Method of blocking the brachial plexus during operations on the upper limb

Cervical vagosympathetic blockade is carried out to influence the plexuses and fibers of the vagus and sympathetic nerves. In addition to a noticeable analgesic effect, this manipulation provides:

• normalization of muscle tone;
• increasing tissue vitality;
• strengthening resistance to infections;
• blocking the cough reflex;
• anti-inflammatory effect (resolution of catarrhal inflammation and limitation of the purulent process due to stimulation of metabolic processes).

Carrying out novocaine blockades

Blockades are the most progressive type of treatment compared to surgery, medication and others, and are already very popular in modern medicine.
This is a form of local treatment of parts of the body using medications. The main indicator for use is pain. It can occur due to osteochondrosis of various parts of the spine, as a result of fractures, as a symptom or consequence of other diseases. Blockades are also used as anesthesia. This method is successfully used by specialists at our clinic, allowing us to effectively treat patients.

Complications of cervical vagosympathetic blockade

As a rule, most complications of vagosympathetic blockade are caused by technical violations of the manipulation or an overdose of novocaine. These include:

• traumatization of blood vessels with further formation of hematomas;
• tissue necrosis due to excessive infiltration of novocaine;
• damage to the esophagus;
• paralysis and paresis due to damage or compression of the nerve;
• arterial hypotension;
• intestinal atony;
• convulsions;
• arrhythmia;
• hallucinations;
• breathing disorders.

In addition, initial intolerance to novocaine is possible, so a preliminary allergy test is indicated.

Brachial plexus block

Indications for use are the need for pain relief for surgery on the upper limb, as well as neurodystrophic syndrome.

There are several ways to administer the drug:

• According to Kulenkampf (supraclavicular). In this case, the patient assumes a supine position. A roller is used at the level of the shoulder blades. The head turns in the direction opposite to the injection. The needle is inserted to a certain depth at a point located 1 cm above the middle of the collarbone.
• According to Morgan (subclavian). With the patient lying on his back, the needle is inserted into a point located 2.5 cm below the middle of the collarbone.
• According to Paschuk (axillary). In the supine position, the patient moves his arm to the side. A tourniquet is applied to it. The needle is inserted into the axillary fossa, where the axillary artery pulsates.

Abstract of the dissertation for the scientific degree of Candidate of Medical Sciences

Scientific supervisor: Doctor of Medical Sciences, Professor A.K. ROVINA

Official opponents: Doctor of Medical Sciences, Professor V.N. KOKHNO Doctor of Medical Sciences, Professor V.N. LOMIVOROTOV

general description of work

Relevance of the topic.

Trauma to the upper extremities ranks first in the structure of general traumatism and is more common in people of young, working age, and the high surgical activity in the treatment of these injuries gives the problem of pain relief from operations on the upper extremities medical and social significance. The choice of anesthesia method depends on the nature of the injury, the patient’s age, his concomitant diseases, the position on the operating table during surgery, and on the tasks and conditions of the postoperative period (Nelzina Z.F., 1980; Kolontai Yu.Yu. et al., 1983 ; Thillaye et al., 1984; Kuzmenko V.V. et al., 1985; Malova M.N., 1985). At the same time, all things being equal, pain relief should be simple to perform and as safe as possible for the patient and medical personnel (Vishnevsky A.A. et al., 1963; Darbinyan T.M. et al., 1981; Polyakov V. A., 1981). To a greater extent, these requirements are met by plexus methods of anesthesia of the upper extremities (Pashchuk A.Yu., 1970, 1987; Jaqo et al., 1984). Existing methods of PS anesthesia differ from each other not only in determining the point of injection of the injection needle and access to the trunks of the plexus, but also in the composition, volume, concentration of the local anesthetic and auxiliary agents used, as well as the position of the patient’s body, head, and upper extremities at the time of conduction anesthesia. . In addition, each of the methods has disadvantages, because it is characterized not only by the percentage of failed anesthesia, but also by the proportion of possible complications (Svetlov V.A. et al., 1986; Schmidt und and., 1981; Kuflik et al., 1986) . When analyzing the causes of neurological disorders, three main factors are distinguished: mechanical, ischemic, chemical or toxic. Different authors attach different importance to the role of these factors, which is associated with different blockade techniques, instruments, choice of local anesthetic and auxiliary agents (adrenaline). The lack of a common point of view is also due to the inability to adequately assess the functional state of nerve trunks after anesthesia using objective criteria, such as electromyography. Most studies are hampered by plaster immobilization of the limbs and the inappropriateness of active movements of the muscles of the operated limb in the postoperative period. The accumulation of a significant number of practical and experimental observations strongly dictates a revision of the technique of conduction anesthesia and its capabilities in order to increase the efficiency and quality of blockades, reduce the number of complications, primarily neurological.

