Раневая аналгезия у больного гемофилией при высокотравматичной операции
Раневая аналгезия у больного гемофилией при высокотравматичной операции
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Аннотация
Цель исследования. Учитывая ряд ограничений по использованию периоперационного обезболивания у пациентов с гемофилией (ввиду тяжелых нарушений гемостаза), раневая аналгезия может являться одним из компонентов мультимодальной аналгезии у данной категории пациентов. Описан положительный опыт использования метода раневой аналгезии у больного гемофилией на примере клинического случая.
Материалы и методы. Пациенту с тяжелой формой гемофилии А проводилось послеоперационное обезболивание после тотального эндопротезирования коленного сустава (в течение первых 48 ч) продленной инфузией местного анестетика (ропивакаина) в рану.
Результаты. За первые 8 ч пациент получил 20 мг морфина (с помощью устройства для контролируемой пациентом аналгезии), уровень боли колебался в пределах от 7 до 4 баллов по шкале NRS. Далее отмечался достаточный (NRS 2 балла) эффект от обезболивания только ропивакаином (без дополнительного использования опиоидов) с помощью системы для обезболивания хирургических ран. Осложнений и побочных эффектов не отмечалось.
Заключение. Клинический случай демонстрирует эффективный и безопасный метод продленного обезболивания у пациентов с гемофилией. Учитывая обнадеживающие данные, необходимо дальнейшее изучение раневой аналгезии у данной категории пациентов.
Ключевые слова: раневая аналгезия, боль, гемофилия, обезболивание.
The aim of the study was to describe the use of the wound analgesia method in a patient with hemophilia in the case of a clinical case.
Materials and methods. A patient with severe hemophilia A underwent postoperative analgesia after total knee replacement (within the first 48 hours) with an extended infusion of local anesthetic (ropivacaine) into the wound.
Results. During the first 8 hours, the patient received 20 mg of morphine (with the aid of a device for patient-controlled analgesia), the pain level ranged from 7 to 4 points. Further, there was a sufficient effect (NRS - 2 points), from anesthesia only with ropivacaine, using a system for anesthetizing surgical wounds. Complications and side effects were not noted.
Conclusion. The clinical case demonstrates an effective and safe method of prolonged analgesia in patients with hemophilia. Considering encouraging data, further study of wound analgesia in this category of patients is necessary.
Keywords: wound analgesia, pain, hemophilia, anesthesia.
Материалы и методы. Пациенту с тяжелой формой гемофилии А проводилось послеоперационное обезболивание после тотального эндопротезирования коленного сустава (в течение первых 48 ч) продленной инфузией местного анестетика (ропивакаина) в рану.
Результаты. За первые 8 ч пациент получил 20 мг морфина (с помощью устройства для контролируемой пациентом аналгезии), уровень боли колебался в пределах от 7 до 4 баллов по шкале NRS. Далее отмечался достаточный (NRS 2 балла) эффект от обезболивания только ропивакаином (без дополнительного использования опиоидов) с помощью системы для обезболивания хирургических ран. Осложнений и побочных эффектов не отмечалось.
Заключение. Клинический случай демонстрирует эффективный и безопасный метод продленного обезболивания у пациентов с гемофилией. Учитывая обнадеживающие данные, необходимо дальнейшее изучение раневой аналгезии у данной категории пациентов.
Ключевые слова: раневая аналгезия, боль, гемофилия, обезболивание.
________________________________________________
The aim of the study was to describe the use of the wound analgesia method in a patient with hemophilia in the case of a clinical case.
Materials and methods. A patient with severe hemophilia A underwent postoperative analgesia after total knee replacement (within the first 48 hours) with an extended infusion of local anesthetic (ropivacaine) into the wound.
Results. During the first 8 hours, the patient received 20 mg of morphine (with the aid of a device for patient-controlled analgesia), the pain level ranged from 7 to 4 points. Further, there was a sufficient effect (NRS - 2 points), from anesthesia only with ropivacaine, using a system for anesthetizing surgical wounds. Complications and side effects were not noted.
