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THE IMPORTANCE OF INVASIVE AND NON-INVASIVE
MONITORING OF CENTRAL HEMODYNAMICS IN EMERGENCY
CARDIOLOGY
S.Sh. Joniev
1,2
, M. Mustabova
1
, K. Kurbonov
2
, M.Dusmatov
1
1
Samarkand State Medical University,
2
Samarkand regional branch of the
Republican specialized scientific practical medical center of Cardiology, Samarkand,
Uzbekistan
Abstract.
The article presents the results of preoperative preparation,
anesthesia and surgical treatment of patients operated on for non-toxic nodular
goiter. A new approach to preoperative preparation for thyroid surgery is
described. The effectiveness in the preoperative period of using the modified
method of preoperative preparation using sibazon and droperidol and anesthesia
with the use of ketamine and the advantages of this method compared with other
methods of general anesthesia are shown.
Key words: modified preoperative preparation, anesthesia, thyroid gland,
nontoxic nodular goiter
Currently, there is a steady increase in the number of thyroid diseases worldwide.
A significant number of population living in the territory of Uzbekistan have obvious
or hidden functional disorders of the thyroid gland [6]. Diffuse non - toxic goiter is the
most common pathology, which takes up to 60% of all cases of thyroid disease. In this
pathology, the functions of the central nervous system and endocrine system, blood
circulation and respiration, liver and kidneys, immunity and metabolism are impaired
[5]. Often, this type of thyroid disease is the leading one in the group of endocrine
diseases, the main method of treatment for which is surgery. It should be considered
that during operations on the thyroid gland, it is important to use the optimal method
of anesthesia, which would prevent the manifestations of pathological reactions
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associated with the nature of the main and concomitant diseases. The high risk of intra
- and postoperative complications associated with the anatomical features of the
surgical intervention area justifies the relevance of the problem of optimizing the
anesthetic allowance for thyroid surgery [2].
Analyzing of currently used methods of general anesthesia for thyroid diseases,
we can assume that not all of them do fully prevent the negative effects and reactions
that occur in the div to surgical stress and have many other serious drawbacks. These
include: the use of narcotic analgesics and anesthetics, postoperative respiratory
depression and rapid cessation of analgesia in the early postoperative period, a number
of adverse hemodynamic changes at traumatic stages of surgery [1].
When choosing an anesthetic to maintain anesthesia for thyroid disease, the
characteristics of the psychological and somatic status of patients, the nature of the
influence of the disease on the circulatory system and the functional state of
parenchymal organs, and the presence of concomitant diseases are guided [3].
Surgical treatment of thyroid pathology, including goiter under General
anesthesia using neuroleptanalgesia (NLA) in the most traumatic moments of the
operation is often accompanied by dangerous circulatory disorders in the form of
tachycardia, arterial hypertension, and heart rhythm disorders [3]. If the patient also
has concomitant diseases (CVS diseases and diabetes mellitus), then the complication
during anesthesia becomes critical. In modern practical anesthesiology, much attention
is paid to the blockage of pathological impulsion, which occurs under the influence of
surgical trauma of the afferent and central nervous system during the medical
preparation of the patient in the preoperative period.
Anesthesiology does not yet know ideal and universal solutions to the problem of
protecting the patient from surgical aggression. The most reasonable approach is a
multi-modal approach that implies a multi-level, multi-purpose antinociception, in
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which the maximum effect (due to synergy or summation of action) is combined with
a minimum of side effects [6].
The appearance of modern drugs for anesthesia and improvement of surgical
treatment results at the current stage of development of endocrine surgery is seen in the
further improvement of preoperative preparation and intraoperative anesthesia.
Objective:
To choose the effective method of preoperative preparation and types
of anesthesia on thyroid gland surgery.
Material and methods:
The research was conducted at
Samarkand State Medical Institute clinic №1.
72
patients operated on non-toxic goiter were under observation. In accordance with the
purpose and objectives of this study, patients were divided into two groups depending
on the type of preoperative preparation and anesthesia. Among the examined patients
there were 8 men (11.1%) and 64 women (88.9%) aged from 32 to 68 years. By age,
the patients were distributed as follows: from 32-45 years
–
13 people (18.05 %), 46-
60 years
–
49 people (74.7 %), over 60 years
–
10 people (7.2%). The length of
anamnesis
for goiter was on average 3.3 ± 2 years. Objective status according to the
classification of the American society of anesthesiologists (ASA) II - 39 (54, 1%), III
- 28 (38.9%), IV - 5 (6.9%). Patients with nodular (multi-nodular) euthyroid colloid
goiter were operated on.
