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Anesthesia, surgical aid and resuscitation in manned space missions
Acta Asrronautica Vol. 8. No. 9-10, pp. 1109-1113, 1981 Printed in Great Britain.
0094-5765/81/091109-05502.00/0 Pergamon Press Ltd.
Anesthesia, surgical aid and resuscitation in manned space missions L. L. S T A Z H A D Z E , I. B. G O N C H A R O V , I. P. N E U M Y V A K I N , V. V. B O G O M O L O V AND I. V. V L A D I M I R O V Ministry of Health, Institute of Biomedical Problems, Moscow, U.S.S.R. (Received 19 May 1981) Alntract--When discussing problems related to medical service in space flight, particular attention should be given to the specific living conditions and changes associated with space flight. In disease and injury, surgery can be provided only after conservative therapy has failed. In this context gnotobiological chambers allowing surgery in aseptic conditions seem promising. A portable set of interchangeable surgical tools should be made of light-weight alloys that can be readily sterilized. Electroanalgesia in combination with auriculoacupuncture as well as peridureal anesthesia may be used as they allow normal operations in autonomous space flight conditions. Changes in the sympatho-adrenal and kallikrein-kinin systems, as well as water-electrolyte balance, should be taken into account in developing methods and means of medical service in critical situations. Special attention should be given to the prevention and treatment of brain edema in view of weightlessness-induced cephalad fluid shifts.
1. Introduction WXTH increased manned space mission duration and widened scope of research programs and inflight activities, the problems of rendering specialized medical service for spacecrews have acquired special importance. Anesthesia, surgical aid and resuscitation in critical situations are the most difficult situations to address. The unique space flight environment sets the requirements for the methods and means of medical service. The majority of the traditional methods for emergency medical service are not acceptable under spaceflight conditions and demand considerable change. Aside from the specificity of the space flight environment in its effect on medical service structure, consideration should be given to the complex of functional changes in the cosmonaut's body caused by space flight effects. This, in turn, might affect the clinical development of possible diseases or other pathological states resulting from exposures to extreme conditions. Medical findings from actual space missions and data obtained in ground based experimental studies are indicative of the complex of functional changes which affect practically all body systems in zero gravity. When considering special medical care, one should take into account the redistribution of body fluids, the relatively decreased circulation volume and associated dehydration, !109
I110
L . L . Stazhadze et al.
the functional hypodynamics of the myocardium and the shifts in the central and humoral parts of hemodynamic regulation. The development of inflight methods and means of anesthesia and resuscitation in life-threatemng states is also based on experimental results. 2. Methods of anesthesia
Anesthesia during space missions will be required not only for surgery but also as an element of therapeutic measures against painful syndromes of different genesis. Our experimental investigations into the effects of different types and methods of anesthesia on the functional state of the body systems in posthypokinetic period revealed a number of clinical peculiarities in all stages of anesthesia. Cardiopulmonary changes noted during reconditioning occur when anesthetics and other pharmacological agents are used, the pharmacodynamics of which brings about functional changes such as those induced by factors resembling aspects of actual space flight. Under conditions of a closed and confined spacecraft volume, the use of inhalation anesthetics are not permitted. Intravenous narcoses present a technical complexity primarily because of the difficulty of producing a reliable liquid/gas partition in the delivery system. The most adequate method for general anesthesia has proven to be an original technique of multicomponent balanced anesthesia, in which the individual pharmacological agents are used in subnarcotic, mutually potentiating doses. However, this kind of anesthesia presupposes an application of assisted pulmonary ventilation, which is undesirable when small crews are aboard the space vehicles. We also feel it is good practice to use such anesthesia as electroanalgesia in combination with reflexotherapy, in particular with auriculoacupuncture. From special experiments and clinical investigations, it is known this kind of approach provides regional anesthesia, which is adequate not only in stopping painful syndromes, but also for extra peritoneal surgical intervention. Another promising kind of regional anesthesia for inflight use is a prolonged peridural anesthesia, in which complete anesthesia and relaxation are achieved and consciousness, adequate spontaneous breathing and the possibility of the operator activities are maintained. The latter is especially important under autonomous space mission conditions. Prolonged peridural anesthesia technique has been experimentally developed and clinically tested in individuals with changed reactivity. 3. Surgery in space flight
In injuries and acute disease, surgery is performed only after conservative therapy has failed. A quite promising method of conservative therapy in inflammatory disease of the organs of the abdominal cavity (pancreatitis, appendicitis) or in gastrointestinal hemorrhage is local hypothermia of the stomach or general external hypothermia of the abdomen. A technical elaboration of the feasibility for using "space cold" is under study; it could decrease to a considerable extent the sizes and power capacity of the devices for hypothermia. The inflight possibilities in which surgery may be needed demand the