Goal of the work.

To develop and scientifically substantiate the optimal option for anesthesiological care in trauma patients during operations on the upper extremities based on conduction anesthesia of the brachial plexus and sedation with Diprivan. To achieve this goal, the following tasks were identified:

1. To develop an algorithm for selecting and implementing options for conduction anesthesia of the brachial plexus.
2. To provide a comparative assessment of various options for combining conduction anesthesia of the brachial plexus with drugs for intravenous anesthesia and to identify the most optimal ones.
3. To assess the adequacy of anesthesia based on the dynamics of the most informative biochemical parameters in trauma patients undergoing operations on the upper extremities.
4. To determine the nature and frequency of registration of complications during brachial plexus blocks, depending on the access used and anesthesia technique.
5. To study the relationship between post-anesthetic neuropathy, the technique of brachial plexus block and the composition of the local anesthetic solution in the anesthetic management options used in trauma patients.

Scientific novelty.

A fundamentally new approach to the choice of PS blockade technique has been developed and scientifically substantiated. Its anatomical and physiological basis is given. For the first time, the adequacy of the proposed method was assessed based on hormonal homeostasis data. Optimal methods for monitoring the level of consciousness during traumatological operations performed under regional anesthesia are proposed. It has been established that using the technique of slowly advancing the needle, carefully performing aspiration test in case of technical difficulties during the brachial plexus block (long-term search for nerve trunks, unintentional puncture of blood vessels) allows one to avoid specific complications of conduction anesthesia.

Practical value.

Methods of the most effective conduction anesthesia have been developed and implemented, acceptable for patients of various age groups and constitution types, providing the ability to perform any surgical interventions on the upper extremities, including the shoulder joint and acromioclavicular joint. The volume, concentration, and composition of solutions for anesthesia, brachial plexus, and the most effective combinations of sedation agents were determined. The proposed methods are simple and do not require special equipment. The proposed option is technically simple, which facilitates training in the process of training an anesthesiologist-resuscitator. The developed method makes it possible to expand the indications for surgery in high-risk patients with severe concomitant pathology. The use of modern, long-acting and low-toxic local anesthetics (anecaine, marcaine) allows you to safely increase the duration of surgical anesthesia from 3 to 6 hours, effective postoperative anesthesia to 16 - 18 hours. The developed method can significantly reduce the frequency of complications and reduce the time of treatment in the hospital, which has a significant economic effect.

Provisions submitted for defense.

1. Brachial plexus block from the supraclavicular approach is the method of choice for trauma surgeries on the upper extremities.
2. The combination of conduction anesthesia with continuous intravenous infusion of diprivan is the optimal method of anesthesia for trauma surgeries on the upper extremities.
3. The introduction of lidase into a local anesthetic solution promotes the development of an effective block of the brachial plexus, despite the absence of characteristic paresthesias.

Implementation of work results.

The developed technique of balanced regional anesthesia based on brachial plexus block, in combination with various combinations of selective drugs, was introduced into the practice of the department of anesthesiology and intensive care of the State Regional Clinical Hospital of Novosibirsk, and into the educational process at the course of anesthesiology and resuscitation of the medical faculty of the Novosibirsk Medical Institute.

General clinical characteristics of patients and research methods.

