| Abstract | Anestezija znači gubitak osjeta, pri čemu se može podrazumijevati samo gubitak svijesti ili samo gubitak osjeta boli, ili istovremeni gubitak i osjeta boli i svijesti. Anestetici su lijekovi koji svojim djelovanjem na živčani sustav izazivaju anesteziju. Regionalna anestezija je tehnika u kojoj injiciranjem lokalnog anestetika u blizinu živca ili kralježničke moždine inhibiramo bol, osjet i motorički podražaj, tj izazivamo neosjetljivost na bol jedne veće regije na tijelu. Blok koji sam upotrebljavao u ovoj studiji je ultrazvukom i neurostimulatorom vođeni paravertebralni blok kod kirurgije dojke. Dosadašnja istraživanja pokazala su visoku uspiješnost paravertebralnoga bloka u kirurgiji dojke za anesteziju i analgeziju. S obzirom da paravertebralni prostor medijalno komunicira s epiduralnim prostorom, dolje preko intervertebralnog ligamenta a gore preko glave i vrata rebara s susjednim paravertebralnim prostorom želim apliciranjem manjih volumena
lokalnog anestetika (7 ml po nivou) na tri razine izbjeći značajniju komunikaciju s epiduralnim prostorom Iako je u mnogim radovima dokazano da je tehnika davanja ukupnog volumena lokalnog anestetika kod paravertebralnoga bloka raspodjeljenog na više nivoa bolja od tehnike davanja na samo jedan nivo još uvijek nije razjašnjeno koja vrsta otopine lokalnih anestetika ima bolja hemodinamska svojstva.
Cilj ovog istraživanja je bio utvrditi koja od dvije otopine lokalnih anestetika kod paravertebralnoga bloka ima najpovoljniji učinak s obzirom na hemodinamsko i analgetsko djelovanje. U istraživanje su uključene bolesnice s tumorom dojke u dobi od 18 - 80 godina, ASA 1 i 2 statusa uz uvažavanje uključnih i isključnih kriterija.Učinio sam randomiziranu prospektivnu dvostruko slijepu studiju na 80 bolesnica podijeljenih u dvije skupine. ULLS- skupini primjenio sam otopinu 0.5% levobupivacaina i 2% lidocaina, 7,0 ml po nivou (ukupno 7ml 2% lidocaina +14ml 0,5% levobupivacaina), dok u drugoj LS - skupini otopinu 0.5% levobupivacaina također 7,0 ml po nivou (ukupno 21 ml). Istraživanje je učinjeno primjenom ultrazvuka in plane tehnikom, neurostimulatora i Vigileo/FloTrac sustava. Sve bolesnice su prije i za vrijeme punkcije PVB monitorirane: EKG - om, neinvanzivnim mjerenjem krvnog tlaka i saturacijom. Nakon uspiješnog nastupa PVB bolesnice su premještenu u operacijsku dvoranu gdje je izvršena indukcija 1% propofolom i verkuronijev bromidom uz postavljenje larigealne maske. Sve su bolesnice potom ventilirane pomoću kontrolirane mehaničke ventilacije uz održavanje anestezije i sedacije kontinuiranom infuzijom 1% propofolom i verkuronij bromidom prema ciljnim vrijednostima BIS-a. Nakon indukcije srednji arterijski tlak i ostale hemodinamske parametre mjerili smo preko arterijske kanile pomoću Vigileo/FloTrac sustava. Od hemodinamskih parametara mjerio sam primarno varijacije udarnog volumena zatim: srednji arterijski tlak, frekvenciju, minutni volumena, indeks minutnog volumena, sistemski vaskulami otpor i indeksirane vrijednosti sistemskog vaskulamog otpora. Mjerenja gore navedenih parametara vršio sam svakih 5 min tijekom prvog sata od nastupa paravertebralnoga bloka, potom svakih 15 min tijekom drugog sata i ukoliko je operacija trajala više od dva sata mjerenje se vršilo svakih 30 min. Postoperacijski sam u sobi za postanestezijski nadzor uklonio arterijsku kanilu te uz zadovoljavajuće sve vitalne parametre bez prisutnih komplikacija bolesnice uputio na matični odjel uz neinvanzivno hemodinamsko praćenje do prestanka djelovanja bloka. Na odjelu sam tijekom prva 24 sata pratio oporavak bolesnica i VAS skalu svaka 3 sata uz primjenu odgovarajućih analgetskih mjera. Istraživanjem sam dokazao statistički značajno više vrijednosti varijacije udarnog volumena u LLS skupini od početka mjerenja, te u svim vremenima mjerenja tijekom prvog sata. Utvrdio sam statistički značajne razlike kod LLS - skupine u vrijednosti SW - a unutar i između skupina osobito tijekom prvih 10 minuta minimalno invanzivnog hemodinamskog mjerenja. Dokazao sam ujednačenost u vrijednostima SVV-a unutar LS - skupine bez statistički značajnih razlika tijekom mjerenja hemodinamskih parametara. Zabliježio sam značajno veću nadoknadu u volumenu intraoperacijski korištenih kristaloida kod LLS - skupine. Provedenom intraoperacijskom primjenom kristaloida smanjio sam primjenu vazoaktivnih lijekova. Primjenom paravertebralnoga bloka postigao sam zadovoljavajuću postoperacijsku analgeziju i mobilizaciju kod obje skupine bolesnica bez primjene opioidnih analgetika u tom vremenskom periodu. Sukladno rezultatima i dokazima ovog istraživanja mogu zaključiti da primjena otopine jednog lokalnog anestetika s duljim vremenom potrebnim za nastup djelovanja kod paravertebralnoga bloka, uzrokuje manje hemodinamske promjene uz produljeni analgetski učinak. Time ova otopina zasigurno ima prednost u budućoj primjeni paravertebralnoga bloka osobito kod bolesnica ASA tri i četiri statusa. |
