Method for giving anesthesia in carrying out surgical treatment of lumbosacral vertebral column segment diseases and injuries

FIELD: medicine.

SUBSTANCE: method involves applying fractal introduction of 0.2 mg/kg MT calypsol and 0.4 mcg/kg MT fentanyl every 10 min during operation. Additional local spinal cord root irrigation with 2% lidocaine solution at maximum traumatic operation moment.

EFFECT: enhanced effectiveness of treatment; preserved spontaneous patient respiration.

1 tbl

 

The present invention relates to medicine, namely to anesthesiology, neurosurgery, traumatology and orthopedics, and can be used in surgical treatment of diseases and injuries of the lumbar-sacral spine.

Known methods of anesthesia in surgical treatment of discogenic sciatica, including the introduction of estimated doses of anesthetic drugs in the epidural space. The most common among them is the way extended epidural anesthesia with the installation of an epidural catheter and the use of local anesthetics (marcain, lidocaine) in pure form and in combination with opioid analgesics (morphine, fentanyl) and adrenopause means (adrenaline, clonidine). According to the authors this method of anesthesia provides a high level antinociceptive patient protection during removal of an intervertebral hernia (1).

Closest to the proposed method is General anesthesia with the use of intravenous anesthetics and narcotic analgesics and controlled breathing on the background of total diplegia, the essence of which is as follows: before surgery, patients receive intramuscularly tranquilizers, analgesics in calculated doses. 40 minutes before the start of the operation, the treatment includes the required dose of tranquilizers, analgesics, antihistamines, antipsychotics, in the absence of contraindications atropine. All drugs are administered intramuscularly. Induction in anesthesia includes one or, more often, a combination of several General anesthetics and analgesics. Usually for induction use these drugs and their combinations, as thiopental sodium, sibazon, sodium oxybutyrate, Diprivan, calypsol. Among narcotic analgesics, used as a component of induction, use fentanyl, morphine. Optionally, the induction include neuroleptics, subpractices dose of non-depolarizing muscle relaxant. Upon reaching the desired level of anesthesia, after the introduction of the estimated doses depolarizing relaxants, perform tracheal intubation and begin artificial respiration. IVL is carried out in the regime of moderate hyperventilation breathing apparatus oxygen-air mixture. Ventilation parameters (tidal volume and minute ventilation) is calculated according to standard formulas and nomograms. After that make laying the patient on his side in the operational position and start the operation. Maintain a surgical level of anesthesia and diplegia needed to adapt with the ventilator, is achieved by intravenous maintenance doses of General anesthetics and narcotic analgesics (fentanyl, morphine, morph is n), nedepoliarizuth relaxants. According to literature data, the described method is most widely used for removal of intervertebral hernias (2).

However, the methods of anesthesia in operations about the DPCR not without significant shortcomings.

Estimating how extended epidural anesthesia with local anesthetics, opioid analgesics, the authors show that features perform this spinal surgery (lateral position of the patient on the operating table, opening the spinal canal, irrigation of the wound, the use of aspiration) often hinder the maintenance of epidural blockade additional introduction of anesthetic through the epidural catheter. In addition, the anatomical features of the spinal structures, typical for patients with DPCR, such as a narrow spinal canal, adhesive epidural various origins, the presence of varicose veins in the epidural space can cause difficulties in the formulation of the epidural catheter, the development of incomplete blockade (mosaic, one-sided), perforation veins with bleeding. Significant is the risk of developing high spinal blockade in case of accidental damage to the Dura mater in the process of puncture and catheter was inserted, and during the operation, and ve is aatest systemic toxic effects used large doses of anesthetic drugs (3, 4).

On the other hand, the method of General anesthesia with the use of anesthetics and narcotic analgesics in combination with a controlled breath against the background of total diplegia characterized by aggressiveness associated with medical complexity, and using hardware IVL. According to literature data anesthetic manipulations associated with the IVL (laryngoscopy, tracheal intubation), differing pronounced reflexologist, often more than very aggressive surgical intervention and can be a source of complications, first of all, the organs of the cardiovascular system. There is also the risk of complications traumatic nature (broken teeth, dislocation and fracture of the mandible, fractures and injuries of the mucous membrane of the mouth, tongue, epiglottis, vocal cords, and others) and the development of hypoxia in the event of technical difficulties with intubation. Volume IVL always leads to impaired ventilation-perfusion relationships, which are exacerbated by the position of the patient on the side. As a result of this increased physiological dead space and shunting of blood from right to left, increased alveolar-arterial gradient for oxygen. Monotonous tidal volume contributes to the flow of air in the same most races is Jaimie parts of the lungs. In these conditions increases the risk of barotrauma alveoli, and in less tensile plots show a tendency to atelectasia. The introduction of muscle relaxants for the adaptation of the patient with the ventilator increases the pharmacological activity and may cause specific complications associated with their use (bradycardia, increased intraocular pressure during anesthesia; myalgia, prolonged or repeated apnea in the postoperative period). The authors also describe a large number of complications extubation trachea, which may reduce the postoperative period(5, 6, 7).

