RU2752989C1 - Method for reducing intraoperative bleeding during endoscopic endonasal rhinosurgical interventions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to rhinosurgery, and concerns the reduction of intraoperative bleeding during endoscopic rhinosurgical interventions. To do this, before the operation, 4% lidocaine is inhaled intranasally, 1-2 ml in each nostril. Then, at the beginning of the main stage of the operation, lidocaine is bolus injected at a dose of 1-1.5 mg/kg for 2-3 minutes intravenously. Further, the administration is carried out in the micro-jet mode at a dosage of 2-5 mg/kg/h, taking into account the traumatic stages of the operation and the hemodynamic reactions of the patient.

EFFECT: effective reduction of bleeding to create the necessary level of visualization of the surgical field without exceeding the permissible parameters of the plasma concentration of lidocaine.

1 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, namely endoscopic rhinosurgery, and can be used to reduce intraoperative bleeding during endoscopic endonasal rhinosurgical surgery.

There are various ways to reduce intraoperative bleeding during endoscopic endonasal rhinosurgical surgery by controlled hypotension (Kolotilov L.V., Filimonov S.V., Pavlov V.E., Borodulin V.G., Karpishchenko S.A., Ryabova M.A. .. Local and general anesthesia in otorhinolaryngology. SPb .: Dialogue, 2017. 192 p.); (Practical outpatient anesthesiology / edited by Johan Raeder, Richard D. Urman; translated from English edited by K.M. Lebedinsky. - M.: GEOTAR - Media, 2018. - 336 p.: Silt).

A common disadvantage of these methods is the presence of contraindications for use. Contraindications for a significant decrease in intraoperative blood pressure are ischemic heart disease, atherosclerosis, diabetes mellitus, old age and other concomitant diseases.

The known use of hemostatic agents to reduce intraoperative bleeding is ineffective with significant damage to tissues and blood vessels, with a large amount of surgical intervention and in some cases may be contraindicated [Barham HP, Sacks R, Harvey RJ. Hemostatic Materials and Devices. Otolaryngol Clin North Am. 2016; 49 (3): 577-584. doi: 10.1016 / j.otc.2016.02.002].

A known method for reducing intraoperative bleeding in endoscopic rhinosurgery, in which preoperatively perform bolus intravenous administration of lidocaine 1-1.5 mg / kg for 2-3 minutes and then micro-jet at a dosage of 2-5 mg / kg / hour, taking into account the trauma of the stages of the operation and hemodynamic reactions of the patient [Pavlov V.E., Karpishchenko S.A. Intravenous use of lidocaine as part of general combined anesthesia in rhinosurgery. Folia Otorhinolaryngologiae et Pathologiae Respiratoriae. 2018.Vol. 24. No. 3. P.1-8.]

The disadvantage of this method is that the use of small doses of lidocaine does not in all cases provide an adequate reduction in bleeding to create the required level of visualization of the operating field without exceeding the permissible plasma concentration of lidocaine.

The technical result of the invention is an adequate reduction in bleeding to create the required level of visualization of the operating field without exceeding the permissible plasma concentration of lidocaine, a decrease in the total dose of injected lidocaine while improving the visualization conditions.

The specified technical result is achieved in a method for reducing intraoperative bleeding during endoscopic endonasal rhinosurgical surgical interventions, including bolus intravenous administration of lidocaine at the start of the main stage of the operation at a dose of 1-1.5 mg / kg for 2-3 minutes and then micro-jet at a dosage of 2- 5 mg / kg / hour, taking into account the trauma of the stages of the operation and the hemodynamic reactions of the patient, in which, before the start of the operation, inhalation of lidocaine 4% is performed intranasally, 1-2 ml in each nostril.

Lidocaine has a biphasic effect on smooth muscle and peripheral blood vessels. At low concentrations in the blood, vasoconstriction occurs, at high concentrations - vasodilation [Beaussier M, Delbos A, Maurice-Szamburski A, Ecoffey C, Mercadal L. Perioperative Use of Intravenous Lidocaine. Drugs. 2018; 78 (12): 1229-1246. doi: 10.1007 / s40265-018-0955-x]. Vasoconstriction leads to a significant reduction in intraoperative bleeding.

