MD, professor Fomichev V.A.
Novosibirsk State Medical
University
INDICATORS
GENERAL hemodynamics in gynecological cancer patients, surgery under
spinal-epidural anesthesia with stress-protection
Changes in hemodynamics are caused not only
a response to pharmacological agents [1, 2], used for anesthesia and sedation;
but are one of the quality characteristics of the adequacy of anesthetic
protection [4].
Purpose of the study. To assess the adequacy and
safety of anesthetic protection we determined the parameters of the general
hemodynamics during gynecological cancer operations under spinal-epidural
anesthesia (CEA) to stress the patronage of clonidine and without thereof.
Material and method. The study was approved by
the Ethics Committee of the Novosibirsk State Medical University and was
conducted in 143 patients who anesthetic maintenance was performed during
surgery for malignant and benign diseases of the female reproductive organs.
In group 1 (control) (n = 70) operations
were carried out under spinal-epidural anesthesia marcaine. In the second group
(basic) (n = 78) for 30 minutes before the anesthesia was administered
intramuscularly clonidine in addition to a dose of 0,002 mg / kg. The treatment
groups were comparable in age, anthropometric data, comorbidities, scope and
duration of the operation.
All patients were operated on in a planned
manner. They carried out a preliminary and immediate premedication on
traditional principles.
To reduce the possible adverse effect of
sympathetic blockade on hemodynamics, all patients underwent preventive
infusion-transfusion therapy in the mode hypervolemic hemodilution in a ratio
of 2: 1 (crystalloid: colloid) 800-1000 mL (784,0 ± 56,0). The total volume of
infusion during surgery Group amounted to 2045,6 ± 22,7 ml and 2061,1 ± 23,6
ml.
A puncture of the spinal and epidural space
was performed in the lateral position by bisegmental method. To provide a
spinal component we used SEA 2 to 5 ml of (3,4 ± 0,05) 0,5% isobaric
bupivacaine solution that was 0.21 ± 0.04 mg / kg body weight. To implement the
epidural component using the standard technique of catheterization of the
epidural space, which was administered in divided doses of isobaric 0.5%
bupivacaine solution in an average dose of 11.0 ± 0.5 ml.
During the operational period of oxygen
therapy was conducted through face mask oxygen-air mixture with an oxygen
content of 60% and gazotokom 4-6 l / min. Insufflation began after translation
into the operational position, and according to the pulse oximeter that was
enough for the prevention of hypoxia in conditions of spontaneous breathing.
Sedation in the operation period was provided by a single administration of
midazolam 0.14 mg / kg bolus and fractional use of ketamine in a dose of 1 mg /
kg.
Translation of patients in the ward was
possible after 7 ± 5,2 minutes after surgery with no evidence of secondary
drug-induced sleep. In the early postoperative period, analgesia was carried
out by introducing into the channel epidural bupivacaine 0.5% in the volume of
4.0 ml in the "on demand" and its average consumption was 0,72 ± 0,07
mg / hr. Apart from epidural anesthesia used in traditional narcotic analgesic
doses. Thus, the use of epidural block it possible not only to implement the
analgesic component of anesthesia, but clinically beneficial effects of
sympathetic blockade on the stages of the direct and immediate postoperative
period.
During anesthesia were monitored: systolic
(BPs), diastolic (BPd), the mean (mBP) arterial blood pressure, heart rate (HR)
and hemoglobin saturation level of arterial blood. Defining the parameters was
carried out in the following stages: 1st - 30 minutes before the surgery, the
second - in the most traumatic time of surgery (removal of the drug) and the
fourth after 60 minutes after admission to the ward office.
The results and discussion. Indicators of general
hemodynamics BPs, BPd, mBP and heart rate, registered in the groups of patients
are shown in Table 1.
Table 1
Indicators hemodynamic research stages of general
|
Indicators |
Groups of patients |
Stages |
|||
|
|
|
1 |
2 |
3 |
4 |
|
BPs |
1
(ï=70) |
148,8±3,5 |
115,3±5,1* ** |
97,4±1,9* |
110,0±1,3* |
|
mm Hg |
2
(ï=78) |
143,0±2,6 |
116,6±1,2* ** |
124,2±2,9* |
123,2±2,2* |
|
BPd |
1
(ï=70) |
92,7±2,8 |
92,6±3,2 |
74,5±0,5* ** |
76,3±1,07* |
|
mm Hg. |
2
(ï=78) |
85,6±1,3 |
78,0±1,6* ** |
72,8±1,4* |
76,7±1,2* |
|
mBP |
1
(ï=70) |
120,8±2,6 |
109,6±3,8* |
85,9±1,9* ** |
92,1±1,05* ** |
|
mm Hg. |
2
(ï=78) |
114,3±1,6 |
97,3±1,7* ** |
98,5±1,6* |
100,0±1,3* |
|
HR |
1
(ï=78) |
81,7±2,2 |
85,9±2,4 |
72,2±2,3* |
89,1±3,1* ** |
|
sp. min |
2
(ï=78) |
82,3±1,0 |
74,9±1,4* |
72,5±0,9* |
72,4±0,8* |
* - P <0.05 significant difference indicator in comparison with the
parameters of step 1
** - P <0.05 significant difference in the indicator compared to the
previous stage settings
The first group of patients to the 2nd
stage (the most traumatic moment of the operation) BPs indicators, mBP and BPd
decreased respectively by 32.9, 9.3 and 0.1%, and the 3rd stage (the end of the
surgery) the decline was 34.5, 27.7 and 19.6% (p <0.05), respectively,
compared with the original data. By the 4 th stage of monitoring (immediate
postoperative period) recorded a slight increase in the overall hemodynamic
parameters. But in comparison with the initial data reduction parameters BPs,
mBP and BPd remained at 26.1, 28.7 and 16.4%, respectively (p <0.05). The
slight acceleration of the heart rate of 4.2% was found to 2 to Phase study,
the 3rd stage marked slowing of the heart rate by 12.9% in comparison with the
baseline. And on the 4th stage of the recorded acceleration of heart rate by
9.0% from baseline.
In the second group of patients, where
stress protection used clonidine to the 2nd phase of the study BPs, mBP and BPd
decreased by 18.5, 17.0 and 8.9% compared with the original data. In the 3rd
stage, these indicators for monitoring were 18.8, 15.8 and 12.8% less than the
original data. In the
immediate postoperative period BPs, mBP and BPd an account by 9.1, 12.5 and
10.4% less than the original data.
Heart rate in patients in group 2 decreased
sequentially by 9.0, 11.9 and 12.0%, respectively, from the stage of the study
raw data.
Conclusion.
Thus, it can be noted that changes in overall hemodynamics were less pronounced
in the second group of patients in comparison with indicators of the first
group, which used a stress patronage by clonidine
References
1.
Stress patronage in the anaesthesiology: monograph /I.P.Nazarov (et al.) .-
Krasnoyarsk, KSU Publishing House, 2010.- 408 p.
2. AA
Popov Anti-stress and clonidine premedication adrengangliolitikami: Abstract.
diss. cand. honey. Science / A.A.Popov.- Novosibirsk, Novosibirsk State Medical
University, 2001.- 24 p.
3.
Karyachkin VA Spinal and epidural anesthesia: A Guide for Physicians /
V.A.Koryachkin, VI Strashnov.- SPb .: Special literature, 2010.- 98 p.
4.
Fomichev VA, Khrustalev EY The use of clonidine in spinal-epidural anesthesia
in gynecological cancer patients // Herald of new medical technologies.
Periodic scientific and practical zhurnal.- Tula, 2008.- Tom HU.- number 1.-
s.90-92