RU2757580C1 - Method for optimizing perioperative period of elderly and senile patients with chronic ischemic heart disease in surgical treatment of lung cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology and resuscitation in oncology, and can be used to optimize the perioperative period of patients with chronic coronary heart disease of elderly and senile age in the surgical treatment of lung cancer. Before the start of surgery, puncture and catheterization of the epidural space are performed at the Th 3 - Th 4 level. Identification tests are carried out. A test dose of lidocaine 2%, 2.0 ml is administered. If the result is negative, the catheter is fixed, an aseptic dressing is applied and a micro-jet injection of a local anesthetic solution at a dose of 10 ml/hour is started into the epidural space. After induction and intubation of the trachea, intravenous administration of levosimendan through an infusomat is started at a rate of 0.1 mcg/kg/min. After the surgical intervention, during the first 48 hours, the micro-jet administration of levosimendan at the previous therapeutic dose and the epidural administration of the solution are continued for 6 days.

EFFECT: method provides the possibility of radical surgical treatment of lung cancer in elderly and elderly patients with subcompensated comorbid pulmonary-cardiac pathology, without aggravating the course of concomitant pathology, creates a favorable background for the course and prognosis of the postoperative period.

1 cl, 1 ex

Description

The invention relates to medicine, namely to anesthesiology and resuscitation in oncology, and can be used in the perioperative period in elderly and senile patients with radical surgical treatment of lung cancer in order to prevent the development of decompensation of chronic heart failure (CHF).

Currently, all over the world, we are witnessing the rapid development of clinical medicine, in particular oncology, which requires constant training, the search for new technologies, advanced training of specialists of various profiles, including anesthesiologists and resuscitators. Without appropriate training, practice, the risk of developing a large number and variety of complications in the perioperative period in patients with severe concomitant diseases increases (see E. S. Gorobets, S. P. Sviridova / Problems and specifics of anesthesia and intensive care in oncosurgery // https: // // rosoncoweb.ru/library / congress / ru / 06 / 95.php; see Karitsky A.P., Chulkova V.A., Pesterova E.V., Semiglazova T.Yu. // Problems of Oncology, 2015. Volume 61, No. 2, pp. 180-184).

Lung cancer is the leader in cancer incidence (13.2%) and mortality (19.4%) worldwide. The number of patients with malignant neoplasms of the lungs and mediastinal organs is steadily growing, requiring an individual approach to specialized treatment (see V.I. Chissov, V.V. Starinsky, O.P. Gretsova, K.K. and the possibility of implementing the population cancer register of the administrative territory / Siberian Journal of Oncology, 2004. No. 2-3 (10-P), pp. 93-97).

With age, the risk of developing various diseases increases, and, unfortunately, oncology is no exception. According to statistics, men suffer from lung cancer in a greater percentage of cases than women. In both gender groups, the average age is 70 or more. This can be explained by the course of natural aging processes, which leads to a loss of the ability to compensate under stressful situations.

Aggressive surgical tactics, an extended scope of surgical intervention have an ambiguous effect on cancer patients, especially on elderly and senile patients. Physiological reserves in most of them are sharply reduced due to the course of the underlying oncological disease, the vastness and prevalence of the process (especially in patients of the departments of thoracoplastic surgery), clinical manifestations of the disease, pronounced concomitant diseases, which is aggravated in older patients (see E.S. Gorobets, AV Zotov, LP Kononenko / Epidural block as a component of anesthesia in oncological operations on the lungs. - Regional anesthesia and pain treatment. Thematic collection. Moscow - Tver, 2004, pp. 116-122) ...

A multidisciplinary approach to the management of the perioperative period in elderly and senile patients suffering from lung cancer makes it possible to perform radical surgery in compliance with oncological principles (safety, radicality, functionality), leveling the percentage of complications in the early postoperative period, improve the course of the rehabilitation period, and increase hospital survival.

Perioperatively, one of the main components of the combined management of patients with lung cancer is considered to be thoracic epidural blockade, which provides full protection of the patient from the surgical stress response by blocking sympathetic afferent and efferent stimulation by introducing local anesthetics, which provides not only an analgesic effect, but also, blocks the innervation zone of the heart and lungs, improving cardiac output, thereby preventing the development of myocardial ischemia (see E.S. Gorobets / Multimodal combined (combined) anesthesia when performing traumatic surgical interventions // NN Russian Cancer Research Center. Blokhin, Moscow, 2018)

At the prehospital stage, all patients of oncological hospitals in the presence of concomitant pathology must undergo the necessary preoperative preparation, as well as extended instrumental and laboratory examination. Standard examinations include: spiral computed tomography (SRCT) of the head, chest organs (TGC), abdominal cavity (OBP), and pelvis (MT); complex ultrasound examination of internal organs (ultrasound examination of the heart, abdominal organs, retroperitoneal space, arteries and veins of the lower extremities, extracranial part of the brachiocephalic arteries); electrocardiography (ECG); Holter monitoring; coronary angiography; spirogram; endoscopic examinations (fibrobronchoscopy (FBS), colonoscopy, gastroscopy). A wide range of laboratory tests: determination of the main blood groups and Rh-affiliation, complete blood count (OAK), biochemical blood test, coagulogram, general urine analysis (OAM), blood test for hormones, markers of hepatitis "B", "C", determination antibodies to Treponema pallidum, HIV.

