Anesthesia for removal of prostate adenoma

Types of anesthesia for prostate adenoma surgery

An operation to excise prostate adenoma is a surgical intervention to remove a benign neoplasm that occurs due to the proliferation of cellular tissue. Prostate adenoma is a very common disorder among older men.

You can get complete information about the type of anesthesia under which operations to remove prostate adenoma are performed from an anesthesiologist after a comprehensive examination of the body, the exclusion of all possible contraindications and the chosen method of performing surgery.

Causes and symptoms of the development of the disease

Despite the fact that the neoplasm is benign, it can significantly increase in size over time and lead to squeezing of the urinary canal.

The causes leading to the formation of this pathology are not yet fully understood. As one of the root causes, experts identify late fertility in men.

Factors affecting the development of the disease:

• chronic inflammatory process affecting the urinary organs;
• hereditary predisposition;
• impaired circulation in the pelvic area;
• drinking alcohol and smoking.

Clinical symptoms characteristic of prostate adenoma: frequent urge to urinate, a feeling of incomplete emptying of the urinary bladder, etc.

Preparing for surgery

Basic interventions on the prostate:

• laser vaporization;
• adenomectomy;
• transurethral resection (TUR-surgery).

The type of anesthesia chosen by the anesthesiologist directly depends on the age of the man, his state of health at the time of the operation, and the chosen method of intervention. To do this, before the procedure, the patient is assigned a number of laboratory and instrumental studies: a general clinical blood test, urinalysis, electrocardiography (to exclude cardiac pathologies), chest X-ray, ultrasound of the pelvic organs.

Anesthesia and anesthesia: description and features

Types of anesthesia used in medical practice:

• General anesthesia: during all surgical procedures, the patient is in a state of sleep. Administered intravenously by an anesthetist.
• An epidural anesthesia involves injecting a local anesthetic into the epidural region (between the fourth and fifth lumbar vertebrae) using a special needle. The anesthetic blocks all the nerve endings responsible for the susceptibility and movement of the body parts that are below the navel.

Transurethral resection is performed under local anesthesia, and other operations - under general anesthesia. If necessary, if the patient categorically refuses local anesthesia, the TUR operation can be performed under general anesthesia.

The main task of the anesthesiologist is to select such a drug, the use of which minimizes the risks of complications. Also, before the operation, many patients are concerned about the question of whether pain relief will affect their future life. The conducted studies and the experience of anesthesiologists prove that the possibility of negative effects of anesthesia on the body is minimized.

"Exit" from anesthesia

When anesthesia is introduced into the body, its reflexes and reaction to tissue injury during intervention are inhibited. At the stage of exit from such a state, the renewal of all biological processes of the organism's vital activity is carried out. When leaving this state, patients are under the control and supervision of medical staff, since neuropsychiatric complications, nausea, vomiting and dizziness may occur.

Surgical treatment of prostate adenoma. Question from Mariam.

Content:

Hello, please tell me if it is possible to perform an adenoma operation with local anesthesia! thank you!

Prostate adenoma - an enlargement of the gland more than 27-30 ml, with compression of the urethra and surrounding neurovascular bundles, resulting from urination and sexual dysfunction.

Adenoma treatment

With a gland larger than 40 ml, recurrent urinary retention and infections, blood in the urine, progressive renal failure, surgical treatment of adenoma is indicated, including minimally invasive:

• Laser techniques: interstitial coagulation (punctures of the prostate tissue with a laser handpiece), vaporization (evaporation of gland tissue layer by layer, 1 mm each), enucleation (formation of a cavity in the prostate by a laser beam).

The advantages of the laser are bloodlessness (there is no need for hemostasis and suturing), asepticity (microorganisms die), stimulation of tissue regeneration, a short rehabilitation period, low trauma.The intervention is carried out through a urethral endoscope, on the second day the urinary catheter is removed, and the patient urinates himself. Laser operations are carried out with prostate sizes from 40 to 80 ml, with a green holmium laser it is possible to operate on the prostate up to 120 ml.

• Transurethral resection (TUR): endoscopic treatment of adenoma through a multi-pass urethral endoscope. In the prostate, a 3.5 ml cavity is formed with an electric loop with simultaneous hemostasis, the bladder is washed through the catheter and blood clots and urine are removed. Minimally invasive intervention, the "gold standard" for the treatment of adenoma with a short recovery period without excessive tissue trauma (all manipulations are performed through the urethra);
• Adenomectomy: removal of the prostate (in 3-5% of men) by access through the anterior abdominal wall when other methods are ineffective.

Pain relief during surgical treatment of adenoma

Minimally invasive techniques can be performed under epidural anesthesia, since it just anesthetizes the entire body below the waist, including the anogenital zone. This is not local, but regional or conduction anesthesia, it is preferred.

