RU2292863C2 - Method for preventing postoperative nausea and vomiting attacks - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves increasing respiration minute volume after applying carbodioxyperitoneum in a way that CO₂ concentration is to be within 32-38 mm of mercury column and remaining at this level during the carbodioxyperitoneum treatment course. The CO₂ concentration is supported at 30-32 mm of mercury column for 5-10 min after canceling the carbodioxyperitoneum with following respiration minute volume reduction until CO₂ concentration reaches normal values.

EFFECT: reduced frequency of postoperative nausea and vomiting attacks.

1 dwg, 4 tbl

Description

The present invention relates to medicine and can be used at the stage of anesthesia during laparoscopic cholecystectomy.

A known method for the prevention of postoperative nausea and vomiting (POT) (Biedler A; Wilhelm W; Silomon M; Awwad R; Larsen R. Ondansetron Prophylaxe und Therapie von Ubelkeit und Erbrechen nach grosseren gynakologischen Eingriffen Ergebnisse einerestienestienestienestienestiesnestienestiesnistennestienestiesnestienestienestiesnistennestiesnistennestiesnistennestiesnesteistennestiesnistennestienestiesnisteenestienestiesnisteenestienestiesnistennestiesnistesnentesnestesnentes - Aug; 47 (8): 638-43), providing for the efficacy and safety of ondansetron for the prevention of POTD in gynecological surgery. The authors conducted a randomized study in 387 patients. Before the initial anesthesia, the first group of patients received ondansetron at a dose of 8 mg, and the second group received placebo. Anesthesia was performed with nitrous oxide and narcotic analgesics. Postoperative evaluation included the time, duration, and severity of POTD in the first 24 hours after surgery. According to the results of the study, after prophylactic administration of ondansetron, vomiting was registered in 35% of cases and 58% after placebo (p <0.01). Nausea occurred in 49% and 64%, respectively (p <0.01). In 28% of cases after the prophylactic use of ondansetron and 48% after placebo, patients needed ondansetron therapy (p <0.01). Thus, the authors of the study prove the effectiveness of ondansetron 8 mg before induction into anesthesia in preventing POTD. In addition, they believe that ondansetron is safe for prevention and therapy.

However, the high cost of ondansetron and a high percentage of POTD (respectively 35 and 49%) indicate the need for a further search for effective drugs for the prevention of POTD.

Also known is the Fujii Y method; Saitoh Y; Tanaka H; Toyooka H. Prophylactic antiemetic therapy with granisetron-droperidol combination in patients undergoing laparoscopic cholecystectomy // Can-J-Anaesth., 1998. - Jun; 45 (6): 541-544. For the prevention of POTD, a combination of granisetron (G) with droperidol (D) was used. The aim of the study was the relatively high frequency of POTD in patients undergoing laparoscopic cholecystectomy. The study was undertaken in order to compare the efficacy of the granisetron-droperidol combination with each drug individually used to prevent POTD after laparoscopic cholecystectomy. A double-blind, randomized trial was conducted in 150 women. Group G received 3 mg of granisetron, group D 1.25 mg of droperidol. GD group granisetron 3 mg plus 1.25 mg droperidol (n = 50 in each group). The drugs were administered intravenously before induction of anesthesia. The standard scheme of general anesthesia based on isoflurane, nitrous oxide and oxygen was used. The study was carried out continuously for the first 24 hours after anesthesia. In 14% of cases, POTR was recorded in group G, in group D - in 36% and in group GD - in 2% (p <0.03 versus group G, p <0.001 versus group D). In all groups, the authors did not observe complications from preventive actions. It is believed that the prevention of POTD after laparoscopic cholecystectomy with a combination of granisetron and droperidol is more effective than using each antiemetic separately.

Disadvantages:

1. The lack of effectiveness of drugs used to prevent POTD. Odansetron and granisetron in combination with droperidol do not eliminate the development of postoperative nausea and vomiting.

2. The significant cost of odansetron and granisetron limits their widespread use for the prevention of POTD.

3. The use of antiemitic drugs can lead to side effects (a transient increase in the activity of hepatic transaminases in the blood, constipation, diarrhea, headache, skin rash), which adversely affects the postoperative period (Vidal Handbook, 2000).

For the closest analogue, invention No. 2161960 "A method for the prevention of postoperative vomiting in patients after laparoscopic cholecystectomy" (Zabolotskikh IB, Savishchev OB, Klevko VA, Makeev SA) was adopted. To prevent vomiting, the authors used the anti-ischemic and prokinetic effects of the halidor. Halidor eliminated the developed peripheral spasm by expanding the terminal arterioles and relieving the spasm of precapillary sphincters.

