RU2557882C1 - Method of carrying out premedication in planned surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: phenazepamum 1.0 mg is prescribed per os to patient on the eve of planned operation; then, in pre-narcosis room after catheterisation of peripheral vein suprastinum in dose 0.3 mg/kg of patient's body weight and atropine in dose 0.01 mg/kg of patient's body weight are introduced intramuscularly 30 minutes before operation. After that, solution of dexmedetomidine with concentration 4.0 mkg/ml in dose 1.0 mcg/kg of patient's body weight is introduced by intravenous infusion by syringe-batcher for 10 min.

EFFECT: method ensures optimal level of sedation and stability of haemodynamics indexes at the background of reduction of patient's psycho emotional stress and preservation of their contact with medical staff.

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Description

The invention relates to medicine, namely to anesthesiology, and can be used as premedication before anesthesiology aid in planned surgical treatment of patients.

From the practice of medicine, methods for premedication using antihistamines, tranquilizers, anticholinergics, antipsychotics, narcotic analgesics and other groups of drugs before surgical operations performed under general anesthesia are known. For example, 2 hours before surgery, 1-2 tablets (0.5-1.0 mg) per os are prescribed phenazepam, 1.0 mg / kg suprastin (but not more than 30.0 mg), atropine are prescribed for 45-60 minutes 0.3-0.6 mg intramuscularly, promedol 0.2-0.3 mg / kg intramuscularly ("Anesthesiology and Intensive Care", authors A. A. Bunyatyan, G. A. Ryabov, A. Z. Manevich, Moscow , publishing house “Medicine”, 1977, p. 174); or 2 hours before general anesthesia, diprazine 0.8 mg / kg is prescribed intramuscularly, 40 minutes before general anesthesia, diphenhydramine 0.3 mg / kg is prescribed intramuscularly (or suprastin 0.6 mg / kg intramuscularly), promedol 0.3 mg / kg intramuscularly, atropine 0.01 mg / kg intramuscularly (Manual of Anesthesiology, edited by Prof. A. Bunyatyan, second stereotyped publication, Moscow “Medicine” 1997, p. 142).

However, the known methods of sedation used in the treatment of surgical patients in a planned manner, with their use have the following disadvantages:

- do not prevent the development of psycho-emotional stress, discomfort, feelings of anxiety and anxiety of patients;

- lead to disorientation of the patient;

- make it difficult for medical personnel to contact the patient;

- insufficient sedation leads to increased release of endogenous catecholamines. As a result, tachycardia, hypertension, vasoconstriction develop, oxygen consumption increases;

- do not provide sufficient amnesia;

- do not provide adequate protection for the neurovegetative system.

A known analogue is the prototype - a method of sedation, which consists in the use of drugs, namely: on the day of surgery at 6-7 a.m., diazepam 0.14 mg / kg is prescribed intramuscularly, 40 minutes before general anesthesia, diazepam 0.14 mg / kg is prescribed intramuscularly, droperidol 0.07 mg / kg intramuscularly, atropine 0.01 mg / kg intramuscularly (Manual of Anesthesiology, edited by Prof. A. Bunyatyan, second stereotyped publication, Moscow “Medicine” 1997, p. 141).

However, the application of this method cannot provide the necessary level of sedation, which helps prevent the development of psycho-emotional discomfort, does not provide sufficient amnesia, the patient’s contact with medical personnel is difficult, the patient is disoriented, droperidol is used in this method of sedation to stabilize hemodynamic parameters, which should be considered as an additional drug load on the patient’s body.

The proposed method of sedation is aimed at improving the psychoemotional status of the patient and achieving stability of the main indicators of homeostasis in the perioperative period with planned surgical interventions.

The specified technical result is achieved by the fact that the patient on the evening before the scheduled operation is prescribed per os phenazepam 1.0 mg; then, in an anesthesia chamber, 30 minutes before surgery after peripheral vein catheterization, suprastin at a dose of 0.3 mg / kg of the patient’s body weight and atropine at a dose of 0.01 mg / kg of the patient’s body weight are intramuscularly administered, followed by intravenous infusion using a syringe of the dispenser for 10 min, a solution of dexmedetomidine with a concentration of 4.0 μg / ml at a dose of 1.0 μg / kg of the patient’s body weight is administered, while before, during and after administration of the drugs, continuous monitoring of blood pressure, pulse, and saturation is performed oxygen, EC G and respiratory rate.

The use of “small” tranquilizers in sedation in the evening on the eve of a planned surgical intervention makes it possible to reduce the patient’s emotional experiences in connection with the upcoming operation and to avoid undesirable consequences of these experiences, as well as to ensure normal sleep. To this end, in this method of sedation on the evening before the operation, 1.0 mg phenazepam is prescribed per os, this drug is selected due to its availability and safety when used in the indicated dosage.

