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"Emergency medicine" 6 (61) 2014

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Multimodal approach to perioperative anesthesia in children

Authors: Mishchuk V.R., MD. PhD. - Danylo Halytsky Lviv National Medical University

Categories: Medicine of emergency

Sections: Clinical researches

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Introduction. With the purpose of perioperative analgesia in children assume ever greater importance the method of multimodal analgesia, which is based on the use of drugs that act on different receptor fields and their analgesic effect is potentiated.

The purpose of research — evaluate efficiency and safety of nociceptive protection in children, that have been applied a multimodal anesthesia throughout intraoperative and early postoperative period during major surgical interventions.

Materials and methods. A research included 42 children at the age of 3 month to 15 years, that had been performed an reconstructive abdominal and urological surgeries. The structure of surgical interventions was: laparotomy, the removement of intestinal obstruction — 7 patients, laparotomy + intestinal anastomoses overlay — 15 patients, lumbotomy, excision of the narrowed part of uretero-pelvic segment and forming an uretero-pelvic anastomose (Anderson-Hynes operation) — 20 patients. A research exclude patients with infectious processes of abdomen and children with cardiovascular, respiratory and the hemostatic system dysfunctions.

Anesthesia was provided by low flow anesthesia combined with thoracic epidural analgesia. In postoperative period analgesia was provided with continuous epidural analgesia (marcain 0,2% — 0,2–0,4 mg/kg/h) + i/v paracetamolum 20 mg/kg every 8 h. If necessary, postoperative analgesia was potentiated with fractional administration of morphine.

The quality of postoperative analgesia in children under 8 years was estimated at Wong — Baker scale, older children at The Numeric Rating Scale (NRS). Valuation of postooperative waking up was conducted with Aldrete scale.

The results of research and discussions. Valuation of analgesic component of anesthesia has shown high efficiency of multimodal anesthesia as a method of anesthesia. In 38 (90.5 %) patients surgery was performed without the use of opioids as a major component of anesthesia. Only 4 (9.5 %) children additionally received fentanyl for the purpose of anesthesia potentiation.

Analysis of hemodynamics showed that the increase in heart rate (HR) relatively to the initial data in children under 8 years did not exceed 7,8 ± 1,1 %. The increase of heart rate in older children (after 8 years) was 9,5 ± 1,4 %, preferably within the first hour. The systolic blood pressure (BPsyst) indicators were stable in children of young age group and variations relatively to original data were not more than 10,3 ± 1,5%. In children after 8 years there was a slight decrease of BPsyst that was differed from the original data to 21,7 ± 3,1 %. This decrease of BPsyst was observed during first hour of anesthesia and it was interpreted as a result of sympathetic blockade of epidural anesthesia. The use of crystalloids in the dosage 10-15 ml/kg resulted in re-establishment of original data of BPsyst during first hour of surgery. Diastolic blood pressure (BPdiast) in children under 8 years was characterized by minor variations, that did not exceed 14,5 ± 2,1 % of the original data. In children after 8 years the decrease of BPdiast was observed with maximum expression in the first 30 min of anesthesia and was different from the original data to 15,4 ± 2,2 %.

After surgery 41 (97.6 %) patients were extubated and able to breath spontaneous. The average score on a Aldrete postooperative waking up scale was 7,6 ± 1,0 points. 1 patient (2.4 %) needed postoperative mechanical ventilation due to intraoperative bleeding, which was > 25% of BCC.

Analysis of postoperative analgesia showed high efficiency of prolonged epidural analgesia combined with fractional use of paracetamol. Additional administration of opioids needed 7 (16.7 %) patients.

The maximum score on a Wong-Baker scale was 3,5 ± 1,3 points and on NRS — 3,6 ± 1,2 points. All patients in the postoperative period had an adequate level of consciousness without respiratory depression caused by medications.

Conclusions:1. The use of multimodal anesthesia is effective and relatively safe method of intraoperative analgesia. 2) Multimodal approach with the use of epidural anesthesia and low flow inhalation anesthesia provides fast waking up and extubation in infants and prevent undesirable effects that are associated with use of opioids. 3. Prolonged epidural analgesia combined with fractional intravenous use of paracetamol is an effective method of postoperative analgesia and promotes fast rehabilitation of patients in the early postoperative period.


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