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INDICATORS OF HEMODYNAMIC IN THE CONDITIONS OF COMBINED ANESTHESIA OPTIONS WITH VENTILATOR AND EXTRACURRICULAR BLOCKADES WITH MORPHINE

 

Anaesthesiology

Анестезиология

 

UDC 617-089

 

INDICATORS OF HEMODYNAMIC IN THE CONDITIONS

OF COMBINED ANESTHESIA OPTIONS WITH VENTILATOR

AND EXTRACURRICULAR BLOCKADES WITH MORPHINE

 

V.A. Fomichev, MD, PhD, Professor

Novosibirsk State Medical University

(630091, Russia, Novosibirsk, Krasny Prospekt, 52)

E-mail: fomichev.va@med54.ru

 

A.Y. Maloletneva, MD, Assistant Professor

Novosibirsk State Medical University

(630091, Russia, Novosibirsk, Krasny Prospekt, 52)

E-mail: malolet67@mail.ru

 

A.S. Busin, Anesthesiologist

Clinical Hospital at Novosibirsk station

(630003, Russia, Novosibirsk, Vladimirovsky descent, 2a)

E-mail: kms.novosibirsk1989@yandex.ru

 

Abstract. Changes in hemodynamic parameters are partly a response to surgical trauma. Assessment of the adequacy and safety of options for anesthetic protection, taking into account the parameters of central hemodynamics, in 162 patients with surgical diseases of the abdominal cavity with various variants of general anesthesia with ventilator and extracurricular morphine blockades in comparable groups. In group 1 (control) (n=64), patients were operated under combined general anesthesia with ventilator and NLA preparations; in group 2, patients (n=54) were operated on the background of combined general anesthesia with ventilator and epidural analgesia with morphine; in group 3 (n=46), patients underwent combined general anesthesia with ventilator it was performed under conditions of paravertebral morphine blockade. Changes in the parameters of central hemodynamics were analyzed in the groups. It was determined that in the group of patients where paravertebral analgesia with morphine was used, the studied parameters were more adequate

Keywords: surgical diseases of the abdominal cavity, combined general anesthesia with ventilator, extracurricular morphine analgesia, central hemodynamic parameters.

 

Introduction

Changes in hemodynamic parameters during surgical interventions are not only a response to pharmacological agents used for anesthesia, but are also a response to surgical trauma [3, 7]. In this regard, when assessing the adequacy of analgesia of the operation, the main thing is to determine the limits of deviations of physiological functions in operated patients [3, 6].

The task of the study. Assess the adequacy and safety of anesthetic protection. Hemodynamic parameters in patients undergoing surgical interventions with various variants of combined anesthesia with ventilator and extracurricular morphine blockades.

Material and method

To solve this problem, 162 patients with various surgical diseases of the abdominal cavity were examined. The patients were operated on as planned, underwent the necessary training and examination.

The patients were divided into 3 groups depending on the method of anesthesia: group 1 – patients who were operated under general combined anesthesia with ventilator and NLA preparations – 64 people;

Group 2 – patients in whom general combined anesthesia with ventilator was performed against the background of epidural morphine analgesia – 54 people;

Group 3 – patients, who underwent general combined anesthesia with a ventilator under conditions of paravertebral morphine blockade – 46 people.

Of the 162 patients examined at the stages of surgical operations and in the first three days of the postoperative period, there were 118 women (78.8%) and 44 men (21.2%). The groups were comparable by gender, age, weight of talus, height, volume of surgical interventions and severity of surgical and anesthetic risk on the MNOAR scale.

