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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 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.


* OPERATION


PCA: PCA: Perfusor Perfusor company company B/Braun B/Braun of of GermanyGermany Monitoring and resuscitation equipmentMonitoring and resuscitation equipment


Positions anesthesia

spinous process

paravertebral space

2,5 cm

Transverse process

Pleural

T9-10

Thoracic Paravertebral Block: a loss of resistance


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


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..


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


* * 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


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


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



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



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


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


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


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


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


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.


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


b

Post operative heart rate Biểu đồ nhịp tim

0

10

20

30

40

50

60

70

80

90

100


Nh

ịp t

im (

lần

/ph

út)

Nhóm TêCCSN Nhóm PCAp>0,05


Post operative average blood pressureBiểu đồ huyết áp trung bình

0

20

40

60

80

100

120


Giá

trị

hu

yết

áp

(m

mH

g)


p>0,05


Post operative respiratory rate

Biểu đồ nhịp thở

0

5

10

15

20

25


Nh

ịp t

hở

(l

ần

/ph

út)


p>0,05


Post operative Spo2

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 ...).

Thank you!

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