RU2598453C1 - Method for regional anaesthesia in ophthalmic-surgical intervention in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to anaesthesiology, and can be used as anaesthesia care in ophthalmic surgeries in children with strabismus, glaucoma, lower injury of orbital wall, gunshot wounds of eye, buckling of retina. Pre-medication is carried out, induction with inhaled anaesthetics with hypnotics, installation of laryngeal mask or intubation of trachea, performing supporting anaesthesia with inhaled anaesthetics. Regional anaesthesia is infraorbital anaesthesia with intra-oral technique in combination with peripheral unit of van Lint. During especially traumatic operations regional anaesthesia is supplemented with palatinal anaesthesia and analgesia is maintained by intravenous administration of analgesic paracetamol, calculated based on patient's body weight.

EFFECT: method improves quality of anaesthesia, and improves efficiency and safety of anaesthesia in children.

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Description

The invention relates to medicine, namely to anesthesiology, and can be used during anesthesia during ophthalmic surgery in children with strabismus, glaucoma, trauma to the lower wall of the orbit, gunshot wounds of the eye, and retinal detachment.

In pediatric ophthalmosurgery, anesthetists rarely resorted to regional anesthesia, with the exception of retrobulbar (or peribulbar) anesthesia, which was mainly performed by ophthalmologists at the request of the anesthesiologist.

However, the following complications are possible with retrobulbar blockade: injury to the eyeball, blood vessels and nerves that nourish and innervate the eyes, hemorrhage in the orbit and the resulting blindness, probably due to injury to the large vein involved in the blood supply to the optic nerve, injury to the optic nerve itself, penetration through the superior orbital fissure in the cavernous sinus, as well as infection. Also, with the introduction of an anesthetic, the development of apnea and oculocardial reflex is possible. With the forced introduction of a local anesthetic into the ophthalmic artery, the direction of blood flow in it changes to the opposite, the drug enters the brain very quickly, which can instantly cause seizures (Weissblat S.N. 2013 - S. 274-276). But now there is a less toxic, relatively strong, almost “ideal” local anesthetic - ropivacaine (napropine).

In children, regional anesthesia should be combined with general, remembering that in pediatric practice the patient’s consciousness should be turned off (Lekmanov A.U., Saltanov A.I. Modern components of general anesthesin in children (Lecture. Part 1) // Bulletin of intensive care . 1999. - No. 2. - S. 14-18).

The authors reviewed approaches to anesthesia in children's ophthalmic surgery, paying particular attention to the widespread introduction of various methods of regional anesthesia into practice, proving its positive effect as a component of multimodal anesthesia, which allows abandoning the use of narcotic drugs, providing a painless way out of anesthesia, giving every chance of an early patient rehabilitation.

As a result of a patent search, the following patents related to ophthalmology were selected for analysis.

RF patent 2110289. The invention is used in anesthesiology for conducting short-term surgical interventions under general anesthesia, for example, in pediatric ophthalmic surgery. The inventive consists in performing premedication according to a standard method and subsequent intravenous administration of solutions of ketamine and fentanyl in a ratio of 1: 2. The technical result consists in a smooth and short period of achievement of the surgical stage of anesthesia without hallucinations, agitation and muscle hypertonicity. The disadvantages of the method: the use of drugs, the severity of pain in the postoperative period.

RF patent 2173972. The invention is used for analgesia in ophthalmic surgery. 30-40 minutes before surgery, Relanium is administered intramuscularly at a dose of 0.14 mg / kg and tramal at a dose of 0.71 mg / kg. 0.2 ml of a 2% lidocaine solution is administered under the conjunctiva. This allows you to increase the effectiveness of pain relief. The disadvantages of the method: insufficient postoperative analgesia.

RF patent 2288721. A well-known method of anesthetics during operations in ophthalmology, including the introduction of short-acting benzodiazepines in the process of sedation and during an ophthalmological operation. During premedication, long-acting benzodiazepines are administered intravenously, then narcotic analgesics are used, and antipsychotics are added for arterial hypertension. Then, regional anesthesia with local anesthetics is performed retrobulbarly, as well as blockade of the wing-palatine ganglion and akinesia of the circular muscles of the eye. The disadvantages of the method: the use of narcotic drugs.

RF patent 2400260. A method for performing retrobulbar anesthesia during band operations on an eyeball, characterized in that a 2% lidocaine solution or 0.5% bupivacaine solution from 4 ml to 5 ml is administered as an anesthetic in 45-60 minutes. before surgery. Muscle relaxation can be achieved using retrobulbar anesthesia and akinesia of the circular muscle of the eye. The disadvantages of the method: the use of retrobulbar anesthesia associated with a number of complications.

