RU2802771C2 - Method of combined spinal-epidural anesthesia with the expansion of the epidural space - Google Patents

Abstract

FIELD: medicine; anesthesiology and surgery.

SUBSTANCE: invention can be used for combined spinal-epidural anesthesia with expansion of the epidural space in obese patients. With the help of an ultrasound navigator sensor, an interspinous gap suitable for puncture is determined at the level of III–IV lumbar vertebrae. Local anesthesia of the skin and subcutaneous adipose tissue with 2% lidocaine solution is performed on the selected area. The epidural space is punctured with a Tuochy 18 G epidural needle. The epidural space is identified by the "loss of resistance" method. Using a Quincke 27 G needle, the subarachnoid space is punctured; upon receipt in the pavilion of the needle of a drop of a transparent colorless cerebrospinal fluid, a 0.5% solution of the local anesthetic bupivacaine is injected into the subarachnoid space. To calculate the dosages of a local anesthetic, the body mass index (BMI) is calculated using the formula:

With a BMI value of 30–35 kg/m² the dose of bupivacaine is 2.5 ml (12.5 mg), and with a BMI of more than 35 kg/m² the dose of bupivacaine is 2 ml (10 mg). After the administration of bupivacaine, the Quinke 27 G needle is removed and a 20 G epidural catheter is inserted into the epidural space 3 cm in the cranial direction. An aspiration test is performed, a sterile bandage is applied to the skin puncture site, the catheter is fixed to the skin of the back with a sticker, and isotonic sodium chloride is injected through it. With a BMI of 30–34 kg/m², the volume of sodium chloride is 16 ml, with a BMI of 35–40 kg/m² the volume of sodium chloride is 13 ml, with a BMI of more than 40 kg/m² the volume of sodium chloride is 10 ml. Then the patient is laid on his back.

EFFECT: method reduces the risk of complications from the cardiovascular and respiratory systems during regional anesthesia in obese patients by taking into account the patient's individual anthropometric data.

1 cl, 2 dwg, 2 tbl, 2 ex

Description

The invention relates to medicine, namely to anesthesiology and resuscitation, and can be used for anesthesia during surgical interventions for hernias of the anterior abdominal wall, on the pelvic organs, and during lower-median laparotomies.

Currently in Russia and in the world there is a stable a trend towards an increase in the incidence of obesity, which is a serious medical problem. The high risk of cardio-respiratory complications in such patients, as well as technical difficulties when performing manipulations (catheterization of peripheral and central veins, mask ventilation, tracheal intubation) requires increased alertness from the anesthesiologist-resuscitator. The Federation of Anesthesiologists and Resuscitators (FAR) has created recommendations for the perioperative management of patients with concomitant morbid obesity [1]. In these recommendations, the authors place emphasis on the low functional reserves of obese patients. They also note a high risk of surgical infection, respiratory, venous thromboembolic and cardiovascular complications. One of the ways to prevent these complications is adequate analgesia in the perioperative period. Otherwise, insufficient pain relief will inevitably lead to immobilization of the patient and an increase in respiratory, infectious and thromboembolic complications. At the same time, the use of narcotic analgesics (fentanyl, trimeperedine, morphine) is fraught with depression of the respiratory and vasomotor centers, intestinal paresis, and drowsiness of the patient. The concept of multimodal analgesia is generally accepted, i.e. the use of painkillers with different mechanisms of action to potentiate their effects. In settings where patient-controlled analgesia is not widely used, reducing or eliminating the use of opioids is an urgent goal for postoperative pain management. In this regard, the use of regional anesthesia in obese patients is of great importance for practical healthcare.

The purpose of the invention is to reduce the risk of complications from the cardiovascular (hypotension, bradycardia) and respiratory systems (hypoventilation, hypoxia) when performing regional anesthesia in obese patients.

The proposed method of performing combined spino-epidural anesthesia with expansion of the epidural space (CSEA with REP) is based on the developed algorithm of sequential manipulations, consisting of:

• puncture of the epidural and subarachnoid space through one skin puncture,

• subarachnoid injection of a reduced dose of local anesthetic,

• catheterization of the epidural space and its expansion with an indifferent solution (sodium chloride 0.9%).

As a prototype, we used a CSEA scheme with REP and a method for selecting doses of local anesthetic and indifferent solution based on intra-abdominal pressure (IAP) [2, 3].

This scheme was developed during anesthesia for caesarean section, i.e. when bladder catheterization is absolutely indicated. It was through the urinary catheter, using a special manometer, that IAP was measured. When performing anesthesia for repair of a hernia of the anterior abdominal wall, catheterization of the bladder is indicated only for long-term operations, over 3 hours, therefore, measuring IAP in the described way is not always possible. Such conditions force us to search for other criteria for choosing the dose of local anesthetic and indifferent solution.

