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2. Копейкина Л. В., Ходзицкая Е. В. Исследование качества и безопасности свинины//Вестник ТГЭУ - 2005. -№ 2. - С. 54-60.
3. Миронова И. В., Карнаухов Ю. А. Особенности формирования качества мясного сырья при использовании глауконита в рационе подсвинков//Известия ОГАУ - 2009. - № 21. - С. 86-88.
4. Семёнова А. А., Кузнецова Т. Г., Анисимова И. Г. Сенсорный анализ инструмент в управлении каче-ством//Пищевая индустрия. - 2011. - № 2/7. - С. 50-52.
5. Антипова Л. В., Глотова И. А., Рогов И. А. Методы исследования мяса и мясных продуктов. - М.: Колос, 2001. - 576 с.
6. Тихонов С. Л., Тихонова Н. В., Монастырев А. М. Актуальные вопросы качества мяса//Известия ОГАУ. -2006. - № 9. - С. 71-73.
7. Бажов Г. М., Крыштоп Е. А., Бараников А. И. технологическая характеристика свинины с пороками PSE и БРБ//Научный журнал КубГАУ - Scientific Journal of KubSAU. - 2013. - № 89-89. - С. 973-984.
8. Белик С. Н. Колмакова Т. С. Использование антибактериальных препаратов в интенсивном свиноводстве и их влияние на качество свинины//ХХШ заседание межвузовского координационного совета по свиноводству и междунар. науч. пр. конф. «Актуальные проблемы производства свинины», п. Персиановский, 2013. - С. 106-111.
Sharipova Visolat Khamzaevna, Republican Research Centre of Emergency Medicine,
Tashkent, Uzbekistan
Clinical-pathogenetic ground of multi-modal analgezia adequacy at peryoperative period in emergency thoracic operative investigations
Abstract: Balanced anesthesia is pharmacological means in combination with regional methods effecting on physiological processes fulfilling nociception, transmission, modulation and perception on the multimodal base. The main point of regional anesthesia contains in the block of conducting nociceptive impulses from operation sphere at different levels proximal from the surgical approach Efficiency of intrapleural and thoracic paravertebral block in combination with general anesthesia in patients performed thoracic interventions due to traumatic injuries of thorax have been studied. Methods: 116 patients admitted to RRCEM in urgent way with chest traumatic injuries have been examined. They have been divided into 3 groups against to the applied method of anesthesia and postoperative pain relief. Results: The received results shows that the use of the regional way of anesthesia in combination with general anesthesia promotes a smooth course of intra- and post-operative periods with the minimal tension of hemodynamic indexes, less revealed pain syndrome in post-operative period, has the economic effect shown up by the decrease of the use of narcotic analgetics both in intra- and post-operative periods.
Keywords: multi-modal analgesia, paravertebral blocade, intrapleural analgesia, pain.
Introduction
Anesthesia adequacy issue and post-operative analgesia attracts an attention of specialists. Traditional anesthetics and opioids are not enough for valuable anesthesiological protection of the patients and need in addition by special things preventing nocioceptive system overexcitation and organ disfunctions connected with it.
The most important issue ofthe world anesthesiology remains working-out and adoption of safe, effective ways of anti-nocioceptive protection of patients from acute pain in emergency medicine and multimodal analgesia deserves a special attention among them. Multimodal
analgesia provides simultaneous usage of two or more anesthetics and analgetics having different mechanisms of action and allowing achieve adequate pain relief at minimum side effects inherent to the big doses of one analgetics in monotherapy [2; 6]. Clinicians familiar with base of pain neurotransmission understand a necessity of multimodal approach to providing nociception inhibition on the different levels of nervous system, activation of inhibitional anti-nocioceptive mechanisms. Both system and regional action ways and systems are used for it. So, balanced anesthesia is pharmacological means in combination with regional methods effecting on physiological processes fulfilling
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Clinical-pathogenetic ground of multi-modal analgezia adequacy at peryoperative period in emergency thoracic...
nociception, transmission, modulation and perception on the multimodal base. [4; 10]. The main point of regional anesthesia contains in the block of conducting nociceptive impulses from operation sphere at different levels proximal from the surgical approach [11].
