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DOI: http://dx.doi.org/10.20534/ESR-17-3.4-49-51
Makhkamov Tokhir H., an anesthesiologist - Intensivist in Intensive care unit, City Oncology Centre, Tashkent, Uzbekistan. E-mail: [email protected] Khojitoev Sanjar V., teacher in Oncology faculty, Tashkent Medical Academy E-mail: [email protected]
General combined anesthesia on the basis of spinal-epidural blockade during oncourologic and oncogynecological surgeries
Abstract: The results of the study showed that the use of general combined anesthesia based on regional blockades justifies for anesthetic supply of long and traumatic surgeries in oncourology and oncogynecology.
Keywords: Extended oncourological and oncogynecological surgeries, general combined anesthesia on the basis of SEB, general multicomponent anesthesia.
Introduction: In recent years, in the surgery of pelvis organs, the indications for over-aggressive, multi-organ and long-term surgeries have expanded. The most typical of these should be considered extended cystectomy and hysterectomy for cancer, followed by broad removal of regional lymphatic collectors. The high traumaticity and duration of such operations with the coverage of the vast reflexogenic zones of small pelvis and surrounding tissues dictates the need for highly effective anesthetic protection capable of reliably blocking the flow of powerful nociceptive stimulation from extensive surgical lesions, both during surgery and in immediate postoperative period. The variants of the general combined anesthesia on the basis of regional blockades meet the most complete requirements [5; 6; 7; 8]. Among them, our attention was drawn to the spinal-epidural block (SEB), which allows to combine the advantages of spinal and epidural anesthesia, to reduce the number of complications and to provide long and highly effective postoperative analgesia [2; 3; 8; 9; 10; 11].
The aim of the study was to evaluate the efficacy and safety of combined anesthesia on the basis of SEB for extended surgeries in oncourology and oncogynecology.
Materials and methods. To evaluate the efficacy of the approved method, 2 groups of patients aged 42 to 74 years, 63 women and 31 men, whose physical status corresponded to ASA classes II-IV were formed. In all patients, in the order of examination and preparation for surgery by the method of echocardiography, CI, HR, and reserve capacity of left ventricle were determined before and after passive orthostatic test [10]. The criterion for preserving the reserve abilities of cardiovascular system was the increase in RV intensity index, CI, and HR in response to orthostatic test. The study groups included only the patients with preservation of reserve capacities of the cardiovascular system.
The main group consisted of 50 patients operated under conditions of general combined anesthesia on the basis of SEB, the control group - 44 patients operated under general multidivision anesthesia. All patients were operated routinely. The volume and nature of surgical interventions were distributed as follows: extended hysterectomy - 24, expanded cystectomy with bilateral ureterocutaneostomy - 70. The duration of surgery ranged from 2 to 3.5 hours, the average blood loss was 550.4 + 230 ml. By age, sex, nature and extent of surgical interventions, both groups of patients were identical, which allowed to make their objective comparative evaluation.
Method of general combined anesthesia based on SEA. Premedication included phenazepam (1-2 mg) the night before the operation, 0.2-0.25 mg/kg sibazone intramuscularly on the day of surgery 40 to 50 minutes before transportation to the operating room. Dexamethasone (0.07 mg/kg), dimedrol (0.2 mg/kg), atropine according to indications were intravenously administered on the operating table. Before anesthesia, for 15-20 minutes, 8-10 ml/kg crystalloid solutions were intravenously administered. All patients were used two-segment variant of SEA. The first moment under local infiltration anesthesia in the lateral position at L1-T10wasconducted the puncture - catheterization of epidural space with catheter in the cranial direction for 4-5 cm followed by introduction of "test dose" (2% - lidocaine solution). The second moment at the L2-L4 level subarachnoid space was punctured and 2.5-3.0 ml of 0.5% hyperbaric bupivacaine solution in combination with fentanyl (0.7 ^g/kg) was injected. Patients were turned on their backs and laid in strictly horizontal position. With the appearance of the first clinical signs of subarachnoidal blockade, induction was conducted in anesthesia (ketamine 1.5 mg/kg), precurarization (1 mg pancuronium), dithil-ine (2 mg/kg), trachea was intubated. Before intubation, the voice gap was treated with 10% lidocaine aerosol and 1.4 ^g/kg fentanyl was administered intravenously. Ventilation in the mode of moderate hyperventilation was performed by air — oxygen mixture (1: 1); the total curarization was provided with pancouronium, consciousness was turned off with propofol [(1.2 mg/(kg/h-1)]. After 110-120 minutes from the moment of subarachnoidal administration of local epidural anesthetic they introduced 14-16 ml of 0.5% solution of bupivacaine with an interval of 120 minutes as needed. The extubation of trachea was carried out after the complete restoration of reflex-muscle activity, consciousness, adequate independent breathing, against the background of stable hemodynamics and compensated hemorrhage. Medicinal decurarization was not used, giving preference to spontaneous. The intraoperative infusiontransfusion program was based primarily on the introduction of crystalloids and hydroxyethylated starches, and with a blood loss of 10 ml/kg and more it corresponded to the conventional protocol. For postoperative analgesia, morphine (0.05-0.07 mg/kg) was used which was dissolved in 10 ml of 9% isotonic sodium chloride solution and was administered epidurally.
