Derin nöromüsküler blokaj uygulaması eşliğinde jinekolojik laparoskopik ameliyatlarda düşük basınçlı pnömoperitoneumun postoperatif omuz ağrısı üzerine etkisinin araştırılması
Yükleniyor...
Tarih
2016
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Bu çalışmanın amacı standart basınçlı pnömoperitoneum (12-14 mmHg) ve
ilımlı nöromüsküler blokaj (NMB) uygulaması ile karşılaştırdığımızda düşük basınçlı
pnömoperitoneum (8-10 mmHg) ve derin nöromüsküler blokaj (NMB) uygulamasının laparoskopik histerektomi ameliyatı sonrası gelişen omuz ağrısını azaltıp azaltmadığını değerlendirmektir.
Yöntem: Çalışma randomize kontrollu prospektif klinik araştırmadır. Çalışmaya benign nedenlerle total laparoskopik histerektomi (TLH) ve bilateral salpenjektomi / total laparoskopik histerektomi ve bilateral salpingooferektomi (TLH ve BSO) operasyonu planlanan 49 hasta dahil edildi. Hastalar iki gruba ayrıldı. Grup 1’e (düşük basınç ve derin NMB grubu) dahil edilen 25 hastada laparoskopi sırasında düşük basınçlı (8-10 mmHg) pnömoperitoneum ile derin nöromüsküler blokaj (roküronyum infüzyonu 0,3-0,6 mg/kg/h ) şartlarında çalışıldı. Grup 2’ye alınan 24 hastaya ise standart basınçlı (12-14 mmHg) pnömoperitoneum sağlandı ve ilımlı nöromusküler blokaj (gereğinde fraksiyone bolus roküronyum ) uygulandı. Grup1 ‘deki hastalarda uygulanan derin nöromusküler blokaj cerrahi koşulları optimuma getirmek, yeterli intraabdominal çalışma alan sağlamak amacıyla yapıldı. Bütün hastalara postoperatif analjezi için standart tedavi uygulandı ve gerektiğinde ek analjezik yapıldı ve kaydedildi. Postoperatif 1.; 6; 24.;36. ve 48. saatlerde NRS ve VAS ile omuz ve karın ağrısı ve diğer ikincil sonuçlar kaydedildi. Postoperatif hastanede yatış suresi kaydedildi. Postoperatif 7. gun omuz ağrısı değerlendirildi. Her iki gruptaki hastaların verileri gruplar arası ve grup içi karşılaştırıldı.
Bulgular: Ortalama operasyon süresi düşük basınç grubunda 148 dk; standart basınç
grubunda ise 155 dk saptandı. Grup 1’de 25 hastadan 13’ünde, grup 2’de 24 hastadan 10’unda takip süresince hiç omuz ağrısı saptanmadı. Grup 2 (standart basınç ve ilımlı NMB grubu) ile karşılaştırıldığında grup 1’de (düşük basınç ve derin NMB grubu ) bakılan tüm zaman dilimlerinde ( 6., 24, 36. ve 48. saatler) her 2 değerlendirme skalasına göre (NRS ve VAS) omuz ağrısında sayısal olarak azalma saptandı. Ancak istatistiksel olarak gruplar arasında anlamlı fark olmadı, Postoperatif 1. Saatte hiçbir hastada omuz ağrısı saptanmadı.
Her 2 grup içinde zamana göre omuz ağrısı değerlendirildiğinde istatistiksel anlamlı fark saptandı.
Sonuç: Düşük basınç ve derin NMB grubunda omuz ağrısının sıklığının ve şiddetinin sayısal olarak az olduğu, ancak istatistik farkın anlamlı olmadığı saptandı. Bu sonucun çalışmaya dahil olan hasta sayısının azlığından da kaynaklanabileceği düşünüldü. Her 2 grup içinde zamana göre omuz ağrısı değerlendirildiğinde istatistiksel anlamlı fark saptandı. Her 2 grupta omuz ağrısının özellikle 24. ve 36.saatlerde ortaya çıktığı ve bu saatlerde daha şiddetli olduğu görüldü. Karın ağrısının ise erken postoperatif dönemde daha şiddetli izlendiği, zamanla hafiflediği saptandı. İki grup arasında operasyon süresi açısından istatistik olarak anlamlı bir
farklılık saptanmadı. Bu da düşük basınçlı pnömoperitoneumun operasyon süresini uzatmadığını gösterdi. Ek olarak çalışmada intraoperatif PETCO2 değerleri de incelendi. PETCO2 değerleri yüksek basınçlı pnömoperitoneum koşullarında sayısal olarak daha yüksek
(PETCO2> 40mmHg) bulundu. Bu da yüksek basınçlı pnömoperitoneumun solunum fonksiyonlarını da olumsuz etkilediğini gösterdi. Düşük basınç ve derin NMB grubunda postoperatif hastanede yatış süresi sayısal olarak daha kısa izlendi.
