RU2711534C1 - Method of analgesic delivery - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to obstetrics-gynaecology and anaesthesiology, and can be used for labour pain anaesthesia. That is ensured by epidural analgesia with local anaesthetic introduction. Local anaesthetic is represented by levobupivacaine in concentration of 0.075 %. In the presence of regular labour, a puncture and catheterisation of the epidural space is performed at the level of L3-L4/L4-L5, a test dose of the solution of lidocaine hydrochloride 2 % - 3.0 is introduced. After 5 minutes, an anaesthetic is induced by administering levobupivacaine 0.075 % - 10.0 ml. In 15 minutes with insufficient anaesthesia, the VAS score >40 mm additionally involves levobupivacaine 0.075% - 10.0 ml. If an analgesic effect is achieved, the infusion pump Mini Rythmic Evolution Micrel Medical Devices SA is connected in 30 minutes with a program of intermittent administration of epidural boluses of levobupivacaine 6.0 ml every 30 minutes in a combination with patient-controlled epidural analgesia in bolus anaesthetic - 6.0 ml, lockout interval - 30 minutes. Programmed intermittent epidural boluses are introduced in the first and second delivery periods, the introduction is stopped after the delivery.EFFECT: method provides pronounced analgesic effect in the absence of development of the motor block, negative effect on the dynamics of labour, foetus and newborn's condition, reduced cases of breakthrough pain, increased satisfaction of women in labour with the analgesia, reduced frequency of instrumental delivery due to prevention of motor unit development.1 cl, 1 ex

Description

The invention relates to medicine, in particular obstetrics-gynecology, anesthesiology, and can be used for delivery through the natural birth canal for the purpose of pain relief.

A known method for pain relief of labor by patient-controlled epidural analgesia (Gambling D., Yu P., Cole C., McMorland GH A comparative study of patient controlled epidural analgesia (PCEA) and continuous infusion epidural analgesia (CIEA) during labor. Can. J Anaesth. 1988: 35 (3), 249-254 p).

The disadvantages of this method are that at the same time a large volume of local anesthetic is injected into the epidural space, as a result, a motor block can develop, which in turn will affect the course of the birth act, leading to secondary weakness of childbirth. In the future, there is a decrease in the amount of local anesthetic in the epidural space to a minimum level and the pain syndrome resumes.

Closest to the claimed is a method of patient-controlled epidural analgesia against a background of continuous infusion of local anesthetic (Sng BL, Zeng Y., de Souza NNA, Leong WL, Oh TT, Siddiqui FJ, Assam PN, Han NLR, Chan ESY, Sia AT Automatedmandatory bolus versus basal infusion for maintenance of epidural analgesia in labor (Review). Cochrane Database of Systematic Reviews. 2018. 81 p).

The disadvantage of the method chosen as a prototype is that with this technique there are cases of breakthrough pain, a greater amount of local anesthetic is required, which can be accompanied by the development of the motor block and affect both the dynamics of the birth act and the hemodynamics of the woman, and disrupt uterine-placental blood flow and worsen the condition of the fetus.

The volume and concentration of local anesthetic also play a large role in the conduct of adequate pain relief for labor. The use of local anesthetics of low concentration and volume leads to less development of the motor block, which in turn does not affect the mechanism of labor, the hemodynamics of the woman and the fetus.

The objective of the present invention is to improve the quality of labor anesthesia through the birth canal in the absence of a negative impact on the dynamics of labor, the state of the woman in labor and the fetus.

The technical result of the task is achieved by the fact that in the method of labor anesthesia, including patient-controlled epidural analgesia with the introduction of a local anesthetic, levobupivacaine at a concentration of 0.075% is used as a local anesthetic, in the presence of regular labor, puncture and catheterization of the epidural space at the level of L3- L4 / L4-L5, a test dose of a solution of lidocaine hydrochloride 2% - 3.0 is administered, 5 minutes after this, anesthesia is induced by the administration of levobupivacaine 0.07 5% - 10.0 ml, after 15 minutes with insufficient analgesia - assessment according to YOUR> 40 mm scale, levobupivacaine is additionally administered 0.075% - 10.0 ml, when the analgesic effect is achieved, after 30 minutes the Mini Rythmic Evolution Micrel infusion pump is connected Medical Devices SA with a program of intermittent administration of epidural bolus of levobupivacaine 0.075% 6.0 ml every 30 minutes in combination with patient-controlled epidural analgesia in bolus anesthetic mode - 6.0 ml, lock-out interval - 30 minutes, programmed intermittent epidural boluses are administered in the first and wto rum periods of childbirth, the introduction is stopped after delivery.

Lidocaine hydrochloride 2% is administered after the catheter is inserted into the epidural space in order to interpret the correct location of the catheter in the epidural space and to prevent possible complications;

As a local anesthetic, a low-concentration solution of levobupivacaine (0.075%) is used without the addition of narcotic analgesics, which eliminates side effects (nausea, vomiting, itching);

Since different women have different pain thresholds and different sensitivity to local anesthetics, to induce analgesia, we do not immediately administer the entire dose of levobupivacaine (20.0 ml), but first we inject 10.0 ml, and only with persisting pain syndrome (rating on a scale YOUR more than 40 mm), after 15 minutes we inject another 10.0 ml of anesthetic;

Subsequently, the introduction of local anesthetic with the intermittent program for the administration of epidural boluses of levobupivacaine (0.075%) of 6.0 ml every 30 minutes allows for more uniform distribution of the anesthetic in the epidural space without a sharp decrease in concentration, which in turn leads to better anesthesia and a decrease in the likelihood of breakthrough pain . In this case, the use of a low concentrated local anesthetic does not lead to the development of the motor block, as a result of which there is no negative effect on the dynamics of the birth certificate and attempts.

