RU2493884C2 - Method for combined general anaesthesia in combination with deep and superficial cervical plexus blockade in carotide endaterectomy or internal carotid artery resection after pathological deformation thereof - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to anaesthesiology, and may be used as an anaesthesia care of a surgical intervention for carotid endaterectomy or internal carotid artery resection after pathological deformation thereof. That is ensured by general anaesthesia in a combination with deep and superficial cervical plexus blockade. Pre-medication is used the day before the operation and on the operative day in the morning. Diazepam is introduced intramuscularly 30 minutes before the operation in a combination with phentanyl; the introduction is followed by ECG monitoring and heart rate count, plethysmography with arterial blood saturation, non-invasive blood pressure measurement and neuromonitring according to a bispectral index or entropy. Catheterisation of patient's peripheral or central vein is followed by an infusion therapy, an ionotropic therapy, a cardiotropic therapy, peripheral resistance maintenance. If heart rate is no more than 80 beats per minute, the anaesthesia is induced to reach an anaesthetic depth according to the bispectral index or entropy within 40-60 units. Analgesia is provided by the intravenous introduction of 0.005% phentanyl; myoplegia is ensured by the intravenous introduction of a myorelaxant. After tracheal intubation, the patient is transferred to forced volumentic artificial pulmonary ventilation with the CO₂ level within 35-45 mm Hg according to capnography. The anaesthesia is maintained by supplying an inhalation anaesthetic to the steam level of 0.8-1.0 MAK 0.8-0.9 litre of the air and oxygen flow containing 50% oxygen with controlling the inhalation anaesthetic volume by the level of the anaesthetic depth according to the bispectral index or entropy. That is followed by deep cervical plexus blockade. A tubercle of the VI cervical vertebra (a carotid tubercle) and a mastoid process are localised; thereafter a line connecting the above reference points is drawn on skin. The second line is drawn 1 cm below the first one in parallel. To verify an injection point of a local anaesthetic, the spines of IV, III, II cervical vertebras being at 1.5 cm from each other are palpated, and the reference point is the VI cervical vertebra. The needle is inserted perpendicularly to the skin and slightly in the caudal direction to reach the spines. The anaesthetic is introduced in a dose of 5-7 ml in each point C₄, C₃, C₂. Another 5-7 ml of the anaesthetic is introduced in a point found in an apex of the mastoid process. The superficial cervical plexus blockade requires introducing he fan-shaped introduction of the anaesthetic solution in a dose of 15 ml in a point found in the middle of a lateral crus of the nodding muscle under the above muscle, 4-5 ml in each direction from the same point; the first and following injections are performed at a depth of a usual intramuscular needle perpendicularly to nodding muscle.

EFFECT: method provides the adequate and safe anaesthesia ensured by avoiding linear blood velocity reduction in the medial cerebral artery during the surgical intervention, preventing intracranial pressure increase, reducing cerebral perfusion pressure in a combination with providing adequate protection against surgical invasion with maintaining stroke volume and arterial pressure.

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Description

The invention relates to medicine, in particular to a method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation, and can be used in surgical and other hospitals.

A known method of combined anesthesia for carotid endarterectomy, including the implementation of a deep blockade of the cervical plexus in combination with general anesthesia (see Berezhnoy DA, Anesthetic management of carotid endarterectomy. Thesis for the degree of candidate of medical sciences, Novosibirsk, 2007).

However, the known method of combined anesthesia for carotid endarterectomy with its use has the following disadvantages:

- insufficiently prevents the decrease in the linear velocity of blood flow in the middle cerebral artery,

- insufficiently prevents an increase in intracranial pressure,

- does not prevent a decrease in cerebral perfusion pressure,

- does not ensure the preservation of stroke volume of the heart and blood pressure.

The objective of the invention is to provide a method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation.

The technical result is to prevent, during a carotid endarterectomy or resection of the internal carotid artery during its pathological deformation, a decrease in the linear blood flow velocity in the middle cerebral artery, prevention of an increase in intracranial pressure, prevention of a decrease in cerebral perfusion pressure, while providing adequate protection against surgical aggression and with preservation of shock heart volume and blood pressure.

