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
341
Effect of combined epidural anesthesia in
children on hemodynamics with abdominal
interventions
Elmira
Satvaldieva
1,2*
,
Otabek
Fayziev
1
,
Anvar
Yusupov
1
,
Ihtiyor
Mamatkulov
1
,
and
Isfandiyor
Mamatkulov
1
1
Tashkent Pediatric Medical Institute, 223, Bogishamol Str., 100140, Tashkent, Uzbekistan
2
National Children’s Medical Center in Tashkent, 294 Parkentskaya Street, Ashgabat district, 100016,
Tashkent, Uzbekistan
https://doi.org/10.5281/zenodo.5593706
Abstract.
The article presents the results of assessing the effect of
combined epidural anesthesia on hemodynamics during abdominal
operations in children with Hirschprugg's and Payr's disease, dolichosigma.
The results of the study, carried out according to the multimodal principle,
showed the efficacy and safety of combined epidural anesthesia with
bupivacaine against the background of low-flow anesthesia with
sevoflurane and continuous sedation with propofol in sick children with
abdominal surgical pathology.
1 Introduction
Traditional methods of anesthesia cannot fully provide “ideal” intraoperative protection of a
child from powerful and prolonged surgical aggression during abdominal operations
[1.2.3.4]. The need to revise the standard mono-opioid approach is primarily determined by
the disadvantages, side effects of opioids and unmanageable anesthesia [5.6.7]. The
progress of surgical technologies has significantly increased the efficiency of surgical
treatment and led to the development of a multimodal program of accelerated rehabilitation
in surgery Fast track surgery (FTS), which was founded by H. Kehlet (1993). FTS assumed
the following aspects to minimize stress reactions and significantly shorten the recovery
period of patients: regional anesthesia, minimally invasive surgery, effective pain relief,
adequate perioperative infusion, aggressive postoperative rehabilitation (early enteral
nutrition and activation of patients) [8-11].
At the current level of development of anesthesiology, the most reliable and controlled
antinociception during traumatic operations in the abdominal cavity is provided by
combined anesthesia, consisting of controlled general anesthesia in combination with
epidural analgesia (EA) [12-15]. This technique not only provides a long-term analgesic
profile, but also stimulates the restoration of intestinal motility, reduces postoperative
complications, shortens the duration of postoperative recovery and the patient's stay in the
* Corresponding author:
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
342
ICU [16.17]. The awakening of children against the background of persisting analgesia due
to the epidural block has a beneficial effect on the psycho-emotional status of the child,
contributing to early mobilization and active postoperative recovery [18.19].
There are no studies in the literature on a comprehensive assessment of the effectiveness
of multimodal anesthesia and analgesia in the perioperative period during interventions for
Hirschsprung's and Payr's disease, dolichosigma in children [20-23]. There is ambiguity
and unresolved issues in solving this problem [24.25]. The ongoing search for optimal
options for the integrated management of the perioperative period in children with
accelerated postoperative rehabilitation has become a prerequisite for conducting our own
study to assess the effectiveness of combined EA bupivacaine in combination with propofol
(continuous infusion) + sevoflurane (low gas flow) [26.27.28]. The analysis used medical
databases Pub Med, Scopus, The Cochrane Library, and our own results.
2 Purpose of the study
The purpose of the study is to examine the effect of combined epidural anesthesia with
bupivacaine on hemodynamics in children with abdominal interventions.
3 Materials and methods
A prospective study of combined epidural anesthesia with bupivacaine in combination with
propofol and sevoflurane was carried out in 45 children operated on at the clinic of the
Tashkent Pediatric Medical Institute in December 2019 - March 2021 for Hirschsprung and
Payr's disease, dolichosigma. The average age of the children was 8.2 ± 0.5 years. The
work was approved by the local ethics committee of TashPMI, informed consent from the
parents was obtained. Preoperative preparation of children for planned operations (84.4%)
was carried out in accordance with generally accepted standards in surgery; if necessary,
correction of water and electrolyte balance, hemostasis, and intoxication syndrome was
performed.
The functional state of the patients corresponded to: class I ASA in 5, II - in 22, III - in
18 patients. The distribution of patients by surgical pathology and age is presented in Table
1. Standard premedication with atropine 0.1% -0.01 mg / kg, sibazone 0.5% -0.2 mg / kg,
antihistamines were administered according to indications, i / m. Induction was started with
propofol 1% - 3 mg / kg, fentanyl 3 μg / kg, intravenously. Myoplegia - Arduan at a dose of
0.08 mg / kg, IV, followed by tracheal intubation and transfer to artificial lung ventilation
(ALV). We started inhalation of sevoflurane - 1 vol% in the composition of oxygen mixture
O2 60-65%, anesthesia-respiratory apparatus "Fabius Plus" with a capnograph (Drager,
Germany). The supply of sevoflurane was gradually increased to 1.5 vol%. Inhalation
anesthesia was performed with low gas flow. Then, in the lateral position, the patient
underwent puncture and catheterization of the epidural space, at the level (Th10-Th7) using
disposable Epidural Minipeak kits (Portax, UK).
