Method for preventing postoperative nausea and vomiting attacks

FIELD: medicine.

SUBSTANCE: method involves increasing respiration minute volume after applying carbodioxyperitoneum in a way that CO2 concentration is to be within 32-38 mm of mercury column and remaining at this level during the carbodioxyperitoneum treatment course. The CO2 concentration is supported at 30-32 mm of mercury column for 5-10 min after canceling the carbodioxyperitoneum with following respiration minute volume reduction until CO2 concentration reaches normal values.

EFFECT: reduced frequency of postoperative nausea and vomiting attacks.

1 dwg, 4 tbl

 

The present invention relates to medicine and can be used under anesthesia while performing laparoscopic cholecystectomies.

The known method of prevention of postoperative nausea and vomiting (NEED) (Biedler A, Wilhelm W; Silomon M; Awwad R; Larsen R. Ondansetron Prophylaxe und Therapie von Ubelkeit und Erbrechen nach grosseren gynakologischen Eingriffen Ergebnisse einer nationalen Multizenterstudie // An-aesthesist, 1998. - Aug; 47(8): 638-43)providing for the efficacy and safety of ondansetron for prevention NEED to change in gynecological surgery. The authors conducted a randomized study of 387 patients. The first group of patients before induction of anesthesia were receiving ondansetron at a dosage of 8 mg, 2-I - placebo. Anesthesia was performed with nitrous oxide and narcotic analgesics. Postoperative evaluation included the timing, duration and severity of NEED in the first 24 hours after surgery. According to a study after prophylactic administration of ondansetron vomiting was reported in 35% of cases and 58% after placebo (p<0.01). Nausea occurred in 49% and 64%, respectively (p<0.01). In 28% of cases after prophylactic use of ondansetron and 48% after placebo patients needed treatment with ondansetron (p<0.01). Thus the authors of the study demonstrate the effectiveness of ondansetron 8 mg before induction of anesthesia to prevent the NEED to change. In addition, they believe that ondansetron without the Asen for prevention and therapy.

However, the high cost of ondansetron and a high percentage of NEED (respectively 35 and 49%) indicates a need for further exploration of effective drugs for prevention NEED to change.

There is also known a method Fujii Y; Saitoh Y; Tanaka H; Toyooka H. Prophylactic antiemetic therapy with granisetron-droperidol combination in patients undergoing laparoscopic cholecystectomy // Can J Anaesth., 1998. - Jun; 45(6): 541-544. For prevention NEED to used a combination of granisetron (G) with droperidol (D). The aim of the study was the relatively high frequency of NEED in patients undergoing laparoscopic cholecystectomy. The study was undertaken in order to compare the effectiveness of granisetron-droperidol combination with each drug separately applied to prevent the NEED to change after laparoscopic cholecystectomy. Randomized double-blind randomized study in 150 women. Group G received 3 mg granisetron group D 1.25 mg droperidola. The group GD granisetron 3 mg plus 1.25 mg droperidola (n=50 in each group). The drugs were injected intravenously before induction of anaesthesia. Used the standard scheme of General anesthesia on the basis of isoflurane, nitrous oxide and oxygen. The study was performed continuously for the first 24 hours after anesthesia. In 14% of cases NEED to register in the group G, the group D is 36% and in the group GD - 2% (p<0.03 against a group G, p<0.001 vs g is oppy D). In all groups, the authors observed no complications from preventive action. Believe that prevention is NEED after laparoscopic cholecystectomies combination of granisetron with droperidol is more effective than using each antiemetic separately.

Disadvantages:

1. Lack of effectiveness used for prevention NEED to change drugs. The odansetron and granisetron in combination with droperidol not eliminate postoperative nausea and vomiting.

2. A significant cost of odansetron and granisetron limits their wide application for prevention NEED to change.

3. Application antiemeticski drugs can lead to side effects (transient increase in the activity of hepatic transaminases in the blood, constipation, diarrhea, headache, skin rash)that adversely affects the postoperative period (Reference Vidal, 2000).