There is evidence of electromyographic studies on the improvement of the conduct of slow waves in the muscle membrane of the gastroduodenal complex under the influence of a halidor (I. B. Zabolotskikh, S. A. Makeev et al., 1998), which indicates the prokinetic activity of the drug. The indicated properties of the halidor made it possible to use it for complex anti-ischemic protection of the gastrointestinal tract and brain.

In order to prevent POTD, the analogue suggests intramuscular administration of a halidor 40-60 minutes before surgery at a dose of 1 mg / kg or the administration of the drug in tablet form 2-3 hours before anesthesia in the same dose.

If there are additional risk factors for the development of postoperative vomiting (impaired gastroduodenal complex motility under carbodioxiperitoneum conditions, air injection into the stomach during mask ventilation during induction of anesthesia, cerebral stem ischemia due to circulatory failure in the vertebrobasilar pool during tracheal intubation and during anesthesia) to reduce the effects of reperfusion with carboxyperitoneum for more than 1 hour, the authors recommend additional administration of halidor in the same dose 6 hours cut. The use of halidor in the prevention of postoperative vomiting after laparoscopic cholecystectomy allowed in 1998-2003. reduce the frequency of POTR from 18% to 6-8%.

However, the issue of preventing POTD after laparoscopic surgery remains not fully resolved. No information was found in the literature on the possibility of decreasing the frequency of POTD after laparoscopic cholecystectomy under conditions of BWAP by means of intraoperative changes in ventilation parameters (in particular, MOD). In this regard, a search has been undertaken for new ways to solve this problem.

Objective: to reduce the incidence of POTD and to ensure a comfortable course of the immediate postoperative period by improving the technology of mechanical ventilation as a component of the anesthetic aid during laparoscopic cholecystectomy.

The essence of the invention is the prevention of POTD when performing laparoscopic cholecystectomy under general anesthesia with mechanical ventilation (mechanical ventilation) by the endotracheal method, including calculating the minute volume of respiration (MOD), determining the content of carbon dioxide at the end of expiration (ETCO ₂ ) to ensure normoventilation in a particular patient. The proposed method is characterized in that after the application of carbodixiperitoneum (KDOP), the MOD is increased directly (domestic devices of the RO type) or by increasing the respiratory rate (anesthesia-respiratory devices of the Drager type) so that ETCO ₂ is within 32-38 mmHg. Art. and remained at that level during the CDAP. After removal of KDOP ETCO ₂ support within 30-32 mm RT.article for 5-10 min, followed by a decrease in the increase during the BDOP MOD until ETCO ₂ reaches normal values.

A total of 52 patients were examined who, after premedication with diazepam and atropine, underwent laparoscopic cholecystectomy under conditions of total intravenous anesthesia based on propofol, midazolam, fentanyl and muscle relaxants.

Patients are divided into two groups. 1st group (n = 27), MOD was calculated according to the formula "Body weight / 10 + 1" and did not change during anesthesia. 2nd (n = 25) - MOD was set individually according to capnometry. In this case, after applying KDOP in order to maintain ETCO ₂ within 32-38 mm RT.article increased MOD. It should be noted that the increase in MOD was individual for each patient. After removal of KDOP (i.e., CO ₂ insufflation into the abdominal cavity was stopped, which led to a decrease in its entry into the blood), the ventilation regimen selected for a particular patient did not change (relative to the KDOP period) until ETCO ₂ reached 30-32 mm Hg. Art. and maintaining it at this level for 5-10 minutes. After that, they switched to the standard ventilation mode by reducing the previously increased MOD.

In order to determine the dependence of the course of anesthesia on the ventilation mode at the stages of anesthesia (before KDOP, during and after it), hemodynamics, fluctuations in the ST interval of the ECG, the recovery time of clear consciousness and extubation of the trachea were recorded and analyzed, and the anesthetic efficacy and consumption of the main drugs for anesthesia were calculated . The results are statistically processed (Excel 2003).

Gas exchange was studied based on capnometry and pulse oximetry. The saturation of hemoglobin with oxygen (SpO ₂ ) did not have significant differences both at the stages of anesthesia and between groups. The dynamics of changes in ETCO _{2 are} presented in the drawing.

From the drawing it follows that in the 1st group there was a tendency to hypercapnia and, as a result, carbon dioxide retention in the body, in the 2nd - normal ventilation provided normal values of ETCO ₂ .

