The method of anesthetic management operations in severe traumatic brain injury

 

(57) Abstract:

The invention relates to medicine, namely to neuroanesthesiology and neurotraumatology. It is suggested to premedication with atropine (0.3 to 0.7 mg) and demerol (10 mg) intravenously; anaesthesia induction to begin with the introduction of full intravenous dose of non-depolarizing muscle relaxant action type (Arduan 0.05 mg/kg body weight), then a mask ventilation with a mixture of nitrous oxide and oxygen and intravenous enter fentanyl at a dose of 3.75 mg/kg) and clonidine at a dose of 1.25 mg/kg; in the maintenance phase of anesthesia intravenous fractional enter thiopental sodium at a dose of 3.5 - 3.75 mg/kg/h; intraoperative intramuscularly to enter 300 mg of vitamin E and intravenously 30 thousand units kontrikala. The method allows to limit the primary and to prevent secondary brain damage and reduce mortality.

The invention relates to medicine and can be used in neuroanesthesiology and neurotraumatology. The known method of anesthesia at the neurotrauma (Manevich, A. H. , Salolikin Century. And. Neuroanesthesiology. - M.: Medicine, 1977), including premedication for 30-40 min before surgery (intramuscularly promedol 30-40 mg, diphenhydramine, when the motor excitation seduxen 20-40 mg), an introduction to the positive ventilation. Tracheal intubation after injection of depolarizing muscle relaxants type of action (succinylcholine 1.5-2 mg/kg) with precarizaciy (tuberin 3-5 mg). Maintenance of anesthesia on the background of anaesthesia nitrous oxide intravenous droperidol and fentanyl.

Disadvantages of analogue.

1. Anesthesia in severe traumatic brain injury is part of resuscitation, therefore, there is no time for sedation for 30-40 min before the operation.

2. Intramuscular administration of drugs for sedation and anesthesia during hemodynamic disorders unreasonably.

3. The beginning of anesthesia with injection of anesthetics causes further depression of consciousness and breathing, which exacerbates the symptoms of hypoxia and hypercapnia, causes an increase in intracranial pressure.

4. Thiopental sodium is used at the stage of induction of anaesthesia can cause a significant reduction in blood pressure and, consequently, reduction of perfusion pressure of the brain below the critical values, which may aggravate existing hypoxia brain.

5. Late onset of mask mechanical ventilation in medicated depressed consciousness and breathing with soysoudara type actions cause muscle fibrillation, that increases intracranial pressure.

7. Application droperidola may cause postoperative muscle rigidity and tremors, which increases intracranial pressure.

8. Taken together, all these factors increase intracranial pressure, reduce perfusion pressure of the brain, exacerbate hypoxia and lead to secondary brain damage that affects the results of treatment of patients with severe traumatic brain injury.

Closest to the claimed is "the Way neuro-vegetative stabilization in the surgical operation on the brain" (A. C. N 1526696 A1 class A 61 K 31/445 /A. N. Kondratyev, M. L. chemical, A. F. Gurchin, T. C. Kharitonov), which uses the combined administration of fentanyl and clonidine to reduce traumatic brain during surgery and to reduce complications.

In the specified way, the treatment is carried out intramuscularly for 30-40 min before surgery (atropine 0.5-1 mg, morphine 20 mg, diphenhydramine 10-20 mg). In the operating intramuscularly injected fentanyl 400-600 mcg. Anaesthesia induction continues with the introduction of a 1% solution of thiopental sodium in the background made by the introduction of narcotic analgesics expressed agnetti the holding of anesthesia by inhalation of nitrous oxide mixed with oxygen in the ratio 2: 1. Neuro-vegetative stabilization is realized by the introduction of 500 mcg of fentanyl and 0.1-0.3 mg of clonidine, dissolved in 500 ml of 0.9% sodium chloride solution. The mixture is injected intravenously, the average infusion rate of 1.5-2 mg/kg/h fentanyl, 0.3 g/kg/h of clonidine. Diplegia - fractional introduction of tuberin 0.3 mg/kg

This method is used when anesthetic ensuring neurooncological operations.