A special place in the proposed method of sedation is occupied by antihistamines. The use of this group of drugs in premedication is justified by the fact that it prevents the development of the effects of histamine, which is produced both as a result of a stress reaction, and due to the histamine-laboratory properties of some drugs used during anesthesiology. The use of suprastin at a dose of 0.3 mg / kg of the patient’s body weight intramuscularly for this purpose provides high efficiency, optimal duration and safety when using this drug.

Traditionally, anticholinergics are used in premedication. They are necessary to block the reflexes of the vagus nerve and reduce the secretion of mucus in the bronchial tree. For this purpose, atropine at a dose of 0.01 mg / kg of the patient’s body weight is used in this method of sedation, the drug is administered intramuscularly. The named dosage and route of administration provide optimal duration, effectiveness and safety when using this drug.

The use of dexmedetomidine in premedication can solve several problems. Firstly, the effect of this drug on brain stem structures responsible for sleep and wakefulness provides moderate patient sedation, which is manifested in the occurrence of a special condition similar to physiological sleep. This avoids the psycho-emotional stress before the surgery and the undesirable consequences of situational injury, which are expressed, inter alia, in the excessive production of catecholamines. Secondly, a feature of the action of this drug is that, despite an adequate level of sedation, the patient’s contact with medical personnel is maintained. Thirdly, the sympatolytic effect of dexmedetomidine, which is undesirable in other situations, consisting in a mild hypotensive effect and a decrease in the heart rate, in sedation, allows to ensure the stability of hemodynamic parameters in the preoperative period and during tracheal intubation, and other methods of sedation use droperidol for this purpose. Fourth, dexmedetomidine has weak analgesic and anesthetic properties, which are especially useful in patients with pain, in addition, dexmedetomidine potentiates the effect of anesthetics during general anesthesia.

The most effective and safe route of administration of dexmedetomidine is diluted intravenous infusion using a controlled infusion device. The infusion of a solution of dexmedetomidine with a concentration of 4.0 μg / ml using a syringe dispenser at a dose of 1.0 μg / kg of patient body weight lasting 10 minutes is convenient in technical design compared to continuous infusion and allows for an adequate level of sedation, patient access to contact with medical personnel in the preoperative period and the stability of hemodynamic parameters before surgery and during tracheal intubation.

Given the pharmacokinetics of dexmedetomidine, the optimal time to start administration of the drug is the period 30 minutes before surgery.

To monitor the patient's condition and the effect of the drugs administered before, during and after their administration, monitoring is performed for blood pressure, pulse, oxygen saturation, ECG and respiratory rate.

The proposed method was tested on 58 patients undergoing surgical treatment on the basis of the NIH MSC in Astrakhan in 2013-2014.

Below are the results of testing.

Example 1. Patient B., 52 years old, weight 86.0 kg, was routinely admitted to the surgical department of the city hospital of the NIH MCH in Astrakhan for chronic calculous cholecystitis to perform elective cholecystectomy with laparoscopic access.

The patient complains of periodically occurring pain in the right hypochondrium caused by eating.

An ultrasound examination of the abdominal cavity revealed a thickening of the walls of the gallbladder and the presence of many small stones in its lumen. Inspected by an anesthetist.

On the evening before surgery, the patient was prescribed phenazepam at a dose of 1.0 mg per os.

On the morning of the day of surgery, the patient was transported to an anesthetic ward, where continuous monitoring of blood pressure, pulse, oxygen saturation, respiratory rate, and an electrocardiogram was started.

Then peripheral vein catheterization was performed using a peripheral venous catheter.

30 minutes before the induction of anesthesia intramuscularly in different syringes are introduced:

- suprastin 2% solution at the rate of 0.3 mg / kg of patient body weight;

- atropine 0.1% solution at the rate of 0.01 mg / kg of patient body weight. Then, an intravenous infusion of dexmedetomidine was started. The infusion was carried out using a syringe dispenser, into which a working solution with a concentration of dexmedetomidine 4.0 μg / ml was refilled; for its preparation, the contents of an ampoule - 2.0 ml of a solution with a concentration of dexmedetomidine 100.0 μg / ml was diluted in 48.0 ml 0 , 9% sodium chloride solution. The dose of dexmedetomidine was selected at the rate of 1 μg / kg. The patient received 86.0 μg of dexmedetomidine within 10 minutes, which corresponds to 21.5 ml of working solution.

After the infusion of dexmedetomidine, the patient’s sedation level was assessed according to the Ramsey scale, which corresponded to level 3 - moderate sedation, the patient is conscious, responds to commands.

Then the patient was transported to the operating room, where continued continuous monitoring of blood pressure, heart rate, oxygen saturation, respiratory rate and electrocardiogram.

