Method for spinal anaesthesia in pregnant women suffering concomitant cardiovascular pathology

FIELD: medicine.

SUBSTANCE: spinal anaesthesia is followed by catheterisation of an epidural space at the level of L1-L2. The spinal anaesthesia is performed at the level of L4-L5 by administering 0.5% bupivacaine. Bupivacaine is administered in a dose of 5-6 mg if the pregnant woman's height is less than 165 cm, and the dose is 6-7 mg if the pregnant woman is from 165 to 175 cm high. After the local anaesthetic is administered into the epidural space, normal saline is introduced. If the intra-abdominal pressure is ≤16 cm H2O, normal saline 15 ml is administered; if the intra-abdominal pressure is 17-21 cm H2O, an amount of normal saline is 10 ml, whereas the intra-abdominal pressure of 22-28 cm H2O requires an amount of 5 ml.

EFFECT: performing the effective spinal anaesthesia combined with reducing a probability of hypertension by dilating the epidural space preliminary in accordance with the intra-abdominal pressure.

1 tbl, 1 dwg, 2 ex

 

The invention relates to medicine, namely to anesthesiology and intensive care, and ensuring spinal anesthesia during cesarean section in pregnant women with concomitant cardiovascular pathology.

One of the disadvantages of spinal anesthesia is hypotension that develops due to vasodilation in the area of sympathetic blockade [Malroi M. Local anesthesia: an Illustrated practical guide / TRANS. angl. S. A. Panfilov; under the editorship of Prof. S. I. Emelyanova. - M.: BINOM. Knowledge laboratory, 2003. - 301 p.]. Development of severe hypotension and even collapse threatens the life of the pregnant woman and the fetus. This circumstance is especially dangerous in pregnant women with concomitant cardiovascular pathology [Shifman E. M., G. V. Filippovich Spinal anesthesia in obstetrics / E. M. Shifman, and G. V. Filippovich. - Petrozavodsk: Intel Tech, 2005. - 558 p.]. It is known that the cranial spread of local anesthetic in the subarachnoid space is influenced by two important factors: the dose of local anesthetic volume and subarachnoid space. The use of small doses of local anesthetic can reduce the risk of hypotension, as is accompanied by its large breeding cerebrospinal fluid and decreased sympathetic blockade interneuronalic ties in gray substances�ve spinal cord, at the same time, the path of pain sensitivity, passing PA the surface of the white matter of the spinal cord, and are easily blocked. However, lower doses of local anesthetic often leads to the development of low sensory block, which reduces the quality of anesthesia for cesarean section [Areola, S. Efficacy of low-dose bupivacaine in spinal anaesthesia for Caesarean delivery: a systematic review and meta-analysis / S. Arzola, P. M. Wieczorek // British Journal of Anaesthesia. - 2011. - N 3. - P. 308-318].

As a prototype, the authors propose is described in the literature method of performing spinal anaesthesia [Anesthesiology and critical care medicine: textbook / Under the editorship of O. A. Valley. - M.: Medicine, 2002. - 544 p.: ill. - 363, 367-368]. The essence of this method consists in the following. At the level of L1-L2 is used to puncture the subarachnoid space and the introduction of 16 mg of local anesthetic (0.5% solution of bupivacaine).

This method of spinal anaesthesia for caesarean section has the following disadvantages.

1. This technique does not take into account individual anthropometric characteristics of the pregnant woman, such as height, weight and the amount of intra-abdominal pressure (IAP).

2. The introduction of 16 mg of bupivacaine often leads to high spinal block and 100% accompanied by hypotonia.

3. For the prevention and treatment of hypotension will inevitably have to use infusion therapy and injection of drugs adrenomimetics�of action (dopamine, phenylephrine) that pregnant women with concomitant cardiovascular pathology is desirable.

The authors propose a way of spinal anesthesia in pregnant women with concomitant cardiovascular pathology during cesarean section. The basis of the method is supposed to perform spinal anesthesia technique with the expansion of the epidural space (epidural introduction of physiological solution). Epidural a physiological solution is performed before spinal anesthesia, the volume of saline injected into the epidural space is calculated based on the value of IAP pregnant (table. 1). Because Pasha previous research has convincingly shown that the magnitude of IAP in pregnant women has a significant impact on the level of spinal anesthesia [RF Patent for the invention №2499554 of the Russian Federation, IPC A61B 5/103. A method of detecting the risk of a high spinal blockade in pregnant women during cesarean section / S. I. Sitkin, ronenson, A. M., J. V. Saveliev; GBOU VPO "Tver medical Academy". - Stated. 11.05.2012; Publ. 27.11.2013, bull. No. 33].

The essence of the method consists in the following.

