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Vol 14, No 2 (2020)
Editorials
Analgesia or analgesia? Discussion about terms
Abstract
Not so long ago, during the discussion of the next issue of our journal, Professor E.M. Shifman raised the issue of the uniformity of spelling of various terms, in particular, he drew attention to the fact that different authors write differently the key word "analgesia" for our topic. A discussion arose - how is it correct, with a soft sign or not? Executive Secretary, Professor V.A. Koryachkin spoke in favor of writing without a soft sign, referring to the fact that there is no consensus, some philologists are for the soft sign, others are against. Both options are available in fundamental dictionaries.
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Reviews
Anaesthetic care of patients undergoing primary hip and knee arthroplasty: evolution of views
Abstract
Operations of total hip arthroplasty (THA) and knee joints (TKA) are among the most frequently performed surgical interventions. At the same time, there is still no consensus regarding the choice of the optimal method of anesthesia for these operations. The review analyzes the approaches to the anesthetic provision of THA and TKA in different countries and different clinics of the same country. The tendencies of a gradual increase in the share of neuraxial anesthesia techniques in the structure of anesthesia for THA and TKA are presented. Based on a number of large population studies, an analysis of the effect of the anesthesia method on the early postoperative period and the results of surgical treatment in general is given. The positive role of epidural and spinal anesthesia, in comparison with general anesthesia, in the complex of anesthetic management of operations on the joints of the lower extremities has been shown.
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Original study articles
Programmed intermittent epidural boluses (pieb) for labor analgesia: study of the sensor block and effects on maternal motor function
Abstract
Background. Programmed intermittent epidural boluses (PIEB) technique is a promising approach that demonstrates certain advantages over traditional techniques of epidural analgesia. We compared the dynamics of the sensory block of PIEB + parturient-controlled epidural analgesia (PCEA) with continuous epidural infusion (CEI) + PCEA for maintenance labor analgesia and the incidence of motor block (MB) in women who received PIEB or traditional techniques.
Methods. A total of 165 subjects were studied. All parturients were divided into five groups: manual boluses, PCEA, PCEA + CEI, PIEB + PCEA; levobupivacaine 0.25 mg/mL; 1.25 mg/mL; 0.625 mg/mL. The level of the MB was evaluated by the classic Bromage scale (0-1-2-3). The level of the sensor block was evaluated by the pin-prick test.
Results. MB was reported in 80% in group 1 120 min after analgesia, 78% and 52% in groups 2 and 3 at the 150th min (p < 0.001); in group 4, the MB frequency was 6% 15 min after the start and was increasing to 40% at full cervical dilation (p < 0.001). In group 5, the relative MB frequency did not exceed 10% at the 120th min and was 0% at full cervical dilation (p < 0.00001). The results indicate that in the PIEB group, the level of sensory block in patients was higher 15 min after the start of analgesia and remained so until the end of the observation period [median PIEB Th5 versus Th8 in the CEI group, (p < 0.0004)].
Conclusions. PIEB + PCEA technique maintained a consistently high level of sensor block throughout the study compared to PCEA + CEI, which ensured effective analgesia in the first and second stages of labor with minimal MB.
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Relationship between catechol-o-methyltransferase gene polymorphism and pain syndrome in breast cancer patients
Abstract
The goal of the study was to explore the influence of single-nucleotide polymorphisms of the COMT gene on the formation and features of pain syndrome, the level of anxiety, and the need for narcotic analgesics in patients with breast cancer.
Materials and methods. The intensity of pain and opioid consumption in the postoperative period were evaluated in 58 patients who met the inclusion criteria of the study and were operated for breast cancer. The frequency of chronic pain syndrome after mastectomy was studied in the same group of patients after a year by using short pain questionnaires, McGill Pain Questionnaire and PainDetect. The anxiety level was assessed by using the HADS questionnaire. Genotyping was performed for single-nucleotide polymorphisms, rs4680, rs740603, rs2097603 = rs2070577, rs4633, of the COMT gene localized in the 22q11.21 region in the studied group of patients. The relationship between the carrier of different genotypes and the intensity of acute and chronic pain, the severity of the pain rating index for sensory and affective characteristics, the presence of a neuropathic component of pain, and the severity of anxiety were studied in the entire sample. The use of narcotic analgesics was evaluated in the postoperative period (IU/day and IU/course) and for the relief of chronic pain.
Results. It is shown that the intensity of postoperative pain and the severity of anxiety do not depend on the presence of a mutant allele for the studied polymorphisms of the COMT gene, while the postoperative consumption of opioids in patients with the rs4680 missense mutation in the exon of this gene is significantly less. The dependence of the intensity of chronic pain syndrome and the severity of anxiety on the presence of a mutant allele for the polymorphic locus rs4680 localized in the exon of the COMT gene was established. No significant relationship was observed between the mutant alleles and the use of opioids for chronic pain relief after mastectomy.
Conclusion. Genotyping for the COMT gene polymorphisms can be useful for choosing the optimal tactics of pain management in patients with breast cancer.
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The optimal method of anesthesia for transurethral resection of a lateral bladder wall
Abstract
In our prospective randomized study, 130 patients underwent a transurethral resection (TUR) because a neoplasm was located on the side wall of the bladder. In the neurostimulation (NS) group (n = 50), a spinal anesthesia with an obturator nerve block was made under the control of a neurostimulation; in the ultrasound (US) + NS group (n = 50), a spinal anesthesia with an obturator nerve block was made under the double control of ultrasound navigation and neurostimulation; in the general anesthesia (GA) group (n = 30), a general anesthesia with a deep myoplegia was made.