In addition, there is the possibility of additional administration of local anesthetic by the patient herself (patient-controlled epidural analgesia), which in most cases has a huge psychological component, since the patient can herself control the process of anesthesia.

By applying a local anesthetic with programmed intermittent boluses, the local anesthetic is distributed more evenly and widely in the epidural space. This technique eliminates the cumulative effect of the anesthetic, which contributes to better anesthesia, reducing the consumption of local anesthetic and reducing the risk of motor block development.

Levobupivacaine was chosen as a local anesthetic, since it has a good safety profile similar to ropivacaine, and the therapeutic effect corresponds to the racemic bupivacaine.

The use of levobupivacaine at a concentration of 0.075% is due to the fact that the use of a higher concentration will lead to the development of the motor block, and a lower concentration will lead to worse pain relief.

The introduction of levobupivacaine in a volume of 6 ml after 30 minutes It is optimal to achieve an adequate analgesic effect without the development of a motor block. An increase in the volume and frequency of local anesthetic administration will lead to the development of the motor block and affect the course of labor, which may require invasive procedures (applying a vacuum or obstetric exit forceps) during delivery. A decrease in the volume and frequency of administration of levobupivacaine will lead to inadequacy of pain relief.

The method is as follows. In the absence of contraindications, after signing the informed consent for manipulation, in the presence of regular labor, puncture and catheterization of the epidural space are performed at the level of L3-L4 / L4-L5. 5 minutes after the test dose was administered with a solution of lidocaine hydrochloride 2% -3.0, levobupivacaine 0.075% - 10.0 ml is administered to induce anesthesia, with insufficient pain relief after 15 minutes (BAS score> 40 mm), levobupivacaine 0.075 is additionally administered % - 10.0 ml. When an analgesic effect is achieved, after 30 minutes the Mini Rythmic Evolution infusion pump (Micrel Medical Devices SA) is connected with a program for intermittent administration of MA epidural boluses of 6.0 ml every 30 minutes in combination with a patient-controlled epidural analgesia, anesthetic bolus - 6 , 0 ml, lock-out interval -30 minutes.

Reception of programmed intermittent epidural boluses continues in the first and second periods of labor. Local anesthetic ceases to be administered only after delivery.

Example. Patient A., 33, was treated at the Perinatal Center of St. Petersburg State Medical University since 11/30/2017, was admitted urgently with complaints of cramping pain. The woman's condition is satisfactory at the time of admission to the reception department, the pulse is 78 per min, blood pressure is the right hand 90/60 mm Hg, left hand 100/60 mm Hg NPV 16 min The abdomen is enlarged due to the pregnant uterus, it corresponds to the full term. Fights after 6 minutes The uterus between contractions completely relaxes. The water did not leave.

Diagnosis: Childbirth 1 urgent in 39 weeks 1 period. On November 30, 2017, the patient was admitted to the maternity ward. Given the complaints of the woman in labor for painful contractions, it was decided to call the anesthesiology team to conduct epidural analgesia in childbirth. Produced anesthesia for childbirth by the present method. At 17.20 a full-term live girl was born according to APGAR 8/9 points. The placenta separated. The uterus is dense, the discharge is moderate bloody. Blood loss 250 ml. The epidural catheter is removed, the integrity is not broken. The patient was transferred to the postpartum unit. The condition is satisfactory.

The inventive method leads to a pronounced analgesic effect in the absence of development of the motor block, a negative effect on the dynamics of labor, the condition of the fetus and newborn.

The method allows to reduce cases of breakthrough pain, to increase the satisfaction of women in labor with anesthesia.

The method also allows to reduce the frequency of instrumental labor by preventing the development of the motor block.

Claims (1)

A method of labor analgesia, including epidural analgesia with the introduction of a local anesthetic, characterized in that levobupivacaine at a concentration of 0.075% is used as a local anesthetic, in the presence of regular labor, the epidural space is punctured and catheterized at the level of L3-L4 / L4-L5, a test is administered -dose of lidocaine hydrochloride solution 2% - 3.0, 5 minutes after this, anesthesia is induced by the administration of levobupivacaine 0.075% - 10.0 ml, after 15 minutes with insufficient anesthesia - assessment by n le YOUR> 40 mm additionally administer levobupivacaine 0.075% - 10.0 ml, when the analgesic effect is achieved after 30 minutes, the Mini Rythmic Evolution Micrel Medical Devices SA infusion pump is connected with a 0.075% 6.0 ml levobupivacaine epidural bolus intermittent program every 6.0 ml 30 min in combination with patient-controlled epidural analgesia in the bolus anesthetic regimen - 6.0 ml, lockout interval - 30 minutes, programmed intermittent epidural boluses are administered in the first and second periods of labor, and administration is stopped after delivery.