MD, Professor V. A. Fomichev

Novosibirsk state medical University

STRESS PROTECTION BY CLONIDINE AND THE QUALITY OF ANALGESIA DURING SPINAL-EPIDURAL ANESTHESIA IN GYNECOLOGICAL CANCER PATIENTS

The focus of anesthesiology is the problem of protecting patients from surgical trauma [ 4 ]. Conducting spinal-epidural anesthesia (sea) completely prevents the development of patients with stress reactions. In this regard, there is to combine regional anesthesia with the stress-protection [ 1, 2 ].
The purpose of the work. The analysis of indicators of cortisol and blood glucose in terms of Oncogynecological operations and in the immediate postoperative period on the background of spinal-epidural anesthesia with the use of stress protection by clonidine and without.
Material and method. Research approved by the Ethics Committee of NSMU and conducted in two groups of patients, using different anesthetic management. 1 the comparison group (n=70) surgery was performed under spinal-epidural anesthesia marcaine. In the 2nd group (basic) (n=78) 30 minutes before the operation is additionally intramuscularly introduced clonidine at a dose of 0.002 mg/kg.
The study groups were comparable: age, anthropometric data, accompanying diseases, the scope and duration of the operation. All patients underwent surgery as planned. They conducted pre-and immediate premedication in the traditional way. The total amount of intraoperative infusion in groups of patients was 2045,6±22.7 ml and 2061,1±23, 6 ml, respectively.
Spinal puncture and epidural spaces was carried out on the side besegmental method. To ensure the spinal component of the SEA was used of 0.5% Isobaric bupivacaine from 2 to 5 ml (about 3.4±0,05), which amounted to 0,21±0,04 mg/kg of body weight. To ensure epidural component used a standard technique of catheterization of the epidural space. Where fractional doses were injected Isobaric 0.5% solution of bupivacaine in average dose of 11.0±0.5 ml.
During the operation they underwent oxygen therapy via face mask insufflation of oxygen-air mixture (oxygen content of 60%) Gattaca 4-6 ml/min. According of pulse oximetry that was enough to prevent hypoxia on the background of spontaneous breathing during the operation. Sedation during operative intervention was provided one-dose injection of midazolam 0.14 mg/kg and the fractional bolus application of ketamine in a dose of 1 mg/kg.
The transfer of patients to the chamber was possible through 7,0±5,2 min after the end of surgery, and we noted the absence of signs of secondary anesthetic sleep. In the early postoperative period analgesia was carried out by introduction into the epidural canal 0.5% solution of bupivacaine in the "on demand" and its average consumption amounted to 0,71±0,07 mg/kg. in Addition to epidural narcotic analgesics were used in traditional doses.
Was determined following laboratory values cortisol and blood glucose. Determination of the parameters was carried out at the following stages: 1st – 30 minutes before surgery, the 2nd in the most traumatic time of the transaction, the 3rd – after the operation, the 4th – 60 minutes after transfer of the patient to the ward.
To determine the qualitative characteristics conducted varieties of sea we used several parameters: the applied amount of local anesthetic, sedative and narcotic drugs; subjective evaluation by patients in both groups analgesia and comfort during surgery, assessment of the "quality" of anesthesia the surgical team.
The quality of analgesia during surgery was assessed through a survey of surgical team, using the following evaluations: excellent, good, satisfactory. In addition, due to the nature of operations was possible contact with patients. In the postoperative period we investigated the time of occurrence of complaints of pain in patients. Evaluation of pain was carried out on a scale verbal pain assessment (SHVO). Using parameters of pain assessment: 0 points – no pain at rest, 1 point - no pain at rest, mild pain on movement 2 points – mild pain at rest and at movement moderate, 3 points – severe pain alone and strong when driving, 4 points – severe pain at rest and very strong when driving.
The results and discussion. The indicators of blood glucose during the stages of study in groups of patients are presented in table 1.