Combined general anesthesia with ventilator and NLA drugs represented a modification of the classical technique. Premedication: atropine in usual dosages of 0.1 mg / kg, diphenhydramine 10-20 mg, 1/2-1/3 doses of droperidol at the rate of 0.2 mg / kg of body weight, depending on the condition, age, blood pressure. Introductory anesthesia with sodium thiopental at a dose of 6-8 mg /kg.Myoplegia was supported by arduan in conventional doses (0.05 mg/kg). Ventilation with nitrous-oxygen mixture 2:1. Analgesia and vegetative protection were provided by fentanyl at a dose of 0.01 mg / kg h and droperidol at a dose of 0.2 mg / kg h. Drug-induced sleep was further deepened by seduxen and ketamine at doses of 0.17 mg/kg hour and 1 mg/kg hour.

To perform combined general anesthesia with a ventilator in the conditions of epidural analgesia, the epidural space was catheterized according to the generally accepted method at the appropriate level of the operation. Morphine hydrochloride was used at a dose of 0.08-0.1 mg/kg, taking into account the age and condition of the patient (on average 5-8 mg) in 6-8 ml of saline solution.

During catheterization of the paravertebral space after anesthesia of the interstitial space, the needle moved in the segital direction with a deviation from the midline of 10-20 degrees maximum with simultaneous administration of 0.25% novocaine 9 if another anesthetic is intolerant) until the appearance of the "loss of resistance" test in the nearest cellular paravertebral space. Since the movement of the needle was necessarily preceded by the introduction of a local anesthetic, slight signs of irritation of the spinal roots appear before the moment when further manipulations can damage the structure of the spinal nerves. If it was necessary to identify the position of the needle, the spinal roots were blocked with a local anesthetic or ultrasound control, as with the ESP block. The fiber in the paravertebral space is denser than in the epidural, which will require a lot of effort. After fixing the catheter, morphine hydrochloride was injected at a dose of 8 mg in 6-8 ml of saline solution.

In the future, the scheme was as follows: premedication – atropine in normal dosages, diphenhydramine 10-20 mg, droperidol 0.05-0.1 mg / kg of weight. Introductory anesthesia and intubation are similar to group 1 patients. Anesthesia was maintained by inhalation of nitrous oxide with oxygen in a ratio of 2:1, if necessary, the hypnotic effect was potentiated by bolus administration of seduxen 0.12 mg / kg hour or ketamine at a dose of 0.7 mg / kg hour.

When using general combined anesthesia with a ventilator against the background of epidural analgesia with morphine, analgesia and vegetative protection were enhanced with fentanyl and droperidol at doses of 0.004 mg/kg hour and 0.07 mg/kg hour. When using general combined anesthesia with a ventilator against the background of paravertebral analgesia with morphine, the doses of fentanyl and droperidol were 0.005 mg / kg hour and 0.07 mg / kg hour.

Studies of the parameters of central hemodynamics were carried out by the method of integral rheography according to Tishchenko in 75 patients, taking into account the peculiarities of anesthesiological support, 3 groups of 25 people per group were allocated. Indicators were recorded: before the operation (stage 1), at the most traumatic moment of the operation (stage 2), in the postoperative period on the background of a ventilator (stage 3), after surgery on the background of spontaneous breathing (stage 4). The values of the following parameters were evaluated: circulating blood volume (CBV), minute circulatory volume (MCV), shock volume (SV), shock index (SI), cardiac index (CI), central venous pressure (CVP), total peripheral resistance (TPR), average arterial pressure (AAP).

Results and disscusion

Parameters of  hemodynamic in 1 group of patient in Table 1.

 

Table 1

Hemodynamic parameters at the stages of combined

general anesthesia with ventilator and nla drugs

Indicator norm

Stage 1

Stage 2

Stage 3

Stage 4

SVml

102,12±7,15

95,23±11,10

89,98±8,50*

92,14±7,80

CBVml/kg

70-72

69,73±1,86

61,74±3,30

63,81±1,70*

65,41±2,02*

AAPmm Hg

109,07±3,25

105,72±2,85

107,54±2,83

108,11±2,02

TPRdin s sm-5 (1300)

