на, т. е. 1/2 той дозы, которая необходима при каудальной блокаде(1 мл/кг) [137]. Кроме того, рассасывание бупивакаина, инъецированного в края раны, у детей происходит значительно медленнее, чем у взрослых. Поэтому концентрация препарата в плазме крови удерживается много ниже токсического уровня [138].

К сожалению, этот технически простой и безопасный метод устранения боли в области разреза не получил должного распространения. Более того, инфильтрационная аналгезия применяется крайне недостаточно или вовсе не используется при операциях у новорожденных.

ЗАКЛЮЧЕНИЕ

В течение последнего десятилетия росло понимание того, что дети всех возрастов испытывают боли точно так же, как и взрослые. Особенно важно, чтобы медицинский персонал, курирующий детей в послеоперационном периоде, постоянно оценивал степень выраженности боли, учитывая при этом уровень развития ребенка. Большинство детей чувствуют себя вполне комфортно, если подобран подходящий анальгетик, устраняющий боль, если этот анальгетик назначен в адекватных дозах и с интервалами, соответствующими особенностям его фармакокинетики. Правильное использование опиоидов и разных методов региональной анестезии/аналгезии приведет к тому, что уйдут в прошлое традиционные внутримышечные инъекции и порождаемые ими страхи у детей.

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23

Аналгезия после операции кесарева сечения

Бет Минзтер (Beth Minzter)

Эффективное обезболивание после операции кесарева сечения может стать крайне необходимым. Важное значение имеет не только само обезболивание, но и небольшая седация, а также возможность передвигаться, позволяющая матери обслуживать новорожденного. Кроме того, желательно быстро устранить боли, удерживая концентрацию препаратов на низком уровне и сводя к минимуму проникновение их в организм ребенка при грудном вскармливании. Именно эти цели имеются в виду в этой главе, содержащей обзор потенциальных возможностей аналгезии, применяемой и после кесарева сечения.

ПОСЛЕРОДОВОЕ РАЗРЕШЕНИЕ ФИЗИОЛОГИЧЕСКОЙ АДАПТАЦИИ ПЕРИОДА БЕРЕМЕННОСТИ

В задачи данной главы не входит обзор механизмов физиологической адаптации при беременности (табл. 23-1), но было бы неверным полностью их игнорировать. В частности, следует рассмотреть вопрос о влиянии этой физиологической адаптации на последующее обезболивание после кесарева сечения. Дискуссия о физиологической адаптации при беременности и ее воздействии на анестезию во время беременности и родоразрешения отражена во многих обзорах [1].

Сердечный выброс заметно возрастает после родов, возвращаясь к уровню, наблюдавшемуся до беременности, лишь через 2-4 нед после родов [2]. Наибольшему риску декомпенсации сразу после родоразрешения подвержены пациентки со стенозом сердечных клапанов и легочной гипертензией. Кроме того, возвращение сердечного выброса к исходному уровню играет очень небольшую роль у подавляющего большинства женщин.

Уменьшение размеров матки способствует быстрому устранению -ле гочных изменений, вызванных подъемом диафрагмы и механическим сдавлением легких (см. табл. 23-1). Величины функционального резервного объема и остаточного объема быстро нормализуются. Альвеолярная вентиляция отражает степень падения уровня прогестерона в крови и его возвращение к исходным показателям, наблюдающееся через 23 нед после родов [3].

Таблица 23-1. Физиологическая адаптация во время беременности

Отечность верхних дыхательных путей начинает уменьшаться по мере развертывания послеродового диуреза. Объем плазмы значительно снижается, и отек дыхательных путей ликвидируется в течение2-4 нед после родов

[4].

Повышенный уровень прогестерона в крови может вызывать снижение двигательной активности кишечника, ослабление всасывания в нем и уменьшение тонуса сфинктеров пищевода[5]. Последствия механического воздействия увеличенной матки на кишечник ликвидируются через2-3 дня после родов, но повышенный уровень прогестерона удерживается несколько недель.

Таким образом, при быстрой нормализации величин функциональной резервной емкости и остаточного объема, даже несмотря на затянувшееся повышение уровня прогестерона и объема плазмы, разрешающаяся физиологическая адаптация периода беременности способна оказывать лишь незначительное влияние на тактику аналгезии после операции кесарева сечения. Некоторый отек дыхательных путей и снижение тонуса пищеводного сфинктера могут иметь клиническое значение «узагруженных» больных с притупленной реакцией. В подобных ситуациях пока не выработано определенной тактики аналгезии.

Поскольку разрешающаяся физиологическая адаптация периода беременности весьма незначительно воздействует на тактику аналгезии и на -ис ходы кесарева сечения, то и «усовершенствованная» аналгезия вряд ли будет заметно влиять на показатели летальности, все же имеющей место у этой в