Anesthesia, surgical aid and resuscitation in manned space missions
1111
elaboration of a special complex of instrumentation and surgical tools. It was proven, that surgical operations during weightless conditions, such as during a flight along a Kepler parabola, are principally feasible. At the same time, increased microbial contamination of the confined space vehicle volume, as well as decreased immunoreactivity of man on long-term exposure to weightless space flight, require novel approaches in the solution of this problem. In this context, gnotobiological chambers allowing surgery in aseptic conditions seem promising. Since medical personnel contact is excluded the possibility of infecting an operative wound is decreased. Experimental and clinical investigations have shown the highly effective use of gnotobiological chambers for surgery. Rigid reliability.requirements and volume-weight restrictions for medical support of manned space missions dictate a need for developing portable surgical tools. Surgical tools made of light-weight alloys with interchangeable common parts and packed in a kit, permit considerable saving in volume-weight characteristics of the surgical tool set, without impairing the emergency surgery requirements. A necessary condition for these tools is the feasibility of their sterilization using physical methods. Silver-impregnated fiber provides sterility safety of surgical tools for periods of time exceeding 9 months. The utility of dressing and suture material developed by the authors is much broader due to additional bactericidal and hemostatic properties as well as the potential for absorption in body tissues. 4. Resuscitation principles and techniques Changes in the sympatho-adrenal and kallikrein-kinin systems, and in the water-electrolyte balance, resulting from space flight effects should be taken into account when developing methods and means for resuscitation. Special attention should be given to the prevention and treatment of brain, keeping in mind the effect of weightlessness-induced cephalad fluid shifts, edema in therapy of any life-threatening states. Along with use of osmotic diuretics, a technique relying on cranio-cerebral hypothermia is being actively developed as a method of dehydration. Besides modifying equipment for assisted pulmonary ventilation and electropulsated therapy of cardiac disorders in spaceflight environments, we are developing at the present time an equipment for emergency infusion-transfusion therapy, sorption purification of biological fluids, regional perfusion and blood oxygenation. Differences between the developed equipment and the usual clinical devices include the compactness, self-contained status, applicability under mobiJe conditions, service simplicity and low power capacity. It is known that numerous medical conditions (renal and hepatic insufficiency, traumatic injuries, food and drug poisoning) are followed by an accumulation of toxic metabolic products in the blood. Our studies indicated that in purifying biological fluids (blood, plasma, lymph), by passing them through different sorbents, can be used a combined treatment of endo- and exo-intoxications. Extensive clinical tests showed that the method of sorption purification of blood m'ight be used to treat different diseases.
1112
L.L. Stazhadze et al. <
In order to put this method into space medicine practice, some technological and methodological questions should be solved. First, it is necessary to develop a universal sorbent with high capacity and mechanical strength. Second, the problem of reliable gas/liquid partition has to be solved to prevent aeroembolism. Preliminary studies indicated that this might be achieved by applying gas-impermeable films or artificial gravity.
GE~IERAL I,.EDIOAL CO[I2ROL
AfiAbYSIS
DiAG:70SIS
C O. ~I S E R 7 A T I V
T P E A T ~,i E N T
S PEC
!~;LI
ZED
L E D I C A L S E E / I C E
REANI~JIAT 1,3N
A~KESTHESIA
iLSi,iO 50RBTI Of~
CRIOT}LERAPY
/ S U R G E R Y I
I
"
II I
II
I
Fig. I. The general medical control, evaluation and diagnosis crown all further actions.
Anesthesia, surgical aid and resuscitation in manned space missions
I 113
Prototype hemosorption equipment, which is a version of apparatus suitable for application in weightlessness, is currently under development. 5. Emergencies outside of the spacecraft Of particular interest is the development of emergency medical support for life-threatening states during tasks outside the spacecraft, while wearing a pressurized space suit and performing extra-vehicular activities in outer space or on the surface of another planet. In the context, scientifically predetermined programs have been worked out to automatizate response to life-threatening exposures. The starting points are the programs more probable life-threatening disturbances in cardiac activity, respiration, critical disorders of vascular tone, etc. 6. Conclusion It is logical that a physician-cosmonaut should be present aboard the spacecraft in order to r e n d e r specialized medical assistance if life-threatening states develop during space flight. At the same time, the possibility of training all the crew members, not only in self- and mutual assistance techniques but in several effective methods for anesthesia and cardiopulmonary resuscitation, should not be ignored (Fig. 1). Despite the technologically complex solutions for the majority of questions of emergency medical service during manned space flights, the trends of scientific investigations in this area are clearly defined.
