RU2288721C1 - Method for introducing anesthetic relief when carrying out ophthalmosurgical operations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves introducing benzodiazepines of short action period into premedication composition when performing ophthalmosurgical interventions. The injection is carried out in continuous intravenous dosed mode using 0.9% NaCl solution. Speed and dose is calculated from formula C=K*1000/V*60, where C is the preparation quantity in mcg/kg/min, corresponding to syringe feeder rate equal to 1 ml/h, K is the short-action benzodiazepine drug quantity in mg dissolved in 0.9% NaCl solution, 1000 is the coefficient for transforming mg into kg, V is the 0.9% NaCl solution volume in ml, M is patient body mass, 60 is the coefficient for transforming 1 hour into minutes.

EFFECT: enhanced effectiveness in selecting optimum short action benzodiazepine dose.

Description

The invention relates to medicine, in particular to ophthalmology, and can be used when conducting anesthetic benefits in ophthalmic surgery.

There are methods of anesthesia for ophthalmic surgical interventions, consisting in that they carry out general anesthesia (endotracheal or intravenous anesthesia), as well as ataralgesia (sedation and analgesia) in combination with regional anesthesia, in which general anesthesia is performed by intravenous administration of anesthetics (J. Edward Morgan Jr., Magid S. Michael, “Clinical Anesthesiology.” - Translation from English. - BINOM Publishing House. - Moscow. - 2004).

But the disadvantages of these methods are:

- uncontrollability of the depth of sedation of patients, which can lead to depression of the cardiovascular system, respiratory depression;

- "effect of the presence" of the patient during surgery due to insufficient sedation;

- the need for large medical and special technical support during general anesthesia;

- the risk of general anesthesia in ophthalmology in patients with concomitant somatic diseases significantly exceeds the risk of surgical intervention.

The closest analogue prototype is a method of bolus administration of short-acting benzodiazepines (BKD) in premedication and in the process of an ophthalmic operation, which consists in the fact that BKD is administered fractionally, repeatedly during the operation (Belov S.M., Pyankov A.G. Use of midazolam and anxate during anesthesia in cataract surgery // Modern technologies of cataract surgery. - 2003. Collection of scientific articles on the materials of the scientific and practical conference. - Moscow. - November 21-22. - 2002. - Edited by H.P. Takhchidi).

The disadvantages of the prototype are:

uneven receipt of the drug and its effect in the form of "bursts";

- the impossibility of selecting the minimum, effective dose of the drug and ensuring its continuous, uniform action;

- the risk of cumulation of the drug, and as a result - depression of the cardiovascular system and breathing, especially in patients with severe somatic pathology;

- the need to use a benzodiazepine antagonist (for example, anexate) in case of cumulation or residual effect of the drug.

Objective: to create a method for safe anesthetic management in ophthalmic surgery.

The technical result is the ability to control the depth of sedation by continuous intravenous dosed administration of BCD.

The technical result is achieved by the fact that long-acting benzodiazepines are administered intravenously during premedication (e.g., sibazon), then narcotic analgesics (e.g., fentanyl) are used, and antipsychotics (e.g., droperidol) are added in case of arterial hypertension. Then, regional anesthesia with local anesthetics is performed retrobulbarly (for example, bupivacaine), and they also provide blockade of the wing-palatine ganglion and akinesia of the circular muscles of the eye (for example, lidocaine).

In the process of performing an ophthalmic surgery, a continuous intravenous controlled and metered infusion of BCD is performed, for example, dormicum or fulsed (0.8-2.5 μg / kg / min), 0.9% NaCl solution using a syringe dispenser. Dosages and rate of infusion of the solution, depending on age, severity of somatic state and multiple organ pathology, were selected empirically.

The dosage of BCD is calculated per kilogram of weight and time interval (μg / kg / min), calculated on the infusion rate of the syringe pump in ml / hour, which allows you to choose the optimal dosage to obtain the desired clinical effect, avoid cumulation of the drug, possible side effects and complications (Yen Smith, Paul White. Total intravenous anesthesia. - Clinical guidance. - Translation from English. - Moscow. - 2004. - S. - 114 -122.).

Calculation of the clinical dose of BCD, taking into account the speed of the syringe dispenser.

