RU2733165C1 - Method of general anaesthesia in vitreoretinal operations - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to anaesthesiology in ophthalmosurgery. Presented is a method for general anaesthesia in vitreoretinal surgeries involving premedication followed by induction into anaesthesia by administering hypnotic propofol and esmeron muscle relaxant, intubation of a trachea, performing a subtenon anaesthesia and supporting anaesthesia by a surgeon. That is combined with application of mixture of 0.75 % ropivacaine solution and viscoelastic.EFFECT: invention provides blocking of afferent impulsation by combined use of general, subtenon and application anaesthesia, thereby contributing to reducing the rate of development of oculocardic and oculogastral reflexes and associated adverse consequences.1 cl, 2 ex

Description

The invention relates to medicine, namely to anesthesiology in ophthalmic surgery, and can be used when carrying out vitreoretinal operations.

A known method of carrying out retrobulbar anesthesia during abdominal operations on the eyeball, which consists in the fact that 45-60 minutes before the operation, a 2% lidocaine solution or 0.5% bupivacaine solution is administered in a volume of 4 to 5 ml. [RF patent No. 2400260 "a method of conducting retrobulbar anesthesia during abdominal operations on the eyeball" Bakunina NA, Ivanov IL].

The disadvantages of this method is that the use of only 2% lidocaine solution for anesthesia in vitreoretinal surgery is not effective enough, given the short duration of its action (60-90 minutes) and the duration of vitreoretinal interventions.

The prototype is a method of conducting general anesthesia during vitreoretinal operations, which consists in the fact that premedication is carried out followed by induction into anesthesia by injecting the hypnotic propofol at a dose of 1.2-1.5 mg / kg and the muscle relaxant trakrium at a dose of 0.5-0.6 mg / kg. Then the trachea is intubated or a laryngeal mask is installed, after which the surgeon performs subtenon anesthesia in the lower inner quadrant by introducing 2 ml of 0.5% naropin and proceeds to perform the intervention. Anesthesia is maintained with a mixture of nitrous oxide and oxygen in a 2: 1 ratio and an inhalation anesthetic sevoran at a dose of 0.5-1.2 vol%. Trakrium is additionally administered at a dose of 0.03 mg / kg / h using a micro-jet syringe dispenser. At the stages of the operation with a more pronounced pain reaction, the anesthesiologist, at the signal of the surgeon, 30 seconds before the start of work in this zone, increases the dose of sevoran to 3.5-4.5 vol% and also at the signal of the surgeon when the zone of increased pain sensitivity is passed. returns the sevoran volume to the initial one. Also, at the beginning or at the end of the operation, the antimemetic zofran is administered at a dose of 4 mg (RF Patent No. 2304963 "Method for conducting general anesthesia in vitreoretinal operations" NV Kazaykin, PN Rylov).

Disadvantages of the prototype:

1. Muscle traction, pressure on the sclera during vitreoretinal operations lead to the development of oculocardial and oculogastric reflexes.

2. It is undesirable to use nitrous oxide during vitreoretinal operations.

3. Postoperative vomiting and nausea are more frequent after inhalation anesthesia than after total intravenous anesthesia [A.A. Bunyatyan, E.V. Flerov, V.I. Stamov, K.M. Tolmachev. Total intravenous anesthesia with propofol (diprivan) according to the target concentration. Bulletin of intensive care №1, 1999, p. 3-11].

4. The use of inhaled anesthetics should be excluded in patients at risk of developing malignant hyperthermia.

5. When ensuring airway patency, an endotracheal tube is preferred over a laryngeal mask.

6. It is also necessary to remember about environmental pollution and the adverse effects of inhalation anesthetics on medical personnel.

The objective of the invention is to provide comprehensive prevention of intraoperative consequences of the oculocardial reflex and postoperative nausea and vomiting caused by the development of the oculogastric reflex during vitreoretinal operations.

