MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF DEFENCE

108 INSTITUTE OF CLINI CAL M EDICAL AND PHARMACEUTICAL SCIENCES

--------------------------------------------------------

TRAN THANH TRUNG

STUDYING ON THE ANALGESIC EFFICACY
AFTER LUNG SURGERY OF ULTRASOUND - GUIDED
CONTINOUS THORACIC PARAVERTEBRAL BlOCK
WITH BUPIVACAIN - FENTANYL
Speciality: Ane sthesiology
Code: 62.72.01.22

ABSTRACT OF MEDICAL PHD THESIS

Hanoi – 2019


THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL
MEDICAL AN D PHARMACEUTICAL SCIENCES

Supervisor:
1. Ass. Prof. PhD. Trinh Van Dong
2. PhD. Dang Van Khoa

Reviewer:
1.

all over the world . However, methods

demonstrated in these studies are not homogeneous and the varying
results are causing much debate.
In Vietnam, there are only a few number of studies about
thoracic para vertebra l block and no study about continuous thoracic
paravertebral block as well as the application of ultrasound in the
thoracic paravertebral block for pain after lung surgery. Therefore, we
conduct research on this topic with the aim of:
1.

Comparing

the

postoperative

analgesis

effect

of

ultrasound- guided continous thoracic paravertebral block with
epidural anesthesia using bupivacaine and fentanyl after lung
surgery.
2. Evaluating changes in circulation, respiratory and some
undesirable effects from these two methods of postoperative pain
relief.




3

1.3.3. Patient Control Analgesia (PCA)
1.3.4.Drug-free technique
1.4. Thoracic paravertebral block
1.4.1. Brief history
1.4.2. Anatomy of the thoracic paravertebral space
The thoracic paravertebral space is a wedge-shaped space tha t
lies on either side of the vertebral column. It is wider on the left than on
the right and ílimited by:
- Front wall: The parietal pleura forms.
- Posterior wall: The superior costotransverse ligament, which
extends from the lower border of the transverse process above to the
upper border of the transverse process below. This ligament connects
with intercostal membrane in the outer.
- Inner wall: the back side of the vertebral body, spinal disc and
split holes between the vertebrae.
1.4.3. Drugs used in the research
1.4.3.1. Bupivacain: There are many drugs used in the
paravertebral block but bupivacain is the most used. It is often combined
with epinephrin to detect mistaken injection into the blood vessels,
reduce circulatory absorption, decrease peak plasma concentrations and
prolong analgesia.
1.4.3.2. Fentanyl: Used in the paravertebral block. The volume of
fentanyl concentration when combined with anesthesia is 1 to 2 µg/ml.
1.4.3.3. The spread of anesth esia in the thoracic paravertebral space
Thoracic paravertebral block takes effect at the corresponding
segments marrow, or it may spread to the contiguous levels above and

pulmonary hemorrhage; hematoma caused by poking into the epidural
space; pain in the anesthesia area; local infection and infection in the
paravertebral space. folding, clogging or slipping of the catheter
- Undesirable effects related to anesthesia: anesthetic intoxication,
anesthetize whole spinal, hypotension, Claude Bernard Horner syndrome.
- Undesirable effects related to morphin: pruritus, vomiting and
nausea, respiratory failure, urinary retention, excessive sedation.


5

Chapter 2
SUBJECTS AND METHODS
2.1. Studying subjects
The study was conducted on 102 patients who received post
opera tive pain relie f after lung surgery, or peeled lung, with the
following criteria:
2.1.1. Selection criter ia for study patients
- Patients with indication to have open lung surgery on one
side according to the program.
- Age: ≥16 year olds.
- Patients who agreed to cooperate with the doctors to conduct
post-operative pain relief methods.
- ASA class I or II (According to the American Society of
Anesthesiologists Classification).
2.1.2. Exclusive crite rial
- Patients do not agree to participate in the study.
- Patients with a history of allergy to anesthesia.
- Patients with diabetes or adrenal insufficiency.
- Drug addicts.