Concentrations of lidocaine in the blood exceeding 6-8 μg / L are toxic and can cause the development of such side effects as psychomotor agitation, general weakness, decreased blood pressure, tonic-clonic seizures, coma, collapse, AV blockade, respiratory arrest, etc. .d. [Instructions for use of the medicinal product for medical use lidocaine. Registration number: LP-001065].

Intravenous administration of lidocaine at a dosage of 4 mg / kg / hour for 30-60 minutes can cause an increase in the concentration of lidocaine in blood plasma up to 5.82-7.10 μg / ml, which can lead to the development of the above toxic reactions [Wang D, Wu X, Li J, Xiao F, Liu X, Meng M. The effect of lidocaine on early postoperative cognitive dysfunction after coronary artery bypass surgery. Anesth Analg. 2002; 95: 1134-41.].

Inhaled intranasal administration of lidocaine can be used for anesthesia of the nasal cavity, blockade of the trigeminal nerve [Br J Anaesth. 2006 Oct; 97 (4): 559-63. Doi: 10.1093 / bja / ael180. Epub 2006 Aug 1.] migraine treatment [JAMA. 1996 Nov 20; 276 (19): 1554; author reply 1554. doi: 10.1001 / jama.276.19.1554], reduces inflammation in the airways [Anesthesiology. 2012 Sep; 117 (3): 580-91. Doi: 10.1097 / ALN.0b013e31826687d5].

However, the effect of inhaled intranasal administration of lidocaine in combination with intravenous administration on intraoperative bleeding during rhinosurgical operations has not been described.

The combined use of intravenous and inhalation administration of lidocaine does not lead to an excess of the permissible plasma concentration of lidocaine, since the administration of maximum intravenous dosages is not required to reduce bleeding.

Studies confirm that the combined use of intravenous and intranasal administration of lidocaine in the indicated doses can reduce the total dose of injected lidocaine and improve the visualization conditions of the surgical field during endoscopic endonasal rhinosurgical surgical interventions.

We studied 57 cases of surgical interventions under general anesthesia and invasive mechanical ventilation (ALV). Surgical interventions were performed in a planned manner after examination according to the protocol adopted in the clinic. All patients underwent a threefold measurement of blood pressure: at the appointment with a therapist 2-3 days before the expected date of surgery, at the time of examination the day before surgery and a few hours before surgery. The hemostatic system was examined once, 3-7 days before surgery: international normalized ratio, activated partial thrombin time, fibrinogen, antithrombin III, blood coagulation time, bleeding duration, quantitative and qualitative characteristics of platelets.

Criteria for inclusion in the study: age from 18 to 65 years, presence of pathology from the nasal cavity and (or) paranasal sinuses with the possibility of correction by minimally invasive surgery, absence of pathology of the blood coagulation system, absence of uncontrolled arterial hypertension.

Exclusion criteria: uncontrolled hypertension, severe ischemic heart disease with frequent pain attacks, severe widespread atherosclerosis, a history of allergic reactions to local anesthetics, taking anticoagulants or antiplatelet agents, significant changes in the hemostasis system. In the case of systemic diseases manifested by vascular lesions (vasculitis, Wegener's granulomatosis, and so on), such patients were also excluded from the study. The average age of the patients was 44 ± 23.3 years. The average time of surgery was 52 ± 46.6 minutes. The average time of intravenous administration of lidocaine was 44 ± 18.3 minutes. All patients underwent general combined anesthesia with invasive mechanical ventilation.

In the operating room, before the beginning of general anesthesia and surgery, inhalation of lidocaine 4% was performed intranasally, 1-2 ml in each nostril.

After the treatment of the surgical field at the beginning of the main stage of the operation, a bolus intravenous administration of lidocaine 1-1.5 mg / kg was performed at a rate of 1 mg / sec. Then micro-jet at a dosage of 2-5 mg / kg / hour, taking into account the traumaticity of the stages of the operation and the hemodynamic reactions of the patient, but not more than 300 mg / min. Premedication: fentanyl 0.002-0.003 mg / kg IV jet, atropine 0.005 mg / kg IV jet. Induction: propofol 2-3 mg / kg. Installation of the supraglottic duct. IVL with a tidal volume of 6-8 ml / kg with control of the concentration of exhaled carbon dioxide at a minimum fresh gas flow of 0.5-1 l / min. Maintenance of anesthesia: desflurane 4-12 vol% until a minimum alveolar concentration of 0.8-1.4 is reached. Fentanyl was administered as needed, depending on the stages of the operation.