Step 1. The definition of intra-abdominal pressure

In the operating room before spinal anesthesia pregnant, lying horizontally, is mounted in the bladder to�Teter the Foley and were produced urine in it. Then through the catheter into the bladder is injected 25 ml of 0.9% solution of sodium chloride. The walls of the bladder begin to perform the function of a passive membrane and serve as a conduit of intra-abdominal pressure, which allows to measure intra-abdominal pressure via a urinary catheter. Then the Foley catheter is connected to an empty system for intravenous infusion, which is raised vertically above the vagina of the patient (Fig. 1). The zero point is the level of the pubic symphysis. From this level with a ruler to determine the height of the vertical standing of the physiological solution in the system for intravenous infusion. This value corresponds to the level of intra-abdominal pressure (cm H2O).

Step 2. Catheterization of the epidural space

In the operating room under aseptic conditions in the sitting position of pregnant is the puncture of the epidural space at the level of L1-L2. To identify the epidural space, the method of loss-of-resistance. After confirming the correct location of the puncture needle through the lumen of a catheter. The catheter is pushed into the epidural space in the cranial direction 3 cm then the epidural needle is carefully removed, and the catheter is placed along the spine, and output in the subclavian region, fixing plaster all over.

Step 3. Performing spinal anaesthesia

Under aseptic conditions, in the sitting position of pregnant, is the puncture of the subarachnoid space at the level of L4-L5. After appearing in the pavilion needle transparent cerebrospinal fluid into the epidural catheter, the nurse-anesthetist injects saline in volume, depending on the magnitude of intra-abdominal pressure. Immediately after infusion of saline into the subarachnoid space to enter the local anesthetic solution (hyperbaric 0.5% bupivacaine). The dose of 0.5% of hyperbaric bupivacaine is 5-6 mg pregnant with growth of up to 165 cm and 6-7 mg with the height from 165 to 175 cm After subarachnoid injection pregnant immediately placed in the supine position to prevent leaking of hyperbaric solution in the sacral portion of the dural SAC.

The advantages offered by the author of the way of spinal anesthesia in pregnant women with concomitant cardiovascular pathology during cesarean section in relation to the prior art include the following.

1. The use of methods of expansion of the epidural space before performing spinal anesthesia warns him of possible fixation in the tissues of the spinal cord only at the lumbar level, and thus significantly increases the efficiency of spinal anesthesia.

2. This with�persons allows the complex to take into account the main factors that affecting the volume of the subarachnoid space (growth and intra-abdominal pressure).

3. This method allows to accurately calculate the volume of injected into the epidural space with saline solution on the basis of the IAP value.

4. This method of spinal anesthesia is not accompanied by hypotension, as a result of using low doses of local anesthetic (5-7 mg) does not develop sympathetic blockade.

The technical result of the proposed method is the possibility to use concrete, specific pre-dose saline is used to expand the epidural space, which increases the effectiveness of spinal anesthesia and minimizes the rate of development of hypotension.

This method of spinal anesthesia during cesarean section in pregnant women with concomitant cardiovascular pathology used in 24 women. The patients ' age ranged from 17 to 39 years.

Clinical example 1

Pregnant K. 18 (No. history With 05229) entered the Regional perinatal center 13.04.12 G. with a diagnosis of Pregnancy 37 weeks, congenital heart disease (corrected transposition of the great vessels with atrio-ventricular and arterial-ventricular discordantly). The WPW syndrome. Valvular stenosis of the pulmonary artery. Open oval window. Prolapse Mitra�professional valve II. State after radiofrequency ablation and pacemaker implantation. NC PA. EF=60%. Of cesarean section. Patient's height was 165 cm, IAP - 15 cm H2O. developed Under the table for the expansion of the epidural space was used 15 ml of saline. For spinal anaesthesia - 1.0 ml (5 mg) of 0.5% solution of marcaine (heavy) and 0.125 mg of fentanyl. The level of spinal blockade after 10 minutes reached Th 5-4. Lower blood pressure were noted.

Clinical example 2

Pregnant L. age 29 (No. history With 05703) entered the Regional perinatal center 21.05.12 with a diagnosis of Pregnancy 37-38 weeks, complicated obstetric history. Congenital heart disease: patent foramen ovale, PMK II., NC 0. Of cesarean section. Patient's height was 158 cm, IAP - 25 cm H2O. developed Under the table for the expansion of the epidural space was used 5 ml of physiological solution. For spinal anaesthesia - 1.0 ml (5 mg) of 0.5% solution of marcaine (heavy) and 0.125 mg of fentanyl. The level of spinal blockade after 10 minutes reached Th 4-3. Lower blood pressure were noted.

Method of spinal anesthesia in pregnant women with concomitant cardiovascular pathology by performing spinal anesthesia, ex�featuring the before spinal anesthesia is performed catheterization of the epidural space at the level of L1-L2, and spinal anaesthesia is performed at the level of L4-L5 by introducing a 0.5% solution of bupivacaine in a dose of 5-6 mg pregnant with growth of up to 165 cm, 6-7 mg with the height from 165 to 175 cm, before the introduction of local anesthetic into the epidural space is injected 15 ml of physiological solution in intra-abdominal pressure ≤16 cm H2O, 10 ml - when intra-abdominal pressure 17-21 cm H2O, 5 ml - when intra-abdominal pressure 22-28 cm H2O.



 

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