RU2828015C1 - Method of anesthesia in orthopedic and traumatological operations on lower extremities in children - Google Patents

Abstract

FIELD: medicine; anesthesiology.

SUBSTANCE: invention can be used for combined anesthesia in orthopedic and traumatological operations on lower extremities in children. Method includes premedication, induction with inhalation anesthetics or hypnotics, installation of a laryngeal mask, performing maintenance anesthesia with inhalation anesthetics and performing nerve block of sciatic and femoral nerves using a peripheral nerve stimulator under ultrasound control. Conduction blocks of the sciatic and femoral nerves are performed with combination of 1% lidocaine and 0.5% ropivacaine in ratio of 1:1. When performing a sciatic nerve block, the volume of local anesthetics is 0.2 ml/kg, and for a femoral nerve block—0.1 ml/kg. Total amount of lidocaine 1% for the blockade of both nerves is 1.5 mg/kg, and ropivacaine 0.5%—0.75 mg/kg.

EFFECT: method provides improving the quality of anesthesia both during the surgical intervention and in the postoperative period, and also increases the effectiveness and safety of anesthesia in children by reducing the amount of narcotic analgesics and inhalation anesthetics during the surgical intervention.

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Description

The invention relates to medicine, namely to anesthesiology, and can be used in providing anesthesiological support for orthopedic and traumatological surgical interventions on the lower limbs of children.

The most common method of anesthetic support for orthopedic and traumatological operations on the lower extremities in children is multicomponent balanced endotracheal anesthesia. However, the most adequate protection of the patient from surgical stress, as well as from postoperative pain, is possible only with a multimodal approach to pain relief [1, 2]. In this regard, in the last decade, combined anesthesia methods based on combinations of general anesthesia and spinal anesthesia, as well as general anesthesia and conduction blocks of peripheral nerves have been used in pediatric anesthesiology. These methods have a number of advantages over general anesthesia, but are not without disadvantages. The disadvantages of spinal anesthesia include the risks of hemodynamic instability and high spinal block, and to ensure adequate analgesia in operations on the lower extremities, a block of several nerves is required, which increases the risk of systemic toxicity due to the use of local anesthetics in high doses [3].

A method of anesthesia for operations on the lower extremities in children is known, based on a combination of general and unilateral spinal anesthesia in children, described in the article by Kozyrev A.S. and co-authors “Monolateral spinal anesthesia in children” in the medical journal “Traumatology and Orthopedics of Russia” No. 2 (56) - 2010 [4].

After premedication and general anesthesia, with the child lying on his side, intrathecal administration of a hyperbaric solution of local anesthetic was performed. The advantage of this method is the high level of intraoperative analgesia. The known disadvantages of the spinal component of anesthesia are the high risk of intraoperative hypotension, as well as a shorter time of postoperative analgesia, according to the authors of the publication up to 2.5 hours.

A method for conducting conduction blocks of the sciatic and femoral nerves under ultrasound control during surgical interventions on the lower extremities in children is known. (Aizenberg V.L., Ulrich G.E., Dypin L.E., Zabolotsky D.V. Regional anesthesia in pediatrics M. SPb. 2011 - 304 p.).

This method involves identifying nerves using an ultrasound machine. After verification of the nerve, a local anesthetic is administered under sonographic control. The authors indicate a recommended dosage of lidocaine up to 5 mg/kg, and ropivacaine up to 2 mg/kg. The advantage of this method is real-time control of the spread of the anesthetic around the nerve. The disadvantage of this method is the high dosage of local anesthetics, which increases the risk of systemic toxicity.

The closest to our method is the method of anesthetic support of high-tech operations in pediatric orthopedics described in the article by Akulov M.S., Vodopyanov K.A. "Anesthetic support of high-tech operations in pediatric orthopedics" published in the medical journal "Medical Almanac" No. 2 (11) - 2010 [6]. This method is based on a combination of general anesthesia using a laryngeal mask and conduction blocks of the sciatic and femoral nerves under ultrasound control. The advantage of this method is the reduction in the consumption of inhalation anesthetics and narcotic analgesics during surgery. The disadvantage of this method is the use of the maximum permissible dosage of local anesthetics, according to the authors, the amount of ropivacaine for the blockade of two nerves was 3.3 mg / kg, which can lead to systemic toxicity.

The objective of the claimed invention is to create a method that allows for increasing the safety of conduction blocks as a component of combined anesthesia by reducing the volume and dosage of local anesthetics, reducing the need for narcotic analgesics and inhalation anesthetics during surgery, early awakening of the child after the end of the operation, and ensuring optimal pain relief in the postoperative period.