1019,1±109,3

1409,8±157,6*

1290,6±50,7*

1210,3±108,8*

CI l/min 2 m2

4.0

4,99±0,47

4,41±0,49

4,40±0,43*

4,40±0,52*

SI ml/m2

45-55

58,87±4,78

54,05±6,18

51,35±4,77

51,10±5,11

MCV l/min

6-7

9,29±0,71

7,49±0,91*

7,82±0,77*

7,96±0,96*

CVPmm water (60-120)

83,4±2,16

75,1±2,64*

82,3±2,11

82,6±2,14

 

* differences between the initial and subsequent stages are significant (p<0.05)

 

As can be seen from the data presented in Table 1, a consistent decrease in CI and SI indicators at the stages of surgical intervention was revealed compared to the initial data. Thus, at stage 2, a decrease in these parameters was recorded by 16.6% and 8.2% below the baseline level (p<0.05).

At the 3rd stage of the study, by the end of the operation, the level of CI and SI continued to decrease and became 11.7% and 12.8% lower than the baseline level (p<0.05).

At the 4th stage of the study (after surgery on the background of spontaneous breathing), the levels of CI and SI remain reduced by 11.7% and 13.3% less than the baseline level (p<0.05).

The tendency to decrease in the most traumatic moments of the operation was in the average indicators of SV by 7.3% (p<0.05), AAP 3.1% (p<0.05), CBV by 11.5% (p<0.05), SV by 19.4% (p<0.05), CVP by 10% (p<0.05) less than the initial level.

At the 3rd stage of the study, a further decrease in the average level was noted only in SV by 11.9% (p<0.05) less than the initial level. As for the AAP, CBV, SV, CVP  then they registered a slight increase of 1.7%. 3.2%, 4.2% and 8.8% compared to the previous stage.

In the postoperative period (stage 4), although there was a further increase in hemodynamic parameters, they did not reach the initial level. SV was reduced by 9.8% (p<0.05), AAP by 0.8%. CBV by 6.2%,  CVP by 3.3%.

During the study, a significant increase in TPR was recorded in this group of patients at the most traumatic moment of surgery by 38.2% (p<0.05) higher than the baseline level (Table 1). At stages 3 and 4, there was a gradual decrease in this parameter, but even after the completion of the operation, the average value of the TPR was 118.7% of the initial one.

Thus, at the stages of surgical treatment under general anesthesia with a ventilator and NLA preparations, regular manifestations of hemodynamic reactions were recorded, which indicates a certain negative effect of surgical intervention on hemodynamics in patients.

The nature of hemodynamic changes at the stages of combined general anesthesia with ventilator in the conditions of epidural morphine analgesia is presented in Table 2.

 

Table 2

Hemodynamic parameters at the stages of combined general anesthesia

with ventilator and epidural morphine analgesia

Indicator norm

Stage 1

Stage 2

Stage 3

Stage 4

SVml

71,97±8,56

78,21±7,83

65,70±5,72

65,54±6,83

CBVml/kg

70-72

63,85±3,86

70,06±5,50

70,57±2,86*

70,84±3,66

AAPmm Hg

98,41±2,75

100,94±1,80

101,90±1,37

101,92±1,44

TPRdin s sm-5 (1300)

1827,1±294,0

1918,3±327,7

1871,8±279,7

1842,1±310,4

CI l/min 2 m2

4.0

3,82±0,54

4,40±0,54

3,47±0,34

3,47±0,41

SI ml/m2

45-55

42,25±4,53

46,75±4,75

39,26±3,50

39,21±4,44

MCV l/min

6-7

6,53±1,03

7,12±0,91

5,61±0,13*

5,56±0,59*

CVPmm water (60-120)

86,3±2,91

101,1±2,13*

103,2±2,04

103,6±1,89*

 

When analyzing the results of the study at the most traumatic moments of the operation, a slight increase in the average values of the indicators was found: SV by 8.7%, SI by 10.7%,  and CI by 9.9% (p<0.05) in comparison with the initial data.