Since the feed rate of the syringe dispenser is measured in ml / hour, the dose of the drug is calculated in μg / kg / min, corresponding to the dispenser speed of 1 ml / hour, which is calculated by the formula derived empirically,

C = K · 1000 / V · M · 60,

Where

C is the amount of the drug in μg / kg / min, corresponding to the speed of the syringe dispenser in 1 ml / hour,

K is the amount of BCD preparation in mg dissolved in 0.9% NaCl solution,

1000 - conversion factor mg to mcg,

V is the volume of 0.9% NaCl solution in ml,

M is the patient’s body weight,

60 - conversion factor 1 hour per minute,

Introduce 30 mg of BCD (for example, dormicum) in 400 ml of 0.9% NaCl solution. With a patient weight of 82 kg, the “price” of 1 ml / hour of dispenser speed is 0.015 μg / kg / min (according to the formula). By adjusting the feed rate of the syringe dispenser, the BKD patient is saturated to achieve drug sleep or a condition close to it. Then, the dispenser speed is reduced to the minimum when the achieved clinical effect (drug sleep) will be maintained throughout the entire surgical intervention.

This way of working by adjusting the feed rate of the syringe dispenser and knowing the “price” of 1 ml / hour allows you to quickly navigate the dosage of BKD (μg / kg / min) and fix it at a given time, and the method allows you to more accurately and efficiently select the required minimum dosage.

Table Pathology (n = 120) average dose of BKD cf. systolic A / D Avg respiration rate in 1 min. Sat O2 (pulse oximeter)% waking time in minutes Saturation μg / kg / min main stage mcg / kg / min Original mmHg main stage mmHg Without concomitant pathology (n = 50) 2,5 1.3 153.6 117.6 13 98.9 four Moderate severe diabetes mellitus (n = 50) 1.9 1,0 183.7 123.7 fourteen 98.3 four Concomitant pathology of 2-3 body systems (n = 20) 1.8 1,1 191.2 131.6 fifteen 97.8 5

Where "Sat O2" - saturation of hemoglobin with oxygen according to the readings of a pulse oximeter

According to the data presented in the table should:

- with the aggravation of the severity of the somatic pathology of the patient, the dose of BKD saturation per unit time decreases (2.5-1.8 μg / kg / min);

- with initial arterial hypertension (153.6-191.2 mm Hg) during the infusion at the accepted dosages, BCD help stabilize the mean systolic blood pressure (117.6 -131.6 mm Hg respectively);

- continuous intravenous controlled and dosed infusion of BKD does not cause depression of respiratory functions (respiratory rate on average 14 cycles per 1 minute in all groups of patients, Sat 02 = 99-98%);

- the time of awakening after the end of the operation is not significantly prolonged even in the presence of severe concomitant somatic pathology in the patient and is 3-5 minutes.

The advantages of the proposed method:

- providing improved structure of intraoperative sleep, close to physiological;

- providing antegrade amnesia;

- a decrease in the total drug load, since the interaction of BCD with intravenous anesthetics is synergistic, and with central analgesics it is additive (Bowville, G. G. Interaction of drugs for anesthesin // Actual problems of anesthesiology and intensive care. Refreshing course of lectures. Issue-8. Translation from English Edited by Prof. E.V. Nedashkovsky. - Arkhangelsk. - 2003. - S. - 19-25);

- ensuring psychophysiological and emotional comfort, quick awakening, the absence of residual phenomena after drug sleep, since BKD have a pronounced anxiolytic effect, a short half-life and do not have active metabolites;

- the ability to select the minimum continuously administered dose of the drug, which allows you to get the necessary clinical effect: sedation and deep sleep without respiratory depression and hemodynamic disorders, since the water solubility of the drug allows you to more accurately titrate it;

- reducing the risk of possible complications from the vital functions of the body and adverse reactions to medications in patients with concomitant somatic diseases, ensuring the stability of the cardiovascular and respiratory systems, since being “pure” hypnotics, BCD do not inhibit nociceptive hemodynamic reactions, reduce the need myocardium and brain in oxygen (Ian Smith, Paul White. Total intravenous anesthesia. - Clinical guidance. - Translation from English. - Moscow. - 2004. - S. - 62);

- the proposed method did not lead to an overdose of BKD, since its cumulation was not observed, and therefore there was no need for the use of antagonist drugs;

the method does not require special training of doctors of anesthesiologists-resuscitators. Example 1

Patient K., 35 years old, weight 78 kg, without concomitant somatic pathology. Operated on post-traumatic retinal detachment. Premedication was performed with sibazon and fentanyl, and regional eye anesthesia with anecaine and lidocaine. Introduce 30 mg of BCD (for example, dormicum) in 400 ml of 0.9% NaCl solution. With a patient weight of 78 kg, the “price” of 1 ml / hour of dispenser speed is 0.016 μg / kg / min (according to the formula). In the process of surgical intervention, a continuous dosed infusion of a dormicum solution in an average dose of 1.3 μg / kg / min was additionally carried out (see table data).

