RU2706230C1 - Method of combined prolonged high spinal and endotracheal anesthesia in operations on the upper abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology. Invention relates to a combination of prolonged high spinal and endotracheal anesthesia in operations on the upper abdominal floor, comprising performing HSA (high spinal anesthesia) in a lying position on the side, after local anesthesia, medial puncture access and spinal space catheterization at the level of L4-L5 using a set for prolonged spinal anesthesia, in which the catheter is delivered in the cranial direction by 3 cm with the introduction of an isobaric solution of marcaine in an initial dose of 20 mg with further prolongation of the preparation administration and regulation of blockade control by inclination of the head end of table to 45–60° with further induction into anesthesia by intravenous administration of propofol 2–3 mg/kg followed by tracheal intubation following administration of fentanyl 2 mcg/kg and tracrium muscle relaxant 0.5 mg/kg, followed by endotracheal anesthesia with sevoflurane inhalation 1–1.5 %, allowing to prolong analgesic effect in postoperative period by repeated introduction of anesthetic in half dosage into spinal catheter.

EFFECT: complete segmental block and muscle relaxation in the operation area, stability of central hemodynamics values during surgical intervention and in the postoperative period.

1 cl, 1 ex

Description

The alleged invention relates to medicine, namely to anesthesiology, and can be used as a combined anesthetic aid in operations on the upper floor of the abdominal cavity and in the postoperative period.

We know the proposed method of extended high spinal anesthesia (RF patent RU 2668793 dated 10/05/2018), which allows performing long-term surgical interventions, as well as prolonging the analgesic effect in the postoperative period, which consists in the fact that after local anesthesia of puncture and catheterization of the subarachnoid space at the LIV-LV level, we conduct a catheter cranially by 2-3 cm. Into the installed catheter, we introduce an isobaric solution of marcaine in an initial dose of 15-20 mg with bubbling of cerebrospinal fluid in bemsya to 5-10 ml within 1-2 minutes. By changing the position of the operating table (tilt of the head end of the table) we regulate the development of the block. In the postoperative period, an anesthetic is inserted into the catheter at the “request”, which causes a prolongation of the analgesic effect.

The disadvantage of this method is the low level of muscle relaxation when performing extensive, prolonged surgical interventions on the organs of the abdominal cavity, as well as the "presence of the patient in surgery", which can negatively affect the patient's condition.

Closest to the proposed technical essence is a method of analgesia, which consists in intraoperative induction of intravenous anesthesia with thiopental, supported by inhalation anesthesia with sevoflurane with endotracheal intubation and mechanical ventilation with the introduction of narcotic analgesic and muscle relaxant and prolonged postoperative analgesia with continuous catheterization through continuous end-to-end catheter levels of Th6-Th8 and L1-L4 of a mixture of 0.1% solution of ropivacaine and hydromorphone (Tobias JD, Gaines RW, Lowry KJ A dual epidural ca theter technique to provide analgesia following posterior spinal fusion for scoliosis in children and adolescents // Pediatric Anaesthesia. - 2001. - Vol. 11. - P. 199-203)

The disadvantage of this method is the absence of high-quality intraoperative anesthesia, epidural blockade is performed only after the operation is completed, which may be accompanied by a number of adverse outcomes in the form of cardiovascular failure, pulmonary dysfunctions and thromboembolic complications, as well as technical difficulties in performing. In addition, epidural anesthesia necessitates the use of large doses of local anesthetic, which has a neurotoxic effect on the body.

The objective of the invention is to develop a combined method, which consists in preliminary performing prolonged high spinal anesthesia with the development of a high neuromuscular block and subsequent performing endotracheal anesthesia with sevoflurane, propofol and fentanyl, which allows performing high-quality, long-term anesthesia during operations on the upper floor of the abdominal cavity. In this case, early awakening and extubation of the patient on the operating table is achieved, the risk of complications is reduced, and high-quality postoperative analgesia is performed by introducing a local anesthetic into the catheter, as well as reducing the dosage of narcotic analgesics in the intraoperative period.

The method is as follows. Before performing endotracheal anesthesia in the patient’s supine position, after local anesthesia, mid-access puncture and then catheterization of the spinal space at the level of L4-L5, using the kit for extended spinal anesthesia. In this case, the catheter is carried out in the cranial direction by 3 cm with the introduction of an isobaric solution of marcaine in an initial dose of 20 mg. with further prolongation of administration of the drug and regulation of the control of blockade by tilting the head end of the table to 45-60 ° with further induction into anesthesia by intravenous administration of propofol (2-3 mg / kg), followed by intubation of the trachea after administration of fentanyl (2 μg / kg) and muscle relaxant tracrium (0.5 mg / kg).

When the operation time is extended and there are signs of restoration of motor and pain sensitivity, the anesthetic is re-introduced into the spinal catheter in half the dose from the initial one with sparging of the cerebrospinal fluid. Maintenance of anesthesia is also carried out by endotracheal anesthesia with inhalation of sevoflurane 1-1.5% vol. In this case, the patient is awakened and extubated already on the operating table. Then, in the postoperative period, assessing the neurological status, anesthetic marcaine is introduced into the spinal catheter at a dosage of half the initial one with bubbling cerebrospinal fluid and in strict observance of bed rest for 24 hours with a raised head end of the bed for 30-45 °. After three days, the catheter is removed. In the early postoperative period for the prevention of complications, the patient is in strict bed rest for 48 hours with a raised head end of the bed at 30-45 °.

