RU2540905C1 - Method for preventing pain and psychoemotional responses in endovascular x-ray surgeries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: at the initial stage of the intraoperative period, immediately before the local anaesthesia and the femoral artery puncture, ketorolac tromethamine is administered intravenously as an analgesic, and propofol as a sedative agent. Ketorolac tromethamine is administered in a dose of 15-75 mg, while propofol is administered in a dose of 50-250 mg.

EFFECT: method prevents developing pain and psychoemotional responses caused by the given interventions, including postoperatively by the fast development of the adequate analgesic effect accompanied by the controlled sedation level.

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Description

The invention relates to medicine, namely to anesthesiology, and is intended for clinical practice in the form of intraoperative analgesia and sedation during endovascular x-ray surgical interventions.

A known method of intraoperative analgesia, which is traditional for endovascular and x-ray interventions, using local infiltration anesthesia, including blockade of the femoral nerve (Bunyatyan A.A. Guide to anesthesiology. - 1994. - S.300). The known method is carried out using syringe infiltration of soft tissues of the front-inner surface of the upper third of the thigh with a local anesthetic solution (usually a 0.5% novocaine solution or 2% lidocaine solution). Anesthesia is performed in the position of the patient on the back. The index finger of the left hand determines the pulsation of the position of the femoral artery. The needle is inserted laterally from it, directly under the inguinal fold, on average to a depth of 3-4 cm. The correct position of the needle is indicated by the pulsation of the femoral artery transmitted to it. A solution of local anesthetic in the concentrations recommended above is administered in an amount of 10-15 ml.

Disadvantages: the presence of cardiac pain in the intraoperative period, the presence of undesirable psycho-emotional reactions, namely anxiety and / or depression in the intraoperative period, the presence of pain in the area of the artery puncture in the postoperative period.

A known method of intraoperative analgesia using spinal anesthesia (Morgan J.E., Mikhail S.M. Clinical anesthesiology: first book, 2001. - P.202). The known method is as follows. A solution of local anesthetic (usually ropivacaine or bupivacaine) is injected in the immediate vicinity of the spinal cord. The technique of the method includes ensuring the appropriate position of the patient (usually on the side with the flexion position of the back and lower extremities), antiseptic treatment of the skin, syringe infiltration of soft tissues with a solution of local anesthetic, introduction of a solution of local anesthetic into the epidural or cerebrospinal fluid using a special puncture needle projections of selected segments of the spinal cord.

Disadvantages: the high complexity of the method, namely, the need to perform technically complex manipulations - spinal anesthesia, the presence of undesirable psycho-emotional reactions, namely anxiety and / or depression, in the intraoperative period.

The closest in technical essence to the proposed method is a method of postoperative analgesia and sedation using ataralgesia (Bunyatyan A.A. Guide to anesthesiology. - 1994. - P.233-236). The known method in the prototype is as follows. Atropine and diazepam are administered intramuscularly with the goal of sedation 30-40 minutes before surgery. Induction begins with an inhalation of a mixture of nitrous oxide and oxygen in a ratio of 2: 1 through a mask of anesthesia apparatus. Then, intravenous administration of general non-inhalation anesthetics (thiopental sodium, hexenal), narcotic analgesics (fentanyl) and muscle relaxants (dithilin, tubocurarine, arduan) is performed, after which the trachea is intubated and mechanical ventilation is performed. Specific is the removal of the patient from the state of general anesthesia: the administration of inhaled and non-inhalational anesthetics is stopped, over time, the restoration of independent breathing, an adequate level of consciousness and muscle tone is achieved.

Disadvantages: the high complexity of the method, namely, the need to use additional equipment of a high level of technical complexity, namely oxygen equipment, anesthesia equipment, equipment for artificial lung ventilation, devices for ensuring airway patency, the presence of pain in the area of the artery puncture in the postoperative period .

Effect: ensuring the absence of cardiac pain in the intraoperative period, undesirable psycho-emotional reactions, namely, anxiety and / or depression in the intraoperative period, pain in the area of the artery puncture in the postoperative period.

The technical result is achieved due to the fact that the method of preventing pain and psychoemotional reactions when performing endovascular x-ray interventions, including the use of ketorolac tromethamine as an analgesic and propofol as a sedative at the initial stage of the intraoperative period, characterized in that the ketorolac tromethamine preparations are in a dose of 15 -75 mg (0.5-2.5 ml of the official solution) and propofol at a dose of 50-250 mg (5-25 ml of the official emulsion) are administered intravenously immediately before Making a local anesthesia and puncture of the femoral artery.

