Analgesia, Spine Fusion
Conditions
Keywords
perioperation, Thoracolumbar interfasial plane, erector spine plane, ultrasound-guided analgesia, patient-controlled analgesia
Brief summary
Background: Pain relief for lumbar spine surgery is being updated to help improve the quality of post-operative recovery, especially ultrasound-guided pain relief anesthesia methods, including two anesthesia methods. Thoracolumbar interfascial plane block (TLIP block) and erector spinae plane block (ESP block) are increasingly commonly applied. Objective: compare the pain relief effectiveness of TLIP block with ESP block for lumbar spine surgery. Methods: Randomized prospective intervention study conducted at Hanoi Medical University Hospital from October 2021 to October 2022 including 100 lumbar spine surgery patients randomly divided into three groups: group control, TLIP group and ESP group. Outcomes regarding perioperative pain score (ANIm, VAS), the effectiveness of 2 ultrasound-guided methods, the complications and the side effects were recorded.
Detailed description
* All research patients were divided into 3 groups by random drawing: control group, TLIP group and ESP group. * TLIP group: patients were anesthetized before surgery using TLIP lumbar block (L3) under ultrasound with 20ml of ropivacaine 0.25% anesthetic on each side. After that, the patient was given endotracheal anesthesia for surgery. * ESP group: patients were anesthetized before surgery with lumbar (L3) ESP block method under ultrasound with 20ml of Ropivacaine 0.25% anesthetic on each side. After that, the patient was given endotracheal anesthesia for surgery. * Control group: patients received regular endotracheal anesthesia, then the incision was anesthetized with 15ml of 1% lidocaine mixed with 1/200,000 adrenaline on each side before surgery. * Anesthesia and monitoring process: all patients in all 3 groups were anesthetized using general anesthesia: * Install monitoring to monitor pulse parameters, blood pressure, SpO2, EtCO2. * Install an Analgesia Nociception Index (ANI) meter and monitor the ANI index continuously during surgery. Monitor ANI monitor V2 during surgery, maintain ANIm within the range of 50-70. * Induction of anesthesia: fentanyl 2mcg/kg slow intravenous injection, wait 3 minutes then inject propofol 2-3mg/kg, rocuronium 0.6mg/kg (when eyelid reflex is lost). Proceed with endotracheal intubation and artificial ventilation at a frequency of 12 times/minute, Vt = 6-8ml/kg, FiO2 50%, I:E = 1:2, PEEP = 5cmH2O, EtCO2 = 35-45mmHg, sevoflurane Install until MAC reaches 0.8-1. * Maintain anesthesia with sevofluran, maintain 1 MAC. * Using fentanyl during surgery: when ANIm index is less than 50: 50mcg fentanyl bolus, repeat after 5 minutes until ANIm greater than 50. Record the amount of fentanyl used during surgery. Record the ANIm index at the time of the study: when skin incision (T0) and every 10 minutes until the end of surgery. * Release of anesthesia: Patients are extubated when they meet the criteria: awake, following orders, breathing rate 12-20 times/minute, SpO2 \> 95% with FiO2 ≤ 40%, Vt \> 5ml/kg, EtCO2 \< 45 mmHg , good cough and swallow reflex and TOF ≥ 90%. After extubation, monitor the patient, record pulse index, blood pressure and VAS score and transfer the patient to the hospital room if it reaches 10/10 points according to Aldrete. * Pain relief: both groups received paracetamol 1g and ketorolac 30mg at the end of skin closure and every 8 hours thereafter. When the patient has postoperative pain (VAS score ≥ 4), they are titrated with intravenous morphine 1mg/time every 10 minutes until reaching a VAS score \< 4. At the same time, an intravenous morphine pain relief machine is installed. Patient controlled analgesia (PCA) with bolus setting 1ml = 1mg, lockout time 10 minutes, maximum dose 20mg/4 hours, no background infusion dose.
Interventions
PROCEDURETLIP Block For Perioperative Analgesia In Patients With Lumbar Spine Fusion Surgery
* Patients were placed in a prone position; * ultrasound-guided TLIP block: (1) The transducer was positioned in a transverse midline position at the level of the L3 vertebra. After the identification of the spinous process and interspinous muscles. (2) The probe was moved laterally to identify the multifidus (MF) and longissimus (LG) muscles. (3) the TLIP block was performed under real-time ultrasound guidance using an insulated 100-mm 22G echogenic needle which was inserted in-plane lateral to the medial direction. (4) After negative aspiration, 20-mL 0.25% ropivacaine was injected in each side bilaterally in the interface between the MF and LG muscles. * patients received general anesthesia
PROCEDUREESP Block For Perioperative Analgesia In Patients With Lumbar Spine Fusion Surgery
* Patients were placed in a prone position; * ultrasound-guided ESP block: (1) The 12th rib was identified in the parasagittal plane, and with probe shifted caudad and medial, the L3 transverse process (TP) was identified. (2) Insulated 100-mm 22G echogenic needle was inserted from cranial to caudal direction. (3) The needle tip was identified between the L2 and L3, and 20 mL of 0.25% ropivacaine was injected in each side bilaterally in ESP. * patients received general anesthesia
PROCEDURELidocaine injection
* patients received general anesthesia * the expected incision was anesthetized with 15ml of 1% lidocaine mixed with 1/200,000 adrenaline on each side before surgery.
Sponsors
Hanoi Medical University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Subject)
Intervention model description
TLIP block group, ESP block group and control group
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
* American Society of Anesthesiologists (ASA) physical status I-III. * Patients had lumbar spinal fusion surgery.
Exclusion criteria
* The patient does not agree to participate in the study. * Patients with severe chronic diseases: liver failure, kidney failure, heart failure, arrhythmia, neuromuscular disease. * Patients are using drugs that affect the autonomic nervous system such as beta blockers, parasympathomimetic drugs. * history of mental disorders, difficulty in communication. * Patients with acute lumbar spine injury or a history of lumbar spine surgery, injections, abscesses, and lumbar infections.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The blockade area of TLIP block and ESP block methods | after 20 minutes of block | Assessing sensory blockade area, according to the pinprick test |
| The perioperative effectiveness of TLIP block and ESP block methods (aspect 1) | up to the end of surgery | Evaluating pain relief effectiveness during surgery by total amount of fentanyl used during surgery. |
| The perioperative effectiveness of TLIP block and ESP block methods (aspect 2) | up to the end of surgery | Evaluating pain relief effectiveness during surgery by Analgesia Nociception Index (ANIm) scores: ANI is based on electrocardiographic data reflecting parasympathetic activity. ANI creates a value from 0 to 100, where a value greater than 50 indicates adequate analgesia (high parasympathetic tone) and a value less than 50 indicates nociception (a high sympathetic tone) and therefore inadequate analgesia. |
| Side effects | up to 24 hours after extubation | Rate of vomitting/nausea, itchy, urinary retention, respiratory failure, circulatory failure postoperative of all groups. |
Countries
Vietnam
Outcome results
None listed