RU2703686C1 - Method of general anesthesia with preserved spontaneous breathing for medium- and low-traumatic surgical operations - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to anesthesiology and resuscitation, and can be used in general anesthesia with preserved spontaneous breathing. That is ensured by monitoring the bispectral sedation depth index (BIS-monitoring) with an index interval of 40–60. For the introductory anesthesia, the sevoflurane monoinduction is performed by means of insufflation of the gas-narcotic mixture with the specified value on evaporator of 8 % and flow of 100 % oxygen 8 l/min. Tracheal tube is intubated with an endotracheal tube having an irrigation port for administering drug preparations into the subglottic space. Tube is introduced into the trachea while achieving MAK 1.5 anesthesia level and with the BIS index ≥40. Before the operation, terminal anesthesia of the tracheal mucosa in the area of contact of the endotracheal cuff end with a sublimate space is performed by administering 40–60 mg of 2 % lidocaine solution into the irrigation port of the endotracheal tube. Performing general anesthesia with auxiliary artificial pulmonary ventilation in pressure support mode with maximum triggering sensitivity of 2 l/min, pressure Psupp 6–8 mm of water with sustained sevoflurane inhalation at 1.0 MAK and BIS monitoring in index ≥50. Constant infusion of fentanyl is performed during the operation at a rate of about 1.0 mcg/kg/h. Infusion is terminated 5 minutes before the operation is completed; the sevoflurane delivery is stopped after the postoperative wound is drained. 10 minutes before the patient's expected awakening, a terminal anesthesia of the tracheal mucosa is performed in a zone of contact of the endotracheal cuff end with a sublimate space by inserting into the irrigation port of endotracheal tube 40–60 mg of 2 % lidocaine. After recovering adequate spontaneous breathing, pharyngeal and larynx reflexes, patient's ability to perform elementary commands by modified Aldrete scale 7–9 points and BIS index values ≥60, extubation of trachea.EFFECT: method provides adequate and safe anesthesia with preserved spontaneous breathing.1 cl, 1 dwg, 2 ex

Description

Technical field

The present invention relates to medicine, to anesthesiology, and more precisely, to a method for performing general anesthesia with preserved spontaneous breathing and can be used to perform moderate to less traumatic surgeries with anesthetic management requiring endotracheal tube intubation.

State of the art

The severity of the patient’s safety problem makes anesthesiologists around the world pay attention to anesthesia performed with spontaneous breathing preserved. However, it has long been known how difficult it is to provide patency and protection of the respiratory tract with such anesthesia.

A known method of conducting general anesthesia with retained spontaneous breathing (VV Moroz and others. "General anesthesia with preserved spontaneous breathing through an endotracheal tube", journal General resuscitation, 2010. volume 6, No. 4, pp. 43-48). When anesthetics are administered to patients with healthy lungs, there are two main reasons for mechanical ventilation: the requirements of surgical technique and respiratory depression caused by most anesthetic drugs. Total myoplegia is necessary for surgeons not throughout the operation, but only at its individual stages. In the process of artificial lung ventilation, regardless of the initial state of the lung tissue, the negative effect of mechanical ventilation on the state of the lungs gradually appears. Respiratory complications develop in 3-4% of patients with planned anesthesia and in 20% of patients with emergency anesthesia.

The harmful factors of forced artificial ventilation are: turbulent air flow in the bronchi, causing an uneven distribution of the respiratory mixture in the pulmonary fields; altered regional relationships between alveolar, arteriocapillary and venous pressure, increasing the amount of extravascular water in the pulmonary interstitium and hampering the outflow of lymph.

The harmful factors also include ventilation with large volumes of an oxygen-air mixture leaching surfactant, leading to atelectasis and hypoxemia, despite an increase in the oxygen fraction and high peak inspiratory pressure leading to barotrauma of the most malleable alveoli, ruptures, hemorrhages, release of inflammatory mediators, aggravating disorders oxygenation. Artificial ventilation disrupts central hemodynamics, eliminating the suction effect of the superior vena cava and impairing the outflow from head tissue through the jugular veins. The preservation of spontaneous breathing during surgical interventions is also important for some diseases of neuromuscular conduction, for example, myasthenia gravis.

