中华劳动卫生职业病杂志
2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
336
Change in central hemodynamic indicators during hip joint
arthroplastic operations in children
Anvar
Yusupov
1*
,
Elmira
Satvaldiyeva
1
,
Makhfuza
Ismailova
1
, and
Mehri
Shakarova
1
1
Tashkent Pediatric Medical Institute, Tashkent, Republic of Uzbekistan
https://doi.org/10.5281/zenodo.5593702
Abstract.
The data from the study of the state of central hemodynamics
testified to the effectiveness of the used variants of anesthesia with fentanyl in
combination with sevoflurane and the variant of anesthesia with fentanyl in
combination with propofol in the anesthetic management of congenital hip
dislocation. The paper assesses the state of the circulatory system in children
with congenital hip dislocation. The development of rational options for pain
relief has identified the advantages of combined anesthesia with fentanyl and
sevoflurane. The study of indicators of daily monitoring of blood pressure,
heart rate, study of indicators of central hemodynamics made it possible to
determine the nature and type of regulation of the circulatory system under the
conditions of the recommended methods of combined anesthesia for surgical
correction of congenital hip dislocation in children.
Keywords:
combined anesthesia; hip arthroplasty; sevoflurane; fentanyl;
propofol.
Relevance.
The problem of adequate anesthetic management of hip joint arthroplasty in children
remains relevant. Its relevance is due, on the one hand, to the need to introduce new technologies into the practice of
numerous medical hospitals, on the other, there remains the need for this surgical intervention in children.
At the present stage of the concept of effective surgical correction of residual deformities of congenital hip
dislocation in children, preference is given to reconstructive extra-articular surgeries, as the most gentle for the hip
joint and allowing to obtain the best functional result. The problem under consideration remains relevant and not
fully resolved; the need to improve the efficiency and safety of anesthetic protection creates the prerequisites for the
search for new methods of anesthetic management. To assess the anesthetic protection from surgical trauma, it is
important to study not only the state of hemodynamics and respiration, but also the vegetative status. It is believed
that the analysis of heart rate variability using cardiointervalography is an objective and fairly simple way to assess
the adequacy of anesthetic protection.
Purpose of the study.
Assessment of the state of central hemodynamics to improve the quality of
anesthetic management during hip arthroplasty operations in children.
Research materials and methods:
The analysis of the results of the study - 46 children aged 3 to 14 years
with congenital hip dislocation was carried out. The duration of anesthetic treatment in 6 (13.04%) patients was up
to 1 hour, in 18 (39.13%) patients up to 1.5 hours, in 22 (47.82%) patients up to 2 hours.
The patients were divided into groups taking into account the selection of an adequate combination of drugs
for anesthesia. As part of premedication, atropine sulfate 0.1% - 0.01 mg / kg of div weight, diphenhydramine 1%
solution of 0.1 mg / kg of div weight was prescribed, patients with psychoemotional stress to enhance
premedication were additionally prescribed: 0.5% solution of Sibazon in dose of 0.25 mg / kg of div weight and
5% solution of ketamine at a dose of 2.5 mg / kg of div weight.
Patients of the first (main) group, 30 minutes after premedication, received inhalation of sevoflurane at a
dose of up to 3.0 vol%; a solution of fentanyl was injected intravenously at a dose of 5 μg / kg of div weight.
Anesthesia was maintained by the introduction of fentanyl ½ or 1/3 of the main dose, inhalation of evoflurane at a
dose of 1.5 vol%. Patients of the second (control) group, 30 minutes after premedication, received a single
intravenous injection of fentanyl solution at a dose of 5 μg / kg div weight and propofol solution at a dose of 3 mg
/ kg div weight. To maintain anesthesia, fentanyl was re-administered at a dose of ½ or ½ part of main. A
continuous infusion of propofol was carried out at a dose of 7.5 mg / kg / hour through an infusion pump.
Patients underwent clinical observation of the introductory period with monitoring of heart rate, blood
pressure, blood pressure, blood pressure, oxygen saturation, studies of central hemodynamics by echocardiography,
studies of autonomic balance by electrocardiography. The analysis of the results was accompanied by statistical
processing.
.
中华劳动卫生职业病杂志
2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
337
Research results and their discussion.
The data obtained show that premedication with diphenhydramine,
atropine, ketamine completely stopped the stress reaction before the forthcoming operation. Indicators of heart rate,
blood pressure and oxygen saturation (sР02) during the introductory period of general anesthesia when using
sevoflurane and fentanyl with sibazone (n = 18), patients fell asleep smoothly within 60-90 seconds after the bolus
administration, while breathing was not observed, skin the covers were warm and had the usual color. The cornea
remained moist and shiny, the corneal reflex was moderately reduced, the eyeballs made swimming movements and
were fixed centrally. The pupils were moderately constricted while maintaining the reaction to light. Moderate
relaxation of the striated muscles was noted.
Moderate relaxation of the striated muscles was noted. Heart sounds remained clear, heart rate increased by
25.46% and there was an insignificant increase in blood pressure by 3.29% and blood pressure by 9.44% compared
to the baseline (Table 1).