Chest injuries and traumas has become one of the most often reasons for admitting patients to emergency surgical hospitals for the last years. At the presence of the chest trauma, bleeding or lung injury it is usually performed thoracoscopy with the aim of pleural cavity revision. It is known that operations on the chest are one of the most traumatic ones as visceral and parietal pleuras are rich in nociceptive receptors and as a rule, they are performed by switching one lung off from the ventilation and can require a long-termed wide rupture of respiratory tracts’ lumen and it is the cause of intra-operative gas exchange disorder, pulmonary and system hemodynamics [1; 3; 8].
In early post-operative period under the pain influence such patients often had hypoxemia and hypercapnia with the development of respiratory acidosis due to hypopnoe and the limitation ofrespiratory excursion. That is why just
after recovery it is necessary to achieve patient’s productive cough and early motor activity. It can be achieved only at the adequate anesthesia [5; 9]. All it dictates definite requirements to anesthesia at thoracic interventions which can be stated as follows: a reliable antinociception, well gas exchange managing, rapid recovery and self-reliant respiration, high quality analgesia both at the recovery and at the early post-operative period [7].
The aim of our investigation is the efficiency estimation of intrapleural (IPA) and thoracic paravertebral analgesia (TPVA) in composition of combined anesthesia in intra- and postoperative periods in patients with chest traumatic injuries.
Methods
116 patients who performed emergency operations due to chest injuries were involved into investigations. Patients were divided into 3 groups subject to applied method of anesthesia and post-operative pain-relief. They did not have differences on age, sex, type of operations (tables 1, 2, 3). According to physical condition and nature of revealed disorders patients refered to II-III Е class by ASA.
Table 1. - Distribution of patients by sex
Sex 1st group (%) 2nd group (%) 3rd group (%) Totally (%)
Woman 10 (25%) 11 (29,7%) 14 (35,8%) 35 (30,2%)
Man 30 (75%) 26 (70,3%) 25 (б4,2%) 81 (69,8%)
Totally\several age 40 (100%)/37±2,2 37 (100%)/37,2±2,7 39 (100%)/34,7±2,2 116 (100%)
Table 2. - Distribution of patients by performed operations
Operations 1st group (%) 2nd group (%) 3rd group (%) Totally (%)
Thoracoscopy with elimination post-traumatic hemothorax, pneumothorax 13 (32,5%) 7 (18,9%) 7 (18%) 27 (23,3%)
Thoracoscopy with closure of injuried parts of lung, bullas 12 (30%) 12 (32,4%) 14 (35,8%) 38 (32,7%)
Thoracoscopy, atypical lung resection 7 (17,5%) 5 (13,5%) 2 (5,3%) 14 (12%)
Minithoracotomy: — with closure of injuried parts of lung; — hemo-pneumothorax elimination; — ehinokokkectomy, cistectomy 3 (7,5%) 3 (7,5%) 2 (5%) 3 (8,2%) 6 (16,2%) 4 (10,8%) 8 (20,5%) 4 (10,2%) 4 (10,2%) 14 (12%) 13 (11,3%) 10 (8,7%)
Totally 40 (100%) 37 (100%) 39(100%) 116 (100%)
Table 3. - Distribution of patients by injury nature at emergency thoracic operations
Injury nature 1st group (%) 2nd group (%) 3rd group (%) Totally (%)
Closed chest injury + ribs fracture + lung injury 6 (15%) 7 (19%) 5 (13%) 18 (15,5%)
Ruptures of cysts, bullas 12 (30%) 16 (43,2%) 20 (51,2%) 48 (41,3%)
Stab-cut wounds 14 (35%) 6 (16,2%) 8 (20,5%) 28 (24,2%)
Closed chest injury + ribs fracture + lung injury 8 (20%) 8 (21,6%) 6 (15,3%) 22 (19%)
Totally 40 (100%) 37 (100%) 39 (100%) 116(100%)
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Ways of premedication, anesthesia and post- operations are given in table 4. operative pain-relief in patients performed thoracic
Table 4. - Ways of premedication, anesthesia and post-operative pain-relief in patients with thoracic operations (n=116)
1st group 2nd group 3rd group
Premedication promedol 20 mg, dime-drol 10 mg, Н2 blocker nevofam 20 mg promedol 20 mg, dimedrol 10 mg, blocker nevofam 20 mg ketonal 100 mg intramuscularly promedol 20 mg, dimedrol 10 mg, blocker nevofam 20 mg ketonal 100 mg intramuscularly
Anesthesia maintenance izofluran 1,5-2 об% fentanil in dose 5-8 mkg\kg\hour izofluran 0,8-1% Analgetic component IPA+bolus dosing of fentanil in traumatic moments of operation by 0,1mg. izofluran 0,8-1% ketamin 0,8 mg\kg — block of NMDA receptors Analgetic component PVB + bolus dosing of fentanil in traumatic moments of operation by 0,1mg.