Tracheal intubation is the main method for ensuring airway patency during endotracheal anesthesia and involves the insertion of an endotracheal tube into the trachea.

In an emergency, for example, signs of a sudden clinical death, tracheal intubation is performed immediately, without induction of anesthesia. The main task is to provide protection and airway patency, then resuscitation measures are carried out.

The tactics of the anesthesiologist during tracheal intubation in standard situations, i.e. a stable patient in clear consciousness is as follows. The patient enters the operating room. The endotracheal tube is installed before the operation - a surgical incision, an operating injury. The most common is orotracheal intubation, when using a laryngoscope, the endotracheal tube passes through the oral cavity, larynx and between the vocal cords is inserted into the trachea. The process of tracheal intubation before surgery begins after intravenous induction of anesthesia, which includes:

- anesthetic injection, as first you need to turn off the consciousness;

- the introduction of an analgesic to suppress reflexes of the oropharynx, larynx, trachea, to suppress the overall neurovegetative response;

- the introduction of muscle relaxant for neuromuscular blockade and turn off spontaneous breathing to create optimal conditions for tracheal intubation;

- either these three components are replaced by mono-induction with an inhaled anesthetic sevoflurane,

- only after this the trachea is intubated and transferred to artificial lung ventilation (IVL), the calculated main doses of analgesics, long-acting muscle relaxants, supporting doses of anesthetics are introduced.

Simultaneously with induction of anesthesia, auxiliary artificial ventilation of the lungs begins in a mask way.

After evaluating the clinic and a sufficient depth of introductory anesthesia, the trachea is intubated, which is carried out under the control of a laryngoscope. The doctor, holding a laryngoscope in his right hand, opens the patient’s mouth with the fingers of his left hand and, visually controlling the process, carefully holds the laryngoscope blade on the back of the tongue, moving the tongue to the left. Then he takes a laryngoscope in his left hand and begins to advance it forward before entering the trachea and displays a glottis in the field of view. Then he introduces the endotracheal tube through the glottis. Retrieves a laryngoscope. Then, the cuff located near the distal end of the tube is inflated with air to fix the position of the tube and provide a seal to protect the lower respiratory tract from blood and aspiration of acidic gastric contents. To control the correctness of intubation, listen to the breath on the left and right, connect the patient to the device, fix the tube to the head, and again listen to the breath. There are the following methods for confirming the correct placement of the endotracheal tube: protozoa and with monitoring.

The simplest include: a) direct visualization, see that the tube passes between the vocal cords; b) the same breathing on both sides of the chest during auscultation; c) the absence of sounds in the epigastric region; d) symmetrical bilateral increase in chest volume during inspiration; e) lack of stomach contents in the tube;

Using monitoring, they carry out: a) capnography, in which the content of CO ₂ at the end of expiration (etCO ₂ ) and the waves on the capnograph screen are controlled; b) pulse oximetry, i.e. monitoring the presence of digital reflection of blood saturation, the absence of a decrease in hemoglobin oxygen saturation.

As the closest technical solution, a short-duration general anesthesia method with controlled spontaneous respiration with tracheal intubation is considered (see, for example, V.V. Moroz, V.V. Likhvantsev, S.A. Fedorov, V.V. Kichin, A. V. Mironenko, OA Grebenchikov “General anesthesia with preserved spontaneous respiration through the endotracheal tube”, GENERAL REANIMATOLOGY, 2010, VI; 4, p. 43-48), which consists in the fact that

introductory anesthesia is performed, for which anesthetic (propofol) is introduced in an amount of about 2 mg / kg, an analgesic (fentanyl 0.05%) in an amount of 3 μg / kg and a short-acting depolarizing muscle relaxant (listenone) in an amount of 1 mg / kg,

