RU2599044C1 - Method of high spinal anaesthesia in operations on top floor of abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to anaesthesiology. In a patient side position performed is a middle or a paramedian access. After local anaesthesia puncture is performed at the level of LIV-LV with a needle of diameter 25 G and less. Introduced into the subarachnoid space are 40 mg of 2 % lidocaine solution, herewith the edge of the needle during puncture of the dura mater and verification of the subarachnoid space is directed sagittally right or left. Then introduced is an isobaric marcaine solution in the total dose of 15-20 mg, while placing the needle edge maximum cranially, herewith the time of a single-stage introduction of marcaine with bubbling liquor in the amount of up to 5-10 ml is equal to 1-2 minutes. Further regulation of the block development and control over the block is done by inclination of the head end of the table to 45-60° and controlled by noninvasive measurement of blood pressure and heart rate.

EFFECT: method enables to combine positive properties of subarachnoid anaesthesia meaning simplified, fast start, prolonged analgetic and myorelaxing effect, besides, softer and easier postoperative period, faster postoperative rehabilitation of patients, no need for a long myoplegia (intraoperative and postoperative), no period of postanesthetic depression, no need for an artificial pulmonary ventilation.

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Description

The present invention relates to medicine, namely to anesthesiology and can be used as regional anesthesia in abdominal surgery when performing operations on the upper floor of the abdominal cavity.

A known method of using artificial lung ventilation (IVL) during surgical interventions on the upper floor of the abdominal cavity (Ryabov G.A., Semenov V.N., Terentyeva L.M. Emergency anesthesiology. - M .: Medicine, 1983). This method consists in the fact that 1 hour before the start of the operation, promedol 0.3 mg / kg, seduxen (relanium) - 0.1 mg / kg, diphenhydramine 0.25 mg / kg and atropine 0.003 mg / kg are administered intramuscularly to the patient. Induction is carried out by fractional administration of seduxen (relanium) 2.5 mg to a total dose of 0.17-0.2 mg / kg in combination with fentanyl (0.008 mg / kg) under conditions of mechanical ventilation.

The disadvantages of this method include inhibition of spontaneous breathing in a patient as a result of the influence of drugs and anesthetics, the presence of a long period of post-anesthetic depression, as well as a number of possible complications associated with tracheal intubation and mechanical ventilation.

Closest to the proposed technical essence is the method of simultaneous spinal anesthesia (Complications and side effects of spinal anesthesia / A. A. Semenikhin, V. B. Shumatov, V. P. Mazaev, // Anesthesiology and intensive care. - M.: “Medicine ", 1991. - No. 4. - S. 59-63). Its essence lies in the fact that the patient undergoes spinal anesthesia by performing subarachnoid blockade. In this case, puncture of the dura mater with a thin needle (22 G) is performed with the simultaneous administration of a solution of local anesthetics.

The disadvantage of using this method of anesthesia when performing surgery on the upper floor of the abdominal cavity is that when performing puncture of the dura mater at the level of L1-L2, there is a risk of damage to the structures of the spinal cord (cauda equina), while puncture of the dura mater at the level of L1-L2 frequency arterial hypotension reaches 44%.

The objective of the invention is the development of a method of simultaneous high spinal anesthesia, with the development of a high neuromuscular block to the level of the first or second thoracic vertebrae (Th2-1), allowing surgical intervention on the upper floor of the abdominal cavity.

The method is as follows. Before the operation, the patient is premedicated using narcotic or non-narcotic analgesics according to the generally accepted method (depending on the estimated volume of surgical intervention). High spinal simultaneous anesthesia is performed by median or paramedial access, taking into account age-related changes (paramedial access is preferred). The greatest advantage is the position of the patient lying on his side ("in the fetal position"). After local anesthesia, a small diameter needle (25 G or less) is punctured in a typical place (at the level of LIV-LV) and a solution of lidocaine 2% - 2.0 (40 mg) is introduced into the subarachnoid space. In this case, the needle section during puncture of the dura mater and verification of the subarachnoid space is directed sagittally (to the right or left) in order to reduce trauma to the dural membrane of the spinal cord. During the introduction of the isobaric solution of marcaine (in a total dose of 15-20 mg), the needle section is positioned as cranially (upward) as possible in order to spread the anesthetic solution to the upper parts of the spinal column. The time of one-stage administration of anesthetic with bubbling liquor in a volume of up to 5-10 ml is (on average) 1-2 minutes, which allows you to create a high degree of turbulence of the injected solution, and also contributes to the distribution of vortex flows in the cranial direction of the cerebrospinal fluid with the aim of distributing the anesthetic further injection sites and the formation of adequate and prolonged sympathicolysis.

