Comparative analysis of types of combined anesthesia for laparoscopic cholecystectomy
Objective – to evaluate through comparative analysis the effectiveness of different types of combined anesthesia during laparoscopic cholecystectomy performed under carboxyperitoneum conditions.
Materials and methods. 119 patients were examined (19 (16 %) men and 100 (84 %) women) aging from 20 to 82. Each patient underwent operative treatment either of acute (39 (32.8 %)) or chronic (80 (67.2 %)) cholecystitis by means of laparoscopic cholecystectomy with carboxyperitoneum. All of the patients were given combined anesthesia accompanied by tracheal intubation and mechanical ventilation, but the base anesthesia was different in each of the studied groups. Depending on the type of given anesthesia, the patients were separated into 3 groups: the first comparative group (n = 44) received combined intravenous general anesthesia, the second comparative group (n = 44) – combined inhalational anesthesia (sevorane), the third main group (n = 31) – combined spinal anesthesia (CSA) using a 0.5 % solution of bupivacaine (marcaine) 1.5-2.0 ml (7.5-10.0 mg) and drugs for intravenous anesthesia. The patients’ age, sex, operation volume and duration of intravenous anesthesia were statistically insignificant (p > 0.05) for the study. Hemodynamic parameters were compared, intraoperative analgesia and demand for opioid analgesic agents in the postoperative period, the dynamics of postoperative pain syndrome, as well as the necessity of using additional antihypertensive drugs. Among other points of major interest were postoperative glucose levels, parameters of recovery from anesthesia and postoperative length of hospital stay.
Results. Average systolic blood pressure levels in groups with insufflation of carbon dioxide into the abdominal cavity: the first group – (137.5 ± 18.9) mm Hg, the second group – (136.6 ± 17.7) mm Hg, the third group – (115.0 ± 13.7) mm Hg. The indicated systolic blood pressure levels in patients of the third group were significantly different from the indicated levels recorded in patients of the first and the second groups (p < 0.001). Averages systolic blood pressure levels during carboxyperitoneum: the first group – (101.7 ± 14.1) mm Hg, the second group – (100.0 ± 12.2) mm Hg, the third group – (86.7 ± 10.4) mm Hg (p < 0.001). However, episodes of tachycardia were also registered (Heart Rate > 90 bpm) in some patients: the first group – in 13 patients (29.5 %), the second group – in 14 patients (31.8 %), the third group – in 3 patients (9.7 %). On average, an hour of anesthesia required: in the first group – 731 p,g of fentanyl, in the second group – 670 p,g, in the third group – 346 p,g (p < 0.01). The low trauma level of laparoscopic cholecystectomy influenced the need for postoperative usage of fentanyl differently in patients from different groups: 7 patients (15.9 %) from the first group did not experience significant need for opioid analgesics, while 15 patients (34.1 %) were content after just one dose of fentanyl in the first postoperative day. In the second group the number of such patients amounted to 9 (20.5 %) and 17 (38.6 %) respectively. The third group had the greatest number (18 patients, 58.1 %) of patients which were given non-opioid analgesics, and just 9 patients required a single dose of fentanyl (29.0 %). The intensity level of the postoperative pain syndrome on the visual analogue scale in patients of the first and the second groups was significantly higher than in patients of the third group during all the postoperative care period. Nearly maximal results on the visual analogue scale were observed already after 2-3 hours in patients of the first and the second groups, while patients of the third group reached their pain maximum after 5-6 hours. Duration of maximal pain levels amounted to 10-12 hours in the first and the second groups and 6-8 hours in patients of the third group. The need for additional antihypertensive drugs during anesthesia and in the postoperative period was observed in 9 patients in the first group (20.5 %) and 8 patients (18.2 %) in the second group. Only one patient (3.2 %; p < 0.001) in the third group required a single intravenous dose of ebrantil (25 mg). Differences in glucose levels during the postoperative period were statistically insignificant in all groups (p > 0.05).
Conclusions. The study revealed clinically and statistically significant advantages of combined spinal anesthesia: the rapid recovery of central nervous system functions, earlier transfer of patients to a spontaneous ventilation mode and a shorter period of postoperative hospital stay (the first group – (7.77 ± 2.11) day, the second group – (7.77 ± 2.34) day, the third group – (4.55 ± 2.17) days (p < 0.001)).
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