Features of anesthetic support in laparoscopic surgeries for acute cholecystitis
Keywords:acute cholecystitis, laparoscopic cholecystectomy, nonopioid anesthesia, pain syndrome, postoperative nausea and vomiting
Background. In many clinics in the world, the number of laparoscopic cholecystectomies (LCE) for acute cholecystitis exceeds 90 %. However, complications after anesthesia often occur, in particular, postoperative nausea and vomiting (PONV), sedation, dehydration, urinary retention. In addition, postoperative pain after LCE is a complex problem, and its treatment should be multimodal. The purpose was to determine the optimal method of anesthetic support in LCE for acute cholecystitis. Materials and methods. In the surgical department of Kyiv Regional Clinical Hospital for the period from 2013 to 2017, 377 patients with acute cholecystitis were hospitalized, 341 (90.4 %) of them underwent surgery. In a total study, 339 patients were randomly assigned to 3 groups depending on anesthetic technique. In group 1 (n = 112), anesthesia was performed without the use of opioids. Introduction to anesthesia — dexmedetomidine 0.6 μg/kg, lidocaine — 1.5 mg/kg and propofol — 1.5 mg/kg. Maintenance of anesthesia (constant infusion): dexmedetomidine 0.3 μg/kg/h, lidocaine 2 mg/kg/h, propofol 2.5 mg/kg/h and mechanical ventilation. In group 2 (n = 117), introduction to anesthesia was performed using propofol (1.5 mg/kg); maintenance of anesthesia — constant infusion of propofol (2.5 mg/kg/h) with fentanyl (3–6 μg/kg/h) and mechanical ventilation. In group 3 (n = 110), anesthesia was carried out with cevoflurane (2.32 ± 0.11 of minimum alveolar concentration) in combination with fentanyl (3–6 μg/kg/h) and mechanical ventilation. In the postoperative period, all patients received oral paracetamol 500 mg (4 times a day), dexketoprofen trometamol 25 mg (up to 3 times a day), and with ineffectiveness of anesthesia (more than 4 points on the visual analogue scale): in group 1 — tramadol 100 mg, in groups 2 and 3 — morphine 5–10 mg intramuscularly. Metoclopramide 10 mg and/or ondansetron 4 mg were administered for the treatment of manifestations of PONV syndrome. Results. Groups of patients were identical in terms of anthropometric and somatic parameters, duration of surgery and anesthesia. In group 1, hyperdynamic reactions were observed at the beginning of surgery. In particular, heart rate and mean blood pressure after induction, during intubation and at the 3rd, 5th and 7th minutes of pneumoperitoneum were significantly higher in group 1 than in other groups (p < 0.05). Other side effects were comparable between groups, with the exception of the frequency of vomiting and the use of ondansetron. Only one patient in group 1 required ondansetron for the treatment of PONV compared to 8 and 6 persons in groups 2 and 3, respectively (p < 0.05). Postoperative pain scores in patients of different groups were identical and had no statistically significant difference (p > 0.05). Conclusion. For any anesthetic support of LCE in acute cholecystitis, any of the proposed techniques may be used. With use of nonopioid anesthesia in the intraoperative period, hypertensive reactions and tachycardia were more often registered, however, in the postoperative period, these patients had a lower overall rate of analgesics use and PONV. Thus, nonopioid anesthesia for LCE should be used most often in patients with a history of PONV and opiate drug abuse.
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