An analysis of the characteristics of PS anesthesia was studied based on the results of 1068 PS blockades in 1062 patients aged 16 to 83 years who underwent planned and emergency traumatological operations on the upper extremities.
Six of these patients were operated on twice under general anesthesia. Patients, depending on the tactics used to perform BPS, were divided into 2 groups: 1st - control, it included 568 patients. In this group, BPS was performed using one of the following methods: axillary, supraclavicular, interscalene. The choice of access for anesthesia of the brachial plexus was carried out in accordance with the recommendations of domestic authors (Pashchuk A.Yu., 1987; Kuzmenko V.V., Khamraev Sh.Sh., Skoroglyadov A.V., 1990; Kuzin M.I., 1993) . 2nd - the main one, includes 500 patients in whom BPS was carried out in accordance with the algorithm we developed. In terms of age, gender, body weight, type of constitution, nature of injury and operation, patients in both groups were comparable. In all age groups, there is a predominance of males - 53%. Patients of working age accounted for 87.6%. Among the patients we examined were patients with unconsolidated and consolidated fractures of the bones of the shoulder, forearm and hand, including complicated ones, as well as with habitual shoulder dislocations, ruptures of the acromioclavicular joint, injuries to muscles, tendons and nerves (Table 1). Distribution of patients by nature of the disease No.

Patients underwent planned and emergency operations of extraosseous and extrafocal osteosynthesis, suture and plastic surgery of tendons and nerves, removal of cysts, hygromas and metal structures. The duration of operations ranged from 10 to 205 minutes (average 49.3±3.57 minutes). Tools:

standard single-use needles for intramuscular and subcutaneous injections;
single-use Luer syringes with a capacity of 10 ml. Local anesthetics:
lidocaine, trimecaine, ultracaine and anecaine were used.
The most frequently used solution was 1.3% lidocaine with the addition of adrenaline (1:200000) in patients of group 1, without the addition of adrenaline in patients of group 2 (Table 2). Comparative characteristics of the results of clinical use of lidocaine, trimecaine, ultracaine and anecaine

*Note.
p < 0.05 Verification of the needle position in relation to the elements of the brachial plexus was carried out by achieving paresthesia. Anesthesia was considered complete and effective when analgesia occurred in all areas of skin innervation by the brachial plexus nerves and there was no spontaneous movement in all joints. Complete effective conduction anesthesia was accompanied by the patient's loss of sense of position of the upper limb. An effective, but incomplete block was characterized by the preservation of pain sensitivity in the zone of innervation of one of the nerves (usually the median, less often the radial), and the preservation of movements in the wrist joint. Anesthesia was considered unsuccessful when analgesia appeared in one or two zones of innervation on the shoulder and spontaneous movements in the wrist and elbow joints remained. The majority of blockades in patients of the first group were performed from the supraclavicular approach according to Kulencampff (1911) - 464 observations. The blockade from the axillary access was performed according to the method of A.Yu. Pashchuk. (1987) - 28 observations. BPS from ML access was carried out according to the method of Winnie AP (1970), Sokolovsky V.S. (1988) - 76 observations. In patients of group 2, BPS was carried out in accordance with the algorithm we developed (Fig. 1). The continuation of the line of the external jugular vein to the upper edge of the clavicle was used as a surface landmark to determine the point of needle insertion. To verify the position of the needle, obtaining paresthesia is mandatory, and the needle moves slowly, progressively, and paresthesia should not be painful or painful. After achieving such paresthesia, the needle was securely fixed and after performing an aspiration test, the calculated volume of LA was slowly introduced over 2–3 minutes, clarifying the patient’s sensations. We consider the optimal option to be delicate paresthesias in the fingers or elbow that persist during the injection of the solution. We have revised the BPS method from NK access. When typical paresthesia was obtained in the area of ​​the long branches of the PS, a solution of MA without lidase was used. In cases where it was impossible to obtain clear paresthesia or if the patient noted paresthesia, but with a delay, lidase was added to the LA solution at the rate of 1 unit per 1 ml of solution, the resulting solution was injected into the area of ​​passage of the PS bundles from the same access.