If it is technically impossible (curvature of the spine and anatomical anomalies in the lumbar region) or contraindications (clotting disorders, increased intracranial pressure, hypotension, epilepsy), short intravenous anesthesia or combined (intravenous and inhalation) is performed. Complications of anesthesia - thrombosis, cardiac death from a heart attack and arrhythmias, cardiopulmonary failure, but their frequency is less than 1%. To prevent complications before surgery, the patient is consulted and examined by an anesthesiologist with a general practitioner. The final version of anesthesia is chosen by the operating urologist together with the anesthesiologist.

Pain relief

The choice of the method of anesthesia in the surgical treatment of patients with prostate adenoma becomes important due to the age of the operated patients, who overwhelmingly have concomitant pathological changes in the cardiovascular system, respiratory organs, central nervous system, kidney and liver failure, hormonal and metabolic changes . This greatly reduces the adaptive-compensatory capabilities of the body and requires special attention to the anesthetic management of adenomectomy. In recent years, preference has been given to epidural anesthesia, which can be used as an independent method, or in combination with various drugs to create drug-induced sleep. Epidural anesthesia in adenomectomy occupies a special position among the methods of pain relief, since the local anesthetics used in its application make it possible to influence the peripheral afferent link of the reflex arc of pain perception. In contrast, narcotic drugs used during general anesthesia act on the central mechanisms of pain perception, without adequately preventing the development of neurovegetative, hormonal and other disorders caused by surgical trauma. In addition, long-term epidural blockade makes it possible to effectively and continuously stop pain and painful urge to urinate in the early postoperative period, which, in turn, is the prevention of coronary heart disease and coronary insufficiency in elderly and senile patients.

Contraindications to epidural anesthesia are pustular skin diseases, uncorrectable hypovolemia. The advantages of epidural anesthesia include the low toxicity of the local anesthetic, the possibility of its re-introduction into the epidural space through a catheter inserted into it with postoperative analgesia for several days. Premedication does not differ from the generally accepted one. On the eve of the day of surgery, the patient receives sleeping pills, a tranquilizer and an antihistamine at night. Droperidol (0.08 - 0.1 mg/kg) and Seduxen (10 mg) are administered intramuscularly 30 minutes before the operation. The puncture of the epidural space is performed in the intervals between LI and LII, or ThXII with the introduction of a fluoroplastic or polyethylene catheter 1-2 segments above the puncture and its fixation to the skin with an adhesive plaster. When the duration of the operation is 1-1.5 hours, it is sufficient to introduce 20-25 ml of a 3% trimecaine solution or 15-20 ml of a 2% lidocaine solution. Anesthetics are administered slowly and fractionally. During the operation, maintenance doses of anesthetics (5-7 ml each) are injected through the catheter into the epidural space. Anesthesia with epidural administration of anesthetics occurs within 15-20 minutes. After the onset of anesthesia, most patients experience a decrease in blood pressure. This reaction to sympathetic blockade is physiological with moderately pronounced changes in hemodynamic parameters - a decrease in blood pressure by 10 - 30 mm Hg. Art., increasing venous pressure by 15 - 40 mm of water. Art., a decrease in heart rate by 5 - 20 beats / min in the absence of initial bradycardia.Moderately pronounced changes in hemodynamics during epidural anesthesia have a beneficial effect on the body, as they unload the pulmonary circulation, reduce blood pressure in patients with hypertension. At the same time, hemodynamic disturbances during epidural anesthesia can in some cases be significantly pronounced and manifest as a sharp drop in blood pressure to 60–70 mm Hg. Art., an increase in venous pressure by 40 - 60 mm of water. Art., phenomena of collapse.

This requires the immediate administration of vasopressors (mezaton intravenously slowly 0.1-0.5 ml of 1% solution in 40 ml of 5-40% glucose solution, or isotonic sodium chloride solution, or 0.4-1 ml of 5% ephedrine solution jet, slowly, in 5% glucose solution, or isotonic sodium chloride solution), analeptics (cordiamin, camphor, cytiton), strophanthin (0.5-1 ml of 0.05% solution diluted in 10-20 ml 5 - 40 % glucose solution, or isotonic sodium chloride solution) or intravenous injection of 0.06% solution of corglicon 0.5 - 1 ml, diluted in 20 ml of 20% glucose solution, inhalation of carbogen.