and ß. From looking

and , we choose C = 10.5. ES is

the coefficient of influence.
In this study, we selected each group of 51 patients.
2.3.2.2. Divide the research groups
Patients who had determined eligibility for the study will be
randomly assigned to 2 groups: pa ravertebral block (PVB) and
epidural block (EPB), each group consists of 51 patients.
2.3.3. Instruments, facilities and drugs used in the study
The combination of 0.125% bupivacain - fentanyl 2 µg/ml:
Take 12.5 ml of bupivacain 0.5% + 0.1 mg fentanyl (2ml) to get a
bupivacain and fentanyl mixture. Mix the above mixture of
bupivacain a nd fentanyl with 35.5 ml of 0.9% natricloride to get a 50
mixture of anesthetic bupivacaine 0.125% - fentanyl 2 µg/ml.


7

2.3.4. Method of proceeding
2.3.4.1. Examination, counseling, guiding patients before surgery
2.3.4.2. Prepare patients at the surgery room
2.3.4.3. Conducting anesthesia and surgery
All patients in the study got an endotracheal anesthesia according
to a general regimen.
Maintain a nesthesia with c losed-loop anesthesia system.
When the skin was closed, the patient was given 1 g of paracetamol.
Endotracheal tube withdrawal when qualified.

Cases of ineffective pain relief (VAS score > 4): install PCA
morphine intravenously. PCA s ettings: Each press (bolus): 1mg/1ml
morphin; lock time: 15 minutes; maintenance dose: no; total dose
limit: 10 mg/4 hours.
- Time of withdrawal of the catheter: After ge tting the
research data of timestamp H 72 .
- Design for pain relief after catheter withdrawal : If there is
still pain after removing the catheter, install the PCA morphin
intravenously with the above settings
* For EPB group
- Insert the catheter into the epidural space
ü Perform when the surgery is finished
ü Patient posture: lying on the side
ü Needle position: T4-5 or T5-6 or T6-7.
ü Using loss of resistanc e technique
- Injection of analgesic
+ Conditions to relieve pain: similar to PVB group.
+ Postoperative analgesic injection:
Patients who met the above conditions for pain relief and had
VAS ≥ 4 points. Inject bupivac aine 0.125% - fentanyl 2 µg/ml with
bolus dose: (height-100)/10 ml. Maintain dose as PVB group.
Cases of poor or ineffective pain relief: install PCA morphin
intravenously. PCA settings as PVB group.
- Time of catheter withdrawal and design of pain relief
after catheter withdrawal: similar to PVB group.


9

2.3.5. Indicators needing evaluation in the study

10

- Evaluate vomiting: 4 levels according to Myles.
- Evaluate the level of motor blocka de on Bromage scale.
- Evaluate Aubrun's secret level.
2.3.7. Some catastrophes and direction of management
- Anesthetic poisoning: stop injecting anesthetic, give
sedation, anticonvulsant, respiratory resuscitation and circulation,
intravenous infusion of 20% lipid solution (intralipid).
- Full spinal a nesthesia: circulatory resusc itation (fluid
infusion, vasoconstrictor) and artificia l re spiration (ball squeezing,
endotracheal intubation).
- Hypotension: ra pid infusion (0.9% natricloride, high
molec ular weight) and e phedrin .
- Bradycardia: atropine sulpha te 0.5 mg intravenously.
- Slow breathing: Monitor breathing, if less than 10 beats
/minute give patient na loxon 0.4 mg intravenous or re spiratory
support.
- Pneumothorax: often self -exacerbated. If there is large air
spill then suck air or dra in the pleura.
2.4. Analyzing and processing data
The research data were analyzed and proce sse d using SPSS
16.0 software .


11

Chapter 3
RESEARCH RESULTS
3.1. General characteristics

postoperative

analgesis

effects

of

ultrasound- guided continous thoracic paravertebral block with
epidural anesthesia
3.2.1. Waiting time for analgesic effect
The waiting time for analgesic effects in the PVB group was
11.9 ± 6.02 minutes and in the EPB group was 11.6 ± 6.45 minutes.
There was no difference in waiting time for analgesic effect between
the two groups with p > 0.05.


