RU2339367C2 - Method for multi-component and multi-level regional anaesthesia in extremities surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly anaesthesiology, and can be applied as anaesthetic aid in extremities surgery. In such cases the multi-component mix is perineurally injected, consisting of 1% lidocaine solution, 0.1 mg phentanile, 50 mg thiamine bromide, 0.2 mg epinephrine, and 0.2 mg clopheline. At the same time 100 mg ketamine diluted in 400 ml 0.9 % NaCl solution is intravenously injected at speed 90 to 120 drops per minute.

EFFECT: anaesthesia efficiency and safety increasing, due to anaesthesiology protection in different levels by mutual anaesthetics potentiation.

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Description

The invention relates to medicine, in particular to anesthesiology, and is a method of regional anesthesia of operations on the limbs.

Regional anesthesia is known, which is carried out using perineural local anesthetic, leading to anesthesia and postoperative analgesia (Pashchuk A.Yu. Regional anesthesia / A.Yu. Pashchuk. - M .: Medicine, 1987, - 160 s .; Local anesthesia: Illustrated Practical Guide / M. Mulroy, translated from English by S.A. Panfilov, edited by Prof. S.I. Emelyanov, Moscow: BINOM, Laboratory of Knowledge, 2003, 301 pp., Ill.).

Sometimes, to increase the duration of anesthesia, vasoconstrictors (adrenaline), vitamin B1 and narcotic analgesics (fentanyl) are added to the local anesthetic (Tetslaf D.E. Peripheral nerve blockade / D.E. Morgan, Morgan - Jr., S.M. Megid. Clinical Anesthesiology // Translated from English - M. - St. Petersburg: Publishing House BINOM - Nevsky Dialect, 1998. - P.320-358; Samandarov V.Kh. Local Anesthesia / Anesthesiology and Intensive Care: Manual, ed. S. Polushina. - St. Petersburg: "ELBI-St. Petersburg", 2004. - S.314-338) or klofelin (Shelokhovich Yu.V. Non-opiate adrenergic prov unique anesthesia. Author's abstract of thesis ... candidate of medical sciences / Yu.V. Shelokhovich. - Novosibirsk, 1999, - 24 p.).

These methods have the following disadvantages:

- a short duration of anesthesia when using only a local anesthetic of lidocaine, and for anesthesia of the plexus requires a greater than 1% concentration of lidocaine, which increases the total dose of anesthetic, the risk of systemic and local toxicity;

- a long latent period when using modern local anesthetics of bupivacaine, mepivacaine, ropivacaine, levobupivacaine with a long duration of anesthesia;

- neurotoxicity with systemic (loss of consciousness, convulsions) and local (damage to the nerve and surrounding tissues) manifestations;

- cardiotoxicity of modern local anesthetics (bupivacaine, mepivacaine), manifested by bradycardia, hypotension, resistant to resuscitation by asystole;

- the high cost of the latest local anesthetics (ropivacaine or levobupivacaine) imported with fewer side effects, although they are not without cardio and neurotoxicity;

- side effects when using clonidine and agents to maintain intraoperative sleep, exacerbating the sympatholytic effect of local anesthetics and causing a violation of hemodynamics.

Closest to the set of essential features is the method according to which clonidine in a dosage of 2-4 mg / kg is added to perineurally administered lidocaine (Shelokhovich Yu.V. Non-opiate adrenergic conduction anesthesia. Author's abstract. Candidate of medical sciences / Yu. V. Shelokhovich. - Novosibirsk, 1999, - 24 pp .; Polushin Yu.S. Features of anesthesia and intensive care in traumatology and orthopedics / Yu.S. Polushin, Yu.I. Kushtan, V.M. Shapovalov. - St. Petersburg. : "MORSAR AV", 2002, 117 s).

The specified method has the following disadvantages:

- the use of clonidine in the dose recommended by the author is accompanied by bradycardia, hypotension, atrioventricular block, requiring hemodynamic correction with the help of sympathomimetic agents and increased infusion therapy;

- the dosage of clonidine 2 μg / kg in addition to lidocaine increases the duration of anesthesia and postoperative analgesia, but its effect is unstable and not in all patients;

- the sedative effect of clonidine to eliminate the sensation of the presence of the patient in his own operation at a dose of 3 μg / kg is not enough, and 4 μg / kg violates spontaneous breathing;

- the use of general-action drugs to create intraoperative sleep (benzodiazepines, propofol, barbiturates) enhances the sympatholytic effect of local anesthetic and clonidine, exacerbating hemodynamic disorders;

- in addition, the use of propofol to create intraoperative sleep increases the cost of anesthesia tenfold.

The aim of the invention is to increase the duration of regional anesthesia and postoperative analgesia in a controlled sedation with potentiation of anesthetic and leveling the negative effects of the drugs used at a low cost of anesthesia.

The goal is achieved by perineural administration of a multicomponent composition: local anesthetic (lidocaine), with excipients (including clonidine) (peripheral level of anesthetic protection) and intravenous - a general-action drug (central level).

