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0COMBINED LOW-FLOW INHALATION ANESTHESIA FOR NEUROSURGERY OF CHILDREN
1Yusupov A.S., 2Kholikov A.A., 3Mamatkulov I.A.
1,3Tashkent Pediatric Medical Institute 2 National Children's Medical Center https://doi.org/10.5281/zenodo.13151015
Abstract. The main task of anesthetic support of neurosurgical interventions in children involves achieving reliable and easily controlled anesthesia without negative impact on intracranial pressure (ICP), cerebral blood flow (CBF) and hemodynamics, hormonal background, as well as creating antihypoxic protection of the brain from local or general ischemia. In this regard, the main requirements for the "ideal" anesthetic for neurosurgical interventions in children are formulated. Such anesthetic should reduce ICP, volumetric CBF and oxygen demand of the brain, maintaining their ratio at an optimal level; minimally disrupt CBF autoregulation; easily control the degree of arterial hypotension at any stage of surgical intervention; ensure rapid awakening and restoration of consciousness at the end of the operation.
Keywords: neuroanesthesiology, neurointensive, oxybutyrate, arcuron.
One of the main clinical indicators in neuroanesthesiology and intensive care of children is intracranial pressure (ICP) [3, 4]. One of the advantages of inhalation anesthesia is the ability to quickly control the alveolar concentration of the anesthetic (depth of anesthesia) [1, 5]. This ability is most often realized by feeding a large number of volatile anesthetics into the circuit in a short period of time, i.e., with a high flow of fresh gas. Traditional anesthesia with a high gas flow also has its serious disadvantages, which consist of a large consumption of anesthetic, significant losses of heat and moisture from the patient's respiratory tract, and pollution of the operating room air. Reducing the gas flow in the breathing circuit allows us to avoid all these negative phenomena, which determines significant interest in inhalation anesthesia methods based on low flows of fresh gas [2, 6]. Recent advances in neurosurgery, neuromonitoring, and neurointensive care have significantly improved the treatment outcomes for patients with surgical lesions of the central nervous system (CNS). Although most of these methods were first applied in the adult population, pediatric patients face a number of inherent problems due to their developing and maturing neurological and physiological status, in addition to the CNS disease process. To ensure optimal protection of the body, the anesthesiologist must have knowledge of the basic neurophysiology of the developing brain and the effect of various drugs on cerebral hemodynamics, in addition to specialized training in pediatric neuroanesthesia [8, 9]. A wide range of drugs for anesthesia (fentanyl and inhalation anesthetics) in the first position, requires adequate combinations of them, maintaining the stability of the central hemodynamics, hormonal activity, taking into account both their positive and negative characteristics, and also noting the ability of drugs to reduce intracranial pressure, which is important in pediatric neurosurgery [7]. In this regard, the choice of various options for combined anesthesia, adequately providing pain relief and not having negative effects on the body of children during intracranial interventions remains relevant.
The purpose of study: Improving anesthetic protection of children using low-flow inhalation anesthesia during neurosurgical interventions.
Materials and methods. To provide anesthetic protection in 48 pediatric patients aged 1 to 16 years undergoing neurosurgical operations, the following combinations were used: sevoflurane with fentanyl (study group I - 61.54%) and sodium oxybutyrate with fentanyl (control group II -38.46%).
Anesthesia was administered for craniosynostosis (54.2%), hydrocephalus (45.8%). The duration of anesthesia in 52.6% of patients was up to 2 hours, in 47.4% - up to 2.5 hours.
After standard premedication, patients in group I were induced by inhalation of sevoflurane up to 3-4 vol%. Fentanyl solution was administered intravenously at a dose of 5 mcg/kg. Tracheal intubation was performed against the background of arcuron administration at a dose of 0.06 mg/kg. The artificial ventilation was carried out on the apparatus «GE Healthcare, Avance CS2» (USA) from close contouring. Myorelaxation was maintained by introducing 1/3 of the main dose of arcuron. Anesthesia was maintained by inhalation of sevoflurane at a dose of 1.5 - 1.8 vol% with a small gas flow. Maintenance of the surgical level of anesthesia was carried out by repeated administration of fentanyl at a dose of 1/2 or 1/3 of the original. After the end of the operation, with the appearance of adequate spontaneous breathing, tracheal extubation was performed. The duration of the awakening stage was 22.5 ± 5.6 min. Patients of the second control group after premedication were intravenously administered sodium oxybutyrate solution at a dose of 80-100 mg / kg, then fentanyl at a dose of 5 mcg / kg. After the introduction of the muscle relaxant arcuron at a dose of 0.06 mg / kg, tracheal intubation was performed. The dose of fentanyl and sodium oxybutyrate to maintain the surgical level was 1/2 of the initial dose. Infusion therapy was administered at a rate of 10-12 ml/kg/hour. Awakening from anesthesia was relatively long, amounting to 40.2±15.6 min.
The study of hemodynamic parameters was conducted on an echocardiograph "GE Healthcare, GE VIVID T8 R3" (USA) with a 3.0 MHz sensor according to the standard protocol. Echocardiography (EchoCG) parameters were calculated automatically. The following values were determined: stroke index (SI) = YOC /S ml/m2, cardiac index (CI) = MOS/S l (min*m2), specific peripheral resistance (SPR) = SBP/SI in conventional units. Computer analysis of echocardiography made it possible to calculate the indices of myocardial contractility and diastolic function of the left ventricle.