The technical result in the implementation of the invention is achieved by the fact that the proposed method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during pathological deformation, including performing a deep blockade of the cervical plexus in combination with general anesthesia Before the implementation of the regional blockade of the deep and superficial cervical plexuses, premedication is carried out, which consists in the patient taking on the eve of the operation, per os phenosepam tablets at a dose of 0.0005-0.001 g and on the morning of the day of surgery 30 minutes before the operation, the patient is administered intramuscularly with diazepam at a dose of 10 mg in combination with narcotic analgesic fentanyl at a dose of 100 mcg and after 30 minutes, after which the operating room begins to monitor the patient's ECG with calculation of the heart rate, plethography with saturation of arterial blood, non-invasive blood pressure, and also perform neuromonitoring after applying electrodes to the patient's frontal region according to the bispectrum index or entropy, then after catheterization of the peripheral or central vein of the patient, infusion therapy is carried out by intravenous administration of Ringer's solution or physiological saline of sodium chloride in a volume of 500 ml and inotropic therapy is started with 200 mg of dopamine hydrochloride diluted in 40 ml of saline in an initial dose of 5 μg / kg / min, cardiotropic therapy by intravenous administration of a 0.5% solution of nitroglycerin in an initial dose of 0.3 μg / kg / min, maintaining peripheral resistance with vessels are administered by intravenous administration of 10 mg of a solution of mesatone diluted in 50 ml of physiological saline with an initial infusion rate of 0.3 μg / kg / min, then, at a heart rate of not more than 80 beats per minute, induction into anesthesia is started by intravenous administration of a solution propofol at a dose of 0.5-1 mg / kg, or sodium thiopental at a dose of 1.5-4 mg / kg, or by inhalation of sevoran until the level of anesthesia is reached according to the bispectral index or entropy within 40-60 units, and analgesia is achieved by internal iv administration of a 0.005% solution of fentanyl at a dose of 5 μg / kg, myoplegia is provided by intravenous administration of a non-depolarizing solution of muscle relaxant nimbex at a dose of 0.15 mg / kg or tracrium at a dose of 0.5-0.6 mg / kg or esmerone at a dose of 0, 3 mg / kg and after 90-100 seconds the patient’s trachea is intubated and transferred to forced mechanical ventilation in the volume ventilation mode with a CO ₂ level in the range of 35-45 mm Hg. according to capnography, the maintenance of anesthesia is carried out by supplying an inhaled anesthetic of sevoran or isoflurane to a level of 0.8-1.0 MAC in a stream of 0.8-0.9 liters of an oxygen-air mixture containing 50% oxygen, with control of the volume of inhalation anesthetic according to the level of depth of anesthesia according to the indicators of the bispectral index or entropy, then before performing regional anesthesia of the deep and superficial cervical plexuses, the anatomical landmarks of the patient's cervical plexuses are determined, while as a first reference point divide the cusp of the VI cervical vertebra (carotid tubercle), the mastoid process of the temporal bone is used as a second landmark, after which a line connecting these landmarks is drawn on the skin with a sterile marker or a coloring antiseptic, then a second line is drawn 1 cm lower and parallel to the first, and for verification the transverse processes of the 4, 3, 2 cervical vertebrae, which are 1.5 cm apart from each other, are palpated at the injection site of the local anesthetic, and the countdown starts from the VI cervical vertebra, then a regional anest deep and superficial cervical plexuses, and when blocking the deep cervical plexus, the finger pressure effect is used to reduce the distance from the skin to the bone structures, after which a needle is inserted on the syringe perpendicular to the skin and somewhat in the caudal direction until the transverse process is reached with a continuous aspiration test due to a slight retraction of the piston of the syringe and in the absence of blood in the syringe with a clear sensation of bone structures, an injection of a 0.5% solution of local anesthetic marcaine is performed 5-7 ml of hydrochloride or napropin hydrochloride at each point of C ₄ , C ₃ , C ₂ and additionally inject 5-7 ml of a local anesthetic solution of marcain hydrochloride or napropin hydrochloride at a point located at the top of the mastoid process, and then block the superficial cervical plexus from a point located in the middle of the lateral leg of the sternocleidomastoid muscle (sternocleidomastoid muscle), by introducing a solution of local anesthetic marcaine hydrochloride or napropin hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml per house direction from one point, wherein the first and subsequent injection is performed to a depth of a conventional intramuscular needle perpendicular to the sternocleidomastoid muscle. In this case, the prevention of vagal effects is carried out, in the absence of contraindications, by the introduction of a 0.1% solution of atropine sulfate in a dose of 0.3-0.5 mg. In this case, as a coloring antiseptic, in determining the anatomical landmarks of the cervical plexuses, a sterile marker, or an antiseptic, potassium iodide or diamond green is used. Moreover, when conducting regional anesthesia of the deep and superficial cervical plexuses, a 10 ml syringe and a 22 G needle or a standard intramuscular needle are used for injection.

