Method for anesthesiological protection against factors of surgical aggression

FIELD: medicine, anesthesiology, traumatology, orthopedics, thoracic surgery.

SUBSTANCE: about 1.5-2 min before spreading the affected lung it is necessary to deepen anesthesia due to injecting phenthanyl at the dosage of 10-12 mcg/kg body weight. The present innovation provides safety of operations of ventral spondyledesis out of transthoracic and thoracodiaphragmatic accesses, stability of arterial pressure level and patient's heart rate, decreases stress loading upon a patient that, in its turn, favors the prophylaxis of intraoperative complications.

EFFECT: higher efficiency of anesthesiological protection.

2 cl, 1 ex

 

The invention relates to medicine, namely to traumatology, orthopedics and thoracic surgery, and can be used to prevent the damaging effects of stress-induced biologically active substances on the organs and systems of the body.

Known methods of anesthetic protection:

I group. General anesthesia with the use of drugs neuroleptanalgesia (NLA) and artificial lung ventilation (ALV) (fishchenko VA, 1982; Andrianov V.A. et al., 1985; Sobolev NS et al., 1991; Hilgenberg J.C., 1981; Malcolm-Smith N.A., Master M.J.,1983; Lauri A. et al., 1989). The following methods there are a number of disadvantages:

- development of sudden cardiovascular, metabolic and hormonal reactions;

- depletion of reserves of adaptation of the organism of the patient, the development of complications of the cardiovascular system, respiration, hemeostasis.

Group II. General anesthesia with the use of inhalation anesthetics in combination with drugs for NLA and IVL (Rose S. H. et al.,1997, Steven H.R, et. al., 1997).

This method of anesthesia with the use of inhalation anesthetics more manageable than total intravenous anesthesia (TBA), and allows you to achieve rapid and adequate recovery of consciousness and spontaneous breathing. The disadvantages include:

- arrhythmogenic effect inherent in many gas anesthetics;

- expensive nascop the exact breathing apparatus and gas analyzers;

- air pollution in the operating room;

- very high cost of modern gas anesthetics.

Group III. General anesthesia drugs NLA in combination with ketamine in conditions of mechanical ventilation on the background of the managed arterial hypotension or without (menyailov NV, 1982; Merova N et al., 1990,1996). These methods of General anesthesia with mechanical ventilation are not without clinically significant disadvantages. This includes:

- complexity, which is difficult to avoid polipragmazie;

- the necessity of using large total doses of narcotic analgesics and sedatives;

- manifestation premarketing, unwanted effects and consequences of the applicable funds;

- slow the exit of patients from narcosis and rapid cessation of anesthetic protection in the immediate postoperative period;

"breakthrough" protection, inadequate autonomic blockade (A. Dauphin, 1997; Aliyev O.M., 1990; Bromage P.R., 1967).

The above methods are not possible to use for anesthetic protection at the stage of unfolding collaborating lung.

Closest to the claimed method is Lebedeva MARINA. - "Anesthetic management of one-stage two-stage surgical correction of scoliosis" (dissertation on competition of a scientific degree of a Candida is and medical Sciences), developed in Novosibirsk research Institute of traumatology and orthopedics health Ministry.

The method consists in the following. Pretreatment and hold for 15-30 minutes before transporting the patient to the operating room. In the diagram, then use the Relanium dose of 0.2 mg/kg and diphenhydramine dose of 0.4 mg/kg, which is administered intramuscularly. The immediate preparation for the induction of anesthesia, a complete intravenous infusion of a solution of atropine at a dose that does not cause severe tachycardia (of 0.004-0.02 mg/kg). The induction of the anesthesia is performed by the administration of fentanyl at a dose of 0.002 mg/kg of thiopental sodium (2.5 to 1% solution, depending on the age of the patient) at a dose of 10 mg/kg After reaching a sufficient depth of anesthesia sleep enter ListenOn at a dose of 2.5-3 mg/kg and produce tracheal intubation. Immediately after intubation (before turning the patient in the desired operating position) bolus administered clonidine 0.01% solution at a dose of 0.4-0.5 mcg/kg Then carry out the laying of the patient in the desired operating position. Delegacia mechanical ventilation was carried out air-oxygen mixture with an oxygen content of 50%. The maintenance of General anesthesia is performed on the continuous background infusion of a solution of the hydrochloride dosing at the rate of 0.42±0,01 µg/kg/h; continuously introducing hypnoanalytic calypsol at the rate of 2.25±0.04 mg/kg/h on the background bolus Central analgetika fentanyl at a dose of 0.003±0.001 mg/kg/is. State total diplegia support arduinos at a dose of 0.03±0.01 mg/kg/h IVL exercise apparatus EVITA-2-DURA, working on the flow regime from a plateau on the inhale with Fi240%. Support moderate hyperventilation with ETA2exhaled air 31-35 mm Hg Feature of the proposed method of anesthetic management is conducting special preoperative preparation of patients (pyrogenes, vitamin E), and also due to use in anesthesia stress-protector hydrochloride to maintain a constant concentration in the blood by continuous infusion.