Ensuring the absence of cardiac pain in the intraoperative period is achieved by intravenously administering ketorolac tromethamine at a dose of 15-75 mg (0.5-2.5 ml of the official solution) and propofol at a dose of 50-250 mg (5-25 ml of the official emulsion) immediately before performing local anesthesia and femoral artery puncture.

Ensuring the absence of undesirable psycho-emotional reactions, namely, anxiety and / or depression in the intraoperative period, is achieved by the fact that propofol is administered intravenously at a dose of 50-250 mg (5-25 ml of the official emulsion) immediately before performing local anesthesia and puncture of the femoral artery.

Ensuring the absence of pain in the area of the puncture of the artery in the postoperative period is achieved by intravenously administering ketorolac tromethamine at a dose of 15-75 mg (0.5-2.5 ml of the official solution) immediately before performing local anesthesia and puncture of the femoral artery.

In the inventive method, unlike analogues, ketorolac tromethamine is administered at a dose of 15-75 mg (0.5-2.5 ml of the official solution) and propofol at a dose of 50-250 mg (5-25 ml of the official emulsion) is administered the time of the intraoperative period immediately before performing local anesthesia and femoral artery puncture.

The advantages of the proposed method are the absence of cardiac pain in the intraoperative period, the absence of undesirable psycho-emotional reactions, namely anxiety and / or depression in the intraoperative period, the absence of pain in the area of the artery puncture in the postoperative period.

Distinctive techniques of the proposed method are: intravenous administration of ketorolac tromethamine at a dose of 15-75 mg (0.5-2.5 ml of the official solution) and propofol at a dose of 50-250 mg (5-25 ml of the official emulsion) during endovascular x-ray interventions immediately before local anesthesia and femoral artery puncture.

The use of intravenous administration of ketorolac tromethamine and propofol provides the possibility of rapid development of an algetic effect with a rapidly achieved and controlled level of sedation. The inventive method does not have side effects, subject to the implementation technique, which consists in the slow introduction of propofol 50 mg (5 ml of the official emulsion) with pauses of 1-2 minutes to assess the level of sedation. Upon reaching a level of sedation corresponding to the level of consciousness "moderate stunning" or "deep stunning", you should stop the introduction of propofol. The rate of administration of ketorolac tromethamine in a dose of 15-75 mg does not affect the safety of the method.

A comparative analysis of the proposed solution with the prototype allows us to conclude that the claimed invention meets the conditions of patentability: it is new, has an inventive step and is industrially applicable.

The proposed method allows to obtain the technical result perceived by the applicant - ensuring the absence of cardiac pain in the intraoperative period, undesirable psycho-emotional reactions, namely anxiety and / or depression in the intraoperative period, pain in the area of the artery puncture in the postoperative period, reducing the complexity of the method.

The inventive method is as follows.

The introduction of drugs is carried out at the initial stage of the intraoperative period immediately before performing local anesthesia and femoral artery puncture.

The drug Ketorolac tromethamine in an amount of 15-75 mg (0.5-2.5 ml of the official solution) is injected into a central or peripheral vein, accessible for venipuncture, using a single-use syringe. The rate of administration is variable and not critical.

The drug propofol in an amount of 50-250 mg (5-25 ml of the official emulsion) is injected into a central or peripheral vein accessible for venipuncture using a single-use syringe. The mode of administration is as follows: 50 mg (5 ml of the official emulsion) is administered intravenously bolus in 10-30 seconds; a pause is made to assess the level of sedation achieved; with a sufficient level of sedation, the administration of propofol stops; if there is insufficient or no sedation, a repeat bolus injection is performed in a similar mode until clinical signs of severe sedation appear. The total dose of propofol can be from 50 to 250 mg (i.e., from 5 to 25 ml of an official emulsion).

The result is the absence of cardiac pain in the intraoperative period; the absence of undesirable psycho-emotional reactions, namely, anxiety and / or depression in the intraoperative period; the absence of pain in the area of puncture of the artery in the postoperative period. The duration of sedation is from 30 to 60 minutes, which is fully consistent with the duration of most endovascular x-ray surgical procedures, namely, coronarography, stenting of the coronary arteries.

The minimum dose of ketorolac tromethamine is 15 mg (0.5 ml of the official solution), as a lower dose is ineffective. The maximum dose of ketorolac tromethamine is 75 mg (2.5 ml of the official solution), as a large dose is associated with a risk of developing overdose effects (nausea, vomiting, poor health).

