Vol 11, No 4 (2017)

The Aristotle score: a complexity-adjusted method to evaluate surgical results. For an assessment of dynamics of quality of the provided cardio-surgical help, comparison of a perioperative case rate and a mortality depending on the degree of surgical risk at cardiac interventions the Aristotle score is used. Thoracic epidural anesthesia (TEA) in comparison with high-opioids intravenous anesthesia (IVA) contributes to hemodynamics stability and early activation of patients. Objective: To analyze a current of the perioperative period at cardiac interventions in children with various categories of complexity of surgical intervention on «Aristotle score» depending on a type of anesthesia. Materials and methods. The 139 children with congenital heart diseases (CHD) underwent surgical correction. Patients were treated in Federal State Budgetary Institution of the Russian Ministry of Health (Penza), and «Almazov National medical research Centre» from 2008 to 2017 yrs. Patients (139 people, the mean age M (SD) of 7.6 (5.6) months of life) were divided into groups according to the categories of operational complexity presented in the Aristotle score. The group 1 consisted of 85 (61.2%) patients underwent interventions of second category of complexity, the group 2 consisted of 49 (39.8%) patients underwent interventions of 3 and 4 categories of complexity. Results. In cardiosurgical operations of the 2nd category of the Aristotle scale complexity a significant positive effect of TEA on the perioperative period was revealed in the form of a decrease in the severity of intraoperative heart failure and the level of glycaemia, the total number of postoperative complications and the time of patients’ staying on mechanical ventilation, as well as the duration of ICU stay and the decrease thrombocytopenia severity and frequency. In operations of grade 3 and 4, in which the duration of extracorporeal circulation was greater, the use of TEA did not have a significant positive effect on the incidence of postoperative complications, but after epidural anesthesia the mean duration of the patients’ stay on the mechanical ventilation and in the ICU was also significantly less. Apparently, the result is a consequence of a lesser severity of heart failure and early activation of patients by excluding the use of opioids, which have a depressing effect on the central nervous system, cardiac, respiratory and other systems. It can also be assumed that the administration of local anesthetics within 24 hours after the operation maintained sympatholytic and antiarrhythmic effects, and also prevented the complications development as a result of effective analgesia. Sufficiently convincing evidence of high antinociceptive activity of TEA is the possibility of safe extubation of patients in both the 2-d and 3-d categories of surgical complexity demonstrated in our study already in the operating room. Conclusion. Use of high TEA as a component of the combined anesthesia at surgical correction of CHD in young children has positive impact on a current of the perioperative period in the form of decrease in severity of heart and respiratory failure, duration of respiratory support, early activation and reduction of ICU stay.

One of the approaches to increasing the effectiveness and safety of postoperative analgesia can be its personification. The goal of the study was to evaluate the efficacy of tramadol analgesia depending on the polymorphisms of the CYP2D6 gene, the cytochrome P-450 isoenzyme, involved in drug biotransformation into the active metabolite. 96 patients with elective endoscopic gynecology procedures were examined. Polymorphisms G1846A and C100T, which reduce the activity of the isoenzyme CYP2D6, were detected, and the intensity of postoperative pain, the autonomic nervous system state by cardiointervalography and hemostasis using rotational thromboelastometry were evaluated. Polymorphisms were detected in 29 (30.2%) patients, united in the 1-st group. The second group consisted of 67 patients without gene polymorphisms. Patients with polymorphisms have a higher pain scores; the frequency of postoperative nausea and vomiting, on the contrary, was significantly lower. According to cardiointervalography, sympathicotonia was observed in Group 1 patients after surgery, while in Group 2 patients the indices did not change significantly compared to baseline. The parameters of hemostasis in patients of the 2nd group were characterized by moderate hypercoagulability (shortening of clotting time and clot formation time), whereas in the firsts group, relative hypocoagulation (decrease in α angle, and clot firmness) was noted. Conclusion. In female carriers of G1846A and C100T polymorphisms of the CYP2D6 gene, the effectiveness of post-operative analgesia based on tramadol is reduced. They have a lower incidence of postoperative nausea and vomiting, and moderate hypocoagulation. Probably, these phenomena are associated with a change in the ratio between the drug and its active metabolite - O-desmethyltramadol.

Material and methods. In group 1 (20 patients) the blockade of the sciatic nerve was performed subgluteal access; in group 2 (20 patients) - subgluteal access to soft tissue compression in the projection of the sciatic nerve for 3-5 cm distal to the injection site; gluteal access is blockade of the sciatic nerve - in the third group (20 patients). All of the blockade of the sciatic nerve was performed by administering 30 mL of 1% lidocaine (epinephrine 1: 200 000). Sensory block was evaluated in the foot, ankle, lower leg, popliteal fossa and hamstring. A total of 60 patients. Also, in addition to the blockade of the sciatic nerve was performed femoral nerve blockade. Results. Complete motor and sensory block of the sciatic nerve occurred in all 60 patients of the 1st, 2nd and 3rd groups. In group 1, a full block back femoral cutaneous nerve and the popliteal fossa region did not develop in any patient. In 19 patients in group 2 developed a full suite of «+» posterior femoral cutaneous nerve. In 1 patient in group 2 block PFCN was assessed as partial «+». In all patients, the third group developed a full suite of «+» PFCN. Conclusion. When the sciatic nerve blockade subgluteal access full sensor unit is not developed in the popliteal fossa and hamstring. When the sciatic nerve blockade gluteal access sensor unit is developing in the area of the foot, lower leg, popliteal fossa and hamstring. Our method wire blockade of the sciatic nerve and PFCN «2-in-1» from subgluteal access can achieve the touch in the foot, lower leg, popliteal fossa and hamstring.

Objective: to evaluate the effectiveness of peripheral nerve blockades innervating the scalp, in combination with general anesthesia in intra- and postoperative analgesia in patients with neurosurgical interventions. Materials and methods. The efficiency of 105 blockages of the peripheral nerves of the scalp in 18 patients with neurosurgical interventions on the head was evaluated. The age of the patients was 47.5 ± 15.5 years. Patients were operated on for intracranial traumatic and non-traumatic hematomas, brain tumors and the need for plastic of postoperative skull defects. The technique of blockade of the nerves of the head is described: supratrochlear, supraorbital, zygomaticotemporal, auriculotemporal, greater auricular, greater and lesser occipital nerves. The technique of ultrasound imaging of the great occipital and auriculotemporal nerves is presented. Results. In all 18 patients, according to intra- and postoperative monitoring, adequate anesthesia was provided. In 2 of 18 patients, an additional fentanyl injection was required to skin incisiondue to an increase in blood pressure and heart rate by 25% of the baseline values, and an increase in CSI until 82 units. The volume of local anesthetic for blockade in one patient was 7.68 ± 1.67 ml of ropivacaine or of bupivacaine. Time for blockade in one patient was 11.4 ± 4.0 minutes. The intensity of pain on a linear visual analog scale in the first day was 0.3-2 points. Conclusion. Blockages of the peripheral nerves of the head were effective in 16 (88.9%) of 18 patients. The safety of blockades was provided by using small volumes (7.68 ± 1.67 ml ) of 0.75-1.0% solution of ropivacaine or 0.5% solution of bupivacaine.