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33DOI: 10.24411/2181-0443/2021-10004 СОСТОЯНИЕ ПОКАЗАТЕЛЕЙ ГЕМОДИНАМИКИ ПРИ КОМБИНИРОВАННОЙ АНЕСТЕЗИИ С ПРИМЕНЕНИЕМ ПРОПОФОЛА У ДЕТЕЙ
Хайдаров Камбарали Имомалиевич Усманова Дурдона Джурабаевна
Ташкентский педиатрический медицинский институт Ташкент, Узбекистан
Авторами было обследовано 159 детей в возрасте от 3 до 14 лет, госпитализированных в клинику для планового оперативного вмешательства с различной хирургической патологией. Целью исследования было определение наиболее оптимального сочетанного применения пропофола с кетамином или промедолом при операциях различной сложности и длительности. Ключевые слова: пропофол, анестезия, кетамин, промедол.
БОЛАЛАРДА ПРОПОФОЛ БИЛАН УТКАЗИЛАДИГАН БИРГАЛИКДАГИ АНЕСТЕЗИЯДА ГЕМОДИНАМИКА КУРСАТКИЧЛАРИНИНГ Х.ОЛАТИ
Муаллифлар томонидан турли жарроХдик патологиялари билан режали жарроХдик аралашуви учун клиникага ёт;изилган 3 ёшдан 14 ёшгача булган 159 болалар кузатилган. Тад;и;от ма;сади турли мураккаблик ва давомийликдаги жарроХдик амалиётларида пропофолни кетамин ёки промедол билан энг оптимал биргаликдаги ;улланилишини ани;лашдан иборат эди. Ключевые слова: пропофол, анестезия, кетамин, промедол.
HEMODYNAMIC CHANGES ON THE STAGES OF COMBINED ANESTHESIA WITH
THE USE PROPOFOL IN CHILDREN
Authors examined 159 children aged 3 to 14 years admitted to hospital for routine surgery with different surgical pathology. The purpose of this study was to determine the optimal combined use of propofol with ketamine or promedol in operations of varying complexity and duration. Key words: propofol, anaesthesia, ketamin, promedol.
The modern concept of general anesthesia is based mainly on concepts such as the adequacy and component nature of anesthesia. In order to maintain adequate anesthesia and fulfill the multi-component principle, modern anesthesiology uses various pharmacological agents that correspond to the main components of anesthesia: hypnotics, analgesics, muscle relaxants. The use of these funds in the anesthetic aid makes the main requirement for the drugs, possibly close to 100% efficiency, since the absence or insufficiency of the effect can lead to severe complications [1, 11].
Therefore, the interest in the use of propofol as a drug for induction of anesthesia is
understandable. It quickly induces sleep, maintains deactivation of consciousness throughout the infusion of the drug, interacts well with narcotic analgesics and antipsychotics, and has fewer side effects compared to other intravenous anesthetics [2].
Propofol, as a component of general anesthesia, is used in various surgical interventions [4, 5, 6, 8, 10]. Experience has been accumulated in the use of propofol in short-term operations and therapeutic and diagnostic manipulations [7, 9], in emergency abdominal surgery [3].
However, a number of publications indicate the possible undesirable manifestations of propofol during anesthesia, including the deterioration of
some parameters of central hemodynamics, although the data on this issue are extremely contradictory. Propofol is not an anesthetic, since it does not possess any pronounced analgesic properties, but is only able to increase the pain threshold, as, for example, most ataractics and tranquilizers.
The aim of this study was to determine the most optimal combined use of propofol with ketamine or promedol in operations of varying complexity and duration.
Materials and methods. We examined 159 children aged from 3 to 14 years, hospitalized to the clinic for planned surgery with various surgical pathologies.
The distribution of patients into groups was carried out depending on the complexity and duration of surgery. 109 patients, who were planned for low-traumatic and / or short-term surgical interventions, underwent combined anesthesia - a combination of ketamine with propofol. General anesthesia in combination with propofol and promedol was performed in the remaining 50 sick children.
Premedication in children in both groups was standard, carried out by intramuscular injection of atropine sulfate 0.1% -0.01 mg / kg, sibazone 0.5% -0.3 mg / kg, ketamine 5% - 3 mg / kg 15 minutes before surgery.
