RU2454935C2 - Method of parapancreatic blockades - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to methods of treating pancreatitis, and is intended for parapancreatic blockade. Puncture of parapancreatic zone in point of intersection of long muscle of back and 12 rib with a thin needle with diameter 18-20 G under US-control is performed. Introduction of therapeutic preparations is started only in case of echoscopically visualised passage with needle end of intraperitoneal fascia. Drug solution is introduced discretely in dose 20 ml with exposition 1 minute and is stopped when pressure in zone of solution introduction increases to 12 mm Hg.

EFFECT: method makes it possible to avoid accidental injury to vitally important organs of abdominal cavity (kidneys, spleen, inferior vena cava, pancreas itself) and microcirculatory disorders in parapancreatic zone in patients with destructive pancreatitis.

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Description

The invention relates to medicine, namely to methods for treating pancreatitis.

Despite the successes achieved in recent years in the treatment of pancreatitis, it remains one of the most important surgical problems. The use of drug-novocaine retroperitoneal blockade in acute pancreatitis (OP), according to most authors [1, 8, 10, 18, 23], is an anatomically and pathophysiologically substantiated treatment method. Single blockades inhibit pancreatic secretion for 7-8 hours, the amount of juice being separated is reduced by 2-2.5 times. The methods for bringing novocaine to parapancreatic fiber are diverse: through the round ligament of the liver, suboxyphoidal, perinephral block according to A.V. Vishnevsky, retroperitoneal block according to L.I. Roman and others.

In our country, the paranephral and vagosympathetic blockade according to A.V. Vishnevsky (1952), retroperitoneal blockade according to L.I. Roman (1968), and parapancreatic blockade [6], controlled by novocainic denervation of the chest, have been most widely used in the treatment of OP sympathetic trunk [5] and others.

However, the currently used methods of novocaine blockade according to various authors are not effective enough, unsafe and are accompanied by a large number of various complications [19, 21]. The complexity of the blockade lies in the anatomical variability of each patient, in the need for special devices that provide a safe dosed introduction of the needle at a certain depth into the retroperitoneal space [6, 10, 23]. A large proportion of the complications of novocaine blockade is due to toxic complications and general vegetative-vascular reactions, iatrogenic damage to organs [21].

With destructive pancreatitis, pronounced microcirculation disorders in the abdominal cavity and retroperitoneal organs were noted in 30 and more percent of patients and develop already with the first degree of intra-abdominal hypertension - 12 mm Hg. [3, 25]. An increase in the volume of fluid in the retroperitoneal tissue due to edema, extensive hematomas or the introduction of fluid for therapeutic purposes is a factor provoking intra-abdominal hypertension and, as a result, multiple organ dysfunction [4]. However, methods for monitoring and correcting pressure in the retroperitoneal space with the introduction of medicinal solutions into it under conditions of pancreatitis are not described in the literature.

An essential role in achieving the therapeutic effect of the blockade is played by the correct selection of the concentration of one or another anesthetic sufficient to block the bezmyelinovye and insufficient to block the myelin fibers. In this case, the final concentration of anesthetic on the membrane of the nerve fiber depends on the accuracy of bringing the solution to it. The closer the anesthetic is delivered to the conductor, the less it will be diluted with interstitial fluid, the lower the initial concentration of anesthetic will be sufficient to perform a qualitative blockade, the lower the risk of toxic complications. The solution of anesthetic and other medications should be delivered as close as possible to the pathological focus, to the center of the painful area, that is, therapeutic blockade should comply with the principle "where it hurts - if there is pain." With an increase in the concentration of anesthetic, the strength of its action increases approximately in arithmetic, and toxicity - in geometric progression [21].

The use of ultrasonic navigation for non-invasive and invasive diagnosis of OP has recently become widespread [14, 7, 9]. The advantages of the ultrasonic diagnostic method are widely known, such as accessibility, ease of research, relative safety, high information content, the absence of any contraindications and the possibility of repeated repeated studies. According to various authors [11, 13], the sensitivity of ultrasound of the pancreas with OP is about 85%, with a specificity of about 90-95%. However, most researchers use fine-needle aspiration puncture (TAP) under ultrasound guidance only to assess the infection of acute fluid accumulations and false pancreatic cysts [2, 12, 17, 24].

Currently, for the treatment of pancreatitis, a method is used that is closest in technical essence to the method we offer, and the prototype we took is retroperitoneal lumbar block according to L. I. Roman [15, 16], in which the novocaine drug mixture is administered bilaterally by the transdermal method in the area of the Lesgaft-Grünfeld triangle in the retroperitoneal layer of fiber of the lumbar region. The blockade is carried out as follows. At the point of intersection of the long back muscle and 12 ribs with a thin needle, observing the principles of asepsis and antiseptics, anesthesia of the skin and subcutaneous tissue is performed. Then, changing the needle (100-150 mm long), it is carried out until it stops at 12 ribs. Having slipped from the lower edge of the rib, the needle is carefully advanced, giving a stream of novocaine in front of it, to a depth of 5-10 mm. After a puncture of the intra-abdominal fascia, the needle appears in the thickness of the parapancreatic fiber, where 100 to 400 ml of a warm 0.25% solution of novocaine and solutions of antibiotics, antienzyme and anti-inflammatory drugs are slowly injected. This blockade is most effective for OP [21], since when it is performed, there is not an indirect, but a direct effect of novocaine on parapancreatic tissues.