Conclusion. The clinical case demonstrates an effective and safe method of prolonged analgesia in patients with hemophilia. Considering encouraging data, further study of wound analgesia in this category of patients is necessary.
Keywords: wound analgesia, pain, hemophilia, anesthesia.
Список литературы
1. Андреев Ю.Н. Многоликая гемофилия. М.: Ньюдиамед; 2006. [Andreev JuN. Many-faced hemophilia M.: N’judiamed; 2006. (In Russ.)].
2. Заболотских И.Б., Синьков С.В., Лебединский К.М., Буланов А.Ю. Периоперационное ведение больных с нарушениями системы гемостаза. Клинические рекомендации ФАР, 2015. [Zabolotskih IB, Sin’kov SV, Lebedinskij KM, Bulanov AJu. Perioperative management of patients with hemostatic system disorders. Klinicheskie rekomendacii FAR, 2015. (In Russ.)].
3. Gueant S, Taleb A, Borel-Kuhner J, Cauterman M, Raphael M, Nathan G et al. Quality of pain management in the emergency department: results of a multicentre prospective study. Eur J Anaesthesiol. 2011; 28(2):97-105. doi: 10.1097/EJA.0b013e3283418fb0
4. Eyster ME, Asaad SM, Gold BD, Cohn SE, Goedert JJ. Second Multicenter Hemophilia Study Group. Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non-steroidal anti-in ammatory drugs. Haemophilia. 2007; 13(3):279-86.
5. Capelle W. Die Bedentung des Wundschmerzes und seiner ausschaltung fur dan Ablauf der Atmungbei Laparoto-mierten. Dtch Z Chir. 1935; 246:466.
6. Forastiere E, Sofra M, Giannarelli D, FabriziL, SimoneG. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. British Journal of Anaesthesia. 2008; 101 (6): 841-7. doi: 10.1093/bja/aen309
7. Овечкин А.М., Никода В.В. Европа против боли. Обозрение материалов IV Конгресса Европейской Федерации международной ассоциации по изучению боли (EFIC). Боль. 2004; (3):69-72. [Ovechkin AM, Nikoda VV. Europe against pain. Review of the IV Congress of the European Federation of the International Association for the Study of Pain (EFIC). Bol’. 2004; (3):69-72. (In Russ.)].
8. Macintyre PE, Walker SM. The scientific evidence for acute pain treatment. Curr Opin Anaesthesiol. 2010; 23(5):623-8. doi: 10.1097/ACO. 0b013e32833c33ed
9. Шулутко Е.М., Левченко О.К., Городецкий В.М., Гемджян Э.Г., Коняшина Н.И., Кречетова А.В. Обезболивание больных гемофилией при ортопедических операциях. Терапевтический архив. 2014; 86(5):56-61. [Shulutko EM, Levchenko OK, Gorodetskii VM, Gemdzhian EG, Konyashina NI, Krechetova AV. Analgesia in hemophiliac patients during or thopedic surgery. Terapevticheskii arkhiv. 2014; 86(5):56-61. (In Russ.)].
10. Srivastava AK, Brewer EP, Mauser-Bunschoten et al. Guidelines for the management of hemophilia. Haemophilia. 2013; 19(1):1-47. doi: org/10.1111/j.1365-2516.2012.02909.x
11. Brennan T, Zahn P, Pogatsky-Zahn E. Mechanisms of incisional pain. Anesthesiol Clin North America. 2005; (23): 1-20.
12. Hopf HW, Hunt TK, West JM. Wound tissue oxygen tension pre- dicts the risk of wound infection in surgical patients. Arch Surg. 1997; 132: 997-1005.
13. Liu S, Richman J, Thirlby R, Wu C. Efficacy of continuous wound catheter delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized con- trolled trials. J Am Coll Surg. 2006; 203: 914-32. doi: 10.1016/j.jamcollsurg.2006.08.007
14. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson ER, White PF. Effect of preincision vs postincision infiltration with bupivacaine on postoperative pain. J Clin Anesth. 1995; 7: 192-6.
