Журнал «Медицина неотложных состояний» 8 (63) 2014

Introduction. Adenotomy with conducting or without tonsillectomy is one of the most frequently performed surgical procedures in otorhinolaryngological practice. Nasopharyngeal tonsil hypertrophy is the most common cause of nasal congestion in children. Anesthesia during adenotomy is designed to provide sufficient perioperative analgesia, a good surgical access, which is aimed to use the same airways by an anesthesiologist and a surgeon and prevention of postoperative nausea and vomiting [1]. Operative stress causes the child’s body to respond by different systems: nervous, immune, neuroendocrine, metabolism [2-4]. It’s worth mentioning that the anesthesia, before joining surgical trauma leads to changes in homeostasis and is actually a component of operational stress [5]. To assess the adequacy of anesthesia using different indicators: the state of central hemodynamics, the level of stress hormones, glucose and free fatty acids. One of the good examples of surgical stress is a change in glucose metabolism as a result of glucocorticoids on carbohydrate metabolism (hyperglycemia is the result of inhibition of gluconeogenesis and glucose oxidation in tissues). Some authors believe that the level of plasma glucose can be quite a qualitative indicator of the level of operative stress [6].

Materials and methods. The research was conducted at the municipal health care «Regional Clinical Hospital» of Kharkiv and included 55 children aged 6 to 11 years, who had adenotomy. The degree of operative risk of anesthesia in all patients was I by ASA. During the study there were not included children younger than 5 years and older than 12 years; otorhinolaryngological surgical interventions except adenotomy; physical status ASA III-IV; the presence of severe chronic diseases accompanied by impaired systemic metabolic and functioning of other organs and systems; presence of organic or functional involvement of central nervous system. Depending on the way anesthesia was performed, patients were divided into two groups. The group I (n = 24) included patients operated under conditions of intravenous anesthesia based on propofol. The group II (n = 31) included patients operated under conditions of inhalation anesthesia with sevoflurane. Patients of the compared groups did not differ significantly in age, height, weight, and volume of the surgery. In group I the induction of anesthesia was performed using 1% solution of propofol (2.5-3 mg/kg) maintenance carried out by fractional rate of administration of propofol (1 mg/kg) approximately 2.5-3 minutes after previous administration. In group II induction of anesthesia was performed sevoflurane-oxygen mixture “bolus method” without filling the respiratory circuit, 8 vol% sevoflurane and the flow of oxygen 4 L/min. Upon reaching the clinic surgical stage of anesthesia, maintenance of anesthesia was performed at feed 2-2.5vol% sevoflurane in fresh gas flow - 2 L/min. We used anesthetic-contained breathing machine MK-1 (Respekt-Plus, Belarus). In both groups, muscle relaxation was provided - suxamethonium (2 mg/kg). In group I intraoperative analgesia was provided by fentanyl (2 mg/kg), and group II was carried out by a combination of fentanyl analgesia (2 mg/kg) with analginum (8-10 mg/kg). In order to prevent nausea and vomiting in patients of both groups intraoperatively administered ondansetron (0.1 mg/kg), and group II patients with combination of dexamethasone (0.1-0.15 mg/kg ). Postoperative analgesia in patients conducted oral ibuprofen (10 mg/kg). Estimation of efficiency analgesia in the early postoperative period was carried out using the scale Wong and Baker FACES Pain Scale, behavioral scale FLACC (Face, Legs, Activity, Cry, and Consolability) and scale Oucher. The level of blood glucose was determined by glucose-oxidase method. The blood for biochemical studies was taken at the following stages: 1st - before surgery; 2nd - traumatic moment of operation; 3rd - extubation; 4th - 20 hours after surgery. Statistical analysis of data was performed using the values ​​of Student t-test. Differences were considered significant at p < 0.05.

Results. Preoperative glycemia parameters in both groups didn’t go beyond laboratory standards and averaged 3.6 ± 0.2 mmol/l in group I and 3.7 ± 0.2 mmol/l in group II (p > 0.05). At the stage of the traumatic moment of operation parameters of blood glucose in groups increased to 4.0 ± 0.1 mmol/l and 4.1 ± 0.3 mmol/l, respectively (p > 0.05). After extubation in group I glycemia index increased within the normal range 4.8 ± 0.1 mmol/l, but it was statistically higher level on the stage of the traumatic moment of operation (p < 0.001). In group II glycemia index was 4.5 ± 0.2 mmol/l, but difference compared to the traumatic moment of operation wasn’t marked (p > 0.05). It is noteworthy that the performance on stage of extubation glycemia in both groups were statistically higher than preoperative values (p < 0.001 and p < 0.01, respectively. The next morning after surgery there was a tendency to decline in glycemia in both groups, without going beyond the norm. We found no statistically significant difference between groups at the final stage of the study (p > 0.05). The average intensity of pain at 1 hour after surgery in groups was (1.0 ± 0.3 points and 1.5 ± 0.2 points, respectively) on a scale «face,» according to this scale score corresponds to the «face» - «a little bit hurt» (p > 0.05). The dynamics observations on these stages of research on a scale Wong and Baker FACES in both groups there is a tendency to decrease in the intensity of pain and the pursuit of «face» - «no pain» (p > 0.05). It is noteworthy that in the early postoperative period, the average intensity of pain on a scale «Oucher» 1 hour after operation was more pronounced in patients of group II – 1.8 ± 0.3 points compared to group I - 0.5 ± 0.2 points (p < 0.001), despite the combination of intraoperative fentanyl with analginum in group II. On a scale of «Oucher» for further stages of the study there is a tendency to decrease in the intensity of pain, while pain intensity in groups corresponding to the picture - «no pain» (p > 0.05). According to behavioral scale FLACC the entire time between groups was not marked significant differences (p > 0.05), interpretation points at all stages of research on this scale suggests that patients in both groups feel comfortable. Thus, given the results of this study, we can suggest that adenotomy of patients in both groups in conditions of general anesthesia, which was conducted with either propofol or sevoflurane with fentanyl in combination with or without analginum, provides effective intraoperative analgesia without significant fluctuations in glycemia.

Conclusions. The complex research of glycemia levels integrated with the study of reactions of pain reaction in children in both groups, demonstrated that the use of ibuprofen dose of 10 mg/kg with the purpose of postoperative analgesia leads to adequate postoperative analgesia. Although the level of glycemia is a sensitive indicator of the surgical stress, it can’t fully identify the adequacy of patient’s antinociceptive protection, so it is necessary to study neuroendocrine responses further such as cortisol and insulin in serum.