Aim: The aim of this study is to determine whether pneumoperitoneum with lower pressure (8-10 mmHg) and the application of deep neuromuscular blockage (NMB) will reduce the shoulder pain developed after laparoscopic hysterectomy surgery, when pneumoperitoneum with standard pressure (12-14 mmHg) and the application of modest neuromuscular blockage (NMB) were compared. Methods: Study is a randomized, controlled prospective clinic research. Study was included 49 patients for whom operations such as total laparoscopic hysterectomy (TLH) and bilateral salpingectomy/ total laparoscopic hysterectomy and bilateral salpingoopheroctomy (TLH and BSO) were planned due to benign reasons. Patients were divided into two groups. In 25 patients included in Group 1 (the lower pressure and deep NMB group), pneumoperitoneum with lower (8-10 mmHg) and deep neuromuscular blockage (rocuronium infusion 0.3-0.6 mg/kg/h) were studied during laparoscopy. For the 24 patients included in group 2, neumoperitoneum with standard pressure (12-14 mmHg) was provided and modest neuromuscular blockage (fraction bolus rocuronium, if required) was applied. Optimization of surgical conditions related to deep neuromuscular blockage applied to patients in group 1 was carried out to provide sufficient intra-abdominal work area. In all patients standard therapy was applied for postoperative analgesia and if necessary additional analgesic was used and recorded At postoperative 1, 6, 36 and 48 hours shoulder and abdominal pains and other secondary results were recorded through NRS and VAS. The length of postoperative hospital stay was also recorded. Should pain was evaluated at postoperative day 7. In both groups the data of patients were compared between groups and within groups. Results: The mean length of operation was 148 min. in lower pressure group and 155 min. in standard pressure group. During follow-up there were no shoulder pains in 13 of 25 patients (group 1) and in 10 of 24 patients (group 2). According to 2 assessment scales (NRS and VAS), in all time frames (6, 24, 36 and 48 hours) a numeric reduction was found in shoulder pain in group 1 (lower pressure and deep NMB group) compared to group 2 (standard pressure and modest NMB group). However, there was no statistically significant difference between groups. Shoulder pain was not detected in any of the patients in postoperative 1st hour. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. Conclusion: In lower pressure and deep NMB group, the frequency and severity of shoulder pain was little numerically, but the statistical difference was found insignificant. It is thought that this result might have resulted from the paucity of patients included in study. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. It was observed in both groups that shoulder pain has appeared especially at 24th and 36th hours and it was more severe at these hours. But more severe abdominal pain was seen at the early postoperative period and it alleviated in time. A statistically significant difference was established between two groups in terms of operation process, indicating that pneumoperitoneum with lower pressure did not prolong the operation process. In addition, intraoperative PETCO2 value was also studied. PETCO2 value was found higher in the conditions of pneumoperitoneum with higher pressure (PETCO2 > 40mmHg). This indicated that the respiratory tract was influenced by pneumoperitoneum with higher pressure negatively. A shorter postoperative hospital stay was observed in lower pressure and deep NMB group.
Aim: The aim of this study is to determine whether pneumoperitoneum with lower pressure (8-10 mmHg) and the application of deep neuromuscular blockage (NMB) will reduce the shoulder pain developed after laparoscopic hysterectomy surgery, when pneumoperitoneum with standard pressure (12-14 mmHg) and the application of modest neuromuscular blockage (NMB) were compared. Methods: Study is a randomized, controlled prospective clinic research. Study was included 49 patients for whom operations such as total laparoscopic hysterectomy (TLH) and bilateral salpingectomy/ total laparoscopic hysterectomy and bilateral salpingoopheroctomy (TLH and BSO) were planned due to benign reasons. Patients were divided into two groups. In 25 patients included in Group 1 (the lower pressure and deep NMB group), pneumoperitoneum with lower (8-10 mmHg) and deep neuromuscular blockage (rocuronium infusion 0.3-0.6 mg/kg/h) were studied during laparoscopy. For the 24 patients included in group 2, neumoperitoneum with standard pressure (12-14 mmHg) was provided and modest neuromuscular blockage (fraction bolus rocuronium, if required) was applied. Optimization of surgical conditions related to deep neuromuscular blockage applied to patients in group 1 was carried out to provide sufficient intra-abdominal work area. In all patients standard therapy was applied for postoperative analgesia and if necessary additional analgesic was used and recorded At postoperative 1, 6, 36 and 48 hours shoulder and abdominal pains and other secondary results were recorded through NRS and VAS. The length of postoperative hospital stay was also recorded. Should pain was evaluated at postoperative day 7. In both groups the data of patients were compared between groups and within groups. Results: The mean length of operation was 148 min. in lower pressure group and 155 min. in standard pressure group. During follow-up there were no shoulder pains in 13 of 25 patients (group 1) and in 10 of 24 patients (group 2). According to 2 assessment scales (NRS and VAS), in all time frames (6, 24, 36 and 48 hours) a numeric reduction was found in shoulder pain in group 1 (lower pressure and deep NMB group) compared to group 2 (standard pressure and modest NMB group). However, there was no statistically significant difference between groups. Shoulder pain was not detected in any of the patients in postoperative 1st hour. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. Conclusion: In lower pressure and deep NMB group, the frequency and severity of shoulder pain was little numerically, but the statistical difference was found insignificant. It is thought that this result might have resulted from the paucity of patients included in study. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. It was observed in both groups that shoulder pain has appeared especially at 24th and 36th hours and it was more severe at these hours. But more severe abdominal pain was seen at the early postoperative period and it alleviated in time. A statistically significant difference was established between two groups in terms of operation process, indicating that pneumoperitoneum with lower pressure did not prolong the operation process. In addition, intraoperative PETCO2 value was also studied. PETCO2 value was found higher in the conditions of pneumoperitoneum with higher pressure (PETCO2 > 40mmHg). This indicated that the respiratory tract was influenced by pneumoperitoneum with higher pressure negatively. A shorter postoperative hospital stay was observed in lower pressure and deep NMB group.
Açıklama
Anahtar Kelimeler
Pnömoperitoneum, Nöromusküler Blokaj, Laparoskopi Sonrası Omuz Ağrısı, Pneumoperitoneum, Neuromuscular Blockage, Post-Laparoscopy Shoulder Pain
