RU2371139C1 - Method for anaesthesia service of laparoscopic gynaecologic operations in women of reproductive age - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely anaesthesiology, and can be used as anaesthetic means in laparoscopic gynaecologic operations in women of reproductive age. It is ensured by spinal anaesthesia that is followed by sedation with midazolam and propofol, and laryngeal masking ProSeal. Thereafter carbodioxyperitoneum is formed, while the patient is moved in Trendelenburg's position.

EFFECT: method allows providing adequate anaesthesia both in ALV and assisted respiration conditions without using muscle relaxants and narcotic analgesic with minimising the negative effect of intraabdominal hypertension owing to carbodioxyperitoneum.

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Description

The invention relates to medicine, in particular to anesthesiology, and can find a place in the anesthetic management of laparoscopic surgery in patients of reproductive age who require surgical treatment of infertility.

Surgical methods occupy an important place in the treatment of infertility. 80-90% of women underwent surgery on the reproductive organs of the pelvis (V. Kulakov et al., 2002). According to our data, about 80% of them are performed by laparoscopic access. Surgical interventions, even performed with endoscopic, minimally invasive access, can themselves reduce the reproductive potential of patients. Features of laparoscopic gynecological surgery include the introduction of carbon dioxide into the abdominal cavity under high pressure (carbodioxiperitoneum (KDP)) and the use of the Trendelenburg position. Each of the conditions for laparoscopic gynecological surgery has its own negative effects, leading to pathophysiological changes in the body. These changes are exacerbated by the generally accepted methodology for performing endoscopic gynecological operations under conditions of general anesthesia (OA) with mechanical ventilation (mechanical ventilation) (Pashkova I.L. Choice of anesthesia method for laparoscopic interventions: Abstract of Ph.D. Cand. Sc. - M., 1995. - 25 p .; Sinepupova NA Problems of hemodynamic disturbance at the stages of diagnostic laparoscopy and translaparoscopic surgery to restore reproductive function in women: Abstract of thesis ... Candidate of Medical Sciences. - M. 1991. - 24 sec.).

The negative effects of CDP are associated with increased intra-abdominal pressure and biochemical changes resulting from the absorption of carbon dioxide into the bloodstream. Increased abdominal pressure, acting uniformly in all directions, causes compression of the abdominal and chest organs. Increase in intra-abdominal pressure up to 15 mm Hg reduces blood flow in all organs of the abdominal cavity, and with concomitant cardiovascular and respiratory pathology, deep disorders of intraorgan oxygen saturation develop with intraperitoneal hypertension of 10-11 mm Hg. (Malchikov A.Ya., Matis V.V., Sigal Z.M., Slobozhanin M.I., Pronichev V.V., Utkin I.Yu. Intraorgan hemopulsomotoroxidinamics during laparoscopic operations // Endoscopic surgery. - 2006. - T.12, No. 2. - S.81-82). The reduction of the network of the inferior vena cava under conditions of high intra-abdominal pressure leads to a 20% decrease in the venous return to the heart, which is essential for cardiac output (Tkachenko B.I., Polenov S.A. Structure and function of the vascular system. // Vascular diseases and hearts.T.1 / Under the editorship of E.A. Chazov. - M .: Medicine, 1992. - P.85-98). Perhaps the development of hypodynamic syndrome in the form of a decrease in cardiac index, stroke volume and an increase in total peripheral vascular resistance (Sapanyuk A.I., Bukharin A.I., Kuklova I.I., Mamedov S.Kh., Khachatryan D.V. Prediction of hemodynamic response when performing laparoscopic cholecystectomy. // Endoscopic surgery. - 2006. - T.12, No. 2. - P.96). The amount of carbon dioxide remaining between the dome of the diaphragm and the liver can contribute to the occurrence of shoulder-shoulder pain in the postoperative period (Duale C, Bolandard F., Duban P., Mission JP, Schoeffler P. Consequences physiopathologiques de la chirurgie cœlioscopique. Ann. Chir 2001. ; 126: 508-514.).