In both groups, hemodynamic parameters fluctuated within physiological values; no intergroup differences were detected.

Automatic analysis of the ST interval of the ECG is presented in table 1.

Table 1 The dynamics of the change in the ST interval of the ECG at the stages of anesthetic management of laparoscopic cholecystectomy Group Source background After sedation After the introductory At the height of KDOP After removing the KDOP After extubation 1 group 0.05 ± 0.014 0.01 ± 0.007 * 0.01 ± 0.007 * 0.007 ± 0.0081 * 0.002 ± 0.0061 * 0.02 ± 0.009 * 2 group 0.044 ± 0.012 0.003 ± 0.0051 * 0.0007 ± 0.00612 * 0.003 ± 0.0074 * 0.003 ± 0.0052 * 0.002 ± 0.0051 ** * - p <0.05 compared with the initial background ** - p <0.05 compared with the first group

From table 1 it is seen that significant differences were noted between the initial background and subsequent stages of anesthesia, as well as between groups after extubation of the trachea. Despite the fact that the ST interval indices were slightly better in the 2nd group, this was not of clinical significance, since in all cases the deviation of the ST interval was close to zero. It follows that the optimized ventilation regimen did not adversely affect the myocardial blood supply.

With the same morbidity of operations, fentanyl consumption (Table 2) in the 1st group was 35%, and propofol was 15% (p <0.05) more than in the 2nd. It can be assumed that in patients of the 1st group, the resulting phenomenon is associated with the need to prevent or eliminate the adverse effects of KDOP and hypercapnia on hemodynamics, which was not observed in the 2nd group. Optimization of mechanical ventilation in them contributed to a more rapid removal of CO ₂ from the body.

table 2 Consumption of essential anesthesia drugs Group Fentanyl (mcg / kgh) Propofol Introductory anesthesia (mg / kg) Maintenance of anesthesia (mg / kg · h) 1st group 13.6 ± 0.52 1.5 ± 0.09 5.5 ± 0.61 2nd group 8.8 ± 0.88 * 1.6 ± 0.15 4.7 ± 0.31 * * - p <0.05 compared with the 1st group

No intergroup differences in the duration of operations were found. Recovery rates after anesthesia (Table 3) were significantly better in patients of the 2nd group. So, the duration of anesthesia was shorter by 13.7% (p <0.05), clear consciousness recovered faster (by 7.2 minutes - 49%) and the trachea was extubated earlier than in patients of the 1st group, which significantly increased the anesthesiology efficiency .

Table 3 Key indicators of recovery after anesthesia Group Operation Duration (min) Duration of anesthesia (min) Recovery of clear consciousness (min) Extubation after surgery (min) Anesthetic management (%) 1st group 43.9 ± 3.82 81.7 ± 4.69 14.6 ± 1.69 37.7 ± 3.36 54.5 ± 3.51 2nd group 43.4 ± 3.93 70.5 ± 4.21 * 7.4 ± 0.85 * 27.2 ± 1.75 * 60.3 ± 2.19 * * - p <0.05 compared with the 1st group

In patients of the 1st group, complications were recorded in 5 patients (18.5%, according to the criterion z p <0.05). These are POTR - 2, persistent crises of tachycardia 3 and hypertension - 2. There were no anesthetic complications in the 2nd group.

Thus, the optimization of mechanical ventilation during laparoscopic cholecystectomy made it possible to ensure an adequate course of anesthesin, improve the performance of anesthetic activity and reduce the risk of complications.

The method is as follows. After application of KDOP, the MOD is increased individually (approximately by 60-70%) to a level that, prior to application of KDOP, provides normal ventilation for a particular patient (ЕСОCO ₂ within 32-38 mm Hg). The established ventilation parameters are maintained after removal of the ECD to reduce ETCO ₂ 30-32 mm Hg. The mode of mild hyperventilation is maintained for 5-10 minutes, which contributes to the rapid elimination of CO ₂ from the body. Then the MOD is reduced until normal values of ETCO _{2 are} reached. At the same time, hemodynamics and acid-base state (CBS) are normal.

The method was tested in 44 patients who underwent laparoscopic cholecystectomy after premedication (benzodiazepines, anticholinergic drugs) under general anesthesia (TBA based on ketamine with fentanyl, TBA based on propofol with fentanyl or endotracheal anesthesia based on isoflurane). In this case, only in 1 case was POTR recorded, which amounted to 2.2% and testified to the high efficiency of the method, as well as its low cost compared to analogues.

