RU2504409C2 - Method for anaesthesia accompanying neck and head cancer surgeries in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to paediatric anaesthesiology, and may be used for executing the surgical operations of neck and head cancers in children. A pre-operative Kerdo index is determined. If observing an initial sympathicotonia, the anaesthesia is induced by sevoflurane inhalations and potentiated by administration of 1% propofol to be followed by sevoflurane inhalations.

EFFECT: method enables optimising the course of anaesthesia, achieving the normotonic sympathovagal balance and providing the haemodynamic stability by taking into account the individual vegetative response, as well as the separate and sequential administration of propofol and sevoflurane.

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Description

The invention relates to medicine, namely to children's anesthesiology, and can be used for surgical interventions for head and neck tumors in children.

Anesthetic management of surgical operations in children imposes stringent requirements on the selection of drugs, taking into account the maximum effectiveness, safety, controllability and adequacy of general anesthesia (Lekmanov A.U., Rozanov EM, Mukhidinov Sh.M. // Anesthesiology and intensive care, M. , Medicine. - 2000 - No. 1. - p. 4-6). According to A.A. Bunyatyan (“A Guide to Anesthesiology”, M., Medicine. - 1994), an anesthesiological aid is intended to create in the body such a degree of anti-stress protection that normal stress stimulation is maintained, but depletion of protective forces and the occurrence of dangerous pathological syndromes can be prevented. The key position on the body's tolerance of various stressful effects and, in particular, the effectiveness of the adaptive abilities of the cardiovascular system is occupied by the problem of providing the autonomic regulatory mechanisms of the sympathetic and parasympathetic systems (Wayne AM, Kolosova OA // Human Physiology. - 1975 - p. .562-569; Wayne AM // A Guide for Doctors. - Moscow - 1991 - p.632). The requirements for anesthesia in pediatric surgery of head and neck tumors, first of all, include high controllability at the stage of induction and intubation of the trachea, rapid and complete restoration of protective reflexes and muscle tone of the upper respiratory tract in the absence of central respiratory depression after the end of anesthesia. In addition, it should provide adequate analgesia and neurovegetative defense, not have a cardiodepressive effect, and help reduce intraoperative blood loss.

The prototype of the invention is a method of anesthesia during long-term ENT operations in children (V.A. Sidorov, E.G. Agavelyan, V.A. Mikhelson and others // Anesthesiologists and intensive care. - 2005. - No. 1. - p. 7-8), which consists in premedication with atropine and benzodiazepine, induction of general anesthesia, either by inhalation (N2O / O2 + halotane), or by the intravenous (diprivan 2.5-3.0 mg / kg) method, myoplegia, tracheal intubation, maintenance of anesthesia 5–6 mg / kg * h was diprivan by continuous infusion against the background of oxygen inhalation or a mixture of N2O + O2, or N2O inhalation: O2 = 2: 1 + isoflurane 0.4-0.6%, with m analgesic component bolus or continuous microfluidic fentanyl.

However, this method has some disadvantages, namely:

1. This method of induction is associated with the need for prolonged inhalation of the anesthetic, or with the painful procedure of venipuncture and the introduction of diprivan, which is difficult, given the children's age, structural features of the upper respiratory tract and the localization of tumors in the head and neck.

2. The method does not take into account the initial vegetative tone. The use of halotan contributes to aggravation of sympathicotonia, which is observed in the preoperative period in 52.6% of children (S. A. Pivovarov. // Diss. Dok. Medical sciences. - M., - 2005), and according to our observations, 80 % of children.

3. Bolus induction by propofol leads to a decrease in SBP and DBP by ~ 19.9-20.9% (V. A. Mikhelson, A. E. Voskerchyan // Bulletin of Intensive Care. - 1999 - No. 1).

4. Maintenance of propofol anesthesia throughout the operation contributes to a longer recovery of spontaneous respiration and consciousness compared to anesthesia with sevoflurane for 3 and 5 minutes, respectively.

In this regard, there is a need to search and develop new approaches to anesthesia in this category of patients.

The technical result of the invention consists in achieving an economical mode of operation of the cardiovascular system with rapid induction and exit from anesthesia.

The specified technical result is achieved due to the fact that in the method of anesthesia during operations for head and neck tumors in children, including the determination of the initial autonomic tone in the preoperative period, the detection of sympathicotonia uses a combination of induction with sevoflurane and potentiation with 1% propofol, followed by switching to inhalation of sevoflurane .