The following operations were performed: strumectomy (14 cases),
hemistrumectomy (24 cases), hemistrumectomy with isthmus removal (7 cases),
extremely subtotal-subfacial strumectomy (11 cases). The average duration of the
operation is 50 ± 13 minutes. The first group (control group
- n=34)
–
patients who
underwent traditional preoperative therapy and standard anesthesia. Group II (study
group - n=38) - patients whose preoperative preparation was performed using a
modified method with the use of sibazone and droperidol. In group 1, premedication
was performed on the operating table: fentanyl 0.002 mg/kg, sibazone 5 mg, atropine
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0.005-0.008 mg/kg. Initial narcosis
—
thiopental Na 4 -7 mg/kg. Intubation was
performed on the background of mioplegii ditilinom (100mg). To maintain anesthesia,
propofol 2
—
4 mg/kg/h, fentanyl 5
—
8 mcg kg/h, and droperidol 0.05
—
0.1 mg/kg
were used. Patients in group 2 were given sibazone 0.2-0.5 mg/kg at 20:00 I/M for 3
days before surgery. In addition to the standard premedication, sibazone at a dose of
0.3-0.5 mg/kg and droperidol 0.05-0.1 mg/kg were administered 30 to 40 minutes
before surgery. Introductory anesthesia
—
thiopental Na 4
—
7 mg/kg. Intubation on
the background of myoplegia with ditillin(100 mg). To maintain anesthesia, propofol
2
—
4 mg/ kg/h, fentanyl 3
—
5 mcg/ kg/h, droperidol 0.05
—
0.1 mg/kg, ketamine
0.5 mg/kg were used. To objectively evaluate the effectiveness of preoperative
preparation and the adequacy of anesthesia, hemodynamic parameters were studied:
systolic blood pressure (SBP, mmHg), diastolic blood pressure (DBP, mmHg), heart
rate (HR, beats/min) were determined in dynamics by the" ARGUS TM-7 "monitor of
the company "SCHILLER". Average dynamic blood pressure (ABP, mmHg) SBP =
DBP + 1/3 (SBP-DBP) (B. Folkov, E. Neil, 1976). The concentration of glucose,
lactate, Sp02, and hormonal parameters (cortisol, free T3, and TSH) were studied using
the STAR-FAX immunoassay analyzer (USA). The level of sedation was determined
on the Ramsay scale (M. A. Ramsay, 1974) 40 minutes after premedication. The study
of hemodynamic parameters was performed five times: at admission, 2 days to
operation, 1 day to operation, in the intraoperative period, on the 1st day after surgery.
RESEARCH RESULT
Our studies showed that the initial parameters of
с
entral hemodynamics in patients
in both groups did not significantly differ from each other (tables 1., 2.). conducting a
step-by-step monitoring of changes in central hemodynamics, we found that patients
in the control group already at the preoperative stage, before induction into anesthesia,
there was a significant increase in blood pressure, SBP, DBP, ABP and heart rate
(p<0.05) compared to the initial parameters. So, after premedication, patients in the
control group showed a significant increase in blood pressure by 4.8% (p<0.001), SBP
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by 6.9% (p<0.001), ABP by 5.5% (p<0.01), heart rate by 4.4% (p<0.05) relative to the
initial values (table 1.). the number of heart contractions, average blood pressure during
the three days before surgery was steadily increased and despite the traditional
antihypertensive therapy, there was no downward trend. It is also noteworthy that
despite the traditional premedication, the number of heartbeats was increased
compared to the previous days.
Table 1.
SBP, DBP, ABP, heart rate in patients of the control group at the main stages
of the perioperative period (M=m, p), (n=34)
Stages of research
Control group
SBP, mm. Hg DBP, mm.
Hg
ABP, mm.
Hg
Heart
rate
beats/min
1.
In
admission
138,3 ± 1,66
88,6 ± 1,03
95,6
±
1,02
89,8 ± 1,03
2.
2 days
before
operation
132,2 ± 1,61
p > 0,5
86,3 ± 0,94
p > 0,5
95,3
±
0,99
p > 0,5
88,8 ± 0,94
p > 0,1
3.
1 day
before
operation
131,8 ± 1,60
p > 0,1
p1 > 0,2
85,9 ± 0,76
p > 0,05
p1 > 0,1
97,2
±
0,99
p > 0,1
p1 > 0,1
86,4 ± 0,87
p < 0,05
p1 > 0,4
4.
In
intraoperative
period
137,9 ± 1,34
p > 0,05
p1 > 0,05
87,1 ± 0,94
p < 0,05
p1 > 0,05
99,1
±
1,03
p < 0,05
p1 > 0,1
86,5 ± 0,81
p < 0,05
p1 > 0,5
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5.
1 day
after operation
135,5 ± 1,35
p < 0,001
p1 < 0,05
86,1 ± 0,86
p < 0,001
p1 > 0,2
100,9
±
0,98
p < 0,01
p1 > 0,1
88,3 ± 0,76
p < 0,05
p1 > 0,3
Note: p - compared to the first stage
P1 - compared to the previous stage
The above data indicate that patients in the control group have significant changes
in blood pressure and heart rate, which are a consequence of the impact on the patient's
div of stress and other adverse factors acting on the patient's div in the perioperative
period. These disorders are not completely blocked by premedication, anesthesia, or
infusion therapy and are amplified under the influence of surgery. Analysis of central
hemodynamic parameters in patients of the study group showed that in the preoperative
period, at the first five stages of the study (3 days, 2 days, 1 day before surgery,
premedication), against the background of the use of sibazone and droperidol, there
was a systematic decrease in blood pressure, SBP, DBP, heart rate compared to the
initial indicators, but within the physiological norm. 2 days before the operation, there
was a significant decrease in SBP by 4.2% (p<0.005), DBP by 4.3% (p<0.01), ABP by
4.2% (p<0.01), and heart rate by 3.9% (p<0.05) compared to the first stage. After
premedication, the SBP is lower than the initial figures by 3.4% (p<0.01), DBP by
5.3% (p<0.001), ABP by 4.5% (p<0.001), heart rate by 4.6% (p<0.05). These changes
in central hemodynamic parameters are positive and are due to the stabilization of the
neurovegetative system against the background of the use of sibazone and droperidol,
since admission to the hospital itself is already a stressful situation for most patients
(table 2).
