Method of carrying out retrobulbar anesthetics in case of cavity operations on eyeball

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used in anesthetics in carrying out cavity operations on eyeball. For this purpose 45-60 minutes before operation 2% solution of lidocaine or 0.5% solution of bupivacaine is introduced in volume from 4 to 5 ml.

EFFECT: method ensures adequate anesthetics and stable hypotensive effect due to introduction of anesthetic in large amount, eliminating at the same time compression of eyeball due to pre-anesthesia.

1 dwg, 3 ex

 

The invention relates to medicine, namely to ophthalmology, and can be used when performing abdominal operations for injuries of the eye, retinal detachment and glaucoma, extracapsular extraction and phacoemulsification of the cataract. In hypertensive patients, people with obesity, with the phenomena of stagnation in the pulmonary circulation, the anesthesia is of particular value.

Currently, due to the wide distribution of cases expulsive hemorrhage and intraoperative intraocular pressure (IOP), as well as the so-called "pseudoexfoliative" (seal eyes and grinding of the anterior chamber during surgery), development of methods of suppression "prolapse" erythrostoma aperture when performing abdominal operations is an important task.

A known method of suppressing "prolapse" erythrostoma aperture (i.e. extrusion of ocular contents) by performing endotracheal anesthesia due to the influence of muscle relaxants, when there is a complete relaxation of all muscles. Their application was given the opportunity to opt-out deep life-threatening level of anesthesia to ensure ideal relaxation of skeletal muscles, effectively use mechanical ventilation when performing anesthesia. Dose tracrium 0.3-0.6 mg/kg, administered intravenously, provides adequate myorelaxants is over 15-30 minutes Tracheal intubation is carried out through the 60-90 sec after its intravenous administration. To muscle relaxants are depolarizers muscle relaxants (succinylcholine) and nedepoljarizatsii (tubocurarine, Arduan, pavulon, tracrium). Depolarizers muscle relaxants act on the postsynaptic muscle membrane like acetylcholine. Nedepoljarizatsii muscle relaxants act as competitive antagonists of acetylcholine receptors. The disadvantage of this method is the need for General anesthesia, which lengthens the time of surgery and the rehabilitation of the patient, and increases the complexity of the method, because a full anesthesia often is the crowding of the patient's eye upward, as in physiological sleep, which is an additional technical difficulty operation. All muscle relaxants are a number of contraindications and side effects that affect the overall performance of the body.

A prototype of the proposed method retro-bulbar anesthesia is retro-bulbar block that runs directly on the operating table when you enter up to 3 ml of anesthetic (Krasnov M., Belyaev V.S. Guide eye surgery, 1988, p.36).

However, as practice shows, it is this method of anesthesia leads to the extrusion of ocular contents during surgery in some cases the x and associated complications (increased intraocular pressure, expulsive haemorrhage and pseudoexfoliative"). The drawback of this technique is the need for sedation (a combination of neuroleptic narcotic analgesic and tranquilizer). The older the patient, the more dangerous the introduction of such drugs because of possible complications.

The objective of the invention is to improve the efficiency and expand the functionality of the method of anesthesia.

This object is achieved by the proposed method lies in the following.

The essence of the method consists in carrying out retro-bulbar injection of anesthetic substance through the lower eyelid is not earlier than 45 minutes prior to surgery, is associated with the opening of the eyeball. Muscle relaxation can be achieved by using retro-bulbar anesthesia and akinesia circular muscles of the eye. But the result will be different depending on, whether made retro-bulbar anesthesia in advance or on the operating table. As practice shows, only one muscle relaxation achieved in the retro-bulbar anesthesia, it is not enough to achieve intraoperative hypotension. You must also exclude the effect of the compression in the eyes of the solution introduced anesthetic.

This is achieved by carrying out the retro-bulbar anesthesia in advance, before the patient is placed on h is th style unlike conventional retro-bulbar anesthesia. Studies have shown that after 45 minutes the liquid part of the anesthetic resolved that eliminates excessive pressure in the orbit on the eyeball and allows you to perform the surgery without intraoperative complications. Moreover, if during anesthesia occurred peribulbar hemorrhage, after 1 hour, the blood plasma is also reabsorbed (as shown by the data of computer tomography of the orbit), and it allows you to perform surgery the next day that psychologically easier for the patient.

It is made in advance anesthesia allows you to enter large (4-5 ml) volumes of anesthetic without embarrassment their eyes during the operation, unlike the prototype, when you enter 2-3 ml of anesthetic. Prior anesthesia eliminates the need to use acolapissa before surgery to reduce the amount of content the eye and the intraocular pressure by decreasing production of eye fluid and increasing its reabsorption. Thus, by the time the patient is directly on the operating table, it reduces intraocular pressure, eliminating the pressure of the eyelids and at the same time, comes complete analgesia. High quality made in advance anesthesia is especially important for patients with wounds of the eyeball with a pronounced Boletim syndrome, when entered on operation the m table anesthetic literally can squeeze eyes. Incoming patients with injuries of the eyeball, having emergency indications to operative treatment, is unlikely to go hungry in the last 3 hours, and then preparing for a General anesthesia is complicated. In such cases comes to the aid made in advance retro-bulbar anesthesia, allowing you to refer the patient to efficiently carried out by obezbolevaniem operating in 45 minutes.