upon reaching an anesthesia level of MAK 1.5 (minimum alveolar concentration), tracheal intubation with an endotracheal tube is performed,

after introductory anesthesia and intubation of the trachea, muscle relaxants are not used and a gradual decrease in the respiratory rate leads to the onset of the patient's independent respiratory activity,

carry out general anesthesia with assisted artificial lung ventilation (IVL) in the mode of breathing pressure support (Pressure Support) with a maximum trigger sensitivity of 2 l / min., Psupp pressure of 14-18 mm. water Art., with continuous inhalation of sevoflurane at 1.5 MAK and BIS monitoring at an index of ≤ 50,

carry out continuous infusion of fentanyl at an average rate of 2.0 μg / kg / h,

fentanyl infusion is stopped 5-10 minutes before the end of the operation, the flow of sevoflurane is stopped after drainage of the postoperative wound,

carry out tracheal extubation after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, the patient’s ability to perform elementary commands on a modified Aldrete scale of 7–9 points.

However, with this method of anesthesia, it is not always possible to avoid cases of transferring a patient to forced ventilation of the lungs arising due to the ineffectiveness of independent breathing. Also a significant drawback of this method in some patients is the level of P supp., Which is 12-18 cm. Aq. Art., which is almost comparable to the automatic ventilation mode.

A serious disadvantage of this method is the need for the introduction of muscle relaxants of short action for intubation of the trachea. Only for some patients it is possible to conduct anesthesia with fully independent breathing. In approximately 25% of cases, against the background of anesthesia and analgesia, spontaneous breathing becomes ineffective, and therefore, forced ventilation with the use of muscle relaxants has to be used.

Also, some patients may be subjected to unnecessarily deep anesthesia, or, conversely, intranarcous awakening, which cannot but affect the quality of surgical treatment in general. Too superficial anesthesia leads to the restoration of the laryngopharyngeal reflexes during the manipulation, which leads to a negative hemodynamic reaction in response to irritation of the upper respiratory tract by the endotracheal tube. The problem of monitoring the adequacy of general anesthesia during spontaneous breathing of a patient is especially relevant.

Summary of the invention

The basis of the present invention is the task of creating a method for performing general anesthesia with preserved spontaneous breathing for medium and less traumatic surgical operations, in which the exclusion of the use of muscle relaxants during the entire period of anesthesia and a reduction in the dose of general anesthetics, as well as the use of an endotracheal tube with an irrigation port for drug administration , in particular, of ledocaine in the subglottic space, will reduce the reflexogenic response without deepening anesthesia, increase the safety of anesthesia and its effectiveness.

The problem is solved by creating a method for conducting general anesthesia with preserved spontaneous breathing, which contains the following steps:

perform introductory anesthesia

tracheal intubation with an endotracheal tube,

carry out general anesthesia with assisted artificial lung ventilation (IVL) with the support of respiration by pressure (Pressure Support) with a maximum trigger sensitivity of 2 l / min, and constant inhalation of sevoflurane,

during the operation, a continuous infusion of fentanyl is carried out,

stop the fentanyl infusion 5-10 minutes before the end of the operation,

stop feeding sevoflurane after drainage of a postoperative wound,

carry out extubation of the trachea after restoring adequate spontaneous breathing, pharyngeal and laryngeal reflexes, the patient’s ability to perform elementary commands, against a background of mild post-narcotic depression,

in the specified method according to the invention

monitor the bispectral index of the depth of sedation (BIS - monitoring) with an interval of index 40-60,

for induction anesthesia, mono-induction in anesthesia of sevoflurane is performed by insufflation of the gas-narcotic mixture with a set indicator on the evaporator of 8% and a flow of 100% oxygen of 8 l / min,

use an endotracheal tube for intubation of the trachea with an irrigation port for introducing drugs into the subglottic space, which is injected into the trachea when the level of anesthesia is MAK 1.5 (minimum alveolar concentration) and with a BIS index ≥ 40;

