Kozlovska I.Yu. Optimizing the technique of spinal anesthesia during orthopedic and traumatological operations on the lower extremities.
Dissertation for obtaining the scientific degree of Doctor of Philosophy in the field of knowledge 22 "Health care" in the specialty 222 "Medicine". - National Pirogov Memorial Medical University, Vinnytsya, Ukraine, 2025.
The aim of this dissertation research is to increase the effectiveness and safety of spinal anesthesia during surgical interventions on the lower extremities in orthopedic and trauma patients by substantiating new and improving existing methods of local anesthetic use.
In order to work out the tasks of this scientific work, a study of various spinal anesthesia techniques was carried out in four groups of patients, totaling 102, who underwent surgical interventions on the lower limbs in the orthopedic and trauma direction. These patients, included in the study, were treated in the trauma department of the Scientific Research Institute for the Rehabilitation of Persons with Disabilities at NPMMU in the city of Vinnytsia in the period from September 1, 2021 to June 30, 2022.
All patients were divided into four groups depending on the dosage of the local anesthetic used (hyperbaric bupivacaine solution 0.5%), which was performed according to the gradation method, which was directly proportional to the patient's height. Also, different methods of spinal anesthesia were performed in the groups, which differed in the use or not of positioning the patient in the lateral position for 20 minutes without placing a roller under the lumbar spine.
As a result of the study, it was found that the longest duration of sensory and motor block was recorded in the group using a high dose of local anesthetic and positioning on the side for 20 min and was 384.4±61.41 min (p<0.05) and 321±50.5 min (p<0.05), respectively, which has a correlation dependence on the dose of local anesthetic used. The shortest duration of analgesia was expected when performing unilateral spinal anesthesia - 189.25±34.27 min (p<0.05), which is associated with the low dose of the medication used. At the same time, the level of sensory block in dermatomes did not exceed Th-6 in any of the study groups and was the highest in the I study group, where bilateral spinal anesthesia was performed without positioning the patient lying on the side after the puncture. In the remaining study groups, the level of blockade did not exceed Th-8.
When studying the safety of this technique, it was found that the most frequent side effects of spinal anesthesia, such as arterial hypotension and bradycardia, which develop during sympathetic blockade and vasodilation accompanying it, do not exceed the frequency of occurrence during spinal anesthesia in the control group. The lowest mean arterial pressure was obtained in the control group at 30 min of spinal anesthesia, which was 74.3±10.6 min (p<0.05), while in the II group - 87.7±13.1 min (p<0.05), in the III group - 82.9±13.5 min (p<0.05) and in the IV group - 77.7±13.1 min (p>0.05). The obtained data indicate that the developed technique is safer even when using high doses of local anesthetic, due to the prevention of the development of bilateral symmetrical sympathetic blockade, providing compensation for vasodilation by the opposite, non-blocked, side of the spinal segment.
When assessing the use of additional medications to stabilize the condition, it is worth noting that the amount of fentanyl used was significantly higher in group II of the study and exceeded this indicator in the control group by more than 80%, due to the mismatch between the duration of the blockade and the time of surgery.
When conducting laboratory studies, it was found that stress factors, such as glucose and cortisol, increased the most with the development of intra- and postoperative pain syndrome. In group II of the study, an increase was recorded after 3 hours of spinal anesthesia by 30% of the initial level, in group I the level also increased, but by 23%. In contrast, in groups III and IV, the increase occurred only 5 h after the onset of anesthesia, which corresponds to the duration of sensory block in the studied groups. Similar results were observed in the study of blood lactate, as an indicator of cellular hypoxia, during the development of pain syndrome.
As a result of the study, based on the data obtained, it was found that the developed method of spinal anesthesia with high doses of anesthetic and positioning for 20 min on the side increases the effectiveness and safety of anesthesia during surgical interventions on the lower extremities in traumatology and orthopedics.