Table 1

Dynamics of indicators of blood glucose at the stages of sea (mol/l)

The Group	Stages
	1	2	3	4
Group 1 (comparison)	5,1±0,1	5,2±0,4	4,9±0,7*	5.4±0,4*
Group 2	5,0±0,2	4,6±0,3*	4,6±0,1	4,5±0,2

p<0.05 significant difference compared with options 1 phase

It is noted that the glucose content in the blood exceeds normal values. But in the 2nd group of patients, where were used clonidine in the conditions of assessment at all stages of the study, this figure was lower by 8% in conditions 1 and 2 stages of the study and 10% in an hour after surgery compared with baseline. At this time in the comparison group parameters blood glucose showed instability, but at the end of the study, the growth rate was 5.9% in comparison with the original.
Indicators of blood cortisol is in the study stages the SER is presented in table 2.

The level of blood plasma did not exceed the normal range, that tells about an adequate anesthesiological protection of the patients. In the analysis of cortisol in blood plasma of patients in the comparison group noted a decrease by 0.27% to the 2nd stage, increased by 0.21% - 3rd stage and increased by 15.0% to 4-th stage of the study compared to baseline values (p<0.05). In the main group of patients to 2nd (most traumatic) phase of the study is the level of cortisol in the blood plasma increased by 6.58% (p<0.05 ), however, by the end of the operation and in the immediate postoperative period marked decrease of this parameter by 0.68% and 11.9%, respectively (p<0.05).

In the study of introduced volumes of local anesthetic in both groups noted that the dose of spinal anesthetic is introduced is identical. But registered a reduction in the dose of anesthetic is 14.3%, is introduced into the epidural space in the 2-nd group of patients.

Table 2

Indicators of cortisol in blood plasma phases of sea (nmol/l)

The Group	Stages
	1	2	3	4
Group 1 (comparison)	587,7±52,3	585,1±77,2	588,9±69,9	675,9±52,1*
Group 2 (the main group)	558,9±61,4	595,7±41,2*	555,1±45,3*	492,5±32.2*

p<0.05 significant difference compared with options 1 phase

On the background of the use of ketamine in 100% of surveyed patients had retrograde amnesia and a feeling of psychological comfort. Differences in the subjective assessment of patients transferred surgical intervention in both groups were not observed. Assessment of the "quality" of the anesthesia and surgical team revealed the following features. In the 1st group of patients in 68,2% of cases, the quality of anesthesia marked as excellent, at 29.3 per cent as good and 2.5% of cases showed satisfactory assessment of the quality of anesthesia. In the 2nd group patients were registered in 86.3% - excellent quality of anaesthesia and 13.7% of cases – assessment of anesthesia is recognized as good.
In the first postoperative day in the 2nd group of patients have a slower onset of postoperative pain (intensity score of 2 for SHVO) on 206,9±6.71 min compared to the control group due to the slow conducting pain clonidine and pulse more prolonged action of anesthetics and analgesics. We identified statistically significant reduction of the doses of injected local anesthetics and analgesics in the first postoperative day in the 2nd group of patients in contrast to 1-Oh: 0.5% solution of bupivacaine by 20.7%, a 2% solution of promedol by 33.7% and 2.5% solution of Ketoprofen 28.1% (p<0.05).
Conclusions. According to the dynamics of cortisol and blood glucose intramuscular application of clonidine in the background, sea in the conditions of oncologic operations allows us to implement more long-lasting and high-quality anti-stress protection.
The use of clonidine in stress protection on the background of sea in Oncology operations creates the best conditions for the operating brigade, prolongs the analgesic effect of anesthesia and provides better postoperative analgesia.

References
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2. Popov A. A. Antistress and draganchovitsa premedication with clonidine: author. Diss. Cand. med. Sciences/ A. A. Popov.- Novosibirsk, ngma, 2001.- 24 p
3. Koryachki V. A. Spinal and epidural anesthesia: a manual for physicians/ Koryachkin V. A., V. I. Strashnov.- SPb.: Special literature, 2010.- 98 p.
4. Fomichev V. A., Khrustalev E. Y. the Use of clonidine in spinal-epidural anaesthesia in oncological patients// Bulletin of new medical technologies. Periodic scientific and practical journal.- Tula, 2008.- Tom HU.- No. 1.- p. 90-92