Suna KOÇ, Zeynep ETİ, AYTEN SARAÇOĞLU, Yılmaz GÖĞÜŞ

Total abdominal histerektomi sonrası epidural hasta kontrollü analjezi ile multimodal analjezinin etkinlik ve yan etkilerinin karşılaştırılması

Amaç: Çalışmamızın amacı; total abdominal histerektomi geçirecek hastalarda epidural hasta kontrollü analjezi (HKA) yöntemi ile multimodal analjezinin etkinliklerinin karşılaştırılmasıdır. Yöntem: Total abdominal histerektomi operasyonu geçirecek 20-60 yaş arası, ASA I-II grubu 60 hasta rastgele epidural analjezi grubu (Grup E) ve multimodal analjezi grubu (Grup M) olarak 30 hasta içeren iki gruba ayrıldı. Grup Ede hastalara yan yatar pozisyonda, L3-4 intervertebral aralıktan epidural aralığa girilerek 15 ml %0.25 bupivakain HCl ve 100 μg fentanil epidural kateterden uygulandı. Tüm hastalarda anestezi indüksiyonu 2 mg kg-1 propofol ve 0.5 mg kg-1 atraküryum intravenöz (iv) ile sağlandı. Endotrakeal entübasyon sonrasında anestezi idamesi 2 MAK sevoşuran ve O2 içinde %70 N2O ile kontrollü ventilasyonla sürdürüldü. Peroperatif kalp atım hızı, ortalama arter basıncı, periferik oksijen satürasyonu ve tidal sonu karbondioksit değerleri 5er dakikalık aralar ile kaydedildi. Grup E'de peroperatif dönemde % 0.25 bupivakain ve 3 μg ml-1 fentanil içeren solüsyondan 10 ml sa-1 infüzyon uygulandı. Derlenmede ise %0.125 bupivakain + 3 μg ml-1 fentanil içeren solüsyon ile bazal infüzyon 5 ml sa-1, bolus 4 ml, kilitli kalma süresi 15 dk olacak şekilde hasta kontrollü epidural analjezi (HKEA) başlandı. Grup Mye indüksiyonda lornoksikam 16 mg + deksametazon 8 mg + parasetamol 1gram (g) iv uygulandı. Operasyon bitiminde cerrahi insizyon hattına cerrah tarafından %0.25 bupivakain 20 ml ile infiltrasyon yapıldı. Derlenmede 10 mg ml-1 meperidin içeren solüsyon ile bolus 1.5 ml, kilitli kalma süresi 8 dk olacak şekilde iv HKA başlandı. Aynı zamanda parasetamol 3x1 g ve lornoksikam 2x16 mg iv uygulanmak üzere postoperatif analjezi planlandı. Hastalarda postoperatif 48 saat boyunca; ortalama arter basıncı, kalp atım sayısı, VAS skorları, uygulanan ek analjezik miktarları ve yan etkiler, GS fonksiyonları (ilk bağırsak sesi zamanı, ilk defekasyon zamanı), ilk mobilizasyon zamanı ve taburculuk zamanı kaydedildi. Bulgular: ki grup arasında ortalama arter basıncı, kalp atım sayısı, VAS skorları, uygulanan ek analjezik miktarları ve yan etkiler, ilk bağırsak sesi duyulma zamanı, ilk mobilizasyon zamanı ve taburculuk zamanı açısından anlamlı farklılık saptanmadı (p>0.05). Epidural analjezi grubunda ilk defekasyon zamanının belirgin şekilde erken olduğu saptandı (p

The optimal postoperative analgesia method after total abdominal hysterectomy: Epidural patient-controlled analgesia or multimodal analgesia

Objective: The aim of our study was to compare the efficacy and side effects of patient-controlled epidural analgesia (PCEA) and multimodal analgesia after total abdominal hysterectomy (TAH). Method: Sixty patients, aged between 20-60 years, undergoing TAH were randomly assigned into two groups each containing 30 patients, as PCEA (Group E) and multimodal analgesia (Group M). In Group E, 15 ml %0.25 bupivakain HCl and 100 μg fentanil was administered through an epidural catheter placed at L3-4 in lateral decubitus position. In all patients, anesthesia was induced with 2 mg kg-1 propofol and 0.5 mg kg-1 atracurium iv and was maintained with 70%/30% N2O / O2 in 1 MAC sevoflurane. Anesthesia was induced by 2 MAC sevofluran and 70% N2O in O2 by controlled ventilation after endotracheal intubation. Preoperative heart rate, mean arterial pressure, peripheral oxygen saturation and end tidal CO2 levels vere recorded every 5 minutes. In Group E, 0.25% bupivacaine+100 μg fentanyl in 15 ml was injected epidurally from L3-L4 intervertebral space preoperatively and 0.25% bupivacaine+3μg/ml fentanyl solution was infused epidurally with a rate of 10 ml h-1 peroperatively. In the recovery room, epidural patient-controlled analgesia (basal infusion 5 ml h-1, bolus 4 ml, lockout time 15 min) was started with 0.125% bupivacaine+3 μg ml-1 fentanyl solution. In Group M, lornoxicam 16 mg, dexamethasone 8 mg and paracetamol 1g iv were administered during induction and the surgeon infiltrated the incision with 20 ml of 0.25% bupivacaine at the end of the operation. At the recovery room, iv meperidine patient-controlled analgesia (10 mg ml -1) (1.5 ml bolus dose, 8 min lockout time) was started and paracetamol 1g three times a day and lornoxicam 16 mg twice a day iv were administered. Postopeatively, visual analogue scale (VAS) scores, additional analgesic requirement, side effects, gastrointestinal system (GIS) functions (time to first bowel sound, time to first defecation), mobilization time and discharge time were recorded. Results: There was no significant difference in mean arterial blood pressure, heart rate, VAS scores, additional analgesic requirement, side effects, time to first bowel sound, first mobilization and discharge time between the groups (p>0.05). In Group E, time to first defecation was significantly earlier than those of Group M (p<0.05). Conclusion: In patients undergoing TAH, multimodal analgesia (iv meperidine PCA, lornoxicam, paracetamol, dexametasone and wound infiltration) provides equivalent analgesic effect and can be an alternative to epidural analgesia, although the time to first defecation was found to be earlier with epidural PCA.

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