Algorithm for choosing a brachial plexus blockade method

Note. Angle ABC is the angle formed by the axis of the clavicle and the straight line connecting the upper edge of the sternoclavicular joint with the mastoid process. (Sokolovsky V.S., 1988). If it was not possible to induce a feeling of paresthesia after several attempts from the NC access, we used the ML access. When typical paresthesia was obtained in the area of ​​the long branches of the PS, a solution of MA without lidase was used. In cases where clear paresthesia was not obtained, a solution of MA with lidase was injected into the interscalene space. Registration of unsuccessful or effective, but incomplete blockade 10 minutes after anesthesia from the NC or ML approaches can serve as an indication for switching to one of the options for general anesthesia. If the risk of general anesthesia is high, the quality of regional anesthesia can be improved by additional blockade of the PS from the axillary approach. Switching off consciousness was considered as an obligatory component of combined anesthesia, responsible for protecting the patient from emotional operational stress. An exception was made for patients who wished to maintain a clear consciousness during the operation. This desire was, as a rule, due to a history of complicated general anesthesia. In such cases, after performing the blockade of the PS, superficial sedation with diazepam was carried out (level 1 - 2 on the Galletly scale). In other cases, the choice of sedation option was carried out in accordance with the algorithm we developed (Fig. 2). Anesthetic tactics took into account possible treatment options: 1) BPS in combination with the administration of ketamine and diazepam; 2) BPS as the only intraoperative component of pain relief; 3) BPS in combination with a hypnotic component (barbiturates); 4) BPS in combination with diprivan; 5) BPS in combination with diazepam and sodium hydroxybutyrate; 6) BPS in combination with barbiturates and sodium hydroxybutyrate; 7) BPS in combination with barbiturates and diazepam; if the chosen method of sedation was ineffective, machine-mask or endotracheal fluorotane anesthesia was performed; 9) if BPS was ineffective, fentanyl was introduced into the regimen to turn off consciousness.

Algorithm for choosing a sedation method

Note: PE - post-traumatic encephalopathy; ICP—intracranial pressure; AH - arterial hypertension.

The effectiveness of various combinations of PAs and intravenous drugs of selective action was monitored in patients of group 2 in three subgroups. Options for combinations and dosages of drugs are presented in Table 3.

Characteristics of combined anesthesia options based on brachial plexus block in patients of group 2

*Note - the doses of diprivan administered in order to completely turn off consciousness are indicated in parentheses.

The dosages of diazepam, ketamine, sodium thiopental and diprivan used were established based on our own experience in using these drugs in combination with BPS for anesthesiological support of trauma surgeries on the upper extremities. When assessing the adequacy of balanced regional anesthesia, the effectiveness of conduction blockade, as the main component of anesthesia, and the effectiveness of the sedative component were assessed separately. It should be emphasized that the typical clinical picture of the development of blockade not only indicates developing anesthesia of the limb, but also allows us to exclude the possibility of systemic toxic reactions. And, conversely, registration of a major or minor toxic reaction does not allow us to hope for the development of an effective blockade. The patients' condition was monitored based on clinical signs (skin color, level of consciousness); in addition, continuous intraoperative non-invasive monitoring of blood pressure (BP), pulse and respiration rate, SpO2 (Drager, Germany) was used. Subsequently, the “double product” and the degree of deviation of the listed indicators from the initial level at the stages of anesthesia and surgery were calculated. The level of sedation was determined according to a 7-point scale proposed by D. Galletly et al: 0 - no effect 1 - the appearance of the first medicinal effects (twanged tongue, yawning) 2 - drowsiness, drowsiness 3 - the patient is sleeping, responds to verbal commands 4 - responds to mild physical stimuli 5 - responds only to painful stimuli (squeezing the trapezius muscle) 6 - does not respond to painful stimuli To retrospectively monitor the adequacy of anesthesia, the concentration of cortisol in the blood plasma was determined at the stages of anesthesia and surgery. Blood samples were collected upon patient admission to the operating room, at the most traumatic moment of the operation, and 30 minutes after surgery. The blood was centrifuged, the serum was stored at -20°C until the time of study. Analysis of cortisol content was performed in 30 patients (90 samples). In 20 patients with concomitant diabetes mellitus, blood sugar levels were monitored at 4 stages (on the eve of surgery, before surgery, at the most traumatic moment of surgery, after surgery). All obtained data were subjected to statistical processing with the calculation of the arithmetic mean (M) and the error of the arithmetic mean (m). The significance of differences (P) was calculated using Student's t test (t). The results were processed on a programmable microcalculator “Electronics MK-61” using programs proposed by Yu.I. Ivanov and I.I. Pogorelyuk.