The Boezaart scale (ASC - Average category scale) [Boezaart AP, van der Merwe J, Coetzee A. Comparison of sodium nitroprusside- and esmolol-induced controlled hypotension for functional endoscopic sinus surgery was used to assess the bleeding of the operating field. Can J Anaesth. 1995 May; 42 (5 Pt 1): 373-6. doi: 10.1007 / BF03015479. PMID: 7614641.], see table.

Intraoperative monitoring was performed in all patients continuously: heart rate (HR), noninvasive blood pressure (NAD) with recording of mean arterial pressure, electrocardiography (EKG), pulse oximetry (SpO ₂₎ and neuromuscular block, BIS-monitoring. After the end of the operation, awakening of patients was assessed using the Aldrete Awakening Scale and the Richmond Arousal-Sedation Scale (RASS). Postoperatively all patients were followed for at least 2 hours with a heart rate control, NAD, ECG, SpO _2.

During general anesthesia, after reaching the equilibrium plasma concentration of lidocaine (about 3-5 minutes after the bolus administration), a steady decrease in the degree of bleeding was observed. The total dose of lidocaine administered averaged 1.5-2.5 mg / kg / hour, which does not exceed the recommended safe values. Hemodynamic parameters during the operation remained stable: heart rate 67.4 ± 24.1 1 / min, mean blood pressure 68.6 ± 8.4 mm. Hg ECG and pulse oximetry readings were within the normal range. After the completion of the main traumatic stage of the surgical intervention, the administration of lidocaine was discontinued in an average of 8.6 ± 4.4 minutes. until the end of the surgical treatment. After the end of the operation, the patients were awakened on the operating table. The time of awakening from the moment of termination of the administration of the inhalation anesthetic to the restoration of consciousness was 7.8 ± 4.2 minutes. State on the Aldrete scale 9-10 points, RASS -2-0 points. In the early postoperative period, nausea and vomiting were observed in 3 patients, which were stopped by the introduction of ondansetron, after 2 hours, 1 patient developed severe weakness and dizziness that did not require specific treatment, which were stopped after the injection of 1000 ml of saline. Postoperative pain relief in all patients was satisfactory; 2 hours after the operation, the administration of narcotic analgesics was not required. There were no signs of the toxic effect of lidocaine - agitation, agitation, perioral paresthesias, visual impairments, etc.

Thus, the combined use of intravenous and inhalation methods of lidocaine administration can reduce the total dose of injected lidocaine and improve the visualization conditions of the surgical field during endoscopic endonasal rhinosurgical surgical interventions. The combined use of intravenous and intranasal administration of lidocaine does not lead to an excess of the permissible plasma concentration of lidocaine, since the administration of maximum dosages is not required to reduce bleeding, which ensures greater safety of the anesthetic and surgical intervention for the patient.

The method is carried out, for example, as follows.

In the operating room, 10 minutes before the start of general anesthesia and surgery, intranasal inhalation of 4% lidocaine, 1-2 ml in each nostril, is performed. The total dose of lidocaine administered was 160 mg intranasally.

5 minutes after induction of anesthesia, assessment of hemodynamic parameters, achievement of the target values of the minimum alveolar concentration (MAC), bolus intravenous administration of lidocaine is performed at a dose of 1-1.5 mg / kg for 2-3 minutes and then micro-jet at a dosage of 2-5 mg / kg / hour, taking into account the trauma of the stages of the operation and the hemodynamic reactions of the patient. To assess the bleeding of the operating field, a scale of average categories (AS C - Average category scale) is used.

The method is confirmed by the following clinical examples.

Example 1 .. Patient C, 42 years old. She was admitted to the ENT clinic in a planned manner with a diagnosis of chronic polypous rhinosinusitis. On examination, complaints of nasal congestion, mucopurulent discharge from the nasal cavity, discomfort in the projection of both frontal sinuses.