Then, in the postoperative period (stages 3 and 4), there was a significant decrease in hemodynamic parameters below the level of stage 1 SV  by 8.8% and 9.0%, SI by 7.1% and 7.7.2%, MCV by 15.1% and 15.9% from preoperative.

In addition, an increase in the following indicators was registered at all stages: in comparison with the data of the 1st stage, the CBV increased by 9.7%, 10.5% and 10.9%, the CVP by 17.1%, 19.5% and 20.0% (p<0.05), and the AAP by 2.5%, 2.8% and 3.5%, respectively. There are grounds to associate such changes in hemodynamics with the insufficient effect of sympathetic blockade in the conditions of epidural morphine analgesia and the influence of infusion-transfusion therapy.

When analyzing the level of TPR, it was revealed that there was a slight increase in this parameter at the 2nd stage of the study by 5% with its gradual decrease in the postoperative period to the initial level.

Thus, during the study, changes in hemodynamic parameters were established, informing about the moderate stress of this homeostasis system.

The hemodynamic features established at the stages of combined anesthesia with a ventilator against the background of paravertebral analgesia with morphine hydrochloride are presented in Table 3.

First of all, in the most traumatic moments of the operation, a decrease in SVby 8.8%, AAP by 1.8%, SI by 2.3%, CI by 7.5%, MCV by 12.2% and CVP by 4.9% was found in comparison with the initial data (p<0.05).

In the postoperative period (stages 3 and 4), there was an increase in average values and they exceeded the data of stage 1, respectively: SI by 5.36% and 8.2%, AAP by 1.35 and 1.4%, CVP by 1.4% and 2.2%, and CI by 0.2%. At the same time, they remained reduced in relation to the preoperative period by 2.5% and the MCV by 6.6% less. The average values of CBV in this group of patients at each stage of the study increased slightly by 1.8%, 2.48% and 3.1%.

 

Table 3

Hemodynamic parameters at the stages of combined general anesthesia

with ventilator and paravertebral analgesia with morphine

Indicator norm

Stage 1

Stage 2

Stage 3

Stage 4

SVml

68,23±4,37

68,28±5,82

66,53±5,38

66,87±6,88

CBVml/kg

70-72

64,08±2,62

65,24±2,43

65,67±3,83

66,17±2,56

AAPmm Hg

102,42±2,24

100,59±2,23

103,79±2,3

103,92±2.41

TPR din s sm-5 (1300)

1517,5±155,7

1574,4±149,5

1617±115,6

1603,1±166,2

CI l/min 2 m2

4.0

3,34±0,23

3,09±0,29*

3,34±0,27*

3,35±0!?*

MCV l/min

6-7

5,99±0,99

5,26±0,59

5,60±0,36

5,60±0,76

SI ml/m2

45-55

37,99±2,84

37,13±3,76

40,03±3,93

41,12±2,87*

CPVmm water (60-120)

84,2±2,22

80,1±1,98

85,4±2,16

86,1±8,10

  • differences between the initial and subsequent stages are significant (p<0.05)

 

TPR at the most traumatic moment of the operation increased by 10.3% compared to the data of stage 1, at stages 3 and 4 there was a slight decrease in this indicator, but it exceeded the initial values by 6.5% and 5.7% (p<0.05).

Thus, changes in hemodynamics in the conditions of the studied version of the anesthetic aid are less pronounced than in patients of the control group 1, which may indicate more adequate anesthetic protection.

Analysis of the main indicators of hemodynamics at the stages of operations under the conditions of the indicated variants of the anesthetic manual revealed that the most depressive effect on the circulatory system occurs against the background of surgical interventions performed using combined general anesthesia with ventilator drugs NLA. The use of opiates as a component of combined general anesthesia with ventilator paravertebral analgesia by the degree of effect on hemodynamic parameters is unreliably superior to that against the background of epidural analgesia with such drugs. But a significantly less pronounced increase in the OPS index at the stages of surgery under conditions of paravertabral analgesia with opiates, in contrast to the dynamics of this parameter in patients in the comparison group, allows us to judge the adequacy of the protection of this method.

