Method for preventing unfavorable hemodynamic carbodioxyperitoneum effects in performing laparoscopic cholecystectomy

FIELD: medicine.

SUBSTANCE: method involves determining vegetative nervous system tonus in preoperative period using Kerdo index and selecting intravenous anesthetic depending its value. Parasympathetic vegetative nervous system tonus being predominant, ketamine is introduced to patient at a dose of 1-1.5 mg/kg/h during the operation. Marked sympathetic vegetative nervous system tonus being predominant, propophol is administered at a dose of 2-4 mg/kg/h. Balanced vegetative nervous system divisions tonus being observed (eutonia), both ketamine and propophol are permitted for being used in generally applied doses.

EFFECT: enhanced effectiveness of treatment; avoided undesirable hemodynamic carbodioxyperitoneum effects.

3 dwg

 

The invention relates to medicine and can be used for anesthesia during laparoscopic cholecystectomy.

At the present time significantly increased the number and duration of laparoscopic procedures and expanded indications for them, it is important to prevent adverse hemodynamic changes caused by carbondioxideemissions (CDOP).

Hemodynamic changes during CDOP caused by decreased venous return due to compression of the gas bubble inferior Vena cava and the depositing of blood in the lower extremities and the vessels of the mesentery; the vasoconstriction caused by the release of renin and vasopressin due to compression of the renal vessels and renal blood flow, increasing intrathoracic pressure, increased pulmonary shunt and compression of the upper Vena cava; the increase in blood pressure due to hypercapnia, arise as a result of suction diciplined through the peritoneum; irritation of the vagus nerve; gravitational obstruction of venous return to the position of Fowler.

Compensatory reactions of the body, aimed at mitigating the adverse hemodynamic effects of cardiorepiratory, are regulated by the autonomic nervous system (ANS) and largely depend on the prevailing tone of her with matichenkov or parasympathetic divisions. Also affected by the state of the ANS during anesthesia, modulating the action of drugs used by the anesthesiologist.

At the present time offered a variety of options anesthetic management of laparoscopic cholecystectomies.

It is known the use of thiopental in the work Vitalia N.A., Ignatenko A.S., S.A. White “anaesthesia Induction with thiopental and propofol during laparoscopic operations” (Vitebsk regional clinical hospital, Vitebsk, Belarus.// Materials of VI all-Russian Congress of anesthesiology and resuscitation, October 7-10, 1998, Moscow, s). Thiopental leads to a significant decrease in stroke volume (PP), minute volume of blood (IOC), cardiac index (SI) by 30-40% during induction of anaesthesia, and after applying the kpod continue to decline at 40-60% of the original level. The decrease in cardiac output induced by thiopental, exacerbated by reduced venous return caused by carbondioxideemissions that, in our opinion, makes it inadvisable to use this drug during laparoscopic cholecystectomy.

It is also known the use of benzodiazepine ultrashort action midazolam. In the work Weavah, Hteenma, Sniadowo Monitoring hemodynamics during endoscopic cholecystectomy during various options midazolam.buy anesthesia”. REP the flare of Uzbekistan, Tashkent // Endoscopic surgery, 1997, No. 1, s-14). When applying the combination of midazolam with inhalation of oxygen-ferrous mixture has decreased UO and C on 8-22%, HELL 8-20%, the increase in HR at 6-30% after induction. After applying cardiorepiratory observed a further reduction in both single and minute performance of the heart at 34-46% from baseline. The combination of midazolam with ketamine phase induction causes a decrease in the PP 5-18%, SI and MO on 7-21%, while HELL or reduced by 3-8%, or increased by 7-12%, and heart rate increases by 8-17%. Unfortunately, the authors do not give preoperative criterion of choosing anesthesia.

