Postoperative analgesia management in thoracic surgery: our two-year experience

Yıl 2021, Cilt: 12 Sayı: 4, 409 - 415, 22.12.2021

Gülay Ülger , Musa Zengin , Ramazan Baldemir , Ali Alagöz , Hilal Sazak

https://doi.org/10.18663/tjcl.1004686

Öz

Aim: BThoracic surgery is one of the most painful surgical procedures. Pain after thoracic surgery can cause respiratory complications, such as atelectasis and pneumonia; longer hospital stays; reduced quality of life and chronic persistent postoperative pain. We aimed to retrospectively analyze our postoperative analgesia practices and results in patients undergoing thoracic surgery through anesthesia and pain follow-up forms.
Material and Methods: In our study, we retrospectively scanned 563 patients who underwent thoracic surgery and were followed up with postoperative analgesia between June 2019 and June 2021. Postoperative analgesia method applied to the patients, visual analog scale (VAS) scores, additional applied analgesia and complications were evaluated.
Results: 28.42% of the patients were women. The most common surgery was lung resections with a rate of 64.30%. Patient-controlled analgesia (PCA) was administered thoracic paravertebral block (TPVB) + intravenously in 458 (81.35%) patients and by epidural route in 105 (18.65%) patients. The VAS scores were 4.1 at the postoperative 1st hour, 1.9 at 24th hour and 1.1 at 48th hour for TPVB + intravenous PCA. For epidural PCA, VAS scores were 3.9 at the first hour, 1.9 at 24th hour, and 1.4 at 48th hour. Side-effect rates were evaluated as 6.99% in patients who underwent TPVB + intravenous PCA and 37.14% in patients who underwent epidural PCA.
Conclusion: Malignancy surgery is frequently performed in our clinic. In these patients, similar analgesic results were obtained for the combination of TPVB and intravenous analgesia, and thoracic epidural analgesia (TEA) administered with elastomeric infusion. Although the complication rates were lower in the group treated with TPVB and intravenous analgesia, they were found to be within clinically acceptable limits in both groups. We think that the choosing analgesia protocols and algorithms according to the experience of the clinicians and the surgical procedure will provide effective analgesia

Anahtar Kelimeler

toraks cerrahisi, postoperatif ağrı, hasta kontrollü analjezi yönetimi, postoperatif ağrıhasta kontrollü analjezi yönetimi

Toraks cerrahisinde postoperatif analjezi yönetimi: iki yıllık deneyimlerimiz

Öz

Amaç: Toraks cerrahisi, en ağrılı cerrahi prosedürlerden biri olarak kabul görmektedir. Toraks cerrahisinden sonra gelişen ağrı; atelektazi ve pnömoni gibi solunum komplikasyonları, daha uzun hastane yatış süreleri, yaşam kalitesinin azalması ve ağrının postoperatif kronik ağrıya dönüşmesi gibi olumsuz sonuçlara neden olabilir. Toraks cerrahisi geçiren hastalarda postoperatif analjezi uygulamalarımızı ve sonuçlarını retrospektif olarak incelemeyi amaçladık.
Gereç ve Yöntemler: Çalışmamız, Haziran 2019 ve Haziran 2021 tarihleri arasında toraks cerrahisi geçiren ve postoperatif analjezi takibi yapılan 563 hastaya ait verinin retrospektif olarak incelenmesi ile yapıldı. Hastalara uygulanan postoperatif analjezi yöntemi, vizüel analog skala (VAS) skorları, uygulanan ek analjezi tedavisi ve gelişen komplikasyonlar değerlendirildi.
Bulgular: Hastaların %28,42’si kadın olup, en sık uygulanan cerrahi %64,30 oranla akciğer rezeksiyonlarıydı. Hasta kontrollü analjezi (HKA) , 458 (%81,35) hastada intravenöz, 105 (%18,65) hastada epidural yol ile uygulanmıştı. Intravenöz HKA için VAS skor ortalamaları postoperatif 1. saatte 4,1, 24. saatte 2,0 ve 48. saatte 1,2 idi. Epidural HKA için ise 1.saatte 3,9, 24.saatte 2,0 ve 48.saatte 1,4 olarak değerlendirilmiştir. Intravenöz HKA uygulanan hastalarda yan etki oranları %6,99, epidural HKA uygulanan hastalarda %37,14 olarak değerlendirilmiştir.
Sonuç: Kliniğimizde sıklıkla malignite cerrahisi yapılmaktadır. Bu hastalarda torasik paravertebral blok (TPVB) ve intravenöz analjezi kombinasyonu ile elastomerik infüzyonla uygulanan torasik epidural analjezide benzer analjezik sonuçlar elde edilmiştir. Komplikasyon oranları TPVB ve intravenöz analjezi kombinasyonu yapılan grupta daha az olmakla birlikte her iki grupta da klinik olarak kabul edilebilir sınırlarda olarak bulunmuştur. Analjezi protokollerinin ve algoritmaların klinisyenlerin deneyimi ve uygulanan cerrahi işleme göre belirlenmesinin etkin analjezi sağlayacağını düşünmekteyiz.

