RU2465926C2 - Method of balanced regional analgesia in perioperative period in highly traumatic operations on thoracic and lumbar spine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology, and can be used in patients during and after highly traumatic operations on thoracic and lumbar spine. For this purpose general anesthesia is performed with sevoflurane. Additionally during operation epidural analgesia is performed by infusion of mixture of 0.2% solution of ropivacaine with fentanyl 2 mcg/ml and adrenalin 2 mcg/ml at rate 5-10 ml/hour. In postoperative period anesthesia is performed by constant infusion of mixture at rate 4-8 ml/hour.

EFFECT: method makes it possible to ensure adequate and safe anesthesia during surgery due to breaking pain impulsation at the level of spine cord segments in combination with superficial sedation, as well as in postoperative period due to multidirectional action of mixture components.

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Description

The present invention relates to medicine, in particular to methods of balanced regional anesthesia, and can be used in patients during and after highly traumatic surgery on the thoracic and lumbar spine.

Closest to the proposed invention is a method consisting in conducting epidural analgesia by the introduction of 20-25 ml of 0.75-1% solution of ropivacaine and general anesthesia with propofol 5-6 mg / kg / hour with muscle relaxation and mechanical ventilation and postoperative epidural analgesia by the introduction of 0.2 % ropivacaine solution through a dispenser at a rate of 10-12 ml / hour for 2-3 days (Lukyanov D.S., Shevchenko V.P., Roerich V.V. Epidural anesthesia as a component of anesthetic protection during operations on the lumbar spine / / Surgery of the spine. - 2004. - No. 3. - S.60-65).

However, the known method does not provide adequate protection for the patient from surgical injury, since epidural blockade is performed only with a solution of local anesthetic - ropivacaine, which does not allow to act on opioid and adrenergic receptors and achieve complete antinociceptive protection at the level of the posterior horns of the spinal cord. In addition, the known method leads to the development of hemodynamic effects, primarily hypotension and bradycardia, due to the large initial dose of local anesthetic, due to sympathicolysis at the lumbar level, which are enhanced by sedation with propofol.

The objective of the invention is to provide adequate protection during and after surgery by interrupting pain impulse at the level of segments of the spinal cord, providing controlled sedation, achieving early awakening and extubation of patients on the operating table, and prevention of intra- and postoperative complications.

The problem is solved due to the fact that in a method involving epidural analgesia with ropivacaine and general anesthesia, epidural analgesia during and after surgery is carried out by constant infusion of a mixture of 0.2% solution of ropivacaine with fentanyl and adrenaline, and general anesthesia is performed with sevoflurane.

A method of balanced regional analgesia in the perioperative period during highly traumatic operations on the thoracic and lumbar spine is as follows: after intravenous sedation with midazolam, an epidural catheter is inserted 3-4 segments higher than the expected level of surgical intervention in the thoracic spine from a level of Th ₄ to Th ₁₂ or L ₁ . After a test dose (2% solution of lidocaine 2-3 ml), a bolus of 0.75% ropivacaine solution from 3 to 10 ml fractionally and fentanyl 50-100 μg is epidurally injected and a mixture of 0.2% ropivacaine with fentanyl is infused (2 μg / ml) and adrenaline (2 μg / ml) at a rate of 5-10 ml / hour. Induction into general anesthesia is performed with sevoflurane 8 vol.% And fentanyl (1 μg / kg). Tracheal intubation is performed, anesthesia is maintained by inhalation of sevoflurane 0.6-1.2 vol.%, Muscle relaxation and mechanical ventilation are performed. Awakening and extubation of patients are carried out in the operating room. After assessing the neurological status in the intensive care unit, patients continue epidural analgesia with 0.2% ropivacaine solution with fentanyl 2 μg / ml and adrenaline 2 μg / ml at a rate of 4-8 ml / hour for 2-3 days.

Clinical example.

Patient M., 47 years old. IS No. 247620. Weight - 95 kg, height - 168 cm.

Diagnosis: Degenerative kyphoscoliosis of the lumbar spine, spinal stenosis at the level of L1 - L2 - L3. Concomitant diagnosis: Arterial hypertension 2 tbsp., II tbsp., Risk 3, NK I, obesity 2 tbsp.

