The method of anesthetic management for the conduct of intraoperative monitoring of the spinal cord

 

(57) Abstract:

The invention relates to medicine, namely anesthesiology, and can be used to provide intraoperative monitoring of the spinal cord through the implementation of planned urgent Wake-up the patient on the stage surgical correction of scoliosis or other spinal deformities. To do this for 30 minutes before surgery are premedication with Relanium 0.2 mg/kg and Dimedrol 0.4 mg/kg intramuscularly; the induction in anesthesia performed with fentanyl at a dose of 0.002 mg/kg, propofol 4-5 mg/kg tracheal Intubation is performed after injection of 0.15 mg/kg nimbexa. IVL exercise machine working flow mode with plateau inspiratory oxygen concentration in the inhaled mixture of 40%. Required monitoring includes ECG, blood pressure (systolic, diastolic, and mean), heart rate, SaO2, ETCO2. Maintain anesthesia by continuous infusion of propofol first 30 minutes at a dose of 6-8 mg/kg/h, then 4-5 mg/kg/h; diplegia - infusion nimbexa 0.1 mg/kg/h during the first 60 min of anesthesia, then 0.05 mg/kg/H. the Analgesia exercise bolus doses of fentanyl in a dose of 0.004 mg/kg/h during the first 60 min of anesthesia, then a dose of 0.002 mg/kg/H. the Last administration of fentanyl spend management and supply them to stop. After monitoring of the spinal cord bolus administered fentanyl in a dose of 0.002 mg/kg, propofol 4 mg/kg nimbeks 0.1 mg/kg and moving to a continuous infusion of propofol 4-5 mg/kg/h, nimbexa 0.05 mg/kg/h bolus doses of fentanyl 0.002 mg/kg/h Method provides urgent intraoperative awakening of the patient with timely diagnosis of neurological disorders due to the controllability of anesthesia. 3 C.p. f-crystals.

The invention relates to medicine, namely anesthesiology, and can be used to ensure intraoperative monitoring of the spinal cord through the implementation of planned urgent Wake the patient at stage one-stage correction rough scoliotic or other spinal deformities different types of surgical instruments with a high risk of developing severe neurological disorders.

Known methods of anesthetic management, enabling intraoperative monitoring of the spinal cord (T. R. Abott, G. Bently. Intraoperative awakening caused during surgery //Anaesthesia. - Ireland. - 1980. -35(3). - R. 298-302; Godat L., Ravussin P. A., Chiolero R. et. al. Flumazenil end peroperative awakening caused in surgery //Ann-Fr-Anesth-Reanim. - 1990. - 9(1). - P. 6-10; Meistelman C. Monitoring during Cotrel Dubousset instrum surgical correction of spinal structures in patients with scoliosis //abstract of thesis...the. the honey. Sciences. - Moscow. - 2002. - 24 S. these methods anesthetic management can implement the task of performing intraoperative monitoring of the spinal cord, but not entirely meet the special requirements to the components of anesthetic management in this clinical situation, especially to hypnotise and muscle relaxant. In particular, the use of inhalation anesthetics, barbiturates, benzodiazepines on the background of long acting muscle relaxants are not effective enough to implement the urgent task of awakening the patient at a particular stage of the operation and in many cases require the use of drugs and antagonists for removal actions used hypnotics and muscle relaxants, i.e. variants of anesthesia are not easy and cannot effectively and safely implement an urgent revival operated. The use of barbiturates does not eliminate their toxic effects, adverse effects on the hemodynamics (hypotension), respiratory depression, and depression of the myocardium, the possibilities of development of the laryngo - and bronchospasm.

In addition, the use of inhalation anesthetics should be avoided at bol is tov, but due to the production of fluoride ions and triperoxonane acid, their use is dangerous in patients with impaired renal function after administration of inhalation anesthetics is more often marked postoperative nausea and vomiting. The use of evaporative anesthetics (isoflurane) requires special expensive anesthetic and respiratory equipment able to operate according to the method of Low Flow Anaesthesia, which the domestic industry produces.