after intubation, before the start of the operation, terminal anesthesia of the tracheal mucosa in the area of contact of the cuff of the endotracheal tube with the subglottic space is performed, for which 40-60 mg of 2% lidocaine is introduced into the irrigation port of the endotracheal tube;

carry out general anesthesia with assisted artificial lung ventilation (IVL) in pressure support breathing mode (Pressure Support) with a maximum trigger sensitivity of 2 l / min., Psupp pressure of 6-8 mm. water Art., with inhalation of sevoflurane at 1.0 MAC and BIS monitoring at an index of ≥ 50,

during the operation, continuous inhalation of sevoflurane is carried out at an anesthesia level of 1.5 MAK with BIS monitoring in the range of the index 40-60;

during the operation, a constant infusion of fentanyl is carried out at a rate of about 1.0 μg / kg / hour,

stop the fentanyl infusion 5 minutes before the end of the operation, the flow of sevoflurane is stopped after drainage of the postoperative wound,

10 minutes before the patient’s supposed awakening, terminal anesthesia of the tracheal mucosa in the area of contact of the cuff of the endotracheal tube with the subglottic space is performed, for which 40-60 mg of a 2% lidocaine solution is introduced into the irrigation port of the endotracheal tube,

they perform tracheal extubation after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, the patient’s ability to perform elementary commands against a background of mild post-narcotic depression according to the modified Aldrete scale of 7-9 points and BIS index values ≥ 60.

The main achieved result of the proposed method for conducting general anesthesia with preserved spontaneous breathing is the absence of negative effects of complications associated with forced mechanical ventilation (IVL), faster tracheal extubation and patient activation after surgery. In addition, the proposed method allows to achieve and realize the optimal level of anesthesia and spontaneous breathing during surgery, to prevent possible early postoperative respiratory disorders due to the exclusion of muscle relaxants from the anesthetic scheme. When using the method, there is an economic effect, which consists in reducing the consumption of drugs, reducing the duration of the patient’s stay in the operating room and waking room, reducing the number of complications, the presence of which requires additional costs. In solving this problem, there is a positive therapeutic effect, which consists in the fact that the duration of general anesthesia is reduced, leading to early postoperative activation of patients, and the safety of anesthesiology benefits is increased.

Brief Description of the Drawing

The invention is further explained in the description of the preferred embodiment with reference to the accompanying drawing (Fig. 1), which shows schematically an embodiment of the placement of the endotracheal tube in the trachea during the operation.

Description of a preferred embodiment of the method

After laying the patient on the operating table, apply electrodes 1 (Fig. 1) for BIS monitoring and evaluate the initial values of the patient who is conscious:

- provide reliable venous access;

- check the readiness of anesthesia-respiratory and follow-up equipment;

- necessarily monitor the bispectral index of the depth of sedation (BIS - monitoring) with an interval of 40-60 index for objective control of the depth of anesthesia throughout the perioperative period. The perioperative period is the entire period from the moment of admission to the operating room until the moment of transfer to the wake-up room. This is necessary in order not to get too deep anesthesia, which can inhibit spontaneous breathing. Clinical signs of the depth of anesthesia may not be enough;

- monitor blood pressure every 5 minutes;

- carry out constant monitoring of heart rate;

- carry out constant monitoring of the electrocardiogram;

- carry out constant monitoring of pulse oximetry according to the method of constantly determining the amount of oxygen associated with hemoglobin in arterial blood;

- carry out continuous monitoring of capnography according to the method of continuous measurement and digital display of the concentration or partial pressure of carbon dioxide in the inhaled and exhaled gas during the patient's respiratory cycle;

- monitor the concentration of inhalation anesthetic on inhalation and exhalation;

- carry out constant monitoring of the gas composition of arterial blood.