Research results and discussion

In our conditions, the main obstacle to the systematic use of the axillary approach was the impossibility of abducting the shoulder 90 degrees to perform the blockade in 53.3% of patients - with shoulder fractures, rupture of the acromioclavicular joint, as well as in patients with other types of injuries of the upper limb (adductor contracture of the shoulder joint). The access could be used in less than half of the patients. Of the 28 anesthesia performed, complete effective block was observed in 23 patients - 82.1%; effective, but incomplete block in 4 patients - 14.3%; in one patient anesthesia was unsuccessful (3.6%). To ensure operations on the proximal parts of the upper limb in patients of group 1, the interscalene method of PS anesthesia was used. The axillary access differs favorably from the axillary one:

1. Abduction of the limb is not required; the patient can lie on his back; the limb can remain in a plaster cast or placed along the body during the blockade.
2. Anesthesia covers the entire upper extremity, including the shoulder joint, acromioclavicular joint, and lateral third of the clavicle.

An obstacle to using this approach was the presence of neuropathies of various origins. 76 blockades were performed using this technique. Despite the presence of reliable anatomical landmarks and the possibility of palpation in many cases identifying the trunks of the brachial plexus, performing the block was often technically difficult. It was possible to obtain paresthesia in 69 patients - 90.8%; nevertheless, the introduction of an anesthetic solution in the absence of paresthesia according to the method of Gavrilin S.V., Tikhonov L.G. (1984) made it possible to achieve effective and complete blockade in 70 patients - 92.1%. In 4 patients, an effective but incomplete block developed - 5.2%, and one of the patients had a partial block of the other upper limb, without signs of epidural or subdural block. In two patients, systemic toxic reactions were noted, accompanied by convulsions - 2.7%. The blockade did not develop. Despite a negative aspiration test, in one case, seizures began shortly after administration of 30 ml of 1% lidocaine solution; in another case, convulsions began at the moment of administration of the first portion of the anesthetic - 6 ml of a 1% lidocaine solution. In both cases, patients noted the appearance of heat, first in the tongue, then in the head, before the development of convulsions. After mechanical ventilation and administration of barbiturates, the patients' condition stabilized, and the operations were performed under general anesthesia. The use of NK access for BPS limited the presence of neuropathies of various origins and anatomical features (Fig. 3). When assessing the effectiveness of BPS, performed according to the method we described in patients of the 1st group - 464 blockades, paresthesia was noted in 426 patients (91.81%). Effective and complete block was observed in 436 patients (93.97%). Effective but incomplete block was observed in 15 patients (3.23%). Anesthesia failure occurred in 13 cases (2.80%).

Possibility of using axillary, supraclavicular and interscalene approaches for BPS in trauma patients

