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9OPTIMIZATION OF ANESTHESIOLOGICAL ASSISTANCE IN WOMEN WITH ARTERIAL HYPERTENSION IN HYSTERECTOMY Мatlubov М.М.1, Yusupov J.T.2, Mallayev S.S.3, Khamrayev Kh.H.4
'Matlubov Mansur Muratovich — Head of Department, DSC;
2Yusupov Jasur Tolibovich — Graduate Student, Assistant;
3Mallayev Surat Sadullayevich — Assistant, DEPARTMENT OF ANESTHESIOLOGY AND RESUSCITATION;
4Khamrayev Khamza Hamidullayevich — PhD, Assistant, DEPARTMENT OF INTERNAL DISEASES № ', SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the article examined 65 patients with uterine myoma with concomitant arterial hypertension who are hospitalized in the gynecological department of the 'st clinic of the Samarkand State Medical Institute. Surgical treatment was performed under total intravenous anesthesia (TIA), spinal anesthesia (SA) and epidural anesthesia (EA) using adjuvants. To correct arterial hypertension, a cardio selective drug from the group of concor ft-blockers (bisoprolol) was used. A comparative analysis between the groups was carried out and the effectiveness of the anesthesiology aid was determined: compared with TBA and CA, epidural anesthesia using adjuvants provided a sufficient level of anesthesia at all stages of the study and in the postoperative period
Keywords: uterine fibroids, hysterectomy, arterial hypertension, coronary heart disease, epidural anesthesia, adjuvant.
Relevance. Today, the most common tumor of the small pelvis of uterine fibroids is a very urgent problem in modern gynecology. This disease is found in 25-30% of women in the reproductive and post-reproductive period [1,4].
Despite the significant progress achieved in recent decades in the study of the pathogenesis, etiology and conservative treatment of uterine fibroids, surgical treatment is one of the main places [4, 13]. However, it is known that uterine fibroids often develop in individuals who have reached a certain older age, which contributes to the development of concomitant diseases [1, 17].
Cardiovascular diseases, especially arterial hypertension (AH), coronary heart disease (CHD) and heart defects are one of the concomitant pathologies in patients with uterine myoma, which are the most common concomitant pathological conditions in anesthesiology, as well as the main cause of preoperative complications.
Anesthetic management for hysterectomy is one of the most serious problems of modern anesthesiology, since surgical intervention has a pronounced stress effect, is accompanied by a pronounced pain syndrome and can be complicated by the development of intraoperative and postoperative development of cardiovascular complications, which is a life-threatening condition and requires immediate measures aimed at hemodynamic stabilization [9, 15, 16]. Recently, there have been many works indicating the preferred use of regional anesthesia (spinal and epidural anesthesia) in gynecological practice and in patients with arterial hypertension, which allows not only to reduce the number of postoperative complications, but also to improve the outcome of surgical treatment in general [2, 7, 9, 15, 17]. Given the above, there is no doubt the relevance of studying the effect of hypertension in women with uterine myoma, the creation on this basis of an optimal anesthetic benefit for this category of women.
Objective: A comparative assessment of the hemodynamic status and effectiveness of anesthesia in women with concomitant arterial hypertension in hysterectomies.
Materials and methods. The study is based on the results of clinical observations and a set of clinical-functional and biochemical studies in uterine myoma in 65 women aged 42 to 56 years with concomitant arterial hypertension. Patients with uterine fibroids and concomitant arterial hypertension who were treated in the gynecology department of the SamMI 1 clinic were examined. Patients were divided into three groups: group 1 consisted of 18 patients who underwent hysterectomy under total intravenous anesthesia (TIA) with mechanical ventilation (control A subgroup); Group 2 - 20 patients who underwent hysterectomy under spinal anesthesia (SA) (control B subgroup) and group number 3 - 27 patients who underwent hysterectomy under EA using adjuvants (fentanyl, morphine) (the main group).
In the preoperative period, patients with hypertension were prescribed a cardio selective P-adrenoblocker concor (bisoprolol) 2.5 mg once a day, in combination with ACE inhibitors 5-10 mg or
ARA II valsacor 40-80 mg, sedation was supplemented with 2.0 sibazon i/m the day and morning before surgery to ensure a pronounced psycho sedative effect. Before anesthesia was performed in 1-A group of patients, 40 mg before dropping into the operating room, 5 mg of droperidol and 0.2 mg / kg of dimedrol, atropine (0.01 mg / kg) were injected intramuscularly, sodium chloride infusion of 10 ml / kg. Anesthesia was carried out against the background of sufficient curation (dithylin) of 2 mg / kg followed by tracheal intubation and artificial ventilation (AVL), propofol (2-4 mg / kg) and fentanyl (2 - 2.5 ^g / kg) were used for induction. Anesthesia was supported by antipsychotic drugs (NLA), mechanical ventilation was continued using non-depolarizing relaxants, taking into account the dosage of the drug and the duration of the operation.