The method is as follows. Premedication is performed on the eve of the operation by administering to the patient per os tablets of phenosepam at a dose of 0.0005-0.001 g. On the morning of the operation 30 minutes before the operation, diazepam is administered intramuscularly at a dose of 10 mg in combination with narcotic analgesic fentanyl at a dose of 100 mcg. 30 minutes after premedication in the operating room, they begin to monitor the patient's ECG with heart rate counting, plethography with saturation of arterial blood, non-invasive blood pressure, and also perform neuromonitoring after applying electrodes to the patient's frontal region with the determination and maintenance of bispectral index or entropy values within 40 -60 units. Then, after catheterization of the peripheral or central vein of the patient, infusion therapy is carried out by intravenous administration of Ringer's solution or physiological solution of sodium chloride in a volume of 500 ml. Inotropic therapy is started with the introduction of a solution of dopamine hydrochloride in a dose of 200 mg, diluted in 40 ml of physiological saline, in an initial dose of 5 μg / kg / min. Cardiotropic therapy is carried out by intravenous administration of a 0.5% solution of nitroglycerin in an initial dose of 0.3 μg / kg / min. Maintaining peripheral vascular resistance is carried out by intravenous administration of a solution of mesatone in a dose of 10 mg, diluted in 50 ml of physiological saline, in an initial dose of 0.3 μg / kg / min. Then, at a heart rate of not more than 80 beats per minute, induction is initiated into anesthesia by intravenous administration of propofol at a dose of 0.5-1 mg / kg, or sodium thiopental at a dose of 1.5-4 mg / kg or by inhalation with sevoran to reach a depth level anesthesia according to the bispectral index or entropy in the range of 40-60 units, moreover, analgesia is achieved by the introduction of a 0.005% solution of fentanyl at a dose of 5 μg / kg. Prevention of vagal effects is carried out, in the absence of contraindications, by the introduction of a 0.1% solution of atropine sulfate in a dose of 0.3-0.5 mg. Myoplegia is provided by the administration of a non-depolarizing solution of nimbeks muscle relaxant at a dose of 0.15 mg / kg, or tracrium at a dose of 0.5-0.6 mg / kg. or esmeron at a dose of 0.3 mg / kg and 90-100 seconds after the introduction of muscle relaxant intubate the trachea and transfer the patient to forced mechanical ventilation in the volume ventilation mode with a CO ₂ level within 35-45 mm Hg. according to capnography. Maintenance of anesthesia is carried out by supplying an inhaled anesthetic of Sevoran or isoflurane to a level of 0.8-1.0 MAC in a stream of 0.8-0.9 liters of an oxygen-air mixture containing 50% oxygen, with a control of the volume of supply of an inhaled anesthetic according to the level of depth of anesthesia according to bispectral index or entropy. Then, before performing regional anesthesia of the deep and superficial cervical plexuses, the anatomical landmarks of the patient's cervical plexuses are determined. In this case, the tubercle of the VI cervical vertebra (carotid tubercle) is determined as the first landmark, the mastoid process of the temporal bone is used as the second landmark, and a line connecting these landmarks is drawn on the skin with a sterile marker or staining antiseptic. At the same time, potassium iodide or brilliant green are used as a coloring antiseptic when determining the anatomical landmarks of the cervical plexuses. Then a second line is drawn on the skin 1 cm lower and parallel to the first, and to verify the injection site of the local anesthetic, the transverse processes of the 4, 3, 2 cervical vertebrae, which are located at a distance of 1.5 cm from each other, are palpated. In this case, the countdown begins from the VI cervical vertebra. Then perform regional anesthesia of the deep and superficial cervical plexuses. Moreover, when blocking the deep cervical plexus, the finger pressure effect is used to reduce the distance from the skin to the bone structures, after which a needle is inserted on the syringe perpendicular to the skin and somewhat in the caudal direction until a transverse process is achieved with a continuous aspiration test due to slight retraction of the syringe plunger in the absence of blood in the syringe. When performing regional anesthesia of the deep and superficial cervical plexuses, a 10 ml syringe and a 22 G needle or a standard intramuscular needle are used for injection. With a clear sensation of bone structures, an injection of 0.5% solution of local anesthetic of marcaine hydrochloride or napropin hydrochloride of 5-7 ml is performed at each point C ₄ , C ₃ , C ₂ and an additional 5-7 ml of local anesthetic solution of marcaine hydrochloride or napropin hydrochloride to a point located at the apex of the mastoid process. Then, the superficial cervical plexus is blocked from a point located in the middle of the lateral pedicle of the sternocleidomastoid muscle by the introduction of a solution of local anesthetic marcain hydrochloride or napropin hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml in each direction from one point, moreover, the first and subsequent injections are performed to the depth of a normal intramuscular needle perpendicularly. At the time of muscle suturing and neck platysma, the inhalation anesthetic is turned off, but the flow of the air-oxygen mixture is maintained at 0.8 L per min, while the MAC was at 0.1, and the bispectral index was 65 units. At the beginning of skin suturing, the flow of the air-oxygen mixture is increased to 8 liters in 1 min. The patient is extubated 1 min after the end of the surgery.

