after cesarean section:

table 2 Stages one 2 3 Nse 13.1 18.9 10.8 SI 1.85 1.51 2,37 OPSS 2858 3230 2528

The postoperative period was uneventful, without infectious and inflammatory complications and hyperthermia. Positive dynamics of blood circulation indices was noted. However, on the fifth day after cesarean section, the NSE level remained elevated, arteriolospasm and hypokinetic type of blood circulation also remained. At the time of discharge of a woman from the maternity hospital on the sixth day after surgical delivery at rest, blood pressure was recorded at 135/85 mm Hg, with moderate physical exertion (after walking) there was arterial hypertension - 140/95 mm Hg.

We conducted a comparative study that determines the degree of central nervous system damage and blood circulation in women with severe gestosis with cesarean section under conditions of conventional spinal anesthesia and the claimed method of anesthetic management.

A survey of 119 women divided into groups:

control - 30 healthy women with a physiological pregnancy during spinal anesthesia (SMA),

the first group - 20 women with severe gestosis against the background of generally accepted spinal anesthesia (without the use of magnesium sulfate and cytoflavin),

the second group - 29 women with severe preeclampsia on the background of spinal anesthesia and the use of magnesium sulfate (which was administered iv in the dose of magnesium sulfate at a dose of 60 mg / kg for 15 minutes),

the third group - 20 women with severe preeclampsia on the background of spinal anesthesia and the use of cytoflavin (to which pre-sedation was carried out iv infusion of cytoflavin - 10 ml per 200 ml of physiological solution for 5 minutes),

the fourth group - 20 women with severe gestosis against the background of the claimed method of anesthetic management.

The groups of women examined were formed using the method of stratified randomization taking into account the severity of gestosis. The severity of preeclampsia was determined according to the Goecke scale in the modification of G. M. Savelyeva. The groups were comparable in severity of gestosis, gestational age, average duration of gestosis, the nature of obstetric and extragenital pathology, indications for surgical delivery, parity, average height, weight and age.

One of the indicators of the degree of hypoxic-ischemic damage to the central nervous system is the concentration in the blood of a neuron-specific enolase (NSE). The NSE level is an informative indicator, since this neurospecific protein is found mainly in neurons and enters the bloodstream only when they are damaged - a marker of the state of neurons (Celtik C. Neuron-specific enolase as a marker of the severity and outcome of hypoxic ischemic encephalopathy. - Brain Dev. - 2004. - V.26.6. - P.398-402).

To determine the level of NSE in the blood, the ELISA method was used. A kit of reagents from Fujirebio Diagnostics was used. The study was conducted on the analyzer "Multiscan Primari EIA V. 2.1-0." Venous blood sampling was performed:

1st stage - before the operation (initial background),

2nd stage - on the first day after the operation,

3rd stage - on the fifth day after the operation.

In order to assess blood circulation, we used indicators of SI and OPSS. These values have great hemodynamic significance and have a clear physiological meaning, reflecting the performance of the heart and vascular tone (K. Lebedinsky, Anesthesia and systemic hemodynamics. - St. Petersburg: Man, 2000. - 200 p.). The type of blood circulation was identified by the generally accepted criteria for the SI parameter, reflecting the recommendations of WHO and domestic researchers. SI levels of up to 2.5 l / min · m ² were considered a hypokinetic type of hemodynamics (K. Lebedinsky, 2000).

The study of blood circulation indices (SI, OPSS) was carried out using the KM-AR-01 “Diamant” rheograph (St. Petersburg) by the method of integral tetrapolar rheography according to Tishchenko M.I.

Studies were carried out in dynamics:

1st stage - before the operation (initial background),

2nd stage - on the first day after the operation,

3rd stage - on the fifth day after the operation.

Statistical processing of the material was carried out by the Excel software package, version 7.0, section “Data Analysis” using the arithmetic mean and standard error of the mean. If necessary, the censorship of the sample was carried out according to the “three sigma” rule, while the extreme options were no more than 5% of the sample. The statistical significance of differences between the groups of women examined, as well as the significance of changes in indicators at the stages of the study, was evaluated using a two-sample t-test with different variances for unrelated samples with a two-sided probability of differences in indicators. Differences between the compared values were recognized as statistically significant at a level of p <0.05.

The results of the study are presented in tables 1-4.

When conducting the claimed method of anesthetic administration on the first and fifth days after cesarean section, the NSE level is determined statistically significantly lower than in the comparison groups (table 3). This indicates a decrease in the degree of damage to the central nervous system and confirms the neuroprotective effect of the combined use of magnesium sulfate and cytoflavin.