The closest analogue decided invention No. 2161960 "Method for prevention of postoperative vomiting in patients after laparoscopiceskih cholecystectomies" (zabolotskikh IB, Savedev O., Levko VA, Makeev S.A.). To prevent vomiting, the authors used the anti-ischemic and prokinetics action galidor. Galidor eliminated evolved peripheral spasm due to the expansion of terminal arterioles and relieving spasm of p is capillary sphincter.

There is evidence electromyographic studies about improving the conduct of slow waves in the muscle sheath gastroduodenal complex under the influence of galidor (Ibizasonica, Saikaew and others, 1998), indicating that prokinetics activity of the drug. These properties galidor allowed to use it for complex anti-ischemic protection of the gastrointestinal tract and brain.

Prevention NEED to change in the analog features intramuscular injection of galidor for 40-60 min before surgery at a dose of 1 mg/kg or a drug in pill form for 2-3 hours prior to anesthesia in the same dose.

If there are additional risk factors for postoperative vomiting (gastroduodenal dysmotility complex in terms of cardiorepiratory, the injection of air into the stomach during ventilation mask during induction of anaesthesia, the stem ischemia cerebral structures due to circulatory failure in vertebrobasilar basin during intubation and during anesthesia) to mitigate reperfusion when carboxypropyl more than 1 hour, the authors recommend the introduction of additional galidor in the same dose after 6 hours. Using galidor in the prevention of postoperative vomiting after laparoscopic cholecystectomies allowed in 1998-200, to reduce the NEED to change the frequency from 18% to 6-8%.

However, the issue of prevention NEED to change after laparoscopic surgery remains not fully resolved. In the literature not found information about opportunities to reduce the NEED to change the frequency after performing laparoscopic cholecystectomies in terms CDOP by intraoperative changes of parameters of mechanical ventilation (including MOD). In this regard undertaken the search for new solutions to this problem.

The objective is to reduce the incidence of NEED and to ensure comfort during the immediately postoperative period by improving technology mechanical ventilation as a component of anesthesia when performing laparoscopic cholecystectomy.

The essence of the invention is the prevention of NEED when performing laparoscopic cholecystectomies in conditions of General anesthesia with artificial lung ventilation (ALV) endotracheal way, including calculation of minute volume of respiration (MOD), determination of carbon dioxide at the end of exhalation (ETA2for normogastria a particular patient. The proposed method differs in that after the imposition of carbocisteine (CDOP) increase MOD directly (Russian units RO) or by increasing breathing frequency (anesthetic breathing apparatus of the type Drager) so that ETCO2b the lo within 32-38 mm Hg and remained at this level during CDOP. After removing CDOP ETA2maintained within the range of 30-32 mm Hg for 5-10 min followed by a decline increased during CDOP FASHION to achieve ETCO2normal values.

There were 52 patients who, after sedation with diazepam and atropine performed laparoscopic cholecystectomy in terms of total intravenous anesthesia on the basis of propofol, midazolam, fentanyl and muscle relaxants.

Patients were divided into two groups. 1st group (n=27), MAUD was calculated by the formula Weight/10+1" and did not change during anesthesia. 2-I (n=25) - MOD has set individually according to capnometry. After blending CDOP with the aim of preserving ETA2within 32-38 mm Hg increased FASHION. It should be noted that the increase of the MOD was individually for each patient. After removing CDOP (i.e., the insufflating CO2in the abdominal cavity was stopped, which led to a reduction of revenues in the blood) is selected for a particular patient ventilation mode was not changed (relative to the period CDOP) to achieve ETA230-32 mm Hg and maintained at this level for 5-10 minutes then moved on mode normogastria by reducing the previously enlarged FASHION.

To determine the dependence of the flow of anesthetic from the mode of mechanical ventilation in the stages of an is statii (up to CDOP, during and after) were recorded and analyzed hemodynamic parameters, fluctuations in the ST interval of the ECG, the recovery time of clear consciousness and extubation trachea, expected anesthetic efficiency and consumption of basic anesthesia. The obtained results are statistically processed (Excel 2003).

Gas exchange was studied on the basis of capnometry and pulse oximetry. The saturation of hemoglobin with oxygen (SpO2) were not significant differences in the stages of anesthesia and between groups. Dynamics of changes in ETA2shown in the drawing.

