RU2649961C1 - Method of anesthesia after carrying out cesarean section operations in patients with excessive body mass - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical obstetrics and anaesthesiology. At the final stage of the surgery, sequential layer-by-layer tissue irrigation is performed with a 0.5% solution of bupivacaine in a total volume of 8.0 ml, including retrouterine space, seam area on the uterus, rectus abdominis and aponeurosis, visceral adipose tissue and subcutaneous fat layer. Then, an intradermal suture is applied to the skin and an aseptic bandage is applied.

EFFECT: method allows to exclude the use of narcotic analgesics in the postoperative period, reduce the duration of stay of patients in the hospital, by blocking the afferent input from the operative field to the central nervous system.

1 cl, 2 ex, 3 tbl

Description

The invention relates to medicine, namely to obstetrics and anesthesiology, and relates to anesthesia in the postoperative period in patients with overweight after cesarean section, which avoids the use of narcotic analgesics in the postoperative period, reduces the time spent in the hospital, significantly reduces the cost of treatment and provide convenience in use, and also contributes to the early activation of the patient.

In recent decades, the percentage of obesity among the population of developed countries has been growing rapidly. Worldwide, the frequency of obesity among pregnant women, according to statistics, ranges from 12 to 28% and does not tend to decrease [1]. Obesity complicates the course of pregnancy - this is due to an increase in the number of complications such as gestational hypertension, preeclapse, gestational diabetes, as well as an increase in the frequency of emergency caesarean sections [2]. Obese patients undergoing cesarean section have a high risk of surgical and postoperative complications [3]. The most common postoperative complications include: wound infection, deep vein thrombosis, atelectasis, postoperative pneumonia [4]. In order to prevent pulmonary and thromboembolic complications, puerperas with obesity should be activated as soon as possible. Early activation of the patient allows not only minimizing the risk of postoperative complications, but also avoiding the disconnection of the child from the mother, which, according to modern concepts, is one of the risk factors in postnatal development [5]. Early activation of the patient is possible only against the background of adequate postoperative analgesia, which corresponds to the modern concept of Fast track surgery and includes the use of regional methods of anesthesia and adequate control of postoperative pain [6].

A known method of standard anesthesia in the postoperative period using opioid narcotic analgesics. One of the side effects of narcotic analgesics is inhibition of the respiratory center, which limits their use for overweight, since such patients have an initially high risk of developing respiratory complications. In addition, patients with overweight require an individual dose calculation based on total body weight, ideal body weight, body mass index or "lean weight" depending on the drug used [7].

A method for choosing postoperative analgesia for women who are overweight is prolonged epidural analgesia. However, when performing this type of anesthesia, it is necessary to take into account a number of features in patients with overweight: fuzzy anatomical landmarks, the need for longer needles, individually calculated doses of local anesthetics compared to patients with normal body weight, the likelihood of catheter migration during epidural anesthesia (> 1 cm) in patients with a body mass index (BMI)> 30 kg / m ² [8].

A known method of anesthesia after cesarean section due to the blockade of nociceptive afferent fibers of the peritoneum by continuous or bolus infusion of local anesthetic through a multi-hole intraoperatively installed catheter [9].

This method can be used in all patients, including overweight, is closest to the claimed technical essence and the achieved result and is selected as a prototype.

The disadvantage of this method is that one catheter installed in one anatomical region does not allow to create a depot of local anesthetic and does not provide adequate analgesia. With this method, ineffective analgesia is possible, in particular during migration of the catheter or its occlusion, which makes it impossible to further postoperative analgesia and slows down the activation of patients. In addition, with this method, the risk of postoperative complications associated with a catheter-associated infection is increased due to possible bacterial colonization of the surface of the catheter tube and the penetration of microorganisms into the wound, and hematoma of the sub-neuropsychiatric space is also possible.

