Seden KOCABAFİ, Demet SERGİN, Fatma Zekiye AFİKAR, Kutsal TURHAN, Şule BİLGİN, Yurday ÇETİN

TORAKOTOMİ SONRASI AĞRI KONTROLÜNDE TORASİK PARAVERTEBRAL BLOK İLE lN'l'RATEKAl. MORFlN UYGllLAMALARlNlN KARŞILAŞTIRILMASI

Amaç: Çalışmamızda genel anestezi altında posterolateral torakotomi ve lobektomi uygulanan hastalarda torasik paravertebralblok ile intratekal morfin uygulamalarının cerrahi sonrası ağrı kontrolünde etkinliklerinin karşılaştırılması amaçlandı. Yöntem: Elektif lobektomi uygulanan 18-65 yaşlarındaki 40 hasta iki gruba ayrıldı. Paravertebral blok (PVB) grubunda(n=20) torakotomi kapatılmadan önce cerrah tarafından paravertebral bölgeye epidural kateter yerleştirilerek cerrahi bitiminde20 mL %0.25 bupivakain bolusu ve postoperatif ilk 24 saat %0.25 bupivakain (0.1 mL kg-1h-1) infüzyonu uygulandı. İntratekalmorfin (ITM) grubunda (n=20) cerrahi bitiminde hastalara intratekal 10 µg kg-1morfin verildi. Postoperatif dönemde tümolgulara morfin ile hasta kontrollü analjezi uygulandı. Sistolik ve diyastolik kan basınçları, kalp atım hızı, solunum sayısı, oksijensatürasyonu, arteriyel kan gazı, pik ekspiratuvar akım hızı, ağrı ve sedasyon skorları kaydedildi. Bulgular: Demografik veriler, hemodinamik ve solunumsal parametreler ve VAS skorları her iki grupta benzer bulundu.Postoperatif 24. saatteki morfin tüketimi ve ilk 4 saat içerisindeki sedasyon skorları ITM Grubunda diğer gruba oranla anlamlıyüksek bulundu (p< 0.05). Her iki gruba ait 12. ve 24. saatlerdeki sedasyon skorları benzer bulundu. Sonuç: Posterolateral torakotomi uygulanan hastalarda ağrı kontrolünde torasik paravertebral blok ve intratekal morfinuygulamalarının her ikisi de etkin olup, postoperatif 24. saatteki morfin tüketimi ve ilk 4 saat içerisindeki sedasyon skorları PVBgrubunda diğer gruba oranla anlamlı olarak düşük bulunmuştur

THORACIC PARAVERTEBRAL BLOCK VERSUS INTRATHECAL MORPHINE FOR PAIN RELIEF AFTER THORACOTOMY

Objective: This study aimed to compare the analgesic efficacies of thoracic paravertebral block and intrathecal morphine inpatients undergoing posterolateral thoracotomy and lobectomy under general anesthesia. Method: Forty patients, aged 18-65 yrs, undergoing elective lobectomies were randomized into two groups: In the paravertebralblock group (PVB, n=20), an epidural catheter was inserted into the paravertebral space by the surgeon before thoracotomyclosure; 20 mL 0.25% bupivacaine bolus was given at the end of surgery and 0.25% bupivacaine (0.1 mLkg-1h-1) infusion wasgiven for 24thhour after surgery. In the intrathecal morphine group (ITM, n=20), intrathecal 10 µg kg-1morphine was given at theend of surgery. Patient controlled analgesia using morphine was administered postoperatively for all patients. Systolic and diastolic arterial pressures, heart rate, respiratory rate, oxygen saturation, arterial blood gases, peak expiratory flows and sedationscores were recorded. Results: Demographic data and postoperative hemodynamic, respiratory parameters and pain scores were similar in bothgroups. Postoperative 24thhour morphine consumption and sedation scores during the initial 4thhour after surgery were higher inthe ITM group (p< 0.05), while sedation scores at 12thand 24thhour were similar between groups. Conclusion: Although both techniques were effective in controlling pain after posterolateral thoracotomy, morphine consumptionat 24thhour was lower and sedation scores during the initial 4thhour after surgery were improved in patients who were administered athoracic paravertebral block when compared to patients who were given intrathecal morphine

PDF

___

1. Soto RG, Fu E. Acute pain management. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg 2003; 75: 1349-1357.
2. Richardson J, Sabanathan S, Shah R. Post-thoracotomy spirometric lung function: the effect of analgesia. J Cardiovasc Surg 1999; 40: 445–456.
3. Kruger M, McRae K. Pain management in cardiothoracic practice. Surg Clin North Am 1999; 79: 387-400.
4. Silimon M, Claus T, Huwer H, et al. Interpleural analgesia does not influence postthoracotomy pain. Anest Analg 2000; 91: 44-50.
5. Peeters- Asdourian C, Gupta S. Choices in pain management following thoracotomy. Chest 1999; 115 (Suppl): 122-124.
6. Katz J, Jackson M, Kavanagh BP, et al. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. The Clinical Journal of Pain 1996; 12: 50-55.
7. Pluijms WA, Steegers MA, Verhagen AF, et al. Chronic postthoracotomy pain: a retrospective study. Acta Anaesthesiol Scand 2006; 50(7): 804-808.
8. Kotze A, Scally A, Howell S. Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression. British Journal of Anaesthesia 2009; 103(5): 626-636.
9. Kavanag Brian P, Katz Joel, Sandler Alan N. Pain control after thoracic surgery. A review of current techniques. Anesthesiology 1994; 81(3): 737-759.
10. Cohen E. Postthoracotomy pain management. Seminars in Cardiothoracic and Vascular Anesthesia 1999; 3(3): 156-167.
11. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78 (5): 606-617.
12. Messina M, Landoni G, Bignami N, et al. A comparison of epidural vs. paravertebral blockade in thoracic surgery. Minerva Anestesiol 2009; 75: 616-621.
13. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side effects of paravertebral vs epidural lockade for thoracotomy- a systematic review and meta- analysis of randomized trials. British Journal of Anaesthesia 2006; 96(4): 418-426.
14. Stoelting RK. Intrathecal morphine- An underused combination for postoperative pain management. Anesth Analg 1989; 68: 707-709.
15. Abboud TK, Dror A, Mosaad P, Zhu J, et al. Mini-dose intrathecal morphine for the relief of post-cesarean section pain: safety, efficacy, and ventilatory responses to carbon dioxide. Anesth Analg 1988; 67: 137-143.
16. Mason N, Gondret R, Junca A, et al. Intrathecal sufentanil and morphine for post-thoracotomy pain relief. British Journal of Anaesthesia 2001; 86 (2): 236-240.
17. Askar FZ, Kocabas S, Yucel S, et al. The efficacy of intrathecal morphine in post-thoracotomy pain management. The Journal of International Medical Research 2007; 35: 314-322.
18. Nilsson E, Perttunen K, Kalso E. Intrathecal morphine for post-sternotomy pain in patients with myasthenia gravis: effect on respiratory function. Acta Anaesthesiol Scand 1997; 41: 549-556.
19. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95: 771-780.
20. Myles PS, Bain C. Underutilization of paravertebral block in thoracic surgery. Journal of Cardiothoracic and Vascular Anesthesia 2006; 20(5): 635-638.
21. Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998; 81: 230-238.
22. Richardson J, Sabanathan S, Jones J, et al. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmoner function and stress responses. Br J Anaesth 1999; 83: 387-392