Method for retrobulbar anaesthesia in vitreoretinal surgeries

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely anaesthiology in ophthalmosurgery, and may be used in vitreoretinal surgeries, including those terminated by the stage of introducing silicone oil. For this purpose, 40-45 minutes before the operation, the retrobulbar introduction of a mixture of 2% lidocaine and 0.75% ropivacaine in proportions 1:1 in the amount of 4-5 ml is prescribed. It is followed by the intraoperative intravenous titration introduction of 0.01% nitroglycerine starting with 1 ml 1-2 minute before the introduction of silicone oil in response to a surgeon's signal. The nitroglycerine introduction is terminated when patient's systolic blood pressure becomes lower than the initial values by 10-20%.

EFFECT: method provides adequate anaesthesia combined with a reduced risk of developing complications due to blood pressure correction at the specific stage of surgery.

1 ex

 

The invention relates to medicine, namely to anesthesia in ophthalmic surgery, and can be used when performing vitreoretinal surgery, which ends with the introduction in the vitreous cavity silicone oil.

Basically vitreoretinal surgery completed by the introduction of silicone oil in the case of retinal detachment, severe diabetic retinopathy, an eye injury. Anesthesia, which is used in these operations can be as General (RF patent No. 2304963 - development of our authors), and local - retro-bulbar. It depends on the presence and severity of comorbidity.

Our invention is intended for the vitreoretinal surgery that can be performed using the retro-bulbar anesthesia.

Traditional vitreoretinal surgery today is the following. Operation begins with the execution of the 3-port vitrectomy, for example 25G, including destruction of the posterior hyaloid membrane. Removal of the vitreous body (ART) is accompanied by a gradual introduction to retrochallenge space liquid performancesthe compounds (PFOS). It should be recalled that the very vitreous body when it is removed is replaced with a saline solution, such as balanced salt solution (BSS), and then the solution is exchanged for PFOS. As the filling of VI the real cavity PFOS is the removal of epiretinal membranes. Each subsequent introduction of PFOS is carried out only after complete removal of epiretinal membranes at this level. If you cannot complete mobilization of the retina is the laxative retinotomy or retinectomy. After filling all vitreal cavity liquid PFOS is endolasercoagulation of the retina. At the end endolaser coagulation is the simultaneous exchange of liquid PFOS in silicone oil. After the exchange of PFOS in silicone oil, is sealing scleral and conjunctival incisions.

There is a method of conducting a retro-bulbar anesthesia during abdominal operations on the eyeball, including about retinal detachment, eye injuries, etc. (RF patent No. 2400260 - prototype). Essence of anesthesia is that as an anesthetic inject 2% lidocaine or 0.5% solution of bupivacaine, while the anesthetic is injected in a volume of 4-5 ml for 45-60 minutes before the operation.

The disadvantages of the method. Vitreoretinal surgery is a relatively long operation and requires some adjustments concerning the anesthetic. The only use of lidocaine 2% - not enough time effects in vitreoretinal surgery. Regarding the solution of bupivacaine 0,5% there are a number of alarm messages, and one of them is random vascular introduction bupivacaine is 0.5% of the causes of ventricular fibrillation and is accompanied by intense cramps; there are also more serious confirmation cardiotoxicity of bupivacaine (http://medi.ru/doc/8100304.htm). Also during surgery vitreoretinal surgery, using the described retro-bulbar anesthesia, it is often difficult to prevent bleeding of blood vessels in the retina at the stage of replacement of PFOS in silicone oil (due to the differential pressure in the vitreous cavity). If bleeding has occurred, it is technically difficult to remove the blood in such a situation, it is also ineffective to coagulate the blood vessels in the environment of silicone oil. The ingress of blood into the cavity of the ARTICLE in the postoperative period causes earlier emulsification of the oil, which would require premature removal.

The objective of the invention is to develop a reliable method of retro-bulbar anesthesia guarantee vitreoretinal interventions, ending with the introduction of silicone oil, without intraoperative complications during introduction of the silicone oil and the maximum physical comfort for the patient during surgery and in the postoperative period.

The technical result is reduced risk of operative and postoperative complications, provided physical comfort for the patient, there are no negative aspects inherent to General anesthesia.

