ANALYSIS OF CRITERIA FOR THE INTENSITY OF HEMODYNAMIC MONITORING IN INTENSIVE CARE UNITS

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ANALYSIS OF CRITERIA FOR THE INTENSITY OF

HEMODYNAMIC MONITORING IN INTENSIVE CARE UNITS

S.Sh. Joniev

1,2

, J. Xalilov

1

, O.Xusanov

1

, D.N. Abdaliyev

2

1

Samarkand State Medical University,

2

Samarkand regional branch of the

Republican specialized scientific practical medical center of Cardiology, Samarkand,

Uzbekistan

The parametres of arterial blood pressure determined in standard conditions in

three groups of patients while carrying out multicomponent endotracheal inhalation

anaesthesia with halogen-containing volatile anesthetics have been analysed

(halothane was used in the first group, isoflurane - in the second group, sevoflurane -

in the third group). The control group was made by almost healthy people. Two

subgroups depending on the ASA physical status were analyzed. The analysis took into

account the systolic, diastolic and pulse arterial blood pressure. The authors offered to

calculate coefficients of arterial blood pressure. The conclusion has been made that the

integrative indicator of arterial blood pressure objectively reflects the quality of

anesthetic protection at stages of anesthesia and can be used as a criterion of adequacy

of anesthesia. It does not depend on age, estimation of the ASA physical status, and

concrete halogen-containing volatile anesthetics.

Key words:

emergency cardiology

cardiosurgery,

anaesthesia,

haemodynamics, arterial blood pressure.

Currently, an important problem in anesthesiology is the assessment of the

adequacy of anesthesia. An analysis of the literature data showed that three groups of

methods for determining the depth of anesthesia are most often used: 1) clinical [4]; 2)

laboratory [2, 3]; 3) neurophysiological [6, 7].

Clinical signs include motor responses, hemodynamic changes, and sympathetic

activation [4]. Specific motor reactions are movements of the eyelids or eyes,

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swallowing, coughing, changes in facial expressions, movements of the limbs or head.

Increased respiratory efforts are due to the activity of the intercostal and abdominal

muscles, which are switched off at deep levels of anesthesia. When using muscle

relaxants, motor reactions cannot provide information about the depth of anesthesia.

Therefore, the assessment of the activation of the sympathetic system acts as an

additional method for monitoring superficial anesthesia. Sympathetic reactions

associated with surface anesthesia include mydriasis, lacrimation, sweating, and

salivation. These signs are non-specific and can change under the influence of

anesthetics, therefore, their presence or absence is an unreliable indicator. The use of

muscle relaxants, especially in combination with nitrous oxide or opioids, may mask

signs of surface anesthesia.

Hemodynamic changes with inadequate anesthesia are tachycardia and changes

in blood pressure. However, systolic, diastolic, pulse and mean arterial pressure are in

a certain relationship to each other. Their quantitative changes are interdependent,

determining the optimal or disturbed state of the entire homeostasis system. In

assessing the state of hemodynamics, there is no integrative indicator that combines

the obtained data on blood pressure.

There are also laboratory methods for studying the “surgical stress response” [2,

3]. They are based on the study of the level of hormones of the hypothalamic-pituitary-

adrenocortic system (ACTH, cortisol, catecholamines, etc.), as well as the study of the

effect of these hormones on the div (the level of glycemia, lactate, lipid peroxidation,

acid - basic state, etc.). These methods require the use of laboratory equipment and

reagents, are laborious, and their widespread use is impossible due to high cost. They

are suitable only for a retrospective assessment and on their basis it is impossible to

make a timely correction of inadequate anesthesia.

Neurophysiological methods include electroencephalography, evoked potentials

and techniques based on their information processing with the help of electronic

computers. They can be used for monitoring the parameters of the div's vital activity

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in a continuous real-time mode (on-line) and have good prospects [6, 7]. The main

disadvantage that limits their widespread use is the high cost of equipment and

consumables (electrodes).

We have proposed to assess the adequacy of anesthesia, in addition to measuring

systolic and diastolic blood pressure and calculating the mean and pulse blood pressure,

to calculate blood pressure coefficients.

The purpose of this study is to analyze the features of changes in blood pressure

during multicomponent endotracheal inhalation anesthesia with halogen-containing

anesthetics in abdominal surgery based on the use of our proposed integrative indicator

of the state of the components that determine blood pressure.

Materials and methods

A study was conducted in 146 patients during endotracheal inhalation anesthesia,

who underwent surgery for diseases of the

in cardiac surgery patients.