However, this method of retroperitoneal novocaine blockade has significant disadvantages [20, 21, 22]:

1) there is no possibility of visual control of the movement of the needle in the tissues, which is the cause of iatrogenic damage to the parenchyma or pelvis of the kidney, inferior vena cava, pleural cavity or the introduction of the drug into the muscles of the lumbar region;

2) there is no possibility of control and correction of pressure in the retroperitoneal space, the prevention of microcirculatory disorders associated with it;

3) there are no visually controlled criteria for the start of administration and localization of the distribution of the solution in parapancreatic fiber, pathogenetically substantiated indications for the termination of its administration. Moreover, an insufficient amount of anesthetic injected into the parapancreatic space leads to a decrease in the therapeutic effect of the blockade, and an excessive amount of anesthetic leads to toxic complications and a dangerous increase in pressure in the retroperitoneal space.

The purpose of the invention is to improve the treatment results of patients with pancreatitis by developing a safe, ultrasound-controlled method of blocking parapancreatic fiber, reducing the number of iatrogenic damage to organs of the parapancreatic zone, preventing the development of pathologically high pressure and microcirculatory disorders in the retroperitoneal space.

The goal is achieved by the fact that the puncture of the parapancreatic zone is performed at the intersection of the long back muscle and 12 ribs with a thin needle with a diameter of 18-20 G under ultrasound control, and the direction of movement and depth of the needle is determined by the anatomical location of the organs of the parapancreatic zone, which helps to avoid iatrogenic damage parenchyma or pelvis of the kidney, inferior vena cava, pleural cavity or the introduction of the drug into the muscles of the lumbar region. The introduction of drugs begins only with echoscopically visualized passage of the intraperitoneal fascia by the end of the needle and the appearance of a solution distribution pattern in parapancreatic fiber, which allows you to create the maximum concentration of the drug directly in parapancreatic fiber. When a needle enters the retroperitoneal space, the process of creating the anesthetic depot is also controlled by ultrasound, the solution is injected discretely in 20 ml with an exposure of 1 min, and after each injection, the pressure in the retroperitoneal space is measured, which avoids pathologically high pressure and microcirculation disturbance in the parapancreatic zone.

Discrete administration of the drug solution is carried out using the device (figure 4), consisting of a syringe - 1, a needle - 2 and an adapter-tee, one of the outputs of which is hermetically attached to the syringe - 3, the second is hermetically attached to the needle - 4, and to the third directed vertically upwards during the puncture - 5, an open transparent tube is attached, which acts as a pressure scale - 6. Before the puncture, the tee outlet with the pressure scale is set to the “closed” position so that it does not communicate with the external environment. After measuring the pressure, if it does not reach 12 mmHg, the outlet of the tee with a pressure scale is again closed and the introduction of the solution continues. Upon reaching a critical pressure value of 12 mm Hg the introduction of the solution into the retroperitoneal space is stopped.

The photographs show the stages of the parapancreatic blockade. Figure 1 - echoscopic picture at the time of the beginning of the introduction of the drug mixture into parapancreatic fiber (accumulation of injected fluid displaces the kidney and spleen). Figure 2 - after the introduction of 20 ml of novocaine solution and exposure of 20 minutes, the pressure in the parapancreatic zone is measured, the pressure does not exceed 12 mm Hg Figure 3 - introduced another 20 ml of the solution into the parapancreatic space, when measuring pressure, the liquid column rose to the entire height of the tube-scale, i.e. the pressure in the parapancreatic region exceeded 12 mm Hg.

The method of ultrasound-assisted novocaine blockade worked out on corpses was used in clinical practice in 8 patients with acute pancreatitis.

When performing in clinical practice drug-procaine blockade of the retroperitoneal space in patients with destructive OP, a pronounced analgesic effect and a decrease in intestinal paresis are always observed. In addition to achieving a direct analgesic effect, the presence of microflora in the washings from parapancreatic fiber was assessed and had the possibility of topical application of broad-spectrum antibiotics (carbapenems) in order to create the maximum concentration directly around the foci of necrosis in the parapancreatic tissue and pancreas.