The proposed method is not labor-intensive, does not require additional equipment and is based only on the patient’s anthropometric data, namely height, body weight and, calculated with their help, body mass index (BMI).

The implementation of the method is illustrated using specific examples.

Example 1.

Patient R., 50 years old, was admitted to the surgical department as planned with a diagnosis of irreducible postoperative hernia. The patient has a history of laparoscopic cholecystectomy a year ago. After 3 months, she began to notice a hernial protrusion in the navel area. Among the concomitant diseases, hypertension stage 2, degree 2, very high risk. And also grade 2 obesity. Height 160 cm, body weight 93 kg. BMI 36.3 kg/ ^m2 . During hospitalization, indications for surgical treatment including hernioplasty were determined. Physical status on the ASA scale was assessed as 2 points. Method of anesthesia CSEA with REP. Standard preoperative preparation was performed. To prevent venous thromboembolic complications, compression bandaging of the lower extremities. In the operating room, monitoring of vital functions was established: blood pressure, heart rate, ECG, SpO ₂ , SV, CO, CI using non-invasive EsCCO technology, based on analysis of the pulse wave transit time. Next, regional anesthesia was performed according to the following algorithm:

1) With the patient in a lateral position, the anesthesiologist’s hands and the puncture site were treated three times with a 70% ethyl alcohol solution, and the puncture site was covered with sterile linen. Local anesthesia of the skin and subcutaneous fat was performed with a 2% lidocaine solution.

2) Using the Espocan set (BBraun, Germany), a puncture of the epidural space was performed through the medial approach using a Tuochy 18 G epidural needle included in the set. Identification of the epidural space was carried out using the “loss of resistance” method. Next, using a Quincke 27 G needle from the same set, the subarachnoid space was punctured. When a drop of clear, colorless liquor is obtained in the needle pavilion, 20 mg of 0.5% bupivacaine is injected into the subarachnoid space.

3) Next, the Quinke needle was removed and a 20 G catheter was inserted into the epidural space 3 cm. An aspiration test was performed. Then a sterile bandage is applied to the skin puncture site, the epidural catheter is fixed and 13 ml of isotonic sodium chloride is injected into it.

Extended hemodynamic monitoring was continued (see Table 1), and the area of distribution of the sensory block was determined over time (see Fig. 1).

As can be seen from Table 1, fluctuations in central hemodynamic parameters (SV, CO and CI) did not exceed 20% of the initial indicators. And the data presented in Figure 1 indicate that the level of spread of the sensory block (Th _VII -S _III ) was sufficient to perform the operation.

Example 2.

Patient S., 59 years old, was routinely admitted to the gynecological department with a diagnosis of “Intramural uterine fibroids 15-16 weeks. Chronic anemia." Among the concomitant diseases: bronchial asthma, moderately severe, hypertension of the 3rd degree, 3 stages, 4 risks. Obesity stage 3. Height 165 cm. Body weight 115 kg. BMI 41 kg/m2. During hospitalization, indications for surgical treatment including uterine amputation were determined. Physical status on the ASA scale was assessed as 3 points. Method of anesthesia CSEA with REP. Standard preoperative preparation was performed. To prevent venous thromboembolic complications, compression bandaging of the lower extremities. In the operating room, monitoring of vital functions was established: blood pressure, heart rate, ECG, SpO ₂ , SV, CO, CI using non-invasive EsCCO technology, based on analysis of the pulse wave transit time. Next, regional anesthesia was performed according to the algorithm described in example 1. The dosages of bupivacaine and indifferent solution were similar (10 mg and 10 ml, respectively).

Extended hemodynamic monitoring was continued (see Table 2), and the area of distribution of the sensory block was determined over time (see Fig. 2).

Table 1 Hemodynamic parameters of patient R. Originally In 2 minutes In 4 minutes In 6 minutes In 8 minutes In 10 minutes In 20 minutes In 30 minutes At the end of the operation BP syst, mmHg 140 135 130 125 127 120 125 130 135 Blood pressure diast, mm Hg 85 80 83 78 80 75 75 80 80 Blood pressure avg, mm Hg 103 98 99 94 96 90 92 97 98 Heart rate, per minute 80 80 83 75 79 72 70 65 73 SpO2,% 98 99 99 99 99 99 99 99 99 UO, ml 76 82 88 80 85 82 80 77 74 SV, l/min 6.1 6.6 7.3 6.0 6.7 5.9 5.6 5.0 5.4 SI, l*m ₂ /min 3.1 3.4 3.7 3.1 3.4 3.0 2.9 2.6 2.8

