Post on 30-Jul-2015
Comparison of analgesic effects of thoracic paravertebral block by
bupivacaine-sufentanil with morphine intravenously patient controlled
analgesia after kidney-ureter surgery
Vice professor. NGUYỄN QUỐC ANH Professor. NGUYỄN QUỐC KÍNH
Ministry of Education and Training Ministry of Health Bach Mai Hospital
NGUYEN HONG THUY
INTRODUCTION
Postoperative pain was interested by the AnesthetistPostoperative pain was interested by the Anesthetist
There are many therapeutic method to treat postoperative There are many therapeutic method to treat postoperative
pain: Drugs (systemic, regional anesthesia), non-pain: Drugs (systemic, regional anesthesia), non-
pharmacological methods. pharmacological methods.
Analgesics are mainly used as mocphin, good pain relief but Analgesics are mainly used as mocphin, good pain relief but
have side effects.have side effects.
Regional anesthesia has many benefits: better pain relief, Regional anesthesia has many benefits: better pain relief,
fewer side effects, higher satisfaction, reduced hospitalization fewer side effects, higher satisfaction, reduced hospitalization
time.time.
Analgesic effects of TPVB: Good~with epidural analgesia, Analgesic effects of TPVB: Good~with epidural analgesia,
there are many technical advantages and clinical.there are many technical advantages and clinical.
Objective
1. 1. Comparison of analgesic effects of thoracic paravertebral block by bupivacaine-sufentanil with morphine intravenously patient controlled analgesia after kidney-ureter surgery block by
2. Comparison of 2. Comparison of side effects of two of two methods.methods.
Subjects and Methods
Criteria included Open surgery under the program with renal and ureteral an incision unilateral. Age over 18, regardless of gender, agreed collaborative research. Physical body ASA status I - II and I.renal ≤ 2. Anesthesia endotracheal and is expected to extubation in the recovery room No contraindications of TPVB No contraindications of anesthetic bupivacaine, sufentanil and morphine.
Exclusion criteria included
Patients’ refusal
Planned bilateral kidney-ureter surgery Patients with a history and current mental disease Patients with severe cardiopulmonary disease,
severe liver failure, kidney failure grade 3-4. History of opioid dependence or addiction Contraindications of Thoracic Paravertebral Block Complications of surgery and anesthesia; required
prolonged mechanical ventilation (over 4 hours) in the recovery room or intensive care.
Subjects and Methods
Subjects and MethodsSubjects and Methods
:: Study Design: Study Design: Randomised Controlled Clinical Trials
Sample size Sample size :: 58 patients were divided into 2 groups
Sampling: Sampling:
• • Group 1: Group 1: Thoracic Paravertebral BlockThoracic Paravertebral Block
• • Group 2:Group 2: PCA with morphine. PCA with morphine.
Time and place of study:Time and place of study:
- Time study: - Time study: from 9/2013 to 06/2014..
- Time analgesic: 48h postoperation- Time analgesic: 48h postoperation
- - In Anesthesiology Health Bach Mai Hospital
1. Patients anesthetized preparation2. Preparation machines, instruments, drugs* Preparation of drugs+ Local anesthetic: - Lidocain 2% tube 10 ml (Hungari),
Sufentanil tube 50g/1 ml, Bupivacain 0,5% tube 20ml- AstraZeneca, Adrenaline tube 1mg/1ml.
+ Morphin tube 10mg = 1ml+ Anesthetics and resuscitation
* Sterile instruments for anesthesia: epidural anesthesia needle; syringes, sterile tray and attempted shirt, betadin antiseptic solution, sterile gant.
Subjects and Methods
* OPERATION
Subjects and MethodsSubjects and Methods
PCA: PCA: Perfusor Perfusor company company B/Braun B/Braun of of GermanyGermany Monitoring and resuscitation equipmentMonitoring and resuscitation equipment
Subjects and MethodsSubjects and Methods
Positions anesthesia
spinous process
paravertebral space
2,5 cm
Transverse process
Pleural
T9-10
Thoracic Paravertebral Block: a loss of resistance
Subjects and MethodsSubjects and Methods
Method of endotracheal anesthesia in a common regimen* Pre-anesthesia: midazolam* Induction: propofol, fentanyl, curare* Maintenance of anesthesia: propofol, fentanyl, curare.* Patients were awakened and extubation: in the recovery room
Subjects and MethodsSubjects and Methods
Design postoperative analgesia : Design postoperative analgesia : the patient is the patient is awake, tracheal extubation and VAS> 4 awake, tracheal extubation and VAS> 4
Group 1:Group 1: - The first dose 0,3ml/kg solution (bupivacain The first dose 0,3ml/kg solution (bupivacain
0,125%-sufentanil 0,5μg/ml + adrenalin 0,125%-sufentanil 0,5μg/ml + adrenalin 1/400.000) by catheter thoracic paravertebral 1/400.000) by catheter thoracic paravertebral
- Continuous infusion at rate of 5 - 10 ml/h.- Continuous infusion at rate of 5 - 10 ml/h. Group 2: Group 2: PCA with intravenous morphine. PCA with intravenous morphine. The The
first dose first dose 1mg, each bolus: 1mg, lock time: 8 1mg, each bolus: 1mg, lock time: 8 phút, phút, tthe maximum dose: 15mhe maximum dose: 15mgg/4/4hh, not transmit , not transmit basic databasic data..