The prototype can not be used for anesthetic management operations in severe craniocerebral trauma, emergency neurotraumatology, as anesthesia in severe traumatic brain injury is part of resuscitation. Therefore, it is impossible premedication for 30-40 min before operation. In addition, the technology of anesthesia in the prototype in conditions of severe traumatic brain injury may cause secondary brain damage.

1. The use of intramuscular drugs for sedation and anesthesia in severe traumatic brain injury, hemodynamic disorders impractical.

2. Featured in the prototype intramuscular and intravenous narcotic analgesics and anesthetics for for the and, raised intracranial pressure and can affect the functional state of the brain to perform the decompression.

3. Featured in the prototype induction of anaesthesia with thiopental sodium exacerbates hemodynamic and perfusion disorders with severe traumatic brain injury.

4. Used in the prototype pharmacological effects on opioidergic and adrenergic antinociceptive systems are insufficient in severe traumatic brain injury, as when it is required to limit the effects of lipid peroxidation, proteolysis, edema - swelling of the brain, damage to the blood-brain barrier.

5. The primary medications oppressive consciousness and breathing in conditions of severe traumatic brain injury, causing the need to start a mask for artificial ventilation of lungs with more available muscle tone, which increases intracranial pressure.

6. Depolarizing muscle relaxants type actions cause muscle fibrillation, which increases intracranial pressure.

Thus, the method of anesthesia in the prototype used in the planned neurooncological operations cannot be applied on the x characteristics of traumatic brain injury and the need to ensure the resuscitation component of anesthesia.

The task of the invention is to improve the protection of the brain during surgical decompression in patients with severe traumatic brain injury.

This object is achieved in that the premedication with atropine (0.3 to 0.7 mg) and demerol (10 mg) are intravenously; anaesthesia induction beginning with the introduction of full intravenous dose of non-depolarizing muscle relaxant action type (Arduan 0.05 mg/kg body weight), then spend mask ventilation with a mixture of nitrous oxide and oxygen and intravenous fentanyl in a dose of 3.75 mg/kg) and clonidine at a dose of 1.25 mg/kg; in the maintenance phase of anesthesia intravenous fractional administered thiopental sodium at a dose of 3.5-3.75 mg/kg/h: intraoperative intramuscularly injected with 300 mg of vitamin E and intravenous 30 thousand units kontrikala.

The use of the proposed method achieved a positive therapeutic effect, increases the efficiency of brain protection during surgical decompression in patients with severe traumatic brain injury.

1. Changing technology induction of anaesthesia, namely preventive full dose of non-depolarizing muscle relaxant action type allows to exclude non-medical reasons for the increase vnutricerepnogo avicennae Central venous pressure, non-functional position of the head).

2. Mask ventilation is carried out under optimal conditions, lack of muscle tone and resistance.

3. The beginning of mask ventilation before the commencement of the drugs, oppressive consciousness and breathing, adequate to deal with severe traumatic brain injury, hypoxia and hypercapnia.

4. Hyperventilation mode mask ventilation within five minutes allows to reduce intracranial pressure due to the achieved hypocapnia.

5. The combination of hyperventilation mask ventilation with the introduction of fentanyl and clonidine on the background proactively reached myorelaxation eliminates the occurrence of hemodynamic responses to direct laryngoscopy and tracheal intubation.

6. The use of intraoperative vitamin "E" and kontrikala allows to inhibit early-stage cascade of pathological reactions of lipid peroxidation and proteolysis, characteristic of severe traumatic brain injury.

7. Using the combined injection of fentanyl, clonidine and thiopental sodium increases the efficiency of brain protection during severe head m is the city of Chania avoiding prolonged mechanical ventilation and its complications.

Thus, due to changing technology induction of anaesthesia and applied pharmacological drugs, it becomes possible to limit the primary and to prevent secondary brain damage, to realize the potential to reduce mortality and improve treatment outcomes in patients with severe traumatic brain injury.

The proposed method of anesthetic management operations in severe traumatic brain injury is as follows.

When entering the patient into the operating room, the treatment is intravenous atropine in a dose of 0.3-0.7 mg and demerol dose of 10 mg.