| Abstract (english) | Anesthesia means the loss of sensation which can include a loss of consciousness or a loss of pain sensation or the simultaneous loss of pain sensation and consciousness. Anesthetics are drugs that with its effects on the nervous system cause anesthesia. Regional anesthesia is a technique in which the injection of a local anesthetic near a nerve or spinal cord inhibits pain, sensation and motor stimuli, which is a cause of the insensitivity to pain of a larger region of the body. The block I used in this study is an ultrasound and neurostimulator guided paravertebral block in breast surgery. Previous studies have shown high performance of external paravertebral blocks in breast surgery for anesthesia and analgesia. Since paravertebral space medially communicates with the epidural space, down over the intervertebral ligaments and up over the head and neck of ribs with the adjacent paravertebral space, I want to, by applying smaller volume of local anesthetic (7 ml per level) on three levels, avoid significant communication with the epidural space. Although
many papers proved that the technique of giving the total volume of local anesthetic in paravertebral block divided on several levels is better than the technique of administering on one level only, it is still not clear what kind of solution of local anesthetics has better hemodynamic characteristics.
The aim of this study was to determine which of the two solutions of local anesthetics in the paravertebral block has the most favorable effect in regards to the haemodynamic and analgesic impact. The study included patients with breast cancer, ages 18 to 80, ASA 1 and 2 status with respect to the including and excluding criteria. I conducted a randomized, prospective, double-blind study in 80 patients divided into two groups. In LLS- group I applied a solution of 0.5% levobupivacaine and 2% lidocaine, 7.0 ml per level (total of 7 ml 2% lidocaine + 14 ml 0.5% levobupivacaine), and in the second LS - group the solution of
0. 5% levobupivacaine also 7.0 ml per level (total 21 ml). The study was done with the application of ultrasound with in plane technique, neurostimulators and Vigileo / FloTrac system All patients were PVB monitored before and during the biopsy using ECG, non¬invasive measurement of blood pressure and saturation. After the successful performance, PVB patients were transferred to the operating room where the induction with propofol 1 % and vecuronium bromide was performed with the positioning of a laryngeal mask. All the patients were then ventilated by means of controlled mechanical ventilation with the maintenance of anesthesia and sedation by continuous infusion of Propofol 1% and Vecuronium bromide according to the target values of the BIS. After the induction, the mean arterial pressure and other hemodynamic parameters were measured through the arterial cannula using Vigileo / FloTrac system Regarding hemodynamic parameters, I measured primarily variations in stroke volume than mean arterial pressure, frequency, output, index cardiac output, systemic vascular resistance and the index of system vascular resistance. The measurements of the above parameters were done every 5 min during the first hour after the onset of paravertebral block and than every 15 minutes during the second hour, and if the surgery lasted more than two hours, measurements were carried out every 30 minutes. Postoperatively, I removed the arterial cannula in the recovery praćenje room and with all vital parameters satisfying, without present complications, the patients were referred to the ward accompanied with non-invasive hemodynamic praćenje til the cessation of the block. I monitored the patients' recovery on the ward during the first 24 hours, as well as the VAS scale every 3 hours by using the appropriate analgesic measures. I proved throught the study significantly higher values of variation in the stroke volume in the LLS group from the beginning of the measurement, and in all measuring times during the first hour. I found statistically significant differences in LLS - group in SW values - within and between the groups, particularly during the first 10 minutes of minimally invasive hemodynamic measurements. I proved the uniformity in SW values within the LS - group with no statistically significant differences during the measurements of hemodynamic parameters. I noted significantly higher compensation in the volume of intraoperative used crystalloids with the LLS group. With the conducted intraoperative crystalloid application, I reduced the application of vasoactive drugs. By applying the paravertebral block I achieved satisfactory postoperative analgesia and the mobilization in both groups of patients without the use of opioid analgesics in that period. According to the results and the proofs of this study, it can be concluded that the application of the solution of a local anesthetic with a longer time required for the participation in paravertebral block causes smaller hemodynamic changes with prolonged analgetic effect. This gives the
solution advantages in the future implementation of the paravertebral block, especially in patients with ASA 3 and 4 status. |