The task is achieved by the fact that in the method of conducting general anesthesia during vitreoretinal operations, including premedication followed by induction into anesthesia by intubating the hypnotic propofol and muscle relaxant, performing tracheal intubation, performing subtenon anesthesia by the surgeon and carrying out maintenance anesthesia, according to the invention, propofol is administered during the induction at a dose of 2.5 mg / kg, and esmeron is used as a muscle relaxant at a dose of 0.5-0.6 mg / kg, and subtenon anesthesia is carried out by the introduction of 4 ml of a 0.75% solution of ropivacaine, a surgical operation is started, maintaining anesthesia propofol is also carried out at a dose of 8 mg / kg / h, while during maintenance anesthesia, esmeron is used as a muscle relaxant at a dose of 0.5-0.6 mg / kg, and during the operation, additionally, on the projection of the eye muscles, the mixture 0 is applied, 75% solution of ropivacaine and viscoelastic.

Anesthesia during vitreoretinal operations, includes: premedication - diphenhydramine, dormicum, promedol, induction with hypnotics - propofol at a dose of 2.5 mg / kg and muscle relaxant - esmeron at a dose of 0.5-0.6 mg / kg, the introduction of a narcotic analgesic fentanyl at a dose of 2 μg / kg. After induction and intubation of the patient, the surgeon performs subtenon anesthesia with 0.75% ropivacaine in a volume of 4 ml and proceeds to perform the surgical operation. For maintenance anesthesia, the administration of propofol 8 mg / kg / h, esmeron 0.5 mg / kg is used. Against the background of general anesthesia, subtenon anesthesia is performed, after which 0.75% ropivacaine-gel is applied along the projection of the rectus muscles of the eye. In the case of the development of manifestations of the oculocardial reflex in the intraoperative period, the surgeon's work is suspended until the normal heart rhythm is normalized and intravenous atropine 0.01 mg / kg, fentanyl 1 μg / kg is prescribed.

Ropivacaine gel is applied after dilution in equal proportions (1: 1) of a 0.75% solution of ropivacaine and viscoelastic. The viscoelastic used was "Viscot" from "Alcon". Each ml of solution contains: sodium hyaluronate 16.5 mg; sodium chondroitin sulfate 40.0 mg: sodium dihydrogen phosphate monohydrate 0.45 mg; disodium phosphate anhydrous 2.0 mg; sodium chloride 3.1 mg; sodium hydroxide and / or concentrated hydrochloric acid to adjust the pH; water for injection to bring the volume to 1 ml. Chondroitin sulfate, like sodium hyaluronate, is a biological polymer of the extracellular matrix of animals and humans. The corneal tissue of the eye has the highest concentration of chondroitin sulfate, while the vitreous humor and aqueous humor of the eye contains the highest concentration of sodium hyaluronate. Ropivacaine (1-propyl-2, 6-pipecoloxylidide hydrochloride) is a long-acting local anesthetic of the amide type, which has both local anesthetic and analgesic effects. 1 ml of solution contains: active substance: ropivacaine hydrochloride monohydrate. Excipients: sodium chloride for injection - 8.6 mg, sodium hydroxide, water for injection.

Among the essential features that characterize the method, the distinctive features are the following:

- induction is carried out with propofol at a dose of 2.5 mg / kg;

- after the performed induction and intubation of the patient, the surgeon performs subtenon anesthesia with ropivacaine 0.75% in a volume of 4 ml and proceeds to the surgical operation;

- maintenance anesthesia, where propofol is used as an anesthetic at a dose of 8 mg / kg / h. and the muscle relaxant esmeron at a dose of 0.5 mg / kg;

- at the stage of the operation preceding muscle traction, ropivacaine gel is applied along the muscle projection;

- at the stages of the operation associated with depression of the eyeball and traction of the muscles of the eyes causing the development of the oculocardial reflex, the anesthesiologist, if necessary, additionally introduces fentanyl 1 μg / kg;

There is a causal relationship between the set of essential features of the claimed invention and the achieved technical result.

