RU2668793C1 - Method of prolonged high spinal anesthesia in operations on the upper abdominal floor - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anaesthesiology. In the position of the patient lying on his side, after local anesthesia, medial access is performed by puncture and catheterization of the subarachnoid space at the level of LIV-LV using the set for extended spinal anesthesia. In this case, the catheter is carried out in the cranial direction for 2–3 cm with the introduction of an isobaric solution of marcaine in the initial dose of 15–20 mg with bubbling of cerebrospinal fluid in a volume of up to 5–10 ml and a time of administration of 1–2 minutes, with further regulation of the development of the block and control of blockade by tilting the head end of the table to 45–60°. Repeated injection of an anesthetic into the spinal catheter at a dose of half of the initial with bubbling of the CSF in the volume of up to 5–10 ml is performed if there is a sign of restoration of pain sensitivity intraoperatively or in the postoperative period. In the early postoperative period, the patient is on strict bed rest with a raised head end of the bed at 30–45° within 48 hours.

EFFECT: method provides sufficient segmental blockade, muscle relaxation in the area of operation, stability of central hemodynamics during surgical intervention and in the postoperative period.

1 cl, 2 ex

Description

The present invention relates to medicine, namely to anesthesiology and can be used as regional anesthesia in abdominal surgery during long-term operations on the upper floor of the abdominal cavity and in the postoperative period.

Our known method of high spinal anesthesia (RF patent No. 2599044), which consists in the puncture of the subarachnoid space at the level of LIV-LV. In this case, the needle is directed sagittally to the right and to the left, introducing an isobaric solution of marcaine in a total dose of 15-20 mg, positioning the needle section as cranially as possible. The time for a single-stage administration of marcaine with sparging of cerebrospinal fluid in a volume of 5-10 ml is 1-2 minutes. Further regulation of the development of the block and control of the blockade is carried out by tilting the head end of the operating table to 45-60 °, controlling heart rate and blood pressure.

The disadvantage of this method is the limited time anesthesia, depending on the duration of the drug - not allowing for long-term surgical interventions and not providing deep postoperative anesthesia.

Closest to the proposed technical essence is a method of prolonged spinal anesthesia (Kuzmin V.V. Induction method for prolonged spinal anesthesia. RF patent No. 2309737; Gallinger E.Yu. et al. Use of extended spinal anesthesia and combined spinal-epidural anesthesia for operations on the vessels of the lower extremities // Vestnik RAMS. 1997. No. 11. P. 53-55).

Puncture and catheterization of the subarachnoid space is carried out at the level of LII-LIV and a catheter is placed. When there are signs of restoration of pain sensitivity in the early postoperative period, prolonged administration of anesthetic into the spinal catheter is performed for pain relief. The method provides reliable segmental blockade with pronounced relaxation of the muscles of the operated area, hemodynamic stability during surgery and in the early postoperative period.

The disadvantage of using this method of anesthesia during operations is the low level of the spinal block, which is not able to cause adequate anesthesia during the operation on the upper floor of the abdominal cavity, and also to prolong the analgesic effect in the postoperative period.

The objective of the invention is to develop a method of prolonged (prolonged) high spinal anesthesia with the development of a high neuromuscular block to the level of Th I-Th II, which allows performing not only a long-term anesthesia of an operative measure on the upper floor of the abdominal cavity, but also an extended postoperative anesthesia.

The method is as follows. Before the operation, the patient is premedicated using narcotic analgesics according to the generally accepted technique. High spinal extended (prolonged) anesthesia is performed by median access, taking into account age-related changes. The greatest advantage is the position of the patient lying on his side ("in the fetal position"). After local anesthesia, puncture and catheterization of the subarachnoid at the level of LIV-LV is carried out using the kit for prolonged spinal anesthesia. The catheter is carried out in the cranial direction by 2-3 cm. Then, an isobaric solution of marcaine is introduced in an initial dose of 15-20 mg, while the time for one-stage administration of marcaine with sparging of cerebrospinal fluid in a volume of up to 5-10 ml is 1-2 minutes, which allows you to create a high degree of turbulence of the injected solution, and also contributes to the distribution of vortex flows in the cranial direction of the cerebrospinal fluid space in order to distribute the anesthetic further from the injection site and the formation of an adequate and prolonged sympathicolysis.