Closest to the claimed is the method of anesthetic management Yilmazlar A., Aydinii U., Korfali G., Kutlay Acting Intra operative awakening during spine sutgery with propofol and alfentanil //Procedings of the 11-th GICD Congress “Neurological complications of spine surgery”. - Arcachon France. - 1994. - P. 122-124.

The method consists in the following. Induction in anesthesia performed using Alfentanil 10 g/kg and propofol in a dose of 3 mg/kg tracheal Intubation is carried out after the introduction of ListenOn 1.5 mg/kg Maintenance of anesthesia are based on the inhalation of nitrous oxide (N2Oh and ABOUT2(1:1), infusion of propofol 4 mg/kg/h, Alfentanil 35 g/kg/h Maintenance of diplegia carry vecuronium 20 g/kg Awakening of the patient is carried out after termination of the injection of propofol and N2Oh, and the introduction of analgesics continue. Ventilazione (BP) systolic diastolic, heart rate (HR), blood oxygen saturation (São2), the concentration of carbon dioxide at the end of exhalation (ETA2).

This method of anesthetic management allows you to effectively implement intraoperative monitoring of spinal cord function by awakening the patient after the distraction of the spine.

However, the method contains elements of polipragmazie. So, the scheme anesthesia N2O is impractical, as a potentiation of the Central depression of consciousness. In addition, when using the N2O should be denitrogenization by induction of anesthesia with inhalation of 100% O2and after cessation of N2O, the moment of awakening the patient requires ventilation 100%2. The long exposure of N2O may be accompanied by the development mielodepressii and agranulocytosis.

Inappropriate is the choice for intubation of the trachea muscle relaxant of ListenOn in connection with the known negative effects of short-acting muscle relaxants - gistaminovogo effect, the effect of myofibrilla, the effect of cardiovascular instability.

A known disadvantage of Misti his actions in connection with the peculiarities of the metabolism of the drug in patients with pathology of the liver and kidneys. In addition, vecuronium has a more prolonged action in comparison with other muscle relaxants average duration. In this regard, vecuronium can be used, but is not ideal if necessary, to minimize timing of recovery of neuromuscular conduction. Using vecuronium does not exclude the risk of side effects in the form of changes in hemodynamics and allergic reactions associated with release of histamine, which is especially important when it is used in patients with scoliosis, often with the original cardiovascular disorders during prolonged surgical procedures involving massive blood loss. In addition, a bolus vecuronium may not provide a reliable neuromuscular block during the stages of surgical treatment.

Objective: to safely and efficiently provide urgent awakening the patient at stage one-stage correction of the scoliotic spinal deformity.

When the task has a positive therapeutic effect, which is that by using hipnotica of propofol and muscle relaxant nimbexa can achieve this steenie patient with timely diagnosis of possible intraoperative neurological disorders.

Propofol has ultrashort action with high accuracy prediction of Wake-up time. Also important is its ability to cause amnesia upon awakening, the patient in the postoperative period. Vasodilatory effect of propofol associated with decreased levels of blood pressure (blood pressure systolic within 6.0-16.3 per cent, AD diastolic - 11,5-25.4 per cent, AD medium - to 9.2-21.6 per cent, which is appropriate in order to reduce operative blood loss.

The main advantage of muscle relaxant nimbexa determining the benefit of his choice when you want a quick recovery of neuromuscular block is a fast onset of action, excretion of the drug from the body by enzymatic elimination Hoffman, regardless of the functional state of the liver and kidneys and, accordingly, no effect of cumulation. In addition, nimbeks has a greater cardiovascular stability, since its introduction does not provide dose-dependent release of histamine and/or hemodynamic disturbances even when large doses of the drug that is clinically safe, which is especially important when performing highly traumatic, continue the Noah intravenous infusion provides reliable neuromuscular block at all stages of surgical intervention.