The most accessible and informative examination in the non-invasive diagnosis of congenital and acquired diseases of the cardiovascular system is considered to be ultrasound examination of the heart with Doppler ultrasound: the study of the left ventricular ejection fraction (LVEF) and the end systolic volume (LVSV), the indicators of which are directly proportional to the prognosis of patient survival.

In elderly and senile patients, the signs of chronic heart failure are more pronounced. The end diastolic volume (EDV) in patients of this group increases as a result of increased preload, the heart muscle is overstretched, the walls of the left ventricle become thinner, which results in a decrease in the left ventricular ejection fraction. The risk of an unfavorable outcome after major surgical interventions on the chest organs increases.

A known method for the prevention of perioperative cardiovascular complications that develop as a result of surgical exposure and the conduct of anesthesia, which consists in conducting transesophageal cardiac pacing (TEE) in an asynchronous mode with the aim of possible correction of hemodynamically significant rhythm disturbances (arrhythmias, critical bradycardia), which can lead to adverse consequences (see patent for invention RU No. 2326704 C1, publ. 20.06.2008, bull. No. 17). This method has both its own advantages and a number of disadvantages. To carry out the manipulation, additional equipment is required (automated complex). An important condition for the implementation of CPES is the cancellation of antiarrhythmic therapy in patients for a period of 7 days to 3 weeks (in cases of taking amiodarone), which can lead to gross violations of the heart rhythm. Also, the performance of CPES has a number of contraindications, one of which is the presence of severe diseases of the lungs and esophagus, which in turn determines the impossibility of using this method in oncological thoracic patients.

The technical result of the invention is to optimize the perioperative period, reduce the operational risk in elderly and senile patients suffering from lung cancer.

The technical result is achieved by the fact that intraoperatively before the start of the surgical intervention under aseptic conditions, puncture and catheterization of the epidural space at the Th 3 - Th 4 level are performed with a sterile set, identification tests are carried out, after which a test dose of lidocaine 2% 2.0 ml is administered, with negative As a result, the catheter is fixed, an aseptic bandage is applied, and micro-jet injection of a local anesthetic solution into the epidural space at a dose of 10 ml / hour is started, after induction and intubation of the trachea, intravenous administration of levosimendan through an infusomat begins at a rate of 0.1 μg / kg / min, after the operation is performed during the first 48 hours, microjet administration of levosimendan is continued at the same therapeutic dose, and for 6 days, epidural administration of a local anesthetic solution with an elastomeric pump at a rate of 6 ml / hour is continued.

The novelty of the invention lies in the fact that the optimal combination of local anesthetic administered intraoperatively into the epidural space with intravenous microjet injection of levosimendan improves cardiac output, coronary blood flow, blocks the reverse afferentation of the reflexogenic zone, reduces post- and preload, increases the left ventricular ejection fraction, which increases in turn, leads to a decrease in EDV and CSR, and also reduces the total vascular resistance.

Levosimendan is a drug with positive inotropic and vasodilating effects, which favorably affects the contractility of the heart muscle, increasing the sensitivity of myofilaments to calcium and troponin C. pressure in the pulmonary capillary network, reduces OPSS. After the administration of the drug in therapeutic dosages, positive post-effects on the indicators of cardiac output and pressure in the pulmonary capillaries remain during the day; on hemodynamics - within a week.

The method is carried out as follows.

After premedication, the patient is fitted with an epidural catheter at the thoracic level (Th 3 - Th 4). In order to identify the position of the catheter, a test dose of a local anesthetic is administered, after which the drug is injected into the epidural space with an elastomeric pump. After induction and intubation of the trachea, intravenous administration of levosimendan is established at a rate of 0.1 μg / kg / min. After performing the surgery, microjet injection of cardiotonics (levosimendan) in the same therapeutic dose continues for the first 48 hours. Epidural administration of local anesthetic is carried out within 6 days after surgery at a rate of 6 ml / hour.

In order to assess the functional state of the heart, an echocardiographic study and an ECG are performed on the first and third days after the operation.