Post-operative pain-relief Morphine 30-50 mg\a day NSAID ketonal 300mg; IPA bupivacaine 0,25%-50mg each 5-6 hours (or lidokain 1%-200 mg each 3-4 hours); Morphine 10 mg at necessity NSAID ketonal 300mg; PVB bupivacaine 0,25%-50mg each 5-6 hours (or lidokain 1%-200 mg each 3-4 hours); Morphine 10 mg at necessity
Рюк 1. Important mechanisms of pain control. Means and ways used in research work
Means and ways of blocking all levels of nociception used in research work are given in the following picture 1.
Ways of investigation:
• ECG for estimation of data of central hemodynamics (Hitachi -500);
• Average blood pressure (ABP), general peripheral vascular resistance (GPVR), left ventricular work index (LVWI), cardiac index (CI) were counted by calculating methods;
• ABP monitoring, heart rate frequency (HRF), ECG, saturation (Sp02) with Nikon-Kohden (Japan) monitor.
• Blood analysis: ABB indexes, glucosae level, stress hormone level (cortisol);
• Subjective estimation of post-operative pain-relief: Visual-analog scale (VAS), Positional discomfort scale (PDS), Verbal estimations scale (VES);
• Extubation time;
• Time of analgetic first requirement (TAFR);
• Consumption of narcotic analgetics in the intra-and post-operative period.
Mentioned above investigations were performed at the following levels:
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Clinical-pathogenetic ground of multi-modal analgezia adequacy at peryoperative period in emergency thoracic...
Intra-operative period at thoracic operative interventions: 1-Outcome -before anesthesia, 2-After block (for thoracic patients), 3-After trachea intubation, 4-Traumatic moment of operation, 5-End of operation
Post-operative period: 1-Before pain-relief,
2-30 min after pain-relief, 3-2 hours after pain-relief, 4-5 hours after pain-relief.
Results.
Our investigations have revealed that both groups patients admitted to operation room with existing respiratory
failure conditioned by the chest injury, hemo- pneumothorax with hypertension and tachycardia which has been regarded as organism’s reaction on trauma pain. The conducted premedication has not removed the pain totally and at the admission to the operation room all the patients have felt the pain equal to 7-8 points by VAS which fits severe pain. In all groups at the initial level (before the block) according to pain sensation, the main hemodynamics indexes were high. A significant difference between groups in hemodynamics indexes has not been revealed.
Pict.2. Hemodynamic indexes in the intra-opeative period at thoracic operative intervention
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At the 2nd stage comparing groups 1 and 2 we revealed that ABP index was 19% higher and HRF — 23,7% higher in patients of group 1. LVWI was more than 26,4% higher and EF had 21,2% difference. GPVR index was 11,9% higher in patients of group 1 than in the 2nd one. Comparing groups 1 and 3 we revealed that ABP index was 19,2% higher, HRF — 21,5% higher in patients of group 1. Reducing HRF in 3rd group led to improving heart work. It was in increasing EF indexes to 21,2%, improving of LVWI to 26,4% in compare with patients from group 1. GPVRindex was 12,9% higher in patients of group 1 than in group 3 (pict.2). Glucose index reduced to 34% in the 2nd group, and in the 3rd one — to 38,3% in compare with group 1 (pict.3). Cortisol index reliably reduced to 24,9% and 23,4% in groups 2 and 3 in compare with group 1 (pict.4).