The creation of the KDP and the Trendelenburg position has an adverse effect on the respiratory system. Increased abdominal pressure reduces lung distensibility and increases peak and average airway pressure (Rauh R., Hemmerling T.M., Rist M., Jacobi K.E. Influence of pneumoperitoneum and patient positions on respiratory system compliance. J Clin Anesth 2001 ; 13: 361-365). Mechanical ventilation also increases the peak pressure in the airways (Vitalev N.A., Klimovich S.P., Stebunov S.S. Changes in the respiratory system with pneumoperitoneum. // 6 All-Russian Congress of Anesthesiologists and Resuscitators: Abstracts - Moscow, 1998 . - p. 79). The high standing of the dome of the diaphragm in combination with the position of Trendelenburg reduces the functional residual capacity of the lungs, causing a decrease in ventilation of the underlying zones of the lungs. Against the background of general anesthesia, atelectasis occurs in 90% of patients, and the venous shunt increases from 1-3% (when awake in a healthy person) to 10% of the volume of cardiac output. (G. Hedenstern. Influence of body position on the ventilation-perfusion ratio. // Actual problems of anesthesiology and intensive care: (Refreshing course of lectures). Issue 10 / Edited by E.V. Nedashkovsky. - Arkhangelsk, 2005. P.256-262 .).

Mechanical ventilation through increased intrapleural pressure reduces blood flow to the right atrium, causing a decrease in cardiac output and blood pressure. Thus, mechanical ventilation has a depressive effect on hemodynamics. Ventilation with the use of muscle relaxants enhances the negative effect of carbodioxiperitoneum on the state of venous blood flow in the lower extremities, exacerbating disorders in the hemostatic system, which reflects the high incidence of asymptomatic deep vein thrombosis, which according to Doppler ultrasound imaging is 55% (Duale C., Bolandard F., Duban P. , Mission JP, Schoeffler P. Consequences physiopathologiques de la chirurgie c –lioscopique. Ann. Chir 2001; 126: 508-514.).

General anesthesia, even in combination with powerful narcotic analgesics, does not fully protect the body from surgical injury. Trauma, including surgery, gives rise to nociceptive impulses that are transmitted to the brain. They, in turn, cause efferent impulses to certain endocrine organs, causing endocrine and metabolic changes. Operations performed under conditions of general anesthesia with inhaled anesthetics increase plasma concentrations of cortisol, aldosterone, renin, vasopressin, growth hormone, adrenaline, norepinephrine, dextrose and lactate. General anesthesia does not suppress the afferent and efferent pathways responsible for the stress response.

Spinal anesthesia (CA), blocking nociceptive afferent or efferent pathways, suppresses the endocrine and metabolic changes that occur due to surgical stress. The secretion of cortisol during surgery under SA does not increase, which is due to the suppression of efferent and afferent fibers, which in turn prevent the release of ACTH from the glands of the mucous membrane. Similarly, lower levels of norepinephrine and epinephrine during operations with high thoracic spinal anesthesia are associated with blockade of the efferent pathways of the autonomic nervous system leading to the adrenal medulla.

The objective of the invention is the reduction of invasiveness and the reduction of the pharmacological load of the anesthetic management of laparoscopic gynecological surgery in women of reproductive age while maintaining the effectiveness and safety of the method.

The use of AS increases the compliance of the abdominal wall, thereby preventing abdominal ischemia, which is possible due to increased intra-abdominal pressure. Protecting the abdominal organs from ischemia, CA reduces the disturbance of oxidative phosphorylation and the active release of cytokines, leading to damage to lysosome membranes and the release of autolytic enzymes. A study of the marker of oxidative stress - 8-isoprostane F2-alpha showed that CA better protects against oxidative stress that occurs during any surgical intervention.

The use of AS during laparoscopic operations in gynecology minimizes the negative impact of intra-abdominal hypertension on the respiratory system. This is due to the fact that SA, providing stable segmental anesthesia and regional muscle relaxation, makes it possible to abandon narcotic analgesics, muscle relaxants, and, therefore, from performing mechanical ventilation (Sokolenko G.V., Korovin A.Ya., Kulish V.A. Spinal anesthesia during gynecological endoscopic operations. // Endoscopic surgery. - 2005. - No. 1. - P.45-46). Preservation of spontaneous breathing during laparoscopy in conditions of SA promotes ventilation of the underlying areas of the lungs adjacent to the moving diaphragm and chest. Therefore, there is no significant decrease in the vital capacity of the lungs and minute volume of ventilation during the entire intra- and postoperative period when using SA during laparoscopic operations, which occurs when using general anesthesia associated with the use of mechanical ventilation. Preserving the tone of the diaphragm prevents its excessive stretching and tension of the final branches of the phrenic nerve, which reduces the likelihood of complications such as postoperative nausea and vomiting.