The set goal is achieved by performing conduction blocks of the sciatic and femoral nerves under ultrasound control with the introduction of local anesthetics in a volume of 0.2 ml/kg for a block of the sciatic nerve and 0.1 ml/kg for a block of the femoral nerve.

When implementing the claimed method, the anatomical features of the structure and topography of the sciatic and femoral nerves in children were taken into account depending on age, body weight, height. Due to the age of the child, the area of the circumference of the said nerves increases, which affects the amount and volume of local anesthetic.

The method of conduction anesthesia with small doses and volumes of local anesthetics proposed by us as a component of combined anesthesia was used in 35 patients. In 96% of cases after the introduction of the calculated amount and volume of local anesthetic, an effective blockade was achieved, expressed in a decrease in the need for narcotic analgesics and inhalation anesthetics, both during the operation and in the postoperative period. The absence of significant complications demonstrated the safety of the proposed method.

The method is carried out as follows. Premedication is carried out 2 hours before the onset of anesthesia orally with diazepam or midazolam. Upon admission to the operating room, anesthesia monitoring is provided. Induction of anesthesia is carried out by inhalation of sevoflurane or intravenous propofol at a dosage of 1.8-2 mg / kg. A laryngeal mask is used to maintain airway patency. Before installing the laryngeal mask, a 0.005% fentanyl solution is administered intravenously at a dose of 0.4-0.5 mcg / kg, but not more than 1 ml. Then conduction blocks of the sciatic and femoral nerves are performed with a combination of 1% lidocaine and 0.5% ropivacaine solutions in a 1: 1 ratio in small doses and volumes of local anesthetics. The total amount of 1% lidocaine for blocking both nerves is 1.5 mg/kg, and 0.5% ropivacaine is 0.75 mg/kg. Anesthesia is maintained with an oxygen-air mixture in combination with sevoflurane. MAC values during surgery are maintained at 0.6-0.8. Technique for performing regional anesthesia:

Sciatic nerve block is performed using the infragluteal approach. The patient is positioned in the prone or lateral position. After visualization of the sciatic nerve, the needle is inserted under aseptic conditions at an angle of 30° to the skin surface, 1 cm away from the sensor using the "in plane" technique. Electrical neurostimulation is performed simultaneously with ultrasound visualization. Reaching the paraneural space is determined by ultrasound visualization of the needle tip, as well as by obtaining induced muscle contractions of the foot at a current of 0.3-0.5 mA in the form of plantar flexion when stimulating the tibial part of the nerve and dorsiflexion upon contact with the peroneal part. After an aspiration test, a local anesthetic solution (hereinafter MA) was administered fractionally by 0.5-1 ml until it was completely distributed around the nerve. The volume of local anesthetics depends on the cross-sectional area of the nerve. For the blockade of the heart muscle, 0.2 ml/kg of MA solution is used, which is 2/3 of the total calculated volume of MA.

Femoral nerve block. The child is positioned in the supine position. The linear ultrasound probe is installed in the inguinal ligament area. The neurovascular bundle is identified. The nerve is defined as a hyperechoic formation located lateral to the pulsating femoral artery under the iliac fascia. The needle is inserted at an angle of 30° to the skin surface from the lateral side in the plane of the probe scanning. During electrical stimulation, contraction of the quadriceps muscle of the thigh or movement of the patella is noted. The local anesthetic solution is administered fractionally by 0.5-1 ml until it is completely distributed around the femoral nerve. For the FN block, 0.1 ml/kg of MA solution is used, which is 1/3 of the total calculated volume of MA.

The use of this method is confirmed by specific clinical examples.

Example 1

Patient M., age 11 years. Height 155 cm, weight 46 kg, underwent surgery for apophysitis of the navicular bone of the right foot. Premedication with diazepam 5 mg orally 2 hours before surgery. Induction of anesthesia with a gas anesthetic mixture: oxygen, sevoflurane. Before installing the laryngeal mask, a 0.005% fentanyl solution - 0.5 mcg / kg was administered intravenously. Then conduction blocks were performed: under ultrasound control using a peripheral nerve neurostimulator, a blockade of the sciatic nerve was performed through the subgluteal access with a solution of 0.5% ropivacaine and 1% lidocaine in a 1: 1 ratio in a volume of 8.5 ml (0.19 ml / kg), and then the femoral nerve with a volume of local anesthetics of 4.5 ml (0.1 ml / kg). The duration of the operation was 60 minutes. The time from the end of the operation to the removal of the laryngeal mask was 5 minutes. The duration of the pain-free period was 360 minutes. The intensity of the pain syndrome, measured by the Wong-Baker linear visual analogue scale: after 2 hours - 0 points, after 6 hours - 5 points, after 24 hours - 3 points (out of 10 possible). There were no complications of anesthesia.