Induction by the proposed route is a quick and controlled introduction of the patient into anesthesia. At the same time, blood pressure decreases, which is important when carrying out vitreoretinal operations, given that among the operated patients there are often elderly people with hypertension and other concomitant diseases. Perioperative complications during vitreoretinal operations are both intraoperative consequences of the oculocardiac reflex, in particular, dangerous forms of heart rhythm disturbances, and the consequences of the oculogastric reflex, in the form of postoperative nausea and vomiting. The intraoperative period with propofol in comparison with inhalation anesthetics is associated with a lower likelihood of postoperative nausea and vomiting. Subtenon anesthesia in ophthalmic surgery provides anesthesia for the structures of the eye, however, in this case, against the background of general anesthesia and subtenon anesthesia, application anesthesia is also carried out, and this combination allows to ensure a smooth course of intraoperative (reducing the likelihood of developing manifestations of oculocardial reflex) and postoperative (prevention of manifestations of oculogastric reflex) and vomiting) periods, positive results of surgery. The long-acting ropivacaine (10-12 hours) local anesthetic used for subtenon anesthesia greatly reduces the need for postoperative pain relief. Application of 0.75% ropivacaine gel on the projection of the eye muscles undergoing traction against the background of general and subtenon anesthesia leads to blockade of nerve endings in the thickness of the eye muscles. Thus, when carrying out vitreoretinal operations, the proper blockade of afferent impulses from the area of surgical intervention ensures the prevention of adverse consequences in the form of oculocardial and oculogastric reflexes. At the same time, the consequences of the oculogastric reflex in the postoperative period can be repeated hemorrhages in the vitreous body, which in turn neutralizes the positive results of the operations performed and requires repeated surgical intervention. Thus, there is a causal relationship between the set of essential features and the achieved technical result.

At certain stages of vitreoretinal operations, for a better visualization of the intervention zone, for a short time, it is necessary to press the sclera, traction of the muscles, which in turn leads to significant nociceptive impulses, as a result of which the blood pressure and intraocular pressure increase. The latter factors lead to increased bleeding of the retinal vessels, and can also lead to the development of oculovisceral (oculocardial and oculogastric) reflexes.

The advantage of the present invention is that the method allows to provide blockade of afferent impulses, by the combined use of general, subtenon and application anesthesia, thereby helping to reduce the frequency of development of oculocardial and oculogastric reflexes and associated adverse consequences.

The method is carried out in the following way. Anesthetic benefits begin with premedication - intramuscular administration of promedol (0.15-0.2 mg / kg), diphenhydramine (0.2 mg / kg), dormicum (0.1 mg / kg) 30 minutes before the operation. After that, the patient is inducted into anesthesia: propofol (2.5 mg / kg), fentanyl at a dose of 2 μg / kg and esmeron (0.6 mg / kg). After achieving complete muscle relaxation, against the background of oxygen supply through the face mask, laryngoscopy and intubation of the patient are performed with further artificial lung ventilation (ALV). For maintenance anesthesia, propofol 8 mg / kg / h, fentanyl 1.5 μg / kg / h, and myoplegia are administered intravenously with Esmeron at a dose of 0.6 mg / kg.

During the entire anesthetic treatment, the general condition of the patient is monitored using an ECG, pulse oximeter, capnograph.

After the introduction into anesthesia, the surgeon injects 4.0 ml of 0.75% ropivacaine solution into the subtenon space. A vitreoretinal operation is started, during which the surgeon performs application anesthesia with ropivacaine gel along the muscle projection. During the operation, in the case of the development of the oculocardial reflex when working in the zone of increased pain sensitivity - depression of the sclera, muscle traction, the anesthesiologist injects atropine 0.01 mg / kg, if necessary - fentanyl 1 μg / kg. During the operation, an infusion of crystalloid solutions is carried out, with diuresis control.

After the completion of the operation, with the full restoration of adequate breathing and consciousness, the patient is extubated.

Example 1. A 20-year-old patient L. 18.10.2018 was admitted to the National Center of Ophthalmology named after Academician Z. Alieva with complaints of visual impairment in the left eye since August 2018. In 2016, the "Excimer laser vision correction" operation was performed in both eyes, and in September 2018, laser coagulation of the retinal periphery was performed on the right eye.