Proceeding from the known level of technology of anesthesia in surgical treatment of diseases and injuries of the lumbar spine, correct existing deficiencies, the task was: to improve the effectiveness of anesthesia, to reduce his aggressiveness.

The problem is solved as follows:

Anesthesia in surgical treatment of diseases and injuries of the lumbar spine performed by intravenous anesthetics, narcotic analgesics and sedatives. New in the solution of the problem is that General anesthesia is performed with preservation of spontaneous breathing of the patient fractional introduction of 0,2 mg/kg of MT calypsol and 0.4 g/kg MT of fentanyl every 10 minutes on the background of deep sedation, the most traumatic moment of operation is conducted additionally local irrigation of the root of the spinal canal with 2% lidocaine solution.

Explain any significant distinguishing features of the proposed method of pain relief:

The General anesthesia on the background of preserved spontaneous breathing of the patient provides a significant reduction of pharmacological and reflex aggressiveness, eliminates the risk of various complications associated with the use of artificial ventilation of the lungs.

Fractional introduction of 0.2 mg/kg of MT calypsol and 0.4 g/kg MT of fentanyl every 10 minutes during operation helps to ensure a continuous high level of analgesia.

Execution at the most traumatic time of surgery supplemental irrigation of the root of the spinal canal with 2% lidocaine solution is needed to enhance the analgesic effect of anesthesia and maintenance of the depth of anesthesia at a level not inhibitory function of the respiratory system.

The essence of the method of anesthesia in operations about the DPCR is as follows:

Before the operation on the night assigned to individual doses of tranquilizers, analgesics. 40 minutes before the operation intramuscularly sibazon (0.14 mg/kg), droperidol (0.06 mg/kg), morphine (0,3±0.06 mg/kg). If the General condition of the Bo is inogo aggravated hypertension, to avoid Pressor reactions in the premedication include clonidine in individually selected dosage.

Anesthesia start with a sibazona and droperidola titration method before the expressed sedative effect, on average, 0.3 mg/kg MT and 0.03 mg/kg MT, respectively. Immediately before the incision is injected dose of fentanyl and calypsol, twice used in the future to maintain analgesia (0.8 g/kg MT and 0.4 mg/kg MT, respectively). Prevention respiratory depression all drugs injected slowly. Also, before you cut administered thiopental sodium at a dose of 1-2 mg/kg MT. Further anesthesia support fractional introduction subarcticus doses of fentanyl (0.4 g/kg MT) and calypsol (0.2 mg/kg MT) after 10-15 minutes and add the calculated doses sibazona and thiopental - 0.1 mg/kg/h and 3.3±1.4 mg/kg/h, respectively. In the most traumatic moment of operation (meningoradiculitis) is the local irrigation spine 2% lidocaine solution. In the postoperative period, rapid and smooth recovery from anesthesia, after an average of 5-15 minutes after the end of the operation.

The effectiveness of anesthesia during operations is confirmed by the concentration of cortisol and glucose, reflecting the functional state of the sympatho-adrenal and hypothalamic-pituitary-adrenal systems, to the which did not exceed the bounds of physiological norm, lack giperdinamicheskim reactions circulation, reducing the need of oxygen, a moderate increase in amplitude photoplethysmogram during the operation. The physiological level of saturation of hemoglobin with oxygen and stable frequency and depth of respiration was maintained at all stages of the operation. We have not registered the decrease of the level of the original proteinemia in the postoperative observation period. Moderate depression indicators of immunity observed in the first days after the operation, tends to a speedy recovery.

Comparison of some of the investigated performance metrics antinociceptive protection when using the combined endotracheal anesthesia with artificial ventilation of the lungs and total intravenous anesthesia with preserved spontaneous breathing patients and local irrigation rootlets of the spinal cord with 2% lidocaine solution presented in the table.