For an objective assessment of the functional state of the cardiovascular system, the method of echocardiography was used on the Aloka SSD-260 apparatus with the analysis of the end-diastolic size (EDS) and the end-systolic size (ESS) of the left ventricle and R-R interval (Sensor 3.5 MHz). For a detailed assessment of the function of the left heart, a computer analysis of echocardiography was used, the indicators of myocardial contractility and diastolic function of the left ventricle (LV) were calculated. Cardiac index (SI), peripheral specific resistance (PSR), stroke index (SI), and ejection fraction (EF) were calculated using generally accepted formulas.
Based on the linear parameters of the LV using mathematical calculations (L. Teichholz et al.), The indices of the morphometry of the heart, its pumping function and myocardial contractility were calculated. Mean BP (SBP), oxygen saturation (SaO2), heart rate (HR) were determined using the PROTOCOL 102E monitor (USA).
When OA was performed in patients of the first group, induction was started with intravenous administration of propofol at a dose of 2.5-3 mg / kg, followed by intravenous administration of anesthetic ketamine at a dose of 3 mg / kg. Anesthesia was maintained by infusion of propofol at the rate of 120 - 150 ^g / kg / min (depending on the stage of the operation). If necessary, ketamine was re-administered at a dose of 1-1.5 mg / kg. During the entire operation, the children did not have any suppression of spontaneous breathing.
When carrying out anesthesia in patients of the second group, induction began with an intravenous bolus of propofol at a dose of 2-2.5 mg / kg, then the analgesic promedol was administered at a dose of 2 mg / kg intravenously. After the introduction of the muscle relaxant Arduan at a dose of 0.06 mg / kg and hyperventilation with 100% oxygen, the trachea was intubated. Artificial ventilation of the lungs was carried out with an anesthesia device "Fabius" in the normal ventilation mode. Anesthesia was maintained by infusion of propofol at the rate of 100 - 150 ¡.xg / kg / min (depending on the stage of the operation) and intravenous administration of promedol 1 mg / kg of body weight every 50-60 minutes.
Research results and their discussion
The data of changes in hemodynamic indices during the anesthetic treatment of the first group are shown in Table 1. When evaluating the results obtained, it was found that the initial values of the studied indices of the first group of patients were within the physiological values.
Table 1
Hemodynamic parameters at the stages of anesthesia in OA with propofol and ketamine
Exodus Premedication Induction Middle of operation End of operation
SBP 80,2±2,9 97,4±3,7 94,5±3,2 90,2±3,1 84,8±3,07**
(mm Hg.)
ShI 42,7±2,3 40,7±2,45 40,4±2,7 39,3±2,6 40,3±2,7
(ml / m2)
CI 4,4±0,9 4,9±0,69 4,5±1,02 4,2±0,9 4,1±0,9
(l / min / m2)
PSR 64,8±5,4 61,9±2,4 61,4±5,4 59,7±5,3 61,5±5,5
(dyn-s / (cm3-2)
HR 102,7±3,5 121,05±2,2 112,9±3,5 108,04±3,5** 102,3±3,3
(beats per minute)
EF 72,8±2,03 74,4±2,13 74,9±2,1 74,9±2,1 73,7±2,2
( %)
Note ** p <0,01
After premedication, there was an increase in SBP compared to baseline by 12%. This hyperdynamic circulation is associated with the sympathomimetic effect of ketamine. A 3% decrease in the SBP parameter was observed against the background of induction (from 97.4 ± 3.7 to 94.5 ± 3.2). By the period of awakening, there was a 13% decrease in SBP compared to the premedication stage. There is a 7% decrease in ShI after premedication (from 42.7 ± 1 to 40.7 ± 0.3). HR increased by 18% after premedication, and during the induction period, it decreased by 8%. During the period of maintaining anesthesia, a decrease in HR by 11% was observed, and by the period of awakening, HR returned to its original values. PSR decreased after premedication by 5% (from 64.8 ± 5.4 to 61.9 ± 2.4), no statistically significant
changes were observed until the end of the surgical intervention. From this it can be concluded that there were no indicators that would indicate peripheral vasodilation and vasoconstriction. The ShI index during the stages of anesthesia remained at the initial values. EF increased at the 2nd stage of anesthesia by 10% compared to the 1st stage. At the rest of the stages, EF retained its normal initial values.
