Method of anaesthetics and prevention of inflammatory complications after median sternotomy

FIELD: medicine.

SUBSTANCE: after performing median sternotomy pericardial and mediastinal drainages are installed and sternum is sutured. After suturing sternum for length of its entire front surface, catheter is installed through skin counterpuncture, with 1.0-2.0 cm indent from lower wound edge. proximal end of catheter is fixed to subcutaneous-adipose cellular tissue with absorbable suture material, and distal part of catheter with cannula is fixed by suturing to skin with non-absorbable suture material. Local anaesthetic is introduced through installed catheter every 6 hours, with antibiotic being introduced every 8 hours. Introduction of medications is performed for 3-5 days.

EFFECT: method provides effective anaesthetics with simultaneous drainage of front sternum surface and skin wound due to introduction of anaesthetics and antibiotics via catheter into said zone, which additionally reduces quantity of exudative inflammatory complications in post-operative period.

2 dwg, 1 ex

 

The invention relates to medicine, namely to anesthesiology and surgery, and can be used for analgesia and prevention of inflammatory complications in the postoperative period in patients who underwent median sternotomy.

Known standard method of pain relief with narcotic analgesics.

For reasons that impede the achievement of specified following technical result when using the known method include lack of analgesic effect, the occurrence of side effects: nausea, vomiting that worsens the postoperative period.

The known method preperitoneal blockade in the postoperative period (Cheraskin L. A., RF patent for the invention №2400259, publ. 27.09.2010), which consists in the introduction of local anesthetic into the preperitoneal space, formed in the left and right on all extent of surgical wound establish the tunnel catheters having multiple openings through which a local anesthetic is administered every 3 h for 3 days.

For reasons that impede the achievement of specified following technical result when using the known method, taken as a prototype, is that it only provides analgesia in the postoperative period and is applied after laparotomy.

Most Blimber�Kim technical solution in relation to the proposed combination of essential features is a method for the prevention and treatment of exudative-inflammatory complications after median sternotomy (D. A. Basarab et al., RF patent for the invention №2467706, publ. 27.11.2012). The inventive method consists in the formulation of an active pericardial and mediastinal drains during the first third of the day after median sternotomy. For prolonged drainage through the lumen of the pericardial drainage in the oblique sinus of the pericardium give birth to blind, perforated at the tip, sterile microdrainage a PVC pipe. After that, pericardial drainage is extracted to the outside. Perforated in the middle third through sterile microdrainage PVC pipe is seamed to the head end of mediastinal drainage, extracted through kontraperturu in the epigastrium.

Thus, the tube is installed on the entire length of the retrosternal space. At the end of three end both microdinamic tubes connected to a vacuum spirituosen devices.

For reasons that impede the achievement of specified following technical result when using the known method, taken as a prototype, is that microdrainage a PVC tube was placed in the retrosternal space, and it provides only preventing the occurrence of exudative-inflammatory complications in the postoperative period after median sternotomy, pain medication has no effect.

The object of the invention I�is to provide a method of pain relief and prevention of inflammatory complications after median sternotomy, providing a technical result, consisting in the fact that effective postoperative analgesia, the simultaneous drainage of the anterior surface of the sternum and the skin wound and the introduction to the zone on the catheter anesthetics and antibiotics, reduced the number of exudative-inflammatory complications, no iatrogenic damage to the organs and tissues.

The technical result is achieved in that a method of pain relief and prevention of inflammatory complications is characterized in that in the method of pain relief and prevention of inflammatory complications after median sternotomy install pericardial and mediastinal drains and sutured the sternum, after suturing the sternum length of its anterior surface installing the catheter through contraportada skin, departing from 1.0 to 2.0 cm from the lower edge of the wound, through which a local anesthetic is administered every 6 hours, and an antibiotic every 8 hours for 3-5 days, while the proximal end of the catheter is fixed to the subcutaneous tissue absorbable suture material a distal portion of the catheter cannula is fixed by a stitch to the skin prasadavum suture material. The invention is illustrated Fig. 1 and Fig. 2.

Fig. 1 illustrates a surgical wound in the chest after suturing the sternum:

1 - sternum after suturing,

2 - leather (edge of wound),

3 - proximal part of the catheter with an inner bore,

4 - the subcutaneous cellular tissue.

