RU2609061C1 - Method of prediction of cardiovascular complications of spinal anaesthesia in oncological patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology and resuscitation, and can be used for prediction of cardiovascular complications of spinal anesthesia in oncological patients. Random limit apnea (RLA) duration is determined in patient by duration of maximum breath taking after deep breath. If RLA is less or equal to 32 seconds, high risk of cardiovascular complications of spinal anaesthesia is detected. If RLA is more than 32 seconds low risk of cardiovascular complications is detected.

EFFECT: method enables non-invasive, simple, high sensitive and specific assessing of functional state of cardiorespiratory system by determining RLA duration.

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Description

The present invention relates to medicine, namely to anesthesiology and intensive care, and can be used for spinal anesthesia in gynecological patients with operations on the pelvic organs.

The main requirement for spinal anesthesia is to ensure the rapid development and good quality of the block, a high degree of muscle relaxation, and a minimal risk of systemic toxic reactions. Spinal anesthesia, in contrast to general anesthesia, is accompanied by a less stressful reaction of the body, reliable analgesia and muscle relaxation with a complete blockade of nociceptive impulses, which suggests a preferable use of the latter for anesthetic management of traumatic surgical interventions on the abdominal cavity and pelvic organs (Svetlov V.A. Chapter 30: Complications of regional anesthesia.In the book: Anesthesiology: national leadership / under the editorship of A.A. Bunyatyan, V.M. Mizikov. - M .: GEOTAR - Media, - 2011. - P. 569-574 ; Koryachkin V.A. Epidural and spinal anesthesia. - St. Petersburg: St. Petersburg Medical Publishing House, - 2000. - 95 p.).

The introduction into widespread practice of small diameter spinal needles and special sharpening and modern local anesthetics pushed into the background the problems of post-puncture headache, high motor block and toxic effects. However, the problem of predicting cardiovascular complications during spinal anesthesia still remains.

Cardiovascular complications during spinal anesthesia include bradycardia, arterial hypotension, cardiac arrest, vasovagal syncope and arrhythmias (Svetlov V.A. Chapter 30: Complications of regional anesthesia. In the book: Anesthesiology: national guide / under the editorship of A.A. Bunyatyana, V. M. Mizikova. - M.: GEOTAR - Media, - 2011. - P.569-574; Shifman E.M., Filippovich G.V. Spinal anesthesia in obstetrics. - Petrozavodsk: IntelTek, 2005. - 558 p .; CookTM, Counsell D., Wildsmith JAW Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of An aesthetists. // British Journal of Anaesthesia. - 2009. - Vol. 102 (2). - P. 179-90; Brendan T. Finucane. Complications of regional anesthesia. - Springer Science + Business Media, LLC. - 2007. - P. 149-167).

Hemodynamic disturbances during spinal anesthesia can lead to various life-threatening complications, often ending in severe disability. The restructuring of hemodynamics under conditions of spinal anesthesia is associated, first of all, with the blockade of preganglionic sympathetic fibers, resulting in segmental vasodilation, lowering blood pressure and venous return. Under conditions of sympathy, hypoxia and hypercarbium contribute to central and peripheral depression of blood circulation, which creates the prerequisites for cardiac arrest. Even successful resuscitation measures most often do not guarantee the prevention of subsequent severe damage to the central nervous system. Desympatization in these cases significantly complicates the possibility of ensuring effective perfusion of the brain during heart massage (Svetlov V.A. Chapter 30: Complications of regional anesthesia. In the book: Anesthesiology: national leadership / edited by A.A. Bunyatyan, V.M. Mizikova. - M.: GEOTAR - Media, - 2011. - P. 569-574).

Thus, the need for predicting cardiovascular complications during spinal anesthesia becomes apparent. Moreover, in recent years there has been a tendency to increase the use of regional anesthesia methods, especially in such fields as obstetrics, gynecology, urology, coloproctology, traumatology, abdominal and thoracic surgery, neurosurgery, etc. According to numerous summary statistics, regional anesthesia is from 15 to 45% of the total amount of anesthetic benefits in various medical institutions (Koryachkin V.A., Strashnov V.I. Epidural and spinal anesthesia: a manual for doctors. - St. Petersburg: St. Pete Rburg Medical Publishing House, 1997. - S. 5-6), and this percentage has been increasing in recent years.