12

3.2.2. Drug used and spread of anesthetic
The total dose of bupivacaine used for 72 hours after surgery
in the PVB group was 432.4 ± 75.01 mg and in the EPB group was
446.2 ± 74.53 mg. The total dose of fentanyl used for 72 hours after
surgery in the PVB group was 335.8 ± 58.21 µg, in the EPBl group
was: 346.4 ± 57.86 µg. There was no difference in the total dose of
bupivacaine a nd fentanyl between the two groups.
The extent of the anesthetic spread after 15 minutes of injection
in PVB group was 4.6 ± 0.8 vertebra, lower than EPB group: 4,9 ± 1,1
vertebra, the difference was statistically significant with p

6.5 ± 1.2

4-9

> 0.05

H1/4

3.5 ± 1.0*

2-6

3.5 ± 0.9*

2-6

> 0.05

H1/2

2.9 ± 0.8*

2-6

3.1 ± 0.7*

2-5

> 0.05


2-4
1-5

2.5 ± 0.6*
2.4 ± 0.6*

2-5
1-4

> 0.05
> 0.05

H12

2.1 ± 0.6*

1-5

2.2 ± 0.6*

1-4

> 0.05

H24

1.9 ± 0.5*

1-3


Notes: * p < 0.01 versus H0


13

Comment:
The VAS static scores at the times of the study in the two groups
was not statistically significant. The VASstatic scores at the times of
15 minutes after injection was reduced statistically significant
compared to H0.
3.2.3.2. The degree of pain when dynamic (VASdyn ami c) in two groups
Table 3.2. VAS score when dynamic (VAS dynamic ) in two groups
Groups

PVB (n = 51)

X

Time s

SD

EPB (n = 51)

X

Min-Max

SD


3.9 ± 0.9*

3-6

3.7 ± 0.7*

3-5

> 0.05

H1

3.6 ± 0.8*

2-6

3.6 ± 0.7*

3-5

> 0.05

H2

3.4 ± 0.6*

2-5

3.4 ± 1.0*


2-5

> 0.05

H24

2.4 ± 0.5*

2-4

2.5 ± 0.6*

2-5

> 0.05

H48

2.1 ± 0.6*

1-4

2.3 ± 0.6*

2-5

> 0.05

H72

3.2.5. Proportion of patients and additional morphin use d
B ng 3.3. Percentage of patients required additional analgesia by PCA
Groups

PVB

EPB

PCA

n

%

n

%

Yes

10

19,6

7

13,7

No


PVB

EPB

(n=10)

(n=7)

Total doses

X ± SD

5.2 ± 3.6

3.7 ± 2.5

in 24 hours

Min - Max

1 - 20

1 - 10

Total doses

X ± SD

8.6 ± 5.2




15

Comment:
The total doses of morphin used for additional pain relief in
the two groups was not statistically significa nt.
3.2.6. Characteristics of gluc ose and cortisol levels
Table 3.5. Glucose levels (mmol/l)
Groups

PVB

EPB

Time s

(n = 51)

(n = 51)

Before surgery

5.7 ± 1.0

6.1 ± 2.7

> 0.05

Before injecting drugs


p

Notes: * p < 0.01 compared to before surgery
Comment:
The glucose leve ls at different times were not statistically
significant. The glucose concentration of the epidural group before
injection and in the first day after surgery increased more than
before surgery (p 0.05

Before injecting drugs


Time s

Notes: * p < 0.01 versus before surgery

p


16

Comment:
The cortisol concentration of the two groups before the
injection and after surgery increased significantly compared to
before surgery. At the second day after surgery, cortisol levels were
lower in PVB group than in EPB group.

%

3.2.7. Satisfaction levels of patients of pain relief methods
100

78.5 82.3

PVB

p > 0,05

EPB

80
60

The average blood pressure of PVB group is higher than that
of EPB group at H1 time (p < 0.01) and H 2 (p < 0.05). At the
remaining times, the difference was not statistica lly signific ant (p >
0.05).


