Рис. 12-11. Алгоритм поведения при частых жалобах на боли во время эпидуральнои инфузии локальных анестетиков и опиоидов.
Осложнения и побочное действие
Эпидуральное введение локальных анестетиков и опиоидов может сопровождаться побочным действием(рис. 12-12). Чаще всего побочные эффекты вызваны опиоидами, вероятно потому, что пока еще недостаточно разработаны оптимальные дозировки этих препаратов при их - комб нированном эпидуральном введении вместе с локальными анестетиками.
При эпидуральном сочетанием введении препаратов этих двух групп всегда могут возникать гипотензия, анестезия и двигательная блокада. Однако если не назначаются высокие дозы бупивакаина и катетер не проникает в субарахноидальное пространство, все эти осложнения встречаются весьма редко. Поэтому данный метод можно считать относительно безопасным.
Рис. 12-12. Алгоритм поведения при побочном действии и осложнениях от эпидуральной инфузии локальных анестетиков и опиоидов.
ЗАКЛЮЧЕНИЕ
Цель данной главы заключалась в клиническом обосновании рационального использования эпидуральных инфузий комбинацией локальных анестетиков и опиоидов. Продолжительная эпидуральная инфузия одними локальными анестетиками сопряжена с частым развитием тахифилаксии. Присоединение опиоидов не только предупреждает развитие тахифилаксии, но и усиливает действие локальных анестетиков (синергизм). Одновременное эпидуральное введение локальных анестетиков и опиоидов, когда оно применяется как составная часть метода балансированной аналгезии, под-
держивает подавление центральной гиперсенсибилизации, достигнутое уже во время операции благодаря региональной анестезии. (Аналогичное воздействие комбинированное эпидуральное введение локальных анестетиков и опиоидов оказывает и на нейроэндокринные реакции, см. гл. 4.)
Таким образом, аналгезия представляет собой продолжительный процесс, который не ограничивается только послеоперационным периодом. Восприятие аналгезии как единого продолжающегося процесса, использование метода балансированной аналгезии и подавление нежелательных патофизиологических реакций должно сократить время выздоровления. Центральную роль в этом играет комбинированное эпидуральное введение локальных анестетиков и опиоидов.
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