After evaluating the clinic and a sufficient depth of introductory anesthesia, tracheal 2 is intubated, which is carried out under the control of a laryngoscope, similarly to the known method. The doctor, holding a laryngoscope in his right hand (not shown), opens the patient's mouth with the fingers of his left hand and, visually controlling the process, carefully holds the laryngoscope blade on the back of the tongue, pushing the tongue to the left. Then he takes the laryngoscope in his left hand and begins to push it forward before entering the trachea and displays the glottis 3 in the field of vision. Then he inserts the endotracheal tube 4 through the glottis 3 and removes the laryngoscope. Then the cuff 5, located near the distal end 6 of the tube, is inflated with air through a control balloon 7 to inflate the cuff to a pressure during use at a safe level of 20-30 cm of water column to fix the position of the tube 4 and ensure tightness to protect the lower respiratory tract from blood and aspiration of acidic gastric contents.

To control the correctness of intubation, listen to the breath on the left and on the right, connect the patient through connector 8 to connect to the ventilator (not shown) , which is designed to connect to the respiratory circuit of the ventilator, fix the endotracheal tube 4 to the head 9, and again listen to the breath .

After intubation, before the start of the operation, terminal anesthesia of the tracheal mucosa is performed in the area of contact of the cuff 5 of the endotracheal tube with the subglottic space. For this, a local anesthetic - lidocaine is drawn into a syringe (not shown), connected to an irrigation port 10 for the introduction of a local anesthetic - lidocaine. 40-60 mg of a 2% solution of local anesthetic - lidocaine are injected into the irrigation port 10 with a syringe. In case of small and moderate traumatic operations, very often the surgical intervention area does not require deep general anesthesia and the main source of pathological impulse is the endotracheal tube 4 installed in the larynx.

Thus, the use of anesthetics in these cases is largely necessary only to suppress the larynxopharyngeal reflexes that occur when the upper respiratory tract is irritated with an endotracheal tube 4. An endotracheal tube with an irrigation port in such situations helps to significantly reduce the dosage of general-action drugs.

After this, introductory anesthesia is performed, for which monoinduction is carried out in anesthesia with sevoflurane according to the VIMA method (Volatile Induction and Maintenance Anesthesia) (inhalation induction and maintenance of anesthesia) by supplying a gas-narcotic mixture at a set rate of 8% on the evaporator and 100% oxygen flow of 8 l / min

Mono-induction in anesthesia with sevoflurane eliminates the use of muscle relaxants.

In some cases, VIMA is an acceptable alternative to the technique in which the induction is carried out by intravenous anesthetics, and inhalation anesthetics are used to maintain it. The VIMA technique allows to exclude insufficient sedation during the transition from intravenous to inhalation anesthesia, to reduce the likelihood of hemodynamic and other disorders associated with the use of intravenous agents for induction in patients whose spontaneous breathing must be maintained until endotracheal intubation is performed.

Mandatory monitoring of the bispectral index of the depth of sedation (BIS - monitoring) with an interval of index 40-60, in order to have objective criteria for the depth of anesthesia.

Upon reaching an anesthesia level of MAK 1.5 (minimum alveolar concentration) and with a BIS index of ≥ 40, tracheal intubation is performed.

The use of local anesthesia on the mucous membrane of the trachea allows you to neutralize the negative pathophysiological reflexes of the mucous membrane of the trachea without deepening general anesthesia, to adapt the patient to placement of an endotracheal tube 4 in the trachea, i.e. to ensure a decrease in the laryngeal pharyngeal reflexes, to realize a quiet effective spontaneous breathing, and practically no reaction to the established endotracheal tube in the trachea.

Before the operation, terminal anesthesia of the tracheal mucosa is carried out in the contact zone of the cuff 5 of the endotracheal tube 4 with the subglottic space, for which 40-60 mg of a 2% lidocaine solution is introduced into the irrigation port of the endotracheal tube.

The amount of lidocaine administered is calculated to maximize the clinical effect of local anesthesia of the contact area of the tracheal mucosa with the cuff of the endotracheal tube.

