RU2662423C1 - Method for carrying out anesthesia while performing vitreorethinal operations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used to carry out anesthesia while performing vitreoretinal operations. To do this, for 10–15 minutes before the surgery, premedication is performed: 5–10 mg of sibazone, 0.05–0.1 mg of fentanyl and 0.5–1.0 mg of atropine are intravenously administered. Anesthesia is then performed by administering into the sub-Tenon's space in the lower inner quadrant a mixture of 2 ml of 2 % lidocaine and 2 ml of 0.5 % naropin. Conduct oculocompression within 3–5 minutes. After this, vitreoretinal intervention is performed using classical technology via three-port access.

EFFECT: method provides adequate and safe anesthesia when it is possible to use it in patients, regardless of the severity of the concomitant pathology.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used for pain relief during vitreoretinal surgery.

Modern ophthalmosurgery is characterized by minimizing operational trauma, increasing the degree of predictability of the results of operations. Therefore, the anesthesiological aid should provide the required depth and duration of anesthesia, the absence of postoperative complications, and be as reliable and safe as possible.

Of particular difficulty is anesthesia during vitreoretinal surgery, since it is the most complex, voluminous and time consuming. Among patients with vitreoretinal pathology, a significant proportion are people with severe concomitant pathology of various organs and systems: cardiopathy, arterial hypertension, bronchial asthma, chronic renal and respiratory failure, diabetes mellitus, etc., often in the stage of subcompensation, as well as persons with morbid obesity. Anesthetic management of such patients is associated with the following problems: difficulty direct laryngoscopy and tracheal intubation; the undesirability of using a laryngeal mask due to the risk of aspiration of the gastric contents during anesthesia; a tendency to decrease pulmonary perfusion and the risk of hypoxemia due to reduced lung capacity; increased oxygen demand and increased carbon dioxide production, which is important when conducting anesthesia with low or minimal flow [Alvares A., Brodsky J., Lemmens N., Morton J. Morbid Obesity // GB, Cambridge, 2010. - 246 p. ; Biring M.S., Lewis M.I., Liu J.I., Mohsenifar Z. Pulmonary physiologic changes of morbid obesity // Am. J. Med. Sci. - 1999. - Vol. 318, No. 5. - P. 293-297]. Therefore, special attention should be paid to an adequate and safe anesthesia, which allows to reduce the risk of intra- and postoperative complications in such cases.

Existing methods for anesthesia during vitreoretinal operations have several disadvantages. A known method of retrobulbar anesthesia during abdominal operations on the eyeball, including regarding retinal detachment, eye injury, etc. [Bakunina N.A., Ivanov I.L., 2009, RF patent No. 2400260]. The essence of anesthesia is that a 2% lidocaine solution or 0.5% bupivacaine solution is administered as an anesthetic, while the anesthetic is administered retrobulbarly in a volume of 4-5 ml 45-60 minutes before surgery. The disadvantages of the method: vitreoretinal surgery is quite long in time and using only 2% lidocaine solution for pain relief is not enough, given its short duration of action - 60-90 minutes. There are also a number of reports in the literature regarding the cardiotoxicity of bupivacaine [Clarkson C.W., Hondeghem L.M. // Anesthesiology. - 1985. Vol. 62. - P. 396-405; Marx G.F. // Anesthesiology. - 1984. Vol. 60. - R. 3-5].

A known method of general anesthesia for vitreoretinal operations [Kazaykin V.N., Rylov P.M., 2005, RF patent No. 2304963]. This method is as follows. Premedication is carried out, followed by induction in anesthesia, by introducing hypnotic propofol at a dose of 1.2-1.5 mg / kg and traumatic muscle relaxant at a dose of 0.5-0.6 mg / kg. Then the trachea is intubated or a laryngeal mask is installed, after which the surgeon performs a subtenon anesthesia in the lower inner quadrant by introducing 2 ml of 0.5% napropin and proceeds with the intervention. Maintenance of anesthesia is carried out with a mixture of nitrous oxide with oxygen in a ratio of 2: 1 and inhaled anesthetic sevoran in a dose of 0.5-1.2 vol. % Additionally, a tracrium is introduced at a dose of 0.03 mg / kg / h using a micro-jet syringe dispenser. Also at the beginning or at the end of the operation, the antiemetic zofran is administered in a dose of 4 mg. The disadvantages of this method are: a high risk of complications in patients with severe concomitant pathology during general anesthesia, the need for postoperative monitoring by an anesthesiologist in the intensive care unit, and conducting infusion therapy; the risk of cognitive impairment in patients after general anesthesia.

The closest analogue - the prototype of the proposed method of pain relief during vitreoretinal surgery - is a method for retrobulbar anesthesia during vitreoretinal operations [Kazaykin V.N., Rylov P.M., 2012, RF patent No. 2462278]. This method is as follows. First, premedication (intravenous promedol at a dose of 0.2 mg / kg, suprastin at a dose of 0.25 mg / kg). 40-45 minutes before the start of the operation, a mixture of 2% lidocaine solution and 0.75% solution of napropin (ropivacaine) in a 1: 1 ratio in a volume of 4-5 ml is administered retrobulbarly. During the operation, 1-2 minutes before the start of the administration of silicone oil, a 0.01% solution of nitroglycerin is administered intravenously by titration, starting from 1 ml, by the surgeon’s signal. The introduction of nitroglycerin is stopped when the patient's systolic blood pressure becomes 10-20% lower than the initial one.