Table 3 The dynamics of the concentration of NSE in the plasma of venous blood (μg / l; M ± m) Groups The value of the indicator at the stages of the study one 2 3 Control (n = 30) 5.94 ± 0.49 10.10 ± 0.53 3.52 ± 0.28 * * * * * *, # # # Group 1 (n = 20) 13.96 ± 1.00 21.21 ± 1.36 11.62 ± 0.95 * * * * * *, # # # Group 2 (n = 29) 12.60 ± 0.52 18.82 ± 0.60 9.73 ± 0.40 * * * * * *, # # # Group 3 (n = 20) 14.48 ± 0.77 20.11 ± 1.37 11.08 ± 0.77 * * * * * *, # # # Group 4 (n = 20) 13.09 ± 0.81 16.59 ± 0.89 7.69 ± 0.81 * * * * * *, # # # p ₁ <0.05 p ₁ <0.01 p ₂ <0.05 p ₂ <0.05 p ₃ <0.05 p ₃ <0.01 Note: the assessment of the difference in NSE levels was carried out between the 1st group and the 2nd, 3rd, 4th groups - p ₁ ; between the 2nd group and the 3rd, 4th groups - p ₂ ; between the 3rd group and the 4th group - p ₃ at each stage of the study. Statistical significance of differences: in comparison with the 1st stage - * * - p <0.01, * * * - p <0.001, compared with the 2nd stage - # # # - p <0.001.

When carrying out the claimed method of anesthetic administration on the fifth day after cesarean section, the cardiac output significantly increases and a rational transition of hemodynamics to the eukinetic type of blood circulation is determined, while the SI value is statistically significantly higher than the similar indicator for puerperas of the 1st and 3rd groups (Table 4).

Table 4 The dynamics of the value of the cardiac index (l / min · m ² ; M ± m) Groups The value of the indicator at the stages of the study one 2 3 Control (n = 30) 3.32 ± 0.08 3.22 ± 0.07 3.03 ± 0.05 * *, # Group 1 (n = 20) 2.15 ± 0.10 1.95 ± 0.11 2.26 ± 0.10 # Group 2 (n = 29) 1.94 ± 0.06 2.01 ± 0.05 2.38 ± 0.05 * * *, # # # Group 3 (n = 20) 1.90 ± 0.10 1.81 ± 0.10 2.18 ± 0.09 *, # Group 4 (n = 20) 2.09 ± 0.10 2.11 ± 0.13 2.57 ± 0.11 * *, # # p ₁ <0.05 p ₃ <0.01 Note: the assessment of differences in SI levels was carried out between the 1st group and the 2nd, 3rd, 4th groups - p ₁ between the 2nd group and the 3rd, 4th groups - p ₂ ; between the 3rd group and the 4th group - p ₃ at each stage of the study. Statistical significance of differences: in comparison with the 1st stage - * - p <0.05, * * - p <0.01, * * * - p <0.001, compared with the 2nd stage - # - p <0.05, # # - p <0.01, # # # - p <0.001.

The level of OPSS on the fifth day after cesarean section when carrying out the claimed method of anesthetic administration is determined statistically significantly lower than that of puerperas of the 1st and 3rd groups, which indicates a lower level of generalized arteriolospasm (Table 5).

Table 5 The dynamics of the value of the total peripheral vascular resistance (dyn · s / cm ⁵ ; M ± m) Groups The value of the indicator at the stages of the study one 2 3 Control (n = 30) 1402.9 ± 32.3 1441.1 ± 30.2 1588.3 ± 20.3 * * *, # # # Group 1 (n = 20) 2683.5 ± 98.8 2877.0 ± 115.6 2407.6 ± 93.7 *, # # Group 2 (n = 29) 2935.6 ± 92.2 2789.0 ± 83.0 2277.2 ± 76.7 * * *, # # # Group 3 (n = 20) 2967.2 ± 104.0 3090.1 ± 110.2 2510.7 ± 140.3 p ₂ <0.05 *, # # Group 4 (n = 20) 2779.7 ± 129.8 2708.2 ± 150.4 2081.5 ± 112.0 p ₃ <0.05 * * *, # # p ₁ <0.05 p ₃ <0.05 Note: the assessment of the difference in levels of SPSS was carried out between the 1st group and the 2nd, 3rd, 4th groups - p ₁ between the 2nd group and the 3rd, 4th groups - p ₂ ; between the 3rd group and the 4th group - p ₃ at each stage of the study. Statistical significance of differences: in comparison with the 1st stage - * - p <0.05, * * * - p <0.001, compared with the 2nd stage - # # - p <0.01, # # # - p <0.001.

