UDC 616.833-009.614:617.741-0041-053.1:615.21/26
MONITORING OF CENTRAL HEMODYNAMICS UNDER CONDITIONS OF COMBINED
ANESTHESIA WITH SEVOFLURAN IN SURGICAL CORRECTION OF CATARACT IN
CHILDREN
I.A. Mamatkulov, E.A. Satvaldieva, A.S. Yusupov, B.T. Buzrukov, M.G. Tolipov
Tashkent Pediatric Medical Institute
Resume
Research purpose: Improvement of the methods of anesthetic management with the use of
sevoflurane in the surgical treatment of cataracts in children.
Materials and methods: 54 sick children were studied during ophthalmosurgical interventions
under combined anesthesia based on the use of sevoflurane.
Results and discussion: The data obtained from studies of central hemodynamic parameters
showed minimal changes in the response of systemic hemodynamics, which were associated with
the peculiarities of the pharmacological action of both fentanyl and sevoflurane. It should be noted
that this condition during anesthesia characterized the state of moderate circulatory hypodynamia.
Keywords: anesthesia in children, inhalation anesthetics, sevoflurane, fentanyl, central
hemodynamic parameters.
МОНИТОРИНГ ЦЕНТРАЛЬНОЙ ГЕМОДИНАМИКИ В УСЛОВИЯХ
КОМБИНИРОВАННОЙ АНЕСТЕЗИИ СЕВОФЛУРАНОМ
ПРИ ХИРУРГИЧЕСКОЙ
КОРРЕКЦИИ КАТАРАКТЫ У ДЕТЕЙ
И.А.Маматкулов, Э.А.Сатвалдиева, А.С.Юсупов, Б.Т.Бузруков, М.Г.Толипов
Ташкентского педиатрического медицинского института
Резюме
Цель исследования: Методы совершенствования анестезиологической помощи с
применением севофлурана при хирургическом лечении катаракты у детей.
Материалы и методы. Обследовано 54 ребенка вовремя офтальмохирургических
операций с применением севофлурана под комбинированной анестезией.
Результаты и обсуждение. Результаты, полученные в результате исследований,
основанных на изучении показателей центральной гемодинамики, показали минимальные
изменения в ответ на системный ответ гемодинамики, эти изменения были связаны с
особенностями фармакологического действия фентанила и севофлурана. Следует
отметить, что во время анестезии для этого состояния характерна тенденция к
умеренной гиподинамии кровообращения.
Ключевые слова: детская анестезия, ингаляционные анестетики, севофлуран,
фентанил, показатели центральной гемодинамики.
БОЛАЛАРДА КАТАРАКТАНИ ХИРУРГИК КОРРЕКЦИЯЛАШДА СЕВОФЛУРАН
БИЛАН КОМБИНИРЛАНГАН АНЕСТЕЗИЯ ШАРОИТИДА МАРКАЗИЙ
ГЕМОДИНАМИКА МОНИТОРИНГИ
И.А.Маматкулов, Э.А.Сатвалдиева, А.С.Юсупов, Б.Т.Бузруков
,
М.Г.Толипов
Тошкент педиатрия тиббиёт институти
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Резюме
Тадқиқот мақсади: Болаларда катарактани хирургик даволашда севофлуранни қўллаб
анестезиологик таъминотни такомиллаштириш усуллари.
Материал ва услублар: Комбинирланган анестезия асосида севофлуран қўлланилиб
офтальмохирургик операцияларда 54 бемор бола текширувдан ўтказилди.
Натижалар ва муҳокама: Тадқиқотлардан олинган маълумотлар марказий
гемодинамика кўрсаткичларини ўрганиш асосида олинган натижалар гемодинамиканинг
тизимли реакциясига жавобан минимал ўзгаришлар мавжудлигини кўрсатди
,
бу
ўзгаришлар
фентанил ҳамда севофлураннинг фармакологик таъсири хусусиятлари билан
боғлиқ
бўлди. Қайд этиш лозимки, анестезия вақтида ушбу ҳолат қон айланишининг
ўртача гиподинамияга мойиллиги билан харектерланади.
Калит сўзлар: болалар анестезияси, ингаляцион
анестетиклар, севофлуран, фентанил,
марказий гемодинамика кўрсаткичлари
.
Relevance
Clouding of the lens - cataract in children is
one of the leading causes of primary blindness
[1]. One of the priority anesthesia drugs in the
surgical treatment of cataracts in children, the
most widely used in pediatric practice, is the
inhalation anesthetic sevoflurane [2,3,5]. The
drug,
characterized
by
dose-dependent
respiratory depression, with a minimal effect on
the cardiovascular system, allows for highly
controlled inhalation anesthesia with instant
induction and rapid awakening, contributing to
the rapid postoperative recovery of the patient's
consciousness [4,8]. Sevoflurane has no negative
hemodynamic effects, slightly affects intracranial
and intraocular pressure [6,9,13]. It is possible to
perform anesthesia using low- and minimal-flow
techniques, which provide more favorable
environmental conditions in the respiratory
circuit, which gives a positive economic effect.