The patient has a long history of chronic polypous rhinosinusitis, bronchial asthma of moderate severity, polysinusotomy is planned under general anesthesia. It is assumed that there is a high probability of significant intraoperative bleeding due to a prolonged pronounced inflammatory process in the nasal cavity and paranasal sinuses. The use of beta-blockers is contraindicated due to the presence of bronchial asthma, and bleeding control may be difficult. The use of intravenous lidocaine alone may be insufficient, higher dosages will be required, which can cause intraoperative complications and ineffective control of the degree of bleeding due to peripheral vasodilation. To reduce the degree of bleeding during surgery, combined administration of intranasal and intravenous lidocaine is planned. During laboratory and instrumental examination, no contraindications for the use of the combined administration of lidocaine were revealed.

In the operating room, 10 minutes before the beginning of general anesthesia and surgery, intranasal inhalation of 4% lidocaine, 2 ml in each nostril, was performed. The total dose of lidocaine administered was 160 mg intranasally. Premedication: fentanyl 0.1 mg IV jet, atropine 0.5 mg IV jet. Induction: propofol 150 mg intravenous jet. Relaxants: rocuronium bromide 30 mg IV jet. Installation of the supraglottic air duct LMA classic No. 4. Ventilation in forced ventilation mode with pressure and volume control, tidal volume 450 ml, respiratory rate 12 1 / min. Maintenance of anesthesia: desflurane 6-12 vol% until a minimum alveolar concentration (MAC) of 1.2 is reached. Fentanyl was administered as needed, depending on the stages of the operation. 5 minutes after induction of anesthesia, assessment of hemodynamic parameters, achievement of the target values of the minimum alveolar concentration (MAC), a bolus intravenous administration of lidocaine 1% -8 ml was performed at a rate not exceeding 1 mg / sec, followed by continuous microjet administration of lidocaine 112 mg / h ( 2 mg / kg / hour). To assess the bleeding of the surgical field, the average category scale (ASC) was used.

The time of the surgical intervention was 10 minutes, the time of the combined administration of lidocaine was 82 minutes, the total dose of lidocaine administered during the operation was 313 mg. During the operation, the severity of bleeding was assessed every 5 minutes by the ASC index, on average it was 1.35 (from 0 to 3). The ASC index during the entire operation did not exceed 3 points, which corresponds to a small level of bleeding, satisfactory visibility of the operating field.

Operation description. Local infiltration anesthesia Sol was performed under general anesthesia. Ultracaini 1: 100,000 - 6.0 mucous membrane of the nasal septum, middle and lower turbinates, agger nasi on both sides. Under the control of a rigid 0 ° endoscope, an incision was made at a typical location on the left. The mucous membrane with the periosteum and perichondrium is separated throughout. Curved sections of quadrangular cartilage were removed with Blakeslee forceps. The mucous leaves are aligned, the suture is cut. Under the control of rigid endoscopes 0 ° and 45 ° and an electromagnetic navigation system, using curved Blakeslee forceps and 15 ° diamond curved burs, the natural anastomosis of the right and left frontal sinuses was expanded, and the Ridel massif was removed. In the cavity of the frontal sinuses, the following was found: polyposis-altered mucosa, the contents were removed with Blakeslee forceps. Under the control of rigid endoscopes 0 ° and 30 °, an artificial anastomosis of the right and left maxillary sinuses was imposed. Found purulent contents and polyposis-altered mucosa: removed with antral forceps and an aspirator. Under the control of rigid endoscopes 0 ° and 30 °, the natural anastomosis of the left maxillary sinus was expanded. A cyst-like formation was found: removed with antral forceps and an aspirator. The material was sent for histological examination. Anterior nasal tamponade with hemostatic tampons. Operation without complications.

After the end of the operation, the patient was awakened on the operating table after 8 minutes 30 seconds, the state of the Aldrete awakening scale is 9 points, RASS -1. In the postoperative period, there were no side effects and complications of surgery, general anesthesia. Postoperative anesthesia 2 hours after the end of the operation was satisfactory, the introduction of painkillers was not required. There are no signs of the toxic effect of lidocaine.

Example 2. Patient D., 30 years old. Was admitted to the otorhinolaryngological clinic in a planned manner with a diagnosis of chronic left-sided frontal sinusitis, cyst of the left maxillary sinus, curvature of the septum of the nasal cavity.

On examination, complaints of nasal congestion, pain in the left side of the head, clear nasal discharge, runoff of mucus along the back of the pharynx. The diagnosis is confirmed. No pronounced concomitant pathology was revealed, laboratory and instrumental parameters were without significant pathological signs.

