1226
Medico-legal Update, October-December 2020, Vol. 20, No. 4
Hemodynamic Shifts in
Children During the Induction into Narcosis Period
Talat Agzamkhodjaev
1
, Anvar Yusupov
1
,
Makhfuza Ismailova
1
, Mamur Talipov
1
, Isfandiyor Mamatkulov
1
1
Associate Professor, Tashkent Pediatric Medical Institute, Uzbekistan, Tashkent
Abstract
The article focuses on the study of hemodynamics of children during the period of induction into anesthesia.
The analysis of the study results has been carried out – 80 children aged 3 to 14 years undergone medical
procedures on diseases of abdominal cavity and anorectal area. The study results have shown that the
combination of sevoflurane and ketamine in small doses has caused an effective analgesic effect with a
significant vegetative stabilizing effect providing a stable course of the following stages of anesthesia and
postanesthetic period.
Keywords: Combined anesthesia, induction period, measurements of central hemodynamic, inhalation
anesthetics, fentanyl, ketamine.
Introduction
Induction narcosis is the most essential stage
of anesthesia. Mistakes and inaccuracies during the
induction narcosis
2
and its complications may become
the very reason for the chain of abnormities that entail
a negative outcome in the future
7
. It is known that
medicines applied during the induction period are
not neutral for the organism and might become the
reason for serious complications due to hard-hitting
medicamental effect of the components
9
of anesthesia
on cardiovascular system
6
. Induction period might be
accompanied by significant hemodynamic shifts
5
. The
most frequent complications of the anesthesia period of
children are the disorders of cardiac rhythm and central
hemodynamics
11
.
The purpose of the work is to study the impact of
various types of induction on the condition of central
hemodynamics during the surgery on abdominal cavity
and anorectal area of children
4
.
Materials and Method
The work is based on the analysis of the study
results – 80 children aged 3 to 14 years 80. The study
has been carried out with children who have undergone
surgery because of the diseases of abdominal cavity –
42 children (52,5%) and of anorectal area – 38 children
(47,5%).
A complete clinical examination has been held. For
the purpose of the objective evaluation of the condition
of cardiovascular system a method of echocardiography
with the analysis of end-diastolic (EDD) and end-
systolic (ESD) dimensions of the left ventricle, R-R
interval and ejection time was applied. The study has
been carried out using the echocardiograph “Sonoscape”
(China, regnumber cfda 20123231386) of patients
on the following stages: prior to surgery (initial), post
premedication and post-induction.
Premedication was aimed at eliminating anxiety,
preventing nausea and vomiting. Atropine sulfate at
a dose of 0.01 mg/kg, diphenhydramine - 0.1 mg/kg,
sibazon - 0.25 mg/kg and ketamine - 2.0 mg/kg div
weight were prescribed as a part of premedication.
Small doses of ketamine (1 mg/kg) and propofol
(1 mg/kg) were administered intravenously to patients
of the first group in 30-40 minutes post premedication
as well as inhalation of sevoflurane at a dose 2,0 – 3,0
vol%.
Before a skin incision, a fentanyl solution of 3 μg/
kg was injected intravenously. The maintenance dose
Medico-legal Update, October-December 2020, Vol. 20, No. 4
1227
of sevoflurane was 1.5 vol%, the fentanyl dose was
2 μg/kg.
Patients of the second group were exposed to
inhalation of isoflurane at a dose 2,0 vol% and intravenous
doses of fentanyl of 5 μg/kg and droperidol of 0,4 mg/kg
div weight 30-40 minutes post-premedication.
The obtained data has been processed via the set of
auxiliary programs Statistica for Windows, Release 5,5
Stat Soft, Inc, with the calculation of arithmetic mean
value (M), the average error (m), all digital data has been
presented as M±m. The significance of differences was
assessed by Student’s criterion (t) with a known number
of observations (n). The differences were considered
significant at P <0.05.
Results
After the premedication patients of the first group
has shown an increase in the measurement of the heart
rate frequency (HRF) by 6% (Р<0,05), the tendency to
an increase in the measurement of the arterial pressure:
systolic arterial pressure (SAP) by 2,3%, diastolic
arterial pressure (DAP) by 2,9% (Table.1). During
the induction period, propofol and sevoflurane have
caused fast and smooth induction, a smooth sleep onset
within 30-60 seconds of patients has been registered.