The method is implemented as follows: the optimal multicomponent composition for perineural administration includes, in addition to 1% lidocaine solution, 0.1 mg of fentanyl, 50 mg of thiamine bromide, 0.2 mg of adrenaline, 0.2 mg of clonidine, but its resorptive side effect causes bradycardia, hypotension, atrioventricular block. The latter can be avoided by using ketamine to create intraoperative sleep using the adaptive inversion technique (V. Shanin, Patterns of Consciousness / V. Yu. Shanin, - Saratov, 2004, 192 pp.).

The dose of ketamine is 1-1.5 mg / min (100 mg is diluted in 400 ml of 0.9% NaCl solution at a rate of 90-120 drops per minute) and is selected in such a way as to stimulate hemodynamics using the property of ketamine (general anesthetic) to induce an increase in the number of heart contractions, blood pressure, atrioventricular conduction against the background of the necessary controlled sedation. The raffatory effect of clonidine, in turn, prevents psychomotor agitation, salivation, and other adverse effects of ketamine.

A practical example.

For anesthetic support of the upcoming operation, the day before, premedication was performed, consisting of 2 mg of phenazepam orally at 22:00. In the morning, similar premedication was repeated and supplemented with intramuscular injection of sibazon at a dose of 10 mg. Anesthesia was performed before surgery in 15-20 minutes. Immediately prior to administration, a multicomponent solution was prepared containing 1% lidocaine solution of 100 ml, in which 0.2 mg of adrenaline, 50 mg of thiamine bromide, 0.1 mg of fentanyl and 0.2 mg of clonidine were present. After treating the surgical field with an antiseptic solution under aseptic conditions, a paresthesia test was performed, the usual amount of solution for anesthesia of the brachial plexus, femoral or sciatic nerves was administered, specifying the patient's sensations. Before the operation, the time of the beginning of limb warming, anesthesia, anesthesia and motor block was determined. By the beginning of the operation, after 15-20 minutes, the effectiveness of anesthesia was evaluated. Anesthesia was considered complete if the shutdown of all types of sensitivity was observed and effective when receiving anesthesia in all segments of the limb. The depth of antinociceptive protection was determined by clinical and laboratory (glucose, cortisol, Kerdo index) signs. Hemodynamics, respiration rate, oxygen saturation of peripheral tissues, ECG were determined intraoperatively, sedation was evaluated on a Ramsey scale. In the postoperative period, the duration of anesthesia and postoperative analgesia was determined on a visual analogue scale. Fixed the time requirements of anesthesia.

After perineural administration of the solution after 4.3 ± 1.7 min (latent period), signs of limb anesthesia appeared. Anesthesia lasted 5.0 ± 0.9 hours, and with a postoperative analgesia duration of 8.8 ± 1.0 hours. Clonidine has no effect on the rate of anesthesia (table 1).

Table 1 The effect of 0.2 mg of clonidine with adaptive inversion of ketamine on the duration of the latent period, the duration of anesthesia and postoperative analgesia The investigated parameters Hidden period, min Duration of anesthesia, hour Duration of anesthesia and postoperative analgesia, hour Result 4.3 ± 1.7 5.0 ± 0.9 8.8 ± 1.0

Analysis of hemodynamic parameters of patients showed the absence of a significant deviation at all stages studied: examination by an anesthesiologist on the eve of blood pressure _Wed 96.4 ± 8.9 mm Hg, heart rate 78.1 ± 7.6 / min, QT interval 0.15 ± 0 , 02 s; the most traumatic moment of the operation (osteotomy and others) BP _mean 85.2 ± 5.7 mm RT. Art., heart rate 77.2 ± 3.5 / min, QT interval 0.16 ± 0.031 s; the end of the operation of blood pressure _Wed 88.7 ± 4.3 mm RT. Art., heart rate 69.4 ± 6.4 / min, QT interval 0.16 ± 0.026 s (Table 2).

table 2 The effect of clonidine in a dose of 0.2 mg with adaptive inversion of ketamine on hemodynamics The investigated parameters Examination of the anesthesiologist on the previous day The most traumatic stage of the operation End of operation ADSR, mmHg Art. Heart rate, min QT interval, s ADSR, mmHg Art. Heart rate, min QT interval, s ADSR, mmHg Art. Heart rate, min QT interval, s Result 96.4 ± 8.9 78.1 ± 7.6 0.15 ± 0.02 85.2 ± 5.7 77.2 ± 3.5 0.16 ± 0.031 88.7 ± 4.3 69.4 ± 6.4 0.16 ± 0.026

Thus, the proposed combination of administered perineurally multicomponent composition with the addition of 0.2 mg of clonidine to a 1% solution of lidocaine and intravenous ketamine to maintain intraoperative sleep mutually potentiates the analgesic and eliminates the negative effects of each other, providing long-term and reliable antinociceptive protection, stable hemodynamics, respiration and prolonged postoperative analgesia of operations on the limbs.

Claims (1)

A method of multicomponent anesthesia for operations on the extremities, characterized in that a mixture consisting of a 1% solution of lidocaine, 0.1 mg of fentanyl, 50 mg of thiamine bromide, 0.2 mg of adrenaline, 0.2 mg of clonidine is administered perineurally 100 mg of ketamine diluted in 400 ml of a 0.9% NaCl solution is administered intravenously at a rate of 90-120 drops per minute.