When performing BPS in patients of group 2, the supraclavicular approach was used in 455 patients (91%). The interscalene approach was initially used in 37 patients (7.4%). The axillary approach was used in 8 cases (1.6%). In patients of group 2, clear paresthesia in the area of ​​innervation of the long branches of the brachial plexus when performing BPS from the supraclavicular approach was obtained in 418 patients (91.87%). Another 19 patients (4.18%) noted paresthesia with a delay; in these cases, lidase was added to the LA solution and this solution was administered from the supraclavicular approach. When performing the blockade, it was not possible to obtain paresthesia in 18 patients (3.96%), and in these patients the blockade was performed from the interscalene approach, and paresthesia was obtained in 11 patients (61.11%), in 7 patients (38.89%) solution LA with lidase was introduced into the interscalene space, since it was not possible to cause paresthesia. When performing BPS from the interscalene approach, paresthesia was obtained in 33 out of 37 patients (89.19%). In 4 patients, a solution of MA with lidase was injected into the interscalene space, since paresthesia was not obtained. 8 blockades were performed from the axillary approach, in 7 cases (87.5%) it was possible to obtain an effective complete blockade, in one case an effective incomplete blockade developed. In 17 patients, BPS was also performed from the axillary approach after receiving effective incomplete anesthesia, performed from the supraclavicular approach - 14 patients, from the interscalene approach - 3 patients. After additional blockade from the axillary approach, in 12 patients the blockade was assessed as effective complete, in 5 as effective incomplete. When assessing the effectiveness of conduction anesthesia in patients of the 1st group, effective complete blockade was noted in 529 observations (93.13%), effective incomplete blockade developed in 23 patients (4.05%), unsuccessful anesthesia occurred in 16 patients (2.82 %). In patients of group 2, effective complete blockade was obtained in 477 patients (95.4%), effective incomplete blockade in 17 patients (3.4%), unsuccessful anesthesia in 6 patients (1.2%). The search for rational combinations of BPS with drugs for intravenous anesthesia was considered as the second objective of the study. For each option, indications and contraindications were determined taking into account the physical condition of the patients, the nature and duration of the proposed operation, as well as the clinical pharmacology of the drugs used. When comparing options for combined anesthesia with preserved spontaneous breathing using the example of patients in group 2, the combination of BPS and intravenous administration of ketamine in small analgesic dosages with diazepam can be considered the safest and most effective. This type of sedation was used in 386 patients (77.2%). Along with achieving regional analgesia and switching off consciousness, the central analgesic effect of ketamine creates conditions for ensuring the patient's immobility throughout the operation. We noted short-term respiratory depression in 18 patients - 4.66%. At the same time, in 37 patients - 9.59% - sedation with diazepam and ketamine was ineffective, which was manifested by motor agitation, a significant increase in blood pressure and an increase in heart rate. The effectiveness of regional blockade in these patients was confirmed by preoperative and postoperative assessment of motor block. It should be noted that intravenous administration of sodium thiopental to these patients at a dose of 4.7±0.9 mg/kg provided complete sedation and normalization of hemodynamic parameters in 32 patients (86.49%). In 5 patients (13.51%), the phenomena of motor excitation could not be stopped by additional administration of barbiturates, as a result of which we used fluorotan inhalation using a hardware-mask method. When barbiturates (sodium thiopental) were used as hypnotics, a reliable switch off of consciousness was noted in 41 patients (8.2%). This combination does not cause significant changes in hemodynamics, but there is a high risk of respiratory depression in 5 patients (12.2%), the need for auxiliary ventilation in 3 patients (7.3%); Secondary sleep limits the use of barbiturates. The use of diprivan for consciousness control in 38 patients (7.6%) against the background of PS blockade confirmed the high effectiveness of the use of this drug both for the purpose of sedation and to turn off consciousness. In all cases of diprivan use, effective sedation was noted, easily achieved by changing the rate of drug administration. The rapid and complete restoration of consciousness after anesthesia distinguishes this drug from other intravenous hypnotic drugs. The use of the drug is somewhat limited by the need for:

1. individual dose selection based on the patient’s response;
2. ensuring continuous infusion of the drug.