The prototype of the present invention, based on the use of vegetative index Cerdo (VIC) as the selection criterion intravenous anesthetic is Niedergang, Tnishino, Webnography, Messager “the Dependence of the efficiency of sedation and neuro protection during operations in conditions neyroleptanalgezii from the initial state of the autonomic nervous system (Anesthesiology and critical care medicine, 1993, No. 6, pp.8-11). The authors for the day before surgery was calculated vegetative index Cerdo by the formula (VIC=(1-DD/HR)*100), minute volume of blood (IOC), the index of the minute volume of blood circulation QVm. Patients operated on for kidney stones and mo is etechnical, conducted two types of sedation: two hours before anesthesia is administered, pipolphen in the dose of 0.7 mg/kg and 40 minutes before anesthesia is administered morphine at a dose of 0.28 mg/kg or two hours before anesthesia is administered seduxen at a dose of 0.14 mg/kg and 40 minutes before anesthesia is administered morphine at a dose of 0.28 mg/kg Atropine in both groups administered intravenously immediately before induction. The level of neuro protection was determined during the operation on the content of adrenocorticotropic hormone and cortisol in plasma. During surgery, the dose droperidola was 0,269±0.02 mg/kg in the first group and 0,193±0.001 mg/kg in the second group, fentanyl 5,8±0.3 ág/kg and 4.1±0.3 ág/kg, respectively. It was shown that the application of the above indicators for evaluating the effectiveness of sedation and level of neuro protection during anesthesia. Unfortunately, the proposed method is used only to monitor the current status of patients and has no prognostic orientation. In addition, the method was tested in conditions neyroleptanalgezii in urologic operations and cannot be used to select an intravenous anesthetic under the conditions of cardiorepiratory during laparoscopic cholecystectomy.

Tasks

1. Reliable anesthesia for patient protection during cardiorepiratory.

2. The maximum of the device is giving undesirable hemodynamic effects of cardiorepiratory.

3. The maximum elimination side effects of intravenous anesthetics.

4. Achieving reduction of hemodynamic changes during anesthesia during cardiorepiratory during laparoscopic cholecystectomy.

The invention consists in that in the preoperative period determine the index Cargo and depending on the received result, when the prevalence of sympathetic autonomic nervous system of the patient intraoperatively enter propofol at a dose of 2-4 mg/kg/hour, and the predominance of parasympathetic tonus of the vegetative nervous system is administered ketamine in a dose of 1-1 .5 mg/kg/hour. With a balanced tone of the nervous system - Estonii - the choice is intravenous anesthetic does not matter.

The method is as follows.

The day before surgery in a patient at rest measured blood pressure and heart rate, on the basis of these values, calculate the vegetation index Cerdo by the formula

VIC=(1-DD/HR)*100,

where DD is the diastolic blood pressure,

HR - heart rate in 1 minute.

Depending on the values of VIC prefer certain intravenous anestetic. When VIC<0, that is, when parasympathicotonia (negative index Cerdo), to the patient during the induction injected ketamine at a dose of 1.5-2 is g/kg, and for the maintenance of anaesthesia submission continues the introduction using syringe-dispenser at a dose of 1-1 .5 mg/kg/hour. When VIC>0, that is, when the sympathicotonia (positive index Cerdo), to the patient during the induction impose propofol at a dose of 1-2 mg/kg, and for the maintenance of anaesthesia submission continues the introduction using syringe-dispenser at a dose of 2-4 mg/kg/hour. When VIC=0, that is, when atonia, the choice of intravenous anesthetic does not play a significant role. Use as ketamine and propofol in conventional doses. For the induction impose propofol at a dose of 2.0 mg/kg and ketamine at a dose of 1.5-2.0 mg/kg For anesthesia maintenance of their introduction produce a continuous infusion or syringe-dispenser: propofol at a dose of 2-4 mg/kg/h ketamine at a dose of 1-1 .5 mg/kg/hour.

The method is tested in 213 patients during 2001-2002

Example 1.

