UDC 616-089.5-031.81
OPTIMIZATION OF COMBINED GENERAL ANESTHESIA FOR ORTHOPEDIC
SURGERY IN CHILDREN
Satvaldieva E.A., Yusupov A.S., Ismailova M.U.
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Resume
The purpose of the study was to improve the quality of anesthesia during orthopedic operations in
children using the opioid-sparing anesthesia technique.
Materials and methods. The course of anesthesia was analyzed in 48 patients aged 3 to 14 years,
during orthopedic operations in children. The distribution of patients into groups was carried out
depending on the technique of anesthesia. Group 1 (main) consisted of 25 children who underwent
general anesthesia using low doses of fentanyl, sevoflurane and propofol. group 2 (control) - 23 children
who underwent general anesthesia with fentanyl and propofol. Echocardiography was used to determine
hemodynamic parameters. The dynamics of changes in the level of cortisol in the blood and the
concentration of catecholamines (adrenaline, norepinephrine, dopamine) in daily urine was studied.
Results.
In children of the first group, during the introductory period of anesthesia, there was a decrease in
CI, an increase in heart rate and UPS. Stroke index (SI), mean arterial pressure (MAP), cardiac index
(CI) changed insignificantly compared to the previous stage of the study. In the children of the second
group in the most traumatic stages of the operation, there was an increase in SI, HR, and AI.
In the most traumatic stages of the operation and after the operation in children of the first group,
there was a tendency to increase cortisol, in the second group of patients, an increase in cortisol was
noted.
Key words: opioids, general anesthesia, fentanyl, sevoflurane, propofol, orthopedic surgery.
ОПТИМИЗАЦИЯ КОМБИНИРОВАННОЙ ОБЩЕЙ АНЕСТЕЗИИ
ПРИОРТОПЕДИЧЕСКИХ ОПЕРАЦИЯХ У ДЕТЕЙ
Сатвалдиева Э.А., Юсупов А.С., Исмаилова М.У.
Ташкентский педиатрический медицинский институт
Резюме
Цель исследования улучшение качества обезболивания при ортопедических операциях у
детей применением методики опиоидсберегающей анестезии.
Материалы и методы. Проанализировано течение анестезии у 48 больных в возрасте от 3
до 14 лет, при ортопедических операциях у детей.
Распределение больных на группы осуществляли в зависимости от методики проводимой
анестезии. 1 группу(основная) составляли 25 детей, которым проводилась общая анестезия с
использованием малых доз фентанила, севофлурана и пропофола. 2 группу (контрольная) - 23
детей, которым проводилась общая анестезия фентанилом и пропофолом. Для определения
показателей гемодинамики применялась Эхокардиография. Изучалась динамика изменения
уровня кортизола в крови и концентрации катехоламинов (адреналин, норадреналин, дофамин)
в суточной моче.
У детей первой группы на вводном периоде анестезии отмечалось снижение СИ,
увеличение ЧСС и УПС. Показатели ударного индекса (УИ), среднего артериального давления
(САД), сердечного индекса (СИ) изменялись незначительно по сравнению с предыдущим этапом
исследования. У детей второй группы в наиболее травматичные этапы операции отмечалось
увеличение СИ, ЧСС, УИ.
В наиболее травматичные этапы операциии после операции у детей первой группы
отмечалась тенденция к увеличению кортизола, во второй группе больных отмечалась
увеличение кортизола.
Ключевые слова: опиоиды, общая анестезия, фентанил, севофлуран, пропофол,
ортопедические операции.
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БОЛАЛАР
ОРТОПЕДИК ОПЕРАЦИЯЛАРИДА КОМБИНИРЛАНГАН УМУМИЙ
АНЕСТЕЗИЯНИ ОПТИМАЛЛАШТИРИШ
Сатвалдиева Э.А., Юсупов А.С., Исмаилова М.У.
Тошкент педиатрия тиббиёт институти, Ўзбекистон
Резюме
Тадқиқот мақсади: болалар ортопедик операцияларида опиоидсақловчи анестезия
усулини қўллаб оғриқсизлантириш сифатини яхшилаш.