In our study, when diprivan was administered for the purpose of sedation to achieve level 2 - 3 on the D scale. Galletly et al, the drug doses changed from 0.5 to 4.25 mg/kg/hour.
The likelihood of developing respiratory and circulatory depression largely depends on the purposes and conditions of use of diprivan. The depressive effect of diprivan on respiration and blood circulation during TVA (drug administration rate 4 - 13 mg/kg/hour), often noted by other authors, did not manifest itself in the study group of patients, since the presence of effective regional anesthesia made it possible to reduce the rate of diprivan administration when the first signs of depression appeared breathing and blood circulation. It is important that all patients gave anesthesia with Diprivan the highest rating. In 6 patients, in accordance with their wishes, superficial sedation with diazepam was performed. The combination of sodium hydroxybutyrate with diazepam or with sodium thiopental was used in 19 patients (3.8%), in 3 cases pronounced motor agitation was noted, which subsequently required a transition to ETN (oxygen + fluorotane). The combination of diazepam and sodium thiopental was used in 10 patients (2%). Reliable sedation was noted, but almost all patients required the use of an airway to maintain patency of the upper respiratory tract; in 4 patients, delayed recovery of consciousness was noted (more than 40 minutes). In order to objectively assess the adequacy of anesthesia, the level of stress hormones in the blood was determined. The results of the study of cortisol levels in the blood (Table 4) showed: 1. Initial cortisol values ​​in all patients were within normal limits. At the most traumatic moment of the operation and 30 minutes after the operation, in patients in whom conduction anesthesia was combined with the administration of ketamine and diazepam, an unreliable increase in cortisol levels was noted from 232.58 ± 30.7 nmol/l to 246.41 ± 52.9 nmol /l and a further increase after surgery to 267.72±41.9 nmol/l (p > 0.05). 2. In the group of patients in whom BPS was combined with the administration of sodium thiopental, the cortisol level also increased slightly at the most traumatic moment of the operation (from 215.73±28.3 nmol/l to 241.29±34.6 nmol/l). However, subsequently the cortisol level decreased to 236.41±47.3 nmol/l (p > 0.05). 3. When BPS was combined with diprivan at the stage of the most traumatic moment of the operation, the cortisol level increased from 226.56±37.3 nmol/l to 242.17±41.5 nmol/l and 30 minutes after the end of the operation it was 249.28± 51.6 nmol/l (p > 0.05). Dynamics of cortisol content in the blood serum of patients (Nmol/l) at the stages of anesthesia and surgery (M ± m, n=30) in selected subgroups

Note: * — significance of the difference compared to the initial level p > 0.05. ** — significance of the difference in comparison with the previous stages p > 0.05.

Such changes in cortisol levels, which did not go beyond normal limits in any of the subgroups, indicate the adequacy of the studied options for balanced regional anesthesia.
We concluded that the combination of BPS with a constant intravenous infusion of diprivan is optimal, since all components of the achieved anesthesia are highly effective, reliable and quite safe (analgesia, muscle relaxation, loss of consciousness, metabolic stability). This balanced regional anesthesia fully meets modern requirements for anesthesia. When studying glucose levels in 20 patients of group 2 with concomitant diabetes mellitus (type II), analysis of the data obtained (Table 5) showed that during the stages of anesthesia and surgery there was a significant decrease in glucose levels. Dynamics of glucose levels (in Mmol/l) at the stages of anesthesia and surgery (M±m, n=20) in patients of group 2

*Note: p < 0.05

An analysis of complications of conduction anesthesia showed that the main danger in the practice of PA is the accidental puncture of blood vessels that are part of the corresponding neurovascular bundles with the subsequent introduction of large dosages of LA into the blood and the development of a systemic toxic reaction. In our practice of using BPS, 72 cases of vascular puncture were registered. In one of the observations, when performing BPS from the axillary approach, a hematoma formed, which became the cause of neurological complications in the postoperative period. When interscalene access was used for BPS in patients of group 1, in 2 cases unintentional intravascular injection of LA was recorded with the subsequent development of generalized convulsive syndrome; in both cases, the aspiration test was negative. Similar observations are described in the literature. We believe that the main reason for intravascular administration of LA is the anatomical features of the relationship between the vessels and nerve trunks of the cervical region. Registration of neurological complications in 4 patients of group 1 was associated in one case with the formation of a hematoma, and in 3 cases with a long-term application of a tourniquet (50 - 70 minutes) in the middle third of the shoulder against the background of conduction anesthesia. The exclusion of such combinations in patients of group 2 made it possible to avoid neurological complications in the study group of patients.

conclusions

1. The developed algorithm for anesthesia management in trauma patients during operations on the upper extremities allows you to choose the optimal option for conduction anesthesia and sedation, ensures intraoperative adequacy of anesthesia and reduces the percentage of unsuccessful brachial plexus blocks.
2. The optimal option for anesthesia in trauma patients undergoing surgery on the upper extremities is blockade of the brachial plexus with a local anesthetic from the supraclavicular approach using the Kulencampff method against the background of sedation by continuous intravenous infusion of Diprivan.
3. The introduction of a local anesthetic solution with lidase into the fascial sheath of the brachial plexus provides effective blockade of the brachial plexus even in the absence of characteristic paresthesias.
4. The anesthesia options we have developed for trauma patients undergoing operations on the upper extremities are adequate, as evidenced by clinical and biochemical data.
5. Complications in the form of intravascular injection of local anesthetic when performing conduction anesthesia of the brachial plexus from the interscalene approach in trauma patients are recorded 2.63% more often than when using the supraclavicular approach.
6. When performing conduction anesthesia of the brachial plexus in trauma patients, it was not possible to establish a relationship between the occurrence of neuropathy and the number of attempts to achieve paresthesia and puncture of blood vessels; the addition of adrenaline to the local anesthetic solution is a risk factor in the development of post-anesthetic neuropathy.