The disadvantages of the prototype method are:

- A large number of side effects of nitroglycerin (collapse, headache, anxiety, increased intracranial pressure);

- a wide range of contraindications to the use of nitroglycerin (contraindicated in glaucoma with high intraocular pressure, anemia, hyperthyroidism, hypovolemia, with anxiety, in children under 18 years of age);

- the need for continuous intraoperative monitoring of the electrocardiogram and blood pressure;

- the need for postoperative observation by an anesthesiologist in the intensive care unit, carrying out infusion therapy due to the use of nitroglycerin;

- a high risk of developing such formidable intraoperative complications of retrobulbar anesthesia as perforation of the eyeball, damage to the optic nerve and, as a result, its atrophy due to the lack of objective visual control of the needle during injection into the retrobulbar space, as well as the occurrence of retrobulbar hematoma, occlusion of the central arteries of the retina.

The objective of the invention is to propose a method of reliable and safe anesthesia, which guarantees vitreoretinal surgery in patients, regardless of the severity of the associated pathology.

The technical result is the provision of adequate and safe anesthesia during vitreoretinal surgery, the possibility of use in patients, regardless of the severity of the concomitant pathology, the absence of severe intra- and postoperative complications.

The technical result is achieved as follows. 10-15 minutes before surgery, premedication is carried out by intravenous administration of 5-10 mg of sibazon, 0.05-0.1 mg of fentanyl and 0.5-1.0 mg of atropine. After this, local anesthesia is performed by introducing into the subtenon space in the lower inner quadrant a mixture of solutions of 2 ml of 2% lidocaine and 2 ml of 0.5% napropine (ropivacaine). Then oculocompression is carried out for 3-5 minutes and the vitreoretinal intervention is performed according to classical technology through a three-port access.

The use for premedication of these three drugs is explained as follows. Sibazon has a good sedative effect and potentiates the action of local anesthetics. Fentanyl is an effective central analgesic, has a strong analgesic effect, does not affect blood pressure. Atropine suppresses the vagal component of the oculocardial reflex. The use of these three drugs allows for adequate anesthesia during the entire time of the surgical intervention, to reduce the risk of bradycardia, and to ensure a smooth course of anesthesia in patients with severe concomitant pathology.

The use of a mixture of solutions of 2% lidocaine and 0.5% napropin for subtenone anesthesia is explained as follows. Lidocaine is an anesthetic with a short period of development of anesthesia and a short period of its action, and napropin is a drug with a longer time of onset of anesthesia, but a lasting analgesic effect for 10-12 hours. Thus, the use of a mixture of these drugs is sufficient for the rapid development of anesthesia, the successful conduct of a long vitreoretinal intervention and does not require additional postoperative analgesia.

With subtenon administration of drugs, they have the ability to control the needle entering the desired area, to exclude perforation of the eyeball.

The advantages of the proposed method:

- allows to provide adequate, long-term intra- and postoperative anesthesia;

- can be used in patients with severe concomitant pathology;

- does not require prolonged postoperative observation in the intensive care unit and infusion therapy;

- the absence of complications inherent in retrobulbar anesthesia;

- quick rehabilitation of the general condition of patients after surgery, since side effects of drugs used for sedation are minimal.

Example 1. Patient K., 57 years old. Received complaints of decreased vision, the appearance of a dark veil from the lower nasal side of the field of vision of the right eye. The above complaints appeared 3 weeks ago. On admission: visual acuity of the right eye - 0.02, intraocular pressure (IOP) - 12 mm Hg The anterior segment of the eye is within normal limits, in the vitreous - filamentous destruction, a suspension of pigment. On the fundus: the retina is detached in all departments, in the equator at 11 hours - valve retinal rupture with curled edges. Diagnosed with regmatogenous retinal detachment, proliferative vitreoretinopathy in the right eye. The patient's height was 170 cm, weight - 169 kg. The body mass index was equal - 58.5 kg / m ² , which corresponds to obesity of 3 degrees (morbid). The patient also had a concomitant disease - arterial hypertension.

Vitreoretinal surgery was performed, including a 3-port vitrectomy, the introduction of organofluorine compounds (PFOS) for retinal expansion, coagulation of the retina, and the replacement of PFOS with silicone oil. In the period of preparation for surgery, the level of blood pressure (BP) was 175/105 mm Hg, Sat O2 - 92-93% with FiO2 = 0.21.