RF patent 2304963, selected as a prototype. A method for conducting anesthesia during ophthalmic operations, including premedication, induction of inhaled anesthetics with hypnotics, performing tracheal intubation or installing a laryngeal mask, carrying out anesthesia-maintaining inhalation anesthetics. After introduction into anesthesia, regional anesthesia is performed by introducing a 0.5% solution of napropine into the subten space, and they begin to perform a surgical operation. The disadvantages of the method: the wound of the eyeball, blood vessels and nerves that nourish and innervate the eyes.

The objective of the proposed method is to improve the quality of anesthesia in ophthalmic surgery by introducing into the ophthalmic anesthesiology infraorbital and palatal anesthesia, which are still used in dentistry, to develop effective and safe methods of regional blockade in ophthalmic surgery in children. This goal is achieved through the use of regional anesthesia during ophthalmic surgery in children, including premedication (according to indications), induction by inhalation anesthetics with hypnotics, installation of a laryngeal mask or tracheal intubation (according to indications), and inhalation anesthetics supporting anesthesia, additionally as regional anesthesia, infraorbital anesthesia in combination with the Van Lint peripheral block, and with especially traumatic During operations, regional anesthesia was supplemented with palatal anesthesia, and analgesia was supported by the intravenous administration of a non-narcotic analgesic, paracetamol, calculated on the basis of the patient’s body weight.

Among all existing non-opioid analgesics of systemic action for use in surgical practice, paracetamol is most safe, characterized by the absence of side effects from the central nervous system (impaired consciousness, respiratory depression), the gastrointestinal tract, does not affect the coagulation system and bleeding time, and does not have a toxic effect on the liver and kidneys in therapeutic doses. The analgesic effect of perfalgan occurs within 5-10 minutes after the start of the infusion and reaches a maximum after 1 hour, the maximum analgesic effect is 4-6 hours. To anesthetically protect the patient, paracetamol triggers additional central non-opioid mechanisms unique to paracetamol.

When carrying out the proposed method took into account the anatomical and physiological features of the development and structure of tissues and organs of the maxillofacial region. In connection with the growth of the child, the position of the target points is changing. The infraorbital foramen descends from the infraorbital margin downward at the age of 6-12 years by 1-2 mm, 13-15 years to 4-4.5 mm. The location of the large palatine opening varies slightly towards the border of the soft and hard palate (the target rises with age). For young children, dentists do not recommend entering the canals and suggest injecting an anesthetic solution near the holes, from where it reaches the goal by infiltration.

When developing methods of regional blockades in ophthalmic surgery in children, 81 anesthesiological aids were studied in patients with strabismus, 33 - for injuries of the lower wall of the orbit, 18 - in patients with glaucoma. Children with strabismus were operated on in a planned manner; children with glaucoma, trauma to the lower wall of the orbit and gunshot wounds to the eyes were operated on both in an emergency and in a planned manner

In children in ophthalmic surgery, inhalation anesthesia was used as an induction in anesthesia. To maintain airway patency, a laryngeal mask was used or trachea was intubated (if indicated), before this hypnotic was injected intravenously - 1% propofol solution at the rate of 2 mg / kg.

The amount of anesthetic administered during regional anesthesia is calculated using the formula age / 2. As a local anesthetic used a solution of napropin 0.75%, with the exception of children under 1 year of age, who use 0.2% solution of napropin, children from 1 year to 5 years - 0.5%.

For all ophthalmic interventions, a classic Van Lint peripheral block and infraorbital (oral) anesthesia were performed. For example, this is enough for surgical treatment of strabismus. For more traumatic operations, the use of palatal anesthesia (pterygopalatine-palatal path) is recommended.

The invention is illustrated by the following blockade techniques.

Blockade access classical facial nerve van Lint: 0.5-1 cm laterally from the lateral angle of the eye needle was inserted, was introduced after sample aspiration _^half dose of anesthetic. Then, a subcutaneous injection was performed in the direction of the upper and lower edges of the orbit, where the remaining dose of the anesthetic was distributed equally. When performing blockade of the facial nerve, we use the needle of an insulin syringe.

