RU2712918C1 - Method of preventing acute pain accompanying chemical pleurodesis following radical thoracoplastic operations of oncological nature - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to anesthesiology and resuscitation in oncology, and is intended to prevent acute pain in postoperative chemical pleurodesis due to the presence of recurrent pleuritis, spontaneous pneumothorax following radical thoracoplastic operations in lung cancer. 24 hours before the chemical pleurodesis is performed by sclerosing preparations, a transdermal therapeutic system based on fentanyl in dose of 75–100 mcg/h is applied on the shoulder or back of the patient depending on the patient's weight and age.EFFECT: use of the invention enables safe, adequate prevention of developing acute pain accompanying chemical pleurodesis by sclerosing agents with minimal risks of developing undesirable therapeutic effects in lung cancer patients following radical thoracoplastic surgeries.1 cl, 2 ex

Description

The invention relates to medicine, namely to anesthesiology and intensive care in oncology, and can be used to prevent acute pain during chemical pleurodesis (talc, doxycycline, bleomycin, betadine) in the postoperative period due to the presence of recurrent pleurisy, spontaneous pneumothorax after radical thoracoplastics operations for lung cancer.

Currently, in oncology there is an opinion that extensive surgical interventions are accompanied by a high frequency of complications and, as a consequence, mortality. The main reason is a surgical stress response, which leads to dysfunction of organs and systems. Its severity and duration is determined by the invasiveness of any intervention (see P.A. Lyuboshevsky. Surgical stress response during abdominal surgeries of high invasiveness and the possibility of its anesthetic correction, 2012, p. 3-4).

Patients with malignant neoplasms are radically different from patients receiving treatment in surgical departments of the general profile with significant changes in the homeostasis system, acid-base state, neuro-endocrine disorders caused by tumor intoxication and the systemic effect of cytostatics, the volume and trauma of surgical interventions (see Osipova N .A. Postoperative analgesia in Russia: clinical and organizational aspects // General intensive care, 2013, IX; 4 pp. 5-10).

The development of a stress response causes the production of mediators affecting tumor growth. It is proved that any surgical manipulations (dissection, sprain, pleurodesis, ischemia, surgical treatment) can become a risk factor for the progression of the oncological process, especially in patients during the suppression of the cellular immunity unit. Depression of the immune system on the first day after performing various surgical procedures also causes acute pain, which stimulates the hypothalamic-pituitary-adrenal axis (see A.M. Ovechkin. Anesthesia and analgesia in oncology: what determines the choice? / 2012, Volume VI, No. 2, p. 5-15).

Severe pain during surgical interventions, as well as any surgical procedures in the postoperative period, causes a negative effect on the body. At present, the quality of life of patients receiving treatment in oncology hospitals is one of the main tasks facing specialists. The concept of “quality of life related to health” appeared long ago and the medical community constantly evaluates this important and controversial parameter (see A.Yu. Nenarokomov, D.L. Speransky, E.V. Arevshatov, A.Yu. Wise. Modern the concept of the study of quality of life in oncology. Fundamental research, 2012.-№2-2. - S. 421-425).

Despite the ongoing research work in clinical practice, the problem of pain after surgical procedures for lung cancer remains, which acquires not only medical, but also socio-economic importance. Any surgical manipulations lead to the formation of the main focus of acute pain, as a result of which neurohumoral processes are activated and, as a result, peripheral pain receptors (nociceptors) are activated. (see. Golub I.E., Kovyrshin A.V. Therapy of postoperative pain syndrome. 2005. S. 5).

Evaluation of pain is one of the most important and significant indicators that are responsible for the depth of action of the damaging factor, the effectiveness of the symptomatic treatment, the severity of the patient's condition. The most commonly used scale for assessing pain is the Visual Analogue Scale (VAS) with a range of 0-10 points, where 1-4 points correspond to mild pain, 5-6 points mean moderate pain, 7-10 points mean severe, intolerable pain (see YA Harchenko. An adequate assessment of pain is the key to its successful treatment. Universum: Medicine and Pharmacology: Electronic Scientific Journal, 2014. No. 4 (5), pp. 3-8).