The dosage of BKD necessary for saturation in preparation for the operation, in this example, was 2.45-2.55 μg / kg / min, which corresponded to a dispenser speed of 153-159 ml / hour. Saturation is carried out for 7-12 minutes. After reaching medical sleep or a condition close to it, the speed of the dispenser is reduced to optimal, which maintains this state until the end of the surgery. During the operation, patient K. selected a maintenance dose of BCD of 1.3 μg / kg / min, which corresponded to a syringe dispenser speed of 81 ml / hour.

The duration of the operation is 90 minutes Original A / D 150/90, and after stabilization 115/60 mm Hg The saturation of hemoglobin with oxygen according to the pulse oximeter on average up to 98.9%. The respiratory rate at the main stage is stable on average up to 13 cycles per 1 minute.

After the operation, waking up after 4 minutes. No complications or adverse reactions were noted.

Example 2

Patient S., 45 years old, weight 68 kg, suffers from insulin-dependent diabetes mellitus of moderate severity for 18 years. Concomitant diabetic angiopathy with a predominant vascular lesion of the central nervous system, discirculatory encephalopathy, hypertension 2 tbsp. Surgery for retinal detachment. Premedication - sibazon, fentanyl. Regional anesthesia of the eye - anecaine, lidocaine. Introduce 30 mg of BCD (for example, dormicum) in 400 ml of 0.9% NaCl solution. With a patient weight of 68 kg, the “price” of 1 ml / hour of dispenser speed is 0.018 μg / kg / min (according to the formula). In the process of surgical intervention, a continuous dosed infusion of a dormicum solution at a dose of 1.0 μg / kg / min was additionally carried out.

The dosage of BKD necessary for saturation in preparation for the operation in this example was 1.87-1.92 μg / kg / min, which corresponded to the dispenser speed of 104-107 ml / hour. Saturation is carried out for 7-12 minutes. After reaching medical sleep or a condition close to it, the speed of the dispenser is reduced to optimal, which maintains this state until the end of the surgery. During the operation, patient C. selected a maintenance dose of BCD of 1.0 μg / kg / min, which corresponded to a syringe pump speed of 55 ml / hour.

The duration of the operation is 45 minutes The original A / D 185/95, and after stabilization 121/75 mm Hg According to the pulse oximeter, hemoglobin oxygen saturation was observed on average up to 98.3%. The respiratory rate at the main stage is stable on average up to 14 cycles per 1 minute.

After the operation, waking up after 4 minutes. Adverse reactions and complications were not noted.

Example 3

Patient M., 68 years old, weight 82 kg. Concomitant pathology: chronic coronary heart disease, post-infarction cardiosclerosis, hypertension 2 tbsp., A constant form of atrial fibrillation, cardiopulmonary and respiratory failure 1 tbsp., Nephropathy 2 tbsp., Cerebrovascular disease, mixed encephalopathy. Surgery for retinal detachment. Premedication - sibazon, fentanyl. Regional anesthesia of the eye - anecaine, lidocaine. Introduce 30 mg of BCD (for example, dormicum) in 400 ml of 0.9% NaCl solution. With a patient weight of 82 kg, the “price” of 1 ml / hour of dispenser speed is 0.015 μg / kg / min (according to the formula). During the surgical intervention, a continuous dosed infusion of a dormicum solution in physiological saline 0.9% NaCl at a dose of 1.0 μg / kg / min was additionally carried out.

The dosage of BKD necessary for saturation in preparation for the operation, in this example, was 1.79-1.87 μg / kg / min, which corresponded to a dispenser speed of 119-125 ml / hour. Saturation is carried out for 7-12 minutes. After reaching medical sleep or a condition close to it, the speed of the dispenser is reduced to optimal, which maintains this state until the end of the surgery. During the operation, patient M. selected a maintenance dose of BCD of 1.05 μg / kg / min, which corresponded to a syringe dispenser speed of 70 ml / hour.

The duration of the operation is 60 minutes Initial A / D 195/100, and after stabilization 135/90 mm Hg Hemoglobin oxygen saturation was observed on average up to 97.8%. The respiration rate at the main stage is stable up to 15-16 cycles per 1 minute.

After surgery, waking up after 5.5 minutes. Adverse reactions and complications were not noted.

Claims (1)

A method for carrying out anesthetics during operations in ophthalmology, comprising administering short-acting benzodiazepines during premedication and during an ophthalmic operation, characterized in that short-acting benzodiazepines are continuously administered intravenously in a 0.9% NaCl solution, while the infusion rate and dosage calculated by the formula C = K · 1000 / V · M · 60, where C is the amount of the drug, mcg / kg / min, corresponding to the speed of the syringe dispenser, 1 ml / h; K is the amount of BCD preparation, mg, dissolved in a 0.9% NaCl solution; 1000 - transfer coefficient mg, mcg; V is the volume of a 0.9% NaCl solution, ml; M is the patient’s body weight; 60 - conversion rate of 1 hour per minute.