Further regulation of the development of the block and control of the blockade is carried out by changing the position of the operating table: by tilting the head end of the table to 45-60 ° and is controlled by non-invasive measurement of blood pressure, heart rate monitoring by pulse oximetry up to 65 per min. The result is the development of the neuroaxial block up to the level of the first and second thoracic vertebrae (Th1-2). Sedation of the patient is carried out with a phenazepam solution - 1 mg (1.0 ml) at the same time or fractionally during the entire time of surgery.

All patients undergo oxygen inhalation through a face mask or nasal catheters - 4.0 l / min. The sensory and motor blocks of the neuroaxial blockade are evaluated. After reaching the level of the first - second thoracic vertebra (Th1-2), surgery is performed under balanced high spinal anesthesia: with adequate infusion-correcting therapy, the volume of which depends on intraoperative losses - but not less than 1500-2000 ml, crystalloid solutions are usually used .

In the postoperative period, non-narcotic analgesics are used for pain relief: 4-6 hours after performing high spinal anesthesia when the first signs of recovery of pain, motor and sensitive innervation appear.

The average duration of the operation with high spinal anesthesia was 3.4 ± 0.5 hours: maximum - 4 hours 05 minutes; minimum - 1 hour 10 minutes. The correction of the level of high spinal anesthesia was performed intraoperatively by changing the angle of inclination of the head end of the operating table - to a maximum of 60 °. Monitoring is carried out according to the state of hemodynamics: non-invasive measurement of blood pressure, heart rate monitoring, oxygenopulsometry and pain sensitivity. The effectiveness of analgesia was monitored by the analog-visual pain scale.

In simplicity and technique, as well as in material support, high spinal anesthesia is close to spinal anesthesia, but unlike it, it provides a sufficient, long-lasting and high level of anesthesia of the abdominal organs (both on the lower, middle and upper floors).

Compared with the “traditional” methods of pain relief with high spinal anesthesia, the risk of thromboembolic complications is reduced, the amount of blood loss is reduced, the risk of complications from the respiratory and cardiovascular systems is reduced, the duration of postoperative intestinal paresis is reduced compared with the systemic administration of promedol and other opioids.

The proposed method is illustrated by clinical examples.

Example 1: Patient L., 83 years old, was admitted to the hospital for emergency reasons with complaints of pain in the epigastrium, right hypochondrium, nausea, vomiting, jaundice, general weakness. From the anamnesis it was found out: he suffers from gallstone disease for several years, notes a paroxysmal course. In 2013, the patient noted jaundice after an attack, was treated conservatively. During the examination and conservative treatment, an increase in jaundice up to 305 μmol / L was observed in dynamics. The patient's condition remained severe, the skin was intensively icteric, the pulse was 80 per minute, blood pressure was 140/80 mm Hg. The tongue is moist, covered with a whitish coating. The abdomen is soft, painful in the right hypochondrium. Symptoms of peritoneal irritation are negative. The urine is dark. Feces are white. Further examined: ultrasound - expansion of the common bile duct, sclerosis of the gallbladder. The diagnosis was established: gallstone disease, acute calculous cholecystitis, increasing obstructive jaundice, liver failure. The presence of this pathology in a patient. And also the lack of effect of conservative therapy was an indication for emergency surgical treatment.

The patient performed high spinal simultaneous anesthesia according to the method described above.