Operation: Microsurgical decompression of the roots of the spinal cord, correction of deformation, transpedicular fixation at the level of Th11-L4, posterolateral autologous fusion.

Anesthetic management. Premedication in the ward 30 minutes before surgery - Relanium 10 mg, suprastin 1 ml. After intravenous sedation with midazolam 5 mg, the epidural space at the thoracic level Th6-Th7 was catheterized, the catheter was performed cranially by 5 cm, 10 ml of a 0.75% ropivacaine solution was introduced in 5 ml fractions for 10 min, 100 μg of fentanyl. An epidural infusion of a 0.2% solution of ropivacaine in a mixture with fentanyl 2 μg / ml and adrenaline 2 μg / ml was started at a rate of 5-10 ml / hour. Induction in anesthesia - bolus - sevoflurane 8 vol%, FiO ₂ - 100%, 8 l / min, fentanyl 100 μg, tracheal intubation without the introduction of relaxants, mechanical ventilation in IPPV mode, normo ventilation. Catheterization of the right subclavian vein for infusion-transfusion therapy and control of CVP. Bladder catheterization to control hourly urine output. Maintenance of general anesthesia by inhalation of sevoflurane 0.8-1.0 vol.%, MAC - 0.5%, FiO ₂ - 40%, Low-Flow, SpO ₂ with an estimate of the depth of anesthesia sleep (BIS = 50-60%). Muscle relaxation by infusion of a tracrium of 0.4 mg / kg / hour (38 mg / hour). Maintenance of hemodynamics: blood pressure - 90-100 mm Hg, heart rate 60-66 beats. in min, ADsr - 60-65 mm Hg, SI - 2.3-2.6. Blood loss during surgery was 350 ml, reinfusion of autoerythrocytes (Cell Saver) - 110 ml. The volume of Int - 1000 ml of crystalloid (Ringer's solution), 500 ml of colloid (Voluven), diuresis was 200 ml, the duration of the operation was 4 hours. At the end of the operation, the patient woke up, performed the commands, spontaneous breathing was restored, adequate, BH - 16 min, SpO ₂ - 98% when breathing air; the patient is extubated on the operating table 6 minutes after the end of the wound closure, transferred to the intensive care unit. The neurological status was assessed, movements in the extremities were preserved, pain was absent. Epidural analgesia was continued with a 0.2% solution of ropivacaine with fentanyl 2 μg / ml and adrenaline 2 μg / ml at a rate of 4-8 ml / hour for 1 day in ICU. After surgery, drainage blood loss was 250 ml, reinfusion was 100 ml of autoerythrocytes. In the morning, the patient was transferred to the ward, where epidural analgesia was continued through the infusion pump for 2 days. The patient was activated on the 2nd day, began to get up, walk in walkers.

A method of balanced regional analgesia in the perioperative period during highly traumatic operations on the thoracic and lumbar spine allows reliably interrupting pain impulse at the level of the posterior horns of the spinal cord. The combination of regional analgesia with powerful and highly controlled inhalation anesthesia with sevoflurane allows you to maintain a superficial level of sedation, which contributes to quick wake up on the operating table, early extubation of patients, early postoperative activation, which helps to prevent early complications. Fast controlled awakening of patients allows us to assess the neurological status at the end of the operation. Reducing a single bolus dose of ropivacaine avoids undesirable adverse hemodynamic as well as toxic reactions in patients. The use of prolonged thoracic epidural analgesia with a mixture of ropivacaine, fentanyl and adrenaline after surgery on the spine contributes to better anesthesia, minimal side effects, early activation (turning, lifting and walking), prevention of postoperative intestinal paresis, and reduces the number of cases of perioperative myocardial ischemia.

Claims (1)

A method of balanced regional analgesia in the perioperative period during highly traumatic operations on the thoracic and lumbar spine, which involves thoracic epidural analgesia and general anesthesia, characterized in that general anesthesia is performed with sevoflurane and epidural analgesia during surgery is carried out by infusion of a mixture of 0.2% a solution of ropivacaine with fentanyl 2 μg / ml and adrenaline 2 μg / ml at a rate of 5-10 ml / h, and after the operation, the mixture is continuously infused at a rate of 4-8 ml / h.