During the operation, assisted artificial lung ventilation (IVL) is performed in the pressure support breathing mode with a maximum trigger sensitivity of 1.5 l / min., Psupp pressure of about 6-8 mm water column.

In the proposed method, the Psupp value varies from 5 to 8 cm Hg, that is, pressure support is necessary only to compensate for the resistance of the endotracheal tube 4.

This method of supporting spontaneous breathing allows you to set the required values and, if necessary, carry out hardware support in the Pressure Support mode, which is provided by the functional capabilities of the mechanical ventilation apparatus mode.

At the same time, safety criteria and patient protection against possible hypoxia during surgery are provided.

During the operation, continuous inhalation of sevoflurane is carried out at an anesthesia level of 1.5 MAK with BIS monitoring in the range of the index 40-60.

During the operation, fentanyl is continuously infused at a rate of about 1.0 μg / kg / h.

Fentanyl infusion is stopped 5 minutes before the end of the operation, the supply of sevoflurane is stopped after drainage of the postoperative wound.

10 minutes before the patient’s expected awakening, terminal anesthesia of the tracheal mucosa is carried out in the contact zone of the cuff 5 of the endotracheal tube 4 with the subglottic space, for which 40-60 mg of 2% lidocaine solution is introduced into the irrigation port 10 of the endotracheal tube.

Finally, tracheal extubation is performed against a background of mild post-narcotic depression according to a modified Aldrete scale of 7–9 points and BIS indices ≥ 60.

At the end of any operation, a moment arises when the anesthetist tries to reduce the dosage of drugs, preparing the patient for awakening and extubation of the trachea. In such cases, the depth of general anesthesia is often quite sufficient to complete the operation, but completely insufficient to suppress the laryngopharyngeal reflexes.

In the inventive method, the endotracheal tube 4 with the irrigation port 10 allows the anesthetist to complete the operation without deepening the anesthesia. For this purpose, 10 minutes before the expected awakening of the patient, terminal anesthesia of the tracheal mucosa is performed in the area of contact of the cuff 5 of the endotracheal tube with the subglottic space, for which purpose, 40-60 mg of a 2% lidocaine solution is injected into the irrigation port 10 with a syringe. Against the background of high-quality anesthesia of the tracheal mucosa, awakening and extubation are achieved, which is characterized by stable hemodynamics, the absence of reaction to the endotracheal tube 4 installed in the trachea, and a favorable course of the early postoperative period.

The task of reducing the reflexogenic response is solved immediately after intubation and then throughout the operation, i.e. as soon as the endotracheal tube 4 has been inserted, this is especially important at the stage of awakening, when the suppressed reflexogenic effect is restored after general anesthesia, for this purpose 40-60 mg of a 2% lidocaine solution is introduced into the irrigation port 10 of the endotracheal tube 10 at certain times.

Due to the overall reduction in the number of used anesthetics and analgesics, in the proposed method, the time of awakening and extubation of the trachea is approximately 1.5-2 times less than in the known method. Using the proposed method reduces the time of post-anesthetic rehabilitation.

The proposed method does not reduce the effectiveness of the anesthesia. BIS monitoring data convincingly indicate a sufficient depth of anesthesia at all stages of the operation. Stable hemodynamic parameters indicate a sufficient level of analgesia.

Psupp values are maintained between 5 and 8 cm aq. Art., necessary only to compensate for the resistance of the endotracheal tube 4, due to which the natural relationship between the pressure in the superior vena cava and the pleural cavity is preserved, and the suction effect of the superior vena cava, which improves blood flow and reduces blood loss. This improves the working conditions of the surgeon and reduces operating time.

The advantages of spontaneous providing breathing are as follows. Spontaneous breathing improves perfusion, metabolism, contractility of the respiratory muscles, improves hemodynamics. With spontaneous breathing, the average airway pressure decreases compared to mechanical ventilation. Ventilation Pressure support (PSV) reduces the patient’s inspiratory effort, reduces oxygen demand, prevents diaphragm fatigue, reduces intrapulmonary shunt and improves extubation rates. The proposed method can be used in the scheme of a number of anesthetic benefits to improve the quality and safety of the intraoperative period of patients with pathology of the cardiovascular system in coronary heart disease, rhythm disturbances, hypertension, etc.