Often in the postoperative period, inflammatory or purulent-destructive changes in the parenchyma of the lungs and pleural cavity are noted, which leads to the development of acute respiratory failure. One of the common methods of treating spontaneous pneumothorax or recurrent pleurisy is chemical pleurodesis (the introduction into the pleural cavity of drugs that cause aseptic inflammation and the development of granulation tissue with subsequent scarring). The most powerful sclerosing agents are talc and tetracycline antibiotics (doxycycline and bleomycin). The introduction of these drugs causes a pronounced pain syndrome (YOUR 8-10 points), which requires intravenous administration of opioid drugs (see Zhestkov K.G., Barsky B.G., Atyukov M.A., Pichurov A.A. National clinical recommendations for the treatment of spontaneous pneumothorax, 2013, C 8-9).

Intravenous bolus administration of opioid analgesics during chemical pleurodesis is accompanied by a sharp increase in the level of opioid in the blood plasma, a pronounced, but short-term analgesic effect. A short period of analgesic action is associated with a sharp decline in the concentration of the drug in the blood serum and the absence of its depot in the body. Intravenous administration of opioid analgesics has a number of undesirable effects: it can cause respiratory depression and consciousness, acute cardiovascular failure (tachycardia, bradycardia, hypotension), hepatotoxicity, and paralytic ileus. With an insufficient dose of the administered opioid analgesic, marked pain is retained (VAS 6-8), which leads to respiratory muscle trismus (apnea), bronchospasm, collapse of lung sections, and reflex cardiac arrest.

In surgical practice, in order to prevent life-threatening complications, an alternative method of treating spontaneous pneumothorax or relapsing pleurisy is used - video thoracoscopic chemical pleurodesis under general anesthesia, separate ventilation in the patient’s position on the side (see patent RU No. 2358775, published on June 20, 2009, Bull. 17) . This method of performing chemical pleurodesis completely eliminates the likelihood of developing acute respiratory failure, as it is performed under general anesthesia with mechanical ventilation, but has several disadvantages. For manipulation, it is necessary to perform separate intubation of the lungs for a certain amount of time (60-90 minutes), which disrupts gas exchange, blood circulation, and can lead to hypoxemia. The forced position of the patient intraoperatively on the side leads to a violation of the ventilation-perfusion ratio (there is a redistribution of blood flow, a violation of gas exchange, which in turn leads to an increase in functional dead space and hypoventilation). It can also cause damage to the nerve trunks of the upper and lower extremities and the brachial plexus. Given the need for general anesthesia, the patient’s activation period has been delayed.

The technical result of the invention is the development of a safe, adequate way to prevent acute pain during chemical pleurodesis with sclerotizing agents with a minimal risk of developing undesirable effects of treatment in patients with lung cancer after radical thoracoplastic operations.

The technical result is achieved by the fact that 24 hours before performing chemical pleurodesis with sclerotherapy drugs, a transdermal therapeutic system based on fentanyl at a dose of 75-100 μg / h is applied to the patient’s shoulder or back, depending on the weight and age of the patient.

The novelty of the invention lies in the fact that the application of TTS based on fentanyl at a dose of 75-100 μg / h (depending on the weight and age of the patient) completely eliminates the additional administration of analgesics, creates a constant concentration of fentanyl in the blood, there is a pronounced analgesic effect, which is confirmed lack of response to the introduction of sclerotic drugs such as talc and antibiotics of the tetracycline group (doxycycline and bleomycin). The visible effect of TTC therapy when performing surgical procedures that cause unbearable pain allows the use of a patch to prevent the development of acute pain after radical thoracoplastic operations in lung cancer during chemical pleurodesis in the postoperative period.

Transdermal administration of a drug based on fentanyl is a more promising method of administration along with enteral and intravenous. A single application of TTC has the advantage of receiving a sufficient dose of the drug over a longer period of time. An easy and affordable method of application, the absence of the need for repeated injections (applications) within three days create a favorable psycho-emotional background of the patient and increase their compliance. Fentanyl-based TTS has linear kinetics, increases the activity of the antinociceptive system, and increases the threshold of pain sensitivity.

The method is as follows.

After surgical treatment of lung cancer, 24 hours before performing surgical manipulation (chemical pleurodesis with sclerosing drugs), a transdermal therapeutic system based on fentanyl at a dose of 75-100 μg / hour is applied to the patient’s shoulder or back, depending on the patient’s weight and age. According to the instructions for the use of fentanyl-based TTS after application of the patch, the absorption and distribution of fentanyl occurs sequentially during the first day, the maximum concentration is reached in the first 17-21 hours and the long amount of time remains unchanged, during which the surgical pleurodesis is performed.

