RU2448743C2 - Method of combined anesthesia in resecting operations on lungs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology and thoracic surgery, and can be used as anesthetic aids in surgery on lung resection. For this purpose carried out is general anesthesia with microrelaxants and artificial lung ventilation in combination with blockades. Before anesthesis induction subpleural blockade is performed. After intubation of patient vagosympathetic blockade is carried out. As local anesthetic, in carrying out said blockades 0.2% ropivacaine solution is used.

EFFECT: method makes it possible to ensure adequate blockade of pain impulse at stages of transduction and transmission in carrying out operation on patients with reduced reserve heart possibilities.

1 ex

Description

The present invention relates to medicine, namely to anesthesiology and resuscitation, and can be used in anesthesiology to ensure a different volume of resecting lung operations.

It is known that “combined anesthesia” includes general anesthesia with muscle relaxants, mechanical ventilation, and the use of an analgesic component.

A known method of combined general anesthesia with muscle relaxants and mechanical ventilation (mechanical ventilation), in which opioid analgesics are used as an analgesic component. The known method is as follows. On the eve of surgical intervention, sibazon, diphenhydramine and ketoprofen are administered intramuscularly, and diphenhydramine 10 mg, fentanyl 200-600 μg, atropine sulfate 0.5-1 mg are administered intramuscularly 20 minutes before surgery. Induction of anesthesia is carried out by the introduction of sodium thiopental 200-500 mg or propofol 80-100 mg. Basic anesthesia includes propofol and nitrous oxide. Analgesia is achieved by fractional administration of fentanyl at a dose of 3.1 + 2.1 mg * kg * hour. Relaxation was ensured by the use of listenone (for tracheal intubation) and arduan or trarium to maintain myoplegia during surgery.

The adequacy of the anesthetic aid was monitored by continuous monitoring of systemic blood pressure, heart rate, pupillary reactions, oxygen saturation of the arterial blood, color and moisture of the skin.

The known method allows for lung surgery of various levels of complexity.

The disadvantages of this method include the fact that it does not inhibit the pain impulse at the stages of transduction and transmission, since an opioid analgesic is used as an analgesic component, which has an effect on segmental and suprasegmental levels of the central nervous system. Therefore, despite the large dose of narcotic analgesics administered, unstable hemodynamics are noted, which is manifested by hypertension and tachycardia at the traumatic stages of the operation - thoracotomy and when working on the root of the lung.

The disadvantages of this method should also include prolonged (up to 10 hours) post-narcotic depression of consciousness and breathing, which prevents the early activation of the patient (Pain 2002 - An. Updated Review. JASP Press. Seattle. 2002. 466 p.).

The closest in technical essence to the proposed one is a method of combined anesthesia with muscle relaxants and mechanical ventilation and using epidural blockade as an analgesic component (Gorobets E.S., Karmanov I.E., Buidenyuk Yu.V. Regional anesthesia and treatment of pain. Thematic collection. - Moscow-Tver 2004. P.134).

The known method is as follows. Premedication is carried out, as in the analogue method. Puncture of the epidural space is carried out in compliance with all aseptic rules at the level of 4-8 thoracic vertebrae with an atraumatic needle of the Tuoha type. After identification of the epidural space, a catheter is installed with its fixation to the skin. A test dose (40 mg of lidocaine hydrochloride) is administered to prevent accidental entry of a catheter into the subarachnoid space. 75 mg of ropivacaine is administered under continuous hemodynamic control. Preparations for basic anesthesia are standard, the doses of narcotic analgesics administered are 0.3-0.5 mcg * kg * hour.

The disadvantages of this method include the impossibility of its use in patients with reduced reserve capacity of the heart (congestive heart failure), when a volemic load leads to a deterioration in the general condition of the patient (F. Michael Ferrante, Timothy R. Wade Boncor. Postoperative pain. - Moscow. Medicine. 1998, p. 421).

The disadvantages of this method should also include the fact that the implementation of epidural blockade requires highly qualified anesthesiologist, since when it is carried out in the thoracic spine, hemodynamic and respiratory complications are possible. In addition, rare (no more than 3%), but very dangerous complications are possible - puncture of the dura mater with the introduction of anesthetic intrathecal and the development of a total spinal block; epiduritis; epidural hematoma with compression and ischemia of the spinal cord, which leads to severe disability of the patient.

The objective of the proposed technical solution is to develop a method for optimal anesthesia during operations for lung resection in patients with reduced reserve capacity of the heart.

The technical result of the proposed method is a blockage of the pain impulse at the stages of transduction and transmission during surgical intervention on the lungs in patients with reduced reserve capacity of the heart.

The technical result is achieved by the fact that the method of combined anesthesia for resecting lung operations involves performing general anesthesia with muscle relaxants, mechanical ventilation and the use of an analgesic component.

The main distinguishing methods of the proposed method is that as an analgesic component blockade is carried out. In this case, subpleural blockade is carried out before the induction of anesthesia, and after intubation of the patient, a vagosympathetic blockade is performed.