For the patients of the control group, itused general multi-component anesthesia with AVL based on ketamine, propofol, fentanyl and benzodiazepines. Premedication, the nature and volume
Section 5. Medical science
of intraoperative infusion-transfusion therapy did not differ from those in the patients of the main group. Postoperative analgesia was carried out with traditional way (narcotic and non-narcotic analgesics, antispasmodics).
The effectiveness of anesthesia was evaluated according to generally accepted clinical signs. Central hemodynamics was assessed by echocardiography using the SA-600 apparatus of MEDI-SON. They studied: stroke index (SI), cardiac index (CI), general peripheral vascular resistance (GPVR). The average dynamic pressure (ADP), heart rate (HR), and saturation (SpO2) were monitored by the monitor (BMP 300 "Biosis") continuously, throughout the surgery. The rate of urination in oncogynecologic patients was assessed using Foley catheter installed in the bladder, and in oncouro-logical patients only at the end of the surgery. The state of autonomic nervous system (ANS) was estimated according to cardiointervalog-raphy, using mathematical analysis of heart rhythm [1]. The mode (Mo), the mode amplitude (AMo), the variation range (Ax) were calculated, the voltage index (VI) was calculated. The response of thesympathetic adrenal system was assessed by the rate of excretion of noradrenaline (NA) in the urine [4], the functional state of the hypothalamo-pituitary-adrenocortical system — by the level of total cortisol (TC) in blood plasma (radioimmunoassay).
The studies were performed in 6 stages: I - the day before the surgery, II - before the cutaneous incision, III - in 10-15 minutes after the cutaneous incision, IV - in the most traumatic stage of the surgery, V - in 3-3,5 hours from the beginning of the surgery, VI - after the end of the surgery. All the numerical values obtained during the study were statistically processed using the Student's test (using the Microsoft Excel program) and are represented in the form M±m, where M is the arithmetic mean value, m is the standard error. Statistically significant differences were considered for p < 0.05. The results are presented in the table.
Results of the study and their discussion. The initial state of hemodynamics of patients of both groups was characterized byeukinetic circulation (see Table). There was moderate activation of the sympathetic divisions of ANS, VI was 236.3±9.1 and 229.3±8.4 conv. units. The concentration of TC in blood approximated to the upper limits of physiological oscillations, the excretion of NA in the urine was 7.9±0.7 nmol/l in the main group, and in the control group - 7.4±0.5nmol/l.
Immediately, before starting the surgery, the patients of the main group were registered significant decrease in the rate of ADP and GPVR by 14.8% and 19.9%, which we regarded as a classic manifestation of segmental sympathetic blockade. The changes in the other indicators studied were insignificant and did not have a reliable character (see Table). The SpO2 index corresponded to 98.9±0.5%, VI - 282.8±12.1 conv. units.