Conclusion

Combined general anesthesia with a ventilator against the background of preliminary paravertebral morphine administration provides a less pronounced depression of hemodynamic parameters at the stages of the perioperative period compared with the recorded shifts in patients operated under general combined anesthesia with ventilator with NLA preparations.

 

REFERENCES

1. Aydin, G., Aydin, O. The Efficacy of Ultrasound-Guided Paravertebral Block in Laparoscopic Cholecystectomy // Medicina. – 2018. – Vol. 54. – N 5. doi: 10.3390/medicina54050075.

2. Bunyatyan, A.A. Anesthesiology: national guidelines / A. A. Bunyatyan, V. M. Mizikov. – M. : GEOTAR-Media, 2013. – Pp. 112-113.

3. Bykov, A.S. Autoregulation of systemic hemodynamics in various variants of anesthesia [Text] / A.S.Bykov // Modern surgical technologies: sat. nauch. tr. / Ed. by Yu.S.Vinnik. – Krasnoyarsk, 2006. – Pp. 771-778.

 

 

4. Bykov, A.S. Slow-wave circulatory processes in elderly patients with various types of anesthesia [Text] / N.S.Davydova, A.S. Bykov, O.G. Malkova, Yu.A. Davydova // Oscillatory processes of hemodynamics. Pulsation and fluctuation of the cardiovascular system: thesis of the II All-Russian Symposium / Edited by A.A. Astakhov, I.D. Bubnova. – Chelyabinsk, 2002. – Pp. 353-364.

5. Carney, J., Finnerty, O., Rauf, J., et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks // Anaesthesia. – 2011. – Vol. 66. – N 11. – Pp. 1023-1030. doi: 10.1111/j.1365-2044.2011.06855.

6. Cowie, B., McGlade, D., Ivanusic, J., Barrington, M.J. Ultrasound-Guided Thoracic Paravertebral Blockade // Anesthesia & Analgesia. – 2010. – Vol. 110. – N 6. – Pp. 1735-1739. doi: 10.1213/ANE.0b013e3181dd58b0.

7. Koryachkin, V.A. Neuroaxial blockades / V. A. Koryachkin. – SPb. Elbi-SPb, 2013. – 544 p.

8. Novak-Jankovič, V. Regional Anaesthesia in Thoracic and Abdominal surgery // ActaClinicaCroatica. 2019. doi: 10.20471/acc.2019.58.s1.14.

9. Ovechkin, A.M. Postoperative pain syndrome: Clinical and pathophysiological significance and promising directions / A.M. Ovechkin // Consiliummedicum. – 2005. – No. 6. – Pp. 486-490.

10. Sabirov, D.M., Sabirov, K.K., Batyrov, U.B., Saidov, A.S. The experience of using paravertebral blockade when providing anesthetic aids in operative urology // News of surgery. – 2010. – Vol. 18. – No. 2. – Pp. 142-145.

 

REFERENCES

1. Aydin G., Aydin O. The Efficacy of Ultrasound-Guided Paravertebral Block in Laparoscopic Cholecystectomy. Medicina. 2018. Vol. 54. No. 5. doi: 10.3390/medicina54050075.

2. Bunyatyan A.A. Anesthesiology: national guidelines. A. A. Bunyatyan, V. M. Mizikov. Moscow. GEOTAR-Media, 2013. Pp. 112-113.

3. Bykov A.S. Autoregulation of systemic hemodynamics in various variants of anesthesia [Text]. A.S.Bykov. Modern surgical technologies: sat. nauch. tr. Ed. by Yu.S.Vinnik. Krasnoyarsk, 2006. Pp. 771-778.

4. Bykov A.S. Slow-wave circulatory processes in elderly patients with various types of anesthesia [Text]. N.S.Davydova, A.S. Bykov, O.G. Malkova, Yu.A. Davydova. Oscillatory processes of hemodynamics. Pulsation and fluctuation of the cardiovascular system: thesis of the II All-Russian Symposium. Edited by A.A.Astakhov, I.D.Bubnova. Chelyabinsk, 2002. Pp. 353-364.