In addition, the proposed method allows to realize an optimal level of stress and antinociceptive protection as evidenced by the hemodynamic parameters (blood pressure, heart rate) at the time of the awakening of the patient (in terms 3-4 hours from start of the operation) that does not exceed the limits of stress rules.

The method can prevent the development of severe neurological complications operational period, and therefore, when the method has an economic effect, which consists in reducing the number of severe neurological complications, the development of which requires significant additional costs.

The problem is solved due to the fact that for 30 minutes before surgery are sedation, including Relanium dose of 0.2 mg/kg and diphenhydramine dose of 0.4 mg/kg intramuscularly; the induction in anesthesia performed with fentanyl at a dose of 0.002 mg/kg, propofol at a dose of 4-5 mg/kg: tracheal intubation is performed after the introduction of nimbexa at a dose of 0.15 mg/kg; artificial lung ventilation (ALV) is performed by the device operating in flow mode with plateau inspiratory oxygen concentration in the inhaled mixture (FiO2) 40%; required monitoring includes: electrocardiography (ECG), blood pressure is ω (SaO2), the concentration of carbon dioxide at the end of exhalation (ETA2); maintenance of anesthesia conduct continuous infusion of propofol first 30 minutes at a dose of 6-8 mg/kg/h, then 4-5 mg/kg/h; diplegia support continuous infusion nimbexa 0.1 mg/kg/h during the first 60 min of anesthesia, then 0.05 mg/kg/h; analgesia exercise bolus doses of fentanyl in a dose of 0.004 mg/kg/h during the first 60 min of anesthesia, then a dose of 0.002 mg/kg/h; the last administration of fentanyl hold for 30 minutes before Wake-up; for 20 minutes before Wake-up doses of propofol and nimbexa reduce in 2 times; 5 minutes before the Wake-up feeding them to stop; after monitoring of the spinal cord bolus administered fentanyl in a dose of 0.002 mg/kg, propofol at a dose of 4 mg/kg nimbeks dose of 0.1 mg/kg, then move on to a continuous infusion of propofol at a dose of 4-5 mg/kg/h, nimbexa at a dose of 0.05 mg/kg/h bolus doses of fentanyl 0.002 mg/kg/H. Monitoring of the spinal cord is carried out at a recovery of consciousness and neuromuscular conduction. The moment of awakening is determined individually on the stage of correction of spinal deformity surgical tools. For artificial lung ventilation (ALV) use apparatus “EVITA-2-DURA”.

The method is as follows. Smilacina; induction in anesthesia performed with fentanyl at a dose of 0.002 mg/kg, propofol at a dose of 4-5 mg/kg; tracheal intubation is performed after the introduction of nimbexa at a dose of 0.15 mg/kg; artificial lung ventilation is performed with the device operating in flow mode with plateau inspiratory oxygen concentration in the inhaled mixture (FiO2) 40%; required monitoring includes: electrocardiography (ECG), blood pressure (BP systolic, diastolic, and mean), heart rate (HR), oxygen saturation (SaO2), the concentration of carbon dioxide at the end of exhalation (ETA2); maintenance of anesthesia conduct continuous infusion of propofol first 30 minutes at a dose of 6-8 mg/kg/h, then 4-5 mg/kg/h; diplegia support continuous infusion nimbexa 0.1 mg/kg/h during the first 60 min of anesthesia, then 0.05 mg/kg/h; analgesia exercise bolus doses of fentanyl in a dose of 0.004 mg/kg/h during the first 60 min of anesthesia, then a dose of 0.002 mg/kg/h; the last administration of fentanyl hold for 30 minutes before Wake-up; for 20 minutes before Wake-up doses of propofol and nimbexa reduce in 2 times; 5 minutes before the Wake-up feeding them to stop; after monitoring of the spinal cord bolus administered fentanyl in a dose of 0.002 mg/kg, propofol in a dose of 0.05 mg/kg/h bolus doses of fentanyl 0.002 mg/kg/H. Monitoring of the spinal cord is carried out at a recovery of consciousness and neuromuscular conduction. The moment of awakening is determined individually on the stage of correction of spinal deformity surgical tools. For artificial lung ventilation (ALV) use apparatus “EVITA-2-DURA”.