The induction of general anesthesia has begun - after inhalation of oxygen through the face mask for 5 minutes, the patient is injected with fentanyl 0.005% - 0.1 mg intravenously, propofol 1% - 200.0 mg intravenously, then, as soon as the surgical stage of anesthesia is reached, III _{1-2 is} administered leafenone 2% - 160.0 mg intravenously and direct laryngoscopy was performed with tracheal intubation with an endotracheal tube with a diameter of 7.0 mm, the cuff was inflated, and mechanical ventilation was started.

During premedication and induction of general anesthesia, blood pressure indicators were in the range 110 / 70-125 / 80 mm Hg, pulse 60-80 in 1 min, oxygen saturation 98-99%, respiratory rate before the introduction of listenone 15-16 in 1 min, no significant changes were observed on the ECG.

Example 2. Patient K., 47 years old, weight 70 kg, was routinely admitted to the surgical department of the city hospital of the NIH MSH in Astrakhan with a diagnosis of ventral hernia to perform planned herniation with plastic of the anterior abdominal wall with a polypropylene mesh.

The patient complains of the presence of hernial protrusion in the abdomen, periodic pain in it.

The patient is examined by an anesthetist.

On the evening before surgery, the patient was prescribed phenazepam at a dose of 1.0 mg per os.

On the morning of the day of surgery, the patient is transported to an anesthetic ward, where continuous monitoring of blood pressure, heart rate, oxygen saturation, respiratory rate and an electrocardiogram is started.

Then peripheral vein catheterization was performed using a peripheral venous catheter.

In 30 minutes before the induction of anesthesia intramuscularly in different syringes are introduced:

- suprastin 2% solution at the rate of 0.3 mg / kg of patient body weight;

- atropine 0.1% solution at the rate of 0.01 mg / kg of patient body weight.

Then, an intravenous infusion of dexmedetomidine was started. The infusion was carried out using a syringe dispenser, into which a working solution with a concentration of dexmedetomidine 4.0 μg / ml was refilled; for its preparation, the contents of an ampoule - 2.0 ml of a solution with a concentration of dexmedetomidine 100.0 μg / ml was diluted in 48.0 ml 0 , 9% sodium chloride solution. The dose of dexmedetomidine was selected at the rate of 1 μg / kg. 70.0 μg of dexmedetomidine, which corresponds to 17.5 ml of the working solution, was administered to the patient within 10 minutes.

After the infusion of dexmedetomidine, the patient’s sedation level was assessed according to the Ramsey scale, which corresponded to level 3 - moderate sedation, the patient is conscious, responds to commands.

Then the patient was transported to the operating room, where continued continuous monitoring monitoring of blood pressure, pulse, oxygen saturation, respiratory rate and electrocardiogram.

The induction of general anesthesia has begun - after inhalation of oxygen through the face mask for 5 minutes, the patient was administered fentanyl 0.005% - 0.1 mg intravenously, propofol 1% - 200.0 mg intravenously, then, as soon as the surgical stage of anesthesia is reached, III _{1-2 is} administered listenone 2% - 140.0 mg intravenously and direct laryngoscopy was performed with tracheal intubation with an endotracheal tube with a diameter of 8.0 mm, the cuff was inflated, mechanical ventilation was started.

During premedication and induction of general anesthesia, blood pressure indicators were in the range 110 / 70-120 / 80 mm Hg, pulse 60-80 in 1 min, oxygen saturation 98-99%, respiratory rate before the introduction of listenone 14-16 in 1 min, no significant changes were observed on the ECG.

The proposed method for premedication improves the condition of patients in the perioperative period with planned surgical interventions. It is expressed in

- reducing the patient’s psychoemotional stress before surgery,

- achieving an optimal level of sedation,

- ensuring adequate patient contact with medical personnel,

- reducing the severity of the stress response in the perioperative period,

- stability of peripheral hemodynamics in the perioperative period without the use of droperidol and thus reducing the drug load on the patient's body.

Claims (1)

The method of premedication in planned surgical treatment by using medications, characterized in that the patient is prescribed phenazepam 1.0 mg on the evening before the scheduled surgery per os; then, in an anesthesia chamber, 30 minutes before surgery after peripheral vein catheterization, suprastin at a dose of 0.3 mg / kg of the patient’s body weight and atropine at a dose of 0.01 mg / kg of the patient’s body weight are intramuscularly administered, followed by intravenous infusion using a syringe of the dispenser for 10 min, a solution of dexmedetomidine with a concentration of 4.0 μg / ml at a dose of 1.0 μg / kg of the patient’s body weight is administered, while before, during and after administration of the drugs, continuous monitoring of blood pressure, pulse, and saturation is performed oxygen, EC G and respiratory rate.