The minimum dose of propofol is 50 mg of the active substance (i.e. 5 ml of the official emulsion), because a lower dose is ineffective. The maximum dose of propofol is 250 mg of the active substance (i.e. 25 ml of the official emulsion), because a large dose is subtoxic for the vast majority of patients and leads to pharmacological depression of the respiratory center, which creates a risk of death, the need for mechanical ventilation and the use of additional time to remove the patient from deep sedation / anesthesia.

The optimal dose of ketorolac tromethamine for the absolute statistical majority of patients is 30 mg (1 ml of the official solution). The optimal dose of propofol is determined empirically in the range of 50-250 mg according to the above administration regimen, but, nevertheless, for most patients it is 100 mg (10 ml of the official emulsion).

The proposed method is illustrated by examples of specific performance.

Example 1

Patient Sobolev Pyotr Andreevich, 56 years old, medical history No. 07520/2, diagnosis: "IHD, unstable angina, acute coronary syndrome", study date: 05/14/2012. Coronarography was performed according to indications in the department of X-ray diagnostic and treatment methods. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 1 ml of the official solution intravenously + propofol 10 ml of the official emulsion intravenously (2 boluses of 5 ml for 20 seconds with an interval of 1 minute) immediately before performing local infiltration anesthesia and puncture of the femoral arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 25 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 14 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 2

Patient Polyakov Sergey Ivanovich, 58 years old, medical history No. 07522/2, diagnosis: "IHD, unstable angina, acute coronary syndrome", study date: 05/17/2012. Coronarography was performed according to indications in the department of X-ray diagnostic and treatment methods. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 2.5 ml of the official solution intravenously + propofol 25 ml of the official emulsion intravenously (5 boluses for 20 seconds in 1 minute interval) immediately before performing local infiltration anesthesia and puncture of the femoral artery . The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 26 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 13 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 3

Patient Krylov Alexander Vladimirovich, 65 years old, medical history No. 07526/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary arteriosclerosis, risk of CVD III-IV st.", Study date: 05/14/2012 By Coronary angiography was performed in the conditions of the department of X-ray diagnostic methods for diagnosis and treatment. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 1 ml of the official solution intravenously + propofol 10 ml of the official emulsion intravenously (2 boluses of 5 ml for 20 seconds with an interval of 1 minute) immediately before performing local infiltration anesthesia and puncture of the femoral arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 24 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 13 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 4

Patient Mukhin Yuri Vitalievich, 67 years old, medical history No. 07527/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary arteriosclerosis, risk of CVD III-IV st.", Study date: 05/14/2012 By Coronary angiography was performed in the conditions of the department of X-ray diagnostic methods for diagnosis and treatment. Prevention / treatment of postoperative pain syndrome was performed by the claimed method: ketorolac tromethamine 0.5 ml of the official solution intravenously + propofol 5 ml of the official emulsion intravenously (1 bolus for 20 seconds) immediately before performing local infiltration anesthesia and puncture of the femoral artery. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 27 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 14 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 5

Patient Samoilov Alexander Sergeevich, 68 years old, medical history No. 07531/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary arteriosclerosis, risk of CVD III-IV st.", Study date: 05/15/2012 By Coronary angiography was performed in the conditions of the department of X-ray diagnostic methods for diagnosis and treatment. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 1 ml of the official solution intravenously + propofol 10 ml of the official emulsion intravenously (2 boluses of 5 ml for 20 seconds with an interval of 1 minute) immediately before performing local infiltration anesthesia and puncture of the femoral arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 23 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 14 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 6

Patient Danilov Mikhail Ilyich, 65 years old, medical history No. 07534/2, diagnosis: "IHD, unstable angina, acute coronary syndrome", study date: 05/23/2012. Coronary stenting was performed according to the indications in the department of X-ray diagnostic and treatment methods. arteries. Prevention / treatment of postoperative pain syndrome was performed by the claimed method: ketorolac tromethamine 2.0 ml of an official solution intravenously + propofol 20 ml of an official emulsion intravenously (4 boluses of 5 ml for 20 seconds in 1 minute interval) immediately before local infiltration anesthesia and femoral puncture arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 25 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 13 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 7