This method provides a constant adequate analgesic effect, as evidenced by monitoring the basic vital functions (respiratory rate, heart rate, blood pressure, saturation) using an electrocardiomonitor, the patient does not respond to the introduction of sclerotic drugs that cause severe pain, and there are no patient complaints. A significant advantage of this method is the absolute elimination of possible complications such as hypoxemia, which can lead to a number of undesirable consequences.

The originality of the invention lies in the fact that the use of fentanyl-based TTC completely eliminates the additional intravenous or intramuscular administration of analgesics, when the patch is applied, the patient does not experience discomfort (minimally invasive method), the constant concentration of fentanyl in the blood plasma provides linear anesthesia, which in turn reduces the risk of toxic action of the drug.

The invention, “A method for preventing acute pain during chemical pleurodesis after radical thoracoplastic oncological operations,” is easily applicable and available, has a dose-dependent effect that does not require correction, and can be used to prevent acute pain during chemical pleurodesis with sclerotizing agents with minimal risk of undesirable effects treatment in patients with lung cancer after radical thoracoplastic operations.

We present clinical examples of the application of the method.

Clinical example No. 1.

Patient R., 60 years old. He entered the Department of Thoracic Oncology 05/07/2018 with complaints of chest pain on the right.

Anamnesis of the disease: a preventive examination in 2016 revealed the formation of the upper lobe of the left lung. He was referred to an oncologist, but did not contact the lower leg due to an injury. A follow-up examination shows an increase in education. Turned to the RNII.

SRKT OGK from 03/28/2018: peripheral tumor of the upper lobe of the left lung 5.5 × 5.0 cm with germination of the mediastinal pleura, centralization. The dynamics is the growth of education since 2016. On the left in the upper lobe are dense post-tuberculous foci up to 1.4 cm intrathoracic lymph nodes are bronchopulmonary on the left up to 1.0 cm, the aortic window is 1.0 cm. FBS from 03/28/2018: chronic endobronchitis. There is no evidence for the centralization of peripheral education. SRKT GM dated 04/28/2018: no volumetric formations were found in the substance of the brain, bone structures without signs of destruction. Ultrasound OBP and OMT from 03/28/2018: hepatomegaly, fatty hepatosis. ZhKB. Diffuse changes in the pancreatic parenchyma. Hydrocalix of the left kidney. FVD from 03/28/2018: VC 45%, VF 37%, FEV1 34%. Echocardiography from 03/04/2018: left ventricular myocardial hypertrophy. Signs of fibrotic changes in heart valves without impaired function. Diastolic dysfunction of the left ventricle according to type 1. ECG from 04.24.2018: moderate sinus tachysystole, heart rate 88 beats / min. Incomplete blockade of PNPG. The left front hemiblock is a distal form. Left ventricular myocardial hypertrophy. Decreased recovery processes of the myocardium of the anterior septal region of the left ventricle.

Therapist consultation dated 03/28/2018: hypertension 2 tbsp stAG3, risk2, CHF2 tbsp. Obesity 2 tbsp. COPD, dust bronchitis (with significant impairment of HF). There is a significant risk of surgery due to the state of the respiratory and cardiovascular systems.

Consultation of a vascular surgeon from 04/22/2018: varicothrombophlebitis of the right lower limb. CVI 2 FC4. Condition after thrombophlebectomy from the right lower limb. There are no contraindications to surgical intervention.

Consultation of the anesthetist on 04.24.2018: ASA III risk, surgical treatment is possible. Hospitalized in OTK for surgical treatment. VMP.

Anamnesis of life: According to the patient, he was treated for tuberculosis in 1995 (deregistered), appendectomy in 1990, excision of an inguinal hernia in 1990, thrombophlebectomy of the right lower limb. Sexually transmitted diseases, viral hepatitis - denies. Injuries - fracture of the lower leg of the lower extremity 2016. Drug intolerance - no. There were no blood transfusions. He smoked up to 1 pack per day; he has not smoked for 10 years. The professional route is a miner. Expert history: not working, disability certificate is not needed.

Objectively: General condition of the patient of moderate severity. The consciousness is clear, it comes into contact adequately. Normosthenic physique, increased nutritional status. No swelling. Percussion - a clear pulmonary sound. Auscultation in the lungs harsh breathing, no wheezing. BH - 20 per min. Heart sounds are clear, rhythmic. Pulse 82 in min. satisfactory filling and tension. HELL = 130/80 mm Hg The abdomen is regular in shape, not swollen, soft, painless on palpation. The liver at the edge of the costal arch, spleen and kidneys are not palpable. The symptom of "striking" is negative on both sides. Physiological administration is not disturbed. Veins of the lower extremities - dilated, without the formation of nodes. Per rectum - no features.