Important social and economic reasons for popularizing the use of regional anesthesia methods are the possibility of using these methods in medical institutions of all levels (from rural district hospitals to large surgical clinics), the relatively low cost of regional anesthesia, and, accordingly, the obvious economic benefit.

But, despite the obvious importance and relevance, today the problem of predicting cardiovascular complications during spinal anesthesia is far from a solution. At the same time, cardiovascular complications significantly complicate the course of anesthesia and the postoperative period, increasing the duration of recovery after surgery, the total duration of hospitalization, increasing mortality and disability rates, worsening the outcome of the disease and increasing the cost of treatment.

An analogue of the proposed method is a bio-impedance method for assessing hemodynamic parameters, which allows to evaluate the reserve capabilities of the cardiovascular system.

Modern rheographic analyzers are computerized complexes that simultaneously record, mark and process electrocardiography signals, measure blood pressure and one or more rheographic channels, respectively, monitor central hemodynamics parameters, as well as blood filling indices of one or several peripheral pools. The list of parameters simultaneously processed by rheographic analyzers is very wide: heart rate and up to 50 derivatives according to the methods of heart rate variability, stroke volume and its derivatives (cardiac output, cardiac and stroke index, cardiac output), blood flow parameters of regional pools (basic impedance, central volume of blood circulation, specific central volume of blood circulation, total specific peripheral resistance, etc.), indicators of the state of contractile function heart ( "post-exercise characteristics of the left ventricle of the heart," phase structure parameters systole et al.), various embodiments of peripheral blood flow parameters (total number 80-100). A peripheral research channel can sometimes be used to record a skin-galvanic reaction (D.V. Nikolaev, A.V. Smirnov, I.G. Bobrinskaya, S.G. Rudnev. Bioimpedance analysis of the composition of the human body. - M.: Science, 2009 .-- S. 126-154).

Necessary equipment for the study of central hemodynamics using the modified tetrapolar rheography method (Intensive care: a guide for doctors / edited by prof. V.D. Malyshev. - M: Medicine, - 2002. - 584 p.):

1. Measuring rheographic transducer;

2. IBM - compatible personal computer;

3. Software;

4. A set of electrodes and cables.

The disadvantages of the method:

1. The need for expensive equipment;

2. Long calibration before research;

3. The complexity of the methodology and interpretation of the research results;

4. The error in the absolute values of the sought quantities;

5. Although the method of tetrapolar rheoplethysmography to some extent according to the initial type of blood circulation regulation (normokinetic, hyperkinetic, hypokinetic) allows predicting a change in hemodynamics, in clinical practice this method is more often used for dynamic monitoring of central hemodynamics.

The closest analogue of the method for predicting cardiovascular complications is a method for predicting the need for hemodynamic correction during regional anesthesia (Patent 2383298 Russian Federation, IPC АВВ 5/02, А61М 19/00, А61К 31/4168, А61Р 9/02. Method for predicting the need for hemodynamic correction during regional anesthesia with clonidine [Text] / Begunov A.A., Shigaev M.Yu., Shigaev Yu.G .; applicant and patentee Begunov A.A., Shigaev M.Yu., Shigaev Yu.G., GOU VPO "Saratov State University named after NG Chernyshevsko on "(RU) -. №2008142334 / 14, stating 24.10.2008, published on 10.03.2010)...

The method is as follows: to predict the need for hemodynamic correction during regional anesthesia in the preoperative period, the Kerdo vegetative index, which determines the type of regulation of the autonomic nervous system, is calculated. To do this, determine the values of systolic blood pressure (ADsist), diastolic blood pressure (ADdiast), mean blood pressure (ADSr) and heart rate (HR).

Vegetative Kerdo Index (VIC), calculated by the formula:

VIC = 100 (1-ADdiast / heart rate),

where ADdiast - diastolic blood pressure, heart rate - heart rate.

With VIC> 0, the sympathetic nervous system prevails, with VIC <0 - parasympathetic.