Table
IndexThe type of anesthesiaThe stages of an operation
IIIIII
Glycemia (mmapi×l-1),KEN (n=25)3,98±0,654,79±1,05 6,68±3,6*
M±mTION (n=25)4.26 deaths±0,564,67±0,84,86±0,79
Cortisolemia (nmol×l-1) P50KEN (n=25)259,95 (137,5;341,3)379,21 (is 171.3;488,2)to 526.4 (281,3;725,4)*
(R25; P75)TION (n=25)245,9 (131,2;290,9)184,5 (50,9;182,6)*149,6 (50,0;156,3)*
GARDEN×HRKEN (n=25)7603,2±041,09172,7±1725,3*8268,5±1883,9*
TION (n=25)8868,4±1429,48638,5±1307,27037,9*1089,3*
*- p<0.05 compared with baseline indicator

Thus, when conducting total intravenous anesthesia using the proposed methodology was not observed significantly increased levels of blood glucose and cortisolemia unlike the comparable way that indicates the absence of activation of the sympatho-adrenal and hypothalamic-pituitary-adrenal systems. Against the background of total intravenous anesthesia was significant reduction in demand of oxygen (GARDEN×heart rate (HR), which confirms the absence of stress the cardiovascular system. The data presented testimony is t o a higher degree antinociceptive protection of patients in terms of the proposed method of anesthesia during operations removal of intervertebral hernias.

The essence of the proposed method is illustrated by a clinical example:

Patient M., aged 47.

Diagnosis: DPCR, herniated disc L4-L5, the expressed painful syndrome. Concomitant diagnosis: hypertensive heart disease, stage I Chronic simple bronchitis, remission stage. Varicose disease.

09.02.2001) underwent operation hemilaminectomy L4, removal of herniated disc L4-L5. The duration is 1 hour and 10 minutes, the duration of anesthesia is 1 hour 25 minutes. With sedation for 40 minutes before surgery intramuscularly entered: sibazon 0.14 mg/kg MT, diphenhydramine 0.14 mg/kg MT, promedol 0,29 mg/kg MT, droperidol 0.04 mg/kg of MT. Held total intravenous anesthesia, which included the introduction of fentanyl 0.4 g/kg and calypsol 0.2 mg/kg every 10 minutes during operation, local irrigation naked spinal spine 2% solution of lidocaine on the background of sedation by sibazon 0.1 mg/kg/hour and thiopental sodium 3 mg/kg/hour.

During anesthesia and surgery were observed stable hemodynamic parameters, adequate spontaneous respiration with NPV: 18-14-15-16 per minute, which supported the saturation of hemoglobin with oxygen in the background insufflation of oxygen via nasal cannula (V - 3 l/min) on the numbers: 97%-97%-99%-98%. The amplitude of the PPG had a significant tendency to increase towards the end of the operation.

Indicators analgesic effect were as follows: glycemia - 3,5-4,7-4,8 (mol/l), cortisol is s - 236,2-418,3-491,3 (nmol/l). The index of resistance of the organism studied before surgery, on the first day and on the 10th day after the operation was changed as follows: 0,29-of 0.16 to 0.75. The level of proteinemia to 10-day postoperative period was decreased compared with baseline, but did not go beyond the limits of normal values (83,9 and of 68.8 g/l).

Blood loss during operation was 320,0, diuresis - 190,0, the volume of the intravenous indusia - 800,0 (crystalloids). Awakening after 12 minutes after the operation. The postoperative period without features. The patient was discharged on the 21st day of recovery.

Thus, the Method of anesthesia in surgical treatment of discogenic sciatica allows comparison with other known methods of anesthesia to avoid reflex aggressiveness anesthesia while maintaining an effective level of antinociceptive protection of patients.

Sources of information

1. Solenkova A.V., A. Lubnin Ceneviva J.V. Epidural anesthesia during surgery on the spine and spinal cord // Anestesiol. and Reanimator. - 2000. No. 4. P.27-37.

2. Management in anesthesiology. Volume 1: St. from English. / Edited Aretested, Gsmit. - M.: Medicine, 1999. - S-432.

3. Arrests OG, Solenkova A.V., A. Lubnin Features of epidural analg the Ziya deleting hernias lumbar intervertebral disks // Questions of neurosurgery them. And operated. - 2000. No. 1. - S-15.

4. Jedward Morgan Jr., Magid Smichael. Clinical anesthesiology:book 1-I/Translated from English. - M - SPb.: Publisher BINOM Nevsky Dialect, 1998.-S-314.

5. Lebedinsky K.M. Anesthesia and systemic hemodynamics. - SPb: Man, 2000. - P.65-90.

6. Kassil V.L. mechanical ventilation in the intensive care unit. - M.: Medicine, 1987. - P.32-47; 161-171.

7. Management in anesthesiology. Volume 1: St. from English. / Edited Aretested, Gsmit. - M.: Medicine, 1999. - S-429.

The method of anesthesia in surgical treatment of diseases and injuries of the lumbar-sacral spine, including intravenous anesthetics, narcotic analgesics and sedatives, characterized in that General anesthesia is performed on the background of preserved spontaneous breathing of the patient fractional introduction of 0.2 mg/kg of MT calypsol and 0.4 g/kg MT of fentanyl every 10 min during the operation, while in the most traumatic moment of operation additionally produce local irrigation spine spinal canal 2%lidocaine solution.



 

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