Example No. 1

Patient K., 63 years old. Diagnosis: nodular goiter, relapse; functional autonomy, thyrotoxicosis of moderate severity, drug-compensated. Surgical treatment planned: thyroidectomy. There are no concomitant chronic diseases, an allergic history is calm. The general condition according to the results of the examination is satisfactory, there are no peripheral edema, respiration is vesicular, there are no wheezing, heart sounds are clear, rhythmic, heart rate is 95 beats / min, blood pressure is 110/70 mm RT. Art. Endotracheal anesthesia is planned. ASA risk - II degree.

At all stages of anesthesia, BIS monitoring was performed.

Premedication: atropine 0.1% - 0.2 w / w, fentanyl 0.005% - 0.5 w / w. Mono-induction in anesthesia with sevoflurane: insufflation of a gas-narcotic mixture with a set indicator on the evaporator of 8% and a flow of 100% oxygen of 8 l / min. After 3.5 minutes, the achieved level of anesthesia (MAK 1.5) allowed tracheal intubation with an endotracheal tube with an irrigation port, without additional administration of analgesics and muscle relaxants.

The BIS monitoring score at this stage was ≥40. Respiratory support: Bleese Focus anesthesia apparatus.

Basic general anesthesia: assisted artificial lung ventilation (ALV) in Pressure Support mode with a maximum trigger sensitivity of 2 l / min., Continuous inhalation of 1.5 sevoflurane MAK and continuous fentanyl infusion (a bolus was excluded due to the risk of respiratory depression) at an average rate 1.0-1.5 mcg / kg / hour. Psupp 8 mm. water column. In the irrigation port of the endotracheal tube (Pervak type) before surgery and in 10 minutes. 60 mg of a 2% lidocaine solution was administered before the expected awakening. The entire main period of the operation maintained spontaneous breathing. The following indicators were evaluated: respiratory rate, tidal volume, tracheal extubation time, average airway pressure (P mean), carbon dioxide content at the end of expiration (EtCO ₂ ), capillary blood oxygen saturation, oxygen content difference in the respiratory mixture FiO ₂ -FeO ₂ , respiratory index RI.

After applying the last suture to the surgical wound, the flow of sevoflurane was stopped and the time of awakening and extubation was recorded. Tracheal extubation was performed after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, and the patient's ability to perform elementary commands. Indicators of systemic intraoperative hemodynamics were within normal values, and no significant changes in tidal volume, respiratory rate, blood saturation, and respiratory index were recorded. The duration of the operation is 52 minutes. The awakening time was 7.2 minutes, tracheal extubation was performed in the operating room 8.9 minutes after the end of the operation. Dynamic observation, the patient was transferred to the general surgical department 30 minutes after extubation in a clear mind, with adequate independent breathing, muscle tone and satisfactory upper respiratory reflexes.

Example No. 2

Patient S., 72 years old. Diagnosis: multifocal atherosclerosis. Stenosis of bifurcation of the common carotid artery on the right up to 90%. Concomitant pathology: coronary heart disease. Angina pectoris 2nd functional class, extrasystole, hypertension 3 degrees, high risk, chronic heart failure of the 2nd functional class.

Surgical treatment planned: Carotid endarterectomy on the right. The somatic status according to the results of the examination is satisfactory, vesicular breathing, no wheezing, heart sounds are clear, rhythmic, single ventricular extrasystoles up to 4-6 minutes, hemodynamically insignificant, heart rate - 84 beats / min., Blood pressure - 140/80 mm RT. Art. Endotracheal anesthesia is planned. ASA risk - II degree.