However, when using this method, it is necessary to prepare the patient by a threefold introduction of domestic polysaccharide drug pyrogenal according to the following scheme: for 72 and 48 hours before surgery pyrogenes injected at a dose of 0.5 mg/kg intramuscularly 24 hours before surgery pyrogenes injected at a dose of 1 mg/kg intramuscularly. In addition, 24 hours before the operation, enter the antioxidant vitamin E in a dose of 10 mg/kg intramuscularly. Within six hours after injection of pyrogenal produce control the body temperature of the patient. The way Lebedeva MARINA. provides protection from factors of surgical aggression at all stages of surgical intervention, however, to use it for protection at the stage of unfolding colaborando what about the light is not possible. In addition:

- preoperative preparation for 72 hours requires monitoring of the condition of the patient;

in the operational period, these doses do not allow for adequate and effective anesthesia;

- the level of neurohumoral insufficient protection for operations in traumatic injuries of the spine in adult patients;

- lack of adequate and effective protection of the most traumatic stage surgery.

Objective: to develop a way of effective damping factors Exo - and autoaggression at the stage of unfolding collaborating lung.

When the task has a positive therapeutic effect, which is to normalize blood glucose levels, homeostasis, vegetabilibus using drugs at stage surgery and immediate postoperative periods.

In addition:

- preliminary pre-operative preparation of patients using stress-protector clonidine;

- deepening the level of anesthesia during unfolding collaborating light;

exception induction emotional tension;

- prevention enable mechanisms of depletion of adaptive reserves of the body.

Higher protective capabilities predlagaemoj the way allow you to:

- to ensure the safety of operations ventral fusion of transthoracic and toracolumbalgia accesses;

- to maintain stable levels of blood pressure (blood pressure) and HR (heart rate) on the stages of the operational period, even in patients with complicated spinal injury;

- reduce the stress load on the patient, which helps to prevent intraoperative complications;

- eliminate the negative impact on the recovery of spontaneous breathing through intubation tube, postoperative condition of the patient;

- the use of metered-dose intravenous infusion of drugs increases the controllability of General anesthesia;

- use special preoperative preparation effectively increases the degree of protection of the patient from the surgical aggression that is expressed in reduction in metabolic and inflammatory reactions of the body, helping to reduce the frequency of complications on the stages of the operation and in the postoperative period;

- stability of the levels of markers of tissue metabolism remains within physiological norms, reflects the adequacy of anesthesia protection.

In addition, the proposed method is simple to perform and can be used in specialized hospitals. Its use is the use of different economic feasibility by reducing the frequency of postoperative complications and shortening of bed-days.

The problem is solved due to the fact that for 1.5-2 minutes before unfolding collaborating lung deepen anaesthesia administration of fentanyl at a dose of 10-12 μg per kg of body weight of the patient. In patients with complicated spinal injury impose additional ingitril - 45 UNITS. Deepening anesthesia is performed on the background of sedation Dimedrol - 0.3 mg/kg, 10 minutes before the induction of anesthesia is injected for 2 min a solution of hydrochloride in the dose 0,0034 µg/kg, begin continuous infusion of clonidine solution through DSW with speed 0,486 µg/kg/h; induction anaesthesia atropine to 0.007-0.01 mg/kg and fentanyl 2 µg/kg; the induction is performed by the introduction of thiopental sodium at a dose of 6.5 mg/kg; then enter Arduan dose 0,115 µg/kg, after the occurrence of adequate diplegia through 4.5 minutes produce laryngoscope and tracheal intubation; further sedation and peopleyou intraoperative achieve continuous infusion of ketamine - 2,82 mg/kg/h, ardoin - 0,033 mg/kg/h, mechanical ventilation through an endotracheal tube in mode IPPV with respiratory volume (UP)=60-80 ml/kg and respiratory minute volume (MOD)=80-100 ml/kg, Fi235% under control Sp2and EtC2.