Table 2. Hemodynamic parameters of patient S. Originally In 2 minutes In 4 minutes In 6 minutes In 8 minutes In 10 minutes In 20 minutes In 30 minutes At the end of the operation BP syst, mmHg 155 147 140 143 138 140 145 137 144 Blood pressure diast, mm Hg 87 82 86 81 80 78 77 82 82 Blood pressure avg, mm Hg 110 104 104 102 99 99 100 100 103 Heart rate, per minute 78 77 81 75 77 76 72 68 73 SpO2,% 98 99 99 99 99 99 99 99 99 UO, ml 80 86 91 85 89 86 84 80 87 SV, l/min 6.2 6.6 7.4 6.4 6.9 6.5 6.0 5.4 6.4 SI, l*m ² /min 2.9 3.4 3.8 3.3 3.5 3.4 3.1 2.8 3.3

As can be seen from Table 2 and Figure 2, in the second example it was also possible to achieve sufficient distribution of the sensory block without significant fluctuations in hemodynamics. In both cases, infusion therapy included 6 ml/kg of a balanced crystalloid solution. Intraoperative sedation in both cases consisted of fractional administration of 15 mg of midazolam. Additional intraoperative administration of analgesics and local anesthetics was not required. In the postoperative period, both patients received 0.2% ropivacaine solution epidurally as analgesia at a rate of 6-8 ml per hour on the first day, 4-6 ml per hour on the second day. No further analgesia was required. Both patients were discharged home in satisfactory condition.

To date, more than 80 regional anesthesia procedures have been performed using the method described above. In all cases, there were no changes in central hemodynamic parameters by more than 20% from the initial values. In all cases, the level of spread of the sensory block was sufficient for the operation. In 15 cases, due to technical difficulties for surgeons, the duration of operations exceeded 3 hours, which required the introduction of an additional bolus of 2% lidocaine into the epidural space in a dose of 4-6 ml. The claimed method is successfully used in the work of the department of anesthesiology and resuscitation of the Clinic of the Federal State Budgetary Educational Institution Samara State Medical University of the Ministry of Health of Russia, Samara. The method has important clinical, socio-economic significance from the point of view of highly effective and safe anesthesia for abdominal, gynecological, urological, and vascular operations, allowing one to maintain hemodynamic stability and obtain effective intra- and postoperative analgesia in high-risk patients.

The method ensures ease of selection of doses of local anesthetic and indifferent solution based only on the anthropometric data of the patient. Our experience in using this technique during anesthesia in more than 70 patients has shown the effectiveness of the somatosensory block and hemodynamic stability at all stages of the operation. The use of ultrasound navigation when choosing the interspinous space for puncture reduces the number of puncture attempts, reduces the risk of back pain after anesthesia and causes less discomfort to patients.

Information sources:

1. Perioperative management of patients with concomitant morbid obesity (third revision) / I. B. Zabolotskikh, K. M. Lebedinsky, M. A. Anisimov, etc. // Clinical recommendations. - M., 2020. - 38 p.

2. Sitkin S.I., Ronenson A.M., Savelyeva Yu.V. New technique for using spinal anesthesia with expansion of the epidural space during cesarean section in pregnant women with cardiac pathology // Anesthesiology and Reanimatology. - 2015. - No. 6. - P.58-61.

3. Pat. 2548510 RF IPC A61M 19/00. Method of spinal anesthesia in pregnant women with concomitant cardiovascular pathology // Sitkin S.I., Ronenson A.M., Savelyeva Yu.V., appl. 03/04/2014, publ. 04/20/2015).

Claims (3)

A method of combined spinal-epidural anesthesia with expansion of the epidural space in obese patients, characterized in that using an ultrasound navigator sensor, an interspinous space suitable for puncture is determined at the level of the III-IV lumbar vertebrae; in the selected area, local anesthesia of the skin and subcutaneous fat is performed with a 2% lidocaine solution; perform a puncture of the epidural space with a Tuochy 18 G epidural needle; identify the epidural space using the “loss of resistance” method; using a Quincke 27 G needle, a puncture of the subarachnoid space is performed; when receiving a drop of transparent colorless liquor in the needle pavilion, a 0.5% solution of the local anesthetic bupivacaine is injected into the subarachnoid space; To calculate local anesthetic dosages, body mass index (BMI) is calculated using the formula: BMI= and with a BMI of 30-35 kg/ ^m2, the dose of bupivacaine is 2.5 ml (12.5 mg), and with a BMI of more than 35 kg/ ^m2 - 2 ml (10 mg); after the administration of bupivacaine, the Quinke 27 G needle is removed, and a 20 G epidural catheter is inserted into the epidural space in the cranial direction for 3 cm in length; perform an aspiration test; A sterile bandage is applied to the skin puncture site; the catheter is fixed to the skin of the back with a sticker and isotonic sodium chloride is injected through it: with a BMI of 30-34 kg/m ² , the volume of sodium chloride is 16 ml, with a BMI of 35-40 kg/m ² - 13 ml, with a BMI of more than 40 kg/m ² - 10 ml; the patient is then placed on his back.