Summary: On the basis of complaints from a patient with a medical history, clinical and instrumental examination data (CRT OGK, FBS), a clinical diagnosis was made upon admission: Peripheral cancer of the upper lobe of the left lung cT2NxM0 stII, class 2.

Concomitant: Varicothrombophlebitis of the right lower limb. CVI 2 tbsp. FC4. Condition after thrombophlebectomy from the right lower limb Hypertension 2 tbsp stAG3, risk2, CHF2 tbsp. Obesity 2 tbsp.

05/10/18 the operation was performed extended combined upper lobectomy on the left with a resection of the mediastinal pleura and phrenic nerve.

The early postoperative period without features. On the 9th day after surgery for pleural drainage, air discharge was noted during breathing and coughing. Conservative measures for four days without effect. On the 13th day after surgery, a decision was made to perform chemical pleurodesis with doxycycline.

30 minutes before the manipulation, 2 ml of a 2% solution of promedol was intramuscularly injected, a solution of 1% - 1 ml morphine was intravenously administered before the procedure. At 15:00 in the conditions of the intensive care unit, the intrapleural administration of doxycycline 500 mg per 20.0 physical units was performed. solution through pleural drainage, in the position of the patient lying on his back with a raised leg end. Marked pain was observed with bradypnea up to 8 per minute for 5 minutes (on the cardiomonitor there was a decrease in SpO ₂ to 84%, blood pressure - 85/55 mm Hg, heart rate - 115 / min. YOUR - 9 points), stopped intravenous administration of trinalgin 3.0 ml, morphine 1% - 2.0 ml.

After antibiotic administration, the drainage is blocked. SpO ₂ - 91-94% against the background of insufflation of moistened oxygen through nasal cannulas with a flow of 5 liters per minute. Change of body position every 15 minutes. By 5 p.m., emphysema was noted in the region of the left upper limb, face, and pectoralis major muscle on the left (which indicates the preservation of severe pain, overstrain of the upper shoulder girdle and limitation of chest excursion).

The pleural drains are open, the drainage can is connected to the central vacuum. The pain syndrome (VAS - 6 points) persisted for 12 hours, which required an additional intramuscular injection of morphine 1% - 1 ml × 3 times.

Clinical example No. 2.

Patient G., born in 1971, was admitted to the Department of Thoracic Oncology 02/19/2019 with complaints of chest pain on the left, daily increase in body temperature to 38.5-39.0 ° С.

Anamnesis of the disease: has been sick since August 2018, when chest pains appeared. In September, body temperature began to rise to subfebrile numbers. In connection with the worsening condition, increasing hyperthermia, he went to the doctor at the place of residence in November, was examined. A tumor of the anterior mediastinum was found. Turned to the RNII.

With CRT of OGKs dated January 21, 2019: in the anterior superior mediastinum, a heterogeneous solid volume formation of 8.0 × 7.0 × 7.9 cm is adjacent to the aorta, the left pulmonary trunk without germination, and is adjacent to the anterior-costal pleura. The bronchi are passable. Axillary lymph nodes up to 1.3 cm on the left. Hilar lymph nodes anterior to the aortic arch up to 1.7 cm.

SRKT OBP and a small pelvis from 01/17/2019: pathological changes from OBP and retroperitoneal space are not revealed.

SRKT GM dated 01/16/2019: No data were found for mts GM damage.

GA: in trepan biopsy, fibrous and muscle tissue, necrotic masses with leukocyte infiltration.

FBS from 10.10.2019: the larynx is mobile. Trachea, carina not changed. The bronchi of both lungs differentiate. CA: Hyperplasia of the cylindrical epithelium.

01/25/2019 performed transthoracic puncture. GA: - in trepan biopsy, fibrous and muscle tissue, necrotic masses with leukocyte infiltration.

ECG from 01/10/2019: Atrial rhythm. Normasystole. Signs of left ventricular myocardial hypertrophy. Decreased recovery processes in the myocardium of the posterior-lower sections.

Ultrasound of the genitals from 01/18/2019: No ultrasound pathological lesions were detected.