Table 1. Indicators of heart rate, blood pressure and oxygen saturation (sPO2) during anesthesia with
sevoflurane in combination with fentany
Note: * - reliability of differences in indicators compared to baseline (P <0.05)
The course of the period of maintenance of anesthesia was characterized by a smooth clinical course. The
pupils remained constricted, the sclera were moist, and a weak reaction of the pupils to light remained. Systolic and
diastolic blood pressure during the period of maintenance of anesthesia did not change significantly compared to the
baseline value. The heart sounds remained clear, the pulse on the peripheral vessels was of average filling and
tension. The course of the period of maintenance of anesthesia was characterized by a smooth clinical course. The
pupils remained constricted, the sclera were moist, and a weak reaction of the pupils to light remained. Systolic and
diastolic blood pressure during the period of maintenance of anesthesia did not change significantly compared to the
baseline value. The heart sounds remained clear, the pulse on the peripheral vessels was of average filling and
tension.
Patients of the second group, like the first, were prescribed premedication - a combination of atropine
sulfate 0.01 mg / kg, diphenhydramine and ketamine 2.5-3 mg / kg.
The applied propofol caused a smooth induction into anesthesia in children, and, depending on the dose and
the rate of intravenous administration, caused, to a varying degree, a cardiorespiratory effect in the form of a
decrease in blood pressure and a decrease in respiration. At the same time, the doses for the induction of anesthesia
and for its maintenance vary depending on the age and the method of induction (the induction dose ranged from 3
mg / kg div weight). Approximately 15-30 seconds after the start of the drug administration, all patients
experienced rapid breathing, which then turned into apnea in most patients, and a rapid loss of consciousness was
observed. Spontaneous limb movements were observed in 80% of children. After the introduction of fentanyl, the
muscle relaxant arduan (0.06 mg / kg) was administered and the trachea was intubated.
The heart rate increased by 3.36% and there was an insignificant increase in blood pressure by 2.24% and
in blood pressure by 0.944% compared to the initial state.
The awakening period was short and lasted 8.2 * 0.5 minutes, depending on the total dose. Tracheal
extubation is performed when adequate spontaneous breathing appears. The skin of the patients remained pink and
warm, the ocular, laryngeal, pharyngeal and cough reflexes, and motor activity were quickly restored. Pupils are
equal in size, of normal size, their reaction to light began to appear, blood pressure decreased by 2.86%, blood
Indicators
Research stages
Exodus
Premedication
Induction into
anesthesia
maintenanc
e period
Awakening
period
denia
Heart rate
94.0
2.38
117.75
2.87*
117.93
3.93*
132.7
8.41*
136.01
8.45*
BP (mm Hg)
116.50
2.69
117.75
2.87
120.33
4.21
115.75
4.20
113.17
2.40
BPd (mm Hg)
74.17
2.30
77.92
3.51
81.17
4.32
73.83
4.75
71.58
3.33
sPO
2
96.36
0.58
98.58
0.26*
97.67
0.53
97.58
0.5
98.08
0.08*
中华劳动卫生职业病杂志
2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
338
pressure by 3.49% compared with the initial data. In the postoperative period, children did not need additional
anesthesia for 5-6 hours, their appearance did not change.
Compared with the initial data, the premedication background showed an increase in heart rate by 25.27%
and peripheral specific resistance (UPS) by 24.52%. Other indicators changed slightly: during the introductory
period of anesthesia, there was a decrease in CI by 10.64%, an increase in heart rate by 15.46%, and an increase in
heart rate by 25.58%. Stroke index (SI), mean arterial pressure (SBP), cardiac index (SI) indices changed
insignificantly in comparison with the previous period.
During the period of maintenance of anesthesia, certain changes in indicators of central and peripheral
hemodynamics were also observed. Thus, in the most traumatic stages of the operation, compared with the previous
period, there was a decrease in SI indicators - by 2.38%, SI - by 2.97% and UPS - by 7.55%, while the heart rate
increased by 12.52%.
Despite this, it can be argued that hemodynamic parameters remained within optimal values, and there was
no risk of ischemia of internal organs, including the brain. Fentanyl caused severe circulatory depression due to
decreased vascular tone (Table 2).
Table 2. Indicators of central and peripheral hemodynamics in children during combined analgesia with
fentanyl and sevoflurane
Note: *- reliability of differences in indicators compared with the initial value (P <0.05).
The data of similar studies of central and peripheral hemodynamics during combined anesthesia with fentanyl and
propofol are presented (in Table 2.) According to available data, it is the change in the regulation of central
hemodynamics that determines the level of compensatory capabilities, subsequently forming the hemodynamic
profile of patients. Therefore, in our study, we focused on the spectral analysis of patients' hemodynamics. In
patients of the first group, the concentration of propofol did not inhibit myocardial contractility, which was not
observed to reduce the indicators of SI, SI. The phenomenon of an increase in the minute volume of blood
circulation (MCV) and a fall in the UPS is described as a transient initial reaction to the administration of fentanyl.