From this figure it follows that in the 1st group had a tendency to hypercapnia and, as a consequence, inhibition of carbonic acid in the body, in the 2nd - normeinrete provided normal values ETCO2.

In both groups, hemodynamic parameters were varied in the range of physiological values, intergroup differences were not found.

Automatic analysis of the ST interval of the ECG is presented in table 1.

Table 1
Dynamics of changes in the ST interval on ECG stages of anesthetic management of laparoscopic cholecystectomies
GroupOriginal vonAfter sedationAfter the introductory At the height of CDOPAfter removing CDOPAfter extubation
group 10.05±0.0140.01±0.007*0.01±0.007*0.007±0.0081*0.002±0.0061 *0.02±0.009*
group 20.044±0.0120.003±0.0051*0.0007±0.00612*0.003±0.0074*0.003±0.0052*0.002±0.0051**
* - p<0.05 compared with the original background
** p<0.05 in comparison with the first group

From table 1 it is seen that significant differences were noted between the original background and the subsequent phases of anesthesia, as well as between groups after extubation trachea. Despite the fact that the indicators ST interval were slightly better in the 2nd group, clinical it didn't matter, because in all cases the deviation of the ST interval was close to zero. This implies that the optimized mode IVL do not adversely impact on the blood supply of the myocardium.

At the same trauma operations consumption of fentanyl (table 2) in the 1st group was 35%, and propofol by 15% (p<0,05) than in the 2nd. You can put that in patients of the 1st group received a phenomenon associated with the need to prevent or astronomianavigazione impacts CDOP and hypercapnia on hemodynamics, then in the 2nd group was not observed. Optimization of mechanical ventilation have contributed to a more rapid excretion of CO2from an organism.

Table 2
Consumption of basic anesthetics
GroupFentanyl (g/kg·h)Propofol
Anaesthesia induction (mg/kg)Maintenance of anesthesia (mg/kg·h)
1st group13,6±0,521.5±0,095.5±0.61
2nd group8.8±0,88*1.6±0.154.7±0.31*
* - p<0.05 compared to the 1st group

Intergroup differences in duration of operations was not found. The indicators of recovery after anesthesia (table. 3) was significantly better in patients of the 2nd group. So, the duration of anesthesia was shorter by 13, 7% (p<0.05), clear consciousness recovered faster (7.2 min - 49%) and the trachea was extubated earlier than in patients of the 1st group that will significantly improve anesthetic efficiency.

Table 3
The main indicators of the no the of after anesthesia
GroupThe duration of operation (min)The duration of anesthesia (min)Restoration of clear consciousness (min)Extubate after surgery (min)Anesthetic efficiency(%)
1st group43.9±3.8281,7±4.6914.6±1.6937,7±3.3654.5±3.51
2nd group43.4±3.9370.5±4,21*7.4±0.85*27.2±1.75*60.3±2.19*
* - p<0.05 compared to the 1st group

Patients of the 1st group complications registered in 5 patients (18.5 per cent, according to the criterion z p<0.05). This NEED - 2, persistent crises tachycardia 3 and hypertension - 2. In the 2nd group of anesthetic complications was not.

Thus, optimization of mechanical ventilation during laparoscopic cholecystectomy ensured adequate for benzocaine, to improve the performance of anesthetic activity and reduce the risk of complications.

The method is as follows. After applying CDOP increase MOD individually (about 60-70%) to a level that before applying CDAP provides specific patient normogastria (ETA2within 32-38 mm Hg). Set of pairs of the m IVL remain after removing CDOP to reduce ETA 230-32 mm Hg Mode light hyperventilation is maintained for 5-10 min, which contributes to the rapid excretion of CO2from the body. Then reduce MOD before reaching normal values ETA2. This saves the normal hemodynamics and acid-base state (abs).

The method is tested on 44 patients who underwent laparoscopic cholecystectomy after sedation (benzodiazepines, anticholinergic) in terms of General anesthesia (TBA on the basis of ketamine fentanyl, TION on the basis of propofol with fentanyl or endotracheal anesthesia based izoflurana). However, only in 1 case was registered NEED to change that amounted to 2.2% and showed high efficiency of the method, and its low cost in comparison with analogues.