The use of modern drugs for general anesthesia
and these schemes for conducting anesthesia,
both during induction and during intraoperative
and postoperative management of the patient,
made it possible to avoid many negative reactions
inherent in other anesthetics, such as ketamine,
halothane, sodium thiopental, which can cause
hypertensive syndrome , increase intraocular
pressure, motor reactions, increase the time of
recovery from anesthesia [9,10,11,12].
Thus, general anesthesia with sevoflurane in
the surgical treatment of cataracts in children is
decisive and optimal.
Purpose:
Improving
the
methods
of
anesthetic management using sevoflurane in the
surgical treatment of cataracts in children.
Material and methods
To provide anesthetic protection in 54 sick
children during ophthalmosurgical interventions,
the following combinations were used: fentanyl
with sevoflurane (Group 1 - 55.6%), fentanyl
with propofol (Group 2 - 44.4%).
Children aged 2
–
4 years accounted for 62.9%,
children aged 5
–
7 years accounted for 37.1% of
the total number of patients.
Anesthesia was performed during operations
of congenital and traumatic cataracts with the
imposition of an IOL (implantation of an
artificial lens). The duration of anesthesia in
59.4% of patients was up to 1 hour, in 40.6% - up
to 2 hours.
Patients of the 1st group after premedication
began inhalation of sevoflurane up to 3 vol%.
Fentanyl was administered intravenously at a
dose of 3 µg/kg. All patients underwent tracheal
intubation against the background of the
introduction of arduan at a dose of 0.06 mg/kg.
IVL was performed using the Drager Fabius plus
device (Germany) along a semi-closed circuit.
Myorelaxation
was
maintained
by
the
introduction of 1/3 of the main dose of arduan.
Anesthesia was maintained by inhalation of
sevoflurane at a dose of 1.0
–
2.0 vol%. Infusion
therapy was carried out at a rate of 5 - 7
ml/kg/hour. After the end of the operation with
the advent of adequate spontaneous breathing, the
trachea was extubated. After the operation, the
patients woke up quite quickly, within 13.8±0.8
minutes.
Patients of the 2nd group received bolus
propofol (3 mg/kg) and fentanyl 0.005% (0.03
mg/kg) during the induction period [7,14]. For
operations lasting more than one hour, the
maintenance of the surgical level of anesthesia
was carried out by repeated administration of
fentanyl at a dose of 1/2 or 1/3 of the initial dose.
The dose of propofol during the period of
maintenance
of
anesthesia,
which
was
administered through the lineomat, averaged
7.3±0.4 mg/kg/h. The duration of the awakening
stage was 15.5±5.6 min.
The study of hemodynamics was carried out
on the echocardiograph "SonoScape" (China)
with a sensor of 3.5 MHz. Echocardiography
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(EchoCG)
parameters
were
calculated
automatically. The following values were
determined: stroke index (SI) = SVR/S ml/m2,
cardiac index (CI) = MOS/S l (min*m2), specific
peripheral resistance (SIR) = SBP/SI in conv.
units Computer analysis of echocardiography
made it possible to calculate indicators of
myocardial contractility and diastolic function of
the left ventricle.
Measurement of intraocular pressure was
made according to A.N. Maklakov. Normal IOP
is 16 - 23 mm. rt. Art. Patients had IOP measured
before and after surgery.
The results of clinical and functional studies
were processed by the method of variation
statistics Student's T-test....
Result and discussion
The results of the study of hemodynamic
parameters during combined anesthesia with the
use of fentanyl and sevoflurane are presented in
Table 1.
Compared with the initial data on the
premedication background, there was an increase
in heart rate by 17.52% and a decrease in specific
peripheral resistance (RPS) by 20.74%. It should
be noted that patients of the first group reacted
more significantly to induction anesthesia and
anesthesia. Even before the start of anesthesia,
they had tachycardia on the operating table. This
was due to the psycho-emotional stress of
patients.
Other indicators changed slightly. After the
administration
of
fentanyl,
hemodynamic
parameters such as stroke index (SI), mean
dynamic pressure (DDP), cardiac index (CI),
ejection fraction (FI) and heart rate decreased
compared with those of the premedication period,
respectively, by 14.21% ( P<0.05), 3.98%,
8.57%, 4.19% and 2.79%, excluding HIPS. These
significant differences in the response of
systemic hemodynamics are associated with the
peculiarities of the pharmacological action of
both fentanyl and sevoflurane.
It should be noted that this condition
characterized the state of moderate circulatory
hypodynamia. Sevoflurane mainly affects the
tone of the peripheral vascular bed, causing
vasoplegia, fentanyl reduces cardiac output,
increasing vascular vasoplegia. 10 minutes after
intubation, there was a significant increase in SI
by 20.44%, SI by 21.65%, and DDS by 8.53%,
while at the same time, there was a decrease in
UPS by 13.76% (P<0.05).
Table 1.
