Lajšanje bolečine z lokalnim anestetikom v kirurško rano po minitorakotomiji za menjavo aortne zaklopke

Mijovski, Gordan (author), Šoštarič, Maja (mentor), Podbregar, Matej (comentor)

Izvleček Izhodišče: Infuzija lokalnega anestetika v kirurško rano je postala neprecenljiv sestavni del multimodalne analgezije. Učinkovitost infuzije 0,2-odstotnega ropivakaina z uporabo PCA-črpalke (ang. PCA – patient controlled analgesia) še ni bila ocenjena pri minimalno invazivnih operacijah na srcu. Testirali smo hipotezo, da infuzija 0,2-odstotnega ropivakaina v kirurško rano z uporabo PCA-črpalke zmanjša skupni odmerek opioida v prvih 48. urah po minitorakotomijski menjavi aortne zaklopke. Metode: V tej prospektivni, randomizirani, dvojno slepi, s placebom nadzorovani raziskavi smo analizirali 70 odraslih bolnikov (31 žensk in 39 moških). Bolniki so bili randomizirani v skupino, ki je z uporabo PCA-črpalke 48 ur po operaciji v kirurško rano prejela infuzijo 0,2-odstotnega ropivakaina, ali v skupino, ki je prejela fiziološko raztopino. PCA-črpalka je bila programirana, da neprekinjeno dovaja lokalni anestetik ali fiziološko raztopino 5 ml h-1 in 5 ml enkratnega odmerka, po potrebi s 60-minutno izključitvijo. Stopnjo bolečine smo ocenjevali in beležili vsako uro po lestvici NRS (ang. NRS – numeric rating scale). Če je bila bolečina višja od 3, je bolnik prejel 3 mg opioida piritramida, odmerek je bil ponovljen in titriran po potrebi, dokler ni bilo doseženo zadovoljivo zmanjšanje bolečine. Primarni izid raziskave je bil skupni odmerek opioida piritramida v prvih 48. urah po operaciji. Sekundarni izidi so bili pogostost rezultatov NRS, višjih od 3, na lestvici od 0 do 10, bolnikovo zadovoljstvo z lajšanjem bolečine, trajanje hospitalizacije, neželeni učinki lokalnega anestetika in zapleti zaradi katetra v kirurški rani. Rezultati: Skupni odmerek opioida piritraimda v prvih 48. urah po minitorakotomijski menjavi aortne zaklopke je bil pomembno nižji (p < 0,001) v skupini z ropivakainom, mediana 3 mg (IQR 6 mg) v primerjavi z 9 mg (IQR 9 mg). Število epizod, pri katerih je bila ocena bolečine po lestvici NRS višja od 3, mediana 2 (IQR 2) v primerjavi s 3 (IQR 3) (p = 0,002) v prvih 48. urah po operaciji, je bilo pomembno manjše v skupini z ropivakainom v primerjavi s kontrolno skupino. Zadovoljstvo bolnikov z lajšanjem bolečine v naši raziskavi je bilo visoko. Okužb kirurške rane ni bilo, prav tako ni bilo neželenih učinkov lokalnega anestetika. Zaključki: Infuzija lokalnega anestetika v kirurško rano z uporabo PCA-črpalke je pomembno zmanjšala potrebo po opioidnem analgetiku in izboljšala pooperativno lajšanje bolečine. Pokazali smo, da je to možna in uporabna metoda analgezije, ki bi lahko bila vključena v strategijo multimodalnega načina lajšanja bolečine po minimalnih invazivnih operacijah na srcu.

• Language: Slovenian
• Keywords: Kateter v rani, PCA, multimodalna analgezija, AVR.
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2021
• PID: 20.500.12556/RUL-124975
• COBISS.SI-ID: 60207619
• Publication date in RUL: 26.02.2021

Secondary language

• Language: English
• Title: Pain relief with local anaesthetic in the surgical wound after minithoracotomy for aortic valve replacement

Abstract

Abstract Background: Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 hours after minithoracothomy aortic valve replacement (AVR). Methods: In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 hours postoperatively. PCA pump was programmed at 5 ml h-1 continuously and 5 ml of bolus with 60min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 hours after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter. Results: The cumulative dose of the opioid piritramide in the first 48 hours after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p=0.002) in the first 48 hours after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic. Conclusions: Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery.

• Keywords: wound catheter, PCA, multimodal analgesia, AVR.