This method was tested in a clinical setting with regional anesthesia with clonidine in 90 patients and without clonidine in 27 patients. 11 patients developed hypotension requiring drug correction due to resorption of clonidine from a multicomponent solution, which is associated with the predominance of parasympathetic regulation of hemodynamics. In 5 patients, hemodynamics were corrected by the introduction of 0.05-0.1 mg of mesatone, in 6 patients - by the introduction of 0.5-1.0 mg of atropine.

The essence of this forecasting method is that if the vegetative Kerdo index is greater than zero, then hemodynamic correction is not required (according to the regression logistic analysis, the probability is less than 10% (low probability of an event), and if the index is less than -30, such correction is necessary (according to regression logistic analysis, the probability of more than 90% (high probability of an event)). In the range of VIC values from -30 to 0, the probability of the need for hemodynamic correction is very variable (ranging from 10% to 90%).

The disadvantages of the method:

1. Low sensitivity and specificity of the method in the range of VIC values from -30 to 0 (that is, for most patients);

2. A large percentage of errors, since the individual level of stress resistance is not taken into account, that is, the safety of adaptation mechanisms to compensate for the changes that the operation and anesthesia cause.

OBJECTIVE: to develop a reliable method for predicting cardiovascular complications (with high sensitivity and specificity) by determining the individual functional state of the respiratory and cardiovascular systems in order to prevent the development of life-threatening complications.

EFFECT: proposed method makes it possible to non-invasively evaluate the functional state of the cardiorespiratory system, it is simple to use, does not require expensive equipment, has high sensitivity and specificity, can be used in medical institutions of all levels (from rural district hospitals to large surgical clinics) and helps to increase the cost-effectiveness of treatment due to a decrease in the number of cardiovascular complications.

The essence of the proposed method for predicting cardiovascular complications during spinal anesthesia in gynecological patients is the determination of individual tolerance to transient hypoxia and hypercapnia: in the evening on the eve of surgery, 2 hours before sedation, the patient determines the duration of an arbitrary threshold apnea (PAP) by the duration of the maximum delay breathing after a deep breath, and with a PAP value of equal to or less than 32 seconds, a low tolerance to transient hypoxia and hypercapnia and a high risk of cardiovascular complications during spinal anesthesia, and with a PAP value of more than 32 seconds, average and high tolerance to transient hypoxia and hypercapnia and a low risk of cardiovascular complications are determined.

The method was tested in clinical conditions on 74 gynecological patients who were routinely operated on with laparotomy access to the pelvic organs for benign neoplasms of the uterus and appendages and genital endometriosis under conditions of spinal anesthesia.

The prognostic value of this method for predicting cardiovascular complications was assessed using sensitivity and specificity indicators, by constructing an ROC curve using the MedCalc program (MedCalc Software, Belgium).

For this, in the preoperative period, tolerance to transient hypoxia and hypercapnia was determined. Depending on tolerance to transient hypoxia and hypercapnia (TSHG), the patients were divided into subgroups: subgroup H (n = 33) was characterized by a low level of TSHG (PAP less than 30 seconds), subgroup C (n = 41) - by an average level of TSHG (PAP 30 -60 seconds); patients with a high level of TSHH (PAP more than 60 seconds) when testing this method of forecasting was not detected.

Of the possible cardiovascular complications during spinal anesthesia (bradycardia, threatening arterial hypotension, cardiac arrest, vasovagal syncope and arrhythmias) in this study, only one complication of anesthesia appeared - threatening arterial hypotension: a rapid decrease in systolic blood pressure below 80 mm Hg . in normotonic patients or more than 40% in hypertensive patients (Anesthesiology: national leadership / under the editorship of A.A. Bunyatyan, V.M. Mizikova. - M .: GEOTAR - Media, - 2011. - P. 560-574).

