ANI-monitoring in assessing the effectiveness of the anesthetic management for plastic surgery of the nose
Background. Perioperative monitoring of nociception/antinociception balance allows optimizing individual titration of the dose and preventing both inadequate anesthesia with risk of awakening, motor reaction and development of hemodynamic instability, and excessive depth of anesthesia with risk of late awakening, postoperative apnea and hyperalgesia. The purpose of this work was to study analgesia nociception index (ANI) for the evaluation of perioperative analgesia and the control of nociception/antinociception balance in various anesthetic management for plastic surgery of the nose. Materials and methods. 116 patients aged 18 to 60 years with deviated septum were examined. They underwent septoplasty under combined anesthesia including total intravenous anesthesia with mechanical lung ventilation and local anesthesia with lidocaine. All patients were divided into 4 groups: group 1 (n = 28) — standard combined anesthesia; group 2 (n = 31) — standard anesthesia and intravenous infusion of paracetamol at a dose of 15 mg/kg (but not more than 1000 mg) once, 30 minutes before the surgery; group 3 (n = 30) — infusion of dexmedetomidine started 10 minutes before the induction of anesthesia at a dose of 0.7 μg/kg/h and ended 10 minutes before the operation was completed; group 4 (n = 27) — infusion of dexmedetomidine at a dose of 0.7 μg/kg/h started 10 minutes before induction of anesthesia and ended 10 minutes before the end of the operation, in combination with intravenous infusion of paracetamol at a dose of 15 mg/kg 30 minutes before intervention (but not more than 1000 mg) once. ANI was registered. After the operation, the level of pain on the Visual Analogue Scale (VAS) and the incidence of postoperative nausea and vomiting were recorded. The patient’s assessment of the quality of anesthesia was made using a modified Iowa Satisfaction with Anesthesia Scale. The study was conducted at the following stages: 1 day before anesthesia; 5 minutes before surgery; during anesthesia (20–30 minutes); after the patient wakes up; 6 hours after anesthesia; 12 hours after anesthesia; on day 2 after anesthesia; on day 3 after anesthesia. ANI was registered in the following stages: 5 minutes before anesthesia was started; during induction of anesthesia; at the time of intubation; at the beginning of the surgery; at the most traumatic moment of the operation; during the awakening. Results. In group 1, ANI at the stage of intubation, the beginning of the intervention, at the most traumatic moment of the operation was less than 50 units, which is probably due to an insufficient level of analgesia. In group 2 with the use of paracetamol, ANI at the time of intubation was reduced to 50 units, but then was within 50–70 units. In group 3 with the use of dexmedetomidine, ANI at the stage of anesthesia and at the time of the patient’s awakening was more than 70 units. In group 4 with the combined use of dexmedetomidine and paracetamol, ANI at all stages was above 70 units except for the beginning of the surgical intervention. When analyzing the level of postoperative analgesia on the VAS scale, the most optimal level was observed in groups 2 and 4. The incidence of postoperative nausea and vomiting was lower in the main study groups: group 2 — 17 %, group 3 — 12 %, group 4 — 14 %, as compared to group 1 — 20 %. When the quality of anesthesia was assessed by Iowa Satisfaction with Anesthesia Scale, the best results were obtained in group 4, in which 25 % of patients rated the quality of anesthesia as “good” and 75 % — as “excellent”. The worst results were obtained in group 1, 30 % of whom rated the quality of anesthesia as “satisfactory”. Conclusions. The use of the ANI in anesthetic practice allows for a high degree of specificity in the online mode to monitor the level of perception of pain in the intra- and postoperative period and provide an improvement in perioperative analgesia. The use of paracetamol and dexmedetomidine enables a more reliable and complete perioperative analgesia.
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