Astudy was conducted to analyze ways to optimize the anesthesia method in patients who need to undergo total abdominal hysterectomy. The main goal of the work was to develop and substantiate the optimal option for low-opioid anesthesia for total abdominal hysterectomy by reducing the total dose of opioid analgesics and using additional neuraxial components of analgesia based on the study of the dynamics of changes in pain intensity, hormonal-metabolic and inflammatory responses.
At almost all stages of the surgical intervention, the level of the ANI index for all groups did not have a statistically significant difference (p>0.05). It ranged in average values of 59.6 (1.4) standard units at the stage of skin incision to 53.5 (1.0) standard units at the stage of devascularization. In the overwhelming majority of cases, the analgesia and nociception index was controlled within the range of normative values (50 - 70 standard units). At the 6th (peritonization) and 7th (skin suturing) stages of the surgical intervention, it was observed that in groups I and II (without statistical difference between them, p>0.05) the ANI index statistically significantly increased when compared with groups III and IV, p<0.001. At the same time, the difference in the analgesia and nociception index between groups III and IV was not observed. The deviation of the bispectral index was in the average values from 45.7 (1.4) standard units before the start of the operation to 55.7 (1.2) standard units at the stage of skin suturing. A statistically significant decrease in BIS indicators was found at each (except before the start of the operation and at the stage of skin incision, p=0.522, p=0.178, respectively) stage of the operation in patients assigned to group IV, compared with the other three groups, p1,2,3=0.012. Analysis of the results of assessments on the subjective scale of postoperative pain VAS showed the worst results in the I group of the study, intermediate in the II and III groups, and the best in the IV group, in which faster and longer-lasting subjective positive assessments of postoperative pain were observed. Within 48 hours after the intervention, a statistically significant decrease in the average VAS score was observed in the IV group at each time interval in which this indicator was measured (p<0.001), and in 100% of cases this average was less than 3.3 points, indicating excellent control of postoperative pain. Groups II, III and IV together had a significant statistical difference from group I at all stages of postoperative observation with varying degrees of correlation at all stages of postoperative observation, p<0.05. According to the results of the correlation rank analysis on the relationship of potential influencing factors with the level of postoperative pain, it was found that the VAS index has an average correlation with the cortisol index after surgery (rs=0.45; p<0.05), the dose of narcotic analgesic (rs=0.41; p=0.032) and hemodynamic indicators at the stage of skin suturing (rs=0.53; p=0.004). A negative correlation was established between the VAS index and the BMI index (rs=-0.38; p<0.05) and the time of the first need for anesthesia (rs=-0.72; p<0.05). There is a strong correlation between the level of procalcitonin on the day after the intervention and the VAS 12 hours after the intervention (rs = 0.72; p = 0.003). While there is an inverse correlation of moderate strength between the level of glucose on the day after the intervention and the VAS 12 hours after the intervention (rs = -0.41; p = 0.029).
These relationships may indicate an increased need for analgesia with the use of traditional doses of opioids, as well as the need for intramuscular administration of opioids.
The dose of fentanyl used during the intervention was directly related to the variability of VAS scores for postoperative pain. This association was observed both after awakening and at other stages of the patient examination and was greatest on the second day after surgery (rs = 0.69; p < 0.005).
A comparative evaluation of different anesthesia regimens for total abdominal hysterectomy showed the feasibility of multimodal analgesia and low-opioid anesthesia with the combined use of epidural bupivacaine and intrathecal morphine. Epidural bupivacaine and intrathecal morphine significantly significantly improve the quality of the postoperative period, especially on the first day (pain according to VAS is lower, the time to the first need for anesthesia is longer; the need for intramuscular morphine is lower, PONV occurs less often). Thus, intrathecal morphine administration and placement of an epidural catheter contribute to accelerated rehabilitation of patients, increasing satisfaction with the hospital stay
