Вибір методу анестезії в залежності від типу кровообігу при операціях на щитоподібній залозі у хворих з ожирінням

Abstract

В роботі проведене дослідження змін центральної гемодинаміки при операціях на щитоподібній залозі у хворих з ожирінням в залежності від типу кровообігу та методу анестезії. За допомогою технології esCOO виявлено, що у пацієнтів з вихідною нормо-гіподинамією використання ТВА на основі пропофолу призводило до поступового зниження СІ до 1,75±0,24 л/хв./м2, в той час, як застосування інгаляційного наркозу севофлураном не впливало на величину СІ (p<0,05). У пацієнтів з вихідною гіпердинамією кровообігу незалежно від метода анестезії протягом всієї операції відмічалась стабільність СІ (p>0,05); В работе проведено исследование изменений центральной гемодинамики при операциях на щитовидной железе у больных с ожирением в зависимости от типа кровообращения и метода анестезии. С помощью технологии esCOO выявлено, что у пациентов с исходной нормогиподинамией использование ТВА на основе пропофола приводило к постепенному снижению СИ до 1,75±0,24 л/мин/м2, в то время, как применение ингаляционного наркоза севофлураном не влияло на величину СИ (p<0,05). У пациентов с исходной гипердинамией кровообращения, независимо от метода анестезии, на протяжении всей операции отмечалась стабильность СИ (p>0,05); Different invasive and non-invasive techniques of cardiac index (CI) assessment are used in modern anesthesiology and intensive care that allows to detect tissue hypoperfusion on time and to carry out early, adequate, individualized therapy by correction of the depth of anesthesia, volume of infusion therapy, prescription of inotropic or vasoactive drugs. But except rapid reaction to the fact of CI decrease its online monitoring in patients with different types of hemodynamic can help the anesthesiologist to choose a safe method of anesthesia before the beginning of surgery and guarantee hemodynamic stability of the patient. This is especially important for patients with obesity in which the avoidance of hypodynamic circulation is a must because of the high risk of tissue hypoxia and acidosis development. That’s why we set out to identify the regularity of central hemodynamic during thyroid gland surgery in obese patients depending on the type of hemodynamic and method of anesthesia. There were patients with BMI>30 kg/m2 included to prospective non-randomized study that were operated with general anesthesia about multinodular goiter or thyroid cancer. Depending on the value of CI, determined by the help of esCOO technology (Nihon Kohden, Japan) patients were included either to the group 1 (n=22, normal-hypodynamic type of hemodynamic, CI<3,5 l/min/m2) or to the group 2 (n=22, hyperdynamic type of hemodynamic, CI>3,5 l/min/m2). All the patients had the same premedication, induction of anesthesia and mechanical ventilation. By random selection patients of each group were divided to 2 same subgroups: subgroup of total intravenous anesthesia (TIVA), where propofol 4 mg/kg/h, fentanyl 10/5/3 mkg/kg accordingly in the 1/2/3 hour of surgery, atracurium 0,5 mg/kg/h were used to maintain anesthesia, and subgroup of inhalation anesthesia by sevoflurane (SEV) where sevofluran 2,5-3% vol., fentanyl 3 mkg/kg/h, atracurium 0,2 mg/kg if necessary were used. Drugs were counted for lean body weight (LBW). During surgery all the patients had non-invasive monitoring of blood pressure (BP), heart rate (HR), capillary blood oxygen saturation (SpO2), and non-stop determination of CI by esCOO technology on Vismo monitor PVM-2701K (Nihon Kohden, Japan). Data of 6 stages of the study appropriating the stages of anesthesia were used for statistics. Patients from both groups had no difference in age, gender, BMI, type and duration of operation, but they were different in functional status of ASA: III class ASA have 8 patients in group 1 and 4 patients in group 2 (p<0,05) by existence of higher percentage of concomitant IHD in them (23 to 9 accordingly, p<0,05). In group 1 the average value of CI was 2,5±0,16 l/min/m2 at the beginning. In TBA subgroup this index tended to decrease reaching the point 1,75±0,24 l/min/m2 during thyroidectomy (p<0,05) but coming back to the normal level at the moment of tracheal extubation. In SEV subgroup the value of CI remained almost unchanged and was in the average 2,45±0,3 l/ min/m2 (p>0,05). In group 2 the average value of CI was 3,7±0,4 l/min/m2 at the beginning. During surgery CI value was stable and didn’t decrease significantly on any stage of the study in both subgroups TIVA and SEV (p>0,05). So we found that during thyroid gland surgery in obese patients with normal-hypodynamic type of circulation the use of inhalation anesthesia by sevoflurane is more expedient than TIVA by propofol because this method allows to keep CI on the level of the lower limit of normal. In the presence of hyperdynamic type of circulation anesthesia can be conducted either by sevoflurane or propofol because of the absence of any negative effect of these methods to central hemodynamic.