目的:胸膜中段横突阻滞(MTPB)是胸椎旁阻滞(TPVB)的一种新变体。这项研究旨在比较TPVB和MTPB在小儿中线胸骨切开术中对手术和术后镇痛的血流动力学应激反应的术中衰减。
方法:单中心,随机化,控制,双盲,非自卑研究。
方法:三级保健儿童医院。
方法:我们招募了83名年龄在2-12岁的儿童,美国麻醉医师协会(ASA)的身体状态为II级,他们计划进行选择性的开放式心脏手术,并进行中线胸骨切开术,以修复简单的非紫癜性先天性心脏病。
方法:符合条件的参与者以1:1的比例随机分为TPVB或MTPB组。在TPVB组中,患者于T4和T5时椎旁间隙双侧注射0.25%布比卡因0.4ml/kg.在MTPB组中,患者在T4和T5水平双侧注射0.4ml/kg0.25%布比卡因中横突和胸膜正后方肋上韧带.
方法:主要结果是胸骨切开术的血流动力学反应,包括心率(HR)和有创平均动脉压(MAP),记录麻醉诱导前后,皮肤切开后,胸骨切开术后,体外循环(CPB)后15分钟,在胸骨闭合后.次要结果是执行双侧阻滞所需的时间,术中芬太尼消耗,术后芬太尼消耗,拔管后1、2、6、12、18和24小时测量的改良客观疼痛评分(MOPS),拔管时间,重症监护病房(ICU)出院时间,和非手术并发症的发生率(术后瘙痒,术后呕吐,气胸,血肿或局部麻醉毒性)。
结果:在以下时间点,与MTPB组相比,TPVB组的HR和MAP没有显着差异:基线,诱导后,皮肤切开后,胸骨切开术后,CPB后15分钟,胸骨闭合后。HR和MAP的组间比较未显示两组之间的显着差异。进行双侧MTPB(7[6-8]min)所需的中位数(IQR)时间显着(p<0.001)短于TPVB(12[10-13]min)。TPVB和MTPB组的术中芬太尼消耗量和术后24h的芬太尼消耗量相似(4[2-4]vs4[2-4]和4.66±0.649vs4.88±1.082μg/kg),分别。TPVB和MTPB组的拔管时间和ICU出院时间具有可比性(2[1-3]vs2[1-3]h和21.2±2.5vs20.8±2.6h),分别。两组拔管后1、2、6、12、18和24h的MOPS疼痛评分相似。两组非手术并发症的发生率相似。
结论:MTPB在减弱对有害手术刺激的术中血流动力学应激反应和减少围手术期阿片类药物消耗方面不劣于TPVB,拔管时间,和ICU出院时间。此外,MTPB在技术上比TPVB更容易,并且需要更少的执行时间。临床试验注册编号临床试验注册在泛非临床试验注册中心进行(PACTR202204901612169,批准日期01/04/2022,URLhttps://pactr。Samrc.AC.za/TrialDisplay。aspx?TrialID=22602)。
OBJECTIVE: The mid point-transverse process to pleura block (MTPB) is a new variant of thoracic paravertebral block (TPVB). This study aimed to compare TPVB and MTPB with respect to intraoperative attenuation of the hemodynamic stress response to surgery and postoperative analgesia in pediatric open heart surgery with midline sternotomy.
METHODS: A single-center, randomized, controlled, double-blind, non-inferiority study.
METHODS: Tertiary care children\'s university hospital.
METHODS: We recruited 83 children aged 2-12 years of both sexes with American Society of Anesthesiologists (ASA) physical status class II who were scheduled for elective open cardiac surgeries with midline sternotomy for the repair of simple noncyanotic congenital heart defects.
METHODS: Eligible participants were randomized into either the TPVB or MTPB groups at a ratio of 1:1. In the TPVB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine in the paravertebral space at T4 and T5. In the MTPB group, patients were bilaterally injected with 0.4 ml/kg of 0.25% bupivacaine mid-transverse process and pleura just posterior to superior costotransverse ligament at the level of T4 and T5.
METHODS: The primary outcome was the hemodynamic responses to sternotomy incision, including heart rate (HR) and invasive mean arterial pressure (MAP), recorded before and after the induction of anesthesia, after skin incision, after sternotomy, 15 min after cardiopulmonary bypass (CPB), and after the closure of the sternum. The secondary outcomes were time needed to perform the bilateral block, intraoperative fentanyl consumption, postoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 2, 6, 12, 18, and 24 h after extubation, extubation time, intensive care unit (ICU) discharge time, and the incidence of non-surgical complications (postoperative pruritus, postoperative vomiting, pneumothorax, hematoma or local anesthetic toxicity).
RESULTS: There were no significant differences in HR and MAP in the TPVB group compared with the MTPB group at the following time points: baseline, after induction, after skin incision, after sternotomy, 15 min after CPB, and after sternal closure. Intergroup comparisons of HR and MAP did not reveal significant differences between the groups. The median (IQR) time needed to perform bilateral MTPB (7[6-8] min) was significantly (p < 0.001) shorter than that of TPVB (12[10-13] min). Intraoperative fentanyl consumption and fentanyl consumption in the first postoperative 24 h after extubation were similar in the TPVB and MTPB groups (4[2-4] vs 4[2-4] and 4.66 ± 0.649 vs 4.88 ± 1.082 μg/kg), respectively. Extubation time and ICU discharge time were comparable in the TPVB and MTPB groups (2[1-3] vs 2[1-3] h and 21.2 ± 2.5 vs 20.8 ± 2.6 h), respectively. Measurements of MOPS pain scores at 1, 2, 6, 12, 18, and 24 h after extubation were similar in both groups. The incidence of nonsurgical complications was similar in both groups.
CONCLUSIONS: MTPB is non-inferior to TPVB in attenuating the intraoperative hemodynamic stress response to noxious surgical stimuli and in reducing perioperative opioid consumption, extubation time, and ICU discharge time. Moreover, MTPB is technically easier than TPVB and requires less time to perform. Clinical trial registration number The clinical trial registration was prospectively performed at the Pan African Clinical Trials Registry (PACTR202204901612169, approval date 01/04/2022, URL https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=22602).