This technical result can be obtained if in the way of retrobulbar the nuclear biological chemical (NBC anesthesia during abdominal operations on the eyeball, consisting in the preoperative introduction of anesthetic in the volume of 4-5 ml, as an anesthetic, a mixture of 2% lidocaine and 0.75% solution of ropivacaine in the ratio of 1:1, the mixture is injected for 40-45 minutes prior to surgery and during surgery for 1-2 minutes prior to the introduction of the silicone oil on the signal surgeon intravenously by titration, starting with 1 ml injected with 0.01% solution of nitroglycerin and stop typing when systolic blood pressure of the patient becomes lower than the initial 10-20%.

Among the essential features that characterize the way, distinctive are:

- as an anesthetic, a mixture of solutions of 2% lidocaine and 0.75% of ropivacaine in the ratio of 1:1;

- the mixture is injected for 40-45 minutes before the start of operations;

- during the operation signal surgeon for 1-2 minutes prior to the introduction of the silicone oil injection titration, starting with 1 ml injected with 0.01% solution of nitroglycerin;

and stop to enter the solution of nitroglycerin, when systolic blood pressure of the patient becomes lower than the initial 10-20%.

Between the set of essential features and the claimed technical result, there is a causal relationship.

For anesthesia is suggested to use a mixture of solutions of 2% lidocaine and 0.75% of ropivacaine in the ratio of 1:1. There is generally time-one of the lidocaine is not enough for long vitreoretinal surgery, and bupivacaine used in the prototype has a toxicity index higher than that of ropivacaine, although the duration of exposure they have the same 8-12 hours. Therefore, choose a mixture of solutions of 2% lidocaine and 0.75% of ropivacaine in the ratio of 1:1, received the necessary characteristics anesthetic for a successful vitreoretinal intervention. This retro-bulbar anesthesia is performed before the operation for 40-45 minutes. It is made in advance anesthesia allows you to enter large amounts of anesthetic (4-5 ml) without embarrassment their eyes during surgery. When this pre-introduction of anesthetic in larger quantities allows us to provide complete analgesia throughout long vitreoretinal surgery, and within a few hours after its completion.

All operations for which they are intended retro-bulbar anesthesia, mean at the final stage of the operation the introduction of silicone oil in the vitreal cavity and leaving it in the cavity of the eye for a long time. During the operation, at the stage of replacement of PFOS silicone oil, there is a pressure drop in the cavity of the ARTICLE, that there is bleeding from the vessels of the retina (krovat vessels that have been damaged when removing membranes or perform retinotomy, especially in the areas of retinal edema). The reason re is hell pressure is his eyes opened and the system is open-loop. When the hollow ARTICLE is PFOS, continues the supply of BSS in the vitreal cavity, and pressure (Bank solution is raised). As a result, in vitreal cavity of PFOS and BSS pressure on the blood vessels of the retina with the force, not allowing the blood vessels. And once you start to enter a silicone oil, replacing PFOS (the filing BSS stops), the pressure in the cavity of the ARTICLE is reduced (note that the open-loop system) and, as a consequence, there is bleeding from the blood vessels into the vitreous cavity.

The resulting solution was found to decrease at the time of introduction of the silicone oil system the blood pressure of the patient. In this case you need a drug that should metered time and power to lower blood pressure and then quickly return to the original pressure, and with it, a cheerful state of the patient after surgery. As this drug is selected 0.01% solution of nitroglycerin, which can be administered intravenously. The effect occurs within 1-2 minutes and lasts 15-20 minutes (silicone oil is injected 10-15 minutes). Enter solution nitroglycerin slowly, by titration, starting with 1 ml, and stop typing when systolic blood pressure of the patient becomes lower than the initial 10-20% (from our experience we see that the volume of injected solution nitroglycerin what is 1-4 ml). Practice has shown that, by reducing short time systolic blood pressure of the patient by 10-20% during the introduction of the silicone oil, the pressure drop is avoided, and the bleeding vessels in the vitreal cavity does not occur.

The method is as follows.

Beginning operations traditional sedation (intravenous morphine in a dose of 0.2 mg/kg, suprastin dose of 0.25 mg/kg).