The technical result is achieved due to the fact that during the unfolding collaborating lung spend prophylaxis aimed at addressing the Opera the ionic stress, as during the most traumatic stage in the bloodstream due to violations of the ventilation-perfusion relationship lungs accumulate acidic products of metabolism (cyclic nucleotide, biologically active substances), which in turn stimulates the sympathetic-adrenal system and, consequently, the release of catecholamines. Respiratory acidosis leads to glucose and reduced Kalemie. Stimulation of the release of hormones is estimated blood loss than traumatica operation, the higher the level of antidiuretic hormone.

The method is as follows: in the chamber for 30 min before the operation is performed premedication. In the scheme of sedation used intramuscular injection of demerol dose of 0.4 mg/kg of body weight of the patient. Transport the patient to the operating room. The original, on the operating table sets two systems into a peripheral vein via the catheter for infusion-transfusion therapy, and with a high degree of surgery and anesthetic risk dotted line in the subclavian vein.

To assess the condition of the patient during surgery and in the immediate postoperative period is mandatory monitoring of vital functions and modes conducted by IVL.

For the extended version of intraoperative monitoring, use the monitor, enabling visa is social control ECG (electrocardiogram), non-invasive measurement of systolic, diastolic and mean arterial pressures, check the level of blood oxygen saturation and registration ETA2peak pressure , compliance (distensibility of the lung tissue), % 02 on the inhale and the exhale, the level of utilization of oxygen ("CARDIOCAP - ULTIMA", "Cardiocap II - Datex - Finland). Control of neuromuscular conduction by the "TOF - WATCH (Netherlands).

A shortened version of monitoring includes measurement of blood pressure according to the method Korotkova, registration of heart rate and blood oxygen saturation.

The program anesthetic management with the use of clonidine for a period of 10 min before the induction of anesthesia is injected for 2 min a solution of hydrochloride in the dose 0,0034 µg/kg and begin continuous infusion of clonidine solution through the dispenser DSV-1 with a speed of introduction 0,486 mcg/kg/hour.

Induction: intravenous infusion of a solution of atropine at a dose that does not cause severe tachycardia (of 0.004-0.02 mg/kg), followed by the introduction of thiopental sodium (2.5 to 1% solution, depending on the age of the patient) at a dose of 6.5±0.5 mg/kg, fentanyl at a dose of 0.002 mg/kg After achieving sufficient depth medication sleep enter Arduan dose 0,115 mg/kg and 4-5 min produce tracheal intubation. Are laying the patient in the desired operating state is.

Maintenance of anesthesia is provided by a continuous infusion of a solution of the hydrochloride, which maintains an effective concentration of the drug in the blood. Begin the introduction hypnoanesthesia of ketamine through the dispenser DSV-1 without a loading dose in the dose 2,85±0.04 mg/kg/h Immediately before skin incision - fentanyl at a dose of 9-10 mg/kg and further bolus every 20 min fentanyl in Tempe 0,228±0.001 microg/kg/h (with somatic diseases correction dose is 10-15%). State total diplegia support arduinos dose 0,033±0.01 mg/kg/h On the main stage of surgical interventions hyperextension more correct medication is not required.

But for 1.5-2 minutes before unfolding collaborating easy side access is the infusion of fentanyl at a dose of 10-12 mg/kg, after which the introduction of the Central analgesic and ketamine after 10 minutes stop (if you do not want the continuation of surgical intervention).

IVL exercise apparatus TITUS or EVITA-2-DURA (firm "Drager"), working on the flow or volumetric respirator RO-6N mode nemovitosti, with concentration on the breath Fi235%. EtCO2support at 35 mm Hg

To assess the condition of the patient during surgery and in the immediate postoperative period of obazatel the NYM is the monitoring of vital functions and modes conducted by IVL.