After processing the surgical field, a laparotomy was performed in the right hypochondrium by Fedorov's access. In the subhepatic space, a marked adhesion process is noted, a dense infiltrate is determined, consisting of the gallbladder, large omentum, transverse colon. Adhesions are acutely separated by electrocoagulation. The liver is greenish-brown in color, with a round edge, dense, with scars on a glisson capsule, not enlarged. The head of the pancreas is mobile, dense, not enlarged. Gall bladder 5.0 × 3.0 × 2.0 cm, sclerotized, stones in the lumen, outwardly infiltrated, crimson. The gall bladder is adjacent to the common bile duct with a Hartmann pocket, in which there is a fixed stone with a diameter of 8 mm, the cystic duct does not differentiate. The cystic artery is bandaged, cut off. Cholecystectomy with technical difficulties from the neck. The gallbladder bed is not sutured, processed by electrocoagulation. In place of the previously existing cystic duct on the common bile duct, a defect of 3 mm, from which white-yellow bile enters. The hepatoduodenal ligament is rigid, cartilaginous density, the elements are not clearly differentiated. With technical difficulties, choledoch was isolated according to a probe established through the stump of the cystic duct, choledochotomy up to 15 m, choledoch wall 5 mm, rigid for 15 mm. When revising the probe, a calculus with a diameter of 10 mm is determined by palpation, removed. Rinsing of the common bile duct - no stones. Keru choledoch drainage with a diameter of 4 mm. The seam of the common bile duct, the fistula of the common bile duct in the projection of the cystic duct is sutured. Control of hemostasis, cholestasis. Dry! Drainage to the bed of the gallbladder through contraception. Layered stitches on the wound. Aseptic dressing.

Infusion-corrective therapy was carried out in the peripheral vein with an average speed of 20.0 ml / min and amounted to 3000 ml. Of them: crystalloids - 2000 ml, glucose solutions - 1000 ml. The rate of solution administration and the volume of infusion therapy were due to a decrease in the total peripheral vascular resistance, followed by a decrease in blood pressure and a redistribution of intravascular fluid volume with a decrease in the general tone of capacitive and resistive vessels. No pronounced hemodynamic changes were noted. The time of the anesthesiological aid was 2 hours 30 minutes. The time of surgery was 2 hours 10 minutes. After the operation, the patient was transferred to the department of anesthesiology and intensive care - under dynamic observation. The neuromuscular block passed within 40 minutes, the patient was transferred to the general ward of the surgical department for further treatment. The patient was discharged on the 14th day with recovery.

Example 2: Patient B., 29 years old, was admitted as an emergency to a hospital with a clinic of acute intestinal obstruction. From the anamnesis it was found out that he had previously been operated on for appendicitis, duodenal ulcer, adhesive intestinal obstruction. After conducting clinical and laboratory, x-ray examination, conducting infusion-correcting therapy and dynamic observation, the patient was taken to the operating room. The patient was performed high spinal simultaneous anesthesia according to the described method.

The patient underwent mid-median laparotomy along the “old” postoperative scar. In the abdominal cavity, a marked adhesion process is noted. The large omentum and loops of the small intestine are soldered throughout the postoperative scar; in the right iliac region and pelvis at a distance of 60-70 cm from the ileocecal angle, 2 cord-like adhesions are observed, which are dissected. In the abdominal cavity there is a serous effusion of light red color up to 500 ml, adhesions were dissected, blockade of the root of the mesentery of the small intestine with a solution of novocaine 0.5% - 60 ml was performed. Produced dissection of the ligament of the treitz, bowel reduction. An attempt at nasointestal intubation is unsuccessful due to the pronounced adhesions in the upper abdomen.

Intraoperatively, 1,500 ml of congestive small intestinal discharge was secreted by the nasogastric tube. Infusion-correcting therapy was carried out in the peripheral vein with an average speed of 27.6 ml / min and amounted to 5100 ml. Of these: crystalloids - 3000 ml, glucose solutions - 500, colloids - 500 ml. The high rate of the introduction of solutions and the large volume of infusion therapy was due to significant electrolyte losses against the background of the underlying disease. Hemodynamic differences in hypotonic type were noted at the initial stage of surgical intervention during the development and formation of the neuromuscular block with a decrease in the total peripheral resistance of the vessels with subsequent redistribution of the intravascular volume of the fluid with a decrease in the tone of the capacitive and resistive vessels. Subsequently, hemodynamics proceeded according to the normotonic type against the background of an adequate intravascular rate of injection of solutions. Intraoperatively, the patient was given antibiotic drugs: ceftriaxone 2 grams and metrogil 100 ml. The time of surgery was 3 hours 05 minutes. After the operation, the patient was transferred to the general ward of the surgical department. The patient was discharged on day 12 with improvement.