Example 1. Honey. hospital patient card No. 108. Patient B., 46 years old, body weight 58 kg, height 152 cm. Main diagnosis: cholelithiasis, chronic calculous cholecystitis. Concomitant diseases have not been identified. Operation - laparoscopic cholecystectomy. Premedication: at night and in the morning, benzodiazepines inside, 60 minutes before surgery - relanium 10 mg and atropine 0.01 mg / kg intramuscularly. Ketamine 1.9 mg / kg was used for induction of anesthesia, foran in a dose of 0.8 to 1.3%, fentanyl 4.4 μg / kg · h was used to maintain anesthesia. The duration of the operation was 79 minutes, the carbodioxiperitoneum was 70 minutes, the value of intra-abdominal pressure was 10 mm Hg during the application of KDOP. Consciousness was noted 10 minutes after the end of anesthesia, extubation 24 minutes, and sent to the ward 39 after the operation. The standard ventilation mode corresponded to: MOD 87 ml / kg, UP to 9 ml / kg. After applying KDOP, the ventilation parameters were changed: MOD - 133 ml / kg, DO - 9 ml / kg, the increase in MOD was 65%. While ETCO ₂ ranged from 34-36 mm RT.article. After removing the KDOP, this ventilation mode was continued to be maintained for 9 min, while ETSO ₂ was 30-31 mm Hg, then it was increased to achieve normal ventilation parameters by reducing the MOD. Anesthesia and the postoperative period were uneventful. The patient had no discomfort from anesthesia. On the 3rd day after the operation, the patient was discharged in satisfactory condition for outpatient treatment.

Example 2 Honey. hospital patient card No. 787. Patient M., 64 years old, body weight 87 kg, height 164 cm. The main diagnosis: cholelithiasis, chronic calculous cholecystitis. Concomitant diseases not found. Operation - laparoscopic cholecystectomy. Premedication: at night and in the morning, benzodiazepines orally, 60 minutes before surgery, relanium with atropine intramuscularly. Drugs for premedication were prescribed in a pharmacocopy dose. Ketamine 1.2 mg / kg was used for induction of anesthesia, foran in a dose of 0.9 to 1.4% and fentanyl 4.2 μg / kg · h were used to maintain anesthesia. The duration of the operation is 65 minutes, the carbodioxiperitoneum is 55 minutes, and the KDOP value is 10 mm Hg. During the operation, the ventilation modes did not change. Before applying KDOP ETCO ₂ 32-34 mm Hg, after - 40-42 mm Hg Recovering in consciousness 10 minutes after the end of the operation, extubation after 20 minutes. The postoperative period was complicated in the first hour after the operation by nausea and repeated vomiting, which led to significant discomfort and the development of early pain.

The given example No. 1, in contrast to No. 2, indicates that the selection and change of mechanical ventilation (MOD) parameters during and after anesthesia contributed to the rapid elimination of CO ₂ from the body, normalization of hemodynamic and CBS parameters, as well as improved blood supply to organs abdominal cavity and, thereby, preventing the development of postoperative nausea and vomiting.

Comparative characteristics of the proposed method for the prevention of POTD and the closest analogue are presented in table 4.

Table 4 Comparison of the proposed method for the prevention of POTD with the closest analogue Indicator The proposed method Analogue Gas exchange status Normocapnia The tendency to hypercapnia The consumption of narcotic analgesics Low Tall Material costs No there is Adverse Effects and Complications No there is Efficiency High Low

The technical result is an effective prevention of the development of postoperative nausea and vomiting, creating a patient comfortable conditions in the postoperative period, reducing the pharmacological load and the cost of preventing and treating POTD and other complications, reducing the duration of hospitalization. This can be achieved by removing excess carbon dioxide from the body and maintaining a normal blood gas composition.

Claims (1)

A method for the prevention of postoperative nausea and vomiting when performing laparoscopic cholecystectomy under conditions of general anesthesia with mechanical ventilation by the endotracheal method, including calculating the minute volume of respiration (MOD), determining the carbon dioxide content at the end of exhalation (ETCO ₂ ) to ensure normoventilation in a particular patient, characterized in that after applying carbodioxyperitoneum (KDOP), the MOD is increased so that ETSO _{2 is} in the range of 32-38 mm Hg. and stayed at that level during the KDOP; after removal of KDOP ETCO ₂ support within 30-32 mm RT.article within 5-10 minutes, followed by a decrease in MOD until ETSO ₂ reaches normal values.