Practical recommendations

1. Conduction anesthesia of the brachial plexus in accordance with the algorithm we have developed can be used both planned and emergency and is the method of choice for operations on the upper extremities in high-risk patients.
2. When carrying out balanced regional anesthesia with preserved spontaneous breathing, a prerequisite for its adequacy is to maintain Fi O2 at a level of 40-50% using a non-sealed face mask from the moment the blockade is completed until the patient’s consciousness is fully restored.
3. When carrying out PS blockade, it is necessary to correct the psycho-emotional reaction of patients to operational stress with medications; diprivan is optimally used for this purpose.
4. When performing brachial plexus anesthesia, the introduction of adrenaline into the MA solution is not advisable. Increasing the effectiveness of the blockade is achieved by adding lidase to the local anesthetic solution, and the use of bupivacaine (anecaine, marcaine) allows you to safely increase the duration of anesthesia.

List of works published on the topic of the dissertation

1. Popov V.Yu. The use of benzofurocaine in traumatology // New methods of diagnosis, treatment of diseases and management in healthcare. - Novosibirsk, 1994. - P. 125-126.
2. Popov V.Yu., Rovina A.K., Yakovleva N.N. The use of diprivan in traumatological and orthopedic operations // V All-Russian Congress of Anesthesiologists and Reanimatologists. - M., 1995. - P. 261.
3. Popov V.Yu., Rovina A.K., Yakovleva N.N. Experience in the use of conduction anesthesia in traumatology // Abstracts of the 56th final scientific conference of students and young scientists. - Novosibirsk, 1995. - P.173-178.
4. Tsybina O.A., Popov V.Yu. Plexus anesthesia for operations on the upper extremities // Abstracts of the 57th final scientific conference of students and young scientists. - Novosibirsk, 1996. - P.211-212.
5. Yakovlev A.V., Popov V.Yu. Balanced anesthesia with diprivan during abdominal operations // Abstracts of the 57th final scientific conference of students and young scientists. - Novosibirsk, 1996. - P.213-214.
6. Popov V.Yu. The use of conduction anesthesia in combination with diprivan during traumatological operations // Russian-German Congress. - Novosibirsk, 1996.

Intravascular and periarticular blockades

Intravascular block is a type of local anesthesia. It is injected directly into the area of ​​the body where it is necessary to reduce pain sensitivity.

There are also periarticular blockades.

Causes of pain in periarticular joints:

• Injuries.
• Great physical activity.
• Congenital developmental problems.
• Disorders of the musculoskeletal system.

The most effective treatment method is injections into the affected area, as they act instantly. The choice of medication and its dosage is influenced by the severity of the pathology, its volume/size, which reduces the risk of side effects.

Paravertebral blockades

Their peculiarity is that they are performed directly near the spine. The solution is injected into the muscle or ligament. This method of treatment is used in combination with other methods. Often used during the treatment of clinical types of osteochondrosis.

Types of paravertebral blockade:

• Cervical or stellate node.
• Chest. When the lesion is located to the side, an intercostal block is performed.
• Lumbar. It blocks the lumbar plexus.

Effective treatment is impossible without accurately identifying the location of the pain. The procedure can relieve post-traumatic or chronic pain, as well as pain during surgery.

Sacroileal blocks (coccyx injury)

Sacroiliitis is a process of inflammation of the sacroiliac joint. It manifests itself as pain in the lower back. There are several forms of the disease depending on its nature and cause. Common prerequisites are injuries, joint overload for a long time, congenital defects, infectious diseases, and so on.

Physiotherapeutic procedures are used for treatment. But in case of severe pain, blockades are performed - injections of medications directly into the source of pain.

Prices