There were no other cardiovascular complications of spinal anesthesia (cardiac arrest, vasovagal syncope, bradycardia and arrhythmias) when testing this prediction method, which is consistent with international studies showing a low incidence of these complications. For example, the incidence of cardiac arrest during spinal anesthesia according to various authors is 0.01-0.07% (Auroy Y., Narchi P., Messiah A. Serious complications related to regional anesthesia. // Anesthesiology. - 1997. - V. 87. - P. 479-486; Aromaa U., Lahdensuu M., Cozanitis D. Severe complications associated with epidural and spinal anesthesias in Finland 1987-1993: a study based on patients insurance claims. // Acta Anaesthesiol Scand. - 1997. - V. 41. - P. 445-452; Kopp S., Horlocker T., Warner M. Cardiac arrest during neuraxial anesthesia: frequency and predisposing factors associated with survival. // Anesthesia & Analgesia. - 2005. - V. 100. - P. 855-865).

According to the presence of cardiovascular complications (threatening arterial hypotension), ROC analysis was performed: complications - 54%, no complications - 46%, Sensitivity - 95.0, Specificity - 88.2, AUROC - 0.962, cut-off point - 32, which indicates about the prognostic value of this method for predicting cardiovascular complications.

The method is as follows. When a patient enters a hospital on the evening before surgery, 2 hours before sedation, the patient determines the tolerance to transient hypoxia and hypercapnia (TSHG) by the duration of the maximum breath holding after a deep breath (duration of arbitrary threshold apnea (PAP)). After a deep breath, breathing is held, the duration of PAP is measured from the beginning of the sample until the appearance of reflex contractions of the diaphragm, determined by palpation. The value of arbitrary threshold apnea reflects the functional state of the respiratory and cardiovascular systems. If the PAP value is equal to or less than 32 seconds, a low tolerance to transient hypoxia and hypercapnia and a high risk of cardiovascular complications during spinal anesthesia are detected, and if the PAP value is more than 32 seconds, average and high tolerance to transient hypoxia and hypercapnia and a low risk of cardio vascular complications.

EXAMPLE No. 1. Patient M, 43 g. Diagnosis: Intramural uterine leiomyoma. Type of surgical intervention: supravaginal amputation of the uterus without appendages. Type of anesthesia - spinal anesthesia.

In the evening on the eve of surgery, 2 hours before sedation, the patient was determined tolerance to transient hypoxia and hypercapnia for the duration of an arbitrary threshold apnea (PAP).

The duration of PAP is 38 seconds, therefore, the risk of developing cardiovascular complications is low.

To detect the presence of cardiovascular complications during anesthesia and in the immediate postoperative period, the following indicators were monitored: systolic blood pressure (ADSyst), diastolic blood pressure (ADdiast), mean blood pressure (ADSR), heart rate (HR), electrocardiography (ECG), the percentage of oxyhemoglobin in arterial blood by pulse oximetry (SpO ₂ ), respiratory rate per minute (NPV), urine output, volume of intraoperative blood loss, the volume and composition of infusion therapy, the frequency of use of vasopressors.

To confirm the prognostic significance of this method and to explain the pathophysiological mechanisms of the development of cardiovascular complications, central hemodynamics were monitored: total peripheral vascular resistance (OPSS), stroke index (UI) and cardiac index (SI).

Monitoring steps: all of the above parameters were evaluated the day before the operation, before the induction of anesthesia, during the induction of anesthesia - with an interval of every 2 min, during the maintenance of anesthesia - every 5 min, in the postoperative period - every hour.

Premedication was carried out with 1 mg phenazepam at night and in the morning and intramuscularly 30–40 minutes before the start of anesthesia with a 0.5% diazepam solution (sibazon) 0.15–0.2 mg / kg. Spinal anesthesia was induced by introducing a 0.5% isobaric solution of bupivacaine into the subarachnoid space using a 27G needle (pencil-point type) with an introducer. The dose of bupivacaine was calculated depending on the age and constitutional characteristics of the patients. The puncture level is L _3-4 . The duration of the operation is 38 minutes. The volume of pre-infusion is 200 ml of crystalloid solution. Intraoperative blood loss - 30 ml. The volume of intraoperative infusion was 22 ml / kg (crystalloid solutions), the rate of urine output during anesthesia was 2.97 ml / kg / hour. During periods of induction and maintenance of anesthesia, humidified oxygen was insufflated through a face mask at a rate of 3-4 liters per minute.