Results: The obturator nerve reflex was recorded for three (6%) patients from the NS group (p < 0.001); it caused a bladder perforation in one patient. The frequency of a sinus bradycardia in the NS (18%) and US + NS (20%) groups was lower than in the GA (43%) group, p = 0.008. Arterial hypotension was observed only in the OA group for 8 (27%) patients (p < 0.001). In the NS and US + NS groups, the patient’s time in the surgery room was significantly less (p < 0.001) than in the OA group averaging 48.36 ± 17.58 min and 50.82 ± 23.6 min, respectively.
Conclusion: The combination of a spinal anesthesia with obturator nerve block under the dual control of an ultrasound navigation and a neurostimulation can be considered as a reliable and safe method of an anesthetic maintenance of the TUR on the wall of the bladder. If it is impossible to provide such a control over the implementation of the blockade, it is necessary to resort to a GA with a deep myoplegia.
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Double-blind randomized study of lidocaine, bupivacaine, levobupivacaine, and ropivacaine myotoxicity in rats
Abstract
Background. Myotoxicity of local anesthetics in a clinical practice was revealed at various types of regional anesthesia. The degree of functional recovery of damaged muscles and the length of time before the recovery differ significantly in different studies. Despite the generally accepted opinion about the anti-inflammatory effect of local anesthetics, a number of experimental studies have shown that an inflammatory reaction developed at the place of injection into a muscle tissue.
Material and methods. A double-blind randomized study was conducted on 800 rats. A control group was formed whose members were introduced with 0.9% sodium chloride solution. Lidocaine concentrations under the study were 0.5%, 1%, 1.5%, 2%; bupivacaine, ropivacaine – 0.25%, 0.5%, 0.75%, 1%; ropivacaine – 0.25%, 0.5%, 0.75%. A 0.2-mL drug was injected into the biceps muscle under the ultrasound control. The sampling of drugs was as follows: stage 1 was in 1 h after the injection, stage 2 was in 2 days, stage 3 was in 7 days, stage 4 was in 14 days, stage 5 was in 21 days. Signs of an inflammation and damage of a muscle tissue were examined.
Results. An injection of a saline solution to laboratory animals of the control group caused the expansion of intercellular spaces and connective tissue partitions. There were no signs of cell necrosis or apoptosis. The injection of local anesthetics within an hour caused an inflammatory infiltration and a damage to a muscle tissue. The data of pairwise comparisons showed that at the stages of 1 h and day 2 in all the studied groups, the severity of a damage and an inflammation was greater than in the control group with the introduction of 0.9% sodium chloride solution. Then, there was a decrease in signs of a damage and an inflammation. At the stage of day 21, there were no statistical differences in comparison with group 1 in any of the study groups. The dependence of the appearances of damage or inflammation in a muscle tissue on the concentration of a local anesthetic was determined by an ordinal regression model. The regression model indicators were significant. They allowed us to describe 87% for damage and 95% for inflammatory changes.
Сonclusion. The toxicity of local anesthetics appeared as a damaging effect and development of an inflammatory infiltration. Local anesthetics were toxic in all studied groups with all concentrations. The higher the concentration of the anesthetic, the more expressed was the damaging effect and the development of signs of the inflammation. The maximum development of the damaging effect was at the stages of hour 1 and day 2 of the study, then there was a decrease in signs of myotoxicity, and by 21 days, the signs of damage and inflammation completely disappeared. The comparative analysis did not reveal any statistical differences that allow us to expressly form a rating from the most to the least myotoxic drug.
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Dynamics of perioperative changes in hemostatic potential according to low-frequency piezoelectric thromboelastography data in open transvesical prostatectomy under epidural analgesia
Abstract
Background. The anesthetic technique of choice for urological surgeries is a controversial issue, especially for transvesical prostatectomy for patients with benign prostatic hyperplasia (BPH). Often, epidural anesthesia and analgesia are considered as the methods of choice. However, the effect of an anesthetic support on perioperative changes in hemostatic potential has been poorly studied.
Aim. The aim of the study was to demonstrate the dynamics of changes in the system of the aggregate blood state regulation by using an instrumental method, a low-frequency piezoelectric thromboelastography (LFPTEG), in the perioperative period for patients with BPH who will undergo transvesical prostatectomy.
Material and methods. The state of the hemostatic system in a group of 71 patients with confirmed BPH who required a transvesical prostatectomy was evaluated by the APC ARP-01M “Mednord” device at the time of the admission, 30 min after the effect of an epidural anesthesia, an hour after the end of a surgery and a day after a surgery.
Results. A perioperative dynamic monitoring of the state of a hemostatic balance showed that a preoperative hypercoagulation, compensated by an increased fibrinolysis, was replaced by a normocoagulation at the moment of a surgery, which was observed in the first hour after the end of a surgery and retained until the end of the first day.
Conclusion. Hypercoagulation was found out for patients with BPH before a transvesical prostatectomy that was masked by an activation of the fibrinolytic system. The hemostatic potential assumed values identical to the reference values that should be taken into account prescribing a postoperative thromboprophylaxis against the background of a prolonged epidural blockade. The APC ARP-01M “Mednord” device allows you to assess all parts of a hemocoagulation at each stage of a perioperative treatment quickly and without high material costs.
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