RU2230577C2 - Anesthetizing method - Google Patents

Abstract

FIELD: medicine, anesthesiology.

SUBSTANCE: invention can be used for anesthetizing. Method involves delivery and fixing a catheter for administration of anesthetizing agent by the course of nerve-vascular bundle into paravertebral space under visual control. Invention provides the multiple anesthetizing and expressed analgetic effect in patients after thoracoplasty, in chest traumas, when costectomy is necessary. This anesthetizing effect can be provided by delivery and fixing catheters into paravertebral space after carrying out thoracoplasty during the surgery operation immediately.

EFFECT: improved anesthetizing method.

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Description

The invention relates to medicine - to anesthesiology.

A known method of paravertebral anesthesia relates to conduction anesthesia and consists in conducting local anesthetics through the skin into the paravertebral space, in which the intercostal nerves, which carry sensitive fibers to all tissues of the chest wall organs, pass (Anesthesiology Manual / Edited by A. Bunatyan - A. - M ., 1997 .-- S. 302).

Anesthesia is carried out in the position of the patient sitting or lying on his side. Injection is performed laterally from the spinous process by 3-5 cm at the level of the corresponding selected segment. After anesthesia of the skin and subcutaneous fat, the needle is inserted in the medial direction at an angle of 20 degrees to the sagittal plane until it stops in the transverse process of the corresponding vertebra. Then it is pulled back and, having felt with the tip of the upper edge of the appendix, is advanced directly above it by 0.5 cm. Having done this, an aspiration test is carried out and 5 ml of anesthetic solution is administered.

The disadvantages of this type of anesthesia is the inability to conduct multiple and prolonged anesthesia, as well as the technical complexity of the procedure. Possible complications in the technique of performing paravertebral anesthesia are damage to the pleura and lung with the subsequent development of pneumothorax, penetration of the needle through the intervertebral opening into the subarachnoid space and the introduction of an anesthetic solution into it.

The aim of the invention is to achieve multiple, prolonged analgesia with a pronounced analgesic effect in patients after thoracoplasty, with chest injuries, the treatment of which necessitates resection of the ribs.

This goal is achieved by bringing and fixing the catheters in the paravertebral space immediately after performing thoracoplasty during surgery.

Method Description

The well-known method of posterior superior thoracoplasty according to Bogush L.K. from paravertebral access, enveloping the angle of the scapula (Fig. 1). Soft tissue dissected to the ribs. Consistently, subtotally, subperiosteally, 4-3-2-1 ribs are resected (Fig. 2). If necessary, the paravertebral sections of 5-6 ribs are removed.

For each transverse process of the thoracic vertebra along the intercostal neurovascular bundle, a silicone catheter is connected and fixed to the paravertebral space under visual control. Fixation is done with suture material for the intercostal muscles. Fixation must begin at the proximal end of the catheter. By means of hooks m. Splenius cervicis or m. Longissimus thoracis and m. spinalis thoracis (depending on the level of height of analgesia). It is advisable to remove the ribs to the joint surface of the ribs, which will provide good access to the paravertebral space. Then the catheter is brought to the transverse process of the vertebra and is fixed as close as possible to the transverse process for intercostal muscles with suture material. Suture material should not be tightened very tightly, as this may interfere with removal. Then, along the neurovascular bundle, the catheter should be fixed at least 2 times to the edge of the scapula and the distal end is brought out through the surgical wound (Fig. 4).

The anatomical and topographical justification is given in FIG. 3. The catheter is fixed at the transverse process of the vertebra (3.1), which is located along the border of the paravertebral space (3.2). A feature of this type of anesthesia is that local anesthetics act on the sympathetic trunk through intervertebral openings (3.3), which enhances the analgesic effect and favorably affects the functioning of the internal organs of the chest. At the same time, anesthetizing the sensitive fibers of the intercostal nerves (3.4), we get anesthesia of all soft tissues of the chest wall, including the skin (3.5).

As a catheter, we use a standard silicone catheter for epidural anesthesia, size 16G. The catheter has lateral openings for 2-3 cm, which also allows you to anesthetize the intercostal nerves along the neurovascular bundle in places of its fixation. The number of catheters should correspond to the number of removed ribs.

The extrapleural cavity is drained by 1 drainage, and the wound is sutured in layers tightly. A tight, pressure bandage is applied to the patient.

In the postoperative period, under the control of the patient’s well-being, hemodynamic parameters, respiratory rate and depth (Fig. 5, description below), additional conductive anesthesia by local anesthetics is performed by introducing them into catheters. Catheters are removed 5-6 days after surgery.