The objective of the invention is to increase the effectiveness of the method of postoperative analgesia after cesarean section in overweight patients, reducing the number of postoperative complications, early activation of the patient, eliminating the use of narcotic analgesics in the postoperative period, reducing the time spent in the hospital, as well as reducing the cost of treatment and ease of use .

The task is achieved by the following technical solution. After cesarean section, overweight patients before suturing the laparotomy wound carry out layer-by-layer tissue irrigation with a 0.5% bupivacaine solution in a total volume of 8.0 ml. The suture area on the uterus and the posterior space are irrigated with a 0.5% bupivacaine solution. Parietal peritoneum is not sutured. Stitches on the abdominal muscles, aponeurosis, subcutaneous fat and skin in the incision area are successively irrigated with a 0.5% bupivacaine solution. An intradermal suture is applied to the skin and an aseptic dressing is applied.

New in the present invention is the use in patients with overweight body of tissue irrigation with a bupivacaine solution of 0.5% in a total volume of 8.0 ml, including the adjacent space, the suture area on the uterus and rectus muscles of the abdomen, visceral and subcutaneous fat.

The technical results of the proposed method as an invention are the exclusion of the use of narcotic analgesics in the postoperative period, the reduction of the patient’s stay in the hospital, the early activation of the patients and ease of use.

The authors in the analyzed literature the use of layered tissue irrigation in patients with overweight, including visceral and subcutaneous fat, with a solution of local anesthetic for postoperative analgesia after cesarean section, the proposed method meets the criterion of "Novelty".

Overweight and obese women should be considered at risk for complications during pregnancy, childbirth and perinatal morbidity. The main principle of perinatal obstetrics is to ensure the health of the mother, fetus and newborn, which in some cases requires quick and gentle delivery. It was a cesarean section that became a tool to maintain the health of both mother and baby. After cesarean section surgery, functional disorders are caused by the presence of pain. Despite the large arsenal of analgesics of various directions of action, as well as the development of various methods of pain relief, the problem of treating postoperative pain remains very relevant both in our country and abroad [10].

According to the pathogenetic principles of treating somatogenic pain and preventing the body from responding to stress, the blockade of afferent entry from the surgical field into the central nervous system is justified, which can be achieved using local anesthetics in the postoperative period. This principle is used, in particular, in the method of bolus infusion of a local anesthetic through a multi-hole intraoperatively installed catheter. With this technique, a single bolus injection of an anesthetic can achieve analgesia up to 8 hours.

With excess body weight, there is an accumulation of not only abdominal (subcutaneous), but also visceral fat (around the internal organs located in the abdominal cavity). Probably, this adipose tissue can be used as a “depot” for fat-soluble preparations. In this case, intraoperative infiltration of adipose tissue with a fat-soluble local anesthetic will allow in the postoperative period for a long time to interrupt the conduct of pain impulses at the level of peripheral processes of nociceptive neurons directly at the site of tissue damage. Local anesthetic bupivacaine (Bupivacainum) has the highest fat solubility. However, the use of tissue irrigation with a bupivacaine solution of 0.5% in a total volume of 8.0 ml at the final stage of cesarean section as sufficient in time (up to 10 hours) and the severity of analgesia is not obvious.

The combination of distinctive features is not obvious to a specialist and does not follow explicitly from the prior art of this field, which allows us to consider the present invention meets the criterion of "Inventive step". The present invention can be used in medical practice for pain relief after cesarean section in overweight patients and meets the criterion of "Industrial applicability".

The invention will be clear from the following description.

The method is carried out in the following way.

When performing a cesarean section in patients with overweight before suturing the laparotomic wound, layer-by-layer tissue irrigation is performed with a 0.5% bupivacaine solution in a total volume of 8.0 ml. The area of the suture on the uterus and the adjacent space is irrigated with a 0.5% solution of bupivacaine. Parietal peritoneum is not sutured. Stitches on the abdominal muscles, aponeurosis, visceral and subcutaneous fat in the incision area are successively irrigated with a 0.5% bupivacaine solution. An intradermal suture is applied to the skin and an aseptic dressing is applied.

