Multimodal approach to perioperative protection in children in abdominal surgery: A prospective comparative study

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Abstract

OBJECTIVE: To increase the effectiveness of perioperative protection by using combined multimodal analgesia (CMA) with epidural blockade (EA) with bupivacaine in combination with low-flow anesthesia with sevoflurane in traumatic abdominal surgery in children.

MATERIALS AND METHODS: A prospective comparative study was conducted (n=102, from 1 to 17 years). Surgical planned pathology: Hirschsprung disease, Ledd and Payr syndrome, liver echinococcosis, enterocystoma, pancreatic cyst. Study period: 2018–2022. Patients were divided into two groups depending on the technique of anesthesia and management of the postoperative period. Group 1 (n=55) received CMA + EA with bupivacaine 0.5%. In the postoperative period — prolonged EA with bupivacaine 0.25% 0.5–1 mg/kg. Comparison group 2 (n=47) — traditional general anesthesia based on opioids. For the treatment of postoperative pain syndrome (PPS) — promedol 0.3 mg/kg. The effectiveness of perioperative analgesia in pediatric abdominal surgery, the time of development and intensity of postoperative pain syndrome were evaluated.

RESULTS: The data obtained as a result of the study clearly showed that the advantages lie behind the optimized method of combined multimodal analgesia CMA + EA with bupivacaine 0.5%. In general, the effectiveness of CMA in combination with epidural analgesia in the intraoperative period was quite high. Additional intraoperative administration of fentanyl was registered in 8 (14.5%) of cases. The stability of hemodynamic parameters and neuroendocrine status was noted in almost all patients of the main group. Analyzing the time of development and intensity of PPS, it can be argued that patients of group 1 had better indicators: the duration of the pain-free period was 2 times longer and the intensity of PPS was lower than in children of group 2. Motor blockade gradually resolved in patients on average, after 209±46 minutes. By this time, there was a recovery of the sensation of a pinprick and motor activity in 32 (58.1%) of patients according to the Bromage <2 scale. Analysis of the results of an oral survey of patient satisfaction with pain relief conducted 24 hours after surgery showed that in group 1 the number of cases 43 (78.1%) satisfied with the level of pain relief was 1.5 times higher compared to the control group 24 (51.1%).

CONCLUSION: Combined multimodal analgesia in combination with epidural blockade with bupivacaine in traumatic abdominal surgery in children provides sufficient perioperative stability of the hemodynamic and neuroendocrine status, significantly reduces the pharmacological burden, reduces complications, early activation of patients and rapid postoperative rehabilitation compared to the traditional method.

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ADDITIONAL INFORMATION

Funding source. This article was not supported by any external sources of funding. Competing interests. The authors declare that they have no competing interests. Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. G.Z. Ashurova — data collection and analysis, text writing; E.A. Satvaldieva - writing the text, editing the article. A.I. Fayziev - statistical processing of results, analysis of literary sources.

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About the authors

Elmira A. Satvaldieva

National Children’s Medical Center; Tashkent Pediatric Medical Institute

Author for correspondence.
Email: elsatanest@mail.ru
ORCID iD: 0000-0002-8448-2670
SPIN-code: 9896-8364

MD, Dr. Sci. (Med.), Professor

Uzbekistan, Tashkent; Tashkent

Otabek Ya. Faiziev

Tashkent Pediatric Medical Institute

Email: fayziev.otabek@mail.ru
ORCID iD: 0000-0003-0847-3585
SPIN-code: 1925-0828

anesthesiologist-resuscitator

Uzbekistan, Tashkent

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Supplementary files

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2. Fig. 1. Changes in hemodynamics at the stages of anesthesia in patients of the 1st group.Note. Here and in Fig. 2: * — significance of differences at p <0.05, ** — significance of differences at p <0.01 compared with outcome. Here and in Fig. 2–5: УПС — specific peripheral resistance, ЧСС — heart rate, УО — stroke volume, СрАД — mean arterial pressure.

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3. Fig. 2. Changes in hemodynamics at the stages of anesthesia in patients of the 2nd group.

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4. Fig. 3. Comparative dynamics of cortisol in the blood at different sites of anesthesiaNote (here and in Fig. 4, 5). * — significance of differences at p <0.05 compared with the outcome.

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5. Fig. 4. Comparative dynamics adrenaline in the blood at different sites of anesthesia.

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6. Fig. 5. Changes in blood glucose levels at the stages of the study in children of both groups.

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