Most surgeons, producing retro-bulbar anesthesia, adds its akinesia almost the thickness of a century, considering that the effect is achieved not only by acting on the branches of the facial (motor) nerve, but also by the impact on the sensitive part of the reflex arc, i.e. branches of the trigeminal nerve. With the proposed method, retro-bulbar anesthesia introduces a somewhat larger volume of anesthetic while in advance, so that he has time to diffuse to the ciliary ganglion, where neoresins nerve that provides the blockade of the latter, and, thus, the need for such akinesia disappears.

The method allows to achieve effectively the myorelaxation orbital part of the circular muscles of the eyes and eye muscles without the use of General anesthesia, and also to extend the functionality of the method by reducing intraocular pressure during surgery without use of the education of oculoplastic and consequently, to avoid a large number of intraoperative complications, including extrusion of ocular contents and prolapse erythrostoma diaphragm due to anaesthesia for 45 minutes - 1 hour before surgery, despite the larger amount of anesthetic (4-5 ml).

As a medicinal mixture for retro-bulbar block use anesthetic 0.5% bupivacaine. If you apply as an anesthetic net 2% lidocaine, but then we must remember that his action is complete within 2 hours. As well as the proposed method involves the tactics of waiting before surgery for 45 min - 1 hour, it should be remembered that the operation needs to be done in 1 hour - 1 hour 15 minutes. In case of any intraoperative complications can not stay within the allotted time. Therefore, depending on the estimated time of intervention is selected anesthetic (or their combination). So, you need to consider that anesthesia with lidocaine 2% departs within 2 hours, and bupivacaine 0.5% in one day.

In accordance with the invention, the retro-bulbar block is carried out for 45 min - 1 hour before surgery needle, 23-25 gauge length of no more than 31 mm in order to avoid puncture of the optic nerve. The patient is asked to look up. The deviation of the medial view can lead to the rotation of the optic nerve and blood vessels in the store is well intended trajectory of the needle and the damage these vessels with the ensuing consequences. The surgeon gives the needle perpendicular to the skin, gently pull the lower eyelid, the point corresponding to the border of the lateral and middle thirds of the eyelid edge, directly above the lower margin of the orbit. Next, the needle is directed backward parallel to the bottom wall of the socket, approximately 3.5 cm in depth "close" to the eye. After passing the end of the needle past the equator her eyes turn slightly upward until you feel resistance muscle fascia, while the eyeball is rotated slightly down. After passing through the muscle fascia of the eyeball returns to its original position. Enter 4-5 ml of anaesthetic mixture. The key right of the anesthesia is the pupil, extending on the eyes and ptosis "on the needle". The needle is removed and within 40-50 seconds to click on the eye in order to stop possible bleeding and facilitate the spread of the introduced mixture.

Applicants was performed computed tomography of the orbit, proving that the liquid part of the anesthetic reabsorbed and redistributed evenly in orbit for at least 45 min - 1 hour after the retro-bulbar anesthesia. And since 45 minutes for the operating table will not wait, retro-bulbar anesthesia should be done in advance.

The technique of computerized tomography of the orbit was included, inter alia, the following :

20 ml % lidocaine mixed with 0.5 ml of water-soluble contrast agent Omnipak (350 mg of iodine per ml) was injected in one case, 4 ml of the resulting mixture for 15, 30, 45, and 50 minutes to computerized tomography of the orbit, in another 5 ml of the mixture.

The invention is illustrated by the following specific example.

Example 1.

The Century patient, 76 years of age, medical history, No. 13834, enrolled in 1 CCH them.

N.I.Pirogov diagnosed with: Mature cataract of the left eye. The artiphakia right eye.

Visual acuity: OD 0.1 with Corr. Sph - 2.0 Diopters=0.2.

OS pr.l.certae.

The fundus of the eye: right eye - the optic nerve disc pale, clear boundaries, in the macular area - the redistribution of pigment, angiosclerosis, my left eye is not ophthalmoscopically.

Patient surgery extracapsular cataract extraction with IOL implantation+21 Diopters. 1 hour before the operation was performed retro-bulbar anesthesia with lidocaine 2% to 4 ml in accordance with the proposed method. The operation was successful. During the operation was not prolapse erythrostoma diaphragm, which allowed to perform an operation for 15 minutes by a standard method.

Examination after treatment:

Visual acuity: OD 0.1 with Corr. Sph - 2.0 Diopters=0.2.