The determination of the initial assessment of pain intensity, as well as stepwise monitoring of the effectiveness of analgesia, is an important part of postoperative analgesia. Since pain is a subjective concept and only the patient himself can evaluate its intensity, in clinical practice, a visual-analogue scale (VAS) is used to evaluate pain. The visual-analogue scale is a 10 cm long ruler, according to which the patient is asked to evaluate his pain sensations from 0 to 10 points. The absence of pain corresponds to 0 points. Unbearable pain - 10 points. 6 hours after the operation, the puerperas are transferred to the room where the mother and the child stay together, which ensures early activation of the patient, minimizes the risk of postoperative complications and avoids disconnection between the child and the mother.

In the postoperative period, additional pain relief is performed at the request of the puerpera in accordance with YOUR indicators. Assessment of the intensity of pain after surgery is carried out during the first day every hour, then as necessary.

Example 1

Patient V., 24 years old, was admitted to clinical hospital No. 42 of the Federal State Budgetary Institution “Federal Siberian Scientific and Clinical Center of the Federal Medical and Biological Agency” on 09.30.16 at 16 hours 08 min with a diagnosis: “Pregnancy 35-36 weeks. Burdened obstetric history (Infertility I). Hyperthrombinemia. Premature maturation of the placenta. Arterial hypertension in pregnant women. Edema of pregnant women. Obesity III Art. " Upon admission, she complained of an increase in body weight for 10 days by 1400 g and the appearance of edema in the lower extremities.

On examination: general condition is satisfactory, clear consciousness, physique hypersthenic. The skin and visible mucous membranes are moist, normal in color. Subcutaneous fat is overdeveloped. The pulse is satisfactory filling and voltage of 76 beats per minute. Blood pressure on the right hand 140/95 mm Hg, on the left - 135/90 mm Hg

The belly is ovoid. The uterus is in a normal tone, painless. The position of the fetus is longitudinal, the underlying part of the fetal head is pressed to the entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 136 beats per minute.

Vaginal examination performed. The vagina is narrow, nulliparous, the cervix along the conductor axis of the pelvis is shortened to 1 cm, the consistency is soft, the cervical canal hardly pass beyond the internal pharynx for 1 finger, the fetal bladder is intact. The head of the fetus lies, pressed against the entrance to the small pelvis, the cape is unattainable, there is no deformation of the bones of the pelvis.

Ultrasound produced. Conclusion: signs of premature maturation of the placenta.

Diagnosed with Pregnancy 35-36 weeks. Burdened obstetric history (Infertility I). Arterial hypertension in pregnant women. Edema of pregnant women. Obesity II tbsp. Chronic feto-placental insufficiency. Chronic intrauterine hypoxia of the fetus. Premature maturation of the placenta.

In order to correct hemodynamics and prevent intrauterine hypoxia of the fetus, a complex pathogenetic therapy was carried out in the conditions of the intensive care unit of the pregnant woman. On the 5th day of stay in the hospital, in connection with the increase in hypertension, it was decided to deliver a caesarean section under spinal anesthesia.

Operation: 10/05/2016. A cesarean section was performed without technical difficulties. The girl weighing 3470 g was recovered with a rating of 8-9 points on the Apgar scale.

Before suturing the abdominal wall, layer-by-layer irrigation with a 0.5% solution of bupivacaine suture on the uterus and the adjacent space, abdominal muscles, aponeurosis, visible visceral fatty tissue, subcutaneous fatty tissue and skin in the incision area was performed. An intradermal suture was applied and an aseptic dressing was glued. The postpartum woman was transferred to the intensive care unit. Table 2 presents the diary for monitoring the intensity of pain in this patient on the YOUR scale. 6 hours after the operation, the patient with the child was transferred to the ward “mother and child”.