Then the patient was laid on his back and bupivacaine 0.5% - 0.3-0.4 mg / kg was
administered. Maintenance of anesthesia with propofol 5-6 mg / kg / h, microinfusion pump
SN-50C6T (China), continued until the end of the operation. Maintenance of myoplegia by
Arduan is fractional, on demand.Evaluation of hemodynamic parameters was carried out by
echocardiography (EchoCG) on the APLIO 500 "TOSHIBA" (JAPAN) apparatus at the
main stages of the study: minute volume of blood circulation (MVC), heart rate (HR),
ejection fraction (PH), mean arterial pressure (MAP) ) and stroke volume (SV) Tissue
perfusion was assessed in terms of oxygen saturation SpO2 (pulse oximetry). The study
was carried out at stages: stage 1 - in the preoperative ward, before premedication, stage 2 -
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
343
induction of anesthesia; Stage 3 - traumatic period; Stage 4 - the end of the operation and
awakening, stage 5 - 2 hours after the operation. The distribution of patients by the duration
of surgery is shown in Table 2.
Infusion therapy was carried out taking into account blood loss and, accordingly,
indicators of blood pressure, heart rate, CVP, urine output. Infusion therapy consisted of
Ringer's solution (or saline); for long-term interventions in preschool children, 10% glucose
solutions were used. Erythrocyte mass was transfused according to indications.
Perioperative monitoring: ECG, blood pressure (non-invasive), SpO2, SevI, SevET, of
sevoflurane using the Nihon Kohden multifunctional monitor.
Starting from the moment of awakening, the intensity of pain sensations was assessed
using a 10-point digital rating scale (DSR). The restoration of intestinal peristalsis
(auscultation) was assessed. Statistical data processing was performed using the Statistica
6.1 statistical software package (StatSoft, USA, 2003).
Results.
Operations on the organs of the abdominal cavity, especially for malformations
of the gastrointestinal tract, such as Hirschsprung's and Payr's disease, are often
characterized by high trauma, duration, often multistage and frequency of postoperative
complications.
Table 1.
Distribution of patients depending on age, gender and the nature of surgical intervention
abs%.
Surgical
pathology
Boys
Girls
Total
Patient age,
years
1
-3
4
-7
8
-11
12
-17
1
-3
4
-7
8
-11
12
-17
Hirschsprun
g's disease
4
6
5
5
4
4
28
(62.2%)
Payr's
disease
-
-
-
4
-
-
-
5
9 (20%)
Dolichosig
ma
1
2
2
1
2
8 (17.8%)
All
4
7
7
11
4
5
2
5
45 (100%)
Total
29 (64.4%)
16 (35.5%)
The postoperative period in this category of patients is also characterized by certain
requirements, namely, the need for adequate pain relief for up to 3-4 days, early restoration
of intestinal motility, refusal of enteral feeding, prescribing complete parenteral nutrition
with a gradual load of daily calorie intake and correction of water-electrolyte balance.
Table 2.
Distribution of patients depending on the duration of the operation.
Anesthesia type
Duration of anesthesia
up to 1.5
hours
up to 2.5
hours
≥2.5
hours
Total
Propofol +
fentanyl + EA +
sevoflurane
9
(20%)
21
(46.6%)
15
(33.3%)
45
(100%)
Therefore, the management of the perioperative period in these patients should correspond
as much as possible to the new strategy of Fast Track Surgery (Kehlet H, 1993): the
awakening of the patient while maintaining effective analgesia (Guryanov V.A., 2009,
Imani F. 2006), which creates a positive psycho-emotional background, promotes active
mobilization and has a significant impact on the rate of recovery and the outcome of the
disease (Pankratova G.S. 2007).
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
344
Stage 1 data corresponded to the initial hemodynamic parameters when the patient was
admitted to the preoperative ward before premedication. Changes in hemodynamic
parameters are presented.
Table 3.
Results of the study of hemodynamics at the stages of research.
indicators
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
SBP
107.8±9.3
117.3±9.4
*
121.2±11.4
*
113.4±10.9
110.2±9.4
mmHg
59.6±7.7
74.7±10.3
*
76.1±10.1
*
67.7±10.2
*
65.4±9.1
DBP
71.2±7.4
82.1±8.5
*
83.2±8.6
*
78.3±9.1
74.8±7.2
mmHg
100.5±10.5
106.4±12.6
108.0±12.5
107.7±11.4
103.2±12.4
ADsr
4.3±1.9
5.0±1.7
*
5.1±1.3
*
4.8±1.8
4.6±2.0
UO, см
3
43.9±12.2
52.3±17.0
56.1±17.2
**
50.3±14.1
48.9±12.5
KDR, cm
3.8±0.7
4.2±0.6
*
4.1±0.7
*
4.0±0.5
*
3.9±0.6
DAC, cm
2.6±0.3
2.7±0.4
2.6±0.6
2.6±0.5
2.5±0.3
FI,
68.3±7.3
71.0±8.4
70.7±10.5
69.3 ±8.1
69.0±7.3
SpO
2
99.6±5.7
97.6±3.0
97.1±4.7
98.6±5.7
99.6±7.7
Note: * significant differences in indicators in relation to stage 1 (
*
Р<0,05;
**
Р<0,001).