0094-5765/81/091109-05502.00/0 Pergamon Press Ltd.
Anesthesia, surgical aid and resuscitation in manned space missions L. L. S T A Z H A D Z E , I. B. G O N C H A R O V , I. P. N E U M Y V A K I N , V. V. B O G O M O L O V AND I. V. V L A D I M I R O V Ministry of Health, Institute of Biomedical Problems, Moscow, U.S.S.R. (Received 19 May 1981) Alntract--When discussing problems related to medical service in space flight, particular attention should be given to the specific living conditions and changes associated with space flight. In disease and injury, surgery can be provided only after conservative therapy has failed. In this context gnotobiological chambers allowing surgery in aseptic conditions seem promising. A portable set of interchangeable surgical tools should be made of light-weight alloys that can be readily sterilized. Electroanalgesia in combination with auriculoacupuncture as well as peridureal anesthesia may be used as they allow normal operations in autonomous space flight conditions. Changes in the sympatho-adrenal and kallikrein-kinin systems, as well as water-electrolyte balance, should be taken into account in developing methods and means of medical service in critical situations. Special attention should be given to the prevention and treatment of brain edema in view of weightlessness-induced cephalad fluid shifts.
1. Introduction WXTH increased manned space mission duration and widened scope of research programs and inflight activities, the problems of rendering specialized medical service for spacecrews have acquired special importance. Anesthesia, surgical aid and resuscitation in critical situations are the most difficult situations to address. The unique space flight environment sets the requirements for the methods and means of medical service. The majority of the traditional methods for emergency medical service are not acceptable under spaceflight conditions and demand considerable change. Aside from the specificity of the space flight environment in its effect on medical service structure, consideration should be given to the complex of functional changes in the cosmonaut's body caused by space flight effects. This, in turn, might affect the clinical development of possible diseases or other pathological states resulting from exposures to extreme conditions. Medical findings from actual space missions and data obtained in ground based experimental studies are indicative of the complex of functional changes which affect practically all body systems in zero gravity. When considering special medical care, one should take into account the redistribution of body fluids, the relatively decreased circulation volume and associated dehydration, !109
I110
L . L . Stazhadze et al.
the functional hypodynamics of the myocardium and the shifts in the central and humoral parts of hemodynamic regulation. The development of inflight methods and means of anesthesia and resuscitation in life-threatemng states is also based on experimental results. 2. Methods of anesthesia
Anesthesia during space missions will be required not only for surgery but also as an element of therapeutic measures against painful syndromes of different genesis. Our experimental investigations into the effects of different types and methods of anesthesia on the functional state of the body systems in posthypokinetic period revealed a number of clinical peculiarities in all stages of anesthesia. Cardiopulmonary changes noted during reconditioning occur when anesthetics and other pharmacological agents are used, the pharmacodynamics of which brings about functional changes such as those induced by factors resembling aspects of actual space flight. Under conditions of a closed and confined spacecraft volume, the use of inhalation anesthetics are not permitted. Intravenous narcoses present a technical complexity primarily because of the difficulty of producing a reliable liquid/gas partition in the delivery system. The most adequate method for general anesthesia has proven to be an original technique of multicomponent balanced anesthesia, in which the individual pharmacological agents are used in subnarcotic, mutually potentiating doses. However, this kind of anesthesia presupposes an application of assisted pulmonary ventilation, which is undesirable when small crews are aboard the space vehicles. We also feel it is good practice to use such anesthesia as electroanalgesia in combination with reflexotherapy, in particular with auriculoacupuncture. From special experiments and clinical investigations, it is known this kind of approach provides regional anesthesia, which is adequate not only in stopping painful syndromes, but also for extra peritoneal surgical intervention. Another promising kind of regional anesthesia for inflight use is a prolonged peridural anesthesia, in which complete anesthesia and relaxation are achieved and consciousness, adequate spontaneous breathing and the possibility of the operator activities are maintained. The latter is especially important under autonomous space mission conditions. Prolonged peridural anesthesia technique has been experimentally developed and clinically tested in individuals with changed reactivity. 3. Surgery in space flight
In injuries and acute disease, surgery is performed only after conservative therapy has failed. A quite promising method of conservative therapy in inflammatory disease of the organs of the abdominal cavity (pancreatitis, appendicitis) or in gastrointestinal hemorrhage is local hypothermia of the stomach or general external hypothermia of the abdomen. A technical elaboration of the feasibility for using "space cold" is under study; it could decrease to a considerable extent the sizes and power capacity of the devices for hypothermia. The inflight possibilities in which surgery may be needed demand the