Материал ва услублар 3 ѐшдан 14 ѐшгача бўлган 48 та беморда ортопедик
операцияларда анестезиянинг кечиши ўрганилди.
Анестезия усулига кўра 1чи гуруҳга(асосий) 25 та бемор киритилиб, уларга кичик дозада
фентанил ва севофлуран, пропофол қўлланилди, 2чи гуруҳда (назорат) 23 та беморга
фентанил ва пропофол билан умумий анестезия ўтказилди. Гемодинамик кўрсаткичларни
аниқлаш учун Эхокардиография усули қўлланилди. Қонда кортизол ва суткалик пешобда
катехоламинлар (адреналин, норадреналин, дофамин) даражасини ўзгариши ўрганилди.
1 чи гуруҳдаги болаларда анестезияга кириш даврида ЮИ нинг пасайиши, ЮҚС ва НПҚ
нинг ортиши кузатилди. ЗИ, ЎАБ, ЮИ кўрсаткичлари тадқиқотнинг аввалги босқичига
нисбатан ўзгариши кузатилди. 2 чи гуруҳдаги беморларда травматик босқичда ЮИ, ЮҚС,
ЗИ кўрсаткичлари ортди.
Жарроҳлик муолажасининг энг травматик босқичида 1 чи гуруҳда кортизолни ошишига
мойиллик кузатилди, 2 чи гуруҳда эса кортизол миқдорининг ортиши қайд этилди.
Калит сўзлар: опиоидлар, умумий анестезия, фентанил, севофлуран, пропофол,
ортопедик операциялар.
Relevance
Surgical treatment in pediatric orthopedics is
characterized by high trauma and significant
blood loss. At the same time, anesthesia methods
must meet the requirements of safety, reliability,
low invasiveness and provide adequate
conditions for the work of the operating team
[1,13]. The volume and invasiveness of
orthopedic surgical interventions in children
require effective and safe anesthesia. For this
purpose, intravenous anesthesia preparations are
widely used [3,12]. However, these drugs at
recommended doses often have a number of
negative effects, and dose reduction leads to
inadequate pain relief [2,8].
Opioids have long been the "gold standard" of
perioperative pain management in both adult and
pediatric patients [4,14]. However, excessive use
of opioid analgesics slows postoperative
awakening, causes drowsiness, and is associated
with a higher risk of postoperative nausea and
vomiting, as well as other side effects that are
associated with the development of a number of
negative effects, such as respiratory depression,
muscle rigidity, pruritus, and tolerance [5,7,9].
The use of high doses of opioid analgesics can
cause opioid-induced postoperative hyperalgesia.
It develops as a result of nociceptive sensitization
caused by neuroplastic changes in the peripheral
and central nervous system and a significant
decrease in the pain threshold [14]. Inadequate
intraoperative analgesia significantly increases
the risk of chronic postoperative pain and
complications. This increases the length of the
patient's stay in the hospital and the cost of
treatment [7].
The maximum use of the possibilities of
opioid-sparing technologies in traumatic
operations in children are elements of a global
ant nociceptive strategy for the use of opioids. In
this regard, for pain management in the
perioperative period, it is relevant to use all kinds
of methods to minimize the use of opioids in
children [11]. The increasing introduction into
surgical practice of the principles of accelerated
postoperative
rehabilitation
of
patients,
designated in the form of the modern concept of
“Enhanced Recovery after Surgery (ERAS)”, is
the use in the schemes of anesthetic management
of drugs that do not adversely affect the speed of
postoperative
rehabilitation
of
patients,
preventing excessive sedation, postoperative
nausea and vomiting [6]. At present, the need to
reduce the doses of opioid analgesics in the
perioperative period seems obvious. From this
position, the widespread use of drug
combinations is very attractive, which can
significantly reduce the need for opioid
analgesics, providing an opioid-sparing effect
[15].