Patient Maksimov Yuri Vadimovich, 76 years old, 07534/2, diagnosis: "IHD, unstable angina pectoris, acute coronary syndrome", study date: 05/23/2012. Coronary artery stenting was performed according to indications in the department of X-ray diagnostic and treatment methods. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 2 ml of the official solution intravenously + propofol 20 ml of the official emulsion intravenously (4 boluses of 5 ml for 20 seconds in 1 minute interval) immediately before performing local infiltration anesthesia and puncture of the femoral arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 26 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 14 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 8

Patient Gordeev Anatoly Vladimirovich, 68 years old, 07537/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary arteriosclerosis, risk of CVD III-IV art.", Study date: 05/25/2012 According to indications in conditions Department of X-ray diagnostic methods of diagnosis and treatment performed stenting of the coronary artery. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 1 ml of the official solution intravenously + propofol 10 ml of the official emulsion intravenously (2 boluses of 5 ml for 20 seconds with an interval of 1 minute) immediately before performing local infiltration anesthesia and puncture of the femoral arteries. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 24 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 13 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 9

Patient Kotov Gennady Ivanovich, 59 years old, 07538/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary artery atherosclerosis, risk of CVD III-IV st.", Study date: 05/25/2012 According to indications in conditions Department of X-ray diagnostic methods of diagnosis and treatment performed stenting of the coronary artery. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 0.5 ml of the official solution intravenously + propofol 5 ml of the official emulsion intravenously (1 bolus for 20 seconds) immediately before performing local infiltration anesthesia and puncture of the femoral artery. The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on a visual analogue scale - means complete absence of pain, the maximum level of anxiety - 25 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning ( 14 points on the Glasgow scale). Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

Example 10

Patient Ivanov Andrei Aleksandrovich, 67 years old, 07542/2, diagnosis: "IHD, stable angina pectoris, FC III-IV, coronary arteriosclerosis, risk of CVD III-IV st.", Study date: 05/31/2012 According to indications in conditions Department of X-ray diagnostic methods of diagnosis and treatment performed stenting of the coronary artery. Prevention of intraoperative pain and unwanted psychoemotional reactions was performed by the claimed method: ketorolac tromethamine 1 officinal solution intravenously + propofol 10 ml of official emulsion intravenously (2 boluses of 5 ml for 20 seconds in 1 minute interval) immediately before performing local infiltration anesthesia and puncture of the femoral . The complete absence of intraoperative development of pain and psychoemotional reactions was noted: the maximum level of pain - 0 points on the visual analogue scale - means complete absence of pain, the maximum level of anxiety - 26 points on the Spielberger situational anxiety scale - means its actual absence, level of consciousness - moderate stunning - 14 points on the Glasgow scale. Confirmed the absence of postoperative pain in the area of the puncture of the femoral artery.

The method was applied in 100 patients with indications for endovascular x-ray interventions. A total of 200 patients were examined with indications for endovascular X-ray interventions. The studies were conducted throughout the intraoperative and first days of the postoperative period. The data obtained are statistically significant and are presented in table 1.

Thus, from the data given in table 1, it follows that improving the quality of analgesia / sedation during endovascular x-ray interventions is possible using the proposed method. The data in table 1 show that under the influence of the combined preventive intravenous administration of ketorolac tromethamine and propofol, the effectiveness indicators of intraoperative analgesia / sedation statistically significantly change in a positive direction. The clinical parameters of the adequacy of analgesia and sedation under the conditions of application of the known and claimed methods are different in absolute and relative magnitude, the difference between them exceeds 99%, i.e. differences are statistically significant.

Thus, the claimed method, unlike the known one, allows the development of pathological conditions characteristic of endovascular X-ray surgical interventions, namely intraoperative cardiac pain syndrome, intraoperative psychoemotional discomfort and postoperative pain syndrome in the area of the femoral artery puncture simultaneously. The latter does not occur when applying analog methods.

Technical and economic effect

The use of the proposed method at present in the Voronezh Regional Clinical Hospital No. 1 allows to ensure the absence of cardiac pain in the intraoperative period, undesirable psycho-emotional reactions, namely anxiety and / or depression in the intraoperative period, pain in the area of the artery puncture in the postoperative period, to reduce the complexity of the method in the postoperative period - in all cases of endovascular x-ray surgery.

Claims (1)

A method for the prevention of pain and psychoemotional reactions when performing endovascular x-ray surgical interventions, including the use of ketorolac tromethamine as an analgesic and propofol as a sedative at the initial stage of the intraoperative period, characterized in that the ketorolac tromethamine at a dose of 15-75 mg and propofol at a dose of 50 -250 mg is administered intravenously immediately before performing local anesthesia and femoral artery puncture.