Technique for palatinal anesthesia:

1. The patient on the operating table with his head thrown back and mouth wide open.

2. The target point is the wing-palatine fossa, located in adults 25-30 mm above the large palatine opening. With this method, they act on the large palatine nerve by injecting an anesthetic into the area of the large palatine opening. An anesthesiologist, after induction in anesthesia and sedation, opens his mouth wide to the patient. It determines the location of the large palatine; for this, two mutually perpendicular lines are drawn. One at the level of the middle of the crown of the third molar (from the gingival margin to the middle of the line of the upper jaw). The other - through the middle of the first and perpendicular to it. The intersection point of these lines will correspond to the projection of the large palatine opening. Or at the level of the middle of the crown from the third molar, in the absence of it - 0.5 cm anterior to the border of the hard and soft palate. After treating the projection site with a 0.05% solution of chlorhexidine bigluconate in a front-down direction, he makes an injection with a 32 mm long and 23 G diameter needle, then the needle goes back and up into the wing-palatine canal, reaching contact with the bone. The tissue in this area is loose and easily permeable to anesthetic. The technique of introducing anesthetic into the wing-palatine fossa is performed in a similar way, but is used only in older children 16-17 years old. When the needle passes through the wing-palatal canal, we feel how it touches the walls of the canal (this indicates that the needle is in the canal). After carrying out an aspiration test, we enter the estimated dose of the anesthetic.

3. With wing-palatine anesthesia, the exposure time is 10 minutes.

4. The duration of anesthesia is 180-360 minutes.

5. Anesthesia zone - the mucous membrane of the hard palate, alveolar ridge from the palatine side, from the third upper molar to the middle of the canine crown, orbital part of the upper jaw.

6. Application - plastic of the lower wall of the orbit, glaucoma.

Method of infraorbital anesthesia

The purpose of this anesthesia is to block the peripheral branches of the infraorbital nerve, and when the anesthetic spreads into the orbit, a blockage of the nerves that innervate the muscles of the eyeball occurs.

The target point is the infraorbital foramen, located in children 0.2-0.4 cm lower from the middle of the infraorbital region.

In accordance with this technique, under aseptic conditions, the anesthesiologist, with his thumb and forefinger, pulls his lip up and slightly forward, exposes the transitional fold, while the middle finger is on the skin of the cheek in the projection of the infraorbital foramen. As far as possible the transitional fold, in order to shorten the path to the target, from the bottom up to the infraorbital region, in the projection: with a temporary bite - between the molar, permanent - between the premolar, and in adults - between the first and second incisors, makes an injection, while the needle advances towards the channel, entering it, then the needle goes backward, outward and upward. Throughout the path of needle advancement, constantly releasing a solution of napropin in small portions, which helps to move the vessels away (prevention of vascular injury). But given the anatomical and physiological features, in particular the narrowness of the channel, the anesthetic can be entered at the entrance to the channel. After the blockade, the place is pressed with a dry swab, and the projection is massaged on the skin.

When performing regional anesthesia, we use an insulin syringe needle. After an aspiration test, we enter the estimated dose of the anesthetic.

At all stages of the operation, the concentration of inhaled anesthetics, capnometry and the level of oxygenation by oxygen were constantly monitored. Intraoperatively controlled heart rate, blood pressure syst., Blood pressure diast., Blood pressure average, ECG cardiomonitor "Infinity". Postoperative pain response was assessed one hour after the intervention on the IRA 4-point verbal pain rating scale.

Clinical example 1. Patient M., 9 years old, weight 33 kg, operated on for left strabismus. Premedication was not carried out. Induction of anesthesia with a gas-narcotic mixture: oxygen, nitrous oxide, sevoflurane. A propofol solution of 1% at the rate of 2 mg / kg was injected intravenously into the laryngeal mask. Then a regional blockade was carried out: the Van Lint block and infraorbital anesthesia with a solution of 0.75% napropine in 1.0 ml (7.5 mg). The monitoring of heart rate, blood pressure syst., Blood pressure diast., BH, SpO2, etCO2, ECG. There was a significant decrease in both systolic and diastolic and average blood pressure after anesthesia, the use of propofol and regional anesthesia. HELL (initial: 100/50; after induction and administration of propofol: 96/47; cf. 73; after blockade: 83/44; 93/47; cf. 71; end of operation: 96/47 mmHg ) The pulse practically did not change (77, 82, 84, 85, 77 beats per minute). BH - 20 per min, SpO2 - 100%, etCO2 - 37. On the ECG - sinus rhythm. An hour later, postoperative pain was assessed using the Wong-Baker rating scale. Made up 0 points, re-examination after an hour - the result is the same.

Clinical example 2. Patient M., 13 years old, weight 53 kg, operated on for a fracture of the lower and upper walls of the orbit on the right. Premedication was not carried out. Induction in anesthesia with a gas-narcotic mixture: oxygen, nitrous oxide, sevoflurane in combination with intravenous administration of 1% propofol solution at the rate of 2 mg / kg. A solution of propofol 1% at the rate of 2 mg / kg was introduced for tracheal intubation. Then a regional blockade was carried out: the Van Lint block with a solution of napropin 0.75% - 2.0 ml, infraorbital and palatal anesthesia with a solution of napropin 0.75% at 1.0 ml (7.5 mg). Analgesia was supported by the intravenous administration of a non-narcotic analgesic paracetamol calculated on the basis of the patient’s body weight. Dosage of paracetamol: from 1-11 years (weighing up to 34 kg) - 15 mg / kg (1.5 ml / kg) up to 4 times a day, the maximum interval between administrations is 4 hours, the maximum daily dose should not exceed 60 mg / kg body weight; adolescents over 12 years old (35-50 kg) 15 mg / kg, the minimum interval between injections is 4 hours, the daily dose is 60 mg / kg; adolescents weighing more than 50 kg - the maximum single dose is 1 g - 1 bottle, the maximum daily dose is 4 g, the interval between injections is 4-6 hours. Intravenous administration of paracetamol was started three minutes before surgery in a dose equal to half the calculated, and continued during the operation.