The proposed method of anesthesia is carried out as follows: At the stage of preoperative examination, the initial vegetative status is determined using the Kerdo index (IR = 100x (1-diast. BP / HR). If the obtained VIC is greater than "+7", then the initial sympathicotonia is recorded, the patient is given The proposed method of anesthesia: Premedication is carried out in the ward 30 minutes before the operation by intramuscular injection of midazolam 0.2 mg / kg and intravenous administration of atropine 0.01 mg / kg and diphenhydramine 0.8 mg / kg on the operating table. vofluranom 8 vol% in oxygen flow of 10 l / min, maintaining 4-5 vol% sevoflurane in oxygen flow of 1-2 l / min, in a semi-closed loop until the stage IIIA anesthesia. Running catheterization central or peripheral veins.

Myoplegia is carried out by intravenous administration of esmeron of 0.6 mg / kg. Then, 0.005% fentanyl 2 μg / kg is injected intravenously and tracheal intubation is performed. Potentiation of anesthesia is carried out by intravenous micro-injection of 1% propofol at a rate of 5-6 mg / kg per hour. The analgesic component of anesthesia is realized with 0.05% fentanyl 5 ± 0.5 μg / kg while maintaining 2 ± 0.5 μg / kg per hour or intravenous micro-jet administration of fentanyl at a rate of 3-4 μg / kg per hour. At the end of the main, most traumatic stage of the operation, propofol is turned off and 1.5-2 vol% sevoflurane is inhaled in an oxygen flow of 1 l / min. 10 minutes before the end of the operation, the inhalation of sevoflurane is stopped and mechanical ventilation is performed with an oxygen-air mixture.

Therefore, the normalization of heart rate and increased diastolic blood pressure provides sympathovagal balance and hemodynamic stability.

The authors in the available patent and medical literature did not find information about the popularity of the proposed method of anesthesia during operations for head and neck tumors in children. Thus, the claimed invention meets the criterion of "novelty."

When performing anesthesia using this technique, induction is highly controllable and takes 6–9 minutes. Venipuncture is painless. Tracheal intubation in the case of a predicted difficult situation can be performed without the use of relaxants.

According to our studies, the initial sympathicotonia is observed in 80% of patients; therefore, the use of anesthetics with sympathomimetic properties is inappropriate in this case. When propofol is used in continuous micro-jet administration, hypersympathicotonia is suppressed, normalization of blood pressure and heart rate is noted, the Kerdo index decreases to "0" - "+5", which indicates a decrease in the voltage of regulatory mechanisms and the achievement of reliable protection of the body from operational stress. The use of sevoflurane reduces the period of awakening to 10 minutes, promotes the rapid restoration of protective reflexes and spontaneous breathing. Thus, the claimed invention meets the criterion of "inventive step".

To assess the effectiveness of the proposed method of anesthesia, we used the determination of systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, Sp O2 monitor PHILIPS M3046A.

Examples of clinical use of the proposed method

Example No. 1.

Patient Sumskaya T.A., 9.5 years old, weight 44 kg.

The medical history No. 19846 / A.

Diagnosis: Tumor of the maxillary sinus on the left.

Operation: maxillary sinusitis, removal of the tumor.

Before surgery: blood pressure 116/62 (76), heart rate 103 beats / min, vegetative Kerdo index - 40.

Anesthesia was performed according to the proposed method.

Premedication 30 minutes before surgery intramuscularly: dormicum 9.0 mg.

Induction: inhalation of sevoflurane 8 vol.% In an O2 stream of 10 l / min; after 3 minutes, inhalation of sevoflurane 4 vol.% In an O2 stream of 2 l / min, on a half-closed circuit.

After 6 min, the IIIA stage of anesthesia was achieved, venipuncture was performed, 0.1% atropine 0.2 ml, 1% diphenhydramine 0.8 ml, esmeron 27 mg, 0.005% fentanyl 1.5 ml were injected intravenously.

Performed orotracheal intubation of the trachea tube number 6 with a cuff. The patient was transferred to a ventilator using a Fabius + oxygen-air mixture.

Potentiation was carried out by intravenous microjet injection of 1% propofol at a rate of 5 mg / kg per hour.

Analgesia was realized by intravenous microjet administration of 0.005% fentanyl at a rate of 3.5 ml / hour.

70 minutes after the start of anesthesia and at the end of the main stage of the operation, propofol was turned off, sevoflurane 2 vol% in an O2 flow of 1 l / min was started, along a half-closed circuit.

10 minutes before the end of the operation (stage of wound closure), the flow of sevoflurane was stopped, and mechanical ventilation was continued with an oxygen-air mixture.

10 minutes after the end of the operation, spontaneous breathing and consciousness were restored. Reconstruction of the oropharynx, extubation of the trachea.

The hemodynamic data of the patient are presented in table No. 1.