Example 1. The honey. map patient No. 108. Patient B., 46 years old, weight 58 kg, height 152 see Main diagnosis: cholelithiasis, chronic calculous cholecystitis. Co-morbidities not identified. Surgery - laparoscopic cholecystectomy. Premedication: at night and in the morning benzodiazepines inside for 60 min before surgery - Relanium 10 mg and atropine 0.01 mg/kg intramuscularly. For induction of anesthesia used ketamine 1.9 mg/kg for anesthesia maintenance - Foran at a dose of from 0.8 to 1.3%, fentanyl to 4.4 g/kg·including Duration OPE the purpose was 79 min, cardiorepiratory - 70 min, the amount of intra-abdominal pressure when applying CDOP 10 mm Hg.. Recovery of consciousness was noted after 10 min after anesthesia, extubate after 24 minutes, sending to the chamber through 39 after the operation. Mode normogastria sootvetstvoval: MOD 87 ml/kg, UP to 9 ml/kg After applying CDOP ventilation parameters changed: MOD - 133 ml/kg, UP to 9 ml/kg, an increase MOD was 65%. At the same time, ETA2ranged 34-36 mm Hg After removing CDOP this mode of ventilation was continued for 9 minutes, with ETA2was 30-31 mm Hg, then it increased to achieve the parameters of normogastria by reducing MOD. Anesthesia and the postoperative period was uneventful. The patient had no discomfort from anesthesia. On the 3rd day after operation the patient was discharged in good condition on outpatient treatment.

Example 2 The Honey. map patient No. 787. Patient M., 64 years, body weight 87 kg, height 164 see Main diagnosis: cholelithiasis, chronic calculous cholecystitis. Comorbidities are not installed. Surgery - laparoscopic cholecystectomy. Premedication: at night and in the morning benzodiazepines inside for 60 min before surgery Relanium with atropine intramuscularly. Drugs for sedation nae is made in farmakopejnoj dose. For induction of anesthesia used ketamine 1.2 mg/kg for anesthesia maintenance - Foran at a dose of from 0.9 to 1.4% and fentanyl 4,2 mg/kg·the hour. The duration of operation - 65 min, cardiorepiratory - 55 min size CDOP - 10 mm Hg During the operation modes of ventilation did not change. Before applying CDOP ETA232-34 mm Hg, after - 40-42 mm Hg entering the consciousness within 10 min after the end of the operation, extubate after 20 minutes the Postoperative period was complicated in the first hour after surgery nausea and repeated vomiting that resulted in significant discomfort and the development of early pain syndrome.

The example No. 1, in contrast to No. 2, suggests that the choice and change settings of mechanical ventilation (MOU) during anesthesia and after contributed to the rapid excretion of CO2from the body, the normalization of hemodynamics and KOS, as well as the improvement of blood supply of the abdominal cavity, thereby preventing postoperative nausea and vomiting.

Comparative characteristics of the proposed method of prevention NEED and the closest analogue is presented in table 4.

Table 4
Comparison of the proposed method of prevention NEED to change with the closest analogue
Index The proposed methodSimilar
State gas exchangeNormocapniaThe tendency to hypercapnia
Consumption of narcotic analgesicsLowHigh
Material costsNo
Adverse effects and complicationsNo
EfficiencyHighLow

The technical result is an effective prevention of postoperative nausea and vomiting, creating patient comfort conditions in the postoperative period, the pharmacological reduction of workload and costs of prevention and treatment NEED and other complications, reduced length of hospitalization. This may be accomplished by removing excess carbon dioxide from the body and maintain normal gas composition of blood.

A method for preventing postoperative nausea and vomiting when performing laparoscopic cholecystectomy in terms of General anesthesia with mechanical ventilation endotracheal method, including calculation of minute volume of respiration (MOD), determination of carbon dioxide at the end of exhalation (ETA2for normogastria a particular patient otlichuy is the, after applying cardiorepiratory (CDOP) boost FASHION so that ETA2was in the range of 32-38 mm Hg and remained at this level during CDOP; after removing CDOP ETA2maintained within the range of 30-32 mm Hg for 5-10 min followed by a decline of FASHION before the achievements of ETA2normal values.



 

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