The position of Trendelenburg created during laparoscopic gynecological operations, leading to positional discomfort, and the lack of the need for the patient to be conscious of the operation for both himself and the surgical team, necessitate the use of sedation as a component of anesthesia that complements spinal anesthesia. In turn, the use of sedation requires ensuring reliable airway patency during surgery with laparoscopic access. The only device that provides reliable airway patency under laparoscopic access is the ProSeal laryngeal mask (LMAProSeal). Due to the presence of a two-cavity cuff at the LMAProSeal, the mask provides sealing at a pressure of up to 30 cm water column. An additional drainage channel makes it easy to determine the correct position of the mask, facilitates access to the contents of the stomach, protects against aspiration, providing an outflow in case of unexpected regurgitation. The fundamental principles of the effective and safe functioning of LMAProSeal are their high physiology, maximum anatomical accuracy with a lower level of invasiveness of the distal end of the airway device (the anatomical congruence of LMAProSeal and the respiratory tract provides the following design nuances:

1. the cuff form after numerous experiments with plaster casts in the anatomical theater allowed us to create the most accurate cast of the human larynx and pharynx, which creates the basis for the tightness of the connection;

2. The consistency of the medical silicone specially created for the cuff has a special elasticity, which ensures and maintains a high tightness of the compound 95-100% or more. At the same time, the soft cuff is non-traumatic and quite tightly surrounds the entrance to the larynx, without affecting the blood flow in the mucous membrane of the larynx and pharynx;

3. the cuff’s dimensions are different in height, while it has a lightweight and pointed distal end, which allows the laryngeal mask (LM) to be fixed when inflated, mainly due to the insertion (in front) of the pear-shaped larynx into the recesses. The pointed tip greatly facilitates the installation of LM, leaving the epiglottis intact, which increases the effectiveness of the respiratory support;

4. the mask has a recess in the form of a bowl, which ensures the presence of pressing pressure necessary to create a tight joint;

5. the inner diameter of the breathing tube corresponds to the I / O characteristics of low pressure, which allows for ventilation at low numbers of inspiratory pressure, preventing the narcotic mixture from entering the stomach with any ventilation methods;

6. The place of attachment of the tube to the cuff is designed so that the recess of the mask bowl is located immediately before the entrance to the larynx, without affecting the esophageal opening, which avoids direct blowing of the gas-narcotic mixture into the stomach. In addition, the marker strip along the entire length of the respiratory tube allows you to control the location of the distal opening of the respiratory tube relative to the entrance to the larynx;

7. the breathing tube is attached to the back of the mask at an angle of 30 degrees, while the natural bending of the LM after installation changes the situation: the elastic breathing tube tends to take its original position, which leads to the raising of the pointed tip of the cuff above the upper esophageal sphincter. As a result, the reflex of “opening the cardia to the throat” does not occur and, accordingly, the occurrence of regurgitation is not provoked;

8. The presence of an aperture grille inside the mask bowl completely prevents the possibility of the epiglottis getting into the lumen of the respiratory tube, which ensures effective and safe ventilation;

9. the presence of a small bulb-shaped expansion (and, accordingly, an increase in the internal diameter of the breathing tube) at the place of attachment of the breathing tube to the back of the mask bowl allows you to strengthen the low-pressure I / O position, which increases the tightness of the respiratory circuit;

10. A separate trunk for inflating the LM cuff minimizes the likelihood of possible depressurization due to damage to the channel. Those. the patient will not be able to bite a thin separate channel of the line for inflating and the tightness of the respiratory circuit is maintained even when biting the respiratory tube of the mask (Dolbneva E.L. Modern aspects of the use of alternative epiglottic airway devices, 2001).

We conducted a clinical study of post-anesthetic awakening on the Aldrete scale. It revealed that the sum of 9-10 patient's points after CA in combination with the use of LMAProSeal was gained 15-30 minutes after the end of the surgery. This total score indicates the possibility of transferring the patient from the department of anesthesiology and intensive care to the general ward. And only the presence of the motor block after SA contributed to the patient being in the postoperative ward for 2-3 hours. After general anesthesia, the same amount of points on the Aldrete scale, patients scored only by the end of 90-120 minutes. During their stay in the postoperative ward in the group of patients with SA, better satisfaction with the transferred anesthesia was noted due to the lower frequency of postoperative side effects and adequate postoperative analgesia. In the group with SA, while in the postoperative ward, no additional pain relief was required. In the postoperative period, non-narcotic analgesics (ketonal) were used in patients after OA in 20% of cases, and narcotic analgesics in 5% of cases (promedol 20 mg). Table 1 below shows the incidence of postoperative side effects depending on the type of anesthesia.