Results and discussions. The results of the study of hemodynamic parameters during combined anesthesia in children of group I are presented in Table 1. After premedication, patients showed a slight increase in heart rate (7.15%) with stable parameters of SDP, UI, CI, UPS and FI. Against the background of induction, a tendency to decrease in heart rate (14%) and SDP (6%) was observed, while the remaining parameters remained little changed.
Table 1. Changes in hemodynamic parameters during combined anesthesia with sevoflurane
in combination with fentanyl (M±m)
Stages of anesthesia and surgery
Indicator outcome premedication introductory traumatic end of
s period stage of the operation operation
HR, min 119,13± 126,81± 119,06± 120,54± 123,94±
-1 1,82 2,2* 2,25** 2,06 2,02
SBP, 84,80± 85,53± 79,40± 82,87± 76,97±
mmHg 1,94 1,93 2,00** 1,71 1,18**
SI, 47,26± 48,44± 46,58± 47,14± 47,38±
ml/m2 1,61 1,59 1,3 1,41 3,27
CI, l/min 4,73± 4,84± 4,66± 5,01± 5,07±
x m2 0,16 0,16 0,13 0,23 0,51
SPR,
convent. 68,29± 70,16± 68,36± 68,13± 72,72±
units 5,03 5,39 4,82 5,05 8,13
FI, % 63,76± 64,47± 63,84± 63,51± 63,73±
0,57 0,72 0,48 0,55 0,47
Note: * - significance of differences at P<0.05 compared to the baseline value
** - reliability of differences at P<0.05 compared to the previous stage of the study At the traumatic stage of the surgical intervention and at the end of the operation, the hemodynamic parameters remained stable. In the second group of patients (Table 2), the following changes were observed. The cholinolytic effect of premedication naturally led to a decrease in CDP by 4.14% and SPR by 9.21% due to peripheral vasodilation compared to the initial values. These changes were compensated by a moderate increase in HR by 5.2%. At the induction stage, reliable changes in hemodynamic parameters were observed. Thus, SI, CDP and CI increased by 16.25%, 17.54% and 18.65%, respectively.
Table 2. Changes in hemodynamic parameters during combined anesthesia with sodium oxybutyrate in combination with fentanyl (M±m)
Indicators Stages of anesthesia and surgery
outcome premedicatio n introductor y period traumatic stage of the operation end of operation
HR, min 1 118,8+6,61 124,5+5,22 127,9+2,88 124,1+4,09 120,2+3,98
SBP, mmHg 83,59±2,09 80,61±2,01 84,77±1,48 81,53±1,81 81,16±1,91
SI, ml/m2 43,15±1,43 42,7±1,59 46,65±3,25 42,1±1,28 42,47±1,76
CI, l/min x m2 5,33±0,39 5,12±0,32 6,05±0,17* * 5,17±0,28 4,95±0,23
SPR, convent. units 17,18+0,9 15,7+1,26 13,46+ 0,36* 16,37+0,79 17,03+0,74
FI, % 69,18+1,14 70,98+0,77 71,27+1,04 69,19+1,11 69,9+0,88
Note: *- reliability of differences compared to the baseline value (P<0,05).
**- reliability of differences compared to the previous period of the study (P<0,05). During the period of induction of anesthesia, insignificant changes in such parameters as HR and FI were revealed compared to the premedication stage. At the same time, SPR decreased by 12.16%. Ten minutes after intubation, compared to the previous stage of the study, a reliable decrease in CI by 14.6% and an increase in SPR by 29.64% were noted. At all subsequent stages of the operation and anesthesia, the central hemodynamic parameters remained relatively stable.
The results of the analysis of cortisol concentration in the blood of pediatric patients belonging to the first group at different levels of complex anesthesia were presented in Table 3.
Table 3. Changes in the concentration of cortisol in the blood during various variants of
combined anesthesia in children
Study groups of Normal cortisol Change in plasma cortisol concentration (nmol/L)
patients concentration before surgery skin incision awakening
(mg/ml) stage stage
1 group 50 - 250 168,41±4,47 172,47±8,77 (2,41%) 176,49±8,6 (4,80%)
2 group 50 - 250 167,62±8,24 180,32±8,24 (7,58%) 181,67±9,62 (8,38%)
Compared with the baseline value, at the skin incision stage - during the anesthesia maintenance period - the cortisol concentration tended to increase by 2.41%, and at the end of the operation - during the awakening period - by 4.8%.
Conclusion
When performing combined low-flow inhalation anesthesia with sevoflurane in combination with fentanyl in children with neurosurgical pathology, minor changes in the main indicators of central hemodynamics are observed, which indicates effective anesthetic protection of the child's body from surgical trauma.
When performing anesthesia based on sevoflurane and fentanyl, a less significant increase in the level of the stress response marker - cortisol to surgical stress is observed than in conditions of total intravenous anesthesia based on fentanyl with sodium oxybutyrate in neurosurgical operations in children.
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