While the study period, an insignificant decrease of the
heart rate frequency measurement by 4,08% has been
noticed compared with similar measurements of the
premedication stage. The systolic and diastolic arterial
pressure measurements were characterized by the
downward tendency respectively by 0,7% and 0,9%.
Table 1. Measurements of the HRF, SAP and DAP at the induction anesthesia period with the use of
ketamine, propofol and sevoflurane
Measurements
Study Stages
Initial
Premedication
Induction
HRF
108,25±7,46
114,75±8,40*
110,06±6,80
SAP
89±8,20
91,06±9,30
90,43±9,15
DAP
45±7,79
46,31±8,56
45,87±7,50
Sp O2
95,31±0,60
97,56±0,51*
98,25±0,68*
Note:
* Reliability of differences in measurements compared to the original (Р < 0,05).
Discussion
On a premedication stage patient of the second
group have shown an increase in the measurement of
HRF by 5,5%. SAP measurements - by 3,0%, DAP
measurements - by 1,7%. Isoflurane inhalation has
caused a slow induction and the solutions of fentanyle
and droperidol have been injected intravenously in this
connection. After the fentanyle injection, a respiratory
depression has been observed, an auxiliary ventilation
has been applied and a tracheal intubation has been
implemented after the administration of muscle relaxants.
Skin cover was warm and had a regular staining whilst
the oxygen saturation indicator increased by 3,9%.
HRF measurement increased by 2,0%, an insignificant
increase in the SAP by 1,2% and DAP by 0,2% compared
with similar measurements of the original period has
been observed (Table 2).
On the background of the administration of
medicines for induction – ketamine, propofol and
sevoflurane after the trachea intubation an insignificant
change in hemodynamics not negatively affecting a
hemodynamic system has been observed. Introduction
period of general combined anesthesia with the use of
small doses of has been characterized by smooth clinical
course.
1228
Medico-legal Update, October-December 2020, Vol. 20, No. 4
Table 2. Measurements of the HRF, SAP and DAP at the induction anesthesia period of children with the
use of isoflurane, fentanyle and droperidol
Measurements
Study stages
Initial
Premedication
Induction
HRF
115±2,38
121,33+ 2,87*
118,93+ 3,93*
SAP
88,40±2,69
91,7±2,87
89,5±4,21
DAP
45,16±2,69
45,92±3,51
45,07±4,32
SpO2
95,38±0,58
97,44±0,6*
99,07±0,73
Note:
* Reliability of differences in measurements compared to the original (Р<0,05).
When conducting a study of the central
hemodynamics measurements of patients of the first
group, in the introduction period compared with the
similar measurements of the initial period, after the
trachea intubation the increase in HRF measurements
by 7,6%, CI by 18,5% (Р<0,05), some tendency to
the increase of SV measurement by 9,3% have been
observed. At the same time, a downward tendency to the
decrease in the measurements of EF by 5,6% and SPVR
by 8,2% has been noted (Table 3).
Table 3. Measurements of central hemodynamics during the anesthesia induction period of children with the
use of isoflurane, fentanyle and droperidol (n=40)
Measurements
Initial
Premedication
Induction
EF
70.49±0.85
68.28±1.03
66.55±0.96*
SV
24.59±1.61
22.9±1.31
26.88±1.63
HRF
97.8±2.21
107±2.11*
105.18±1.91*
SPVR
30.29±1.54
32.16±1.77
27.81±1.04**
CI
2.87±0.09
3.02±0.11
3.4±0.1***
Note:
* Reliability of differences in measurements compared to the original (Р < 0,05).
Table 4 represents the data on the study of central
hemodynamics during general anesthesia of children
with the use of isoflurane, fentanyle and droperidol.
The increase in the measurements of HRF and Specific
peripheral vascular resistance.
Table 4. Measurements of central hemodynamics during the anesthesia induction period of children with the
use of isoflurane, fentanyle and droperidol (n = 40)
Measurements
Initial
Premedication
Induction
EF
71.96±1.48
71.51±1.17
72.05±1.4
SV
24.87±1.54
23.56±1.31
23.67±1.35
HRF
96.48±2.07
109.15±2.2*
109.9±2.33*
SPVR
29.7±1.41
25.52±1.25*
26.59±1.42
CI
2.81±0.14
3.08±0.15
3.12±0.17
Note:
*Reliability of differences in measurements compared to the original (Р < 0,05).