Mono-induction in anesthesia with sevoflurane was performed: tightly fixing the face mask on the patient's face, insufflation of the gas-narcotic mixture was carried out with the set indicator on the evaporator 8% and a flow of 100% oxygen 8 l / min. After 3.5 minutes, the achieved level of anesthesia of MAK 1.5 allowed tracheal intubation with an endotracheal tube with an irrigation port, without additional administration of analgesics and muscle relaxants.

At the main stage of the operation, BIS monitoring indicators were: 40-60.

Respiratory support: Bleese Focus anesthetic respiratory apparatus. Basic general anesthesia: auxiliary mechanical ventilation in Pressure Support mode with maximum trigger sensitivity of 2 l / min + continuous inhalation of Sevoflurane 1.5 MAK and continuous fentanyl infusion at an average rate of 1.0-2.0 μg / kg / h, P supp 8 mm . water column. Spontaneous breathing was provided for the entire operation. 40 mg of a 2% lidocaine solution were introduced into the irrigation port of the endotracheal tube with the irrigation port before the operation and 10 minutes before the expected awakening. Fentanyl infusion was stopped 10 minutes before the end of the operation, and the supply of sevoflurane - after drainage of the postoperative wound.

Tracheal extubation was performed after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, the patient’s ability to perform elementary commands using the modified Aldrete scale, 7–9 points and BIS ≥ 60. The duration of the operation is 68 minutes. The awakening time was 8.4 minutes, tracheal extubation was performed in the operating room 11.6 minutes after the end of the operation. The patient was transferred to the intensive care and resuscitation department 26 minutes after tracheal extubation, with stable vital functions for dynamic observation and treatment.

Claims (1)

A method for performing general anesthesia with retained spontaneous breathing, comprising the following steps: performing introductory anesthesia, intubating the trachea with an endotracheal tube, performing general anesthesia with assisted ventilation (Pressure Support) with pressure support breathing with a maximum trigger sensitivity of 2 l / min , and continuous inhalation of sevoflurane, during the operation, conduct a continuous infusion of fentanyl, stop the infusion of fentanyl 5-10 minutes before the end of the operation, stop feeding lurana after drainage of a postoperative wound, trachea is extubated after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, characterized in that they monitor the bispectral index of the depth of sedation (BIS monitoring) with an interval of 40-60 index, for induction anesthesia monoinduction is performed in anesthesia sevoflurane by insufflation of a gas-narcotic mixture with a set indicator on the evaporator 8% and a flow of 100% oxygen 8 l / min, endotracheal trap is used to intubate the trachea a cap having an irrigation port for administering drugs to the subglottic space, which is inserted into the trachea when the level of anesthesia is MAK 1.5 (minimum alveolar concentration) and with a BIS index of ≥ 40; before the operation, terminal anesthesia of the tracheal mucosa is carried out in the zone of contact of the cuff of the endotracheal tube with the subglottic space, for which 40-60 mg of a 2% lidocaine solution is introduced into the irrigation port of the endotracheal tube; they undergo general anesthesia with assisted artificial lung ventilation (IVL) under pressure support with a maximum trigger sensitivity of 2 l / min, Psupp pressure of 6-8 mm Hg, with constant inhalation of sevoflurane at 1.0 MAC and BIS monitoring at an index of ≥ 50, during the operation, continuous fentanyl infusion is carried out at a rate of about 1.0 μg / kg / h, fentanyl infusion is stopped 5 minutes before the end of the operation, sevoflurane is stopped after drainage of the postoperative wound, 10 minutes before the patient’s supposed awakening, terminal anesthesia of the tracheal mucosa in the zone of contact of the cuff of the endotracheal tube with the subglottic space, for which 40-60 mg of a 2% lidocaine solution is introduced into the irrigation port of the endotracheal tube, after which the trachea is extubated after restoration of adequate spontaneous breathing, pharyngeal and laryngeal reflexes, the patient’s ability to perform elementary commands on a modified Aldrete scale of 7–9 points and BIS index values ≥ 60.

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