At the same terms in the control group of patients, the significant increase in heart rate was registered by 10.7%. At that, ADP, GPVR, SI and CI remained without reliable dynamics.VI increased by 76.9%, amounting to 405.7±15.4 conv. units in the autonomic balance, the tone of the sympathetic division of ANS dominated. This indicates the more pronounced tension in the regulatory systems of the heart rhythm in comparison with the main group of patients. The SpO2 index at that time corresponded to 99.1±0.6%.
Ten to fifteen minutes after the cutaneous incision, hemody-namic stability persisted in the patients of the main group. The hemodynamic parameters studied did not differ significantly from the previous stage of the study (see Table). ADP was 90.1±2.7 mm Hg, HR - 78.4±2.2 per min, GPVR - 1302.2±52 dyne-centimeter cm-5, CI - 3.34±0.17 l/m2/min. From the side ofANS, there was still mod-
erate increase in the activity of the sympathetic division ofANS with a minimal degree of stress in the regulatory systems of the heart rhythm. At that stage of the study VI was 313.9±13.8 conv.units.
At the same time the control group of patients, in spite of stable indicators of single and minute cardiac output and trends towards normalization of ADP and GPVR (see Table), there was a significant increase in VI, respectively, relative to the previous stage of the study and initial preoperative values, by 101, 2% and 256%, which indicates the significant strain of regulatory systems of heart rate. At the same time, it should be noted that the absolute value ofVI (816.4±21.7 conv. units) did not exceed the limits of the "stress norm".
In the most traumatic stage of the surgery, the hemodynamic parameters studied remained stable in patients operated under conditions of general combined anesthesia on the basis of SEB, did not differ significantly from the previous stage of the study (see Table). ADP was 92.1±1.8 mmHg, HR-80.2±1.6 beats per min, CI - 3,38±0,14 l/min/m2, GPVR - 1320,6±60 dyn.c-cm-5The value ofVI was 529.3±12.6conv. units, and TC of blood plasma was 427.6±42.3 nmol/l.
In patients operated under GMA conditions, the studied he-modynamic parameters also remained relatively stable, did not differ significantly from the initial preoperative values and the previous stage of the study (see Table). However, they differed to a great extent from those in the patients of the main group. Thus, ADP was 104.2±13.6 mm Hg, HR was 86.8±1.4 per min, GPVR -1563.4±51 dyn.c-cm-5 At this stage of the study VI corresponded to 1256.4±19.8 conv. units, and blood plasma TC was 749.3±39.1 nmol/l, which indicates the more pronounced activation of sympathetic division of the ANS in comparison with the main group of patients, the degree of tension of the regulatory systems of heart rhythm, activation of the hypothalamic-pituitary-adrenal system.
After 3-3.5 hours fromthe beginning of the surgery, the hemodynamic stability (see Table), the decrease in the activity of sympathetic division of the ANS and the degree of stress of the regulatory systems of heart rhythm were still registered in the patients of the main group. VI was 324.6±8.4 conv. units.
Patients of the control group had clear tendency to decrease in the ADP and GPVR, reduction in HR, increase in CI (see Table). VI, in comparison with the previous stage of the study, significantly decreased from 1256.4±19.8 st.units up to 850.4±9.5 standard units. However, significant differences remained between the studied parameters ofhemodynamics and the degree of stress ofheart rhythm regulatory systems between the main and control groups of patients (see Table).
The end of the surgery in patients of the main group was characterized by hemodynamic stability. HR was reduced to 72.8±1.4 b/min. ADP and GPVR were, respectively, 86.6±2.7 mm Hg and 1236±63 dyne c-cm-5, CI - 3.36±0.16 l/min/m2. VI corresponded to 356.0±9.4 conv. units, TC of blood plasma -513.4±48.4 nmol/l, and the rate of excretion of NA in urine for the surgery period was 9.1±1.2 nmol/l and significantly was not different from the day before surgery (see Table). The hourly diuresis during the surgery was 40.6 ml/h, which indirectly indicates the preservation of peripheral blood flow and kidney function as a whole. In thoseterms, normalization of the hemodynamic parameters studied was also recorded in the control group. ADP was 95.4±2.7 mm Hg. HR - 80.3±2.6 per min. GPVR - 1385.1±54.3 dyne c-cm-5However, all of the above indicators were significantly different from those in the main group ofpatients (see Table). VI was 718.2±41.2conv. units, the concentration in blood plasma TC - 718.2±41.4 nmol/l, and the
excretion of NA in the urine during the surgery - 17,9±1,6 nmol/l, which indicates the more pronounced, in comparison with the main group, activation of sympathoadrenal and hypothalamic-pituitary-ad-renocortical systems in response to operational trauma. Comparative characteristics of the course of anesthesia and the nearest postoperative period in patients ofthe main and control groups revealed significant advantages of the method we tested, which lead to:
- minimal consumption of narcotic drugs and muscle relaxants;
- rapid recovery and restoration of reflex-muscle activity, allowing to make trachea extubation at an earlier time;
- the possibility of using epidural catheter to obtain long-term postoperative analgesia;
- early activation of patients and restoration of motor-evacuation function of gastrointestinal tract.