Among the essential features characterizing the proposed method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation, are distinguished:

- premedication prior to the regional blockade of the deep and superficial cervical plexuses of the neck on the eve of the operation with a per os patient taking phenosepam tablets at a dose of 0.0005-0.001 g and in the morning on the day of surgery 30 minutes before the operation with diazepam intramuscularly in a dose of 10 mg in combination with a narcotic analgesic fentanyl at a dose of 100 mcg,

- 30 minutes after premedication in the patient’s ECG operational monitoring with calculation of heart rate, plethysmography with saturation of arterial blood, non-invasive blood pressure, as well as neuromonitoring after applying electrodes to the patient’s frontal area with determination of bispectral index or entropy,

- carrying out after catheterization of the peripheral or central vein of the patient infusion therapy by intravenous administration of Ringer's solution or physiological solution of sodium chloride in a volume of 500 ml,

- the beginning of inotropic therapy by intravenous administration of 200 mg of a solution of dopamine hydrochloride diluted in 40 ml of physiological saline, in an initial dose of 5 μg / kg / min,

- conducting cardiotropic therapy by intravenous administration of a 0.5% nitroglycerin solution in an initial dose of 0.3 μg / kg / min,

- maintaining peripheral vascular resistance is carried out by intravenous administration of 10 mg of a solution of mesatone diluted in 50 ml of physiological solution, in an initial dose of 0.3 μg / kg / min,

- performance at a heart rate of not more than 80 beats per minute of induction into anesthesia by introducing a solution of propofol in a dose of 0.5-1 mg / kg, or thiopental sodium in a dose of 1.5-4 mg / kg or by inhalation with sevoran until the level of depth of anesthesia is reached according to the bispectral index or entropy within 40-60 units, moreover, analgesia is achieved by intravenous administration of a 0.005% solution of fentanyl at a dose of 5 μg / kg, myoplegia is provided by intravenous administration of a non-depolarizing solution of muscle relaxant nimbex at a dose of 0.15 mg / kg or tracrium at a dose of 0 5-0.6 m / Esmerone kg or 0.3 mg / kg,

- 90-100 seconds after administration of the muscle relaxant, the patient’s trachea is intubated and transferred to forced mechanical ventilation in the volume ventilation mode with a CO ₂ level in the range of 35-45 mm Hg. according to capnography,

- the implementation of maintaining anesthesia by feeding an inhaled anesthetic of Sevoran or isoflurane to a level of 0.8-1.0 MAC in a stream of 0.8-0.9 liters of an oxygen-air mixture containing 50% oxygen, with a control of the volume of supply of an inhaled anesthetic according to the level of depth of anesthesia by bispectral index or entropy indicators,

- determination before performing regional anesthesia of the deep and superficial cervical plexuses of the anatomical landmarks of the patient’s cervical plexuses, the tubercle of the VI cervical vertebra (carotid tubercle) being determined as the first reference point, the mastoid process of the temporal bone being used as the second reference point, after which it is carried out on the skin with a sterile marker or a coloring line connecting these landmarks with an antiseptic, then draw a second line 1 cm lower and parallel to the first,

- determination for verification of the injection site of the local anesthetic by palpation of the transverse processes of the 4, 3, 2 cervical vertebrae that are 1.5 cm apart, while the reference point is from the VI cervical vertebra,