Hemodynamic parameters during combined anesthesia with the use of fentanyl and
sevoflurane (M±m)
Indicators
Research stages
Exodus
Premedication
Introductory
period
traumatic
ny stage of the
operation
End of opera
tions
UI, ml/m
2
42,14
0,99
39,34
1,69
33,75
0,96***
39,22
2,11
41,33
1,04
SDD,
mm. rt. st
74,63
1,85
75,07
1,92
72,08
1,85
75,85
2,13
74,58
2,24
Heart rate, min
–
1
113,0
6,64
132,8
5,9
129,1
3,15
124,9
6,15
117,7
5,89
SI, l/min x m2
4,82
0,41
4,9
0,28
4,48
0,29
4,66
0,26
4,83
0,27
UPS, arb. unit
18,18
1,57
14,41
1,07
17,0
0,73
17,63
1,44
15,57
1,48
FI, %
62,73
1,66
65,09
2,89
62,36
2,7
63,19
3,16
65,57
2,24
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).
There was a trend towards a decrease in the
index of the fraction of exile (FI). In the period of
maintenance of anesthesia, certain changes in the
indicators of central hemodynamics were also
observed. Thus, at the stage of skin incision,
compared with the previous period, there was a
decrease in DDS by 6.52%, heart rate - by 8.49%,
CI - by 12.84%. At the same time, there was an
increase in the SPS by 13.44%.
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The reasons for the decrease in DDS and SI
were
the
presence
of
rigidity
of
the
microcirculatory
bed,
limited
cantractile
capabilities of the heart muscle. At the end of the
operation, there were also minimal changes in
indicators.
Under
the
influence
of
drugs
for
premedication in patients of group 2 (table 2), the
following hemodynamic changes were noted: an
increase in heart rate by 6.45% (P<0.05), SI by
2.5%, SI by 2.33%, SBP by 0 86%, UPS by
2.74% and FI by 1.11% (P>0.05), associated with
emotional discomfort before surgery and the
condition of patients after premedication.
Table 2.
Hemodynamic parameters during combined anesthesia with the use of fentanyl in
combina
tion with propofol (M±m)
Indicators
Research stages
Exodus
Premedication
Introductory
period
traumatic
ny stage of the
operation
End of opera
tions
UI, ml/m2
47,26
±
1,61
48,44±
1,59
46,58
±
1,3
47,14±
1,41
47,38±
3,27
SDD, mm. rt. st
119,13
±
1,82
126,81
±
2,2*
119,06±
2,25**
120,54±
2,06
123,94±
2,02
SI, l/min x m2
4,73
±
0,16
4,84
±
0,16
4,66
±
0,13
5,61
±
0,23***
5,97±
0,51*
UPS, arb. unit
84,80
±
1,94
85,53±
1,93
79,40±
2,00**
82,87±
1,71
76,97±
1,18***
UPS, arb. unit.
48
,29±
4,03
5
0,16±
4,39
4
8,36±
3,82
4
8,13±
4,05
5
2,72±
4,13
FI, %
63,76±
0,57
64,47±
0,72
63,84±
0,48
63,51±
0,55
63,73±
0,47
Note: * -
significance of differences at Р<0.05 compared to the initial value
** -
significance of differences at Р<0.05 in comparison with the previous stage of the study
Against the background of induction into
anesthesia, a slight decrease in indicators was
observed: CI, HR, SI and SBP by 1.44%, 2.42%,
1.48% and 6.37%, respectively. At the same
time, the SSA and FI increased slightly - by 0.1%
and 0.13%, respectively, which turned out to be
statistically unreliable (P>0.05). Compared with
the stage of premedication, there was a decrease
in heart rate by 12.01%, SBP by 7.17% (P<0.05).
Given the hypotensive effect of fentanyl and
propofol, the infusion was started without waiting
for the fall in blood pressure. This approach made
it possible to prevent, and in some cases
completely eliminate the critical drop in blood
pressure at all stages of anesthesia.
At the end of the operation, hemodynamic
parameters remained stable. The changes we
found in the studied parameters at the stages of
the operation were unreliable, except for the SI
and SBP indicators. In relation to their initial
value, there was some change, which was
expressed by an increase in CI by 26.22%, a
decrease in SBP by 9.23% (P<0.05).
During anesthesia in the 1st group of patients
in the postoperative period, there was an
unreliable decrease in IOP by 13.43%, in the 2nd
group - 7.44% (Table 3).
Table 3.
Change in IOP during combined anesthesia in children
№
Type of anesthesia
Before surgery
After operation
1
Fentanyl + sevoflurane
25
.7±1.58
2
1.2±1.25
2
Fentanyl + propofol
24,4
±1,2
2
22,
3±1,2
9
Conclusions
1. The study of the response of the cardiovascular
system to combined anesthesia and surgery in
children
with
ophthalmic
pathology
is
accompanied by a slight and compensated change
in the main hemodynamic parameters.
2. Anesthesia using fentanyl with sevoflurane and
fentanyl with propofol is accompanied by a
decrease in IOP, which creates optimal
conditions for the surgical treatment of cataracts
in children.
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Entered 09.09.2022
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