The use of catheter subarachnoid blockade in abdominal surgery
Background. In modern abdominal surgery, significant proportion belongs to long surgical interventions. The technique of prolonged subarachnoid block (SB) with G22 and G24 catheters helps reliably identify the subarachnoid space, quickly inject the anaesthetic, ensuring its adequate mixing with liquor. The rate of anaesthesia development, its depth, reliability, controllability and the absence of systemic toxicity characterizes catheter SB as a promising technique in the practice of the anaesthesiologist. Materials and methods. The study involved 15 patients (64.4 ± 5.2 years; 78.9 ± 6.6 kg; II–III ASA). Diseases: destructive cholecystitis (1), postoperative ventral hernia, obesity (6), strangulated postoperative ventral hernia with necrosis of the small intestine (1), acute intestinal obstruction with segmental thrombosis — necrosis of the small intestine (1), acute intestinal obstruction due to sigmoid colon cancer (2), sigmoid colon cancer (2), gastric cancer with pyloric stenosis (2). At the L2–3 level, the spinal canal catheterization was performed using Spinocath kit with G22 catheter (B. Braun, Germany). SB was performed with hyperbaric bupivacaine at a dose of 20 mg in combination with 0.06 mg of buprenorphine. The position of the patient was lateral. The head end of the operating table was lowered (angle — 10–15°). After intrathecal injection, the patient was turned on his back, and the table was put in a horizontal position. SB level — Th2–3. The prolongation of anaesthesia was carried out “as needed” by the additional injection of hyperbaric bupivacaine 10 mg. Before the surgery, patients received: orally — 6 mg of melatonin at bedtime the day before intervention and 1 h prior to the surgery; orally/intravenously — 1 g of paracetamol; intramuscularly — 20 mg of nefopam; intravenously — 8 mg of dexamethasone; intravenously — 8 mg of ondansetron; intravenously — 50 mg of dexketoprofen. After the operation, for two/three days: orally/intravenously — 1 g of paracetamol every 8 h, intravenously — 50 mg of dexketoprofen every 8 h. Hemodynamic stabilization was carried out by administration of intravenous adrenaline hydrotartrate (0.09–0.27 mg/h or 0.019–0.057 μg/kg/min). In the postoperative period, 0.06 mg of intrathecal buprenorphine was injected every 24 h for 2 days, and a spinal catheter was removed. Results. After premedication with melatonin and nefopam, patients had a relatively quiet psycho-emotional status. The adequacy of anaesthesia was determined by the patients themselves, who characterized their condition as comfortable with “no pain”. Analgesia covered the Th2–3-S5 innervation zone. The maximum dose of bupivacaine during the operation reached 40 mg. Correction of hypotension and bradycardia was effectively provided by infusion of small doses of adrenaline. Depending on the level of blood pressure and heart rate, the rate of adrenaline injection was changed. Optimization of blood pressure and heart rate occurred reciprocally. Respiratory rate was 12–16 per minute, SpO2 — 96–99 %. After the operation, patients were transferred to the surgical department. During transportation and further treatment, patients were conscious, hemodynamic parameters and respiratory function remained stable, a partial motor block was detected, its regression rate depended on the intrathecal dose of bupivacaine. There was no postdural puncture headache. During the first postoperative day, active peristalsis was noted. Patients began to move actively 2–3 h after the transfer from the operating room. From the first day after the surgery, early enteral feeding was started. The dynamics of postoperative pain severity according to a numerical rating scale was: 3 h after — 0 points; 10 h — 1.60 ± 0.02 points (p = 0.0001); 24 h — 1.20 ± 0.02 points (p = 0.0001); 48 h after — 1.06 ± 0.01 points (p = 0.0001). Thirty minutes after the intrathecal administration of buprenorphine, the severity of postoperative pain was 0. Conclusions. The use of subarachnoid catheterization made it possible to perform SB during abdominal surgeries of any duration and injury rate. Catheter SB with bupivacaine and buprenorphine in combination with nefopam, dexketoprofen and paracetamol was an effective method for pain control in the postoperative period. Improving the quality of analgesia allowed for early activation and nutrition of patients and, accordingly, shortened the rehabilitation period.
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