Učinci magnezija primijenjenoga epiduralno u perioperacijskom liječenju torakokirurških bolesnika [Effects of epidural magnesium on perioperative treatment in thoracic surgical patients]

Kogler, Jana (2016) Učinci magnezija primijenjenoga epiduralno u perioperacijskom liječenju torakokirurških bolesnika [Effects of epidural magnesium on perioperative treatment in thoracic surgical patients]. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Patients undergoing surgical resection of the lungs are generally classified as the American Society of Anesthesiology (ASA) class III, along with preoperatively impaired pulmonary function, mostly coronary comorbidity and compromised immune status due to malignant and chronic lung diseases. Thoracic surgery is associated with severe painful stimuli, reflex activity of the mediastinum vascular structures that frequently causes arrhythmias, unavoidable ventilation and circulation disorders, difficulty in maintaining hemodynamic stability and appropriate oxygenation and strong stress response. The aim of the present study was to assess the complex effect of epidural magnesium during thoracic surgery procedure on the overall stress response, modulation of anesthesiologic drug use and in particular its antinociceptive effect during 48 hours postoperatively in thoracic surgery patients. This prospective placebo-controlled randomized study included 70 ASA I-III patients undergoing elective thoracic surgery resection of the lungs. Seventy patients were randomized to two groups of 35 patients: magnesium group received epidural 10% magnesium sulfate (MgSO4) along with anesthesiologic drugs, and control group received epidural 0.9% sodium chloride (NaCl) solution along with anesthesiologic drugs intraoperatively. Postoperatively, magnesium group patients were administered epidural 10% magnesium sulfate in addition to local anesthetic and opioid, whereas control group patients were administered local anesthetic and opioid alone. On preoperative examination, patients were informed on the methods of pain intensity assessment, which included visual analog scale (VAS) for rest and movement (TORDA) . In all patients, the following parameters were determined: total doses of intraoperatively administered propofol , rocuronium and sufentanil ; total doses of epidural sufentanil and levobupivacaine administered during 48 hours postoperatively; levels of the stress hormone cortisol before operation, after the operation and every 8 hours during first 24 hours postoperatively. The parameters associated with perioperative course were: systolic and dyastolic blood pressures monitored continuously for 48 hours; pulse rate monitored continuously; peripheral oxygen saturation (SaO2), and BIS values; VAS score for rest and movement every 4 hours; level of sedation immediately after arrival in the ICU ; cardiovascular complications, respiratory and neurological complications; rate of postoperative shivering; nausea and vomiting and global patients satisfaction. Results of the present study indicated that the addition of magnesium in the epidural mixture of opioid sufentanil and local anesthetic levobupivacaine led to more efficient intraoperative and postoperative analgesia and to lower utilization of opioid sufentanil and local anesthetic levobupivacaine. The intraoperative utilization of anesthetic propofol and myorelaxant rocuronium was decreased, along with a lower rate of postoperative nausea, vomiting and postoperative shivering. The magnesium dosage used in the study was associated with normal hemodynamic and respiratory status of the patients. We can conclude that, based on the favorable effects recorded, epidural magnesium appears to be a useful adjunct to anesthesiologic drugs, which can exert positive effects on the course and outcome of thoracic surgery procedures.

Abstract in Croatian

Bolesnici koji su podvrgnuti resekcijskom zahvatu na plućima najčešće se klasificiraju kao status ASA III te već preoperativno imaju oštećenu plućnu funkciju, najčešće koronarnu prateću bolest i poremećaj imunološkog statusa zbog malignih i kroničnih plućnih bolesti. Osobitosti torakokirurških operacija su izrazito snažan bolni podražaj, refleksna aktivnost vaskularnih struktura medijastinuma koja često uzrokuje aritmije, neizbježni poremećaji ventilacije i cirkulacije, teško održavanje hemodinamske stabilnosti i zadovoljavajuće oksigenacije bolesnika te snažan stresni odgovor. Cilj ovog kliničkog istraživanja bio je utvrditi da li epiduralna primjena magnezija u vidu otopine 10% MgSO4 tijekom torakokirurškog zahvata može modulirati potrebna doze anestetika, mišićnog relaksansa i analgetika tijekom operativnog zahvata i u prvih 48 sati postoperativno, smanjiti stresni odgovor te učestalost postoperativnih nuspojava i komplikacija. U ovu prospektivnu dvostruko slijepu, placebo-kontroliranu, randomiziranu studiju bili su uključen bolesnici, podvrgnuti elektivnom torakokirurškom resekcijskom zahvatu na plućima. 82 Randomizacijom smo formirali dvije skupine po 35 bolesnika: magenzij skupina ispitanika koja je tijekom operativnog zahvata uz anesteziološke lijekove primala 10% magnezijev sulfat (MgSO4) epiduralno i kontrolna skupina koja je uz anesteziološke lijekove epiduralno primala 0.9% otopinu natrijevog klorida (NaCl) . Postoperativno, magnezij skupina je epiduralno uz lokalni anestetik i opioid primala i 10% magnezijev sulfat, dok je kontrolna skupina primala samo lokalni anestetik i opioid. Tijekom preoperativnog pregleda bolesnici su bili upoznati sa metodama određivanja intenziteta boli – vizualnom analognom ljestvicom (VAS) i TORDA ljestvicom. Za sve bolesnike bila je utvrđena: ukupna doza anestetika propofola , mišićnog relaksansa rokuronijuma i opioida sufentanila primijenjena tijekom operacije; ukupno primijenjena doza opioida sufentanila i levobupivakaina tijekom 48 sati poslije operacije; razina hormona stresa- kortizola, prijeoperacije, nakon operacije te svakih 8 sati tijekom prva 24 sata postoperativno. Posebno je bilježena pojava kardiovaskularnih komplikacija,učestalost javljanja postoperativne drhtavice, mučnine i povraćanja te pojava bilo kakvih neželjenih događaja. U svih naših bolesnika primjena magnezijeva sulfata (MgSO4) se pokazala sigurnom. Niti u jednog bolesnika epiduralna primjena magnezija nije bila uzrokom cirkulacijske nestabilnosti, niti se očitovala značajnom hipotenzijom ili bradikardijom. Nije opažena alergijska reakcija na infuziju magnezija. Rezultati našega istraživanja pokazali su da dodavanje magnezija u epiduralnu smjesu opioida sufentanila i lokalnog anestetika levobupivakaina dovodi do učinkovitije intraoperativne i postoperativne analgezije te manje potrošnje sufentanila i levobupivakaina. Smanjena je intraoperativna potrošnju anestetika i mišićnog relaksansa uz nižu učestalost javljanja postoperativne mučnine, povraćanja i drhtavice. Uz primijenjenu dozu magnezija hemodinamski i respiratorni status bolesnika bio je uredan. Zaključujemo da je zbog navedenih povoljnih učinaka magnezij primijenjen epiduralno koristan dodatak anesteziološkim lijekovima koji može povoljno utjecati na tijek i ishod torakokirurškog zahvata.

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