Example 2

Patient B. Age 6 years. Height 130 cm, weight 35 kg, underwent surgery for a closed fracture of the right tibia. Premedication with diazepam 5 mg orally 2 hours before surgery. Induction of anesthesia with a gas narcotic mixture: oxygen, sevoflurane. Before installing the laryngeal mask, a 0.005% fentanyl solution - 0.45 mcg / kg was administered intravenously. Then conduction blocks were performed: under ultrasound control using a peripheral nerve neurostimulator, a blockade of the sciatic nerve was performed through the gluteal approach with a solution of 0.5% ropivacaine and 1% lidocaine in a 1: 1 ratio in a volume of 6.5 ml (0.18 ml / kg), and then the femoral nerve with a volume of local anesthetics of 3.5 ml (0.1 ml / kg). The duration of the operation was 65 minutes. The time from the end of the operation to the removal of the laryngeal mask was 3 minutes. The duration of the pain-free period was 350 minutes. The intensity of the pain syndrome, measured by the Wong-Baker linear visual analogue scale: after 2 hours - 0 points, after 6 hours - 1 point, after 24 hours - 1 point (out of 10 possible). There were no complications of anesthesia.

Example 3

Patient V. Age 11 years. Height 150 cm, weight 35 kg, operated on for a closed fracture of the right tibia. Premedication with diazepam 5 mg orally 2 hours before the operation. Induction of anesthesia with propofol 1% at a dose of 2 mg/kg. Before installing the laryngeal mask, a solution of fentanyl 0.005% - 0.43 mcg/kg and dithiline 2% - 1.4 mg/kg were administered intravenously. Then conduction blocks were performed: under ultrasound control using a peripheral nerve neurostimulator, a blockade of the sciatic nerve was performed via the subgluteal approach with a solution of 0.5% ropivacaine and 1% lidocaine in a 1:1 ratio in a volume of 7 ml (0.2 ml/kg), and then the femoral nerve was blocked with a volume of local anesthetics of 4.0 ml (0.1 ml/kg). The duration of the operation was 90 min. The time from the end of the operation to the removal of the laryngeal mask was 1 minute. The duration of the pain-free period was 390 minutes. The intensity of the pain syndrome, measured using the Wong-Baker linear visual analogue scale: after 2 hours - 0 points, after 6 hours - 1 point, after 24 hours - 2 points (out of 10 possible). There were no complications of anesthesia.

Documents cited in the search report:

1. Prokhorov A.V., Dzyadzko A.M., Dzyadzko M.A. Surgical interventions and anesthesia. - Minsk: Popurri, 2007. - 287 p.: ill.

2. Ilyukevich G.V., Oletsky V.E. Regional anesthesia. Minsk: Kovcheg, 2006. - 164 p.: ill. 86-91.

3. Pechersky V.G., Marochkov A.V. Possibility of femoral nerve block under U3 control using a peripheral nerve stimulator with small doses of ropivacaine. Regional anesthesia and treatment of acute pain. 2018; 12 (4): 217-221.

4. Kozyrev A.S. and co-authors. Monolateral spinal anesthesia in children. Traumatology and Orthopedics of Russia. 2010; 2(56): 13-17.

5. Ayzenberg V.L. et al. Regional anesthesia in pediatrics. St. Petersburg: "Sintez Buk", 2011, p. 304.

6. Akulov M.S., Vodopyanov K.A. Anesthetic support of high-tech operations in pediatric orthopedics. Medical almanac.2010;2(11):205-207.

Claims (1)

A method of combined anesthesia for orthopedic and traumatological surgeries on the lower extremities in children, including premedication, induction with inhalation anesthetics or hypnotics, installation of a laryngeal mask, maintenance anesthesia with inhalation anesthetics and performance of conduction blocks of the sciatic and femoral nerves using a peripheral nerve neurostimulator under ultrasound control, differs in that conduction blocks of the sciatic and femoral nerves are performed with a combination of 1% lidocaine and 0.5% ropivacaine solutions in a 1:1 ratio; when performing a sciatic nerve block, the volume of local anesthetics is 0.2 ml / kg, and for a femoral nerve block - 0.1 ml / kg; The total amount of lidocaine 1% for blocking both nerves is 1.5 mg/kg, and ropivacaine 0.5% is 0.75 mg/kg.