10 minutes before the operation, premedication (intravenous administration of sibazon 10 mg, fentanyl 0.1 mg, atropine 0.5 mg) was performed, after which the surgeon performed anesthesia by introducing a mixture of solutions of 2 ml of 2% lidocaine and 2 ml into the subtenon space in the lower quadrant 0.5% napropine, oculocompression for 3 minutes. Surgery began after stabilization of systolic blood pressure at a value of 130 mm Hg. With spontaneous breathing, an oxygen-air mixture was supplied through nasal catheters (FiO2 = 0.3).

The time of the operation is 1 hour 30 minutes. The effectiveness of intraoperative analgesia was assessed objectively: by indicators of systemic hemodynamics, the absence of autonomic reactions, and also subjectively by the presence / absence of complaints of pain during surgery and in the postoperative period. Postoperative analgesia was not performed.

Throughout the duration of the operation, the course of anesthesia is smooth, which is confirmed by monitoring data: heart rate 79 ± 5 beats per minute, blood pressure 112 ± 6/60 mm Hg, respiratory rate 16 ± 2 per minute. The patient was conscious and reacted to the commands of the anesthesiologist and surgeon. No operational complications were observed. A complete absence of pain was achieved at all stages of the surgery. Immediately after surgery, the patient was transferred to a general ward.

In the postoperative period, there was no anxiety, respiratory dysfunction, manifestations of nausea and vomiting, the retina is adjacent, visual acuity on the 3rd day after the operation is 0.2 with correction. The optical media are transparent; silicone oil is in the vitreal cavity. The patient was discharged on the 4th day of the postoperative period, the general condition was stable.

When viewed after 3 months: visual acuity - 0.5 with correction, IOP - 20 mm Hg, transparent optical media, silicone oil completely fills the vitreous cavity, the retina is adjacent. An operation was performed to remove silicone oil from the vitreous cavity according to a standard method. 1 month after removal of silicone oil: the retina is adjacent, visual acuity is 0.6, IOP is 18 mm Hg.

Example 2. Patient B., 65 years old. Received complaints of a sharp decrease in vision of the left eye 2 months ago. She was hospitalized in the ophthalmic department at the place of residence for hemophthalmus of the left eye, without effect, she was sent for vitreoretinal surgery. Concomitant diseases: type 2 diabetes mellitus, insulin-dependent form, subcompensation, arterial hypertension. On admission: visual acuity of the left eye - the correct light projection, IOP - 18 mm Hg The cornea is transparent, the depth of the anterior chamber is 3.5 mm, moisture is transparent. Partial opacification of the cortical layers of the lens. In the vitreous body - a diffuse suspension of blood. The fundus is not ophthalmoscopic. According to ultrasound data: intense opacification in all parts of the vitreous body, epiretinal membranes in the posterior pole of the eye, flat traction retinal detachment along the vascular arcades. Diagnosed with proliferative diabetic retinopathy, advanced stage, subtotal hemophthalmus of the left eye, proliferative diabetic retinopathy, advanced stage of the right eye, initial age-related cataract of both eyes.

Vitreoretinal surgery was performed, including a 3-port vitrectomy, removal of epiretinal membranes, retinal expansion by introducing air into the vitreous cavity, endolaser retinal coagulation, and the introduction of silicone oil. 15 minutes before the operation, premedication (intravenous administration of sibazon 10 mg, fentanyl 0.1 mg, atropine 0.5 mg) was performed, after which the surgeon performed anesthesia by introducing 2 ml of 2% lidocaine and 2 ml of 0 into the subtenon space, 5% napropine, oculocompression for 5 minutes. The operation was successful, bleeding from the vessels of the retina and other intraoperative complications were not observed.

Throughout the duration of the operation (1 hour 40 minutes), the course of anesthesia is smooth, which is confirmed by monitoring data: heart rate 76 ± 4 beats per minute, blood pressure 128 ± 5/80 mm Hg, respiratory rate 16 ± 2 per minute . A complete absence of pain was achieved at all stages of the surgery. Postoperative analgesia was not performed.

When viewed the next day, the retina is adjacent, visual acuity is 0.1 with correction. The optical media are transparent; silicone oil is absent in the vitreal cavity; there are no hemorrhages. The patient was discharged on the 4th day of the postoperative period, the general condition was stable.

When viewed after 3 months: visual acuity - 0.3 with correction, IOP - 19 mm Hg, transparent optical media, silicone oil completely fills the vitreous cavity, the retina is adjacent, the foci of laser coagulation are pigmented. An operation was performed to remove silicone oil from the vitreous cavity according to a standard method. 1 month after removal of silicone oil: the retina is adjacent, visual acuity is 0.4, IOP is 17 mm Hg.

Claims (1)

A method of carrying out anesthesia during vitreoretinal operations, including premedication and administration of lidocaine and napropin, characterized in that premedication is carried out 10-15 minutes before surgery by intravenous administration of 5-10 mg of sibazon, 0.05-0.1 mg of fentanyl and 0, 5-1.0 mg of atropine, then anesthesia is performed by introducing into the subtenon space in the lower inner quadrant a mixture of 2 ml of 2% lidocaine and 2 ml of 0.5% napropin, oculocompression is performed for 3-5 minutes, after which vitreoretinal surgery is performed according to the classical those ologii through the three-port access.