- performing regional anesthesia of the deep and superficial cervical plexuses, and when blocking the deep cervical plexus, the finger pressure effect is used to reduce the distance from the skin to the bone structures, after which a needle is inserted on the syringe perpendicular to the skin and somewhat in the caudal direction until the transverse process is continuously performed with aspiration samples due to a slight retraction of the piston of the syringe and in the absence of blood in the syringe with a clear sensation of bone structures perform an injection of 0.5% solution and local anesthetic of marcaine hydrochloride or napropin hydrochloride 5-7 ml at each point C ₄ , C ₃ , C ₂ and additionally inject 5-7 ml of a solution of local anesthetic marcaine hydrochloride or napropin hydrochloride at a point located at the top of the mastoid process,

- blocking the superficial cervical plexus from a point located in the middle of the lateral leg of the sternocleidomastoid muscle (sternocleidomastoid muscle) by introducing a solution of local anesthetic marcain hydrochloride or napropin hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml in each direction from one point, and the first and subsequent injections are performed to the depth of a normal intramuscular needle perpendicular to the sternocleidomastoid muscle,

- warning vagal effects, in the absence of contraindications, the introduction of a 0.1% solution of atropine sulfate in a dose of 0.3-0.5 mg,

- use as a coloring antiseptic in determining the anatomical landmarks of the cervical plexuses of potassium iodide or brilliant green,

- the use of deep and superficial cervical plexuses during regional anesthesia for the injection of a 10 ml syringe and a 22 G needle or a standard intramuscular needle.

Experimental studies of the proposed method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation showed its high efficiency. It was found that the proposed method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation provides a decrease in the linear velocity of blood flow in the middle cerebral artery, prevents an increase in intracranial pressure. At the same time, a decrease in cerebral perfusion pressure was prevented and at the same time adequate protection against surgical aggression was provided while maintaining stroke volume of the heart and blood pressure.

The implementation of the proposed method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during its pathological deformation is illustrated by the following clinical examples.

Example 1. Patient K., 72 years old, was admitted to the A.A. Institute of Surgery Vishnevsky with a diagnosis of "Critical stenosis of the right ICA. SMN 3 tbsp. IBI, angina pectoris 2 FC. Hypertension stage 2 stage 3 high risk of developing cardiovascular complications. " The diagnosis was made on the basis of history, examination of auscultation, ultrasound scan and color duplex scanning of the carotid arteries.

The patient underwent a carotid endarterectomy operation under combined general and regional anesthesia.

Premedication was performed, which consisted of the patient taking phenosepam tablets at a dose of 0.0005 g on the eve of per os surgery. On the morning of the day of surgery, 30 mg of diazepam in combination with narcotic analgesic fentanyl at a dose of 100 mcg was administered intramuscularly 30 minutes before surgery. 30 minutes after premedication in the operating room, the patient began to monitor the ECG of the patient with a calculation of the heart rate, plethography with saturation of arterial blood, non-invasive blood pressure, and neuromonitoring was performed after applying electrodes to the frontal area of the patient with the determination of the bispectral index. Then, after catheterization of the peripheral vein, the patient was given infusion therapy by intravenous administration of Ringer's solution in a volume of 500 ml. Inotropic therapy was started by administering 200 mg of a solution of dopamine hydrochloride diluted in 40 ml of physiological saline at an initial dose of 5 μg / kg / min. Cardiotropic therapy was carried out by intravenous administration of a 0.5% solution of nitroglycerin in an initial dose of 0.3 μg / kg / min. The peripheral vascular resistance was maintained by intravenous administration of 10 mg of a solution of mesatone diluted in 50 ml of physiological saline in an initial dose of 0.3 μg / kg / min. Then, at a heart rate of not more than 80 beats per minute, induction into anesthesia by inhalation of Sevoran was started until the level of anesthesia was reached according to the bispectral index or entropy within 40-60 units, and analgesia was achieved by intravenous administration of a 0.005% solution of fentanyl at a dose of 5 μg / kg Prevention of vagal effects was carried out by intravenous administration of a 0.1% solution of atropine sulfate in a dose of 0.5 mg. Myoplegia was provided by intravenous administration of a non-depolarizing solution of esmeron 0.3 mg / kg, and 90 seconds after administration of the muscle relaxant, the patient's trachea was intubated and the patient was transferred to forced mechanical ventilation in the volume ventilation mode with a CO ₂ level of 40 mmHg. according to capnography. Anesthesia was maintained by feeding an inhaled anesthetic of Sevoran to a level of 0.8 MAA in a stream of 0.8 liters of an oxygen-air mixture containing 50% oxygen, with a control of the volume of supply of an inhaled anesthetic according to the level of depth of anesthesia according to the bispectral index. After the start of combined general anesthesia, the patient was given a horizontal position with her head turned in the opposite direction from the operated side. Then, before performing regional anesthesia of the deep and superficial cervical plexuses, anatomical landmarks were determined. In this case, the tubercle of the VI cervical vertebra (carotid tubercle) was determined as the first landmark, the mastoid process of the temporal bone was chosen as the second landmark, after which a line connecting these landmarks was drawn on the skin with a sterile marker. Then a second line was drawn on the skin 1 cm lower and parallel to the first, and to verify the injection site of the local anesthetic, the transverse processes of 4, 3, 2 cervical vertebrae, which are 1.5 cm apart, were palpated. In this case, the countdown began from the patient’s VI cervical vertebra. Then they performed regional anesthesia of the deep and superficial cervical plexuses. Moreover, when blocking the deep cervical plexus, the finger pressure effect was used to reduce the distance from the skin to the bone structures, after which a needle was inserted on the syringe perpendicular to the skin and somewhat in the caudal direction until a transverse process was reached with a continuous aspiration test due to slight retraction of the syringe plunger to make sure in the absence of blood in the syringe. When carrying out regional anesthesia of the deep and superficial cervical plexuses, a 10 ml syringe and a 22 G needle were used for injection. With a clear sensation of bone structures, an injection of a 0.5% solution of local anesthetic of napropine hydrochloride of 5 ml was injected at each point C ₄ , C ₃ , C ₂ and additionally injected 5 ml of a solution of local anesthetic napropine hydrochloride at a point located at the apex of the mastoid process. Then, the superficial cervical plexus was blocked from the point located in the middle of the lateral leg of the sternocleidomastoid muscle of the patient by introducing a solution of local anesthetic napropine hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml in each direction from one point, the first and subsequent injections were performed to the depth of a normal intramuscular needle perpendicular to the specified muscle with the mandatory performance of an aspiration test. At the time of work in the vegetatively sensitive region of the carotid artery (the sympathetic trunk runs along the posterior surface), an increase in the heart rate from 64 to 82 beats was noted. in 1 min and an increase in systolic blood pressure from 130 to 165 mm Hg Moreover, the level of adequacy of anesthesia was confirmed by the bispectral index data (48 units). In this regard, the dose of the inotropic preparation of dopmin hydrochloride was reduced from 5 μg / kg / min to 2 μg / kg / min, and the administration of the solution of the mesatone vasopressor was discontinued. At the same time, the dose of nitroglycerin was increased from 0.3 μg / kg / min to 0.8 μg / kg / min. After changing the parameters of the infusion of vasoactive drugs, the heart rate was 67 beats. at 1 min, and systolic blood pressure was determined at 140 mm Hg. At the same time, the bispectral index data remained the same 48 units, which indicated an adequate level of anesthesia and confirmed that hemodynamic changes were associated with activation of the sympathetic zone of carotid artery innervation. At the time of measuring retrograde pressure, which indirectly indicates an adequate level of compensation of cerebral blood flow, at the time of carotid clamping, the injection of a mesatone vasopressor solution was not required, which with standard general anesthesia is a necessary condition for creating pharmacological arterial hypertension. The further course of anesthesia is smooth. At the time of muscle suturing and neck platysma, the supply of an inhaled anesthetic was stopped, but the flow of the air-oxygen mixture was maintained at 0.8 L per min, while the MAC was at 0.1, and the bispectral index was 65 units. At the beginning of skin suturing, the flow of the air-oxygen mixture was increased to 8 liters in 1 min. The patient was extubated 1 min after the end of surgery.