Example 3: Patient S., 65 years old, was admitted as planned to the hospital for surgical treatment with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. After conducting a clinical examination and conducting infusion preoperative preparation, the patient was taken to the operating room.

The patient was performed high spinal simultaneous anesthesia according to the described method. The patient had a mini-access incision in the right hypochondrium 6 cm long and the abdominal cavity was opened in layers. An annular retractor is installed. There is no effusion in the abdominal cavity. The liver is dark cherry in color, not enlarged, the usual consistency. During the audit, the gallbladder is 8.0 × 3.0 cm in size, the wall is sealed, stones are palpated in the cavity. Choledoch 0.6 cm. Cystic duct 0.3 cm in diameter was isolated, crossed at the clamp, bandaged. The cystic artery is separately isolated, crossed, and ligated. Cholecystectomy from the bottom with an electrocoagulation hook. Bleeding from the bed of the bubble is small, stopped by electrocoagulation. Control of hemostasis. Dry! Drainage of 0.5 cm to the Vinslov hole, a separate puncture in the right hypochondrium is brought out through the w / o. Layered stitches on the wound. Aseptic sticker. Infusion-correcting therapy was carried out in the peripheral vein with an average speed of 50.0 ml / min and amounted to 3000 ml. Of these: crystalloids - 2000 ml, glucose solutions - 500, colloids - 500 ml. The high rate of injection of solutions and the large volume of infusion therapy were due to a decrease in the total peripheral vascular resistance, followed by a decrease in blood pressure and a redistribution of the intravascular volume of fluid with a sharp decrease in the tone of capacitive and resistive vessels.

Hemodynamic changes with a tendency to hypotonic type were noted at the initial stage of surgical intervention during the development and formation of the neuromuscular block. Subsequently, hemodynamics proceeded according to the normotonic type against the background of an adequate intravascular rate of injection of solutions. Intraoperatively the patient was administered an antibiotic drug - ceftriaxone 2 grams. The time of surgery was 1 hour 10 minutes. After the operation, the patient was transferred to the general ward of the surgical department. The patient was discharged from the hospital on the 14th day.

Thus, the proposed method of simultaneous high spinal anesthesia allows combining the positive properties of subarachnoid anesthesia (simplicity, rapid onset of action, excellent long-term analgesic and muscle relaxant effects) and can be a reasonable and safer alternative to the method of endotracheal anesthesia and intravenous anesthesia in upper abdominal surgery during surgery floor of the abdominal organs - both in a planned and emergency manner. The postoperative period is softer and easier. Postoperative rehabilitation of patients is faster. So, unlike endotracheal anesthesia, prolonged myoplegia (intraoperative, postoperative) is not required; there is no period of post-narcotic depression; no mechanical ventilation is required. All patients in the postoperative period did not require analgesia with narcotic drugs and early motor activation was noted on the second day; decreased time of postoperative intestinal paresis.

Claims (1)

A method of high spinal anesthesia during operations on the upper floor of the abdominal cavity, including, in the position of the patient lying on his side, median or paramedial access, performing after local anesthesia puncture at the level of LIV-LV with a needle with a diameter of 25 G or less and the introduction of 40 mg into the subarachnoid space a solution of 2% lidocaine, while the needle section during puncture of the dura mater and verification of the subarachnoid space is sent sagittally to the right or left, then an isobaric solution of marcain is introduced in total at a dose of 15-20 mg, positioning the needle section as cranially as possible, while the time for single-stage administration of marcaine with sparging of liquor in a volume of up to 5-10 ml is 1-2 minutes, further regulation of the development of the block and control of the blockade are carried out by tilting the head end of the table to 45- 60 ° and control by non-invasive measurement of blood pressure and heart rate.