Induction of anaesthesia start with the preventive injection of the full dose of non-depolarizing muscle relaxant action type of ardoyne at a dose of 0.05 mg/kg body weight intravenously. After that, immediately begin artificial mask ventilation with a mixture of nitrous oxide and oxygen in the ratio 2:1 or 1:1 (depending on the state of consciousness) in the mode of hyperventilation (150-200% of adequate minute volume of breathing), with the performance of reception of Cellica. the in average dose of 1.25 mg/kg of body weight. The duration of induction of anaesthesia five minutes. Then perform the intubation. The flow of nitrous oxide cease. Artificial lung ventilation spend an oxygen-air mixture in the regime of moderate hyperventilation.

Maintenance of anesthesia is drip intravenous fentanyl in an average dose of 2.5 mg/kg of body weight per hour, clonidine average dose of 0.6 mg/kg of body weight per hour and intravenous fractional introduction of thiopental sodium at a dose of 3.5-3.75 mg/kg of body weight per hour. Intraoperatively administered 300 mg of vitamin E intramuscularly and 30 thousand units kontrikala intravenously. Diplegia supported by non-depolarizing muscle relaxant action type arduinos dose of 0.04 mg/kg of body weight per hour. At the stage of hemostasis introduction of fentanyl and clonidine is stopped. Anesthesia continues with the introduction of thiopental sodium.

When restoring consciousness and spontaneous breathing are extubation. In severe condition, the absence of consciousness exercise prolonged ventilation to stabilize neurologic syndrome.

Example 1. The history N 3890.

Patient P., 24 years. Did 04.07.96,

The diagnosis of compression of the brain otrisovany skull in the middle cranial fossa. Subarachnoid hemorrhage.

Operation 04.07.96, 14 h 00 min - 16 h 10 min Right decompressive resection trepanation of the skull, the destruction of acute subdural hematoma.

The weight of the patient: 95 kg

When entering a serious condition. The severity of the condition due to severe craniocerebral trauma, compression of the brain, disorders of consciousness, breathing and hypoxia. Expressed stunning. Convulsive twitching in the extremities, muscle hypertonicity, laryngospasm. Cyanosis of the lips, acrocyanosis. Blood pressure of 140/90 mm RT.art., the pulse rate of 92 ID/min.

Sedation intravenous 0.7 mg of atropine and 10 mg of demerol.

Anaesthesia induction was started with the preventive injection of 5 mg of non-depolarizing muscle relaxant action type of ardoyne. Then immediately launched an artificial mask ventilation with a mixture of nitrous oxide and oxygen in the ratio 2: 1 mode hyperventilation, with implementation taking Celica. Simultaneously intravenously injected fentanyl at a dose of 8 ml of a 0.005% solution and clonidine in a dose of 1.5 ml of 0.01% solution. The duration of induction of anaesthesia five minutes.

After preventive intravenous muscle relaxant to nodeposite the cramps, muscle hypertonicity. Mask ventilation is carried out under optimal conditions. By the end of the induction of anaesthesia skin pink, hypoxia cropped. Blood pressure dropped to 120/80 mm RT.article In the sixth minute performed tracheal intubation, artificial started hardware ventilation air-oxygen mixture in the regime of moderate hyperventilation. The flow of nitrous oxide is discontinued. Hemodynamic responses to direct laryngoscopy and tracheal intubation was not.

Maintenance of anesthesia was carried out drip intravenous fentanyl and clonidine in doses of 2.5 mcg/kg/h and 0.6 g/kg/hour, respectively, and the fractional intravenous injection of thiopental sodium at a dose of 3.5 mg/kg/h Diplegia intravenous, ardoyne dose of 0.04 mg/kg/H. Intraoperative introduced 300 mg vitamin E intramuscularly and 30 thousand units kontrikala intravenously.

During anesthesia was stable hemodynamic performance at all stages of operations, including skin incision, manipulation on the periosteum and Dura membrane, as well as on stage decompression brain (110/80 - 120/80 mm RT.cent.).

At the stage of hemostasis introduction of fentanyl and clonidine is discontinued. Anesthes brain stable, the brain is malleable. Phenomena worsening swelling and dislocation brain was not. Correction intracranial volume smodulename and dehydration was not required.

When he recovered consciousness and spontaneous breathing, excubitor. In the recovery room set in consciousness on its own breath.

Recovery. Was discharged in good condition.

This observation suggests that due to changing technology induction of anaesthesia and applicable combinations of pharmacological agents managed to avoid exacerbating the primary and to prevent secondary brain damage. Already at the stage of induction of anaesthesia and then during anesthesia realized the potential to reduce mortality and improve outcomes.