Anesthesia, surgical aid and resuscitation in manned space missions
1111
elaboration of a special complex of instrumentation and surgical tools. It was proven, that surgical operations during weightless conditions, such as during a flight along a Kepler parabola, are principally feasible. At the same time, increased microbial contamination of the confined space vehicle volume, as well as decreased immunoreactivity of man on long-term exposure to weightless space flight, require novel approaches in the solution of this problem. In this context, gnotobiological chambers allowing surgery in aseptic conditions seem promising. Since medical personnel contact is excluded the possibility of infecting an operative wound is decreased. Experimental and clinical investigations have shown the highly effective use of gnotobiological chambers for surgery. Rigid reliability.requirements and volume-weight restrictions for medical support of manned space missions dictate a need for developing portable surgical tools. Surgical tools made of light-weight alloys with interchangeable common parts and packed in a kit, permit considerable saving in volume-weight characteristics of the surgical tool set, without impairing the emergency surgery requirements. A necessary condition for these tools is the feasibility of their sterilization using physical methods. Silver-impregnated fiber provides sterility safety of surgical tools for periods of time exceeding 9 months. The utility of dressing and suture material developed by the authors is much broader due to additional bactericidal and hemostatic properties as well as the potential for absorption in body tissues. 4. Resuscitation principles and techniques Changes in the sympatho-adrenal and kallikrein-kinin systems, and in the water-electrolyte balance, resulting from space flight effects should be taken into account when developing methods and means for resuscitation. Special attention should be given to the prevention and treatment of brain, keeping in mind the effect of weightlessness-induced cephalad fluid shifts, edema in therapy of any life-threatening states. Along with use of osmotic diuretics, a technique relying on cranio-cerebral hypothermia is being actively developed as a method of dehydration. Besides modifying equipment for assisted pulmonary ventilation and electropulsated therapy of cardiac disorders in spaceflight environments, we are developing at the present time an equipment for emergency infusion-transfusion therapy, sorption purification of biological fluids, regional perfusion and blood oxygenation. Differences between the developed equipment and the usual clinical devices include the compactness, self-contained status, applicability under mobiJe conditions, service simplicity and low power capacity. It is known that numerous medical conditions (renal and hepatic insufficiency, traumatic injuries, food and drug poisoning) are followed by an accumulation of toxic metabolic products in the blood. Our studies indicated that in purifying biological fluids (blood, plasma, lymph), by passing them through different sorbents, can be used a combined treatment of endo- and exo-intoxications. Extensive clinical tests showed that the method of sorption purification of blood m'ight be used to treat different diseases.
1112
L.L. Stazhadze et al. <
In order to put this method into space medicine practice, some technological and methodological questions should be solved. First, it is necessary to develop a universal sorbent with high capacity and mechanical strength. Second, the problem of reliable gas/liquid partition has to be solved to prevent aeroembolism. Preliminary studies indicated that this might be achieved by applying gas-impermeable films or artificial gravity.
GE~IERAL I,.EDIOAL CO[I2ROL
AfiAbYSIS
DiAG:70SIS
C O. ~I S E R 7 A T I V
T P E A T ~,i E N T
S PEC
!~;LI
ZED
L E D I C A L S E E / I C E
REANI~JIAT 1,3N
A~KESTHESIA
iLSi,iO 50RBTI Of~
CRIOT}LERAPY
/ S U R G E R Y I
I
"
II I
II
I
Fig. I. The general medical control, evaluation and diagnosis crown all further actions.
Anesthesia, surgical aid and resuscitation in manned space missions
I 113
Prototype hemosorption equipment, which is a version of apparatus suitable for application in weightlessness, is currently under development. 5. Emergencies outside of the spacecraft Of particular interest is the development of emergency medical support for life-threatening states during tasks outside the spacecraft, while wearing a pressurized space suit and performing extra-vehicular activities in outer space or on the surface of another planet. In the context, scientifically predetermined programs have been worked out to automatizate response to life-threatening exposures. The starting points are the programs more probable life-threatening disturbances in cardiac activity, respiration, critical disorders of vascular tone, etc. 6. Conclusion It is logical that a physician-cosmonaut should be present aboard the spacecraft in order to r e n d e r specialized medical assistance if life-threatening states develop during space flight. At the same time, the possibility of training all the crew members, not only in self- and mutual assistance techniques but in several effective methods for anesthesia and cardiopulmonary resuscitation, should not be ignored (Fig. 1). Despite the technologically complex solutions for the majority of questions of emergency medical service during manned space flights, the trends of scientific investigations in this area are clearly defined.