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ID naloge: 128 Letnik: 2002 Predmet: anesteziologija
Lajšanje bolecine po operaciji rame
Avtor: Rihard Knafelj in Barbara Peric
Mentor: prof. dr. Vesna Paver-Eržen
Somentor: mag. Neli Vintar
Izhodišce: Zgodnja bolecina po operaciji rame je zelo huda, še posebno prvih 48 ur. Njeno ucinkovito lajšanje je pomembno za zgodnje razgibavanje in hitrejše okrevanje, bistveno pa prispeva tudi k zmanjšanju pojava kronicne bolecine. Pooperacijsko bolecino zdravimo na razlicne nacine. Novejša metoda, pri kateri dajemo zdravila neposredno v operacijsko rano, je ucinkovitejša in za bolnika varnejša od sistemskega lajšanja bolecine z opiati. V operacijsko rano prek katetra dajemo lokalne anestetike. Da bi zmanjšali njihov odmerek ali podaljšali njihovo delovanje, jim lahko dodajamo še druga zdravila. Znano sinergisticno ucinkovanje klonidina in lokalnega anestetika pri vbrizgavanju v operacijsko rano do sedaj ni opisano.
Namen: V raziskavi smo želeli ugotoviti, ali dodatek klonidina ropivakainu, ce ju vbrizgavamo prek katetra v operacijsko rano, ucinkoviteje lajša pooperacijsko bolecino v primerjavi s samim ropivakainom.
Hipoteze: 1) hkratno dajanje ropivakaina in klonidina ucinkoviteje zmanjša jakost bolecine kot sam ropivakain, 2) po odmerku analgeticne mešanice ropivakaina in klonidina traja analgezija dlje, kot ce dajemo samo ropivakain, 3) bolniki, ki dobivajo mešanico klonidina in ropivakaina, porabijo manj morfina za dodatno analgezijo v primerjavi z bolniki, ki dobijo samo ropivakain.
Metode: V dvojno slepi, prospektivni, nakljucni raziskavi si je prek katetra, vstavljenega v operacijsko rano, ena skupina bolnikov ob pomoci crpalke za PCA dajala najpogosteje na 2 uri 10 ml 0,55 % ropivakaina (kontrolna skupina), druga pa 10 ml 0,55 % ropivakaina in 18,75 µg klonidina (klonidinska skupina). Ce je bolnike kljub temu še bolelo, so si ob pomoci druge crpalke za PCA najpogosteje na 30 min lahko v žilo vbrizgali 2 mg morfina. Pri obeh skupinah bolnikov smo spremljali jakost bolecine, ocenjene po VAS, pred danim odmerkom analgeticne mešanice in po njem, porabo morfina, zadovoljstvo bolnikov in celjenje rane. Konice katetrov smo po odstranitvi poslali na mikrobiološko analizo. Za statisticno obdelavo podatkov smo uporabili Studentov t-test.
Rezultati: Z dajanjem alangeticne ucinkovine so si bolniki uspešno olajšali pooperacijsko bolecino (VAS 1,75 ± 1,24 v kontrolni in VAS 2,2 ± 1,2 v klonidinski skupini). Jakost bolecine se po dajanju analgeticnih ucinkovin med skupinama ni statisticno pomembno razlikovala (p > 0,05). Klonidinska skupina bolnikov je kazala tendenco k daljšemu trajanju analgezije (p = 0,06). Pri porabi morfina med skupinama (3,33 mg v kontrolni in 4,0 mg v klonidinski skupini) nismo ugotovili statisticno znacilne razlike (p > 0,05). Rezultati mikrobiološke preiskave konic katetrov so bili pri vseh bolnikih negativni.
Zakljucki: Zdravljenje bolecine po operaciji rame z lokalnim anestetikom ropivakainom prek katetra v rani je uspešna in varna metoda lajšanja pooperacijske bolecine. Ropivakainu dodan klonidin ne vpliva na trajanje in uspešnost analgezije ter porabo morfina. Ta nacin lajšanja bolecine ne pomeni tveganja za okužbo operacijske rane.
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[Abstract / English version]
Lajšanje bolecine po operaciji rame
Author: Rihard Knafelj in Barbara Peric
Mentor: prof. dr. Vesna Paver-Eržen
Co-mentor: mag. Neli Vintar
Background: Major shoulder surgery is often associated with severe postoperative pain especially within the first forty-eight hours. The efficient treatment of early postoperative pain significally reduces the occurrence of chronic pain. Pain can be treated in various ways. Recent method which enables local anesthetic administration via a catheter placed in the surgical wound treats pain effectively and with little side-effects. It is safer for the patient compared to pain treatment with systemic opioids. In order to reduce local anesthetic consumption, different pharmacological agents can be added. Sinergistic effect of small doses of clonidine, added to local anesthetic solution was shown in some studies, while the data concerning the use of clonidine in wound infiltration analgesia are lacking.
Aim: The study tried to determine whether clonidine added to ropivacaine enhances ropivacaine's analgesic action compared to ropivacaine alone when given via catheter placed in the operating wound.
Hypothesis: 1) pain is treated more efficiently if analgesic mixture containing clonidine is used compared to one with ropivacaine only, 2) when using the mixture of ropivacaine and clonidine the analgesic effects last longer in comparison to the use of ropivacaine alone, 3) patients treated with analgesic mixture of ropivacaine and clonidine have lesser need for additional intravenous narcotics, compared to patients receiving ropivacaine only.
Methods: Patients were enrolled in the prospective, double-blind, randomized study. At the end of a surgery, a catheter was placed in the operating wound and connected to a PCA pump. Postoperatively patients in the control group self-administered 10 ml 0.55 % ropivacaine in the surgical wound with 120 min lockout interval and patients in the clonidine group 10 ml of mixture of clonidine (18,75 µg) and 0.55 % ropivacaine. As rescue medication 2 mg morphine could be self-administered intravenously with 30 min lockout interval by another PCA pump. The variables recorded in both groups were: pain scores according to VAS before and after the self-administration of analgesic mixtures, morphine consumption, microbiological analysis of catheter tips, wound healing, patient's satisfaction. The data obtained were statistically analysed using two-tailed Student's t-test.
Results: In both groups of patients pain scores were low after the treatment with analgetic mixture (VAS 1.75 ± 1.24 in control group and VAS 2.2 ± 1.2 in clonidine group during the first day) and did not differ significantly between the groups (p > 0.05). There was a tendency toward longer duration of analgesia in the group receiving mixture of ropivacaine and clonidine, yet statistic significance has not been established (p = 0.06). The need for additional morphine (3.33 mg in the control group and 4.0 mg in clonidine group during the first day) did not differ significantly between the groups (p > 0.05). Microbiological analysis showed that all the catheter tips remained sterile.
Conclusion: The results of the study show that treating postoperative pain with ropivacaine via catheter placed in the operating wound is safe and efficient pain-control method. Adding clonidine to the ropivacaine given in the same manner does not effect duration or efficiency of analgesia nor does the morphine consumption. The method described showed no additional risk for wound infection .
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