The effect of a drop in MOF is blocked by Ca2 + ions. As a result, there is a pronounced (by 25-40%) drop in blood
pressure, which is the most characteristic feature of the hemodynamic profile of the drug (Table 3).
Table 3. Indicators of central and peripheral hemodynamics in children during combined anesthesia with
fentanyl and propofol
Indicators
The initial state
Premedication
Induction
period into
anesthesia
Traumatic
stage of the
operation
End of
operation
UI, ml / m
2
41.54
1.22
40.49
3.15
41.74
2.01
40.5
3.68
39.63
4.19
GARDEN, mm.
rt. st
88.85
1.21
91.2
2.93
94.22
3.75
87.81
4.0
85.44
2.56
Heart rate, min
–1
94.0
2.38
117.75
2.87*
117.93
3.93*
132.7
8.41*
136.01
8.45*
SI, l / min x m
2
4.7
0.4
5.0
0.5
4.2
0.2
4.1
0.4
4.0
0.4
UPS,
conventional
units
40.42
5.31
50.33
7.74
50.76
5.85
46.93
5.17
48.16
7.56
Indicators
The
initial
state
Premedication
Induction
period
into anesthesia
Traumatic stage
of the operation
End
of
operation
UI, ml / m
2
44.86
0.79
51.12
2.14*
49.08
1.91
50.34
2.15*
53.54
6.91
中华劳动卫生职业病杂志
2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
339
Note: *- reliability of differences in indicators compared with the initial value (P <0.05).
**- reliability of differences in indicators compared with the previous stage of the study (P <0.05).
***- reliability of differences in indicators compared with the initial and previous stages of the study (P <0.05).
The study of indicators of central hemodynamics at various stages using fentanyl and propofol showed the
following figures.
During the introductory period of anesthesia, there was an increase in heart rate by 32.68% (P <0.05), CPR
by 23.77%, SI by 9.41% in relation to its initial values.
In the most traumatic stages of the operation, there was an increase in CI, HR, SI, respectively, by 37.27%,
41.65% and 12.22% (P <0.05), and compared with the previous stage of the study, these indicators changed
insignificantly. At the end of the operation, in comparison with the stage of the traumatic moment of the operation,
the indices of central hemodynamics changed insignificantly, which were unreliable.
Despite this, it can be argued that hemodynamic parameters remained within optimal values, and there was
no risk of ischemia of internal organs, including the brain. Fentanyl does not cause marked circulatory depression,
however, blood pressure often decreases as a result of bradycardia, vasodilation, and suppression of sympathetic
reflexes.
Thus, a comparative assessment of the clinical course of anesthesia, changes in the main indicators of
central and peripheral hemodynamics, when carrying out two variants of combined anesthesia, showed that, despite
the existing small changes in the main vital functions, they provided a smooth course of anesthesia, providing
adequate protection of the child's div from operating injury. Combined general anesthesia based on sevoflurane
and fentanyl early activity and stable postoperative course.
Analysis of the data obtained allows us to state that the use of fentanyl with sevoflurane and fentanyl with
propofol provides controllability, the achievement of a sufficient depth of anesthesia with minimal changes in
hemodynamics and respiratory disorders. The effect of fentanyl on the endorphin system of the brain and the
mechanism of hallucinations is explained by the ability of the drug to release dopamine in the brain. There is a rapid
awakening and restoration of orientation, the absence of mental disorders, minimal toxicity in relation to the liver,
kidneys, adrenal glands and hematopoietic organs with repeated repetition, good compatibility with cardiotropic and
psychotropic drugs, no persistent loss of appetite with repeated use. Fentanyl, both in combination with sevoflurane
and in combination with propofol with its peculiar pharmacokinetic and pharmacodynamic properties, is a valuable
tool for various fields of anesthesiology, which can significantly improve the quality of anesthesia, provided that
you know the characteristics of its effect on the div and use the optimal tactics of its use in each specific situations.
The priority is to modify the version of general anesthesia using sevoflurane and fentanyl, which expand the
indications for its use.
CONCLUSIONS
1. Combined variants of anesthesia using fentanyl with sevoflurane and fentanyl with propofol in children are
characterized by a smooth clinical course, provide effective anesthetic protection of the child's div from surgical
trauma and can be recommended for practical pediatric anesthesiology.
GARDEN,
mm. rt. st
72.42
2.27
77.03
2.29
77.03
2.4
75.97
2.78
73.03
2.06
Heart
rate,
min
–1
92.14
2.09
125.26
3.07*
122.25
2.13*
130.52
5. 23*
143.75
7.93*
SI, l / min x m
2
4.83
0.35
5.11
0.21
4.91
0.19
6.63
0.48***
8.03
1.39*
UPS,
conventional
units
71.18
4.74
88.1
10.6
82.24
8.69
83.72
10.6
72.88
4.87
中华劳动卫生职业病杂志
2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
340
2. Combined variants of anesthesia based on fentanyl with sevoflurane and fentanyl with propofol are
accompanied by moderate changes in the main indicators of central hemodynamics without a decrease in heart
performance.
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