During anesthesia of cardiovascular complications (bradycardia, arterial hypotension, cardiac arrest, vasovagal syncope and arrhythmias) were not detected. Hemodynamic fluctuations in systolic, diastolic and mean blood pressure did not exceed 15% of the initial level of blood pressure. Heart rate, electrocardiography, arterial oxyhemoglobin percentage (SpO ₂ ) and respiratory rate per minute remained within the physiological norm. The need for the use of vasopressors did not arise.

Vasodilation (a decrease in total peripheral vascular resistance (from 1527 to 947 dyn⋅s ^-2 cm ^-5 ; by 38% from the initial value by the 30th minute of anesthesia)) was sufficiently compensated by an increase in stroke and cardiac index (by 49% and 25 % of the initial value by the 30th minute of anesthesia, respectively). Cardiovascular complications and hemodynamic instability during anesthesia were not observed.

EXAMPLE No. 2. PATIENT P, 53 g. Diagnosis: Glandular hyperplasia of the myometrium. Benign neoplasm of the ovary. Type of surgical intervention: Extirpation of the uterus with appendages. Type of anesthesia - spinal anesthesia.

In the evening on the eve of surgery, 2 hours before sedation, the patient was determined tolerance to transient hypoxia and hypercapnia for the duration of an arbitrary threshold apnea (PAP).

The duration of PAP is 48 seconds, therefore, the risk of developing cardiovascular complications is low.

To detect the presence of cardiovascular complications during anesthesia and in the immediate postoperative period, the following indicators were monitored: systolic blood pressure (ADSyst), diastolic blood pressure (ADdiast), mean blood pressure (ADSR), heart rate (HR), electrocardiography (ECG), the percentage of oxyhemoglobin in arterial blood by pulse oximetry (SpCO ₂ ), respiratory rate per minute (NPV), urine output, volume of intraoperative blood loss , the volume and composition of infusion therapy, the frequency of use of vasopressors.

To confirm the prognostic significance of this method and to explain the pathophysiological mechanisms of the development of cardiovascular complications, central hemodynamics were monitored: total peripheral vascular resistance (OPSS), stroke index (UI) and cardiac index (SI).

Monitoring steps: all of the above parameters were evaluated the day before the operation, before the induction of anesthesia, during the induction of anesthesia - with an interval of every 2 min, during the maintenance of anesthesia - every 5 min, in the postoperative period - every hour.

Premedication was carried out with 1 mg phenazepam at night and in the morning and intramuscularly 30–40 minutes before the start of anesthesia with a 0.5% diazepam solution (sibazon) 0.15–0.2 mg / kg. Spinal anesthesia was induced by introducing a 0.5% isobaric solution of bupivacaine into the subarachnoid space using a 27G needle (pencil-point type) with an introducer. The dose of bupivacaine was calculated depending on the age and constitutional characteristics of the patients. The puncture level is L _3-4 . The duration of the operation is 42 minutes. The volume of pre-infusion is 200 ml of crystalloid solution. Intraoperative blood loss - 50 ml. The volume of intraoperative infusion was 23 ml / kg (crystalloid solutions), the rate of urine output during anesthesia was 2.77 ml / kg / hour. During periods of induction and maintenance of anesthesia, humidified oxygen was insufflated through a face mask at a rate of 3-4 liters per minute.

During anesthesia of cardiovascular complications (bradycardia, arterial hypotension, cardiac arrest, vasovagal syncope and arrhythmias) were not detected. Hemo-dynamic fluctuations in systolic, diastolic and mean blood pressure did not exceed 17% of the initial level of blood pressure. Heart rate, electrocardiography, arterial oxyhemoglobin percentage (SpO ₂ ) and respiratory rate per minute remained within the physiological norm. The need for the use of vasopressors did not arise.

Vasodilation (a decrease in total peripheral vascular resistance (from 1518 to 911 dyn⋅s ^-2 ⋅cm ^-5 ; by 40% from the initial value by the 30th minute of anesthesia)) was sufficiently compensated by an increase in stroke and cardiac index (by 48% and 24% of the initial value by the 30th minute of anesthesia, respectively). Cardiovascular complications and hemodynamic instability during anesthesia were not observed.