Advantages of the proposed method over analogues

1. Visually, catheters are precisely placed in the paravertebral space, thereby providing a high analgesic effect.

2. Through established catheters, anesthesia can be performed repeatedly as necessary, without causing the patient's concern, while with paravertebral anesthesia, it is necessary to seat the patient each time and perform a complex technical procedure.

3. Technical complications that are possible with the classical method of performing paravertebral anesthesia are excluded.

4. The developed technique reduces the use of narcotic analgesics by 2–2.5 times.

Clinical observation.

Patient K., 45 years old, was admitted to the thoracic and surgical department of the Yakutsk Research Institute of Tuberculosis on February 26, 2002 with the diagnosis: Fibro-cavernous tuberculosis of the upper lobe of the left lung, VK (+).

From the anamnesis. The duration of the disease is 2 years. Treatment in the district TB dispensary for 1.5 years with interruptions due to violation of the hospital regime.

Upon admission to the thoracic department, the condition is satisfactory. Actively does not make complaints. Control blood test without pathology. In the study of sputum by a bacterioscopic method, single tuberculosis mycobacteria were identified. In a functional study, a decrease in HPF of the 2nd degree is of a mixed type. With bronchoscopy, catarrhal endobronchitis 2 degrees.

On the chest x-ray in a direct projection of March 7, 02 (Fig. 6), the upper lobe of the left lung is significantly reduced in volume, the roots of the left lung are pulled up. The mediastinal organs are displaced to the left. In the right lung of medium intensity, tuberculous foci. On the chest tomogram in a direct projection of March 7, 02 (Fig. 7) there is a cavern in 1-2 segments of the left lung with thick uneven walls, connected with the root by an insignificant inflammatory “path”.

Considering fibro-cavernous tuberculosis of the upper lobe of the left lung with an unstable course, on April 8, 02, 5 rib upper-back thoracoplasty according to Bogush was performed. Introoperatively, according to the developed technique, 5 silicone catheters were installed and fixed for subsequent anesthesia. 1 drainage was introduced into the subscapular space, catheters were brought out through the wound. The wound is sutured in layers tightly. The postoperative period was uneventful. Conduction anesthesia was performed for 6.5 days and subsequently the catheters were removed. Narcotic analgesics were used only 2 times a day - in the morning and at night for the purpose of a long and deep sleep. The change in the main indicators of the criteria for the effectiveness of anesthesia is presented in the diagram (Fig. 5). From the graphs presented, it is clear that local anesthetics were anesthetized every 4 hours. Moreover, the increase in pain according to the patient’s well-being (Fig. 5. p. 3) coincided with an increase in respiratory rate (Fig. 5. p. 1), pulse and blood pressure (5. p. 2, in which a is systolic blood pressure; c - diastolic blood pressure; c - pulse). The introduction of a local anesthetic through catheters dramatically improved the objective and subjective indicators of the effectiveness of pain relief.

Thus, the patient received anesthesia with narcotic analgesics for 10 days only 10 times (Omnopon solution 2% 1 ml each), while the vast majority of cases during this time spent 28 ampoules per patient after thoracoplasty.

On April 10, contrasting of catheters was performed to clarify the localization of the accumulation of contrast medium. On 2 aim radiographs in a direct projection dated April 10, 02 (Fig. 8), an accumulation of radiopaque substance is observed in the transverse processes of the first 5 vertebrae, which undoubtedly confirms penetration into the paravertebral space. On the 1st and 2nd vertebrae, the contrast medium is located medially transverse processes of the vertebrae, which implies penetration into the intervertebral foramen, and anesthesia is performed at the level of the sympathetic trunk. Excessive contrast accumulates in the subscapular space.

On the overview chest x-ray before discharge from 05/06/02 (Fig. 9), 1-2-3 segments of the upper lobe of the left lung are collapsed. The cavern is not determined. In the subscapular space, homogeneous dimming due to the emerging limited extrapleural fibrothorax. Foci in the right lung without dynamics.

The patient was discharged from the hospital on 05/05/02 in a satisfactory condition with the recommendation of further treatment at the place of residence.

The anesthesia performed according to the method developed by us has shown good efficiency, simplicity of the method, objectivity of controlling the effects of anesthetic in the paravertebral space and a sharp reduction in the use of narcotic analgesics.

Claims (1)

A method of anesthesia by introducing a solution of local anesthetic through the skin into the paravertebral space, characterized in that a catheter for administering painkillers is introduced and fixed intraoperatively along the neurovascular bundle into the paravertebral space under visual control.

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