Subjects and MethodsSubjects and Methods
The main evaluation criteriaThe main evaluation criteria** Target 1Target 1- Pain scores Pain scores VASVAS:: static and dynamic- The total - The total amount of local anesthetic and of local anesthetic and
sufentanilsufentanil:: first dayfirst day, second day , second day andand two days two days after surgery after surgery in the in the TPVBTPVB group. group.
- The total The total amount of of momorrphinphine requirements: first e requirements: first dayday, second day , second day andand two days two days after surgery after surgery in in the PCA group.the PCA group.
- Number of patients with need for supplemental administration and total of and total of morphine
- Patient satisfaction scoresPatient satisfaction scores
Subjects and MethodsSubjects and Methods
* * Target 2Target 2+ Heart rate, arterial blood pressure, respiratory + Heart rate, arterial blood pressure, respiratory
rate, SpO2 in 48h after surgery.rate, SpO2 in 48h after surgery.+ The complications related to TPVB+ The complications related to TPVB+ The Other side effects: nausea, vomiting, pruritus, + The Other side effects: nausea, vomiting, pruritus,
sedation excessive, sedation excessive, recovery time peristalsis
** Other evaluation criteriaOther evaluation criteria Age, gender, height, weight, BMI, ASA.Age, gender, height, weight, BMI, ASA. Total of anesthetics, analgesics.Total of anesthetics, analgesics. Duration of surgeryDuration of surgery, time of anesthesia, and time , time of anesthesia, and time
of extubation.of extubation. Method of operationMethod of operation,, incision, drainage quantityincision, drainage quantity
Subjects and MethodsSubjects and Methods
Statistical analysisStatistical analysis:: SPSS 19.0 SPSS 19.0
Quantitative variables were described as mean Quantitative variables were described as mean
and standard deviation (SD). Comparison of 2 and standard deviation (SD). Comparison of 2
groups: Test T – Studentgroups: Test T – Student
Qualitative variables were described in terms of Qualitative variables were described in terms of
the percentage (%) the percentage (%) Chi-square test. Chi-square test.
p<0p<0,,05 05 The difference was statistically The difference was statistically
significant.significant.
XX
RESULTS AND DISCUSSIONSAge, Height, Weight, BMI
GroupGrouppp
TPVBTPVB PCAPCA
AgeAge(year)(year)
XX SD SD 48,68±48,68±11,5811,58 47,06±47,06±14,0814,08 >0,05>0,05
Min – MaxMin – Max 28-6828-68 22-7222-72
HeightHeight(cm)(cm)
XX SD SD 160,6 ± 8,05160,6 ± 8,05 159,93±7,03159,93±7,03>0,05>0,05
Min – MaxMin – Max 145-175145-175 143-175143-175
Weight Weight (kg)(kg)
XX SD SD 54,5 ± 54,5 ± 8,898,89 55,1±55,1±11,2511,25>0,05>0,05
Min – MaxMin – Max 40-7340-73 35-8435-84
BMIBMIXX SD SD 21,02 ± 21,02 ± 2,332,33 21,41±21,41±3,313,31 >0,05>0,05
Min – MaxMin – Max 16-2716-27 15-2715-27
Patients’ characteristics
RESULTS AND DISCUSSIONS
Gender and ASA
GenderGender ASAASA
MaleMale
n (%)n (%)
FemaleFemale
n (%)n (%)
ASA 1ASA 1
n (%)n (%)
ASA2ASA2
n (%)n (%)
TPVBTPVB 16 (55,1)16 (55,1) 13 (49,1)13 (49,1) 14 (48,2)14 (48,2) 12 (41,3)12 (41,3)
PCAPCA 13 (49,1)13 (49,1) 16 (55,1)16 (55,1) 15 (51,8)15 (51,8) 17 (58,7)17 (58,7)
pp > 0,05> 0,05 > 0,05> 0,05
Patients’ characteristics
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONS
Type of surgeryType of surgery
TPVBTPVB PCAPCA pp
nn %% nn %%
NephrolithotomyNephrolithotomy 1010 34,534,5 1111 3838
>0,05>0,05ureteral stone ureteral stone removalremoval
44 13,813,8 55 17,217,2
Nephrolithotomy + Nephrolithotomy + ureteral stone ureteral stone removalremoval
55 17,217,2 22 6,96,9
NephrectomyNephrectomy 99 3131 99 3131
Plastic of pyelonephritis-pyelonephritis-ureter
11 3,53,5 22 6,96,9
Patients’ characteristics
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONS
Side of operationSide of operation incisionincision
RightRight
n (%)n (%)
LeftLeft
n (%)n (%)
FreyFrey
n (%)n (%)
PararectalPararectal
n (%)n (%)
TPVBTPVB 13 (44,8)13 (44,8) 16 (55,2)16 (55,2) 15 (51,8)15 (51,8) 14 (48,2)14 (48,2)
PCAPCA 14 (48,2)14 (48,2) 15 (51,8)15 (51,8) 10 (34,5)10 (34,5) 19 (65,5)19 (65,5)
pp > 0,05> 0,05 > 0,05> 0,05
Side of operation and incisionSide of operation and incision
Patients’ characteristics
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONS
Duration of surgery, anesthesia, extubation
TPVBTPVB PCAPCA pp
Duration of Duration of surgery surgery (minute)(minute)
XX SD SD 84,89±23,69 98,62±33,98>0,05>0,05
Min - MaxMin - Max 45-150 50-200
Duration of Duration of anesthesia anesthesia (minute)(minute)
XX SD SD100,66±24,9
9115,0±34,33 >0,05>0,05
Min - MaxMin - Max 60-170 65-215
Duration of Duration of extubationextubation(minute)(minute)
XX SD SD 27,0±7,25 30,06±4,68 >0,05>0,05
Min - MaxMin - Max 15-45 20-44
Patients’ characteristics
GroupGroup Propofol Propofol (mg)(mg)
Sufentanil Sufentanil (µg)(µg)
TPVBTPVBXX SD SD 367,93367,93 103,35 103,35 339,65339,65 52,4 52,4
Min - MaxMin - Max 200-700200-700 200-450200-450
PCAPCAXX SD SD 420 420 106,87106,87
363,79 363,79 66,6766,67
Min - MaxMin - Max 200-800200-800 300-500300-500
pp >0,05>0,05 >0,05>0,05
Total amount of anesthetics, analgesics
RESULTS AND DISCUSSIONSPatients’ characteristics
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONS
Length of the incision and number of drain
TPVBTPVB PCAPCA pp
Length of Length of incisionincision (cm)(cm)
X X SD SD 22,6522,653,783,78 22,4822,483,993,99
>0,05>0,05Min - MaxMin - Max 16-3516-35 18-3518-35
Number Number of drainof drain
X X SD SD 1,171,170,380,38 1,211,210,490,49>0,05>0,05
Min - MaxMin - Max 1-21-2 1-31-3
RESULTS AND DISCUSSIONS
TPVBTPVB PCAPCA pp
Time Time required to required to
first first analgesic analgesic (minute)(minute)
X X SD SD 29,7229,727,17,1 32,7532,756,376,37
>0,05>0,05
Min - MaxMin - Max 18-4618-46 20-5020-50
The criteria related to pain
VAS static
RESULTS AND DISCUSSIONS
Biểu đồ điểm VAS tĩnh
0
1
2
3
4
5
6
7
8
Thời điểm nghiên cứu
Điể
m đ
au
VA
S t
ĩnh
Nhóm TêCCSNNhóm PCA
p<0,05
p>0,05
Karger 2013, nephrolithotomy, single-dose, VASs TPVB 2,3 vs <PCA 4,3 in 24h, p<0,05. Ji SB 2014: nephrectomy, single-dose, VASs TPVB <PCA 24h, p<0,05; Emmanuel 2005, postthoracotomy, continuous I, VASs TPVB <PCA in 36h PO, p<0,05.
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONSVAS dynamic
Biểu đồ điểm VAS động
01
23
456
78
910
Thời điểm nghiên cứu
Điể
m đ
au
VA
S đ
ộn
g
Nhóm TêCCSN Nhóm PCA
p<0,05
p>0,05
Subileau A 2011, nephrectomy, CI: VASd TPVB (5) sv PCA (8), p<0,05; Ji SB 2014: nephrectomy, single-dos, VASđ CCSN<PCA 24h, p<0,05. Denal 2004, breast surgery, CI, VASd TPVB<PCA in 24h; Emmanuel 2005, postthoracotomy, VASd TPVB<PCA in 48h.