In traumatic moment of operation in both groups where used combination of general anesthesia with PVB
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1-lev 2-lev 3-lev 4-lev 5-le\ Pict. 3. Glucosae indexes
Glucose index was higher in group 1 to 44,8%, in group 2 to 48,6%. Cortisol index in the 1st group was 62,5% higher than in the 2nd one and in compare with group 3 — to 68,4%.
Combined use of general anesthesia and IPA in the intra-operative period in the 2nd group patients allowed to reduce a consumption of fentanil to 30%. Combined use of PVB and general anesthesia in the 3rd group patients allowed to reduce a consumption of fentanil to 58% in compare with the control group. In the group with the use of PVB + general anesthesia it was pointed a reducing of fentanil consumption to 20% than in group with the use of IPA + general anesthesia. Extubation time in patients of group 3 reduced on 57,4% than in group 1. At comparing groups 1 and 2 where IPA was used, extubation time reduced in 43,5% in patients of group 2.
It is noticed reliable shortening of TARF on 34,7% in 1st group than 2nd one and on 70% than in the 3rd one. Comparing groups 2 and 3 we noticed
and IPA it was pointed a stability ofhemodynamic indexes. In group 1with the use of isolated general anesthesia it was detected reliable increasing of ABP index to 26,8% and HRF — to 38,5% 3 in compare with group 2.
Comparing groups 1 and 3 we observed increasing of ABP index to 36,8% and HRF — to 41,4% in the control group. EF index at comparing groups 1 and
2 was 14,6% lower in the 1st one.At comparing groups
1 and 3 this index was 14% higher in group 3. LVWI in group 1 reacted by increasing to 72,5% in compare with group 3 and at comparing with the 2nd one — this index was 53,3% higher. Comparing groups 2 and
3 this index was 12% higher in the 2nd one. CI index in the 1st group was 24,2% higher in compare with group
2 and comparing with group 3 it was 19,6% higher. GPVR index at comparing groups 1 and 3 had reliable difference in 13%.
Pict. 4. Cortisol indexes
augmentation of TARF on 34,8% in group 3 than in the 2nd one and it proved longer effect of anesthesia at using PVB. At pain estimation by VAS we revealed that pain senses in group 1 were 28,5% higher than in group 3 and between groups 1 and 2-25,3%. Subjective pain estimation in three groups revealed that patients of groups 1 and 2 felt more intensive pain which was 20% higher than patients of group 3. Subjective pain estimation by PDS detected that there was a difference of 45,8% in pain sense between patients of groups 1 and 3. This difference made 35% between patients of groups 2 and 3 and between groups 1 and 2-20%. At pain estimation by VES we revealed that pain senses in group 1 were 45,4% higher than in group 3. At comparing groups 2 and 3 it was detected that pain factor prevailed in group 3 and this difference made 22,7%. At the 1st stage of post-operative period in three groups hemodynamics indexes did not have reliable differences and corresponded to patients’ pain sense (pict.5).
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Clinical-pathogenetic ground of multi-modal analgezia adequacy at peryoperative period in emergency thoracic...
Pict.5. Hemodynamics indexes after thoracic operative interventions.
At the 2nd stage ABP index was 12,1% higher in group 1 than in the 3rd one. HRF index in the 1st group was 14,5% higher than in the 3rd one. At comparing groups 2 and 3 группы the difference on 12% was detected. EF index in the 2nd group increased to 11,8% than in the 1st one. In the 3rd one this index was 19% higher than in the 1st group. GPVR index was 16% higher in group 1 than in the 2nd one and at comparing with the 3rd one it was 13% higher and it proved better efficiency of anesthesia at using NSAID ketonal and PVB. Pain sense in patients of group 1 by VAS in spite of pain relief by morphine was 41,6% higher than in group 2. Comparison of VAS index between groups
1 and 3 revealed a difference in 68,8% to the benefit of pain relief in patients of group 3. Comparison of pain sense between groups 2 and 3 on the base of VAS detected that patients of group 3 did not feel pain and difference of 46,6% proved it. Estimation index by VES revealed better anesthesia in group 3 for 68,8% in compare with the 1st one and at comparing groups 1 and
2 it was pointed worse pain relief in group 1 for 62,5%. Estimation by PDS revealed that this index in group
1 was 72,1% higher than in group 3 and 21,7% — in compare with group 2.