EXAMPLE No. 3. Patient P, 51 g. Diagnosis: glandular myometrial hyperplasia. Type of surgical intervention: supravaginal amputation of the uterus with right appendages. Type of anesthesia - spinal anesthesia.

In the evening on the eve of surgery, 2 hours before sedation, the patient was determined tolerance to transient hypoxia and hypercapnia for the duration of an arbitrary threshold apnea (PAP).

PAP duration is 24 seconds, therefore, the risk of developing cardiovascular complications is high.

To detect the presence of cardiovascular complications during anesthesia and in the immediate postoperative period, the following indicators were monitored: systolic blood pressure (ADSyst), diastolic blood pressure (ADdiast), mean blood pressure (ADSR), heart rate (HR), electrocardiography (ECG), the percentage of oxyhemoglobin in arterial blood by pulse oximetry (SpO ₂ ), respiratory rate per minute (NPV), urine output, volume of intraoperative blood loss, the volume and composition of infusion therapy, the frequency of use of vasopressors.

To confirm the prognostic significance of this method and to explain the pathophysiological mechanisms of the development of cardiovascular complications, central hemodynamics were monitored: total peripheral vascular resistance (OPSS), stroke index (UI) and cardiac index (SI).

Monitoring steps: all of the above parameters were evaluated the day before the operation, before the induction of anesthesia, during the induction of anesthesia - with an interval of every 2 min, during the maintenance of anesthesia - every 5 min, in the postoperative period - every hour.

Premedication was carried out with 1 mg phenazepam at night and in the morning and intramuscularly 30–40 minutes before the start of anesthesia with a 0.5% diazepam solution (sibazon) 0.15–0.2 mg / kg. Spinal anesthesia was induced by introducing a 0.5% isobaric solution of bupivacaine into the subarachnoid space using a 27G needle (pencil-point type) with an introducer. The dose of bupivacaine was calculated depending on the age and constitutional characteristics of the patients. The puncture level is L _3-4 . The duration of the operation is 40 minutes. The volume of pre-infusion is 200 ml of crystalloid solution. Intraoperative blood loss - 50 ml. During periods of induction and maintenance of anesthesia, humidified oxygen was insufflated through a face mask at a rate of 3-4 liters per minute.

Although heart rate, electrocardiography, arterial oxyhemoglobin percentage (SpO ₂ ), and respiratory rate per minute remained within the physiological norm, cardiovascular complications were detected during anesthesia: threatening arterial hypotension, which required the use of vasopressors (mesatone (phenylephrine) )). The total dose of mesatone (phenylephrine) was 400 mcg. Hemodynamic fluctuations in systolic, diastolic and mean blood pressure accounted for 42% of the initial level of blood pressure. Due to the development of threatening arterial hypotension, an increase in the volume, speed and changes in the components of infusion therapy was required (the need arose for adding colloids). The total intraoperative infusion was 34 ml / kg (crystalloid and colloidal solutions), the rate of urine output during anesthesia was 2.31 ml / kg / hour.

Vasodilation (a decrease in total peripheral vascular resistance (from 1268 to 660 dyn⋅s ^-2 ⋅cm ^-5 ; by 48% from the initial value by the 30th minute of anesthesia)) was not sufficiently compensated by an increase in stroke and cardiac index (by 40% and 14% of the initial value by the 30th minute of anesthesia, respectively), which confirms the fact that the functional reserves of the cardiovascular system in this patient are sharply limited and compensatory reactions are not able to cope with the negative effect of anesthesia on hemodynamics.

During anesthesia, hemodynamic instability and the occurrence of threatening arterial hypotension were observed, which required the use of vasopressors and an increase in the volume, speed and changes in the components of infusion therapy.

Conclusion: thus, the application of the proposed method allows to predict the risk of cardiovascular complications during spinal anesthesia in gynecological patients.

Claims (1)

A method for predicting cardiovascular complications during spinal anesthesia in gynecological patients, which consists in the fact that after determining the duration of an arbitrary threshold apnea (PAP) in a patient by the duration of the maximum breath holding after a deep breath with a PAP value equal to or less than 32 seconds, a high the risk of cardiovascular complications during spinal anesthesia, and with a PAP value of more than 32 seconds - a low risk of cardiovascular complications.