Dilek YÖRÜKOĞLU, Halide Hande ŞAHİNKAYA, Enver ÖZGENCİL, Ayhan ATTAR, Yüksel KEÇİK

MAJOR SPİNAL CERRAHİDE EPİDURAL ANALJEZİ VE DERLENMENİN DEĞERLENDİRİLMESİ: BUPİVAKAİN-FENTANİL VE BUPİVAKAİN-FENTANİL-STEROİD KOMBİNASYONUNUN KARŞILAŞTIRILMASI

Amaç: Major spinal cerrahi planlanan hastalarda epidural analjezi ve derlenmeyi değerlendirmek amacıyla bupivakain-fentanil ve bupivakainfentanil-metilprednizolon asetat kombinasyonlarını karşılaştırdık.Yöntem: 18-70 yaş arası, ASA I-II, posterior lomber ve/veya alt torakal vertebra enstrümantasyonu planlanan toplam 24 hasta kabul edildi.Hastalar kapalı zarf usulüne göre 2 gruba ayrıldı. Hastalara entübasyonu takiben cerrahi planlanan disk mesafesinin 2 disk mesafesi üzerindenepidural kateter yerleştiriİip cilt altı tünelize edildi. İintraoperatif epidural yolla bupivakain-fentanil solüsyonu infüzyon olarak verildi.Grup II'deki hastalara cerrahi başlangıç öncesinde 80 mg epidural metilprednizolon asetat verildi. Postoperatif 48 saat hasta kontrollü epiduralanaljezi uygulandı. Ağrı değerlendirmesi görsel analog skala (VAS) ve sözel ağrı skalası (VRS) ile yapıldı. VAS>4 olanlara 1 gr intramuskulermetamizol uygulandı. Analjezik talepleri (demand), ihtiyacı karşılama (delivery), total uygulanan epidural solüsyon miktarı, ek analjezik gereksinimleri,yan etkiler kaydedildi. Ağrı tedavisi memnuniyeti sorgulandı. Bulgular: Demografik veriler, intraoperatif hemodinamik parametreler, kanama miktarı, transfüzyon sayısı, ekstübasyon, derlenme süreleriaçısından gruplar arası farka rastlanmadı. Postoperatif hemodinamik parametrelerde fark bulunmadı. Gruplar arası VAS değerlerinde anlamlıfarklılık olmamasına karşın Grup II'deki hastaların 24. saatteki VAS değeri daha düşük tespit edildi (p=0.04). Grup II'de ilaç talebi (demand)Grup I'dekine göre istatistiksel olarak anlamlı derecede daha azdı (p=0.007). Gruplar arasında ihtiyacı karşılama (delivery), ek analjezikgereksinimi açısından anlamlı fark bulunmadı. Yan etkiler benzer bulunurken Grup I'de bulantı daha fazla görüldü. Hastaların %87.5'i ağrıtedavisi yönteminden memnun kaldı. Sonuç: Postoperatif ağrı tedavisinde hasta kontrollü epidural analjezinin güvenilir ve etkili bir yöntem olduğu, epidural steroiduygulamasının analjezik ihtiyacını azalttığı, ama ağrı skorları üzerinde anlamlı bir fark oluşturmadığı sonucuna vardık.

ASSESSMENT OF EPIDURAL ANALGESIA AND RECOVERY AFTER MAJOR SPINAL SURGERY: COMPARISON OF BUPIVACAINE-FENTANYL AND BUPIVACAINE-FENTANYL-METHYLPREDNISOLONE ACETATE COMBINATIONS

Objective: We compared bupivacaine-fentanyl and bupivacaine-fentanyl-methylprednisolone acetate combinations in order to evaluate epiduralanalgesia and emergence after major spinal surgery.Method: Twenty-four patients, aged between 18-70 years, ASA I-II status, undergoing posterior fusion surgery of lumbar and/or lower thoracicregions of the spine were enrolled in the study. Patients were randomly allocated into two groups via sealed envelope technique. After the patients wereanesthetized, epidural catheter was introduced through two segments above the surgical site and pulled out subcutaneously. Both groups recievedepidural bupivacaine-fentanyl solution intraoperatively. Group II recieved additional 80 mg methylprednisolone acetate before the initiation of thesurgery. Postoperative pain was managed via patient-controlled epidural analgesia for 48 hours. Pain parameters were assessed by visual analog scale(VAS) and verbal rating scale (VRS). Rescue medication of 1 gr metamizole intramuscular was delivered when VAS>4. Demand, delivery, total volumeof epidural infusion and additional analgesic requirement, side effects were noted. Patient satisfaction about the analgesic technique were noted.Results: Demographic data, hemodynamic parameters, blood loss, number of transfusion were similiar among groups. Extubation time andemergence time were also similar between the two groups. There was no difference in the postoperative hemodynamic parameters. Although therewas no difference in VAS data between the groups, VAS at 24thhour in Group II was significantly lower (p=0.004). Delivery data for PCA settingswere analogous among groups but demand was lower in Group II compared to Group I. Although side effects were similar nausea was seen inGroup I higher than in Group II. 87.5% of the patients were satisfied about the pain management.Conclusion: We conclude that patient controlled epidural analgesia is a reliable and effective technique for postoperative pain management.Epidural administration of steroids reduce PCA demand, but has no significant effect on VAS parameters.

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