The main principles for infusion-transfusion therapy during surgery - recovery of circulating blood volume (CBV), gas recovery possibilities blood, stabilization oncotic pressure, restoring the concentration of total protein and hemostatic potential of the blood. The volume and rate of infusion therapy are determined by the volume and rate of blood loss. When blood loss up to 10 ml/kg filling the BCC spend solutions of crystalloids (15-20 ml/kg, the following day 10-15 ml/kg) and colloids (Gamaches" in volume 5-12,5 ml/kg; "Poliglyukin", "Reopoliglyukin" 3-8 ml/kg). Blood loss in excess of 10 ml/kg, correction BCC carried out with the use of blood products (red blood cells and FFP). The volume of infusion therapy average of 10.0 ml/kg/h and exceed in total the amount of blood loss by 100-200%. Blood loss of more than 30% of BCC conducted a blood transfusion using erythrocyte mass up to 75% of the lost volume of erythrocytes and plasmatreeview using EWS in the amount of 50-90% of the volume plasmopara (average er-weight 4,8-5,5 ml/kg FFP of 5.3 to 6.2 ml/kg). Filling the BCC solutions of crystalloids (high in potassium to 1.6 g per 400 ml) 30-49 ml/kg, the following day 15-20 ml/kg; colloids: "Gamaches" in the volume of 10-25 ml/kg; "Poliglyukin", "Reopoliglyukin" 4-10 ml/kg of Adequatel the infusion therapy is evaluated on the basis of registration of hemodynamic parameters, blood cells, hemoglobin, potassium, glucose, albumin, hematocrit, monitoring of neuromuscular conduction and hourly urine output.

After the operation the patient is transferred to the intensive care unit in support of anesthesiologists, where they perform ventilation (on average within 1.5 hour), the monitoring and correction of volemic shifts and qualitative composition of the blood.

An example of the clinical use of the method.

Patient E. born in 1948 (54 years old) was admitted to the hospital of traumatology and orthopedics with a diagnosis of Chronic uncomplicated compressional wedge penetrating the broken body D12 p-ka. Post-traumatic kyphosis 18°.

Given the diagnosis at admission, the patient was planned operation: 1. Ventral bisegmental fusion D11-L1 p-Cove bisegmented indification and autograft of resected ribs, correction of kyphosis. 2. Transpedicular fixation D11-L1 p-ing.

During examination and history taking, the patient identified comorbidities: Chronic gastritis. Chronic cholecystitis. Kidney stones, the stone of the left kidney. Rheumatism? Arterial hypertension of II degree. Aortic regurgitation I-II degree, mitral regurgitation first degree. Allergic reactions when using any medication marked the but. Body weight 50 kg patient Blood pressure (BP) is 140/90 mm Hg Reasonably conduct total intravenous anesthesia in an artificial lung ventilation through an endotracheal tube. Anesthetic risk by ASA (American Sosiety of Anesthesiologi) IV degree.

The patient was performed following anesthetic manual:

The first step is pretreatment for 30 min before surgery solution Dimedrol 1%-2,0 intramuscularly.

In the operating room was performed following monitoring: ECG, HR, BP, systolic, BP, diastolic, and mean BP non-invasive method, Sp2, EtCO2. the rate of diuresis. Laboratory diagnostics: tests of cortisol, potassium, glucose, lactate and pyruvate, leukocytosis source on the main stage and 1 in the night.

HELL when entering the patient into the operating 153/87 mm Hg heart rate 88 beats per minutes Before induction of anaesthesia were preinfuse solutions of crystalloids in the amount of 600 ml with clonidine 0,01%-1,0 for 1.5 hour.

The second stage - tracheal intubation, sedation and diplegia. The patient laid on the left half-side with rollers under the buttocks and shoulder areas.

Anaesthesia induction: to prevent excessive vagusnye effect on the myocardium injected with a solution of atropine 0.1% to 0.7 and for pain relief during laryngoscopy and intubation - solution of fentanyl of 0.005% to 2.0.

Induction was carried out by introduction typint the La sodium 2,5% - 400 mg After administration of the relaxant of ardoyne 6 mg were mechanical ventilation via face mask under control Sp2. After the occurrence of adequate diplegia made laryngoscopy and tracheal intubation, begin ventilation through an endotracheal tube with D0=60-80 ml/kg and MOD=80-100 ml/kg, FiO250% under control Sp2and EtC2.

Further sedation and peopleyou intraoperatively was achieved by continuous infusion of ketamine 2,85±0.04 mg/kg/h, ardoyne 0,033±0.01 mg/kg/h fentanyl anesthesia in Tempe 0,228±0.001 microg/kg/h, the Duration of surgical intervention amounted to 5 h 20 min, the operation ventral fusion 2 hours 40 minutes

To deepen the level of anesthesia for 1.5-2 minutes before unfolding collaborating light entered fentanyl at a dose of 11 mg/kg

On the stages of surgical intervention indicators hemodynamics were stable. The AD ranged 112/61 - 94/67 mm Hg, heart rate 68 - 74 beats per minute, SpO2- 99-100%, EtCO234 - 35 mm Hg Total volume of infusion therapy in the perioperative period amounted to 2600 ml of crystalloids. Intraoperative blood loss was 650 ml after surgery the patient was transferred to the observation in the intensive care unit and intensive care.