Analysis of hemodynamics showed an increase in SBP, DBP and BP avg at stage 2
(induction and intubation of the trachea) by 8.6%, 24.5% and 14.8%, respectively. HR,
IOC, and SV increased simultaneously by 5.8%, 15.5%, and 18.3%, respectively. At stage 3
- the traumatic stage of the operation, a relative stabilization of hemodynamics was noted in
relation to the previous stage, and in relation to stage 1 of SBP, DBP, and BP, cf. remained
increased by 12.2%, 27.1% and 16.3%, respectively, and were of a reliable nature. HR, IOC
and SV remained stable at the stages of maintaining anesthesia, significantly increased in
relation to stage 1 by 7.3% (p> 0.05), 17.7% and 26.5%. At the next stage, the awakenings
of SBP, DBP and BP avg remained relatively stable, increased towards the outcome with a
noticeable decrease in relation to the most traumatic stage of the operation. Thus, SBP,
DBP and BP avg decreased in relation to the previous stage by 6.4%, 11% and 5.8%, and in
relation to the outcome were increased by 5.1%, 13.4% (p <0, 05), and 9.6%, respectively.
Heart rate, IOC and SV at the stage of awakening remained increased in relation to the
outcome of 7%, 11.1% and 11.7, respectively.A significant increase in DBP, MAP at the
stages of maintaining anesthesia and awakening indicate the absence of the
cardiodepressant effect of sevoflurane in combination with the indicated dosages of
propofol in children. In addition, FI was stable throughout all stages of the study, the
absence of significant statistically significant fluctuations in FI confirmed the absence of a
depressive effect on the performance of the heart and ensuring the div's need for adequate
perfusion under the conditions of this method of anesthetic management. At the 5th stage, 2
hours after the operation, 87.9% of children woke up with persistent analgesia due to the
epidural block.
Thus, based on the revealed statistically significant increase in SBP, DBP, BP cf. and
stable indicators of pulse oximetry during maintenance of anesthesia compared with the
outcome, it can be argued that combined epidural anesthesia stabilizes hemodynamics, has
a positive effect on systemic and peripheral blood flow, tissue perfusion during abdominal
interventions in children. A statistically significant increase in the SV value during and
after surgery indicates the absence of a negative effect of the proposed technique on the
contractile function of the myocardium. The IOC significantly increased at the 2nd and 3rd
stages of the study compared to the initial data, and at the 4th and 5th stages it had an
unreliable tendency to decrease. According to our data, there were no significant changes in
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
345
heart rate at the stages of the study; therefore, changes in the IOC were associated with SV,
which significantly increased during and after anesthesia and indicated the absence of a
cardiodepressive effect.
At the stage of awakening, spontaneous breathing was restored 25-30 minutes after the
sevoflurane evaporator was turned off (subject to the last administration of a maintenance
dose of the muscle relaxant 35-40 minutes before the end of the operation). Some of the
patients (42.2%) were extubated in the operating room. In all extubated patients in the
operating room, post-anesthetic chills were absent or mild. In 16 cases (35.5%), prolonged
mechanical ventilation was performed in the next 5-7 hours, due to the initial aggravated
state, the patient's early age and blood loss. In other cases (22.3%), patients were extubated
within 1 hour in the ICU. Hemodynamic tension at the stage of awakening against the
background of ongoing epidural analgesia was not revealed. All hemodynamic parameters
were practically at the level of the initial data. Awakening without pain had a beneficial
effect on the psychoemotional state of children and contributed to their early activation and
adequate contact with medical personnel. Patients (77.7%) who underwent abdominal-
perineal proctoplasty underwent prolonged epidural anesthesia with bupivacaine for 3 days.
By the end of 3 days, intestinal peristalsis appeared in patients. The stable course of the
postoperative period, early mobilization facilitated the transfer of 32% of patients to the
specialized surgical department by the beginning of 4 days. The results of a study carried
out according to the multimodal principle showed the efficacy and safety of combined
epidural anesthesia with bupivacaine against the background of low-flow anesthesia with
sevoflurane and continuous sedation with propofol in children with the indicated abdominal
surgical pathology.
5 Conclusions
1.
Combined epidural anesthesia with bupivacaine against the background of low-flow
anesthesia with sevoflurane with continuous sedation with propofol provides effective
and controlled anesthetic protection during abdominal operations for Hirschsprung's
and Payr's disease, dolichosigma in children.
2.
Logical continuation of EA with bupivacaine in the early postoperative period
adequately provides antinociceptive protection in this category of patients, promotes
early restoration of intestinal motility and active mobilization of patients.
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2021
年
13
月第
39
卷第
13
期
Chin J Ind Hyg Occup Dis
，
2021
，
Vol.39
，
No.13
346
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