Table 1. - Some indicators of hemodynamics, sympathoadrenal and hypothalamo - pituitary - adrenocortical systems during the stages of anesthesia and surgery in patients of the main and control groups.
Indicators studied Groups Stages of the study
I II III IY V VI
Mean dynamic pressure, mmHg Main 108.4±3.1 92.4±4.3 * Д 90.1±2.7 * Д 92.1±1.8 * Д 90.2±1.6 * Д 86.6±2.7 * Д
Control 106.1±2.8 110.8±2.4 102.8±2.1 104.2±3.6 98.8±1.9 * 95.4±2.7 *
Heart rate, in 1 minutes Main 81.5±2.1 78,1±1,1Д 78,4±2,2Д 80,2±1,6Д 74,6±2,1 * Д^ 72,8±1.4 * Д
Control 82.6±2.3 91.4±2.2 * 88.5±3.1 86.8±1.4 82.2±1.6 • 80.3±2.6
Voltage index, conv. units Main 236.3±9.1 282.8±12.1Д 313.9±13.8 * Д 529.3±12.6 * Д • 324.6±8.4 * Д • 356.0±9.4 * Д •
Control 229.3±8.4 405.7±15.4 * 816.4±21.7 * • 1256.4±19.8 * • 850.4±9.5 * • 584.1±10.1 * •
Cardiac index, l/m 2/min Main 3.26±0.17 3.36±0.15 3.34±0.17 3.38±0.14 3.44±0.12 3.36±0.16
Control 3.12±0.18 3.28 ±0.14 3.29±0.16 3.36±0.16 3.41±0.18 3.41±0.13
General peripheral vascular resistance, dyne/(c.cm-5) Main 1610±78 1290±39*Д 1302±52*Д 1320±60* Д 1252±58*Д 1236±63*
Control 1608±61 1649±48 1514±74 1564±51 1407±43* • 1385±54*
Total cortizol (blood plasma), nmol/l Main 369.8±32.2 427.6±42.3Д 513.9±48.4 *Д
Control 396.3±36.4 749.3±39.1 * 718.2 ±41.2 *
Noradrenalin in urine, nmol/l Main 0.73±0.06 0.88±0.03 * 9.1±1.2Д
Control 0.74±0.04 0.86±0.04 * 17.9±1.6 *
Hourly diuresis, ml/hour Main 62.4±5.2 40.6±4.3 * Д
Control 60.9±4.8 21.4±1.2 *
Note: * - statistically significant differences (p <0.05) relative to the initial preoperative values; •-statistically significant differences (p < 0.05) relative to the previous stage of the study; A - statistically significant differences (p < 0,05) between the groups studied.
The data obtained make it possible to assert that the general combined anesthesia on the basis of SEB provides reliable antinociceptive protection of the organism from surgical aggression, provides smooth course of anesthesia and the nearest postoperative period, and, therefore, has a clear advantage over the traditional variant of general multicomponent anesthesia.
Conclusions:
1. The use of general combined anesthesia based on spinal-epi-dural blockade is justified for anesthetic supply of long-term and traumatic oncological operations on pelvis organs.
2. The tested variant of balanced anesthesia on the basis of regional blockades provides reliable antinociceptive protection of the organism from surgical aggression, hemodynamic stability and smooth course of the nearest postoperative period.
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