There is no neurological deficit, blood pressure 130/70 mmHg, heart rate 62 in 1 min, no pain. After transferring the patient to the intensive care unit, hemodynamic parameters remained stable, pain was absent for 9 hours after surgery with stable hemodynamics and a clear consciousness of the patient.

The stability of the linear blood flow velocity in the middle cerebral artery was achieved, the increase in intracranial pressure was prevented, the decrease in cerebral perfusion pressure was prevented, and at the same time, adequate protection against surgical aggression was ensured while maintaining the stroke volume of the heart and blood pressure.

Example 2. Patient V., 64 years old, was admitted to the A.A. Institute of Surgery Vishnevsky with a diagnosis of "Stenosis of the left ICA. SMN 3 tbsp. IHD, atherosclerotic coronary cardiosclerosis. Hypertension stage 2 stage 3 high risk of developing cardiovascular complications. " The diagnosis was established on the basis of history, examination of auscultation, ultrasound of the carotid arteries and color duplex scanning of the carotid arteries.

The patient underwent a carotid endarterectomy operation under combined general and regional anesthesia.

Premedication was carried out, which consisted in taking the patient per os the pill of phenozepam at a dose of 0.001 g on the eve of the operation. On the morning of the operation 30 minutes before surgery, the patient was injected intramuscularly with diazepam (relanium) at a dose of 10 mg in combination with narcotic analgesic fentanyl at a dose of 100 μg. 30 minutes after premedication in the operating room, they started monitoring the patient's ECG with heart rate counting, plethography with saturation of arterial blood, non-invasive blood pressure, and also performed neuromonitoring after applying electrodes to the patient's frontal region with determination of entropy indices. Then, after catheterization of the peripheral vein of the patient, infusion therapy was carried out by intravenous administration of Ringer's solution in a volume of 500 ml. Inotropic therapy was carried out by intravenous administration of 200 mg of a solution of dopamine hydrochloride diluted in 40 ml of physiological saline in an initial dose of 5 μg / kg / min. Cardiotropic therapy was carried out by intravenous administration of a nitroglycerin solution in an initial dose of 0.3 μg / kg / min. The peripheral vascular resistance was maintained by intravenous administration of 10 mg of a solution of mesatone diluted in 50 ml of physiological saline in an initial dose of 0.3 μg / kg / min. Then, at a heart rate of not more than 80 beats per minute, induction was started into anesthesia by intravenous administration of a solution of propofol at a dose of 0.75 mg / kg until the level of anesthesia according to entropy was reached within 50 units, and analgesia was achieved by intravenous administration of a 0.005% solution fentanyl at a dose of 5 mcg / kg. Prevention of vagal effects was not carried out, because there were contraindications. Myoplegia was provided by intravenous administration of a non-depolarizing solution of nimbeks muscle relaxant at a dose of 0.15 mg / kg and after 100 seconds, after the administration of which, after 90 seconds, the trachea was intubated and the patient was transferred to forced ventilation in a volume ventilation mode with a CO ₂ level of 35 mmHg. according to capnography. Anesthesia was maintained by supplying an isoflurane inhalation anesthetic to a level of 0.9 MAA in a flow of 0.95 liters of an oxygen-air mixture containing 50% oxygen, with the volume of an inhaled anesthetic being controlled according to the level of anesthesia depth according to entropy indices. After the start of combined general anesthesia, the patient was given a horizontal position with his head turned in the opposite direction from the operated side. Then, before performing regional anesthesia of the deep and superficial cervical plexuses, the anatomical landmarks of the patient's cervical plexuses were determined. At the same time, the tubercle of the VI cervical vertebra (carotid tubercle) was identified as the first landmark, the mastoid process of the temporal bone was chosen as the second landmark, after which a staining line connecting these landmarks was drawn on the skin with a staining antiseptic - potassium iodide. Then a second line was drawn on the skin 1 cm lower and parallel to the first, and to verify the injection site of local anesthetic, the transverse processes of the patient's 4, 3, 2 cervical vertebrae, which were located at a distance of 1.5 cm from each other, were palpated. In this case, the countdown began from the VI cervical vertebra of the patient. Then they performed regional anesthesia of the deep and superficial cervical plexuses. Moreover, when blocking the deep cervical plexus, the finger pressure effect was used to reduce the distance from the skin to the bone structures, after which a needle was inserted on the syringe perpendicular to the skin and somewhat caudally until a transverse process was reached with a constant aspiration test due to slight retraction of the syringe plunger to verify the absence blood flow into the syringe. When conducting regional anesthesia of the deep and superficial cervical plexuses, a 10 ml syringe and a 22 G needle were used for injection. With a clear sensation of bone structures, an injection of 0.5% local anesthetic solution of marcaine hydrochloride (bupivacaine hydrochloride) 7 ml at each C ₄ point was performed. C ₃ , C ₂ and additionally introduced 7 ml of a solution of local anesthetic marcaine hydrochloride (bupivacaine hydrochloride) at a point located at the apex of the mastoid process. Then, the superficial cervical plexus was blocked from the point located in the middle of the lateral leg of the sternocleidomastoid muscle of the patient by introducing a solution of local anesthetic marcaine hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml in each direction from one point, the first and subsequent injections were performed to the depth of a conventional intramuscular needle perpendicular to the sternocleidomulus with the obligatory performance of an aspiration test. Tissue infiltration was carried out in 5 ml in each direction on the reverse course of the needle. After a skin incision, the patient showed no signs of a reaction to a pain stimulus, which was confirmed by entropy data (52 units), which indicated an adequate level of anesthesia. At the time of work in the vegetatively sensitive region of the carotid artery (the sympathetic trunk runs along the posterior surface), an increase in the heart rate from 56 to 84 beats was noted. in 1 min and an increase in systolic blood pressure from 140 to 170 mm Hg The level of adequacy of anesthesia was confirmed by entropy data (50 units). In this regard, the dose of the inotropic dopamine hydrochloride solution was reduced from 5 μg / kg / min to 2 μg / kg / min, and the administration of the mesatone vasopressor solution was discontinued. At the same time, the dose of nitroglycerin was increased from 0.3 μg / kg / min to 1.0 μg / kg / min. After changing the parameters of the infusion of vasoactive drugs, the heart rate was 67 beats. in 1 min, and systolic blood pressure was determined at the level of 150 mm Hg. At the same time, the entropy data remained the same 52 units, which indicated an adequate level of anesthesia and confirmed that hemodynamic changes were associated with the activation of the sympathetic zone of innervation of the carotid artery. At the time of measuring retrograde pressure, which indirectly indicates an adequate level of compensation of cerebral blood flow, at the time of carotid clamping, the injection of a mesatone vasopressor solution was not required, which with standard general anesthesia is a necessary condition for creating pharmacological arterial hypertension. The further course of anesthesia is smooth.

After the start of blood flow through the carotid artery, the amount of inhaled anesthetic was sharply reduced from 0.8 MAC to 0.2 MAC. At the same time, the patient showed signs of independent breathing. In this regard, the mode of ventilation was changed from forced to auxiliary with pressure support. A decrease in MAC led to a slight increase in the activity of the central nervous system, which, according to entropy, corresponded to 67 units. The transition to a superficial level of anesthesia and the appearance of muscle activity in the patient made it possible to assess the neurological status of the patient. The appearance of movement in the limbs with contralateral side surgery was noted, which confirms the absence of a neurological deficit. At the time of muscle suturing and neck platysm, the inhalation anesthetic was turned off, but the flow of the air-oxygen mixture was kept at 0.8 L per min, while the MAC was at 0.1, and the bispectral index was 65 units. At the beginning of skin suturing, the flow of the air-oxygen mixture was increased to 8 liters in 1 min. The patient was extubated 1 min after the end of surgery.

There is no neurological deficit, blood pressure 130/70 mmHg, heart rate 62 in 1 min, no pain. After transferring the patient to the intensive care unit, the hemodynamic parameters remained stable, pain was absent for 9 hours after surgery with stable hemodynamics and a clear consciousness of the patient.

The stability of the linear blood flow velocity in the middle cerebral artery was achieved, the increase in intracranial pressure was prevented, the decrease in cerebral perfusion pressure was prevented, and at the same time, adequate protection against surgical aggression was ensured while maintaining the stroke volume of the heart and blood pressure.

Example 3. Patient S., 32 years old, was admitted to the A.A. Institute of Surgery Vishnevsky with a diagnosis: “Pathological tortuosity of the right ICA. SMN 2 tbsp. " The diagnosis was made on the basis of history, examination, auscultation, color duplex scanning and ultrasound of the carotid arteries.

The patient underwent resection of the internal carotid artery under conditions of combined general combined with regional anesthesia.