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONS
TPVBTPVB PCAPCA
24h24h24h24h tiếptiếp
Trong Trong 48h48h
24h 24h đầuđầu
24h 24h tiếptiếp
Trong Trong 48h48h
Bupivacain Bupivacain (mg)(mg)
XX SD SD246,07 ± 18,03
217,24±25,24
463,31 ± 41,26
Min - MaxMin - Max 212-290 163-250 390-540
SufentanilSufentanil(µg)(µg)
XX SD SD98,43 ±
7,2186,89 ± 10,09
185,32 ± 16,5
Min - MaxMin - Max 85-116 65-100 156-216
MocphinMocphin(mg)(mg)
XX SD SD 0,340,3437,37±
7,2821,13±3
,4658,17 ±
9,60
Min - MaxMin - Max 0-10 25-50 15-30 41-57
Analgesic consumption
Subileau 2011, nephrectomy, CI: TPVB 9mg sv PCA 39,5mg morph 24h, p<0,05; Karger 2013, nephrolithotomy, , single-dose, TPVB 22,3±6,1 sv PCA 43,2±9,5mg mor24h,p<0,05Salah 2011: postthoracotomy, intermittent injection, TPVB 9mg sv PCA 36mg morph in 24h, p<0,05.
RESULTS AND DISCUSSIONSRESULTS AND DISCUSSIONSPatient satisfaction scores
Our Results: TPVB 3,24 ± 0,43 sv PCA 2,97 ± 0,18, 4 point scale, p<0,05; Karger 2013, nephrolithotomy, single-dose, 5-point scale, TPVB (4,2 ± 0,6) sv PCA (2,4 ± 0,5), p<0,05; Samy 2014, nephrolithotomy, single-dose, 8,8 ± 1,1 10-point scale
0
5
10
15
20
25
30Số lượng bệnh nhân
Hàilòng
Rấthài
lòng
Chấpnhậnđược
Mức độ hài lòng
Sự hài lòng của Bệnh nhân
Nhóm Tê CCSNNhóm PCA
p<0,05
RESULTS AND DISCUSSIONS
b
Post operative heart rate Biểu đồ nhịp tim
0
10
20
30
40
50
60
70
80
90
100
Thời điểm nghiên cứu
Nh
ịp t
im (
lần
/ph
út)
Nhóm TêCCSN Nhóm PCAp>0,05
RESULTS AND DISCUSSIONS
Post operative average blood pressureBiểu đồ huyết áp trung bình
0
20
40
60
80
100
120
Thời điểm nghiên cứu
Giá
trị
hu
yết
áp
(m
mH
g)
Nhóm TêCCSN Nhóm PCA
p>0,05
RESULTS AND DISCUSSIONS
Post operative respiratory rate
Biểu đồ nhịp thở
0
5
10
15
20
25
Thời điểm nghiên cứu
Nh
ịp t
hở
(l
ần
/ph
út)
Nhóm TêCCSN Nhóm PCA
p>0,05
RESULTS AND DISCUSSIONSSide effects: nausea, vomiting, pruritus
012
345678
Số lượng bệnh nhân
Buồnnôn
Nôn Mẩnngứa
Tác dụng phụ
Biểu đồ tác dụng phụ
Nhóm Tê CCSN Nhóm PCA
p<0,05
Our Results: TPVB 17,2% sv PCA 41,3%, p<0,05.Karger 2013, nephrolithotomy, single-dose, nausea, vomiting: TPVB 8% sv PCA 42,8%, p<0,05; Emmanuel 2005, postthoracotomy, nausea, vomiting: TPVB 5% sv PCA 45%, p<0,05; Ashraf 2007, laparoscopic cholecystectomy, TBVB 14,2% sv PCA 57,1%, p<0,05.
RESULTS AND DISCUSSIONS Side effects: Sedation level, time of gaz
CCSNCCSN PCAPCA pp
SSedationedation(Ramsay)(Ramsay)
X X SD SD 2,05±2,05±0,140,14 2,9 ±2,9 ±0,180,18<0,05<0,05
Min - MaxMin - Max 1-31-3 1- 41- 4
Time of gaz (h)(h)
X X SD SD 48,34 ±8,5348,34 ±8,53 59,03 ±5,7559,03 ±5,75
<0,05<0,05Min - MaxMin - Max 28-6628-66 46-7246-72
CONCLUSIONCONCLUSION
Effective analgesic of thoracic paravertebral block by
bupivacaine-sufentanil is better morphine intravenous
PCA after kidney-ureter surgery:
VAS score was lower in static and dynamic
The rate higher satisfaction
Side effects: nausea, vomiting, pruritus, sedation level
lower.
Gaz shorter time
The complications: vascular puncture 3.4%, other
complications not encountered (local anesthetic toxicity,
pleural puncture, pneumothorax ...).