Patient L., 39 years old, was admitted to the hospital 21.04.2001, On the basis of anamnesis, physical examination, laboratory and clinical research has been diagnosed with “GCB. Chronic calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, when the HELL is 120/80 mm Hg, pulse rate is 72 in 1 min VIK=-11,1, testified to the predominance of the parasympathetic tone of the ANS. When this type of hemodynamics were characterized with edowski parameters: UO - 64,77 ml; SI - 2,6 l/min*m2; IOC - 4,6 l/min, SVR - 1600 Dyne/s*cm-5. As intravenous anesthetic was selected ketamine. The induction took 0.14 mg/kg sibazona; 1.4 mg/kg of ketamine and 2,85 µg/kg of fentanyl with standard precarizaciy and myorelaxation, arduinos and ListenOn. Anesthesia was maintained intravenous injection of ketamine in a dose and 2.14 mg/kg*hour and fractional bolus administration of fentanyl in a dose of 10 µg/kg*h. After applying cardiorepiratory (CDOP) 10 mm Hg had natural changes of hemodynamics: PP - 89,52 (increased 38.2%) from the original C - 4,39 l/min*m2(increased 68.9%), IOC - 7,8 l/min (increase of 68.9%), SVR - 913,7 Dean/s*cm-5(decrease 42,91%), which testified to the good perfusion of peripheral tissues. When the HELL has risen to 130/70 mm Hg, pulse rate to 88 in 1 min. Increase in VIC to +21 testified about the activation of sympathoadrenal system. Awakening the patient lasted 15 min (until extubation), duration kpod was 20 minutes On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting.

Example 2.

Sick,, 66 years old, was admitted to the hospital 15.02.2002, On the basis of anamnesis, physical examination, laboratory and paraclinical studies was the deliver the diagnosis: “GCB. Chronic calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, when the HELL is 160/100 mm Hg, HR - 88 1 min, VIC=-13,64, testified to the predominance of the parasympathetic tone of the ANS. When this type of hemodynamics was characterized by the following parameters: UO - 39,16 ml; SI - 1,79 l/min*m2; IOC - 3,45 l/min, SVR - 2784 Dean/s*cm-5. As intravenous anesthetic used propofol. The induction took 0,12 mg/kg sibazona; 1.25 mg/kg of propofol and 2.5 µg/kg of fentanyl with standard precarizaciy and myorelaxation, arduinos and ListenOn. Anesthesia was maintained intravenous injection of propofol at a dose of 1.6 mg/kg*hour and fractional bolus administration of fentanyl in a dose of 6.7 mg/kg*h. After applying CDOP 10 mm Hg had natural changes of hemodynamics: PP - 48,84 (increasing by 24.7%) from the original, SEA of 1.57 l/min*m2(decrease by 12.2%), IOC - 3,03 l/min (reduced by 12.1%), SVR - DIN 1052/s*cm-5(decrease 62.2%). When the HELL was reduced to 100/65 mm Hg, pulse rate to 62 in 1 minutes Despite the increase in VIC -5, dominated the tone of the parasympathetic division of the ANS, indicating that insufficient activation of the sympathoadrenal system. The absence of a compensatory increase in HR, SI in response to a significant reduction in SVR due to paricipate the mimetic action of propofol. Awakening the patient lasted 15 min (until extubation), duration kpod was 30 minutes On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting. Figure 1 shows the effect of ketamine and propofol in parasympathotonia.

Example 3.