To reduce the degree of bleeding during surgery, combined administration of intranasal and intravenous lidocaine is planned. Considering the low BMI of the patient, no pronounced inflammatory process in the nasal cavity and paranasal sinuses, the dosage of intranasal and intravenous lidocaine can be reduced to the minimum effective.

In the operating room, 10 minutes before the beginning of general anesthesia and the operation, intranasal inhalation of 4% lidocaine, 1 ml in each nostril, was performed. The total dose of lidocaine administered was 80 mg intranasally. Premedication: fentanyl 0.2 mg IV jet, atropine 0.5 mg IV jet. Induction: propofol 150 mg intravenous jet. Installation of the supraglottic air duct LMA classic No. 5. Mechanical ventilation in the mode of auxiliary ventilation with pressure and volume control, with a tidal volume of 500-550 ml., Respiratory rate 12-14 1 / min. Maintenance of anesthesia: desflurane 6-12 vol% until MAC 1.0 is reached. Fentanyl was administered as needed, depending on the stages of the operation. 5 minutes after induction of anesthesia, assessment of hemodynamic parameters, achievement of target MAC values, bolus intravenous administration of lidocaine 1% -7 ml was performed at a rate not exceeding 1 mg / sec, followed by continuous microjet administration of lidocaine 105 mg / hour (1.5 mg / kg / hour). To assess the bleeding of the surgical field, the average category scale (ASC) was used.

The time of the surgical intervention was 10 minutes, the time of the combined administration of lidocaine was 74 minutes, the total dose of lidocaine administered during the operation was 230 mg. During the operation, the severity of bleeding was assessed every 3 minutes by the ASC index, on average it was 1.2 (from 0 to 2). The ASC index during the entire operation did not exceed 2 points, which corresponds to a small level of bleeding, good visibility of the operating field. Low concentrations of lidocaine cause constriction of peripheral blood vessels, which leads to a decrease in the bleeding of the surgical site.

Operation protocol. Sol infiltration was performed under general anesthesia under the control of a rigid 0 ° endoscope. Ultracaini 2 ml into the agger nasi area, the inferior turbinate, the bottom and lateral wall of the nasal cavity on the left, the nasal septum on both sides. An incision in the vestibule of the nasal cavity. The quadrangular cartilage was isolated with a raspator-suction. The deformed areas of the cartilage were removed. The bone crest is knocked down at the base. The mucosal leaves are juxtaposed. Two stitches for the wound. From the anterior end of the inferior nasal concha on the right with a Frey raspator, it was performed for mucous vasotomy, disintegration, and lateropexy. Likewise on the left. The left frontal sinus was opened under the control of rigid 0 ° and 70 ° endoscopes and an electromagnetic navigation system. In the lumen of the sinus, polyposis altered mucosa. All abnormalities were removed with Blakeslee forceps. The sinus is flushed with warm saline solution. Under the control of rigid endoscopes 0 ° and 30 ° and an electromagnetic navigation system, an artificial anastomosis was applied from the left maxillary sinus. There is a cyst in the lumen of the sinus. All abnormalities were removed with a Blakeslee aspirator and forceps. Revision of the sinus with a 30 ° endoscope. Hemostasis with hemostatic tampons. The surgical material was sent for histological examination. Operation without complications.

After the end of the operation, the patient was awakened on the operating table after 7 minutes 10 seconds, the state of the Aldrete awakening scale is 9 points, RASS 0. In the postoperative period, there were no side effects and complications of the operation, general anesthesia. Postoperative anesthesia 2 hours after the end of the operation was satisfactory, the introduction of painkillers was not required. There are no signs of the toxic effect of lidocaine.

EFFECT: method allows to reduce the total dose of injected lidocaine and improve visualization conditions of the surgical field without exceeding the permissible plasma concentration of lidocaine during endoscopic endonasal rhinosurgical surgical interventions.

Claims (1)

A method for reducing intraoperative bleeding during endoscopic endonasal rhinosurgical surgical interventions, including bolus intravenous administration of lidocaine at the beginning of the main stage of the operation at a dose of 1-1.5 mg / kg for 2-3 minutes and then micro-jet at a dosage of 2-5 mg / kg / h, taking into account the trauma of the stages of the operation and the hemodynamic reactions of the patient, characterized in that before the operation begins, inhalation of lidocaine 4% is performed intranasally, 1-2 ml in each nostril.