Depending on

the inhalation anesthetic used, all patients were divided into three groups. The first

group included patients who used halothane as one of the components of anesthesia

maintenance, the second group - isoflurane, the third group - sevoflurane. The

anesthetic benefit was carried out according to the following plan. Induction into

anesthesia in the first and second groups (patients using halothane or isoflurane) was

carried out by the introduction of fentanyl 2.18±0.56 µg/kg and propofol 2.03±0.31

mg/kg. Induction into anesthesia in the third group (patients using sevoflurane)

consisted of sequential

administration of fentanyl (1.2 ± 0.6 μ

g/kg) and diazepam (0.12

± 0.04 mg/kg), after which through the face The mask was supplied with a gas narcotic

mixture -

nitrous oxide with oxygen (FiO2 = 50%) and sevoflurane (2.9±0.55 vol%,

0.99±0.06 MAC). Tracheal intubation was performed after the admi

nistration of

dithylin 1.5-

1.8±0.3 mg/kg. Anesthesia was maintained in all those groups by

inhalation of an anesthetic in a ferrous-oxygen mixture with an oxygen concentration

of 40% and an additional bolus of fentan

yl (5.2 ± 2.14 µg/kg). Halothane (0.6±0.17

vol%, 1.00±0.14 MAC) was used in the first group, isoflurane (2.0±0.4 vol%, 1.01±0.1

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MAC), in the third -

sevoflurane (1.4 ± 0.32 vol%, 1.03 ± 0.1 MAC). After intubation,

myoplegia was maintained by administration of arcuron (0.04±0.01 mg/kg) or trakrium

(0.45±0.01 mg/kg).

Intraoperative monitoring of the patient's condition included electrocardiography,

heart rate, non-invasive blood pressure measurement, pulse oximetry, thermometry,

control of the gas composition (oxygen concentration, nitrous oxide, inhalation

anesthetic) in the inhaled and exhaled mixture, determination of the minimum alveolar

concentration of inhalation anesthetic (MAC ), concentrations of carbon dioxide during

inhalation and exhalation, capnography. We also recorded ventilation parameters - tidal

volume (Vt), minute breathing volume (MV), peak inspiratory pressure (Pmax),

plateau pressure (Pplato), airway resistance (R), compliance (C ). The quality of the

neuromuscular block and the need for additional administration of muscle relaxants

were determined by stimulation of peripheral nerves in the TOF mode.

Electroencephalographic entropy (Entropy) was monitored to assess the level of the

depth of anesthesia sleep. Taking into account all the above parameters, the course of

anesthesia was regarded as adequate.

Blood pressure was measured using an ADU-5 anesthetic-respiratory monitor

(Datex-Ohmeda, Finland-USA) at several stages: 1st - before anesthesia; 2nd - 5

minutes after tracheal intubation; 3rd - 10 minutes after intubation; 4th - 20-30 minutes

after tracheal intubation (which corresponded to the main stage of the operation); 5th -

the end of the operation; 6th - before extubation of the patient.

The first group: the number of examined people was 34, the average age was

52.1±15.6 years, the average div weight was 83.5±17.1 kg, among them there were

30 women (88.2%) and 4 men ( 11.8%. According to the ASA scale, 17 people

belonged to the 1-2 class, 17 people - to the 3-4 class. The second group: the number

of examined people was 100, the average age was 52.4±13.0 years, the average div

weight was 82.1±16.5 kg, among them there were 77 women (77%) and 23 men (23

%). According to the ASA scale, 45 people belonged to grades 1-2, 55 people - to

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grades 3-4. The third group: the number of examined - 39 people, the average age of

the examined was 51.9 ± 16.2 years, the average div weight was 79.9 ± 20.1 kg,

among them there were 33 women (84.6%) and 6 men (15.4%). According to the ASA

scale, 14 people belonged to grades 1-2, 25 people - to grades 3-4. As a control group,

practically healthy people were examined, who at the time of the examination did not

suffer from any pathology. The group consisted of 33 people, the average age was

31.7±7.6 years, among them were 21 women (63.6%) and 12 men (36.4%). T

he

number of blood pressure measurements was 171. Blood pressure was measured

automatically using a Philips heart monitor according to generally accepted rules [1].