This method provides pronounced beneficial effects of the therapy on the myocardium, reduces post- and preload, reduces pulmonary vascular resistance, enhances coronary blood flow, reduces postoperative pain, prevents the development of cardiac arrhythmias and aggravation of a history of arrhythmias.

The originality of the invention lies in the fact that this invention allows for radical surgical treatment of lung cancer in elderly and elderly patients with subcompensated comorbid pulmonary cardiac pathology, without aggravating the course of concomitant pathology. An integrated approach to patient management creates a favorable background for the course and prognosis of the postoperative period.

Here is a clinical example of demand application.

Patient N., 77 years old, 05/04/2019 was admitted to the Department of Thoracic Surgery of the Federal State Budgetary Institution "National Medical Research Center of Oncology" of the Ministry of Health of the Russian Federation (FSBI "National Medical Research Center of Oncology" of the Ministry of Health of Russia) with complaints of a rare dry cough.

Anamnesis of the disease: during the prophylactic examination, a formation in the right lung was found. He independently applied to the Federal State Budgetary Institution "National Medical Research Center of Oncology" of the Ministry of Health of Russia.

With SRCT OGK from 16.03.2019: On the right in the lower lobe, a subpleural tumor 5.6 × 5 × 3 cm with pleural invasion, on the left in the upper lobe there is a dense post-tuberculous focus of 1.1 cm.Pneumatization of the lung tissue is not changed. Transthoracic puncture of the lower lobe tumor was performed. Cytological examination - carcinoma cell complexes.

SRCT GM, OBP and OMT from 03/21/2019: no pathology.

Fibrobronchoscopy (FBS) from 03/25/2019 - chronic endobronchitis.

Consultation with a vascular surgeon dated 26.03.19: no pathology of the great vessels was revealed. According to ultrasound Doppler sonography of the neck vessels: in the common carotid, internal carotid and external carotid arteries on both sides of the main blood flow, no signs of hemodynamically significant stenoses were detected. There were no contraindications to surgical treatment.

ECHO KG from 03/25/2019: atherosclerotic changes in the base of the aorta, aortic valve leaflets. Relative insufficiency of the mitral, tricuspid valve 1 tbsp. The global contractile function of the left ventricle (LV) is not impaired, the diastolic function of the LV is type 1. Pathological streams were not identified. The pericardial cavity is intact. Ejection fraction (EF) 57.7%.

ECG from 22.03.2019: sinus normosystole. Atrio-ventricular block (AV block) 1 tbsp. Violation of intraventricular conduction. Decrease in recovery processes in the antero-septal region of the LV myocardium.

Anesthesiologist consultation from 03/27/2019: risk of anesthetic benefits according to ASA III, surgical treatment is possible.

Anamnesis of life: tuberculosis, sexually transmitted diseases and viral hepatitis denies. Allergic history: not burdened. Injuries - fracture of the left shoulder, osteosynthesis in 2010. Hemotransfusion denies. Diabetes mellitus type 2 since 2012, takes galvus in the morning, metformin 1000 mg in the evening. Professional route - sports worker.

Expert history: does not work, does not need a certificate of temporary disability.

Objectively: The general condition is satisfactory. Consciousness is clear, accessible to contact, adequate. Body temperature 36.6. Normosthenic physique, satisfactory nutritional status. Skin and visible mucous membranes of physiological color, warm, moderately moist, clean. The lymph nodes are not enlarged. BH 18 / min. Both halves of the chest are evenly involved in the act of breathing. With comparative percussion - pulmonary sound, with auscultation - breathing is hard, no wheezing. Heart sounds are rhythmic, muffled. Pulse 78 / min., Satisfactory tension and filling. BP = 130/80 mm. rt. Art. The abdomen is soft, painless on palpation in all parts. 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 stool is regular.

On the basis of the patient's complaints, previous observation and data of clinical and instrumental examination, the diagnosis was established at admission: (C34.3) Peripheral cancer of the lower lobe of the right lung, T2NxM0, st IB, class. gr. 2.

Complications of the main: none.

Concomitant diseases: ischemic heart disease, atherosclerotic cardiosclerosis. Type 2 diabetes mellitus, subcompensation.

On April 10, 2019, the operation was performed: extended lower lobectomy on the right.

Type of anesthetic aid: multimodal combined anesthesia.

At 9.00 after standard sedation in a sitting position under aseptic conditions, puncture and catheterization of the epidural space at the Th 3 - Th 4 level were performed. Identification tests were performed.

A test dose of lidocaine 2% - 2.0 ml (40 mg) was introduced, the result is negative. The catheter is fixed on the skin and an aseptic bandage is applied. An elastomeric pump started micro-jet injection of a local anesthetic solution into the epidural space at a rate of 10 ml / hour.

