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THE NON-OPIOID ANALGESIC NEFOPAM IN ANESTHESIA GUIDE IN SURGICAL INTERVENTION IN ONCOPROCTOLOGY

Авторы:
Город:
Ростов-на-Дону
ВУЗ:
Дата:
12 декабря 2018г.

Intraoperative analgesia is one of the most important components in the intensive care system of a surgical patient. On the part of the doctor, anesthesia is not only a manifestation of a humane attitude to the patient, but also a consequence of understanding the mechanisms of pain as a powerful factor of negative impact on the basic functional parameters of the body. Despite the fact that epidural anesthesia has been used in anesthesiology for a long time, the quality of their technology can not be considered ideal[1,2,6]. The very technique of epidural anesthesia is almost impossible to improve [1,7,10]. However, using new anesthetics and accompanying preparations, it is possible to significantly improve the quality of epidural anesthesia. Of particular interest to improve the quality of epidural anesthesia is not narcotic analgesic Central action akupan (international name: nefopam; (3,4,5,6-tetrahydro-5-methyl - 1-phenyl-1H-2,5-benzoxazocine hydrochloride) — non-narcotic analgesic, structurally not similar to other analgesics [3]. This analgesic is not an opioid analgesic of Central action. Nefopam in clinical studies showed a positive effect relative to postoperative analgesic action, and has no anti-inflammatory or antipyretic action, does not inhibit breathing and does not affect intestinal peristalsis, has a slight anticholinergic effect [3,8]. Considering that the conduct of epidural anesthesia is very often muscular tremors, acupan is of interest and in terms of effectiveness edema [6,8,9].

Objective: to determine the use of non-opioid analgesic nephopam in anesthetic practice and in the early postoperative period after cancer surgery.

Material and methods: we investigated the use of the drug akapana when conducting epidural anesthesia was performed in 2014-2017 in the surgical Department of the city of Coloproctology center. According to the results of treatment of 97 patients operated in the surgical Department of the city Coloproctology center, including 54 men and 43 women aged 21 to 78 years. Patients were done the following operations under epidural anesthesia: anterior-posterior resection of the rectum (23); abdominoperineal extirpate rectum (33); transanal resection of the rectum with preservation of the Sphynx (28); transanal removal of benign tumors of the rectum (18). The patients were randomized into three groups of 34 people by double-blind method. In group 1, before epidural anesthesia on the operating table after vein puncture and water load creation, a single recommended dose of acupan — 20 mg was administered intramuscularly, after which an epidural anesthesia with bupivacaine was performed, 1 ml of Dimedrol was administered intravenously [10]. After intramuscular administration at a dose of 20 mg, the maximum concentration of acupuncture in the blood serum is determined after 30-60 min — 25 ng/ml, the half — life of the acupuncture is 5h (the firm annotation to the drug akupan). In the 2nd group on the operating table after vein puncture and water load creation, epidural anesthesia with bupivacaine was performed, 1 ml of Dimedrol, 1 ml of atropine, 1 ml of 2% solution of promedol, 1-2 ml of 0.5% solution of sibazone were intravenously injected [1,10]. In the 3rd group on the operating table after vein puncture and water loading, epidural anesthesia with bupivacaine was performed, 1 ml of Dimedrol, 1 ml of atropine were intravenously administered [1,3,10].. The quality of anesthesia was assessed by the severity of pain, sedation level, glucose and cortisol levels, hemodynamic parameters and pulse oximetry in intraoperative and postoperative period. To assess the effectiveness of analgesia, indirect measurement of analgesia quality was used on the visual analog scale of pain (VAS) [8,9]. The patient was offered to make a mark on the value of a 10-centimeter ruler, which corresponds to his level of pain [8]. A value of 0 does not represent pain, and a value of 10 represents the most severe pain. The quality of analgesia in all patients was studied on the operating table and every hour after the operation. The Richmond Agitation Sedation Scale (RASS) was used to assess the level of sedation in the patients under study [8]. Registration of the level of sedation by RASS was carried out on the operating table, as well as every hour after the operation. To assess the stress reaction, cortisol and glucose levels were measured in blood plasma. Blood samples to determine the level of cortisol and glucose in plasma were collected on the operating table before and after surgery, as well as after the restoration of movements in the lower limbs. Cortisol level was determined by enzyme immunoassay (N = 100-660 nmol/l). glucose level was determined by the end point method (N = = 4.2 — 6.0 mmol/l). The statistical analysis was performed using the software Statistica 8.0 Statistically significant difference was considered at a probability of error of the 1st kind for less than 5 % (p < 0.05).

