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"Emergency medicine" 5(52) 2013

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Effect ofprolongedperineuralfemoral nerveblockadeonoxygen metabolismin patients with arterialocclusivedisease of the lowerextremities

Authors: B.A. Kabakov - KhMAPE, Department of Anesthesiology, Intensive Care,Transfusiology and Hematology., Ukraine, Kharkov

Categories: Medicine of emergency

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Extended perineuralblockade,oxygenation

Relevance. Arterial occlusive disease of the lower extremities (AODLE) often represents a manifestation of atherosclerosis, which can affect different segments of the arterial tree [12]. According to statistics, AODLE affected 2-3% of the total population that is more than 20% of all types of cardiovascular disease, 5% of middle-aged and elderly, which is 3 - 4% of all surgical diseases [1]. Frequency of occlusive arterial disease of the lower extremities in the older age group may reach 23%, including a 20 - 40% developed chronic critical ischemia of the lower extremities [2, 3, 6]. In the U.S. alone 8.5 million of people aged over 60 years affected. Approximately 50% of them are asymptomatic, and 40% suffer from various degrees of lameness. 10% have critical levels of ischemia, manifested by pain or loss of tissue in the form of incurable ulcers and gangrene [5, 8]. In the last decade number of patients with this disease progressively increasing [11]. Atherosclerosis of major vessels makes more than 20% of all types of cardiovascular diseases, which corresponds to 2 - 3% of the total population of Ukraine [10]. The most typical localization of lesions in atherosclerosis of great vessels is the femoral-popliteal segment [9]. Despite the advances in modern vascular surgery in the treatment of atherosclerosis, there is a high rate of postoperative complications [13]. Most common complication is thrombosis of shunt, which in most cases require repeated reconstructive operations or performance disabling operations amputation [7]. Great importance for the efficiency and prediction of shunt functioning has a state of the distal channel [4].So far there is no unambiguous understanding of the impact of blood flow through the vessels of the lower extremities in patients with AODLE. Purpose of this study was to determine the effect of different methods of anesthesia on tissue oxygenation, and its relationship to vascular resistance and flow rate.

Materials and methods. Study had been conducted in central hospital of south railroad of Ukraine. 64 patients participated. Average age was 62,2 ± 2,1 years. Among the patients were 34 (53.2%) men and 30 (46.8%) women. In all patients on admission to hospital was diagnosed degree of ischemia by Fontaine Pokrovsky, 1954. [8]All patients were blindly separated into two groups of comparison: I (n = 34) - control, II (n = 30) - main. In group I anesthesia was subdural by the standard technique without catheterization at L4-L5 using bupivacaine 0.5% in volume of 3,0 ± 0,2 ml. In II group in addition to subdural anesthesia developed technique of elongated perineural blockade of the femoral nerve was applied. The basis of the method of elongated perineural anesthesia of the femoral nerve is the introduction of local anesthetic of bupivacaine 0.125% in volume of 5,0 ± 0,8 ml for 6 hours with the preset of epidural catheter in the perineural space.All patients underwent bypass of main arteries of lower limb with autoveinor synthetic prosthesis.Duration of surgery was 307,2 ± 19,2 minutes in group I and 319,2 ± 21,4 minutes in group II. Duration of anesthesia was 364,8 ± 12,6 and 376 minutes, 4 ± 18,5 minutes in groups I and II, respectively. Volume of blood loss in groups I and II study was 384,2 ± 11,3 ml and 395,5 ± 10,9 ml, respectively.Patients were randomized by gender, age, degree of ischemia and disease duration. I study group (n = 34) were 21 (61.76%) men and 13 (38.23%) women average age was 63,1 ± 2 years. II study group (n = 30) were 13 (43.33%) men and 17 (56.67%) women average age was 61,3 ± 3 years.

Disease duration was 12,6 ± 0,6 months for the study group I and 13,0 ± 0,7 for II group. Exclusion criteria were: age less than 18 or more than 90 years, the degree of ischemia by Fontaine Pokrovskij below IIa or above III, lack of patient consent. Stages of studies: early surgical approach, imposing a clamp on the artery ischemia period, lifting clamps on the artery, immediately after the transfer to ICU, 1, 2, 3, 5, 7, 14, 28 days. The dynamics of the partial pressure of oxygen (SpO2, rate - 98,0 ± 1,0%) in the affected limb was studied using pulse oximeter on device "Yutas 300M."The method of ultrasonic Doppler (device "EGAS 6PXM") have used to determined speed characteristics of local flow of inferior extremity. Was investigated following quantitative parameters of popliteal artery of affected limb: peak systolic velocity (Vs, 32,3 ± 6,5 cm / s), peak diastolic velocity (Vd, regional rate - 11,4 ± 4 , 1 cm / s), mean velocity (Vm, regional norm - 4,1 ± 1,3 cm / s), Gosling-King pulsatile index (IPgk, regional rate - 11,6 ± 3,8 units). Thus, local characteristics of blood flow have investigated for objectification of their dynamics in the postoperative period.

Conclusions. 1. Pathophysiological consequences ofoccluive pathology of lower limb arteries are closely related to hypoxia of peripheral tissues. Applicationthe proposed technique of elongated perineural blockade in the perioperative period have improved oxygenation of tissues which are located distal to the operated occlusion. In addition, the recovery of oxygen metabolism in II group happened in the first postoperative day, while in I group only on the twenty-eighth day.

2. Applicationthe proposed technique of elongated perineural blockade of the femoral nerve, due to prolonged sympathetic block, provided better tissue oxygenation in the postoperative period, maintaining the relative vasodilatation in the operated limb. In I group of the study, significant peripheral vascular resistance somewhat impeded adequate oxygenation from the first postoperative day.

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