Anahtar Kelimeler

toraks cerrahisi, postoperatif ağrı, hasta kontrollü analjezi yönetimi

Kaynakça

• 1. Marshall K, McLaughlin K. Pain Management in Thoracic Surgery. Thorac Surg Clin. 2020; 30: 339-46
• 2. Liu X, Song T, Xu HY, Chen X, Yin P, Zhang et al. The serratus anterior plane block for analgesia after thoracic surgery: A metaanalysis of randomized controlled trails. Medicine (Baltimore). 2020; 99: 20286
• 3. Razi SS, Stephens-McDonnough JA, Haq S, et al. Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol. J Thorac Cardiovasc Surg. 2021; 161: 1689-701
• 4. Fang B, Wang Z, Huang X. Ultrasound-guided preoperative single-dose erector spinae plane block provides comparable analgesia to thoracic paravertebral block following thoracotomy: a single center randomized controlled double-blind study. Ann Transl Med. 2019 ; 7 :174
• 5. Zengin M, Baldemir R, Ulger G, et al. Postoperative Analgesic Efficacy of Thoracic Paravertebral Block and Erector Spinae Plane Block Combination in Video-Assisted Thoracic Surgery. Cureus. 2021; 13: 15614
• 6. Luketich JD, Land SR, Sullivan EA, et al. Thoracic epidural versus intercostal nerve catheter plus patient-controlled analgesia: a randomized study. Ann Thorac Surg. 2005; 79: 1845-9
• 7. Nagaraja PS, Ragavendran S, Singh NG, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. 2018; 21: 323-27 .
• 8. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012 ; 116: 248-73
• 9. Ochroch EA, Gottschalk A. Impact of acute pain and its management for thoracic surgical patients. Thorac Surg Clin. 2005; 15: 105-21 .
• 10. Rogers ML, Henderson L, Mahajan RP, et al. Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg. 2002 ; 21: 298-301
• 11. Sugiyama T, Kataoka Y, Shindo K, et al. Retrolaminar Block Versus Paravertebral Block for Pain Relief After Less-Invasive Lung Surgery: A Randomized, Non-Inferiority Controlled Trial. Cureus. 2021; 13: 13597
• 12. Piccioni F, Segat M, Falini S, et al. Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols. J Thorac Dis. 2018; 10: 555-63
• 13. Hirai K, Usuda J. Uniportal video-assisted thoracic surgery reduced the occurrence of post-thoracotomy pain syndrome after lobectomy for lung cancer. J Thorac Dis. 2019; 11: 3896-902
• 14. Shady RHA, Asmaa IAS, Marwa FM. Effectiveness of acupressure in the reduction of pain and anxiety among patients with open thoracotomy. American Journal of Nursing. 2020; 8: 182-91
• 15. Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001; 95: 771-80
• 16. Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev. 2016; 2: 9121
• 17. Kotzé A, Scally A, Howell S. Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression. Br J Anaesth. 2009 ; 103: 626-36
• 18. Alagöz A, Ergüven M, Tunç M, et al. Preoperatif Anksiyete Skoru İle Torakotomi Sonrası Ağrı Arasında Bir Korelasyon Var mıdır?. Ortadogu Medical Journal/Ortadoğu Tıp Dergisi 2012; 4: 117-21.