Table 2.
SBP, DBP, ABP, heart rate in patients of the study group at the main stages
of the perioperative period (M=m, p), (n=38)
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Stages of research
Control group
SBP, mm. Hg DBP, mm.
Hg
ABP, mm.
Hg
Heart
rate
beats/min
1.
In
admission
140,4 ± 1,26
p2 > 0,1
88,7 ± 0,82
p2 > 0,5
95,9
±
0,93
p2 > 0,5
89,4 ± 1,06
p2 > 0,5
2.
2 days
before
operation
137,3 ± 1,18
p > 0,05
р2
> 0,5
87,2
± 0,61
p > 0,05
р2
> 0,1
93,9
±
0,74
p > 0,05
р2 > 0,4
86,0
± 0,82
p > 0,05
р2
< 0,01
3.
1 day
before
operation
127,1 ± 0,99
p < 0,005
p1 > 0,1
р2 < 0,05
81,4 ± 0,63
p < 0,01
p1 > 0,05
р2 < 0,001
92,0
±
0,68
p < 0,01
p1 > 0,05
р2 < 0,001
78,4 ± 0,69
p < 0,05
p1 > 0,1
р2 < 0,001
4.
In
intraoperative
period
121,2 ± 0,84
p < 0,005
p1 > 0,5
p2 < 0,01
71,4 ± 0,57
p < 0,001
p1 > 0,2
p2 < 0,001
91,4
±
0,58
p < 0,001
p1 > 0,5
p2 < 0,001
72,2
± 0,62
p < 0,01
p1 > 0,1
p2 < 0,001
5.
1 day
after operation
122,0 ± 0,75
p < 0,01
p1 > 0,5
р2 < 0,001
72,7 ± 0,52
p < 0,001
p1 > 0,5
р2 < 0,001
91,8
±
0,51
p < 0,001
p1 > 0,5
p2 < 0,001
74,9 ± 0,
58
p < 0,05
p1 > 0,2
p2 < 0,001
Note: p - compared to the first stage
p1 - compared to the previous stage
p2 - compared to the same stage of the control group
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By analyzing the level of preoperative sedation, it was found that in 80% of
patients in the control group, the effect of premedication was unsatisfactory, it was
expressed in emotional tension, anxiety, and fear of surgery. In the study group, the
level of preoperative sedation was adequate in 100 % of cases.
At the traumatic stage of the operation, there was a significant increase in the
average blood pressure values in group 1 by 19.2 % (p < 0.05), in group 2-by 12 % (p
< 0.05). Heart rate in the most traumatic stages of surgery increased by 15.6 % (p
<0.05) in group 1 and by 16 % (p<0.05) in group 2. These changes indicated a
hyperdynamic reaction of the cardiovascular system, activation of the neuro-vegetative
system. There were no significant differences between the two groups at this stage of
the study (p>0.05). SBP returned to normal in group 2 after the operation, and in group
1 only by the first day after the
operation. In the postoperative period, the heart rate
remained stable.
In group 1, the glucose level increased during the traumatic stage of the operation,
reaching a maximum by the end of the operation (6.98 mmol/l; p < 0.05), and returned
to normal only on the first day. In group 2, the blood glucose concentration was
normalized by the first day after surgery.
The level of TSH and T3 in both groups remained within the reference values at
all stages of the study, no significant differences in these indicators were found in the
comparison groups (p > 0.05). In all groups, SpO remained at the normal level of 97-
99% during anesthesia and in the early postoperative period.
Conclusions:
1. Patients operated on for thyroid diseases, in the intraoperative period,
undesirable hemodynamic, vegetative and neuroendocrine reactions of the div occur,
which negatively affect the course of the perioperative period and the anesthetic
allowance.
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2. The use of a modified method of preoperative preparation with the use of
sibazone and droperidol in patients operated on for thyroid diseases helps to reduce
emotional stress, providing an adequate level of preoperative sedation, allows you to
optimize the anesthetic effects, minimize the negative effects and doses of anesthetics.
3. The use of general anesthesia with fentanyl and droperidol does not fully block
nociceptive impulses, which indicates insufficient protection of the patient from
surgical aggression, characterized by instability of hemodynamics, preservation of
endocrine and metabolic changes. The addition of ketamine to General anesthesia and
the use of a modified method of preoperative preparation can reduce the dose of
opioids, stabilize hemodynamics and ensure safety of the perioperative period.
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