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Title:Intratekalna analgezija ob splošni anesteziji za laparoskopske ginekološke operacije: vpliv na mikrohemodinamiko, stresni odgovor in bolečino
Authors:Zdravković, Marko (Author)
Kamenik, Mirt (Mentor) More about this mentor... New window
Podbregar, Matej (Co-mentor)
Files:.pdf DOK_Zdravkovic_Marko_2020.pdf (2,71 MB)
MD5: F1B8AD42085C429F1506B9D3B7E01921
 
Language:Slovenian
Work type:Doctoral dissertation (mb31)
Typology:2.08 - Doctoral Dissertation
Organization:MF - Faculty of Medicine
Abstract:Izhodišče Mikrohemodinamsko dogajanje in regionalna dostava kisika sta v anesteziologiji pomembna zaradi povezave med moteno mikrocirkulatorno funkcijo in slabšim perioperativnim izhodom. Kljub manj boleči laparoskopski kirurški tehniki v primerjavi s klasično “odprto” kirurgijo pa bolnice po laparoskopskih ginekoloških operacijah občutijo hudo bolečino v 40% do 65% primerov. Dodatek intratekalne anelgezije k splošni anesteziji bi teoretično lahko izboljšal mikrocirkulacijo in perioperativno zdravljenje bolečine ter zmanjšal stresni odgovor. Metode Bolnice (n=102), ki so imele načrtovano laparoskopsko ginekološko operacijo, smo naključno razvrstili v tri skupine. Prejele so kombinacijo splošne anestezije z nizkim odmerkom intratekalne analgezije (NOIA: 7,5 mg levobupivakaina in 2,5 μg sufentanila) ali zelo nizkim odmerkom intratekalne analgezije (ZNOIA: 3,75 mg levobupivakaina in 2,5 μg sufentanila) ali zgolj splošno anestezijo (kontrolna skupina). Uporabili smo 3 minutni zažemni test in s spektroskopijo blizu infrardečega spektra izmerili tkivno oksigenacijo in opredelili mikrocirkulatorno funkcijo v m. brachioradialis in m. triceps surae v treh časovnih točkah: pred uvodom v splošno anestezijo, 5 minut po trahealni intubaciji in 15 minut po začetku pnevmoperitoneja. Primarni mikrohemodinamski izidi so bili: (1) primerjava spektroskopsko dobljenih mikrohemodinamskih parametrov med skupinami; (2) primerjava mikrovaskularnih trendov v mišicah nog s tistimi v mičicah rok znotraj skupin; in (3) korelacija krvnega tlaka s hitrostjo povratka tkivne oksigenacije po zažemnem testu. Trije primarni cilji s področja lajšanja bolečine so bili: (1) poraba sufentanila med operativnim posegom; (2) poraba piritramida za zdravljenje pooperativne bolečine; in (3) ocena bolečine z 11 točkovno številčno lestvico (od 0 do 10). Za oceno zgodnjega stresnega odgovora smo določili nivo kortizola in glukoze v serumu pred in med operacijo. Rezultati Med tremi skupinami ni bilo razlik v mikrohemodinamskih parametrih na podlahti. Na merilnem mestu na nogi so imele bolnice v skupinah z dodatkom intratekalne analgezije že pred uvodom v anestezijo počasnejšo hitrost tkivne reoksigenacije po zažemnem testu (NOIA 34 ±16 %/min, p=0,002; ZNOIA 36 ±13 %/min, p=0,006) v primerjavi s kontrolno skupino (52 ±27 %/min). Med splošno anestezijo smo opazili poslabšanje mikrocirkulatorne funkcije v vseh skupinah in razlik med njimi več ni bilo zaznati, med laparoskopijo pa smo zaznali pomembno zmanjšanje hitrosti tkivne reoksigenacije po zažemnem testu v skupini z NOIA (14 ±11 %/min) v primerjavi z ZNOIA (22 ±11 %/min; p=0,023) in kontrolno skupino (24 ±17 %/min; p=0,040). Poraba sufentanila (mediana [interkvartilni razpon]) je bila 2,9 (0-4) μg/h v skupini z NOIA, 4,7 (3,2-9,2) μg/h v skupini z ZNOIA in 16 (11-23) μg/h v kontrolni skupini (p<0,001), poraba piritramida znotraj 24 ur po operaciji pa 2 (0-2,5) mg, 5 (0-7,5) mg in 7,3 (2,1-9,5) mg (p=0,001), v enakem vrstnem redu skupin. Pooperativna ocena bolečine je bila ves čas <3 zgolj v skupini z NOIA. Zadovoljstvo bolnic z anesteziološko oskrbo in sodelovanjem v raziskavi je bilo ocenjeno kot odlično. Med skupinami ni bilo razlik v nivoju kortizola in glukoze v serumu. Zaključki Ne glede na uporabljeno anesteziološko tehniko so bolnice ohranile ali imele izboljšano oksigenacijo in mikrocirkulatorno funkcijo v področju m. brachioradialis med laparoskopijo. V področju m. triceps surae pa sta bili oksigenacija in mikrocirkulatorna funkcija slabši. Dodatno zmanjšanje hitrosti reoksigenacije na nogi v skupini z NOIA je treba tolmačiti z razumevanjem simpatolitičnih učinkov spinalne analgezije, ki povečajo gostoto odprtih kapilar, kar skrajša difuzijske razdalje. Nižja hitrost toka krvi ob krajših difuzijskih razdaljah je mikrohemodinamsko ugodnejša. Uporaba nizkega odmerka intratekalne analgezije zmanjša porabo opioidnih zdravil za laparoskopske ginekološke operacije in zmanjša intenziteto pooperativne bolečine.
Keywords:kombinirana splošna in spinalna anestezija, spinalna analgezija, intratekalna analgezija, laparoskopska kirurgija, ginekologija, hemodinamika, mikrocirkulacija, tkivna oksigenacija, zadovoljstvo pacientov, stresni odgovor, zdravljenje bolečine, poraba opioidov, pospešeno okrevanje po operaciji, kortizol
Year of publishing:2020
Source:Maribor
COBISS_ID:22823683 New window
NUK URN:URN:SI:UM:DK:YAWR2EBL
Views:483
Downloads:53
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Licences