An example of the clinical use of the method:

Patient Z. 1989 R. (12 years old) was admitted to the hospital of Novosibirsk research Institute of traumatology and orthopedics 11.02.02, In the clinic according to the established procedure performed, a complete clinical and radiographic examination. Clinical diagnosis: Congenital uncomplicated progressive left-sided breast compensated kyphoscoliosis IV degree. In the study of respiratory function revealed a slight decrease pulmonary ventilation capacity with vital lung capacity (VC) 73%, forced vital lung capacity (FVC) 71% and forced expiratory volume (Fwyd) 90% of the predicted parameters. When x-ray examination of the chest found thorax deformation and dislocation of the internal organs. A General analysis of blood, urine biochemical tests within normal limits. After clinical review it was decided to perform one the ring of the spinal cord. Given the initial severity of spinal deformity and the amount of the forthcoming operation, surgical and anesthetic risk corresponded to the fourth degree classification of Vologodskogo. The operation of the multilevel mobilizing diskectomy (D5-6-D10-11) and posterior spinal fusion using the tools of the Novosibirsk research Institute of traumatology and Orthopaedics (research Institute) made 28.02.02, in conditions of total intravenous anesthesia (TBA) with artificial lung ventilation (ALV). Premedication held for 30 min before surgery using Dimedrol at a dose of 0.4 mg/kg and Relanium dose of 0.2 mg/kg Induction in anesthesia: atropine 0.006 mg/kg, fentanyl 0.002 mg/kg, propofol at a dose of 5 mg/kg nimbeks 0.15 mg/kg followed by tracheal intubation. Maintenance of anesthesia was carried out by continuous infusion of propofol at a dose of 8 mg/kg/h for the first 30 min, followed by 4 mg/kg/h, nimbexa 0.1 mg/kg/h during the first 60 min of anesthesia, then 0.05 mg/kg/HR, administration of fentanyl in a dose of 0.004 mg/kg/h during the first 60 min of anesthesia, next to 0.002 mg/kg/h (“doing bolus every 30 min) with the IVL device “EVITA 2-DURA”, working on the flow regime with the plateau inspiratory oxygen concentration in the inhaled mixture (FiO2) 40%.

Anesthesia at all stages of the operational period was characterized at schlieske 95-90 mm RT.art., HELL the average 70-65 mm RT.art., HELL diastolic 55-45 mm RT.CT.) and heart rate (HR 100-80). Indicators of blood oxygen saturation (SaO2- 99-100), the concentration of carbon dioxide at the end of exhalation (ETA2- 31-35 mm RT.cent.). Blood loss at the first stage (diskectomy) was 100 ml, blood loss at the second stage (posterior spinal fusion) was 650 ml (10 ml/kg). Total intraoperative blood loss 750 ml, which was 17.3% of circulating blood volume (CBV). Infusion therapy was carried out using solutions of crystalloids of 7.6 ml/kg/h, FFP (fresh frozen plasma) 11.5 ml/kg, erythrocyte mass of 5.7 ml/kg of the Need for monitoring of the spinal cord occurred at the second stage surgery for deformity correction surgical instrumentation research Institute in time after 3 h 20 min from the start of the operation. For 20 minutes before waking the patient dose of propofol and nimbexa were reduced in 2 times and 5 min to Wake them feeding discontinued. After 5 min came in contact with the patient, at the request marked a distinct movement in the hands and feet, which allowed us to verify the integrity of the conductive function of the spinal cord. The results of the revival were convincing for the surgeon and anesthesia was continued under the scheme - bolus entered fentanyl at a dose of 0.002 mg/who nimbexa at a dose of 0.05 mg/kg/h bolus doses of fentanyl 0.002 mg/kg/H. Significant deviations of monitored parameters (ECG, blood pressure, heart rate, SaO2ETA2from level stress rules in the moment of awakening was not observed. After the operation the patient when restored adequate independent breathing and stable hemodynamics was transferred to the intensive care unit. Transferred to the relevant Department on the 1st day after surgery, the postoperative period without complications.