It is noteworthy that at the beginning of the induction period, patients developed hypoventilation, which is associated with the action of propofol, no excitement or motor reactions were observed.
Characteristics of changes in hemodynamic parameters during the anesthetic treatment of Promedol + Propofol are shown in Table 2.
Table 2.
Hemodynamic parameters at the stages of anesthesia in OA with propofol and promedol
Exodus Premedication Induction Middle of operation End of operation
SBP 67,3±2,5 74,6±2,6 73±2,2 74,3±2,2 78,1±2,2
(mm Hg.)
ShI 40,7±3,5 45,3±3,5 40,6±3,8 35,9±3,8 47,7±3,7
(ml / m2) (+10%) (-12%) (+10%)
CI 4,3±0,9 5,5±1,1 4,8±1,2 4,0±1,1 5,7±1,1
(l / min / m2)
PSR 57,9±3,0 65,3±3,3 57,7±4,0 49,9±3,5* 68,6±3,5
(dyn-s / (cm3-2)
HR 114,7±6,3 124±3,6 121,9±3,7 117,1±3,67 122,8±3,7
(beats per minute)
EF 68,1±2,1 74,1±2,3 70,0±2,5 68,6±2,7 73,9±3,1
( %)
Note: * p <0,05.
General anesthesia using promedol and propofol, which was carried out in more voluminous and prolonged surgical interventions, revealed the following changes in hemodynamic parameters at the stages of anesthesia (Table 3). After premedication, there was an increase in HR by 8%, SBP by 10%, ShI by 10%, CI by 27%, PSR by 12%, EF by 8%. The noted hyperdynamia in the premedication period is associated with the M-cholinomimetic effect of atropine and the sympathomimetic effect of ketamine. The minimum average HR for the entire study period is 117.1 ± 3.67. No significant differences were found between HR indicators. The maximum SBP value was 78.1 ±
2.2 at the end of the operation. ShI during the induction stage and during the period of maintenance of anesthesia decreased to 12%, which indicates adequate tissue perfusion. A decrease in HR and ShI scores causes a significant decrease in CI to 28%. Metabolism in tissues improves, the need for oxygen does not increase. At the induction stage, PSR decreases by 12%; during the period of maintenance of anesthesia, a significant decrease by 24% is noted. At the end of the operation, it increases by 5%. Perhaps due to an increase in vascular tone. Starting from the second stage, the downward trend in the EF indicator is growing.
30% 20% 10% 0% -10% -20% -30%
HR propofol promedol HR propofol ketamin SBP propofol promedol SBP propofol ketamin ShI propofol promedol ShI propofol ketamin
Premedication.
Middle of an operation .
The end of the operation.
Figure 1. Comparative characteristics of the parameters of heart rate, systolic and stroke in the general anesthesia propofol ketamine and propofol promedol
When comparing heart rate, systolic and stroke between the two groups is clearly visible reduction in ShI in the induction period and a more pronounced decrease in the middle of an operation with general anesthetic propofol in combination with promedol. By the end of the operation ShI getting closer to the values premedikation period. Indicators of SBP and heart rate during general anesthesia combined with propofol ketamine tend to decrease and by the end of the operation, these indicators are returned to their original values.
30%
20%
10%
0%
-10%
-20%
-30%
-40%
CI propofol promedol CI propofol ketamin SPR propofol promedol SPR propofol ketamin EF propofol promedol EF propofol ketamin
Premedication.
Middle of an operation .
The end of the operation.
Figure 2 Comparison of parameters of the SI, SPR, and EF with general anesthesia, propofol
ketamine, and propofol promedol.
The figure number 2 marked a distinct reduction in CI and SPR in the middle of an operation with general anesthesia with propofol promedol. Growing tendency to decrease in the CI of general anesthesia with propofol ketamine. In the first group of EF remain within normal limits when there is a decrease of stages of anesthesia with propofol with promedol.
3. The combination of propofol with ketamine in low-traumatic operations and propofol with promedol in more traumatic and long-term operations provides adequate anesthesia characterized by the stability of the indicators of central and peripheral hemodynamics.
2. Anesthesia with propofol in combination with ketamine or promedol ensured hemodynamic stability at all stages of surgery without reducing myocardial contractility.
Conclusions.
1. The combination of propofol and ketamine makes it possible to neutralize some of their unwanted hemodynamic effects.
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