License:CC BY-NC-ND 4.0, Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Link:http://creativecommons.org/licenses/by-nc-nd/4.0/
Description:The most restrictive Creative Commons license. This only allows people to download and share the work for no commercial gain and for no other purposes.
Licensing start date:03.01.2020

Secondary language

Language:English
Title:Intrathecal analgesia in addition to general anaesthesia for laparoscopic gynaecological surgery: effects on microhaemodynamics, stress response and pain
Abstract:Background Having insight into the patient microvascular state is clinically important because impaired microcirculation has been associated with worse perioperative outcomes. Even though the pain is less severe for laparoscopic surgery in comparison to open surgical procedures, severe postoperative pain after laparoscopic gynaecological surgery occurs in 40% to 65% of patients. Addition of intrathecal analgesia to general anaesthesia can theoretically improve microcirculation and perioperative pain management and reduce the surgical stress response. Methods Patients (n = 102) undergoing elective laparoscopic gynaecological surgery were randomized to receive general anaesthesia combined with low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) or very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) spinal analgesia or general anaesthesia only (control group). Tissue oxygenation and microcirculatory function were assessed with near-infrared spectroscopy over m. brachioradialis and m. triceps surae during a 3-minute vascular occlusion test at three measurement points: before general anaesthesia induction, 5 min after tracheal intubation, and 15 min after pneumoperitoneum commencement. Primary outcomes for microhaemodynamic aspects were: (1) comparison of spectroscopically derived microhaemodynamic parameters between groups, at the three measurement points; (2) comparison of microvascular trends in the calf to those in the forearm, within groups; and (3) correlation of the blood pressure with post-ischaemic recovery rate. For perioperative pain management the primary outcomes were (1) intra-operative sufentanil consumption; (2) postoperative piritramide consumption; and (3) pain scores measured with the 11-point numeric rating scale (from 0 to 10). Early surgical stress response was assessed with serum cortisol and glucose levels before and during surgery. Results There were no differences in microhaemodynamic parameters between the groups for the forearm measurement site. For the calf, before general anaesthesia induction, low- and very-low-dose spinal analgesia significantly slowed the post-ischaemic recovery compared to control (34 ± 16 %/min and 36 ± 13 %/min vs. 52 ± 27 %/min, respectively; p = 0.002 and p = 0.006, respectively). General anaesthesia abolished differences between the groups and impaired post-ischaemic recovery rate was observed in all groups. During laparoscopy, low-dose spinal analgesia further reduced the post-ischaemic recovery in the calf (14 ± 11 %/min) compared to very-low-dose spinal analgesia (22 ± 11 %/min) and control (24 ± 17 %/min) groups (p = 0.023 and p = 0.040, respectively). Intra-operative sufentanil (median [interquartile range]) consumption was 2.9 (0-4) μg/h in the low-dose spinal analgesia group, 4.7 (3.2-9.2) μg/h in the very-low-dose spinal analgesia group and 16 (11-23) μg/h in the control group (p < 0.001), whereas the piritramide consumption at 24 h post-surgery was 2 (0-2.5) mg, 5 (0-7.5) mg and 7.3 (2.1-9.5) mg in the respective groups (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anaesthetic care and participation in research was very high in all groups. There were no differences between the groups in serum cortisol or glucose levels. Conclusions During gynaecological laparoscopy patients show impaired calf but maintain or improve forearm oxygenation and microcirculatory function, regardless of the anaesthetic technique. Reduction in post-ischaemic recovery with low-dose spinal analgesia is explained by its sympatholytic effects: number of perfused capillaries is increased, leading to a haemodynamically more favourable state. Low-dose spinal analgesia in combination with general anaesthesia reduces peri-operative opioid consumption and pain scores in laparoscopic gynaecological surgery.
Keywords:combined general spinal anaesthesia, spinal analgesia, intrathecal analgesia, laparoscopic surgery, gynaecology, haemodynamic, microcirculation, tissue oxygenation, patient satisfaction, stress response, pain management, opioid sparing, enhanced recovery after surgery, cortisol


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