Тhe results of the study and their discussion: the Average age of patients in group 1 was 54 ± 2.0 years, in group 2-38.4 ±4.5 years, in group 3-32.5 ± 1.5 years. The average duration of full recovery of motion in the lower extremities were as follows: in the 1st group and 3.7± 2.4 hours, in the 2nd group and 3.9 ± 2.3 hours in the 3rd group and 3.4 ± 2.1 hours. The groups did not differ statistically significantly. To assess the level of pain in all patients in the intraoperative period and until the movement in the lower extremities is fully restored, the visual- analog scale of pain was used [8]. Patients of the 1st group showed an increase in VASH values from 0.80 ±0.11 points in the intraoperative period to 2.70 ±0.42 points by the time of full recovery of movements in the lower limbs. Patients of the 2nd group noted a tendency to increase the level of pain from 0.20 ± 0.09 to a high of 1.50 ± 0.73 points to the moment of recovery of motion in the lower extremities. In patients of the 3rd group, the level of pain in VAS was 1.80 ± 0.12 points in the intraoperative period and 4.20 ± 0.80 points after the complete restoration of movement in the lower limbs. The following differences between the groups were found in the comparison of sedation levels. Thus, in patients of group 1, the level of RASS sedation during the operation ranged from -1.45 to - 0.88 points, p = 0.0179. Patients of the 2nd group had a deeper level of sedation - from -3.9 to -3.2 points, p = 0.0629. In the analysis, the level of RASS sedation in group 3 ranged from +0.3 to -0.4 points, p = 0.0154. In the study, the level of glycemia in patients of group 1 was a maximum of 7.2 ± 1.1 mmol/l (7.4-8.4), in group 2-6.8 ± 1.9   mmol/l (6.2 — 7.9), in group 3-7.9 ± 0.9 mmol / l (7.4-8.4). When changes of blood glucose levels of statistical znachimye statistically significant differences. By the end of the recovery period of movement in the lower limbs revealed differences were not statistically significant (p = 0.0029). Thus, in the study of the level of cortisol in patients of the 1st group of observation its content was 753.8 ± 328.1 nmol / l (579.0-928.6); 754,0 (620-992,5), in the 2nd group 754,7 ± 323,1 nmol/l (582,5-926,9); 755,0 (605-1025), in the 3rd group, the content of cortisol in plasma amounted to 725,3 ± ± 271,6 nmol/l (580,6-870,0); 737,5 (647,5- 917,5), p = 0,0494 that exceeded the upper limit of normal for this indicator. Heart rate during surgery in the 1st group was 79.2 ± 8,9 beats/min, in the 2nd group and 84.7 ± 9,4 beats/min, in the 3rd group of 91.2 ± 10,2 beats/min. When assessing the presence of muscle tremor during the operation on the principle of "is", "no" in the 1st group of our studies, akupan cupped it in 100% of cases, in the 2nd group muscle tremor was noted in 18.9 ± 2.7% of cases, in the 3rd group muscle tremor was noted in 43.7 ± 5.2% of cases. Because subdural anesthesia is self-sufficient in terms of analgesic effect acupan is of clinical interest and are shown mainly for elimination of muscle tremors. In this case, we have only studied this effect akapana. In our studies with subdural anesthesia acupan eliminated muscular tremor in 100% of cases.

Conclusions: To date, acupan drug relief muscle tremors surpasses the effectiveness of any other known combination of drugs used in epidural anesthesia for the relief of muscle tremors Acupan has quite a pronounced analgesic effect, potentiating the effect of epidural anesthesia, so good anticholinergic effect it can be recommended as the drug of monotherapy with an epidural.



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2. Carl. K. Henwood Clinical anesthesiology /Moscow, BINOM,2011. S. 117 to 120, 212-214, 217-219.

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5.   Rational Pharmacoepidemiology /Guide for practitioners/ Under the General editorship of Acad. RAMS Bunatyan A. A, Professor V. M. Mizikov, Moscow, Izd. "Littera", 2010, P. 99-101, 135-136, 220-225, 289-291.

6. Modig J. Regional anaesthesia and blood loss. // Acta anaesthesiol. "Scand. -1988. -Vol. 32. - P. 44-48

7.   Ranawat C. Effect of hypotensive epidural anaesthesia on acetabular cement-bone fixation in total hip arthroplasty // J. Bone Jt. Surgery. -1991. -Vol.73.