After 9 and 18 hours after surgery, the patient was parenterally administered a drug of a group of non-steroidal anti-inflammatory drugs with a sufficient analgesic effect. The need for the introduction of central non-narcotic or narcotic analgesics did not arise.

The postoperative period was uneventful. On the 7th day in satisfactory condition, the patient was discharged home with the child.

Example 2

Pregnant P., 22 years old, was admitted to a planned cesarean section in a clinical hospital No. 42 of the Federal State Budgetary Institution “Federal Siberian Scientific and Clinical Center of the Federal Medical and Biological Agency” on May 24, 2016 with a diagnosis of Pregnancy 38-39 weeks. Scar on the uterus. Obesity III Art. " Upon receipt of complaints did not show.

On examination: general condition is satisfactory, clear consciousness, physique hypersthenic. The skin and visible mucous membranes are moist, normal in color. Subcutaneous fat is overdeveloped. The pulse is satisfactory filling and voltage of 80 beats per minute. Blood pressure on the right hand is 120/80 mm Hg, on the left - 120/85 mm Hg.

The belly is ovoid. The uterus is in a normal tone, painless. The position of the fetus is longitudinal, the underlying part - the fetal head - is pressed to the entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 134 beats per minute.

Vaginal examination performed. The vagina is narrow, nulliparous, the cervix along the conduit axis of the pelvis is shortened to 1 cm, the consistency is soft, the pharynx is closed, the fetal bladder is intact. The head of the fetus lies, pressed against the entrance to the small pelvis, the cape is unattainable, there is no deformation of the bones of the pelvis.

Ultrasound produced. Conclusion: the scar on the uterus is consistent, single calcifications in the placenta.

Diagnosed with Pregnancy 39-40 weeks. Scar on the uterus. Obesity III Art. "

In connection with the full term of pregnancy, it was decided to perform a cesarean section in a planned manner under conditions of spinal anesthesia.

Operation: 05.25. 2016 Cesarean section performed without technical difficulties. A boy weighing 3,500 g was recovered with an assessment of 8-9 points on the Apgar scale.

Before suturing the abdominal wall, layer-by-layer irrigation with a 0.5% solution of bupivacaine suture on the uterus and the adjacent space, abdominal muscles, aponeurosis, visible visceral fatty tissue, subcutaneous fatty tissue and skin in the incision area was performed. An intradermal suture was applied and an aseptic dressing was glued. The postpartum woman was transferred to the intensive care unit. 6 hours after surgery, the patient was transferred to the ward "mother and child" with a child.

10 hours after surgery, the patient was parenterally administered a drug of a group of non-steroidal anti-inflammatory drugs with a sufficient analgesic effect. The need for the introduction of central non-narcotic or narcotic analgesics did not arise. The postoperative period was uneventful. On the 5th day in a satisfactory condition, the patient with the child was discharged home.

Thus, the proposed method allows for sufficient postoperative analgesia after cesarean section in patients with overweight.

The data presented indicate that layer-by-layer tissue irrigation with a bupivacaine solution of 0.5% in a total volume of 8.0 ml in patients with overweight during cesarean section before suturing the laparotomy wound avoids the use of narcotic analgesics in the postoperative period, and improves the efficiency of the postoperative anesthesia, reducing the number of postoperative complications, reduces the time spent in the hospital, significantly reduces the cost of treatment, as well as e contributing to the early activation of the patient.

Bibliography

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Claims (1)

The method of analgesia after cesarean section in overweight patients, using local anesthetic at the final stage of the operation, characterized in that sequential layer-by-layer tissue irrigation is performed with 0.5% bupivacaine solution in a total volume of 8.0 ml, including the marginal space, the area of the suture on the uterus, rectus abdominis and aponeurosis, visceral fatty tissue and the subcutaneous fat layer, then an intradermal suture is applied to the skin and an aseptic dressing is applied.