In the 1-B group of patients, premedication was carried out 30 minutes before transportation to the operating room with atropine (0.01 mg / kg) and dimedrol (0.2 mg / kg) and promedol (0.2-0.3 mg) intramuscularly. Spinal puncture was performed at the level of L2- L4 in a sitting position or lying on one side. A 0.5-0.75% hyperbaric solution of bupivacaine 2.5-3.0 ml (12.5-15 mg) was intrathecal. Immediately after the introduction of MA patients turned on their backs and gave a horizontal position with a raised head end.
All patients who had planned epidural anesthesia with adjuvants (group 2) underwent night sedation using sleeping pills in standard dosages. On the day of surgery, dimedrol (0,2 mg / kg), atropine (0.01 mg / kg), promedol (0.2-0.3 mg / kg) were used for premedication, preinfusion was performed (with sodium chloride 10 ml / kg) 15-20 minutes before surgery. The epidural space was punctured in the ThXI - L¡ projection area according to the generally accepted method using the Portex 16-18 G kit using the "loss of resistance" technique followed by catheterization with cranial direction and fixation of the epidural catheter. The test dose was administered, in the absence of signs of spinal block (7-10 minutes after the test dose was administered), the main dose of the local anesthetic was slowly introduced - 0.25% bupivacaine solution. To prolong analgesic activity and ensure postoperative analgesia, 1,4 mg / kg of fentanyl was introduced into the epidural space (up to 6-12 h). The level of the sensor block was evaluated using the pin prink test. After the operation, all patients were transferred to the intensive care unit.
The study included 5 stages:
I-stage - initial state;
II-stage - the period of basic anesthesia (after completion, the beginning of the operation);
III - stage - the most traumatic stage of surgery;
IV stage - t he end of the operation.
V-2 hours after surgery
At the stages of the study, the indicators of Sbp, Dbp, MBP, HR, SpO2, BR and glucose were checked. All numerical values obtained during the study were processed by the method of variation statistics using Student's criterion. Moreover, the obtained results were processed using the package of computer statistics programs Microsoft Excel, Statistics 6.0 and SCCHSS 9.0 for Windows (Stat Soft Inc., USA).
Results and their discussion. To assess the functional state of the cardiovascular system during anesthetic management in women suffering from uterine fibroids and in need of surgical treatment, a study of the main indicators of systemic hemodynamic was performed. In a comparative analysis of hemodynamic parameters between the main and control groups, significant differences were observed at the levels of MAP, HR at almost all stages of the study. The initial values of these indicators after antihypertensive therapy were normalized, practically did not differ.
Table 1. Characterization of the main indicators of systemic hemodynamic during anesthesia (1st group IVA)
(M±m)
Indicators Stage of operation
I II III IV V
Sbp 136,38±3,47 133,61±3,20 125±2,10* 124,78±2,08 129,61±2,73*
Dbp 80,83±1,23 76,72±1,58 74,66±0,86 81,5±0,71* 79,28±1,20**
MBP 99,35±1,82 95,68±2,04 91,44±1,19* 95,92±1,09** 97,38±2,63
HR 83,88±1,69 89±0,63* 85±0,40 83±0,49** 82,55±0,80
SpÜ2 97,77±0,129 96,94±0,127 96,5±0,14 95,78±0,19* 97,11±0,16
BR 17,5±0,437 AVL 17,56±0,18*
Blood Glucose 3,6 4,0 4,6 4,3 4,2*
(mmol / l)
Note: * - statistically significant (p <0.05) relative to the initial values ** - in comparison with the next stage of the study
Here the values of MBP, DBP are given in mm. Hg, HR - beats per minute
In patients of the 1st group on the operating table, the MBP value was 99.35 ± 1.82 mm Hg, heart rate 83.88 ± 1.69 beats. in min., after the administration of NLA preparations in the intraoperative period, relative hemodynamic stability remained, however, the MBP remained relatively high 95.92 ± 1.09 mm Hg, heart rate 83 ± 0.49 beats. in minutes that characterized the persistent spasm of the peripheral vessels. In the postoperative period, the indicators of the functional state of the CVS of the 1st and 2nd groups were within the MBP of 97.38 ± 2.63 mm Hg, heart rate of 82.55 ± 0.49 beats. in minutes and 95.70 ± 0.49 mmHg, heart rate 86.70 ± 0.46 beats. in minutes, respectively. Patients after surgery were under the influence of drugs without a conscious state and complaints of pain, the need for painkillers depended on the doses of narcotic analgesics made during the operation. The late activation of patients was observed, which depended on the additional use of antihypertensive and analgesic drugs (see table 1.).