In women with severe preeclampsia after cesarean section on the background of generally accepted spinal anesthesia (SMA), by the fifth day arterial hypertension persisted in 45.0% of cases. When carrying out the claimed method of anesthetic administration, in 30.0% of cases, which is 15.0% less (values of ADsyst. 140 mmHg and (or) ADdiast. 90 mmHg and above were considered arterial hypertension (Abramchenko VV Epidural anesthesia for hypertensive disorders during pregnancy. - Materials of the IV All-Russian Interdisciplinary Scientific and Practical Conference "Critical Conditions in Obstetrics and Neonatology. - Petrozavodsk, 2006. - P.487-495)).

The data presented indicate a more intensive rational restructuring of the neurohumoral regulation of blood circulation after cesarean section in women with severe preeclampsia using the claimed method of anesthetic management, which contributes to the early regression of arterial hypertension and a favorable course of the postoperative period.

In order to determine a rational time period for iv administration of magnesium sulfate - 60 mg / kg, women of the 2nd group were divided into subgroups:

2A - 15 women with severe preeclampsia, in which the introduction of magnesium sulfate was carried out in a sedation before performing SMA,

2B - 14 women with severe preeclampsia, who started the administration of magnesium sulfate after performing SMA and stabilizing blood circulation with the help of infusion therapy.

Table 6 The course of the prenatal cesarean section in women with severe gestosis on the background of SMA and the use of magnesium sulfate Complications Number (%) of puerperas by subgroups Subgroup 2A (n = 15) Subgroup 2B (n = 14) Complaints of nausea, vomiting, respiratory discomfort 8 (53.3%) 3 (21.4%) A decrease in mean blood pressure at the 5th minute from the onset of SMA by more than 20% of the initial * 4 (26.7%) 1 (7.1%) The volume of infusion therapy by 10 minutes from the onset of SMA is necessary to stabilize hemodynamic parameters (decrease in mean blood pressure no more than 20%) 810.0 ± 48.1 ml 657.1 ± 47.1 ml, p <0.05 * a decrease in mean arterial pressure by ≥20% of the initial value during cesarean section on the background of spinal anesthesia reflects pronounced arterial hypotension (Ngan Kee WD Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. - Anesth. Analg. - 2004. - V.98.3 . - P.815-821).

With the introduction of magnesium sulfate at a dose of 60 mg / kg for 15 minutes after performing the MCA and stabilizing blood circulation, a smoother course of the anesthesiological aid is noted and the anesthesiological risk is reduced, which indicates the rationality of the developed sequence of stages of the claimed method of the anesthesiological aid (Table 6).

Assessment of the condition of newborns on the Apgar scale at the 5th minute from birth with conventional spinal anesthesia in 4 cases (20.0%) corresponded to 7 points, and in 16 cases - 8 points. When carrying out the claimed method of anesthetic administration, the assessment of the condition of newborns on the Apgar scale in 5 cases (25%) corresponded to 7 points, and in 15 cases - 8 points. Thus, there were no significant differences in assessing the condition of newborns in women with severe gestosis during conventional anesthesia and the claimed method of anesthesiological benefits.

We have confirmed the rationality of the combined use of magnesium sulfate and cytoflavin in women with severe gestosis during surgical delivery on the background of spinal anesthesia. This reduces the degree of damage to the central nervous system. As a result, normalization of blood circulation and regression of arterial hypertension in the postoperative period occurs faster.

Thus, the claimed method of anesthesia with the use of cytoflavin and magnesium sulfate in the sequence we developed for spinal anesthesia is characterized by the optimal course of anesthesia and the postoperative period, is not accompanied by complications from the mother and the newborn and can be recommended for widespread clinical use with surgical delivery in pregnant women with severe gestosis.

The proposed technical solution does not require significant economic costs, it is simple, affordable and effective for the prevention of hypoxic-ischemic damage to the central nervous system and to increase the adequacy of anesthetic benefits in pregnant women with severe gestosis with surgical delivery.

The inventive method is tested on sufficient clinical material and can be recommended for use in anesthesiology practice.

Claims (1)

A method of anesthetic management for surgical delivery of women with severe gestosis, including premedication, spinal anesthesia and intraoperative therapy, characterized in that cytoflavin is used as one of the components of sedation - 10 ml in a dilution of 200 ml of saline intravenously for 5 minutes, then they perform spinal anesthesia by intrathecal administration of marcain-spinal, after the development of neuroaxial blockade (spinal anesthesia) and stabilization blood circulation - a decrease in average blood pressure of not more than 20%, begin the intravenous administration of magnesium sulfate at a dose of 60 mg / kg for 15 minutes and carry out the operation.