Premedication was performed on the eve of the operation, which consisted of a patient taking peroz os tablets of phenosepam at a dose of 0.001 g. On the morning of the day of surgery, 30 minutes before surgery, the patient was injected intramuscularly with diazepam at a dose of 10 mg in combination with narcotic analgesic fentanyl at a dose of 100 μg. 30 minutes after premedication in the operating room, the patient began to monitor the ECG of the patient with a calculation of the heart rate, plethysmography with saturation of arterial blood, non-invasive blood pressure, and also performed neuromonitoring after applying electrodes to the frontal area of the patient with the determination of bispectral index values. Then, after catheterization of the central vein, the patient was given infusion therapy by intravenous administration of a physiological solution of sodium chloride in a volume of 500 ml. Inotropic therapy was started by intravenous administration of a solution of 200 mg of dopamine hydrochloride, diluted in 40 ml of physiological saline, at an initial dose of 5 μg / kg / min. Cardiotropic therapy was carried out by intravenous administration of a 0.5% nitroglycerin solution in an initial dose of 0.3 μg / kg / min. The peripheral vascular resistance was maintained by intravenous administration of 10 mg of a solution of mesatone diluted in 50 ml of physiological saline in an initial dose of 0.3 μg / kg / min. Then, at a heart rate of up to 77 beats per minute, induction in anesthesia was started by injecting sodium thiopental at a dose of 1.5 mg / kg. to reach the level of depth of anesthesia according to the bispectral index within 50 units, and analgesia was achieved by intravenous administration of a 0.005% solution of fentanyl at a dose of 5 μg / kg. Prevention of vagal effects was performed by intravenous administration of a 0.1% solution of atropine sulfate in an amount of 0.3 mg. Myoplegia was provided by intravenous administration of a 0.5 mg / kg trarium solution, and 95 seconds after the administration of the muscle relaxant, the trachea was intubated and the patient was transferred to forced mechanical ventilation in the volumetric ventilation mode with a CO ₂ level of 40 mmHg. according to capnography. Anesthesia was maintained by supplying an inhaled anesthetic of Sevoran to a level of 1.0 MAA in a flow of 0.9 liters of an oxygen-air mixture containing 50% oxygen, with a control of the volume of supply of an inhaled anesthetic according to the level of depth of anesthesia according to the bispectral index. After the start of combined general anesthesia, the patient was given a horizontal position with her head turned in the opposite direction from the operated side. After determining the anatomical landmarks, which were chosen as the tubercle of the VI cervical vertebra (carotid tubercle) and the mastoid process of the temporal bone, then a staining antiseptic - diamond green was drawn on the skin connecting these landmarks and then drew a second line on the skin 1 cm lower and parallel first, and to verify the injection site of the local anesthetic, the transverse processes C ₄ , C ₃ , C _{2 of the} patient’s cervical vertebrae, which are 1.5 cm apart, were determined by palpation. In this case, the countdown began from the patient’s VI cervical vertebra. Then they performed regional anesthesia of the deep and superficial cervical plexuses. Moreover, when blocking the deep cervical plexus, the finger pressure effect was used to reduce the distance from the skin to the bone structures, after which a needle was inserted on the syringe perpendicular to the skin and somewhat caudally until a transverse process was reached with a constant aspiration test due to slight retraction of the syringe plunger to verify the absence blood flow in the syringe. During regional anesthesia of the deep and superficial cervical plexuses, a standard intramuscular needle was used for injection. With a clear sensation of bone structures, an injection of a 0.5% solution of local anesthetic of marcain hydrochloride of 5 ml was performed at each point C ₄ , C ₃ , C ₂ and an additional 5 ml of a solution of local anesthetic of marcain hydrochloride was injected at a point located at the apex of the mastoid process. Then, the superficial cervical plexus was blocked from the point located in the middle of the lateral leg of the sternocleidomastoid muscle of the patient by the introduction of a solution of local anesthetic marcaine hydrochloride in a volume of 15 ml under the specified muscle fan-shaped, 4-5 ml in each direction from one point, the first and subsequent injections were performed to the depth of a normal intramuscular needle perpendicular to the sternocleidomulus with the obligatory performance of an aspiration test. Tissue infiltration was carried out in 5 ml in each direction on the reverse needle stroke. After the operation began, the patient did not respond to pain stimuli (skin incision, carotid artery secretion), which was confirmed by the bispectral index (45 units), which indicated an adequate level of anesthesia. At the time of work in the vegetatively sensitive region of the carotid artery (the sympathetic trunk runs along the posterior surface), an increase in the heart rate from 67 to 82 beats was noted. in 1 min and an increase in systolic blood pressure from 130 to 155 mm Hg The level of adequacy of anesthesia was confirmed by bispectral index data (50 units). In this case, the dose of nitroglycerin was increased from 0.3 μg / kg / min to 1 μg / kg / min. After changing the parameters of the infusion of vasoactive drugs, the heart rate was 74 beats. in 1 min, and systolic blood pressure was determined at the level of 130 mm Hg. At the same time, the bispectral index data remained the same 52 units, at an adequate level of anesthesia, which in turn confirmed that hemodynamic changes were associated with activation of the sympathetic zone of carotid artery innervation. At the time of measuring retrograde pressure, which indirectly indicates an adequate level of compensation of cerebral blood flow, at the time of carotid clamping, the injection of a mesatone vasopressor solution was not required, which with standard general anesthesia is a necessary condition for creating pharmacological arterial hypertension. The further course of anesthesia is smooth.

After the start of blood flow through the carotid artery, the amount of inhaled anesthetic was reduced from 0.8 MAC to 0.2 MAC. In this case, the patient appeared spontaneous breathing. In this regard, the spontaneous ventilation mode was selected. A decrease in MAC led to an increase in central nervous system activity, which, according to the bispectral index, corresponded to 86 units. The transition to a superficial level of anesthesia and the appearance of muscle activity in the patient made it possible to evaluate its neurological status. The appearance of movement in the extremities with contralateral side surgery was noted, which confirmed the absence of a neurological deficit.

At the time of muscle suturing and neck platysm, the inhalation anesthetic was turned off, but the flow of the air-oxygen mixture was kept at 0.8 L per min, while the MAC was at 0.1, and the bispectral index was 78 units. At the beginning of skin suturing, the flow of the air-oxygen mixture was increased to 8 liters in 1 min. The patient was extubated 1 min after the end of surgery.