Medico-legal Update, October-December 2020, Vol. 20, No. 4
1229
In the introduction period of anesthesia after the
trachea intubation compared with the premedication
stage only a slight tendency to the measurement change
has been noted. In comparison with the initial period, only
HRF was subjected to a significant change and increased
by 13,9%. Only the SV and SPVR measurements had
a downward tendency by 4,8% and 10,5% respectively.
Subsequent laryngoscopy and intubation do not cause
such a pronounced hyperdynamic response as with
induction with ketamine and barbiturates. Hypotension
was prevented and eliminated by infusion loading.
The results of the existing study show that the
combination of sevoflurane with propofol and ketamine
in small doses has caused the effective analgesia with a
significant vegetative stabilizing effect associated with
central suppression of sympatic activity, and has ensured
a stable course of subsequent stages of anesthesia and
post-anesthesia period. Patients experienced a rapid
restoration of the preoperative level of neuropsychic
status after surgery.
Conclusions
1. Insignificant changes of the main measurements
of central hemodynamics are contingent to the
condition of patients during the introduction period,
the trachea intubation and the manipulations
taken. The vasodilating properties of propofol
and sevoflurane suring the introduction narcosis
determine a switch hypodynamic reaction of the
circulatory system.
2. The evaluation of the clinical course of the
introduction period and of the changes of the
main measurements of central hemodynamics
at conducting the two variants of the combined
anesthesia has shown smooth introduction into
narcosis and therefore an auxiliary stable course of
the subsequent anesthesia stages.
3. Applying small doses of ketamine and propofol
coupled with sevoflurane is an optimal method of
induction during traumatic and extensive surgery in
the abdominal cavity and anorectal area in children.
Ethical Clearance:
No ethical approval is needed.
Source of Funding:
Self
Conflict of Interest:
Nil
References
1.
Vasilkov V.G. MVN, KAF, YNG, ROP.
Antihypoxic antioxidants for the prevention of
perioperative hemodynamic disorders in elderly
patients with hip fracture [Antigipoksanti-
antioksidanti dlya profilaktiki perioperatsionnykh
narusheniy gemodinamiki u pozhilikh patsientov s
perelomom bedra]. Meditsinski alfavit. 2015; 2(9):
p. 23-9.
2.
Dyomin V.V. NVF, KMV, DAV, DDV.
Hemodynamics and heart rate variability in children
with congenital heart defects during anesthesia.
2018;: p. 57-58.
3.
Zabolotskikh I.B. VRV, TNV. Recruitment
maneuver in conditions of general anesthesia during
abdominal operations. Vestnik anestezioologii I
reanimatologii. 2016; 13(6).
4.
Pidgirniy Y.M. UZO, IAV. Multimodal anesthetic
management of a stumectomy operation. Meditsina
neotlozhnykh sostoyaniy. 2019; 4(99).
5.
Nasriev
S.A.
KEG,
MSS,
ABR,
PSK.
Hemodynamic effect of selective spinal anesthesia
during proctologic operations. Dostizheniya nauki I
obrazovaniya. 2018; 1(729).
6. Kulikov A.Y. KOV, LKM. The effect of xenon
anesthesia on hemodynamics: what we know by
2015. Anesteziologiya I reanimatologiya. 2015;
60(6).
7. Kuralov E.T. YAS, NHK. The effect of propofol
on hemodynamics in anti-glaucomatous surgery in
children. Nauchnaya diskussiya: voprosi meditsini.
2016; 60(6)(5).
8.
Kachur S.V. SAO. Pathophysiological assessment
of stress response in the early postoperative period
in patients operated on for lung tumors under
multimodal anesthesia. Omskiy nauchniy vestnik.
2015; 2(144).
9.
Yusupov A.S. KAE, ELK. Hemodynamic changes
during pain relief in minor surgeries in children.
Sovremennaya meditsina: noviye podkhody I
aktualniye issledovaniya. 2019;: p. 11-17.
10. Terkawi
AS,
MTSHMJMHSTaMED.
“Ondansetron does not attenuate hemodynamic
changes in patients undergoing elective cesarean
delivery using subarachnoid anesthesia: a double-
1230
Medico-legal Update, October-December 2020, Vol. 20, No. 4
blind, placebo-controlled, randomized trial.” 2015;:
p. 344-348.
11. Helwani MA AMAAKDCJHBKH. Effects of
regional versus general anesthesia on outcomes
after total hip arthroplasty: a retrospective
propensity-matched cohort study. JBJS. 2015 Feb
4; 97(3): p. 186-93.
