Pooperativna analgezija s katetrom pod mišico erector spinae pri videotorakoskopskih operacijah pljuč

Gams, Polona (author), Šoštarič, Maja (mentor)

Uvod Zgodnja rehabilitacija in aktivacija po operaciji v prsnem košu sta izrednega pomena za ohranjanje pljučne funkcije in preprečevanje pooperativnih zapletov. Razlog slabega sodelovanja bolnikov pri rehabilitaciji so najpogosteje bolečina v pooperativni rani ali stranski učinki opioidnih analgetikov. Do sedaj znane metode regionalne analgezije po torakalnih operacijah imajo pomembne omejitve, uporaba opioidnih analgetikov v večjih količinah pa je nezaželena zaradi njihovih stranskih učinkov. Namen raziskave je dokazati protibolečinsko delovanje nove metode regionalne anestezije z dovajanjem lokalnega anestetika preko katetra pod mišico erector spinae (erector spinae ploskovni blok ESPB) z zmanjšanjem porabe opioidnih analgetikov, manjšo bolečino v mirovanju in gibanju ter boljšo rehabilitacijo v prvih 48-ih urah po video-torakoskopski operaciji pljuč. Metode V prospektivno, randomizirano, kontrolirano raziskavo smo vključili polnoletne osebe, ki so bile predvidene za elektivne video-torakoskopske operacije pljuč. Bolnike smo naključno razdelili v dve skupini. V skupini ESPB smo bolnikom predoperativno vstavili kateter pod mišico erector spinae na strani operacije. Ob zaključku operacije smo jim dovedli začetni odmerek, nato pa nadaljevali z infuzijo lokalnega anestetika po protokolu. Bolniki v skupini ICNB so prejeli standardno obliko analgezije, ki je intraplevralni interkostalni blok (ICNB), izveden s strani kirurga ob koncu operacije. Vsi bolniki so dobili črpalko (ang. patient-controlled analgesia PCA), preko katere so si ob bolečini >3 po vizualni analogni lestvici (VAS) aplicirali odmerek opioidnega analgetika. Vsi bolniki so prejeli še dodatne periferno delujoče analgetike. Bolniki so vsako uro, razen med spanjem, ocenili subjektivno zaznavanje bolečine v mirovanju in med kašljanjem od 0-10 po VAS lestvici. Bolniki so na dan operacije, po 24-ih ter 48-ih urah izvedli meritve inspiratorne in ekspiratorne moči. Pooperativno mišično moč smo izmerili kot odstotek izhodiščne predoperativne vrednosti. Spremljali smo tudi pogostnost stranskih učinkov opioidnih analgetikov in pojav morebitnih zapletov v zvezi s katetrom. Rezultati V raziskavo smo vključili 60 bolnikov, od katerih je 25 iz vsake skupine prišlo do končne analize. Skupna poraba opioidnega analgetika piritramida v 48-ih urah v skupini ESPB je bila 21,64 ± 14,22 mg in v skupini ICNB 38,34 ± 29,91 mg (p=0,035). Bolniki v skupini ESPB so imeli nižje VAS v mirovanju kot bolniki iz primerjalne skupine (1,19 ± 0,73 proti 1,77 ± 1,01; p=0,039). Ni bilo statistično značilnih razlik med skupinama pri meritvah maksimalnega inspiratornega pritiska (MIP) ter maksimalnega ekspiratornega pritiska (MEP) po 24-ih urah (MIP p=0,088; MEP p=0,182) ali po 48-ih urah (MIP p=0,110; MEP p=0,645). Skupini se nista razlikovali po pogostnosti pooperativnih zapletov in pogostnosti stranskih učinkov opioidnih analgetikov. Prav tako ni bilo razlik v času do odstranitve torakalne drenaže in odpusta iz bolnišnice. Zaključki Bolniki s kontinuiranim ESPB v prvih 48-ih urah po video-asistirani torakalni (VATS) operaciji pljučnega tumorja potrebujejo manj opioidnih analgetikov in občutijo manj bolečine kot bolniki z ICNB. Med skupinama ni razlik glede pooperativne respiratorne mišične moči, pooperativnih zapletov in časa do odpusta iz bolnišnice. Kateter pod mišico erector spinae je zahtevnejši za vstavitev ter zahteva več nege kot ICNB.