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3.3.2. Changes in respiratory at the time of postoperative
3.3.2.1. Changes in breathing rate and SpO2
After injection, breathing rate of EPB group wa s significantly
lower than ve rsus H 0 (p < 0.01).
There was no difference in spO2 after surgery (p > 0.05).
3.3.2.2. Changes in respiratory function
Ventila tion function of both groups was lower than before
surgery (p 0.05).
3.3.3. Undesirable effects
10
8
6
4

infection at puncture point.


%

18

17.6

20
15

PVB

p < 0,05

11.8

9.8

10
5
0

EPB

3.9
0
Hypotension


7.8

10

p > 0,05

19.6
p > 0,05

15.7

11.8

9.8
5.9

7.8

5
0

Vomiting,
nausea

Tremor

PVB

Urinary
retention

The use of opioid drugs and the characteristics of anesthesia
time, duration of surgery, pulmonary ventilation time and duration of
endotracheal intubation a ffect the postoperative pain level
4.1.3. Characteristics of thoracic paravertebral block
Our studies have used ultrasound-guided to locate the
transverse process, paravertebral space, pleural as well as
determining the distance from the skin to these anatomica l
la ndmarks, therefore the success rate was relatively high.
4.2. The postoperative analgesis effect of ultrasound- guided
continous thoracic paravertebral block with epidural anesthesia
4.2.1. Waiting time for analgesic effect
The duration of the a nalgesic effect varies depending on the


20

anesthetic technique, the conce ntration and volume of anesthesia
used. Acc ording to Nguyen Hong Thuy, the average waiting time for
pain relief is 14.7 minutes (10-20 minutes). Hara found that she
started to reduce the pain after 10 minutes. For Abdallah, the average
la tency is 10 minutes (10.3 - 14.3 minutes).
4.2.2. Drug used and spread of anesthetic
There was no difference in the total dose of bupivacaine and
fentanyl between the two gro ups.
The time from after the second injection onwards, the extent
of the anesthetic spre ad in the two groups did not differ (p > 0.05).
4.2.3. Postoperative pain level in two groups
The VAS score during both resting time and activities at the
time of study of the EPB group was lower than the PVB group.
However, the difference was not statistically significant (p > 0.05).

groups at the corresponding times.
4.2.8. Satisfaction levels of patients of pain relief methods
The proportion of patients who rated from above satisfaction
with PVB group was 96.1%; and that of EPB group was 98%. There
was no difference in satisfa ction level between the two groups (p >
0.05).
Our results are consistent with Ria in, the post-opera tive
satisfaction score on the average 10-points scale is 9 points.
4.3. Changes in circulation, respiratory and more undesirable
effects
4.3.1. Changes in about circulation and respiratory at the time
of postoperative
The results of our study show that paravertebra l anesthesia is
more hemodynamically stable than epidural anesthesia, which is also
consistent with studies by Swati Bisht (2015), O Cucu (2005) a nd
Richardson (1999). Pintaric (2011) also has similar conclusions that
paravertebral anesthesia has consistently resulted in similar analgesic
but hemodynamic stability compared to epidural anesthesia in
patients with thoracotomy.


22

After surge ry, lung ventilation function decreased significantly
compared to before surgery (p < 0.01). However, rehabilitation of
postoperative ventilation is better than in the PVB group. This result
is also consi stent with the research results of Bisht and Richardson ,
which state that respiratory function is better preserved in the PVB
group than the EPB group.
Throughout the study, the pH, PCO 2, PO2 and HCO 3- index of

hours after surgery; plasma glucose and cortisol after surgery
increa sed more than before surgery of the two groups were not
different statistically significant (p > 0.05). The percentage of
patients requiring PCA and total doses of supplemental morphin
in the ultrasound- guided continous thoracic paravertebral block
group and the epidural group were not significantly different (p>
0.05): 19.6% and 10.1 ± 6.6 mg versus 13.7% a nd 8.7 ± 5.2 mg,
respectively.
2. Thoracic paraverte bral block was less like ly to affect circulation
and breathing than epidural anesthesia: the perce nta ge of patients
with hypotension and respiratory depression was 3.9 and 0%
ve rsus 17, 6% and 9.8% (p < 0.05). The recovery of FVC, FEV1
and PEF of the thoracic paravertebral block group was better
than epidural anesthesia group (p