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Today, the issue of using dexamethasone is
being studied, which reduces local tissue edema
in the area of damage [10]
The purpose
of the study was to improve the
quality of anesthesia during orthopedic
operations in children using the opioid-sparing
anesthesia technique.
Material and methods
The course of anesthesia was analyzed in 48
patients aged 3 to 14 years who were hospitalized
at the TashPMI clinic for planned surgery for
congenital pectus excavatum (22 patients) and
congenital dislocation of the hip joint (26
patients). The data are presented in tab. 1. The
duration of the operations in which the studies
were carried out ranged from 105.2 ± 11.2
minutes.
The distribution of patients into groups was
carried out depending on the technique of
anesthesia. Group 1 (main) consisted of 25
children who underwent general anesthesia using
low doses of fentanyl, sevoflurane and propofol.
group 2 (control) - 23 children who underwent
general anesthesia with fentanyl and propofol. In
both groups, premedication was used, consisting
of atropine sulfate with diphenhydramine in age
dosages. In the main group of patients, anesthesia
was carried out under the conditions of opioid-
sparing technology: 40 minutes before surgery,
dexamethasone 2-4 mg was added to the
premedication.
Induction was carried out by introducing:
fentanyl-0.005% - 2 μg/kg, propofol 1% -2.5
mg/kg and sevoflurane 3 vol.%, arduan-0.2%
(0.06 mg/kg) and transfer of patients to
mechanical ventilation . IVL was carried out by
the Fabius plus device (Germany) in the
normoventilation mode with PetCO2 37-38 mm
Hg. The gas mixture was supplied in a volume of
2 l/min. Sevoflurane 1-2 vol.% was used to
maintain anesthesia. The control group was
anesthetized with fentanyl 5 µg/kg and propofol
3 mg/kg. After intravenous administration of the
muscle relaxant arduan 0.06 mg/kg, the patients
were transferred to mechanical ventilation. After
the first bolus administration, repeated doses of
fentanyl were 3-2 µg/kg.
The following indicators were determined:
systolic blood pressure (BPs), diastolic blood
pressure (BPd), mean arterial pressure (BPmean),
oxygen saturation (SaO2), heart rate (HR) on the
multifunctional BLD monitor (China).
The analysis of the dynamics of central
hemodynamic parameters was carried out at 5
key points: the 1st stage - before the operation,
the 2nd stage - after premedication, the 3rd stage
- induction, the 4th stage - the most traumatic
moment of the operation and the 5th stage - the
end surgery. The severity of surgical stress was
determined by the level of stress hormone
cortisol in 3 stages: before surgery, at the most
traumatic stage and immediately after surgery.
The dynamics of the concentration of
catecholamines (adrenaline, norepinephrine,
dopamine) in daily urine was studied in two
stages: before surgery and in the postoperative
periods.
Result and discussion
For this purpose, hemodynamic parameters
were studied during anesthesia using fentanyl in
combination with propofol and sevoflurane. The
results of studies of the BP indicator are
presented in Table 2. In both groups, the
maximum increase in BP was noted at the stage
of induction. At this stage of the study, in
children of the second group, blood pressure
increased by 9.8% more than in children of the
first group.
Table 1 Patient characteristics
Groups
%
1
2
Age
7,76±0,5
6,78±0,59
7,88
Body mass
24,58±1,56
22,54±1,72
8,25
Operation duration
61±3,38
73,09±3,65
19,82*
Note: sign * - reliability of differences in the indicators of the second group to the first group at
P<0.05.
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Table 2. BP indicators in children of the study groups
Groups Indicato
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
1
BPs., mm Hg
92±1,9
101±1,2
107,5±1,9 101±1,7
101±0,8
BDD, mm Hg 55±1,3
61,5±1,3
63,5±1,9
59±0,8
61±1,7
2
BP, mmHg
105,4±7,3 110,2±7,58 118±7,0
113,6±6,35 107,1±4,99
BDD, mm Hg 68,1±7,1
72,3±7,25
77,2±7,08 74,2±6,23
69,9±5,57
Studies of central hemodynamic parameters in
children of the first group showed the following.