Lidocaine causes a predominant blockade of the sensory and motor pathways of the spinal cord and, to a much lesser extent than Trimecaine, a blockade of the sympathetic ganglia. This makes it preferable to use lidocaine in patients with severe damage to the cardiovascular system, hypertension, who are at increased risk of developing severe hemodynamic disorders during epidural anesthesia. Preliminary correction of relative hypovolemia with plasma-substituting solutions prevents a decrease in blood pressure during anesthesia and improves renal hemodynamics. With a threatening decrease in blood pressure during adenomectomy, an increase in the volume of circulating blood is a pathogenetically substantiated therapy. In such cases, during the operation, plasma-substituting solutions (polyglucin, gemodez), 5% glucose solution 500-1000 ml are administered intravenously. This reduces the discrepancy between the volume of circulating blood and the volume of the vascular bed, which increases as a result of sympathetic blockade and vasodilation in the anesthetized area. It should be emphasized that intravenous administration of 0.5-1 l of a 5% glucose solution in a jet immediately after the last portion of the anesthetic was injected into the epidural space prevents a significant decrease in blood pressure and eliminates the need for the introduction of vasopressors.

With epidural anesthesia, it is important to eliminate the undesirable influence of the emotional factor on the operation, which inevitably occurs with the preserved consciousness in most patients. Intravenous administration of small doses of seduxen - 2 ml of a 0.5% solution (introduced slowly in isotonic sodium chloride solution) is sufficient to provide a sedative effect. The introduction of narcotic analgesics into the epidural space (2-3 mg of morphine hydrochloride or omnopon in 10 ml of isotonic sodium chloride solution 1-2 times a day) causes a fairly pronounced and prolonged pain relief in the postoperative period, which contributes to the normalization of the functions of vital body systems. The use of narcotic analgesics for postoperative analgesia has a significant advantage over prolonged epidural anesthesia with local anesthetics, which can cause arterial hypotension when there is a shortage of circulating blood volume. At the same time, the use of narcotic analgesics is not without its negative aspects, such as the occurrence of dizziness, nausea, vomiting, and itching of the skin. However, their side effects during prolonged epidural anesthesia appear in a small number of patients and do not significantly affect the course of the postoperative period. These symptoms are eliminated by subcutaneous injection of 1 ml of a 0.2% solution of platyfillin, subcutaneous or intramuscular injection of 1 ml of a 0.1% solution of metacin. Prolonged epidural anesthesia with preliminary correction of relative hypovolemia with plasma-substituting solutions is the method of choice for emergency adenomectomy. In these cases, premedication is carried out 30-40 minutes before surgery; it includes the introduction of sedatives and antihistamines, atropine. The accumulated experience shows that prolonged epidural anesthesia allows you to expand the indications for emergency adenomectomy.

The main disadvantage of epidural anesthesia is the development of hemodynamic disorders, which can be prevented by a complex of therapeutic and preventive measures. Epidural anesthesia can be combined with intravenous or intramuscular administration of ketamine or with electrical stimulation of the central nervous system (electrosleep) Lenkovsky F. M. et al., 1984.

Ketamine is a non-barbiturate drug with a general anesthetic and analgesic effect.The drug has a stimulating effect on the cardiovascular system, increases blood pressure by 20-30% of the initial level, increases the minute volume of blood circulation and leads to an increase in heart rate. With combined epidural anesthesia with ketamine, the drug is administered intravenously slowly over 30-60 seconds at a dose of 2 mg / kg. The drug is contraindicated in patients with a history of cerebral circulation disorders, high blood pressure, severe decompensation of blood circulation. Combined epidural anesthesia using ketamine, electrosleep makes it possible to obtain a good analgesic effect for transcystic adenomectomy, promotes relaxation / muscles of the anterior abdominal wall, stabilization of hemodynamic parameters, which reduces the need for the introduction of vasopressors during surgery, it should be taken into account that an attempt to epidural anesthesia in some patients with prostate adenoma glands of senile age may fail due to involutional obliteration of the epidural space. The complications of epidural anesthesia include dysfunction of the pelvic organs, epiduritis, arachnoiditis, purulent meningitis.

The advantages of spinal anesthesia are the simplicity of the technique, fast-onset anesthesia with deep sensory and motor blockade in the anesthesia zone, lasting 1.5-2 hours, which makes it possible to perform adenomectomy. At the same time, due to the risk of infection in the spinal canal, one should not resort to prolonged spinal anesthesia using its catheterization. Currently, for spinal anesthesia, a 0.5-1% solution of sovcaine is used in an amount of 0.3-1 ml. Premedication is the same as for epidural anesthesia. The disadvantages of spinal anesthesia include the difficulty of dosing the anesthetic and regulating its action. Possible complications are associated with the effect of the anesthetic on the vasoconstrictor vegetative formations of the spinal cord, which is manifested by a drop in blood pressure and respiratory distress. Vascular disorders with spinal anesthesia are more significant than with epidural.