Table 2. Characterization of the main indicators of systemic hemodynamic during anesthesia (2nd group -spinal
anesthesia) (M±m )
Indicators Stage of operation
I II III IV V
Sbp 131,5±2,21 114,25±3,23 113,75±2,05 115,10±2,16 128,00±1,11
Dbp 82,5±0,77 68,9±1,67* 71,15±0,69** 76,90±1,51** 79,55±0,31
MBP 98,83±1,13 84,01±2,10 85,35±1,08 89,63±1,36** 95,70±0,49*
HR 81,9±0,9 92,1±0,31* 86,20±0,25 83,20±0,39 86,70±0,46**
SpO2 98,15±0,182 95,65±0,15 95,55±0,19* 96,15±0,11* 97,25±0,10**
BR 17,7±0,4 16,65±0,21* 17,65±0,23 17,95±0,18 17,80±0,10
Blood Glucose 3,6 3,8 4,2 4.1* 4,0*
(mmol / l)
Note: * - statistically significant (p <0.05) relative to the initial values; ** - in comparison with the next stage of the study.
Here the values of MBP, DBP are given in mm. Hg, HR - beats per minute.
Characterizing the clinical course of CA with a 0.5% hyperbaric solution of bupivacaine (longocaine heavy, Yuri-Farm), it should be noted that the classic signs of complete segmental sensory-motor blockade were formed by 5-7 minutes after subarachnoid administration of local anesthetic and persisted for 1 -1.5 hours. At this point, a decrease in SBP of 10-15 mm Hg was recorded. Patients did not respond to a skin incision, remained calm, did not show any complaints. It should be noted that earlier, a marked decrease in blood pressure was noted, requiring vasopressor support. However, the timely use of the minimum doses of vasopressors (mesatone) made it possible to quickly stabilize arterial hypotension. And only in individual cases, vasopressor support was required throughout the operation. According to all clinical signs, anesthesia was quite adequate and made it possible to provide comfortable conditions for surgeons to work even in situations requiring an expansion in the volume of surgery. Sedation was required in single observations and only in the first minutes after the start of the operation, which can be explained by the complete segmental sensory-motor blockade that had not yet formed at this point in the surgical intervention zone.
Table 3. Characterization of the main indicators of systemic hemodynamic during anesthesia (3rd group —
epidural anesthesia) (M±m)
Indicators Stage of operation
I II III IV V
Sbp 136,48±1,53 117,22±1,85* 113,52±0,746* 117,78±0,62** 111,48±5,73
Dbp 82,04±1,17 71,63±1,07* 70,93±0,536* 78,22±0,92** 77,93±0,65
MBP 100,18±0,96 86,83±1,216 85,12±0,54* 91,41±0,78** 89,11±2,06
HR 81,26±0,86 92,37±0,30 86,52±0,23* 82,37±0,36 80,29±0,41**
SpO2 97,51±0,11 96,15±0,10 95,78±0,18* 96,74±0,165 97,55±0,123
BR 19,15±0,236 16,81±0,19* 17,85±0,20 17,78±0,154 17,63±0,12**
Blood Glucose (mmol / l) 4,5 4,7 4,8 4,5 4,5*
Note: * - statistically significant (p <0.05) relative to the initial values ** - in comparison with the next stage of the study
Here the values of MBP, DBP are given in mm. Hg, HR - beats per minute
The clinical course of EA had differences from that in the 2nd group of patients both in terms of the development of complete segmental sensory-motor blockade, and in terms of its distribution and duration. However, the degree of decrease in blood pressure at the time of EA development was not so pronounced. It should be noted that in the subsequent stages of the operation until its completion, the blood pressure remained stable and did not require correction. But only in isolated cases, a vasopressor correction of blood pressure was required. Postoperative epidural analgesia provided adequate analgesia, early activation and rapid restoration of the motor-evacuation function of the gastrointestinal tract. Characterizing the course of EA with bupivacaine in combination with fentanyl (group 3) with breathing preserved, it should be noted that 10-15 minutes after the epidural administration of painkillers, a decrease in blood pressure by 8-14 mm Hg was formed. By this moment, all clinical signs of segmental sensory-motor blockade began to form, reaching a maximum by the 15 th minute with a duration of 1.5-2 hours. Patients did not respond to a skin incision and surgical trauma, and remained calm. Throughout the operation, blood pressure remained stable. No clinical signs of hypoxia and hypercapnia were observed. At the end of the operation, all patients of the 3 groups were active, accessible to the contact, pain complaints were not yet presented within 5-6 hours. The use of EA by generally accepted concentrations and volumes of local anesthetics at the stage of complete segmental sensory-motor and sympathetic block was accompanied by moderate arterial hypotension requiring correction. However, not as pronounced as when using CA. The function of external respiration and gas exchange did not change significantly.
