Vol 17, No 2 (2023)

The authors analyzed studies on the issues of perioperative analgesia in hip and hip joint surgery. Based on the analysis, modern recommendations are presented regarding the choice of optimal anesthetic techniques for proximal femoral fractures and hip arthroplasty. Early surgical intervention in older patients contributes to the restoration of the supporting function of the limb, enables rapid rehabilitation, and reduces the risk of life-threatening complications. This requires pain relief for preoperative preparation and high-quality intraoperative and postoperative pain relief, allowing early rehabilitation of the patient. The review included materials from recent congresses, and webinars of the European Society of Regional Anesthesia & Pain Treatment. According to many authors, ileofascial blockade is the method of choice for preoperative anesthesia for proximal femoral fractures. Variants of the blockades of the branches of the lumbar and sacral plexuses in various anatomical spaces and plane blocks are considered. In addition, recommendations of the PROSPECT group (Procedure Specific Postoperative Pain Management) on the use of various technologies in the perioperative period are considered based on data from multicenter randomized trials and meta-analyses in relation to a specific procedure. The effectiveness of new approaches to the branches of the lumbar plexus was also considered, for example, suprainguinal ileofascial blockade and blockade of the pericapsular nerves. Anesthesiologists have used relatively new and traditional tools available to reduce pain and speed up postoperative recovery for patients with injuries and undergoing surgery for the proximal femur. Although the effectiveness of not all of them is confirmed by evidence-based medicine, clinical practice shows a positive effect on their use.

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.

BACKGROUND: Diode-laser transscleral cyclophotocoagulation (DLTCPC) is one of the most commonly used treatment options for intraocular pressure reduction in refractory glaucoma in adult and pediatric patients. To achieve the necessary effect, these operations often have to be repeated. Repeated general anesthesia inductions increase the risk of cognitive disorders in children and sometimes do not provide sufficient postoperative analgesia.

OBJECTIVE: To analyze the results of transscleral DLTCPC in children under regional anesthesia and identify factors predisposing to the choice of this anesthesia method.

MATERIALS AND METHODS: The study included 33 children aged 10–17 years who had undergone 57 transscleral DLTCPCs in IRTC Eye Microsurgery Ekaterinburg Center between 01.09.2017 to 31.08.2022. In each case, the anesthesia method was selected individually according to the principle of reasonable sufficiency.

RESULTS: Of 57 operations, 36 (73%) were performed under regional and 21 (37%) were under general anesthesia. Factors that favor regional anesthesia include (1) psycho-emotional maturity of the patient, (2) older age, and (3) greater number of previous operations. An algorithm for the selection of the anesthesia method is presented, as well as a plan for the conversation with the patient and his / her legal representatives. Regional anesthesia provides good intra- and postoperative anesthesia and prophylaxis of postoperative cognitive disorders in children who are emotionally stable and suitable for this type of anesthesia.

CONCLUSION: Considering the psycho-emotional features of children, general anesthesia remains the main method in ophthalmic anesthesiology. Nevertheless, following the principle of reasonable sufficiency and accounting for the short duration of DLTCPC and the large extent of general anesthesia survived by these children previously, regional anesthesia can be successfully used in a portion of these children.

BACKGROUND: For extended blockade of the brachial plexus from the supraclavicular access, the catheter is fixed in the supraclavicular region. Owing to the anatomical features of the supraclavicular fossa and the short inner part of the catheter, this fixation method cannot be fully considered reliable and convenient both for the personnel operating the catheter and the patient. The most convenient place for fixing the catheter is the infraclavicular region because of its flat surface. If a catheter is installed to the brachial plexus from the supraclavicular access and the catheter is passed under the skin in the infraclavicular region, then the catheter exit site on the skin will be located further from the surgical intervention area and the inner part of the catheter will be larger.

CLINICAL CASE DESCRIPTION: This study describes a clinical case of blockade of the brachial plexus by interscalene access with catheterization for prolonged analgesia via supraclavicular access and fixation of the catheter under the skin in the subclavian region in an older patient with polymorbidity during surgical treatment of a closed fracture of the middle third of the humerus. In anesthetic provision, when inducing brachial plexus blockade via a supraclavicular approach, the catheter was fixed in the subcutaneous tunnel of the infraclavicular region for prolonged blockade of the brachial plexus.

CONCLUSION: This fixation method prevented internal and external dislocation of the catheter, which contributed to high-quality and long-term postoperative analgesia, early patient activity, and absence of infectious complications and created comfortable conditions for the handling of the catheter for both the medical staff and the patient.