Compared with the initial data on the
premedication background, there was an increase
in heart rate by 9.78% and specific peripheral
resistance (RPS) of the vessels by 24.51%. Other
indicators changed slightly (Table 2).
Table 3. Indicators of central hemodynamics in children during combined anesthesia with
fentanyl, sevoflurane and propofol
Note: * - reliability of differences in indicators compared with the initial value (P<0.05).
During the introductory period of anesthesia,
there was a decrease in CI by 10.63%, an
increase in heart rate by 25.45% and an increase
in UPS by 25.58%. Stroke index (SI), mean
arterial pressure (MAP), cardiac index (CI)
changed insignificantly compared to the previous
stage of the study.
During the maintenance period of anesthesia,
certain changes in the indicators of central and
peripheral hemodynamics were also observed.
So, at the 4th stage of the study, compared with
the 3rd stage of the study, there was a certain
trend towards a decrease in CI indicators - by
12.76%, CI by 2.5%, while heart rate increased
by 41.1%, UPSS - by 16.1% .Despite this, it can
be argued that the hemodynamic parameters
remained within the optimal values.
In connection with the use of low doses of
fentanyl, there was no pattern of pronounced
circulatory depression due to a decrease in
vascular tone. Clinical concentrations of propofol
did not inhibit myocardial contractility. The
increase in UPS was associated with a transient
initial response to the administration of drugs;
subsequently, a return of UPS closer to the initial
value was observed.
Sevoflurane during the induction period
provided suppression of pharyngeal and laryngeal
reflexes, after which tracheal intubation was
performed. The applied low dose of Fentanyl as
part of combined anesthesia did not cause severe
circulatory depression, however, there was a
moderate decrease in blood pressure as a result of
vasodilation, inhibition of sympathetic reflexes
and relative bradycardia. Apparently, this
occurred due to the activation of the opiate
receptor (mu) by inhibition of presynaptic release
and postsynaptic interaction of excitatory
neurotransmitters (acetylcholine) of nociceptive
neurons.
Data from similar studies of central
hemodynamics during combined anesthesia in
children of the second group are presented in
Table 3.
Indicators
Outcome
premedication introductory
period
traumatic
stage of the
operation
end of the
operation
UI, ml /м
2
41,54
1,22 40,49
3,15
41,74
2,01
40,5
3,68
39,63
4,19
SAD,
mm Hg
Art.
78,85
1,21 81,2
2,93
84,22
3,75
77,81
4,0
75,44
2,56
Heart
rate, min
–1
84,0
2,38
107,75
2,87* 107,93
3,93* 122,7
8,41* 126,01
8,45*
SI, L/min х м
2
4,7
0,4
5,0
0,5
4,2
0,2
4,1
0,4
4,0
0,4
UPS,
r.u.
30,42
5,31 40,33
7,74
40,76
5,85
36,93
5,17
38,16
7,56
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Table 4. Indicators of central hemodynamics in children during combined anesthesia with
fentanyl and propofol
Note: * - reliability of differences in indicators compared with the initial value (P<0.05).
During the introductory period of anesthesia,
there was an increase in heart rate by 32.67%
(P<0.05), UPS by 15.53%, AI by 9.4% relative to
its initial values.
In the most traumatic stages of the operation,
there was an increase in SI, HR, SI, respectively,
by 37.26%, 41.65% and 12.21% (P<0.05), and
compared with the previous stage of the study,
these indicators changed unreliably. At the end of
the operation, compared with the stage of the
traumatic moment of the operation, the indicators
of central hemodynamics changed insignificantly.
Thus, the use of low doses of fentanyl in
combination with sevoflurane and propofol as
part of combined anesthesia was accompanied by
minor and compensated changes in the main
indicators of central hemodynamics, which
indicated that effective anesthetic protection of
children was ensured.