Patient P., aged 35, was admitted to the hospital 15.03.2001, On the basis of anamnesis, physical examination, laboratory and clinical research has been diagnosed with “GCB. Chronic calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, when the HELL is 130/80 mm Hg, HR - 94 1 min, VIC=+14,89, testified to the prevailing tone of the sympathetic division of the ANS. When this type of hemodynamics was characterized by the following parameters: UO - 76,53 ml; SI - 3,63 l/min*m2; IOC - 7,2 l/min, SVR - DIN 1074/s*cm-5. As intravenous anesthetic was selected propofol. The induction took midazolam 0.08 mg/kg, propofol 1.0 mg/kg, fentanyl 2,35 µg/kg, with a standard precarizaciy and myorelaxation, arduinos and ListenOn. Maintenance of anesthesia was carried out by intravenous injection of propofol at a dose of 2.7 mg/kg*hour and fractional bolus administration of fentanyl in a dose of 7 mg/kg*h. After applying CDOP 10 mm is TST had natural changes of hemodynamics: PP - 76,53 (left baseline), SI - 2,93 l/min*m (decrease by 19.3%), IOC - of 5.82 l/min (reduced by 19.2%), SVR - 1329 Dean/s*cm-5(increased by 23.7%). If this AD remains the same 130/80 mm Hg, heart rate decreased to 76 in 1 min. Reduction VIC -5 testified to the predominance of the parasympathetic tone of the ANS. Small changes in hemodynamics in this case allowed to consider propofol the drug of choice in somatotonic. Awakening the patient lasted 30 min (until extubation), duration kpod was 50 minutes On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting.

Example 4.

Patient K., 33 years old, was admitted to the hospital 19.05.2001, On the basis of anamnesis, physical examination, laboratory and clinical research has been diagnosed with “GCB. Chronic calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, with AD - 125/80 mm Hg, pulse rate is 92 1 min, VIC=+13,04, testified to the prevailing tone of the sympathetic division of the ANS. When this type of hemodynamics was characterized by the following parameters: UO was 74.3 ml; SI - 4,07 l/min*m2; IOC - 6,84 l/min, SVR - 1111 Dean/s*cm-5. The quality is TBE intravenous anesthetic was used ketamine. The induction took 0.16 mg/kg sibazona; 1.6 mg/kg of ketamine and 3.22 µg/kg of fentanyl with standard precarizaciy and myorelaxation, arduinos and ListenOn. Anesthesia was maintained by injection of ketamine at a dose of 1.76 mg/kg*h and fentanyl infusion at a dose of 10 µg/kg*h fractional bolus. After applying CDOP 10 mm Hg had natural changes of hemodynamics: PP - 78,36 (increase by 5.4%) from the original C - 4,67 l/min*m2(increased by 14.7%), IOC - 7,84 l/min (increase of 14.6%), SVR - DIN 986/s*cm-5(decrease by 11.2%). When the HELL has risen to 130/80 mm Hg, pulse rate to 100 in 1 min. Increase in VIC to +20 testified further activation of sympathoadrenal system with subsequent depletion of its reserves. Awakening the patient lasted 45 minutes (until extubation), duration kpod was 45 minutes. On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting.

From examples 3 and 4 shows that the minimal hemodynamic changes in somatotonic during CDOP occurred when using propofol (figure 2).

Example 5.

Patient M., 48 years old, was admitted to the hospital 18.02.2002, On the basis of anamnesis, physical examination, laboratory and clinical research has been diagnosed with “GCB. Chronic is s calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, when the HELL is 120/80 mm Hg, pulse rate is 80 in 1 min, VIC=0, indicating that the balanced tone of the ANS. When this type of hemodynamics was characterized by the following parameters: UO - 56,5 ml; SI - 2,89 l/min*m2; IOC - 4.5 l/min, SVR - 1650 Dean/s*cm-5. As intravenous anesthetic was selected propofol. The induction took 0.18 mg/kg sibazona; 0.9 mg/kg of propofol and to 3.64 ág/kg of fentanyl with standard precarizaciy and myorelaxation, arduinos and ListenOn. Anesthesia was maintained intravenous injection of propofol at a dose of 2.97 mg/kg*hour and fractional bolus administration of fentanyl in a dose of 9,92 µg/kg*h. After applying cardiorepiratory (CDOP) 10 mm Hg hemodynamic changes were observed: PP - 56,5, C - 2,89 l/min*m2IOC - 4.5 l/min, SVR - 1650 Dean/s*cm-5. When the HELL was 120/80 mm Hg, pulse rate 80 in 1 min. Awakening the patient lasted 55 min (up to extubation), duration kpod was 40 minutes On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting.