Time (min) Systolic blood pressure Diastolic blood pressure BP mean Heart rate VIC Originally 122 71 84 119 41 3 118 73 83 110 6 112 53 67 108 51 9 104 51 64 95 47 12 116 56 71 one hundred 44 fifteen 108 60 72 91 35 eighteen 111 62 73 87 21 107 63 73 84 24 105 64 73 83 27 107 70 79 85 eighteen thirty 118 74 84 80 33 111 63 75 77 36 117 70 79 75 39 114 73 82 76 four 42 112 73 83 77 45 115 73 82 77 48 116 74 83 75 2 51 116 73 82 73 54 125 83 88 80 57 117 70 79 74 60 114 81 91 87 63 122 79 91 80 2 66 116 67 80 70

69 114 70 81 74 72 114 59 72 65 10 75 118 55 71 70 23 78 116 56 71 74 81 116 62 76 80 23 91 114 70 81 81 101 122 71 84 90 22

Example No. 2.

Patient Mamedagaeva S.P., 16 years old, weight 48 kg.

The medical history No. C-19667 / A.

Diagnosis: nodular formation of the left lobe of the thyroid gland.

Operation: hemithyroidectomy on the left with an isthmus.

Before surgery: blood pressure 115/58 (71), heart rate 95 beats / min, vegetative Kerdo index - 40

Anesthesia was performed according to the proposed method.

Premedication: intramuscularly dormicum, 30 mg 30 minutes before surgery

Induction: inhalation of sevoflurane - 8% by volume in an oxygen stream - 10 l / min. After 7 breaths, inhalation of sevoflurane 5 vol% in an oxygen stream of 2 l / min, on a half-closed circuit.

After 9 minutes from the start of induction, peripheral vein catheterization was performed, 0.1% atropine 0.3 ml, 1% diphenhydramine 1.5 ml, 0.005% fentanyl 2.0 ml, esmeron 30 mg injected intravenously. Sevoflurane has been discontinued.

Performed tracheal intubation with tube No. 7 with a cuff, the patient was transferred to mechanical ventilation with an oxygen-air mixture.

Potentiation: intravenously microjet 1% propofol 6 mg / kg per hour.

Analgesia was realized by intravenous fractional administration of 0.005% fentanyl at the rate of 4.5-2.0 μg / kg. 90 minutes after the start of anesthesia and at the end of the main stage of the operation, propofol was switched off, and sevoflurane 2 vol% was inhaled in a flow of 02 1 l / min, along a half-closed circuit.

10 minutes before the end of the operation (stage of wound closure), the flow of sevoflurane was stopped, and mechanical ventilation was continued with an oxygen-air mixture.

After 7 minutes after the operation was completed, spontaneous breathing was restored, and then after 3 minutes consciousness. Performed extubation of the trachea. After 20 minutes at the end of the operation, the patient was transferred to the postoperative ward.

The hemodynamic data of the patient are presented in table No. 2.

Time (min) Systolic blood pressure Diastolic blood pressure BP mean Heart rate VIC Originally 116 59 73 91 36 3 90 44 54 one hundred 56 6 90 41 52 96 9 94 59 66 95 12 102 51 63 103 51 fifteen 103 66 75 103 eighteen 109 66 77 101 21 114 71 81 99 29th 24 111 72 82 95 27 114 71 81 87 thirty 112 65 77 85 33 111 68 79 83 eighteen 36 110 65 77 80 39 117 71 82 76 7 42 120 72 82 74 45 118 71 81 73 48 115 78 87 78 0

51 123 73 86 75 54 123 75 85 78 57 124 76 86 76 0 60 124 72 84 74 3 63 118 65 75 72 66 114 65 78 70 69 114 69 81 71 3 72 116 61 74 70 75 114 71 81 73 3 78 114 71 81 75 81 119 65 78 70 84 121 68 81 72 87 123 76 85 75 90 118 70 80 72 3 93 114 62 73 70 96 116 61 74 79 99 110 56 70 75 102 108 65 76 78 105 107 60 70 76 22 115 106 57 69 69 eighteen

The number of operated sick children aged 7 to 16 years using the proposed method of anesthesia was 18 people.

The proposed method of anesthesia is easily reproducible in a hospital setting. Thus, the claimed invention meets the criterion of "industrial applicability".

Claims (1)

The method of anesthesia during operations for head and neck tumors in children, which consists in identifying the initial sympathicotonia in the preoperative period, performing standard premedication, intubation of the trachea, characterized in that the induction of anesthesia is carried out by inhalation of sevoflurane, and potentiation until the end of the main stage of the operation is performed by continuous microjet the introduction of 1% propofol, after which the sevoflurane is again inhaled.