At the 3rd stage of post-operative period hemodynamics indexes in three groups remained normal but there was some tachycardia in the 1st group. HRF was 14,4% higher in group 1 than in the 3rd one. EF in group
2 was 18% higher than in the 1st one. EF in group 3 was 19,3% higher than in the 1st one. С index was 9% lower in group 1 than in the 2nd one. GVPR was 16% higher in group 1 than in the 2nd one and 11,2% — than in group 3. VAS index in the 3rd group was 75% lower than in the 1st one. Comparing subjective pain senses by VAS between patients of groups 2 and 3 revealed a reliable difference in 74%. Estimation of anesthesia quality by VES detected that pain sense by patients of the 1st group were 33,3% higher than in the 2nd one and 86,6% higher than in the 3rd one. Estimation by PDS revealed reducing pain to 86,6% than in group 1 and 83,7% — than in group 2.
Glucose index was 36,1% lower in 2nd group than in the 1st one and in the 3rd one it was 32,5% lower than in the 1st one. Cortisol index was 28,7% higher in control group in compare with groups 2 and 3.
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1-lev 2-lev 3-lev 4-lev
Pict. 6. Cortisol indexes
At the 4th stage difference in subjective pain senses by VAS in 3rd group was in 76,9% than in the 1st one, proved longer and more qualitative efficiency of anesthesia at using PVB in combination with NSAID. Analgesia quality by VAS in the 3rd group was 74,6% better than in the 2nd one. Estimation of pain relief quality by VES and PDS revealed that 3rd group patients felt less pain on 87,5% than ones from groups 1 and 2. HRF in group 1 was 36,7% higher, ABP — 24% than in group 3. CI index in 1st group was 11,7% higher than in 3rd one. LVWI was 38% higher in the 1st group than in 3rd one. Comparing groups 1 and 2 it was revealed that this index was 14% higher in the 1st one. Comparing groups 2 and 3 LVWI increased in the 2nd one for 22,4% than in 3rd one. EF index in 3rd group was 20,6% higher than in the 1st one. At comparing groups 2 and 3 ABP the difference in 15,2% and HRF 25% was detected to the benefit of 3rd group where PVB was used. Comparing groups 1 and 3 revealed increasing of glucose on 56,8% in group 1. Comparing groups 2 and 3 revealed that this index was 44,8% higher in group 1. Cortisol in group 1 was 17,8% higher than in 2nd one. At comparing groups 1 and 3 we detected increasing of it on 45,2% in group 1. Comparing groups 2 and 3 revealed increasing of cortisol on 33,3% in the 2nd one.
On the base of intrapleural analgesia by bupivacaine the quantity of consumed morphine reduced on 42,8% when combination of using paravertebral block by bupivacaine and ketonal reduced using morphine on 57,1% in compare with group 1. At comparing groups 2 and 3 where it was used a combination of regional blocks with NSAID it was noticed reducing of morphine in group 3 on 25%.
On the base of multimodal analgesia on the base of TPVB post-operative pneumonia developing reduced
1-lev 2-lev 3-lev 4-lev
Pict.7. Glucosae indexes
on 46% than in group with traditional analgesia by narcotic analgetics. In group 2 with the use of IPA + narcotic analgetics there was also detected the reducing of post-operative pneumonia developing to 28% than in
the 1st one.
Conclusion
1. At emergency thoracic operative interventions use of perioperative multimodal anesthesia promotes stability ofcentral and peripheral hemodynamics indexes, sympato-adrenal system, ABB in compare with traditional analgesia.