The distinctive techniques should also include the use of a 0.2% solution of ropivacaine during these blockades.

A comparative analysis of the proposed method and the prototype shows that the claimed method differs from the known above methods. This difference allows us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

From the analysis of patent and other specialized literature, the authors found that the proposed solution has features that distinguish it not only from the prototype, but also from other technical solutions in anesthesiology. We have not found a method for conducting combined anesthesia for resecting lung operations, which contains the distinctive techniques of the proposed method.

Carrying out during the surgical intervention on the lungs of the proposed method of anesthesia allows to provide reliable analgesic protection both at the stage of thoracotomy, and during the intervention on the root of the lung.

Both blockades are not difficult to implement, can be performed in any initial condition of the patient. These blockages are devoid of side effects characteristic of epidural blockade - the prototype method.

A distinctive method of the proposed method, which consists in the use of a 0.2% solution of ropivacaine during these blockades, reduces the toxic effect of the drug on the patient by reducing its concentration in the solution.

This allows us to conclude that the claimed technical solution meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in healthcare. The possibility of its implementation is confirmed by the methods and means described in the application. The inventive method ensures the achievement of the technical result perceived by the applicant, namely, to guarantee the blockade of the pain impulse at the stages of transduction and transmission during surgery on the lungs of patients with reduced reserve capacity of the heart.

From the above it follows that the claimed invention meets the condition of patentability "industrial applicability".

The inventive method is as follows. For a patient who is scheduled to undergo lung surgery, subpleural blockade is performed in the operating room prior to the induction of anesthesia. For this, in sterile conditions, from the operation side, 5 rib is palpated 5-6 cm from the spinous process of the vertebra. A needle is inserted until it comes into contact with the rib, then the needle is moved under the rib until there is a slight dip (3-5 mm from the back surface of the rib). After the implementation of the "aspiration test" injected 40-50 ml of a 0.2% solution of ropivacaine.

After induction of anesthesia and intubation of the patient, a vagosympathetic blockade is performed. For this, 40-60 ml of a 0.2% solution of ropivacaine is injected at the posterior edge of the sternocleidomastoid muscle, slightly above or below its intersection with the external jugular vein. The solution, spreading along the prevertebral fascia throughout, blocks the sympathetic trunk and the vagus nerve.

The proposed method of combined anesthesia for resecting lung operations is illustrated by an example of a specific implementation.

Patient P. 62 years old with a diagnosis of Peripheral volumetric formation of the lower lobe of the right lung with decay. The patient is scheduled for right-sided thoracotomy, lower lobectomy on the right. From concomitant diseases: sinus node weakness syndrome, which required the installation of a temporary pacemaker (for the duration of the operation). Risk of anesthesia 3 by ASA.

Under aseptic conditions, subpleural blockade was performed - 40 ml of 0.2% ropivacaine was administered. After tracheal intubation, a vagosympathetic block was performed - 60 ml of 0.2% ropivacaine was administered (reg. P No. 014458.01 by Astra Zeneka). After 15 minutes, a one-sided block developed. This made it possible to perform surgery lasting 6 hours.

The stability of hemodynamics (blood pressure within 132-111 / 78-63, pulse within 68-86 beats per minute, peripheral saturation 98-100%), consumption of narcotic analgesics (fentanyl 400 μg (4 ampoules) during the operation, and with standard central anesthesia, the flow rate in the first hour is 7-10 μg / kg, the second hour - 5 μg / kg, in the following hours - 3 μg / kg). The patient is extubated 1 hour after surgery. In the morning, the patient was transferred from the intensive care unit to the general ward.

Currently, the proposed method has been anesthetized in 50 patients.

The average age of patients is 63 years. Concomitant pathology - pulmonary hypertension (estimated pressure in the right ventricle above 35 mm Hg), severe forms of coronary heart disease (angina pectoris 3-4 functional class). Anesthesia is performed according to the proposed method. No complications were noted, since this combination of blockades can significantly reduce the consumption of drugs that cause respiratory depression in the early postoperative period.

Thus, the proposed method of combined anesthesia for resecting lung operations in patients with reduced reserve capabilities of the heart can be used in everyday practice of a thoracic anesthesiologist. The inventive method for the analgesic effect is not inferior to epidural blockade, it is safer, which allows us to recommend it to ensure anesthesia in patients with high operational risk. In addition, the use of a 0.2% ropivacaine solution can reduce the toxic effect of the drug on the patient by reducing its concentration in the solution.

Claims (1)

A method of combined anesthesia for resecting lung operations, including general anesthesia with muscle relaxants, artificial lung ventilation and the use of an analgesic component, characterized in that blockade is performed as an analgesic component, while subpleural blockade is performed before induction of anesthesia, and after the patient is intubated, vagosympathetic blockade, and when carrying out these blockades, a 0.2% solution of ropivacaine is used.