Conclusion: 1. The use of SA and EA in women with concomitant arterial hypertension with hysterectomies, provided that the optimal doses of local anesthetics are individually selected, ensures hemodynamic stability throughout the intraoperative period, does not have a depressing effect on external respiration function, the possibility of using an epidural catheter for carrying out long and continuous postoperative anesthesia.
2. During hysterectomy, the conduct of SA and EA with the addition of small doses of fentanyl eliminates the need for additional administration of analgesics in the intraoperative and postoperative period.
3. The advantage of EA for hysterectomy in women with concomitant hypertension should be considered the possibility of using an epidural catheter for a long and continuous postoperative analgesia, thereby contributing to the early activation of patients.
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КЛИНИКО-ЛАБОРАТОРНЫЕ ОСОБЕННОСТИ ТЕЧЕНИЯ ДИСМЕТАБОЛИЧЕСКОЙ НЕФРОПАТИИ У ДЕТЕЙ С НАРУШЕНИЕМ ПУРИНОВОГО ОБМЕНА Тураева Н.Ю.
Тураева Назира Юлдашевна — ассистент, кафедра 2 госпитальной педиатрии, неонатологии и пропедевтики детских болезней, Самаркандский государственный медицинский институт, г. Самарканд, Республика Узбекистан
Ключевые слова: дисметаболические нефропатии, дети, нарушение пуринового обмена, интерстициальный нефрит.
Введение. Научный прогресс и совершенствование технологий обусловили появление таких новых направлений педиатрической науки и практики как метаболическая педиатрия, экологическая педиатрия. В последние годы отмечается увеличение частоты почечной патологии в детском возрасте [4,10]. Особенностью нозологической структуры заболеваний почек за последние десятилетия является значительное возрастание частоты дисметаболических нефропатий [4], удельный вес которых среди заболеваний органов мочевой системы (ОМС) составляет, по данным разных авторов от 29 до 40% [9]. Изучаются особенности течения и корригирующей терапии пиелонефрита, развившегося на фоне обменных нарушений [5, 10]. Наиболее изученной из числа дисметаболических нефропатий является так называемая дисметаболическая нефропатия с оксалатно-кальциевой кристаллурией, которая оказалась полигенно наследуемой полиорганной мембранопатией с семейной нестабильностью цитомембран [1]. Экологически обусловленные поражения тубулоинтерстициальной ткани почек также проявляются в виде дисметаболических нефропатий [6], что связано выявлением мутантного эффекта со стороны ряда ферментов, в частности ответственных за пуриновый обмен [8].
В последние годы привлекает внимание исследователей дисметаболические хронические интерстициальные нефриты, среди которых особое место занимают уратные нефропатии [5]. Частота уратных нефропатий в общей детской популяции составляет- 4,2%, а среди учтенной почечной патологии-9,9% [10]. Возрастные особенности манифестации и течения уратных нефропатий находится в стадии изучения.
В силу интенсивности метаболизма пуринов в растущем организме, патологические синдромы, обусловленные гиперпродукцией мочевой кислоты (МК) у детей встречаются чаще, чем диагностируются.
Целью данной работы является изучение клинико-лабораторных особенностей течения интерстициального нефрита развившегося у детей на фоне гиперурикемии с гиперурикозурией.
Материалы и методы. Под наблюдением находились 82 больных с интерстициальным нефритом на фоне уратурии в возрасте от 2 до 14 лет. Метаболический статус больных оценивали по результатам многократных исследований, проводившихся по многоэтапной специальной программе, включавшей генеалогический анализ, скрининг тесты и количественные биохимические исследования. В качестве основного биохимического маркера нарушенного обмена пуринов определяли уровень урикемии и урикозурии по Мюллер-Зейферту, суточную экскрецию с мочой