2. At emergency thoracic operations use of prolonged IPA in content of multimodal anesthesia-analgesia promotes reducing of consumption narcotic analgetics in intra-operative period to 30% and in postoperative period — to 42,8%.
3. Including prolonged PVB into scheme of multimodal anesthesia at emergency thoracic operative interventions leads to reducing of consumption of narcotic analgetics in intraoperative period to 58% and in postoperative period — to 57,1%.
4. Applying multimodal analgesia in postoperative period provides less subjective pain intensity (in 2,5 times) by VAS and better quality of postoperative anesthesia (in 3 times) by PDS and VES in compare with traditional analgesia with narcotic analgetics after traumatic abdominal and thoracic operative interventions.
5. The action ofpostoperative anesthesia on the base of PVB 1,5 times longer than period anesthesia scheme with IPA and it is connected with the combination of local anesthetics with pleural cavity liquid, decreasing of the concentration of local anesthetics and its run-out from drainage tube.
References:
1. Volchkov V. A., Ignatov Yu. D., Strashnov V. I. Pain syndromes in anesthesiology and reanimatology. М 2006; 166-186.
2. Edvard J. Morgan-junior, Megid S., Michail M. Clinical anesthesiology: book 1. M 2004; 301-314.
3. Zilber A. P., Maltsev V. V. Regional anesthesia. М. 2007; 100-111.
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Experimental and clinical investigations of drugs for systolic heart failure treatment
4. Malroy M. Local anesthesia. М 2003; 97-119, 126-140.
5. Ovechkin A. M., Prophylaxis of post-operative pain syndrome: pathogenetic basic and clinical application: Author’s abstract. М 2000.
6. Svetlov V. A., Zaytsev A.Yu., Kozlov S. P. Balanced anesthesia on the base of regional blocks: strategy and tactics. Anesthesiology and reanimatology. 2006; 4: 4-12.
7. Bimston DN., McGee JP., Lip tay MJ., Fry WA. Continuous paravertebral extrapleural infusion for post-thoracotomy pain management. Surg. 1999; 126: 650-6.
8. Giesecke К., Hamberger В., Jarnberg PO., Klingstedt C. Paravertebral block during cholecystectomy: effects on circulatory and hormonal responses. Br J Anaesth 1998; 61: 652.
9. Gilbert J., Hultman J. Thoracic paravertebral block: a method of pain control. Acta Anaesthesiol Scand 1998; 33:142.
10. Detterbeck F. C. Efficacy of methods of intercostals nerve blockade for pain relief after thoracotomy. Ann. Thorac. Surg. 2005 Oct; 80 (4): 1550-1559.
11. Klein S. M., Bergh A., Steele S. M., Georgiade G. S., Greengrass R. A. Thoracic paravertebral block for breast surgery. Anesth Analg. 2000 Jun;90 (6): 1402-5.
12. Lonnqvist P. A., MacKenzie J., Soni A. K., Conacher I. D. Paravertebral blockade: failure rate and complications. Anaesthesia 1995; 50: 813-815.
Gorchakova Nadija Oleksandrivna, professor, Bogomolets A. A. state medical university, The Department of pharmacology.
E-mail: xl@bigmir.net Shumeiko Elena Volodymyryvna, associate professor, Bogomolets A. A.
state medical university The Department of pharmacology, Shumeiko Mykola Volodymyrovych, assistent The Department of pharmacy and industrial technology of drugs, Bogomolets A. A.
state medical university.
Experimental and clinical investigations of drugs for systolic heart failure treatment
Abstract: The review is covered the problem of the optimizing treatment of systolic heart failure that is one of the most urgent tasks in modern cardiology. The experimental and clinical works are directed to looking for the inotropic agents and drugs influencing on the neurohumoral pathways which are able to enhance cardiac outpoot and decrease the pre- and postload on the myocardium.
Keywords: systolic heart failure, inotropic agents, neurohumoral pathways
Горчакова Надежда Александровна, профестр, кафедра фармакологии, Национальный медицинский университет имени А. А. Богомольца E-mail: xl@bigmir.net Шумейко Елена Владимировна, доцент, кафедра фармакологии, Национальный медицинский университет имени А. А. Богомольца
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