Thus, achieved the objective - increased efficiency of brain protection during surgical decompression in a patient with severe traumatic brain injury.

Example 2. The history N 2367.

Patient P., 43 years. Did 21.04.96,

The diagnosis of compression of the brain acute subdural hematoma in the left parietotemporal the Operation 21.04.96, 6 hours and 20 minutes to 7 hours and 30 minutes left decompressive resection trepanation of the skull. Destruction of acute subdural hematoma.

The weight of the patient: 65 kg

On admission, the patient's condition is severe. The severity of the condition due to severe craniocerebral trauma, compression of the brain, disorders of consciousness, breathing and hypoxia. Deep spoor, coordinated motor response to pain. Anisocoria, dull photoreactive. Cyanosis of the lips, acrocyanosis. Bleeding from the nasal and ear passages. Laryngospasm, pronounced muscle tension, cramps in the extremities. Blood pressure 100/60 mm RT. Art., pulse 84 beats./min, respiratory rhythm broken.

Sedation intravenous administration of 0.5 mg of atropine and 10 mg of demerol.

Anaesthesia induction was started with the preventive injection of 4 mg of non-depolarizing muscle relaxant action type of ardoyne. Then immediately launched an artificial mask ventilation with a mixture of nitrous oxide and oxygen in the ratio 1: 1 mode hypoventilation, with implementation taking Celica. Simultaneously intravenously was administered fentanyl in a dose of 5 ml of a 0.005% solution and clonidine at a dose of 1 ml of 0.01% solution. The duration of induction of anaesthesia five minutes.

After PR is increasing intracranial pressure laryngospasm, muscle hypertonicity, convulsions. Mask ventilation is carried out under optimal conditions. By the end of the induction of anaesthesia cropped to hypoxia, pink skin, cyanosis, acrocyanosis no. In the sixth minute produced tracheal intubation, artificial started hardware ventilation air-oxygen mixture in the regime of moderate hyperventilation. The flow of nitrous oxide is discontinued. Hemodynamic responses to direct laryngoscopy and tracheal intubation was not. Blood pressure 100/70 mm RT.art., pulse 78 beats./min

Maintenance of anesthesia was performed intravenous drip of fentanyl and clonidine in doses of 2.5 mcg/kg/h and 0.6 g/kg/h, respectively, and the fractional intravenous injection of thiopental sodium at a dose of 3.5 mg/kg/h Diplegia intravenous, ardoyne at a dose of 2 mg Intraoperatively introduced 300 mg vitamin E intramuscularly and 30 thousand units kontrikala intravenously.

During anesthesia was stable hemodynamic performance at all stages of operations, including skin incision, manipulation on the periosteum and Dura membrane, as well as on stage decompression brain (100/70 - 110/70 mm RT.cent.).

At the stage of hemostasis introduction f what.

Throughout the operation the volume of the brain is stable, the brain is malleable. Phenomena worsening swelling and dislocation brain was not. Correction intracranial volume smodulename and dehydration was not required.

After the operation in conditions of prolonged mechanical ventilation was transferred to the intensive care unit. After one hour has recovered consciousness, then excubitor.

Recovery. Was discharged in good condition.

This observation suggests that due to changing technology induction of anaesthesia and applicable combinations of pharmacological agents managed to avoid exacerbating the primary and to prevent secondary brain damage, was able to provide resuscitation component of anesthesia. Already at the stage of induction of anaesthesia and then during anesthesia realized the potential to reduce mortality and improve outcomes.

Thus, achieved the objective - increased efficiency of brain protection during surgical decompression in a patient with severe traumatic brain injury.

The method of anesthetic management of apraksinom, holding mask ventilation with a mixture of nitrous oxide and oxygen, intravenous injection of fentanyl and clonidine and anaesthesia, characterized in that the pretreatment is conducted by the intravenous injection of these drugs, in the opening anaesthesia use of non-depolarizing muscle relaxants type, in the maintenance phase of anesthesia fractional administered thiopental sodium at a dose of 3.5 - 3,75 mg/kg/h, intraoperative intramuscularly injected with 300 mg of vitamin E and intravenously 30 thousand units kontrikala.

 

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