On admission - visual acuity in the right eye - 0.4, on the left eye - 0.1. Intraocular pressure on the right eye is 10 mm Hg, on the left eye - 2 mm Hg. Biomicroscopy data in both eyes did not reveal any pathology in the anterior segment of the eye. On the basis of the data from the fundus studies, the patient was diagnosed with rhegmatogenous retinal detachment.

24.10.2018. the patient underwent the operation "Circular scleral circulation, posterior vitrectomy". Premedication carried out 30 minutes before the start of the operation included diphenhydramine (10 mg), dormicum (0.1 mg / kg), promedol (0.15 mg / kg), administered intramuscularly. Induction was carried out by intravenous administration of propofol at a dose of 2.5 mg / kg and fentanyl at a dose of 2 μg / kg, after which muscle relaxation was carried out with Esmeron at a dose of 0.6 mg / kg. After preoxygenation, tracheal intubation was performed, followed by transfer to mechanical ventilation. Then the surgeon performed subtenon anesthesia as follows: after the incision of the conjunctiva and the tenon capsule in one of the lower quadrants, at the surgeon's choice, 10-13 mm from the limbus, with a curved spatula, the tenon fascia is bluntly separated from the sclera. A blunt cannula, curved according to the shape of the eyeball, is inserted between the sclera and the tenon capsule to the posterior pole of the eyeball. 4 ml of 0.75% ropivacaine solution is injected from a syringe attached to the cannula.

Anesthesia was continued with the introduction of propofol 10 mg / kg / h, fentanyl 1.5 μg / kg / h, myoplegia - with the introduction of esmeron at a dose of 0.6 mg / kg, crystalloids were infused. During the operation, in addition to general anesthesia and subtenon anesthesia, the technique of application anesthesia was carried out, which included the application of ropivacaine gel to the surface of the eye, along the projection of the muscles, providing anesthesia of the nerve endings. During the operation after scleral circling, 23 G 3-portal vitrectomy was performed and the internal border membrane was removed in the macular zone, endolaser-photocoagulation was performed at 360 °, then intravitreal cavity tamponade with 15% C3F8 gas was performed. In the intraoperative period, the development of manifestations of the oculocardial reflex was not observed. After the end of the operation and restoration of muscle tone, laryngopharyngeal reflexes and adequate spontaneous breathing, tracheal extubation was performed. The postoperative period was uneventful: hemodynamic parameters were normal, there was no postoperative nausea and vomiting, there was no need to administer antiemetics and pain relievers.

The next morning after the operation, the retina was adjoining, the circling effect was detailed, the zones exposed to the photocoagulation by the laser, and the gas was located in the intravitreal cavity. Visual acuity of the left eye - hand movement near the face, intraocular pressure - 17.3 mm Hg. In the dynamics of observations: a month after surgery, the retina was adjoining, and 70% of the gas was noted in the intravitreal cavity. Visual acuity of the left eye 0.03, intraocular pressure 17.3 mm Hg.

Example 2. Patient F., 27 years old, was admitted to the National Center of Ophthalmology named after Academician Z. Alieva, due to complaints of sudden loss of vision in the left eye. From the anamnesis: in 2016, the patient underwent enucleation of the eyeball with the introduction of an endoprosthesis on the right eye for terminal glaucoma. On examination: right eye - anophthalmos, left eye - visual acuity with 0.1 correction, intraocular pressure on the left eye - 30 mm Hg. Based on the results of the fundus examination and other studies carried out, the patient was diagnosed with: Right eye - anophthalmos. Left eye - Rhematogenous retinal detachment, high myopia, complicated immature cataract, O / U 2 C glaucoma, the consequences of anterior uveitis. To the patient 10/24/2018. surgery was performed on the left eye - scleral circlage, 3-portal posterior vitrectomy 23 G, endolaser photocoagulation 360 and injection (endotamponade) of 15% C3F8 gas.

Premedication carried out 30 minutes before the start of the operation included: diphenhydramine (10 mg), dormicum (0.1 mg / kg), promedol (0.15 mg / kg), intramuscularly. Induction was carried out by intravenous administration of propofol at a dose of 2.5 mg / kg and fentanyl at a dose of 2 μg / kg, followed by muscle relaxation with esmeron at a dose of 0.6 mg / kg. After preoxygenation, tracheal intubation was performed, followed by transfer to mechanical ventilation. Then the surgeon performed subtenon anesthesia with the introduction of 4 ml of a 0.75% ropivacaine solution.