Puncture is carried out in the patient's position on the right side with the maximum possible lateral extension on the roller under the control of ultrasound. For unilateral blockade, a 0.25% solution of novocaine is used, to which 2.0 ml of 50% analgin and 80 mg of no-shpa are added. Anesthesia of the skin and subcutaneous tissue is carried out strictly under ultrasound control in order to give the needle movement the exact direction in the direction of the parapancreatic tissue on the left and to avoid damage to the kidney and spleen. The trajectory and depth of the needle are controlled by ultrasound throughout the procedure, using needles with a diameter of 18 G. Before the puncture, the outlet of the tee with a pressure scale is set to the “closed” position so that it does not communicate with the external environment. If a needle enters the retroperitoneal space, the process of creating the anesthetic depot is also controlled by ultrasound, the solution is injected discretely in 20 ml with an exposure of 1 min, and after each injection, the pressure in the retroperitoneal space is measured by opening the outlet of the adapter tee with a scale.

In all cases, a pronounced analgesic effect is observed, which occurs immediately during the administration of the anesthetic mixture (“on the tip of the needle”) and lasts an average of 24-36 hours, tachycardia disappears, blood pressure stabilizes, nausea and vomiting disappear, and amylase levels decrease. blood and leukocytosis.

Retroperitoneal therapeutic blockade under the control of ultrasound is performed once every two days, from 2 to 6 procedures in each patient. In patients with severe destructive changes in the pancreas according to ultrasound and CT, in order to prevent infection of foci of destruction and purulent complications, the blockade is supplemented with the introduction of 500 mg of thienam (meronem) into the retroperitoneal tissue.

Clinical example. Patient S., 52 years old, and.b. No. 6102, was admitted to the hospital on June 29, 2009 with the clinical picture of acute destructive pancreatitis. From the anamnesis: I was sick for 7 days, became ill acutely after an error in the diet, and received intensive infusion and antibacterial therapy for 5 days.

Upon admission to the hospital, the state of moderate severity, blood pressure - 110/70 mm Hg, pulse 90 beats./min, NPV 16 in 1 min, 37.6 ° C. The abdomen is slightly swollen, moderately painful in the epigastrium and left hypochondrium, a positive symptom of Voskresensky is determined. In the epigastrium, a dense, moderately painful formation up to 15 cm in diameter is palpated, the symptom of fluctuations is not clearly defined. In the general analysis of HB blood - 105 g / l, white blood cells 10.7 × 10 ⁹ / l, ESR 25 mm / h, TSN ++. Total bilirubin - 25.9 μmol / L, alkaline phosphatase 92 U / L, amylase 74 U / L, blood sugar 5.2 mmol / L. According to ultrasound data, the pancreas is enlarged, head 44 × 33 × 36 mm, body 28 mm, tail 31 mm. The contours are uneven with the presence in the head region of the infiltrate zone of an inhomogeneous echostructure measuring 44 × 20 mm. The area of the body and tail displaces the volumetric fluid formation in the stuffing bag of dimensions 64 × 60 mm with a heterogeneous liquid content. In the cavity of the gallbladder, the calculus is up to 14 mm. Intra- and extrahepatic bile ducts are not dilated. In the lower abdominal cavity and interlobularly - up to 100 ml of free fluid.

Since July 1, 2009, despite the ongoing therapy, the patient has a pronounced pain syndrome of the type of herpes pains that cannot be stopped by the massive administration of analgesics. 07/01/09, 07/03/09 and 06/07/09, the patient under ultrasound control performed blockade of parapancreatic fiber according to Roman 0.25% solution of novocaine with the addition of dipyrone 4.0 ml, but-shp 4.0 ml and Tienama 1.0. The pain syndrome stopped immediately with the introduction of the treatment mixture and the analgesic effect continued for 48-72 hours. Considering the recurrent nature of the pain syndrome and the presence of fluid formation in the stuffing bag, 07.07.09, the patient underwent percutaneous puncture drainage of the formation - a dark brown liquid was obtained with flakes in a volume of up to 450 ml, E. Coli was detected in the crop at a concentration of 10 ² CFU / ml. Subsequently, the pain syndrome did not recur. The cavities of the liquid formations partially reduced. In the early postoperative period, there was a slight hemorrhage for drainage, stopped by conservative measures. The condition is regarded as an acute post-necrotic cyst of the body of the pancreas. When ultrasound control after 14 days, the cyst cavity was not visualized, the infiltrate in the head area was reduced by 2 times. During further intensive conservative therapy, a gradual resorption of parapancreatic infiltrate was noted. Discharged under the supervision of a surgeon at the place of residence July 26, 2009. When examined on October 7, 2009, he does not show any complaints, with ultrasound, there were no cavities.

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Claims (1)

The method of parapancreatic blockade, which consists in puncture of the parapancreatic zone at the intersection of the long back muscle and 12 ribs, the introduction of a solution of novocaine and an antibiotic into the parapancreatic tissue, characterized in that the puncture is performed under ultrasound and pressure control in the area of the solution, and the introduction of drugs start only with an echoscopic picture of the end of the needle passing the intra-abdominal fascia, and the drug solution is injected discretely in 20 ml with an exposure of 1 min and end at Vyshen pressure in introducing the solution to 12 mm. Hg. Art.

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