Fig. 2 illustrates a side view, in section:

5 - distal part of the catheter cannula (outer hole).

The method is as follows.

After surgical interventions on the organs of the chest, performed through access median sternotomy, establish pericardial and mediastinal drains.

Then after suturing the sternum 1 length of its anterior surface establish plastic catheter with multiple holes through kontraperturu (hole) of the skin 2, departing from 1.0 to 2.0 cm from the lower edge of the wound. The proximal portion 3 of the catheter with the inner hole is fixed to the subcutaneous tissue 4 absorbable suture material. The distal portion 5 of the catheter cannula (external opening of the catheter) is fixed by a stitch to the skin prasadavum suture.

In the postoperative period the catheter is injected with a local anesthetic for pain relief for 3-5 days, which provides a pronounced analgesic effect and antibacterial drug for the prevention of purulent-inflammatory complications.

Clinical example.

Patient E., aged 56, was admitted to the cardiac surgery Department Gosplanovsky regional clinical hospital №1 with a diagnosis of coronary artery disease: angina 3 FC, myocardial infarction (AMI - 1996). Multifocal stenosis of the lad (CAG from 06.11.2013) Hypertension stage 3, degree 2, risk 4. Hypertensive heart, hypertrophy of the myocardium of the left ventricle with diastolic dysfunction. Angiopathy of the retina. Dilatation of the Atria. Dyscirculatory encephalopathy in the form of a left-side pyramidal insufficiency. CHF 1 St, 2 FC (NYHA).

Operation: 13.01.2014, duration 90 minutes. Under General endotracheal anesthesia, after processing the surgical field by the method of Philonchikova performed median sternotomy. Left internal thoracic artery. In parallel, highlighted the great saphenous vein of the left lower leg. The opened pericardium. AIC scheme aorta - PP. Started IR. Cardioplegic needle into the aortic root. The clamp on the aorta. Antegrade cardioplegia solution custodiol. Asystole. In the middle segment opened DW, diameter up to 1.5 mm. Formed an anastomosis with autovenous end-to-side thread Prolen 8/0. In the distal segment opened the PNA, diameter up to 2.0 mm. Formed an anastomosis with LUGA end-to-side thread Prolen 8/0. Removed the clamp from the aorta. Heart rate recovered independently. On the lateral deflection of the aorta formed proximal anastomosis with autovenous from DW end-to-side thread Prolen 6/0. Reperfusion. With stable hemodynamics stopped IR. Decannulate. Hemostasis. Shunts raspy�Lena anastomoses are patent, sealed. The drains in the anterior mediastinum and the cavity of the pericardium. Layer-by-layer suturing of the surgical wound. After suturing the sternum length of its anterior surface mounted plastic catheter (which has a few holes) through kontraperturu (hole) of the skin, retreating 1.5 cm from the lower edge of the wound. The proximal part of the catheter with the inner hole fixed to the subcutaneous tissue absorbable suture material. The distal portion of the catheter cannula (outer hole) recorded by stitch to the skin prasadavum suture material. ACE-bandage.

In postoperative catheter-injected local anesthetic 0,25% novocaine in the amount of 2 ml for pain every 6 hours and the antibiotic gentamicin 80 mg every 8 hours for 3 days.

The postoperative period was uneventful, smooth. A pronounced analgesic effect, there were no complications. When removing drains from the anterior mediastinum and the pericardial cavity, pain and discomfort the patient experienced.

Postoperative wound healed by primary intention. In satisfactory condition 22.01.2014 the patient was discharged from hospital.

Thus, the proposed method provides effective postoperative analgesia and the prevention vospitatel�'s complications after median sternotomy.

Method of pain relief and prevention of inflammatory complications, characterized by the fact that after median sternotomy install pericardial and mediastinal drains and sutured the sternum, after suturing the sternum length of its anterior surface installing the catheter through contraportada skin, departing from 1.0 to 2.0 cm from the lower edge of the wound, through which a local anesthetic is administered every 6 hours, and an antibiotic every 8 hours for 3-5 days, while the proximal end of the catheter is fixed to the subcutaneous tissue with absorbable suture material and the distal portion of the catheter cannula is fixed by a stitch to the skin with nonabsorbable suture material.



 

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