1. The method of anesthetic management of surgical correction of scoliosis by a managed shutdown of consciousness and managed diplegia with adequate antinociceptive protection of the patient, characterized in that for 30 minutes before surgery are sedation, including Relanium dose of 0.2 mg/kg and diphenhydramine dose of 0.4 mg/kg intramuscularly; the induction in anesthesia performed with fentanyl at a dose of 0.002 mg/kg, propofol at a dose of 4-5 mg/kg; tracheal intubation is performed after the introduction of nimbexa at a dose of 0.15 mg/kg; artificial lung ventilation is performed by the apparatus, working on the flow regime with the plateau inspiratory oxygen concentration in the inhaled mixture (FiO2) 40%; required monitoring includes ECG, blood pressure (systolic, diastolic, and mean), heart rate, S/kg/h, next 4-5 mg/kg/h; diplegia support continuous infusion nimbexa 0.1 mg/kg/h during the first 60 min of anesthesia, then 0.05 mg/kg/h; analgesia exercise bolus doses of fentanyl in a dose of 0.004 mg/kg/h during the first 60 min of anesthesia, then a dose of 0.002 mg/kg/h; the last administration of fentanyl hold for 30 minutes before Wake-up; for 20 minutes before Wake-up doses of propofol and nimbexa reduce in 2 times; 5 minutes before the Wake-up feeding them stop; after monitoring of the spinal cord bolus administered fentanyl in a dose of 0.002 mg/kg, propofol at a dose of 4 mg/kg nimbeks dose of 0.1 mg/kg, then move on to a continuous infusion of propofol at a dose of 4-5 mg/kg/h, nimbexa at a dose of 0.05 mg/kg/h bolus doses of fentanyl 0.002 mg/kg/h

2. The method according to p. 1, characterized in that the monitoring of the spinal cord is carried out at a recovery of consciousness and neuromuscular conduction.

3. The method according to p. 1, characterized in that moment of awakening determined individually on the stage of correction of spinal deformity surgical instruments.

4. The method according to p. 1, characterized in that is used for artificial lung ventilation apparatus “EVITA-2-DURA”.

 

Same patents:

The invention relates to medicine, namely to psychotherapy
The invention relates to medicine, in particular to methods of treatment of alcoholism, drug abuse, Smoking, obesity, addiction, disorders of sexual violence, etc
The invention relates to medicine, in particular therapy, and can be used in medical institutions for the treatment of pain in patients with chronic somatic diseases

The invention relates to the field of medicine and is intended for the correction of body weight
The invention relates to medicine, namely to psychiatry and psychotherapy
The invention relates to medicine, namely to psychotherapy, and can be used for adaptation and rehabilitation of persons who are in a difficult social and natural conditions
The invention relates to medicine, namely to methods psychosomatic healing people

The invention relates to medicine, in particular for preventive medicine, therapy, physiology and valeology, and can be used in intelligent computer system as in the treatment individually and collectively disorders functional status
The invention relates to medicine, namely to psychotherapy and acupuncture
The invention relates to medicine, namely to psychotherapy and acupuncture

The invention relates to medicine, namely to neuroregenerative, neurosurgery and neurology

The invention relates to medicine
The invention relates to medicine, anesthesiology, can be used for anesthesia during simultaneous reconstructive plastic surgery with lymph node dissection for cancer lesion of rectum
The invention relates to medicine, anesthesiology, can be used as anesthesia when performing minimally invasive operations neuroactive

The invention relates to medicine

The invention relates to the derivatives of resorcinol used to obtain cosmetic preparations

The invention relates to medicine, anesthesiology, and can be used for multicomponent anesthesia for surgical interventions

The invention relates to the field of pharmacology and concerns microdrops and pharmaceutical composition for injection
Up!