At 09.45, after induction and intubation of the trachea, intravenous administration of levosimendan was started at a rate of 0.1 μg / kg / min.

At 10.00 in the position of the patient on the left side, anterolateral thoracotomy was performed in the 5th intercostal space.

14.00 - the end of the operation.

At 2.30 pm, after complete restoration of consciousness and muscle tone, sanitation of the tracheobronchial tree, the patient was extubated. Ramsay II. Breathing is spontaneous, adequate. NPV 16 per minute. The supply of a humidified oxygen-air mixture was adjusted by a high-flow generator with the following parameters: flow 30 l / min, FiO ₂ 45%, T 31 °, against this background SpO ₂ 95%. Stable hemodynamics; BP 120/70 mm Hg, heart rate = Ps = 59 per minute. ECM shows sinus rhythm.

After surgery, microjet injection of cardiotonics (levosimendan) at the same therapeutic dose of 0.1 μg / kg / min is continued for the first 48 hours.

Within 6 days after surgery, an epidural injection of local anesthetic is performed at a rate of 6 ml / hour.

The patient was transferred to ARC for further treatment and dynamic observation. Monitoring of vital functions, laboratory control continues.

Instrumental and laboratory studies were performed 20 hours after the surgical intervention: ECG, EchoCG, troponin test, OAK, OAM, coagulogram, biochemical blood test.

ECG: sinus normosystole with a heart rate of 65 per minute. AV block of 1 tbsp remains. Violation of intraventricular conduction. Decrease in recovery processes in the anterior septal region and the apex of the LV myocardium.

EchoCG: EF 54.2%.

Laboratory:

1. OAK: Hb 129 g / l, erythrocytes 4.43 * 10 ¹² / l, Ht 39.2%. Leukocytes 13.44 * 10 ⁹ / l, p / i 18, s / s 70, m 3, l 9.

2. B / x blood: amylase 39.6 U / L, ASTL 42.3 U / L, ALTL 37.9 U / L, creatinine 88.5 umol / L, urea 5.22 mmol / L, o.protein 55.7 g / L.

3. Coagulogram: APTT 44.8 sec, MHO 1.25, PTI 84.3%, fibrinogen 3.88 g / l, thrombin time 15.4 sec.

4. Troponin test - 0.03 ng / L.

Microjet injection of cardiotonics continues, epidural injection of local anesthetic at the same rate. Laboratory, instrumental control. Intensive therapy in the conditions of the department of anesthesiology and resuscitation.

The patient received treatment under ARC conditions for three days. Transferred to the specialized department for the supervision of the attending physician. Inotropic support has been discontinued.

At the control examination:

ECG without significant dynamics. According to the EchoCG data, the recovery of EF is 58.1%. The rest of the data is the same.

Laboratory:

1. UAC: Hb 114 g / l, erythrocytes 3.89 * 10 ¹² / l, Ht 34.4%. Leukocytes 7.43 * 10 ⁹ / l, p / box 15, s / box 65, m 1, l 19.

2. B / x blood: amylase 47.1 U / L, ASTL 37.2 U / L, ALTL 31.4 U / L, creatinine 62.3 umol / L, urea 4.65 mmol / L, o.protein 59.2 g / L.

3. Coagulogram: APTT 34.8 sec, MHO 1.05, PTI 96.6%, fibrinogen 3.07 g / l, thrombin time 14.6 sec.

4. Troponin test - 0.01 ng / L.

Thus, the above-described invention "A method for optimizing the perioperative period of patients with chronic ischemic heart disease of elderly and senile age during surgical treatment of lung cancer" provides an opportunity for patients with chronic ischemic heart disease of elderly and senile age to carry out extensive radical surgery, preventing the development of CHF decompensation in the postoperative period.

The method is simple to implement, does not require special skills and additional training, is safe and easily applicable in clinical practice. Application of this method makes it possible to expand the indications for radical surgical treatment of lung cancer in elderly and senile patients, preventing the dynamic worsening of coronary heart disease.

Claims (1)

A method for optimizing the perioperative period of patients with chronic ischemic heart disease of the elderly and senile age in the surgical treatment of lung cancer is that before the start of the surgical intervention, puncture and catheterization of the epidural space are performed at the Th 3 - Th 4 level, identification tests are performed, and then a test is introduced. a dose of lidocaine 2% 2.0 ml, in case of a negative result, a catheter is fixed, an aseptic dressing is applied, and micro-jet injection of a local anesthetic solution into the epidural space at a dose of 10 ml / hour is started, after induction and intubation of the trachea, intravenous administration of levosimendan is started through an infusomat at a speed of 0, 1 μg / kg / min, after performing the surgery, microjet administration of levosimendan in the same therapeutic dose is continued for the first 48 hours and epidural administration of the solution is continued for 6 days.