For 40-45 minutes prior to surgical vitreoretinal surgery, the patient with a needle, for example, 23 gauge, is retro-bulbar anesthesia. As the anesthetic takes a mixture of 2% lidocaine and 0.75% solution of ropivacaine in the ratio of 1:1, the volume of 4-5 ml after 40-45 minutes start to vitreoretinal surgery according to the classic technology - in 3-port access. When the surgeon came up to the stage of introduction of silicone oil (butter substitute PFOS), for 1-2 minutes, he informs the doctor-anesthesiologist. Immediately to the patient intravenously injected with 0.01% solution of nitroglycerin and injected slowly by titration (i.e. the gradual addition of a volume controlling pressure), starting with 1 ml. That is injected and measured pressure. If systolic blood pressure of the patient becomes lower than the initial 10-20%, this means that the number of injected solution nitroglycerin enough, it immediately Ave is krasuetsa. The surgeon proceeds to the exchange of PFOS in silicone oil. When the oil completely fills the ARTICLE, stitched on the sclera and the conjunctiva. Silicone oil is securely tympanium the retina by blocking the blood vessels. This operation was completed.

EXAMPLE. Patient L. 29 years. Did 17.02.2011, with the diagnosis of proliferative diabetic retinopathy severe stage, recurrent full hemophthalmus right eye, proliferative diabetic retinopathy developed stage left eye. Two months ago there has been a sharp reduction of the right eye, took a course of conservative therapy over the case with a slight improvement in visual acuity.

Admission: visual acuity of the right eye - right projection light, the intraocular pressure of 15 mm Hg Anterior segment of the eye within the normal range, blood in the cavity of the ARTICLE, the fundus of the eye is not ophthalmoscopically. According to the U.S.: intense opacification in the posterior part vitreal cavity, flat traction retinal detachment in the course of the vascular bundles.

The patient took vitreoretinal surgery of the right eye.

Sedation: morphine at a dose of 0.2 mg/kg, suprastin dose of 0.25 mg/kg (intravenously).

Retro-bulbar anesthesia was performed for 40 minutes prior to the start of the operation and as an anesthetic used a mixture of 2% lidocaine and 0.75% solution of ropiak is in the ratio of 1:1, in a volume of 5 ml

The operation consisted of a 3-port vitrectomy, the introduction of PFOS unfolding of the retina, removal of epiretinal membranes, endolaser coagulation of the retina, the replacement of PFOS in silicone oil. 2 minutes prior to the introduction of the silicone oil on the signal surgeon intravenously by titration introduced a 0.01% solution of nitroglycerin in a volume of 2 ml (volume of 2 ml systolic blood pressure of the patient was lower than the initial 18%; blood pressure prior to introduction of the solution nitroglycerin - 135/85 and after injection of 2 ml was - 110/80). Then the surgeon began to exchange PFOS in silicone oil. The introduction of silicone oil is successful, bleeding from retinal vessels were observed. The surgery is completed by suturing to the sclera and the conjunctiva. After 5 minutes, the blood pressure of the patient returned to the initial - 135/85. The operation lasted 1 hour and 20 minutes.

Throughout the course of the operation during anesthesia smooth (confirmed by the data monitor, allowing the surgeon to perform all phases of vitreoretinal surgery successfully. The patient was in maximum physical comfort both during surgery and in the postoperative period.

During the inspection the next day retin-adjoined, edema in the macula; acuity of 0.02 with correction; IOP of 18 mm Hg Optical medium pet is acnee; in the vitreal cavity silicone oil, no blood.

When viewed through 3 months - retin-adjoined, acuity of 0.1 with correction. Silicone oil remains in the cavity of the ARTICLE to complete resorption of edema of the retina.

In Yekaterinburg Centre of IRTC "eye microsurgery" operated 39 patients with vitreoretinal pathology with the use of retro-bulbar anesthesia according to the invention. In all cases, the anesthetic manual has proven to be a reliable, managed, allowed to carry out the operation and provided reliable hemostasis. Pain, nausea and vomiting in the postoperative period was absent, the patient felt well and after 4 hours after surgery could eat.

The way of retro-bulbar anesthesia during abdominal operations on the eyeball, consisting in the preoperative introduction of anesthetic in the volume of 4-5 ml, characterized in that as an anesthetic use a mixture of 2% lidocaine and 0.75% solution of ropivacaine in the ratio of 1:1, the mixture is injected for 40-45 minutes prior to surgery and during surgery for 1-2 min before the injection of silicone oil on the signal surgeon intravenously by titration, starting with 1 ml injected with 0.01% solution of nitroglycerin and stop typing when systolic blood pressure of the patient hundred is ulitsa below source 10-20%.



 

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