On the background of reduced spontaneous breathing after 1 hour and 50 min after transfer to the intensive care unit on the background of pantanoso breath, recovered consciousness and muscle tone was extubate. Complications were not registered.

Proof of the adequacy of anesthesia protection can serve the following markers of severity of stress: cortisol on the main stage was higher from the original 13.2%at the stage of unfolding collaborating light drop of 2.1%. Glycemia compared with statistics decreased by 43.2% at stage lung straightening and was 4,19 - 6.8 mmol/L.

Thus, allowing the possibility of the proposed method anesthetic protection ensured the safety of the current operating period, to exclude possible hemodynamic disturbances to achieve adequate output from the anesthesia, which contributed to uncomplicated the postoperative period.

Literature

1. Andrianov V.L., Bayrou GA, Sadofyev VI, Raya RA Disease and injuries of the spine in children and adolescents. - 1985. - L., Medicine. 256 C.

2. Merova N, Kirilina SR, Krivoshapkin A.L., Lebedeva M.M., Smorodinov A.P., Kovalenko A.I. Anesthesia in surgical vertebrology //abstracts of the all-Russian scientific-practical conference: "problems of spine surgery and spinal cord". - 1996. - Novosibirsk. - S-122.

3. The menyailov NV Traumatology and Orthopaedics //Reference anesthesia is ohii and resuscitation. - 1982. - Moscow. - S-207.

4. Sobolev NS, dolecki A.S., Onuchin NB, Stroganoff I.A. Continuous intravenous fentanyl in multicomponent anesthesia in children //Anesth. and reanim. - 1991. No. 1. - P.58-59.

5. Fishchenko VIA Blood loss, its prevention and compensation operations on the spine in scoliosis //Orthoptera. Protter. - 1982. No. 2. - P.5-7.

6. Hilgenberg J.S. Intraoperative awareness during high-dose fentanyl-oxygen anesthesia//Anesthesiology. - 1981. - Vol. 54. - P.341-343.

7. Lauri A., Corbari M., Galli C., M. Marri Use of neuroleptoanesthesia for carrying out a Harrington intervention in a patient probably susceptible to malignant hyperthermia //Minerva Anestesiol. - 1989. - Sep., 55(9). - P.331-335.

8. Malcolm-Smith and Nigel A., Mc Master Michael J. The use of induced hypotension to control bleeding during posterior fusion for caused by //J Bone Joint Surg Br. - 1983. - Vol. 65-B. - N.3. - P.255-258.

9. Steven H.R., Elliot B.A., Horioker T.T. Anesthesia, positioning and postoperative pain management for spine surgery //The adult spine: principles and practice, 2ndedition. - 1997. - Philadelphia. - P.703-718.

1. Method anesthetic protection factors of surgical aggression by affecting the homeostasis of the organism, characterized in that for 1.5-2 minutes before unfolding collaborating lung deepen anaesthesia administration of fentanyl at a dose of 10-12 μg per kg of body weight of the patient.

2. The method according to claim 1, characterized in that in patients with complicated spinal injury impose additional ingitril 45 UNITS.

3. The method according to claim 1, characterized in that the deepening of anaesthesia performed on the face then Dimedrol - 0.3 mg/is g; 10 minutes before the induction of anesthesia is injected for 2 min a solution of hydrochloride in the dose 0,0034 µg/kg; start continuous infusion of clonidine solution through the dispenser DSV-1 with a speed of introduction 0,486 µg/kg/h; induction anaesthesia atropine to 0.007-0.01 mg/kg and fentanyl 2 µg/kg; the induction is performed by the introduction of thiopental sodium at a dose of 6.5 mg/kg; then enter Arduan dose 0,115 µg/kg; after the occurrence of adequate diplegia after 4.5 min produce laryngoscopy and tracheal intubation; further sedation and peopleyou intraoperative reach continuous infusion of ketamine - 2,82 mg/kg/h, ardoin - 0,033 mg/kg/h; mechanical ventilation through an endotracheal tube in mode IPPV, respiratory volume (D0)=60-80 ml/kg and respiratory minute volume (MOD)=80-100 ml/kg, FiO235% under the control of the SpO2and EtCO2.



 

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