OS=0.4 n/K.

The fundus of the eye: right eye - the state still on the left eye: optic nerve disc pale, clear boundaries, in the macular area - the redistribution of pigment, angiosclerosis.

The patient felt no pain during the operations and after discharge anesthesia 1.5 hours after surgery, expressed concerns, was pleased with the result of surgical treatment. On the second day of subjectively felt corneal suture.

Example 2.

The patient Including, 82 years, the case history No. 7050, enrolled in 1 CCH them. N.I. Pirogov diagnosed with the Subtotal hyphema, post-secondary Bossa terminal glaucoma of the left eye. Pain in the eye the patient was worried about during the month. From removal of the eyeball refused, insisting on conservative operations.

Visual acuity: OD 0.01 with Corr. Sph+11.0 Diopters-0.1; IOP=19 mm Hg

OS pr.l.incertae; IOP=48 mm Hg(maximum medication mode).

Left eye: eyelid oedema, severe congestive injection, corneal edema of the epithelium, a total hyphema, more deep superficial environment are not visible.

With the aim of relieving pain, lowering of intraocular pressure and preservation of the eyeball was a combined operation - irrigation of the anterior chamber, panretinal cryopexy, transscleral cyclotrimethylene and laser diode cyclotouriste. This operation is characterized by the fact that patients are very difficult to tolerate the interference due to cryopexy, taking muscles on the handle. As anesthesia for 1 hour before the operation was performed retro-bulbar anesthesia of the proposed method with bupivacaine 0,5% to 5 ml, the Patient did not experience pain during the por is conducting the operation. Anesthesia bupivacaine 0.5% is allowed to protect the patient during the day from postoperative pain due to inevitable after such interventions reactive hypertension. Such pain patients begin to feel, as a rule, one hour after the operation, when it starts to wear off the effects of lidocaine 2%.

Examination after treatment:

Visual acuity: OD 0.01 with Corr. Sph+11.0 Diopters=0.1; IOP=20 mm Hg

OS=pr.l.incertae; IOP=19 mm Hg(without drops).

The left eye at discharge: almost calm, transparent cornea, anterior chamber average depth of hyphema almost resorbed. For resorbed by lifemay viewed the opaque crystalline lens.

The patient does not experience pain, she was pleased that we were able to save the eye.

Example 3.

Patient K., 58 years old, medical history, No. 12855, enrolled in 1 CCH them. N.I.Pirogov diagnosed with immature cataract of the left eye. The artiphakia right eye.

Visual acuity: OD 0.6 n/a

OS 0.1 g/K.

The fundus of the eye: right eye - the optic nerve disc pale pink, clear boundaries, in the macular area - the redistribution of pigment, angiosclerosis on the left eye - the optic nerve disc pale pink, clear boundaries, in the macular area - the redistribution of pigment, angiosclerosis.

Patient surgery phacoemulsification cataract with corneoscleral tunnel with IOL implantation+20 Diopters in the left eye. It is known that corneoscleral the second tunnel subjectively harder tolerated by patients due to the increased sensitivity zone limb compared with the corneal tunnel. So 1 hour before the operation was performed retro-bulbar anesthesia with bupivacaine 0,5% to 4 ml by the method described above. The operation was successful. During the operation was not prolapse erythrostoma diaphragm, which allowed to perform an operation for 15 minutes by a standard method.

Examination after treatment:

Visual acuity: OD 0.6 n/K.

OS-0.9 n/K.

The fundus of the eye: both eyes - condition still.

The patient felt no pain during the surgery and after termination of anesthesia (24 hours), was pleased with the result of surgical treatment.

The number of operated patients, which when executed various intraocular operations, in particular, extras and intracapsular cataract extraction, phacoemulsification cataract, sinustrabeculectomia, non-penetrating deep sclerectomy was applied the proposed method of anesthesia is 300 patients. When the operation is performed in all the patients showed prolonged analgesic and hypotensive effects, there were no side effects, both during surgery and in the postoperative period. However, most importantly, there was no case expulsive hemorrhage and pseudoexfoliative"that lipsy again proves the importance of retro-bulbar block in advance, pozvoljajushej is to avoid "prolapse" erythrostoma diaphragm and associated most intraoperative complications (after the vitreous body, expulsive haemorrhage and pseudoexfoliative haemorrhage). Prolonged analgesic effect in the postoperative period continued during the first days after the operation due to the use of marcaine (0,5% bupivacaine). In the absence of the need for long-term analgesic effect in the postoperative period (traditional cataract and glaucoma) anesthesia enough to hold lidocaine 2%.

The way of retro-bulbar anesthesia during abdominal operations on the eyeball, characterized in that as an anesthetic inject 2% lidocaine or 0.5% solution of bupivacaine, while the anesthetic is injected in a volume of 4 to 5 ml for 45-60 min before surgery.



 

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