There is no neurological deficit, blood pressure 130/70 mmHg, heart rate 62 in 1 min, no pain. After transferring the patient to the intensive care unit, hemodynamic parameters remained stable, pain was absent for 9 hours after surgery with stable hemodynamics and a clear consciousness of the patient.

A stable linear blood flow velocity in the middle cerebral artery was achieved, an increase in intracranial pressure was prevented, a decrease in cerebral perfusion pressure was prevented, and at the same time, adequate protection against surgical aggression was ensured while maintaining the stroke volume of the heart and blood pressure.

Claims (4)

1. The method of combined general anesthesia in combination with blockade of the deep and superficial cervical plexuses during carotid endarterectomy or resection of the internal carotid artery during pathological deformation, including performing a deep blockade of the cervical plexus in combination with general anesthesia, characterized in that before the regional blockade is deep and superficial cervical plexuses carry out sedation, which consists in taking the patient on the eve of the operation per os phenazepam tablets at a dose of 0.0005-0.001 g and in the morning on a day surgery, 30 minutes before surgery, the patient is injected intramuscularly with diazepam at a dose of 10 mg in combination with narcotic analgesic fentanyl at a dose of 100 mcg and after 30 minutes, after which the patient’s ECG is monitored in the operating room with a calculation of the heart rate, plethography with saturation of arterial blood , non-invasive blood pressure, and also carry out neuromonitoring after applying electrodes to the frontal region of the patient according to the bispectral index or entropy, then after peripheral catheterization of the patient's central or central vein, infusion therapy is carried out by intravenous administration of Ringer's solution or physiological saline of sodium chloride in a volume of 500 ml and inotropic therapy is started with 200 mg of dopamine hydrochloride diluted in 40 ml of saline in an initial dose of 5 μg / kg / min, cardiotropic therapy by intravenous administration of a 0.5% solution of nitroglycerin in an initial dose of 0.3 μg / kg / min, the peripheral vascular resistance is maintained by intravenous administration of a 10 mg solution a hezatone diluted in 50 ml of physiological saline with an initial infusion rate of 0.3 μg / kg / min, then, at a heart rate of not more than 80 beats per minute, induction in anesthesia is started by intravenous injection of a propofol solution in a dose of 0.5-1 mg / kg, or sodium thiopental at a dose of 1.5-4 mg / kg, or by inhalation of sevoran until the level of anesthesia is reached according to the bispectral index or entropy within 40-60 units, and analgesia is achieved by intravenous administration of a 0.005% solution fentanyl at a dose of 5 mcg / kg, mi Plegia is provided by intravenous administration of a non-depolarizing solution of nimbeks muscle relaxant at a dose of 0.15 mg / kg or trakrium at a dose of 0.5-0.6 mg / kg, or esmeron at a dose of 0.3 mg / kg, and after 90-100 s they are intubated the patient’s trachea and transferred to forced mechanical ventilation in the volume ventilation mode with a CO ₂ level in the range of 35-45 mm Hg. according to capnography, the maintenance of anesthesia is carried out by supplying an inhaled anesthetic of sevoran or isoflurane to a level of 0.8-1.0 MAC in a stream of 0.8-0.9 l of an oxygen-air mixture containing 50% oxygen with a control of the volume of supply of an inhaled anesthetic according to the level of anesthesia according to the indicators of the bispectral index or entropy, then before performing regional anesthesia of the deep and superficial cervical plexuses, the anatomical landmarks of the patient's cervical plexuses are determined, while the first reference point is determined the cusp of the VI cervical vertebra (carotid tubercle) is used, the mastoid process of the temporal bone is used as a second reference point, after which a line connecting these reference points is drawn on the skin with a sterile marker or staining antiseptic, then a second line is drawn 1 cm lower and parallel to the first, and for verification injection site local anesthetic determined by palpation transverse processes C _4, C _3, C ₂ vertebrae that are spaced 1.5 cm apart, with the count start from C ₆ vertebra is then performed regional anesthesia glubokog and superficial cervical plexuses, and when the deep cervical plexus is blocked, the finger pressure effect is used to reduce the distance from the skin to the bone structures, after which the needle is inserted perpendicular to the skin and somewhat caudally until the transverse process is reached with a constant aspiration test due to slight tightening the piston of the syringe, and in the absence of blood in the syringe with a clear sensation of bone structures, an injection of a 0.5% solution of local anesthetic marcaine hydrochloride is performed 5-7 ml of horida or napropa hydrochloride at each point of C ₄ , C ₃ , C ₂ , and an additional 5-7 ml of a solution of local anesthetic of marcaine hydrochloride or napropin hydrochloride is added to the point located at the top of the mastoid process, and then the superficial cervical is blocked plexus from a point located in the middle of the lateral leg of the sternocleidomastoid muscle (sternocleidomastoid muscle) by the introduction of a solution of local anesthetic marcaine (bupivacaine) hydrochloride or napropin (ropivacaine) hydrochloride in a volume of 15 ml under the specified muscle fan 4-5 ml in each direction from one point, and the first and subsequent injections are performed to the depth of a normal intramuscular needle perpendicular to the sternocleidomastoid muscle. 2. The method according to claim 1, characterized in that the prevention of vagal effects is carried out, in the absence of contraindications, the introduction of a 0.1% solution of atropine sulfate in a dose of 0.3-0.5 mg. 3. The method according to claim 1, characterized in that as a coloring antiseptic when determining the anatomical landmarks of the cervical plexuses, a sterile marker, potassium antiseptic iodide or brilliant green are used. 4. The method according to claim 1, characterized in that when conducting regional anesthesia of the deep and superficial cervical plexuses for injection, a 10 ml syringe and a 22 G needle or a standard intramuscular needle are used.