Further regulation of the development of the block and control of the blockade is carried out by changing the position of the operating table: tilting the head end of the table to 45-60 ° and is controlled by non-invasive measurement of blood pressure, heart rate by pulse oximetry (up to 65 beats per min.). The result is the development of the neuroaxial block to the maximum level Th I-Th II.

Sedation of the patient is carried out with a solution of phenazepam 1 mg (1.0 ml) at the same time or fractionally during the entire time of surgery.

All patients undergo oxygen inhalation through a face mask or nasal catheters 4.0 l / min.

The sensory and motor blocks of the neuroaxial blockade are evaluated. After reaching the level of Th I-Th II, surgery is performed under balanced high spinal anesthesia: with adequate infusion-correcting therapy, the volume of which depends on intraoperative losses, but not less than 1500-2000 ml, crystalloid solutions are usually used. When lengthening the time of surgical treatment and the appearance of signs of restoration of pain and motor sensitivity intraoperatively or in the postoperative period, for the purpose of anesthesia, repeated administration of the anesthetic into the spinal catheter is carried out at a dose half from the initial. After two days, the catheter is removed, an aseptic dressing is applied to the puncture site.

The average duration of surgery with high prolonged (prolonged) spinal anesthesia was 4.5 ± 0.5 hours: maximum - 5 hours, minimum - 3 hours 10 minutes. Intraoperatively, correction of the level of high spinal anesthesia is performed by changing the angle of inclination of the head end of the operating table to a maximum of 60 °. The control was carried out according to the state of hemodynamics: non-invasive measurement of blood pressure, heart rate monitoring, pulse oximetry, as well as the assessment of pain sensitivity. The effectiveness of analgesia is monitored on a visual analogue pain scale. In the early postoperative period, for the prevention of complications in the form of a high spinal block, the patient is in strict bed rest for 48 hours with a raised head end of the bed at 30-45 °.

In terms of simplicity and technique, high spinal prolonged anesthesia is close to high spinal anesthesia, but the material support requires a kit for prolonged spinal anesthesia. Unlike high spinal anesthesia, prolonged provides a prolonged, controlled and fairly long high level of analgesia during surgery and in the postoperative period both on the upper and lower floors of the abdominal cavity.

The proposed method is illustrated by clinical examples.

Example 1: Patient T., 53, was admitted to the hospital for emergency reasons with complaints of pain in the epigastrium, vomiting of blood, black stool, general weakness. From the anamnesis it was found out that he suffers from peptic ulcer of the stomach; he has repeatedly taken courses of antiulcer therapy.

Upon receipt, the condition is serious. The skin is pale, clean. HELL - 100/60 mm Hg, heart rate - 124 bpm. Lungs on auscultation without features. Symptoms of peritoneal irritation are negative. In the general analysis of blood Hb - 66 g / l. With FGDS: on the lesser curvature of the stomach, there is a deep ulcerative ulcer 3 × 3 cm in size. There is a thrombosed vessel in the bottom of the ulcer. The patient was diagnosed with gastric ulcer. An ulcerative ulcer of lesser curvature of the stomach, complicated by bleeding. After installing the probe in the stomach, conducting preoperative preparation, the patient was taken for surgery.

The patient performed prolonged high spinal anesthesia according to the method described above.