5. Carney J., Finnerty O., Rauf J., et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia. 2011. Vol. 66. No. 11. Pp. 1023-1030. doi: 10.1111/j.1365-2044.2011.06855.

6. Cowie B., McGlade D., Ivanusic J., Barrington M.J. Ultrasound-Guided Thoracic Paravertebral Blockade. Anesthesia & Analgesia. 2010. Vol. 110. No. 6. Pp. 1735-1739. doi: 10.1213/ANE.0b013e3181dd58b0.

7. Koryachkin,V.A. Neuroaxial blockades. V. A. Koryachkin. SPb. Elbi-SPb, 2013. 544 p.

8. Novak-Jankovič V. Regional Anaesthesia in Thoracic and Abdominal surgery. ActaClinicaCroatica. 2019. doi: 10.20471/acc.2019.58.s1.14.

9. Ovechkin A.M. Postoperative pain syndrome: Clinical and pathophysiological significance and promising directions / A.M. Ovechkin. Consiliummedicum. 2005. No. 6. Pp. 486-490.

10. Sabirov D.M., Sabirov K.K., Batyrov U.B., Saidov A.S. The experience of using paravertebral blockade when providing anesthetic aids in operative urology. News of surgery. 2010. Vol. 18. No. 2. Pp. 142-145.

 

Материал поступил в редакцию 01.09.24

 

 

 

ПОКАЗАТЕЛИ ГЕМОДИНАМИКИ В УСЛОВИЯХ

ВАРИАНТОВ КОМБИНИРОВАННОЙ АНЕСТЕЗИИ

С ИВЛ И ЭКСТРАДУРАЛЬНЫМИ БЛОКАДАМИ МОРФИНОМ

 

В.А. Фомичев, доктор медицинских наук, профессор

Новосибирский государственный медицинский университет

(630091, Россия, Новосибирск, Красный просп., 52)

E-mail: fomichev.va@med54.ru

 

А.Ю. Малолетнева, кандидат медицинских наук, ассистент профессора

Новосибирский государственный медицинский университет

(630091, Россия, Новосибирск, Красный просп., 52)

E-mail: malolet67@mail.ru

 

А.С. Бусин, Врач- анестезиолог

Дорожная клиническая больница на ст. Новосибирск

(630003, Россия, Новосибирск, Владимировский спуск, д. 2а)

E-mail: kms.novosibirsk1989@yandex.ru

 

Аннотация. Изменения показателей гемодинамики частично являются ответом на операционную травму. Оценка адекватности и безопасности вариантов анестезиологической защиты, учитывая параметры центральной гемодинамики, у 162 больных с хирургическими заболеваниями органов брюшной полости при различных вариантах общей анестезии с ИВЛ и экстрадуральными блокадами морфином в сопоставимых группах. Оценка показателей центральной гемодинамики при различных вариантах комбинированной общей анестезии с ИВЛ И экстрадуральными блокадами морфином. В 1  группе (п=64) больные оперированы в условиях комбинированной общей анестезии с ИВЛ и препаратами НЛА; во 2 группе больные (п=54) оперированы на фоне комбинированной общей анестезии с ИВЛ и эпидуральной аналгезией морфином; в 3 группе (п=46) больных комбинированную общую анестезию с ИВЛ проводили в условиях паравертебральной блокады морфином. В группах определены и проанализировали изменения параметров центральной гемодинамики при изучаемых  вариантах анестезиологической защиты.. Определено, что в группе больных, где использовалась паравертебральная аналгезия морфином, изучаемые параметры более адекватны.

Ключевые слова: хирургические заболевания брюшной полости, комбинированная общая анестезия с ИВЛ, экстрадуральная аналгезия морфином, показатели центральной гемодинамики.