The monitoring of heart rate, blood pressure syst., Blood pressure diast., BH, SpO2, etCO2, ECG. There was a significant decrease in both systolic and diastolic and average blood pressure after anesthesia, the use of propofol and regional anesthesia. HELL (initial: 120/75; after induction and administration of propofol: 96/47; cf. 73; after blockade: 83/44; 112/55; 107/45; 103/40; 105/41, cf. 71 ; 108/40, cf. - 70; end of operation: 112/55 mmHg). The pulse practically did not change (90, 80, 73, 74, 74, 70, 68, 80, 78, 86 beats per minute). BH - 20 rpm, SpO2 - 99-100%, etCO2 - 38-39. On the ECG - sinus rhythm. An hour later, postoperative pain was assessed according to the Wong-Baker rating scale, and it amounted to 0 points, repeated examination after an hour - the result is the same.

Clinical example 3. Patient P., 17 years old, weight 64 kg, operated on for bilateral strabismus. Premedication was not carried out. Induction of anesthesia with a gas-narcotic mixture: oxygen, nitrous oxide, fluorotan. A propofol solution of 1% at the rate of 2 mg / kg was injected intravenously into the laryngeal mask. Then a regional blockade was carried out: the Van Lint block on the right and left with a solution of napropin 0.75% in 1.5 ml, infraorbital anesthesia on both sides with a solution of napropin 0.75% in 1.0 ml. The monitoring of heart rate, blood pressure syst., Blood pressure diast., BH, SpO2, etCO2, ECG. There was a significant decrease in both systolic and diastolic and average blood pressure after anesthesia, the use of propofol and regional anesthesia. HELL (initial: 115/70; after induction and administration of propofol: 110/65; after blockade: 105/55; 103/50; cf. - 75; end of operation: 103/50 mmHg). The pulse practically did not change (98, 96, 92, 90, 86 beats per minute). BH - 18 rpm, SpO2 - 99-100%, etCO2 - 38-39. On the ECG - sinus rhythm. An hour later, postoperative pain was assessed according to the Wong-Baker rating scale, and it amounted to 0 points, repeated examination after an hour - the result is the same.

The use of combined regional anesthesia with a solution of napropin in combination with inhalation anesthesia gives a sufficient depth of anesthesia and the absence of an additional effect on hemodynamic parameters, prevents the development of an oculocardial reflex. There were no difficulties during blockades and complications after them.

The use of the claimed anesthesia does not provoke the development of an oculogastric reflex, as evidenced by the absence of nausea and vomiting after surgery.

According to the Wong-Baker rating scale, the assessment of pain in the near term is 0 points, which made it possible to abandon postoperative pain management.

Conclusion

The studies were carried out on the basis of the Morozov Children's City Clinical Hospital. Given the analysis of the results of the study, we can conclude that the proposed anesthetic aid for ophthalmic surgery in children with strabismus, glaucoma, trauma to the lower wall of the orbit, gunshot wounds to the eye, namely combined anesthesia with the use of regional anesthesia, is effective: it has a pronounced extended analgesic Effect; allows you to abandon the use of narcotic analgesics; does not require repeated anesthesia in the early postoperative period; gives a sufficient depth of anesthesia and the absence of additional effects on hemodynamic parameters; does not provoke the development of oculocardial and oculogastric reflexes; reduces the time of postoperative fasting; contributes to the rapid rehabilitation of patients.

Claims (2)

1. A method of regional anesthesia for ophthalmic surgery in children, including premedication, induction by inhalation anesthetics with hypnotics, installation of a laryngeal mask or tracheal intubation, and maintenance anesthesia by inhalation anesthetics, regional anesthesia with a napropin solution, characterized in that the region of anesthesia is performed as an inferior anesthesia as anesthesia anesthesia by the intraoral method, supplementing it with the Van Lint peripheral block. 2. The method according to p. 1, characterized in that, in especially traumatic operations, regional anesthesia is supplemented with palatal anesthesia and analgesia is supported by intravenous administration of a paracetamol analgesic calculated on the basis of the patient’s body weight.