After processing the surgical field, a laparotomy was performed. Produced mobilization of the stomach, with ligation of the gastric arteries. Resection of 2/3 of the stomach was performed according to Billroth I. Hemostasis was monitored. Sutures on the wound and aseptic dressing were layered in layers. Infusion-correcting therapy was carried out in the peripheral vein with an average speed of 20.0 ml / min and amounted to 4000 ml, of which crystalloids - 2500 ml, glucose solutions - 1500 ml. The rate of solution administration and the volume of infusion therapy were due to a decrease in the total peripheral vascular resistance, followed by a decrease in blood pressure and a redistribution of intravascular fluid volume with a decrease in the general tone of capacitive and resistive vessels. No pronounced hemodynamic changes were noted. The time of the anesthesiological aid was 4 hours 30 minutes. The time of surgery was 3 hours 20 minutes. After the operation, the patient was transferred to the department of anesthesiology and intensive care under dynamic observation. The neuromuscular block passed within 40 minutes, during the first postoperative days the anesthesia was carried out in a spinal catheter according to the method described above - the frequency of administration was twice a day. On the second day, the patient was transferred to the general ward of the surgical department for further treatment, where postoperative anesthesia was also performed into the catheter during the day (twice) with a dose reduction of the administered drug by 50% less than the repeated one, after which the catheter was removed, an aseptic dressing was applied to the puncture site . The patient was discharged on the 14th day with recovery.

Example 2: Patient K., 73, was admitted with complaints of cutting pain in the upper abdomen, left iliac region, nausea, vomiting, general weakness, delayed stool and gas, lack of appetite.

From the anamnesis it is known that he is sick for 3 days, when, against the background of a satisfactory condition, nausea, vomiting, and abdominal pain of a cutting nature appeared. Upon admission to the hospital, the patient was examined by the surgeon on duty, who, after the examination (on the X-ray diffraction pattern, Kloiber’s cup), diagnosed with acute intestinal obstruction. She had a history of uterine amputation in 1992. Objectively: a state of moderate severity. The skin is clean, normal color, dry, satisfactory nutrition. Breathing is carried out in all departments, vesicular, no wheezing. Heart sounds are clear, muffled, the pulse is 94 beats / min, blood pressure is 120/80 mm Hg. The tongue is wet, coated with a white coating. The abdomen is swollen, soft, painful in the left iliac region, mesogastrium. Peristalsis is sonorous, rare, there are positive symptoms of peritoneal irritation in the same place. There was no stool for 5 days. Ultrasound - diffuse changes in the liver. With endoscopic hypertension - grade 1, acute duodenogastric reflux.

The patient underwent prolonged high spinal anesthesia and underwent surgery - laparotomy, dissection of adhesions, nasointestinal intubation, rehabilitation, drainage of the abdominal cavity.

Postoperative diagnosis: acute commissural small bowel obstruction, diffuse peritonitis.

On the second day, the patient was transferred to the general ward of the surgical department for further treatment, where postoperative analgesia was also carried out into the catheter during the day with a 50% reduction in the dose of the administered drug.

The patient was discharged on the 14th day with recovery, the catheter was removed after 48 hours.

Thus, the proposed method of prolonged high spinal anesthesia allows you to perform long-term surgical interventions, as well as prolong the analgesic effect in the postoperative period. Prolonged high spinal anesthesia is the method of choice, especially in individuals with high operational and anesthetic risk. Possessing technical simplicity, it is easier for patients to tolerate and allows the anesthetist to keep the basic parameters of central hemodynamics stable. This type of anesthesia is characterized by the controllability of dosing anesthetic in each case. The prolonged nature of anesthesia allows the introduction of an anesthetic according to the catheter “on demand”, without resorting to the use of narcotic analgesics.

Claims (1)

A method of prolonged high spinal anesthesia during operations on the upper floor of the abdominal cavity, including in the position of the patient lying on his side, after local anesthesia, with mid-access puncture and catheterization of the subarachnoid space at the level of LIV-LV using the kit for prolonged spinal anesthesia, characterized in that the catheter is carried out in the cranial direction by 2-3 cm with the introduction of an isobaric solution of marcaine in it at an initial dose of 15-20 mg with bubbling of cerebrospinal fluid in a volume of up to 5-10 ml and the time of administration I take 1-2 minutes, with further regulation of the development of the block and control of the blockade by tilting the head end of the table to 45-60 °, re-introducing the anesthetic into the spinal catheter in a dose half from the initial one with bubbling cerebrospinal fluid in a volume of up to 5-10 ml is performed when there are signs of recovery pain sensitivity intraoperatively or in the postoperative period, in the early postoperative period, the patient is in strict bed rest with a raised head end of the bed by 30-45 ° for 48 hours.