Method for correcting respiratory disorders

FIELD: medicine.

SUBSTANCE: method involves applying auxiliary non-invasive lung ventilation with air-and-oxygen mixture in PSV mode with supporting pressure being equal to 8-12 cm of water column at inspiration phase, FiO2 0.25-0.3, positive pressure at expiration phase end equal to 2-4 cm of water column being applied. Inspiration trigger sensitivity being equal to 15-2 cm of water column relative to positive pressure at expiration phase end level to reach tidal respiratory volume not less than 6-7 ml/kg under SpO2 and blood gases control.

EFFECT: prevented acute respiratory insufficiency; improved alveolar ventilation; reduced venous bypass.

 

The invention relates to medicine, to the field of epidural and combined spinal-epidural anesthesia with preservation of spontaneous breathing patients in abdominal surgery.

There is a method of conducting an epidural (EA) and combined spinal-epidural anesthesia (CSEA) in abdominal surgery with preservation of spontaneous breathing patients[2, 3, 5, 8]. When EA in the thoracic epidural space is entered the clearing dose of the local anesthetic with the purpose of distribution of sensory blockade spinal roots from L5 to 4 Th±1, as well as motor and sympathetic blockade. When the additional injection of local anesthetic into the lumbar subarachnoid space develops CSEA with enhanced antinociceptive qualities in comparison with isolated epidural anesthesia [2, 3]. At the same time preserve spontaneous breathing patients as physiologically preferred[6, 7, 8].

However, the EA and XAA in conditions of spontaneous breathing is associated with risk of respiratory disorders in patients during surgery, which is associated with the following factors:

1. Mechanical limit excursions of the diaphragm by the retractors are used by surgeons during abdominal operations [9, 11].

2. If necessary, increase ventiljats and lung patient latter is impossible due to motor blockade external intercostal muscles as a result of blocking vermehrung spinal segments; participation in the act of inhaling unlocked additional respiratory muscles - stair and sternocleidomastoid muscles leads to increased energy consumption of the patient [10].

There are various methods of correction of respiratory disorders during surgery. The most important of these is the oxygen facial mask [4]. This provides an increase in alveolar oxygen concentration at the optimum flow humidified oxygen in the inhaled mixture. However, this method of treatment of respiratory disorders is not effective enough, because when these violations mechanics of breathing of the patient is necessary inhalation of high concentrations of oxygen (FiO2of 0.4-0.6 and more)that can lead to decreased cardiac output and, respectively, the systemic delivery of oxygen to tissues [12].

An alternative method of correction of respiratory disorders during surgery is the carrying out of an artificial lung ventilation, which is possible only when deep sedation patients [1]. Thus leveled the main advantage of EA, KSEA - the possibility of anesthesia in terms of preserved spontaneous breathing of the patient, avoiding neprimiromogo effects on the body of General anaesthetics and negative influences of artificial lung ventilation and total myorelaxation [4, 5].

Offers the suggested method of correction of respiratory disorders differs while carrying out abdominal operations in the conditions of the EA, CSEA with preservation of spontaneous breathing patients used noninvasive assisted ventilation (NWL) air-oxygen mixture in the mode PSV pressure support breath 8-12 cm Vogt, FiO2of 0.25-0.3, positive pressure, end-expiratory (peep) 2-4 cm Vogt, the sensitivity of the trigger inhalation of 1.5-2 cm water. Art. of the level of peep, to achieve a tidal volume of not less than 6-7 ml/kg under the control of the SpO2and blood gases.

The method is as follows:

After performing EA or CSEA a patient in position on the back. After making sure the sensor unit reaches the required level Th 4±1, embarking NWL, which is carried out with the help of ventilator - "Servoventilator-C900" (Siemens, Sweden), "Erica" and "Elvira" ("Gambro, Sweden), "Puritan-Bennett 7200 and Respironix Inc (USA). NWL conducted via face mask, matched in size to the face of the patient. The mask is conveniently disposed on the face of the patient and fastened it with special straps to avoid excessive pressure on the skin and at the same time to prevent leakage in the breathing mixture. NWL conducted an air-oxygen mixture in the mode PSV pressure support breath 8-12 cm Vogt, FiO2of 0.25-0.3, peep 2-4 cm Vogt, sensitivity trigger inhalation of 1.5-2 cm vods from the level of peep, dagotiere tidal volume not less than 6-7 ml/kg Parameters NWL picked up individually, as the comfort of the patient during the absence of resistance to the fan under the control of the SpO2and blood gases. A necessary condition for conducting NWL at EA, CSEA is the cooperation of the patient with the doctor, which is achieved preliminary explanatory conversation with obtaining informed consent for anesthesia and NWL and minimal sedation of the patient during anesthesia and surgery, which helps to maintain verbal contact with the patient. According to the testimony mask may be withdrawn at any time and re-imposed.