Anesthesia was continued with the introduction of propofol 10 mg / kg / h, fentanyl 1.5 μg / kg / h, myoplegia - with the introduction of esmeron at a dose of 0.6 mg / kg, crystalloids were infused. During the operation, in addition to general anesthesia and subtenon anesthesia, the technique of application anesthesia was carried out, which included the application of ropivacaine gel to the surface of the eye, along the projection of the muscles, which provided anesthesia of the nerve endings. During the intraoperative period, there were no manifestations of the oculocardial reflex. After the end of the operation and restoration of muscle tone, laryngopharyngeal reflexes and adequate spontaneous breathing, tracheal extubation was performed. The postoperative period was uneventful: hemodynamic parameters were normal, there was no postoperative nausea and vomiting, there was no need to administer antiemetic and pain relievers.

On examination the next morning, the retina was adherent, the circling effect, the zones exposed to laser photocoagulation were noticeable and the eye was located in the intravitreal cavity. Visual acuity - movement of hands near the face, intraocular pressure - 22 mm Hg.

Ensuring proper anesthesia during vitreoretinal operations is one of the most difficult, due to the length of time, trauma and complexity of the intervention itself.

The advantage of local anesthesia is that the side effects of the drugs used are minimal, so there is a rapid rehabilitation of the general condition of patients after surgery, which is especially important in severe concomitant pathology: cardiomyopathy, chronic renal failure, respiratory failure, etc. anesthesia, possible complications. The risk of damage to the vessels of the apex of the orbit with the formation of a retrobulbar hematoma during retrobulbar anesthesia is up to 1.7%. Direct trauma to the optic nerve with a needle can lead to blindness, and trauma to other nerve trunks can lead to paresis of the extraocular muscles, and perforation of the eyeball is possible. At the same time, local anesthesia does not provide controlled arterial hypotension, therefore, good hemostasis is not always ensured. [Samokhvalova N.M., Rozhko Yu.I., Gurko N.A. Complication of retrobulbar anesthesia, clinical case / Modern technologies for the treatment of vitreoretinal pathology. Collection of abstracts / FGBU "MNTK" Eye Microsurgery ", Moscow 2013. p. 162-164].

At certain stages of vitreoretinal operations, for a better visualization of the intervention zone, for a short time, it is necessary to press the sclera, traction of the muscles, which in turn leads to significant nociceptive impulses, as a result of which blood pressure and intraocular pressure increase. The latter factors lead to increased bleeding of the retinal vessels, and can also lead to the development of oculovisceral reflexes. Oculocardiac reflex refers to oculovisceral reflexes, the clinical manifestations of which include severe bradycardia, extrasystole, atrioventricular blockade, and asystole.

In the National Center of Ophthalmology named after Academician Z. Aliyeva, vitreoretinal operations were performed on 76 patients according to the invention. In all cases, the proposed method of combined anesthesia proved to be optimal: it provided the prevention of the oculocardial reflex and the oculogastric reflex.

Claims (1)

A method of conducting general anesthesia in vitreoretinal operations, including premedication followed by induction into anesthesia by intubating the trachea, performing subtenon anesthesia by the surgeon, and conducting maintenance anesthesia, characterized in that during the induction period propofol is administered at a dose of 2.5 mg / kg, and esmeron is used as a muscle relaxant at a dose of 0.5-0.6 mg / kg, and subtenon anesthesia is carried out by the introduction of 4 ml of a 0.75% solution of ropivacaine, a surgical operation is started, maintenance anesthesia is also performed with propofol at a dose of 8 mg / kg / h, while during maintenance anesthesia, esmeron is used as a muscle relaxant at a dose of 0.5-0.6 mg / kg, and during the operation, a mixture of 0.75% solution of ropivacaine and viscoelastic is applied in addition to the projection of the eye muscles ...