15. Givens A, Lipscomb G, Meyer N. A randomized trial of post- operative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol. 2002; 186: 1188-91.
16. Lee SH, Gwak MS, Choi SJ, Park HG, Kim GS, Kim MH, Ahn HJ, Kim J, Kwon CH, Kim TS. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013 Sep; 19(9):1036-45. doi: 10.1002/lt.23691. Epub 2013 Aug 18.
17. Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS, Du W, Gao X, Wang J, Xia Y. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Aug; 22(8):1949-57. doi: 10.1007/s00167-013-2566-0. Epub 2013
2. [Zabolotskih IB, Sin’kov SV, Lebedinskij KM, Bulanov AJu. Perioperative management of patients with hemostatic system disorders. Klinicheskie rekomendacii FAR, 2015. (In Russ.)].
3. Gueant S, Taleb A, Borel-Kuhner J, Cauterman M, Raphael M, Nathan G et al. Quality of pain management in the emergency department: results of a multicentre prospective study. Eur J Anaesthesiol. 2011; 28(2):97-105. doi: 10.1097/EJA.0b013e3283418fb0
4. Eyster ME, Asaad SM, Gold BD, Cohn SE, Goedert JJ. Second Multicenter Hemophilia Study Group. Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non-steroidal anti-in ammatory drugs. Haemophilia. 2007; 13(3):279-86.
5. Capelle W. Die Bedentung des Wundschmerzes und seiner ausschaltung fur dan Ablauf der Atmungbei Laparoto-mierten. Dtch Z Chir. 1935; 246:466.
6. Forastiere E, Sofra M, Giannarelli D, FabriziL, SimoneG. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. British Journal of Anaesthesia. 2008; 101 (6): 841-7. doi: 10.1093/bja/aen309
7. [Ovechkin AM, Nikoda VV. Europe against pain. Review of the IV Congress of the European Federation of the International Association for the Study of Pain (EFIC). Bol’. 2004; (3):69-72. (In Russ.)].
8. Macintyre PE, Walker SM. The scientific evidence for acute pain treatment. Curr Opin Anaesthesiol. 2010; 23(5):623-8. doi: 10.1097/ACO. 0b013e32833c33ed
9. [Shulutko EM, Levchenko OK, Gorodetskii VM, Gemdzhian EG, Konyashina NI, Krechetova AV. Analgesia in hemophiliac patients during or thopedic surgery. Terapevticheskii arkhiv. 2014; 86(5):56-61. (In Russ.)].
10. Srivastava AK, Brewer EP, Mauser-Bunschoten et al. Guidelines for the management of hemophilia. Haemophilia. 2013; 19(1):1-47. doi: org/10.1111/j.1365-2516.2012.02909.x
11. Brennan T, Zahn P, Pogatsky-Zahn E. Mechanisms of incisional pain. Anesthesiol Clin North America. 2005; (23): 1-20.
12. Hopf HW, Hunt TK, West JM. Wound tissue oxygen tension pre- dicts the risk of wound infection in surgical patients. Arch Surg. 1997; 132: 997-1005.
13. Liu S, Richman J, Thirlby R, Wu C. Efficacy of continuous wound catheter delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized con- trolled trials. J Am Coll Surg. 2006; 203: 914-32. doi: 10.1016/j.jamcollsurg.2006.08.007
14. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson ER, White PF. Effect of preincision vs postincision infiltration with bupivacaine on postoperative pain. J Clin Anesth. 1995; 7: 192-6.
15. Givens A, Lipscomb G, Meyer N. A randomized trial of post- operative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol. 2002; 186: 1188-91.
16. Lee SH, Gwak MS, Choi SJ, Park HG, Kim GS, Kim MH, Ahn HJ, Kim J, Kwon CH, Kim TS. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013 Sep; 19(9):1036-45. doi: 10.1002/lt.23691. Epub 2013 Aug 18.
17. Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS, Du W, Gao X, Wang J, Xia Y. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Aug; 22(8):1949-57. doi: 10.1007/s00167-013-2566-0. Epub 2013
2. Заболотских И.Б., Синьков С.В., Лебединский К.М., Буланов А.Ю. Периоперационное ведение больных с нарушениями системы гемостаза. Клинические рекомендации ФАР, 2015. [Zabolotskih IB, Sin’kov SV, Lebedinskij KM, Bulanov AJu. Perioperative management of patients with hemostatic system disorders. Klinicheskie rekomendacii FAR, 2015. (In Russ.)].
3. Gueant S, Taleb A, Borel-Kuhner J, Cauterman M, Raphael M, Nathan G et al. Quality of pain management in the emergency department: results of a multicentre prospective study. Eur J Anaesthesiol. 2011; 28(2):97-105. doi: 10.1097/EJA.0b013e3283418fb0
4. Eyster ME, Asaad SM, Gold BD, Cohn SE, Goedert JJ. Second Multicenter Hemophilia Study Group. Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non-steroidal anti-in ammatory drugs. Haemophilia. 2007; 13(3):279-86.
5. Capelle W. Die Bedentung des Wundschmerzes und seiner ausschaltung fur dan Ablauf der Atmungbei Laparoto-mierten. Dtch Z Chir. 1935; 246:466.
6. Forastiere E, Sofra M, Giannarelli D, FabriziL, SimoneG. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. British Journal of Anaesthesia. 2008; 101 (6): 841-7. doi: 10.1093/bja/aen309
7. Овечкин А.М., Никода В.В. Европа против боли. Обозрение материалов IV Конгресса Европейской Федерации международной ассоциации по изучению боли (EFIC). Боль. 2004; (3):69-72. [Ovechkin AM, Nikoda VV. Europe against pain. Review of the IV Congress of the European Federation of the International Association for the Study of Pain (EFIC). Bol’. 2004; (3):69-72. (In Russ.)].
8. Macintyre PE, Walker SM. The scientific evidence for acute pain treatment. Curr Opin Anaesthesiol. 2010; 23(5):623-8. doi: 10.1097/ACO. 0b013e32833c33ed
9. Шулутко Е.М., Левченко О.К., Городецкий В.М., Гемджян Э.Г., Коняшина Н.И., Кречетова А.В. Обезболивание больных гемофилией при ортопедических операциях. Терапевтический архив. 2014; 86(5):56-61. [Shulutko EM, Levchenko OK, Gorodetskii VM, Gemdzhian EG, Konyashina NI, Krechetova AV. Analgesia in hemophiliac patients during or thopedic surgery. Terapevticheskii arkhiv. 2014; 86(5):56-61. (In Russ.)].
10. Srivastava AK, Brewer EP, Mauser-Bunschoten et al. Guidelines for the management of hemophilia. Haemophilia. 2013; 19(1):1-47. doi: org/10.1111/j.1365-2516.2012.02909.x
11. Brennan T, Zahn P, Pogatsky-Zahn E. Mechanisms of incisional pain. Anesthesiol Clin North America. 2005; (23): 1-20.
12. Hopf HW, Hunt TK, West JM. Wound tissue oxygen tension pre- dicts the risk of wound infection in surgical patients. Arch Surg. 1997; 132: 997-1005.
13. Liu S, Richman J, Thirlby R, Wu C. Efficacy of continuous wound catheter delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized con- trolled trials. J Am Coll Surg. 2006; 203: 914-32. doi: 10.1016/j.jamcollsurg.2006.08.007
14. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson ER, White PF. Effect of preincision vs postincision infiltration with bupivacaine on postoperative pain. J Clin Anesth. 1995; 7: 192-6.
15. Givens A, Lipscomb G, Meyer N. A randomized trial of post- operative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol. 2002; 186: 1188-91.
16. Lee SH, Gwak MS, Choi SJ, Park HG, Kim GS, Kim MH, Ahn HJ, Kim J, Kwon CH, Kim TS. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013 Sep; 19(9):1036-45. doi: 10.1002/lt.23691. Epub 2013 Aug 18.
17. Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS, Du W, Gao X, Wang J, Xia Y. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Aug; 22(8):1949-57. doi: 10.1007/s00167-013-2566-0. Epub 2013
________________________________________________
2. [Zabolotskih IB, Sin’kov SV, Lebedinskij KM, Bulanov AJu. Perioperative management of patients with hemostatic system disorders. Klinicheskie rekomendacii FAR, 2015. (In Russ.)].
3. Gueant S, Taleb A, Borel-Kuhner J, Cauterman M, Raphael M, Nathan G et al. Quality of pain management in the emergency department: results of a multicentre prospective study. Eur J Anaesthesiol. 2011; 28(2):97-105. doi: 10.1097/EJA.0b013e3283418fb0
4. Eyster ME, Asaad SM, Gold BD, Cohn SE, Goedert JJ. Second Multicenter Hemophilia Study Group. Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non-steroidal anti-in ammatory drugs. Haemophilia. 2007; 13(3):279-86.
5. Capelle W. Die Bedentung des Wundschmerzes und seiner ausschaltung fur dan Ablauf der Atmungbei Laparoto-mierten. Dtch Z Chir. 1935; 246:466.
6. Forastiere E, Sofra M, Giannarelli D, FabriziL, SimoneG. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. British Journal of Anaesthesia. 2008; 101 (6): 841-7. doi: 10.1093/bja/aen309
7. [Ovechkin AM, Nikoda VV. Europe against pain. Review of the IV Congress of the European Federation of the International Association for the Study of Pain (EFIC). Bol’. 2004; (3):69-72. (In Russ.)].
8. Macintyre PE, Walker SM. The scientific evidence for acute pain treatment. Curr Opin Anaesthesiol. 2010; 23(5):623-8. doi: 10.1097/ACO. 0b013e32833c33ed
9. [Shulutko EM, Levchenko OK, Gorodetskii VM, Gemdzhian EG, Konyashina NI, Krechetova AV. Analgesia in hemophiliac patients during or thopedic surgery. Terapevticheskii arkhiv. 2014; 86(5):56-61. (In Russ.)].
10. Srivastava AK, Brewer EP, Mauser-Bunschoten et al. Guidelines for the management of hemophilia. Haemophilia. 2013; 19(1):1-47. doi: org/10.1111/j.1365-2516.2012.02909.x
11. Brennan T, Zahn P, Pogatsky-Zahn E. Mechanisms of incisional pain. Anesthesiol Clin North America. 2005; (23): 1-20.
12. Hopf HW, Hunt TK, West JM. Wound tissue oxygen tension pre- dicts the risk of wound infection in surgical patients. Arch Surg. 1997; 132: 997-1005.
13. Liu S, Richman J, Thirlby R, Wu C. Efficacy of continuous wound catheter delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized con- trolled trials. J Am Coll Surg. 2006; 203: 914-32. doi: 10.1016/j.jamcollsurg.2006.08.007
14. Victory RA, Gajraj NM, Van Elstraete A, Pace NA, Johnson ER, White PF. Effect of preincision vs postincision infiltration with bupivacaine on postoperative pain. J Clin Anesth. 1995; 7: 192-6.
15. Givens A, Lipscomb G, Meyer N. A randomized trial of post- operative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol. 2002; 186: 1188-91.
16. Lee SH, Gwak MS, Choi SJ, Park HG, Kim GS, Kim MH, Ahn HJ, Kim J, Kwon CH, Kim TS. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013 Sep; 19(9):1036-45. doi: 10.1002/lt.23691. Epub 2013 Aug 18.
17. Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS, Du W, Gao X, Wang J, Xia Y. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Aug; 22(8):1949-57. doi: 10.1007/s00167-013-2566-0. Epub 2013
Авторы
О.К. ЛЕВЧЕНКО, Т.Ю. ПОЛЯНСКАЯ, В.Ю. ЗОРЕНКО, Г.М. ГАЛСТЯН
ФГБУ «Национальный медицинский исследовательский центр гематологии» Минздрава России, Москва, Россия
National Research Center for hematology, Moscow,Russia
ФГБУ «Национальный медицинский исследовательский центр гематологии» Минздрава России, Москва, Россия
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National Research Center for hematology, Moscow,Russia
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