In children of the first group after the
operation, there was a decrease in adrenaline in
the urine by 16.69%. At the same time, there was
a slight decrease in the concentration of
norepinephrine and dopamine in the urine (Table
4). A decrease in the excretion of dopamine
apparently indicates a decrease in the initial
substrate for dopamine, which in turn leads to a
slowdown in the conversion of tyrosine into
dopamine. When the div is exposed to stress
factors of various etiologies and severity,
followed by activation of the hypothalamic-
pituitary-adrenal system, which may have led to
an increase in the concentration of
glucocorticoids and catecholamines.
Table 5 Urinary catecholamine concentrations during combined anesthesia with fentanyl,
sevoflurane and propofol
Catecholamines, mcg/day
Before surgery
After surgery
Adrenalin
5,39±0,88
4,49±0,65
Norepinephrine
10,97±1,40
10,76±1,53
Dopamine
112,69±5,15
108,63±3,75
The dynamics of the concentration of
catecholamines in the daily urine during general
anesthesia with fentanyl and propofol are shown
in Table 6. In patients of the second group, the
concentration of catecholamines in the urine -
adrenaline and norepinephrine tended to decrease
in the postoperative period. At the same time, the
concentration of dopamine tended to increase
(Table 5).
Table 6 Urinary Catecholamine Concentrations During Combined Anesthesia with Fentanyl and
Propofol
Catecholamines,
mcg/day Before surgery
After surgery
Adrenalin
6,19±0,99
6,74±0,85
Norepinephrine
14,49±2,27
14,58±2,38
Dopamine
124,64±4,92
125,57±2,7
Studies have shown that during general
anesthesia using fentanyl, sevoflurane and
propofol, there was a decrease in the
concentration of catecholamines in the
postoperative period.
The study noted minor changes in the
concentration of cortisol. In the most traumatic
Indicators
Outcome
premedication
introductory
period
traumatic
stage of the
operation
end
of
the
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
SAD,
mm.
rt.st
62,42
2,27
67,03
2,29
67,03
2,4
65,97
2,78
63,03
2,06
Heart
rate,
min
–1
82,14
2,09
115,26
3,07*
112,25
2,13* 120,52
5,23* 133,75
7,93*
SI, L/min х м
2
4,83
0,35
5,11
0,21
4,91
0,19
6,63
0,48*
8,03
1,39*
UPS,
r.u.
31,18
4,74
48,1
10,6
42,24
8,69
43,72
10,6
32,88
4,87
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stages of the operation and after the operation,
the children of the first group showed a tendency
to increase cortisol, in the second group of
patients in the most traumatic stages of the
operation there was an increase in cortisol by
14.59% more than in the children of the 1st study
group. In the postoperative period, the cortisol of
the 2nd group increased by 15.75% than the
cortisol of the 1st study group.
Table 7. Change in cortisol concentration (nmol/l) in the postoperative period
Groups
Before surgery
Traumatic moment
After operation
1 группа
323,5±12,3
326,8±10,9
321,1±11,1
2 группа
346,2±14,9
374,5±11,6
371,7±11,1
Analysis of the obtained data shows that the
opioid-sparing variant of combined general
anesthesia used by us makes it possible to
prevent excessive tension of the sympathoadrenal
system and provide adequate protection of
patients from surgical stress. The stability of the
studied parameters in the main group indicates a
more reliable antinociceptive protection. This
variant of anesthesia also made it possible to
limit the total doses of fentanyl by almost two
times.
Conclusions
1. General anesthesia with fentanyl,
sevoflurane and propofol provides adequate
protection for patients in the intraoperative
period, causing a slight activation of the
hormonal status, which should be considered as a
favorable factor that does not require correction.
2. The introduction of dexamethasone 40
minutes before surgery, in contrast to the
sedation of the second group, prevents an
increase in the level of catecholamines in daily
urine against the background of a decrease in the
excretion of their precursors.
3. The use of an opioid-sparing version of
general anesthesia in the scheme of anesthesia
management aimed at minimizing doses can
significantly limit the side effects of surgical
stress and improve the reliability, safety and
quality of anesthesia during orthopedic
operations in children.
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