Endotracheal anesthesia is used for adenomectomy in patients who do not have severe concomitant diseases of the heart and respiratory organs (postinfarction cardiosclerosis, atrial fibrillation, chronic pneumonia, bronchiectasis, bronchial asthma). It allows you to adjust the dose of the narcotic substance and, if necessary, to perform a long-term operation using small doses of the drug, which became possible due to the use of muscle relaxants and controlled artificial lung ventilation, which is a powerful prophylactic tool to combat hypoxia and is extremely important, especially in the elderly. . The most dangerous for elderly and senile people suffering from prostate adenoma and chronic renal and hepatic insufficiency is deep anesthesia. At present, in connection with the development of the technique of superficial endotracheal anesthesia, it was possible to ensure the relative constancy of the main physiological functions of the body involved in the regulation of hemodynamics, respiration, gas exchange, acid-base state, electrolyte balance during the period of adenomectomy. Endotracheal anesthesia using neuroleptic analgesia in combination with artificial ventilation of the lungs with a mixture of oxygen and nitrous oxide and turning off consciousness with a hypnotic (barbiturates, seduxen, sodium oxybutyrate, etc.) ensures adenomectomy under normal blood gas conditions. Premedication for endotracheal anesthesia includes taking a tranquilizer, antihistamine and hypnotic drugs on the eve of the operation (at night) and in the morning on the day of the operation. 30 minutes before surgery, 10 mg of seduxen, 2 mg of promedol or 5 mg of droperidol are administered intramuscularly. 10 minutes before surgery, 0.5 ml of a 0.1% solution of atropine with calcium chloride (10% solution per 20 ml of 40% glucose solution) is injected intravenously. For induction anesthesia, droperidol is administered intravenously at a dose of 0.05 ml / kg of 0.25% solution in combination with fentanyl at a dose of 0.05 ml / kg of 0.005% solution, thiopental sodium 100 mg, myorelaxin 2% solution 1 - 1.5 mg/kg. During the introduction of these drugs, the patient breathes a mixture of nitrous oxide and oxygen (1: 1). At the end of the introduction of drugs for neuroleptic analgesia, the patient's consciousness is lost, tracheal intubation is performed. Neuroleptic analgesia is supported by artificial ventilation of the lungs and the introduction of fentanyl at a dose of 0.05 - 0.1 mg every 20 minutes. The introduction of fentanyl is stopped 20-30 minutes before the end of the operation. In the course of the operation, fractional muscle relaxants (myorelaxin, arduan) are injected. The non-depolarizing muscle relaxant arduan is administered intravenously at a dose of 0.04-0.06 mg/kg. In these doses, the drug in 2-3 minutes causes complete relaxation, which lasts for 50 minutes; if it is necessary to prolong the effect, 0.02-0.03 mg/kg is re-introduced.In patients with severe arterial hypertension at the time of tracheal intubation, the risk of an even greater increase in blood pressure and the development of a hypertensive crisis increases. To prevent this complication, it is recommended to slowly inject pentamine at a dose of 10 mg intravenously before induction of anesthesia. With a decrease in blood pressure to 30 - 40% of the initial value, induction anesthesia is started. It should also take into account the risk of barbiturates administration to patients with prostate adenoma with cardiovascular and pulmonary insufficiency due to the tendency to fall in blood pressure and inhibition of the respiratory center. The use of pressuren and epontol for induction anesthesia is more appropriate in elderly patients, since hemodynamic changes are less pronounced and normalization of blood pressure is observed. When using droperidol in anesthesiology, it is necessary to carefully monitor the state of blood circulation and respiration. Large doses can cause a decrease in blood pressure and respiratory depression. Droperidol has an a-adrenolytic effect, resulting in a decrease in blood pressure, especially in malnourished, debilitated patients with prostate adenoma. In these cases, it is more rational to use balanced analgesia or ataralgesia instead of neuroleptic analgesia, in which hemodynamic changes are less pronounced.

During ataralgesia, premedication is the same as for neuroleptic analgesia. Induction anesthesia includes intravenous administration of seduxen or relanium (0.25 mg / kg), fentanyl (0.05 ml / kg) or dipidolor (0.05 mg / kg), inhalation of a mixture of nitrous oxide and oxygen (2: 1), administration muscle relaxant, tracheal intubation. Maintenance therapy is carried out by artificial lung ventilation, fractional administration of a muscle relaxant, fentanyl.

When anaesthetizing patients with prostate adenoma, one should take into account the increased risk of adverse effects of medications due to their impaired kidney and liver function and a number of hormonal and metabolic changes. In patients with prostate adenoma, hypersensitivity to neuroleptics, tranquilizers, barbiturates is often observed. In such cases, it is necessary to reduce the dose of the drug by 1/2 or 1/3 of the usual dose for a middle-aged person. When anesthesia in cases of emergency adenomectomy, it is necessary to take into account the slow rate of absorption, destruction and release of pharmacological drugs in elderly and senile patients. In this regard, the doses of drugs for anesthesia should be chosen individually.