In addition, all examined in three groups were divided into two subgroups

depending on the initial assessment of the physical status according to ASA: the first -

grades 1-2 according to ASA, the second - grades 3-4 according to ASA. In the first

subgroup, the number of examined people was 76 people, the average age was

47.2±14.2 years, the average div weight was 81.7±18.1 kg, among them there were

60 women (78.9%) and 16 men (21.1 %). In the second subgroup, the number of

examined people was 97 people, th

e average age was 59.8±11.0 years, the average

div weight was 83.5±16.4 kg, among them there were 80 women (82.5%) and 17 men

(17 ,5%).

To assess the state of hemodynamics, we proposed the following criteria [5]: the

ratio of systolic blood pressure to diastolic blood pressure - coefficient 1 (K-1); the

ratio of diastolic blood pressure to pulse blood pressure - coefficient 2 (K-2). Statistical

data processing was carried out on a personal computer using Microsoft Excel,

Statistica 6.0 programs. Data are presented as mean and standard deviation

(Mean±SD), the distribution was standard (chi

-square test was used to test for

normality). A statistically significant difference in the means was assessed using

analysis of variance, a significant difference in the means for specific groups was made

according to the Newman-Keuls test.

Results and discussion

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The calculation in the control group (healthy people) of the average value of the

coefficient 1 was 1.67±0.18; the average value

of coefficient 2 is 1.60±0.49.

In patients

during endotracheal inhalation anesthesia, the average values of the selected

coefficients for each stage are presented in Table 1. We compared the values of

coefficients 1 and 2 obtained by us for three groups at various stages of anesthesia with

the values in the control group. At stages 2-6, coefficients 1 and 2 approach the values

in the control group. At the 1st stage, the coefficients 1 and 2 significantly differ from

the values of the control group in the groups of halothane, isoflurane and sevoflurane

(p<0.05). At the second stage, in the group using isoflurane, there was a significant

difference in coefficients 1 and 2 from the values of the control group (p<0.05).The

relationship between the average values of the coefficients 1 and 2 in the three groups

at the stages of inhalation anesthesia and the average values in the control group are

shown in Figures 1 and 2. The results of comparing the average values of the

coefficients in subgroups according to ASA are presented in Table 2. When comparing

the entire population, significant differences for coefficients 1 and 2 were obtained at

the first stage.

Table 1 - Values of coefficients 1 and 2 by groups.

anesthesia

Stage

.

Halotane (n=34)

Isoflurane

Isoflurane

(n=100)

Sevoflurane

(n=39)

К

-1

К

-2

К

-1

К

-2

К

-1

К

-2

1

1,8±0,29*

1,41±0,55

*

1,81±0,2

5*

1,35±0,45*

1,85±0,3

*

1,32±0,5*

2

1,64±0,18

1,67±0,43

1,76±0,2

6*

1,43±0,4*

1,64±0,3

1,55±1,0

3

1,63±0,21

1,75±0,57

1,68±0,2

1

1,62±0,53

1,65±0,2

1,7±0,5

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4

1,64±0,21

1,71±0,52

1,68±0,2

2

1,63±0,49

1,65±0,2

1,69±0,4

5

1,71±0,4

1,61±0,52

1,72±0,2

2

1,51±0,41

1,66±0,2

1,62±0,5

6

1,67±0,19

1,61±0,46

1,68±0,2

1,59±0,5

1,68±0,2

1,57±0,4

Note: * - significant differences from the control group.

We compared the values of coefficients 1 and 2 obtained by us for ASA

subgroups at various stages of anesthesia with the values in the control group. In

the first subgroup (ASA 1-2), coefficients 1 and 2 approach the values in the control

group. In the second subgroup (ASA 3-4), at the 1st stage, the coefficients 1 and 2

significantly differ from the values of the control group (p<0.05), at the subsequent

stages, no significant differences were obtained.

The relationship between the average values of the coefficients 1 and 2 at the

stages of inhalation anesthesia in the ASA subgroups and the average values in the

control group are shown in Figures 3 and 4.

Conclusions

1. The integrative indicator of the state of arterial pressure proposed by us

objectively reflects the quality of anesthetic protection at the stages of anesthesia

and can be used as one of the criteria for assessing the adequacy of anesthesia.

2. The integrative indicator of the state of arterial pressure in patients during

surgery with adequate anesthetic support is for a coefficient of 1 -

1.67 ± 0.18 rel.

units and for coefficient 2 -

1.60±0.49 rel. units It does not depend on age, physical

status assessment according to ASA, a specific halogen-containing anesthetic. The

sensitivity of coefficient 1 is higher than that of coefficient

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