Table 1 The incidence of postoperative side effects depending on the type of anesthesia Postoperative Side Effects General anesthesia,% Spinal anesthesia,% Nausea 35 5 Vomiting 25 3 Chills 68 3 Moderate and severe pain 25 0 Remembering the progress of the intervention (presence at the operation) 10 - Dizziness fifteen 10 Mood decline 10 5 Mood improvement 5 fifty

Practically anesthetic support of laparoscopic gynecological operations is carried out as follows: a puncture is performed at the level L ₁ -L _{2 with a} spinal needle with a pencil-shaped tip (Pencil Point) measuring 27G × 90 mm. After identification of the spinal space, an isobaric solution of S. Marcaini spinali 0.5% in a dose of 3-3.5 ml is introduced. The level of anesthesia is T ₄ -T ₆ . Sedation: a combination of benzodiazepine - midosalam and non-inhalational anesthesia - propofol. Maintaining airway patency - the ProSeal laryngeal mask, which provides the possibility of anesthesia both with spontaneous breathing and in conditions of auxiliary or forced ventilation.

The following examples illustrate the invention.

Example 1. Patient M-va, 34 years old. Diagnosis: Secondary infertility. Chronic bilateral salpingoophoritis, stage of remission. From the anamnesis: the duration of the disease is 11 years, 3 operations on the organs of the reproductive system. In April 2008, surgery was performed: hysteroscopy, laparoscopy, salpingo-ovariolysis. The operation was performed under spinal anesthesia with sedation: a combination of fractional administration of midazolam and propofol. To ensure airway patency, the laryngeal mask ProSeal is installed. Spinal puncture was performed at the level L ₁ -L ₂ with a needle with a pencil-type tip (Pencil Point) measuring 27G × 90mm. After identification of the spinal space, an isobaric solution of S. Marcaini spinali 0.5% in a dose of 3.2 ml was introduced. Received anesthesia level T ₆ . Against the background of sedation, 2.0 mg of fractionally midazolam was performed hysteroscopy, then propofol 150 mg was introduced to install a laryngeal mask. The mask was installed from 1 attempt without complications, an air-oxygen mixture 1: 1 was supplied through it. Further, the expense for the operation of midazolam was 0.05 mg / kg / h, and propofol 1 mg / kg / h. Throughout the entire intraoperative period, starting from the moment the patient entered the operating room, hemodynamic monitoring of central hemodynamic parameters (CHD) and pulse oximetry were monitored on a NICCOMO impedance cardiography monitor. Table 2 presents the dynamics of the main parameters of CHD and pulsokimetry during surgery.

The method was tested on sufficient clinical material, which allowed to prove the safety and effectiveness of the method of anesthetic management. We examined 23 women of reproductive age who underwent laparoscopic gynecological surgery. Patients underwent laparoscopic verification and surgical treatment of the following infertility factors: tubal-peritoneal, genital endometriosis, polycystic ovaries, tumors and tumor-like formations of the uterus and associated pathology. Considering the increasingly frequent use of laparoscopic access for gynecological operations in outpatient clinics, the use of this method of anesthetic management is also possible in one-day hospitals.

Thus, the claimed method of anesthetic management of laparoscopic gynecological operations in women of reproductive age has the following advantages: high efficiency; sufficient security; better satisfaction; less chance of complications; reduces the pharmacological burden; reduces the effect on vital organs, thereby facilitating the postoperative period and reduces the time spent in the hospital; can be widely used in specialized gynecological clinics.

The method is quite simple, less invasive, available for widespread use in anesthesiology practice both in the hospital and in the outpatient clinic.

Claims (1)

A method of anesthetically providing laparoscopic gynecological operations in women of reproductive age, characterized in that 20 minutes after performing spinal anesthesia, a ProSeal laryngeal mask is established against sedation with midazolam and propofol, then a carbodioxiperitoneum is created and the patient is transferred to Trendelenburg position, thus, IVL or B without muscle relaxants, and anesthesia - without narcotic analgesics or with less of them.