Consultation of a vascular surgeon from 01/22/2019: anticoagulant prophylaxis with low hemorrhagic risk in the mid-term period. There are no contraindications to surgical treatment at the time of examination. Therapist consultation: MKD, NK0, ankylosing spondylitis, remission. Hospitalized at the Department of General Medicine for surgical treatment of VMP.

Anamnesis of life: Denies tuberculosis and viral hepatitis, ELISA from 01/18/2019: HDs-Ag, HC-Ag, HIV 1.2 AT / AH - not found. An allergic history is not burdened. There were no blood transfusions. Ankylosing spondylitis since 2005. Operations: 1993 appendectomy; 2000-ZCHMT, SGM. Smokes 25 years at 2 packs a day, does not abuse alcohol. Heredity is not burdened. Professional route - driver.

Expert history: needs to issue a primary CVD.

Objective: General condition is closer to satisfactory. The consciousness is clear, the position is active, it comes into contact adequately. Body temperature 36.6. Normosthenic physique, satisfactory nutritional status. The skin is dark and visible mucous membranes, moderately pale clean. Lymph nodes are not enlarged. BH = 18 in min. Both halves of the chest evenly participate in the act of breathing. With comparative percussion - a pulmonary sound, with auscultation - hard breathing, no wheezing. Heart sounds are rhythmic, muffled, clean. Pulse 78 min., Satisfactory voltage and filling. HELL = 130-80 mm. Hg. Art. The abdomen is soft, painless on palpation in all departments. Liver at the edge of the costal arch. The spleen and kidneys are not palpable. Pasternatsky’s symptom is negative on both sides. Urination is not disturbed, the chair is regularly decorated. Veins of the lower extremities are not dilated, there is no edema.

Based on the patient’s complaints, previous observation and clinical and instrumental examination data, the patient was admitted upon admission: Clinical diagnosis: (C38.1) Tumor of the anterior mediastinum, Cl. 2. Complications of the main: no. Concomitant diseases: MKD, NK0, ankylosing spondylitis, remission.

02/26/19 the operation was performed: median sternotomy, thoracotomy on the left, removal of a mediastinal tumor, thimectomy, resection of the phrenic nerve, upper lobectomy on the left.

The early postoperative period without features. On the 11th day after surgery for pleural drainage, air discharge was noted during coughing, the patient is connected to a vacuum aspirator. Dynamic observation for three days. In connection with the preservation of air discharge through pleural drainage by surgeons, it was decided to perform a chemical pleurodesis on March 13, 2019 (the 15th day after surgery).

03/12/2019 a day before surgery at 15:00, a fentanyl-based patch at a dose of 75 mcg / h was applied to the patient on the right shoulder. The patient is active within the ward; no complaints.

On March 13, 2019 at 14.30, a chemical pleurodesis was performed with a sclerosing drug doxycycline 500 mg per 20.0 saline through pleural drainage, in the patient’s position, lying on his back with a raised leg end.

During administration of the drug, the patient’s level of consciousness is clear, accessible, adequate. No complaints of pain. YOUR 0 points. Hemodynamics stable blood pressure 125/75 mm Hg, heart rate = Ps = 75 per minute, ECM correct sinus rhythm. BH 17 per minute, SpO ₂ 97%. After the introduction of the drug, a change in body position every 15 minutes. Hemodynamics is stable. The patient is active, spontaneous breathing, adequate, pain is not marked. YOUR 0 points.

This method prevented the development of pain during chemical pleurodesis after surgical treatment of lung cancer in 15 patients.

The technical and economic effectiveness of the invention “A method for preventing acute pain during a chemical pleurodesis after radical thoracoplastic oncological operations” is that its use prevents the development of acute pain during a chemical pleurodesis with sclerotizing agents and does not lead to respiratory disorders (apnea, bradypnea, desaturation ), which compensatoryly cause hemodynamic disturbances (hypotension, tachycardia). The method is safe, non-invasive, easily applicable and affordable, completely eliminates the additional bolus administration of pain medications, does not require hemodynamic correction and observation in the intensive care unit.

Claims (1)

A method of preventing acute pain when performing chemical pleurodesis after radical thoracoplastic oncological operations, including anesthesia with narcotic analgesics, characterized in that 24 hours before performing chemical pleurodesis with sclerosing drugs, a transdermal therapeutic system based on fentanyl in a dose of 75-100 is applied to the patient’s shoulder mcg / h depending on the weight, age of the patient.