• Language: Slovenian
• Keywords: Erector spinae blok, interkostalni blok, video-torakoskopske operacije, torakalna analgezija, regionalna anestezija
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-151712
• Publication date in RUL: 18.10.2023

GAMS, Polona, 2023, Pooperativna analgezija s katetrom pod mišico erector spinae pri videotorakoskopskih operacijah pljuč [online]. Doctoral dissertation. [Accessed 11 April 2025]. Retrieved from: https://repozitorij.uni-lj.si/IzpisGradiva.php?lang=eng&id=151712

Secondary language

• Language: English
• Title: Postoperative analgesia with a catheter under the erector spinae muscle for videothoracoscopic lung surgery

Abstract

Introduction Early rehabilitation and activation after thoracic surgery are extremely important for maintaining lung function and preventing postoperative complications. The reason for patients' poor participation in rehabilitation is most often pain in the postoperative wound or side effects of opioid analgesics. The hitherto known methods of regional analgesia after thoracic surgery have significant limitations. The purpose of the research is to demonstrate the analgesic effect of a new method of regional anesthesia by delivering local anesthetic through a catheter under the erector spinae muscle (erector spinae plane block ESPB) with a reduction in the consumption of opioid analgesics, less pain at rest and cough, and better rehabilitation in the first 48 hours after video-thoracoscopic lung surgery. Methods Adult subjects scheduled for elective video-thoracoscopic (VATS) lung surgery were included in a prospective, randomized, controlled study. Patients were randomly divided into two groups. In the ESPB group, a catheter was inserted preoperatively under the erector spinae muscle on the side of the operation. At the end of the operation, the initial bolus of local anesthetic was delivered through catheter, and then continued with the local anesthetic infusion according to the protocol. Patients in the ICNB group received a standard form of analgesia, which is an intrathoracic intercostal block (ICNB) performed by the surgeon at the end of surgery. All patients received a patient-controlled analgesia pump, through which they administered a dose of opioid analgesic in case of pain >3 on the visual analogue scale (VAS). All patients received additional peripherally acting analgesics. Every hour, except during sleep, the patients assessed the subjective perception of pain at rest and during coughing from 0-10 according to the VAS scale. On the day of the operation, after 24 and 48 hours, the patients performed measurements of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Postoperative muscle strength was expressed as a percentage of the baseline preoperative value. We also monitored the frequency of side effects of opioid analgesics and the occurrence of possible complications related to the catheter. Results We included 60 patients in the study, of which 25 from each group made it to the final analysis. The total consumption of the opioid analgesic piritramide in the ESPB group was 21.64 ± 14.22 mg and in the ICNB group 38.34 ± 29.91 mg (p=0.035) in the first 48 hours postoperatively. Patients in the ESPB group had a lower VAS at rest than patients in the comparison group (1.19 ± 0.73 vs. 1.77 ± 1.01; p=0.039). There were no statistically significant differences between the groups in measurements of maximal inspiratory and expiratory power after 24 hours (MIP p=0.088; MEP p=0.182) or after 48 hours (MIP p=0.110; MEP p=0.645). The groups did not differ in the frequency of postoperative complications and the frequency of opioid side effects. There were also no differences in the time to removal of the thoracic drain and discharge from the hospital. Conclusions Patients with continuous ESPB require fewer opioid analgesics and experience less pain than patients with ICNB in the first 48 hours after VATS lung tumor surgery. There were no differences between the groups regarding postoperative respiratory muscle strength, postoperative complications and time to hospital discharge. A catheter under the erector spinae muscle is more difficult to insert and requires more care than ICNB.

• Keywords: Erector spinae plane block, intercostal nerve block, video-assisted thoracic surgery, thoracic anesthesia, regional anesthesia