The combination of high spinal anesthesia and endotracheal anesthesia allows you to expand the area of surgical intervention, including both operations on the upper (due to EPSA) and, if necessary, expansion of the volume on the lower floor of the abdominal cavity (due to ETH). In addition, a combination of two types of anesthesia can prevent the so-called "syndrome of the presence of the patient in surgery", thereby the patient manages to avoid painful impressions. Combined anesthesia allows to maintain endotracheal anesthesia at the superficial level (III ₁ ) for a long time. At the same time, there is no need to deepen anesthesia to obtain sufficient muscle relaxation and high-quality anesthesia. Anesthesia will be carried out by introducing an anesthetic into the spinal catheter. A superficial level of endotracheal anesthesia allows for early waking up and extubation of the patient, which does not require monitoring of the patient in the intensive care unit and allows him to be placed in the postoperative ward. Prolonged high spinal anesthesia in the postoperative period provides high-quality analgesia without resorting to the use of narcotic analgesics.

The proposed method is illustrated by a clinical example.

Patient K., 61, was hospitalized on May 29, 18 to the surgical department with complaints of constant pain in the left abdomen, bloating, dry mouth, periodic nausea, and a tendency to constipation. The patient considers himself ill from the beginning of May 2018, when he began to notice periodic abdominal pain, bloating, nausea, belching. I went to the general practitioner. Examination of the patient revealed a chronic duodenal ulcer. The patient underwent a course of conservative antiulcer therapy. The ulcer healed, however, periodic abdominal pain persisted, there was a periodic increase in body temperature to 38 ° C. During the examination, the patient was diagnosed with acute intestinal obstruction. The patient is prepared for surgery.

In the operating room, the patient performed catheterization of the spinal space at the level of L4-L5 using the kit for extended spinal anesthesia. High spinal anesthesia was performed according to the method described above, followed by induction of anesthesia with intravenous propofol (2-3 mg / kg) and tracheal intubation after administration of fentanyl (2 μg / kg) and tracrium muscle relaxant (0.5 mg / kg) with maintenance anesthesia by inhalation of sevoflurane 1-1.5% vol.

Operation: Mid-median laparotomy, resection of the ileum, cecum, ileoascendoanastomosis, drainage of the abdominal cavity.

The time of surgical treatment was 2 hours 55 minutes. Hemodynamics - as moderate hypotension. Blood loss was 400 ml. Infusion therapy in the operating room - 4100 ml (crystalloids 2500 ml; glucose solutions 1000 ml; colloids 500 ml; antimicrobials 100 ml). At the end of surgical treatment: awakening on the operating table, consciousness restored, adequate breathing. The patient underwent rehabilitation of the trachebronchial tree and oral cavity, then extubation of the trachea. The respiratory rate of 18 per minute, Sp About ₂ - 98% in atmospheric air. Catheter diuresis was 850 ml. The patient was transferred to the intensive care unit, where for two postoperative days the anesthesia was performed in a spinal catheter according to the method described above - the frequency of administration was twice a day. On the second day, the patient was transferred to the general ward of the surgical department for further treatment, where postoperative anesthesia in the catheter was also performed (twice) during the day with a 50% less dose than the repeated dose, after which the catheter was removed, an aseptic dressing was applied to the puncture site . The patient was discharged on the 14th day with recovery.

Thus, the proposed method of combined anesthesia, combining the execution of pre-extended high spinal and endotracheal anesthesia based on marcaine, propofol, fentanyl and sevoflurane during operations on the upper floor of the abdominal cavity, allows for high-quality and long-term anesthesia. The advantage of the proposed method is the early awakening and extubation of the patient already on the operating table, the stability of the central hemodynamics, a reduced risk of complications, prolonged anesthesia with a decrease in the dose of narcotic analgesics in the intraoperative period. Prolonged high spinal anesthesia in the postoperative period provides high-quality analgesia without the use of narcotic analgesics.

Claims (1)

A method of combining prolonged high spinal and endotracheal anesthesia during operations on the upper floor of the abdominal cavity, comprising performing an ICA (high spinal anesthesia) on a patient lying on his side, after local anesthesia, using mid-puncture and catheterization of the spinal space at the level of L4-L5 using a set for prolonged spinal anesthesia, in which the catheter is carried out in the cranial direction by 3 cm with the introduction of an isobaric solution of marcaine in an initial dose of 20 mg into it, with further by ongation of drug administration and regulation of blockade control by tilting the head end of the table to 45-60 ° with further induction in anesthesia by intravenous administration of propofol 2-3 mg / kg followed by intubation of the trachea after administration of fentanyl 2 μg / kg and tracrium muscle relaxant 0.5 mg / kg , followed by endotracheal anesthesia with inhalation of sevoflurane 1-1.5%, allowing to prolong the analgesic effect in the postoperative period by re-introducing the anesthetic in half dosage into the spinal catheter.