Example 1

Patient W, 65 years, diagnosed with chronic calculous cholecystitis, the amount of the alleged operation cholecystectomy, the selected method of anesthesia - EA with preservation of spontaneous breathing and holding NWL. In position on the left side under local anesthesia performed traditional puncture and catheterization of the epidural space at the level of Th 7-8. After fixation of the catheter and the patient's transfer back into the epidural catheter introduced a test dose of bupivacaine 0,5% 2,0. After 5 minutes in the absence of effects of spinal anesthesia entered the main calculation dose of bupivacaine 0.5% and 16 ml After 25 minutes, the upper boundary of the block was set at level 4 Th. Started NWL through facial mask mode support respiratory pressure apparatus is m "Puritan-Bennett 7200". Maintaining verbal contact with the patient, selected individual parameters NWL, focusing on achievement of the respiratory patient comfort. Parameters NWL: FiO20,3, pressure support breath 10 cm Vogt, peep 2 cm water. Art., respiratory volume of 480 ml of Sedation of the patient was performed bolus administration of 2.5 mg of diazepam before surgery, then continuous infusion of diazepam at a rate of 0.2 mg/kg/hour. Was monitorowanie SpO2and capillary blood gases, which remained within the physiological parameters. After surgery the patient was transferred to the intensive care unit for observation and treatment in the early postoperative period.

Example 2

A female patient, 65 years, diagnosis: exacerbation of chronic calculous cholecystitis, the amount of the alleged operation cholecystectomy, the selected method of anesthesia - XAA with preservation of spontaneous breathing and holding NWL. In position on the left side under local anesthesia performed traditional puncture and catheterization of the epidural space at the level of Th 7-8. Put the test-dose bupivacaine 0,5% 2,0, after 5 minutes in the absence of effects of spinal block is made puncture of the subarachnoid space at the L3-4, introduced bupivacaine 0,5% 2,5 ml After fixing the epidural catheter and transfer the patient in position on the back rated pinalenos anesthesia. When it reaches the top level of the spinal anesthesia Th 10±1 proceeded to fractional introduction into the epidural catheter of bupivacaine 0,5%, achieving the upper level of sensory block 4 Th. The total dose entered epidurally of bupivacaine 0,5% was 8 ml After 17 minutes after the first dose of bupivacaine upper level spinal-epidural anesthesia has reached 4 Th. Started NWL through facial mask mode support respiratory pressure apparatus "Puritan-Bennett 7200". Parameters NWL: FiO20,3, pressure support breath 12 cm Vogt, peep - 3 cm Vogt, tidal volume - 520 ml. of Sedation of the patient was performed bolus administration of 2.5 mg of diazepam before surgery, then continuous infusion of diazepam at a rate of 0.2 mg/kg/hour. Also monitorowanie SpO2and capillary blood gases, which remained within the physiological parameters. She felt sufficient breathing comfort during anesthesia and surgery. Transferred to the intensive care unit for observation and treatment in the early postoperative period.

Literature

1. Crackin VA, Strashnov V.I. Spinal and epidural anesthesia. //Manual for doctors. - SPb, 2000. - 95 S.

2. Crackin VA Combined spinal-epidural anesthesia in emergency anesthesiology. //VIII all-Russian Congress of anesthesiology and resuscitation. About the SC. - 2002. - S.

3. Mamyrov D.U., Garbuzenko O.N., Hadjidinev S.M. Combined epidurally-spinal anaesthesia in a multidisciplinary hospital. //VIII all-Russian Congress of anesthesiology and resuscitation. - Omsk. - 2002. - S.

4. Svetlov V.A., Kozlov Specjalna anesthesia - a step back or a step forward? //Anesthesiology and resuscitation. - 1997. No. 5. - P.45-51.

5. N.M. Fedorovsky, Kosachenko V.M., Korsun S. B. Epidural anaesthesia ropivacaine in elderly and senile age. //The Bulletin of intensive therapy. - 2002. No. 1. - P.70-74.

6. Shanin YU.N., Shanin VY Saving anesthetic aid the normal functioning of the external respiratory system after operations on the organs of the upper floor of the abdominal cavity. //Anesthesiology and resuscitation. - 1991. No. 5. - P.24-27.

7. Tents A.I., Alexandrov V., Ariav SURDS Balanced regional anesthesia on the basis of epidural blockade in a patient with a tumor of the stomach and an open form of fibrous-cavernous tuberculosis. // Anesthesiology and resuscitation. - 1994. No. 3. - P.58-59.

8. Click beetles B.C. Epidural anesthesia. - L., “Medicine”, 1976

9. Aitkhenhead A.R., Smith G. Textbook of anaesthesia. Third edition. Management in anesthesiology. // Moscow. Medicine - 1999. - 2. - 539 S.

10. Grippi M. A. Pulmonary pathophisiology. Pathophysiology of the lungs. //Moscow, 1997. 327 S.

11. Hurford W.E., Bailin M.T., J.K. Davison, Haspel K.I., Rosov C. Clinical Anesthesia Pocedures of the Massachusetts General Hospital. Clinical anesthesiology. //Moscow, GEOTAR-Med. - 2001. - 815 S.

12. Marino P. L. The ICU Book. Intensive therapy. //Moscow. GEOTAR Medicine. - 1998. - 639 S.

Treatment of respiratory disorders in terms of epidural and combined spinal-epidural anesthesia with preservation of spontaneous breathing patients in abdominal surgery, characterized in that it further incorporate complementary non-invasive ventilation air-oxygen mixture in the mode PSV pressure support breath 8-12 cm of water. Art., FiO2of 0.25-0.3, positive pressure, end-expiratory (peep) 2-4 cm of water. century, the sensitivity of the trigger, breath - 15-2 cm water. Art. of the level of peep, to achieve a tidal volume of not less than 6-7 ml/kg under control SO2and blood gases.



 

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