Example 6.

Patient D., aged 65, was admitted to the hospital 12.04.2002, On the basis of anamnesis, physical examination, laboratory and paraclinical the research was diagnosed: “GCB. Chronic calculous cholecystitis”. In addition to routine examination was defined vegetative index Cerdo by the formula: VIK=(1-DD/HR)*100, when the HELL is 140/80 mm Hg, heart rate of 80 in 1 min, VIC=0, indicative of atonia. When this type of hemodynamics was characterized by the following parameters: UO - 57,2 ml; SI - 2.38 l/min*m2; IOC - of 4.57 l/min, SVR - DIN 1748/s*cm-5. As intravenous anesthetic was selected ketamine. The induction took 0,12 mg/kg sibazona; 0.9 mg/kg of ketamine and 2.5 mg/kg of fentanyl, with standard precarizaciy and myorelaxation, arduinos and ListenOn. Anesthesia was maintained intravenous injection of ketamine at a dose of 1.25 mg/kg*hour and fractional bolus administration of fentanyl at a dose of 8 µg/kg*h. After applying cardiorepiratory (CDOP) 10 mm Hg hemodynamic changes were minimal: PP - 61,2 (increased by 7.0% from baseline), SI - 2,23 l/min*m2(decrease by 6.3%), IOC - 4,29 l/min (a decrease of 6.1%), SVR - DIN 1897/s*cm-5(increase by 8.5%). HELL has risen to 145/80 mm Hg, with a decrease in heart rate to 70 in 1 min. Awakening the patient lasted 45 min (until extubation), duration kpod was 60 minutes On the second day after surgery the patient was discharged in good condition under the supervision of a surgeon clinics. Sutures were removed on the seventh day in the outpatient setting.

From examples 5, 6 and 3, it follows that PR is zero values, VIC (atonia) the use of any intravenous anesthetic did not lead to marked changes in hemodynamics during kpod.

Our proposed method can reduce the frequency and severity of hemodynamic changes caused by the imposition of cardiorepiratory. Smoother for anesthesia allows to decrease the duration of hospital stay. A rational method of choice is intravenous anesthetic allows you to reduce the unnecessary consumption of expensive propofol.

The way to prevent adverse hemodynamic effects of carboxymaltose during laparoscopic operations, characterized in that in the preoperative period determine the tone of the autonomic nervous system index Cargo and choose an intravenous anesthetic, depending on its value, while the predominance of parasympathetic tonus of the vegetative nervous system of the patient during surgery is administered ketamine in a dose of 1-1 .5 mg/kg/h, and when expressed sympathetic tone of the patient enter propofol at a dose of 2-4 mg/kg/h; with a balanced tone of the nervous system - Estonii - allow the use of ketamine and propofol in conventional doses.



 

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EFFECT: improved preparing method, valuable medicinal properties of compounds.

13 cl, 3 tbl, 35 ex

FIELD: medicine, pharmacy.

SUBSTANCE: invention proposes new tablets with size less 3 mm with sustained-releasing the opioid analgesic drug for 30 min in the amount above 75%. Invention provides opioid for oral intake with taking into account individual necessity of patient due to selection of required amount of mictotablets by dispenser.

EFFECT: valuable properties of tablet, expanded assortment of medicinal formulations of opioid analgesics.

19 cl, 4 tbl, 4 ex

FIELD: medicine.

SUBSTANCE: means is manufactured as capsule containing dibunol and 15% oil extraction of propolis.

EFFECT: enhanced effectiveness of treatment; prolonged regenerating and antibacterial action.

2 cl

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