O papel da preservação do nervo intercostal no controle da dor aguda pós-toracotomia.
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2013
Authors
Marchetti Filho, Marco Aurelio [UNIFESP]
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Leão, Luiz Eduardo Villaça [UNIFESP]
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Tese de doutorado
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Abstract
Apesar da crescente utilizacao de tecnicas minimamente invasivas para abordagem das doencas toracicas, a toracotomia ainda se constitui em uma via de acesso insubstituivel em muitas situacoes. A queixa recorrente dos pacientes submetidos a toracotomias e de dor, desde o pos-operatorio inicial e muitas vezes persistente nas consultas ambulatoriais. Adotam-se algumas medidas, com resultados, muitas vezes insatisfatorios, para minimizar esse sintoma como, a anestesia peridural toracica e variantes na tecnica cirurgica. O objetivo desse estudo foi o de avaliar se a disseccao do feixe neurovascular, previamente a colocacao do afastador de Finochietto, e o cuidado de nao esmagar o nervo intercostal (sutura subperiostal) durante o fechamento da toracotomia sao medidas eficazes na minimizacao da dor no pos-operatorio intra-hospitalar (ate o quinto dia). Foram selecionados 40 pacientes candidatos a toracotomia eletiva na Disciplina de Cirurgia Toracica da Escola Paulista de Medicina, randomizados em dois grupos de 20 pacientes para submeterem-se a toracotomia convencional sem os cuidados de protecao do feixe neurovascular, e 20 pacientes nos quais se protegia o feixe. Todos os pacientes foram operados pela tecnica de toracotomia poupadora da musculatura, submetidos a anestesia peridural toracica com cateter que foi retirado no terceiro dia de posoperatorio. Pela caracteristica subjetividade da dor, sua avaliacao em posoperatorio nao e tarefa facil. Optamos como estrategia de analise pela utilizacao da Escala Visual Analogica (EVA) e a medida do consumo de analgesicos de demanda no pos-operatorio (cloridrato de tramadol e dipirona sodica). Os resultados do estudo apontaram que as medidas de protecao do feixe neurovascular foram efetivas na diminuicao da dor, na comparacao nos escores da EVA, sendo que no quinto PO com significancia estatistica (3,29-grupo convencional x 1,50-grupo com protecao, p=0,04). Quando medimos o consumo de analgesicos, os resultados foram equivalentes nos dois grupos. Concluimos que a variacao na tecnica, quando se protege o feixe neurovascular previamente a colocacao do afastador e o cuidado de nao comprimir o feixe no fechamento da toracotomia sao medidas simples e de rapida execucao que podem minimizar a dor no pos-operatorio intra-hospitalar de pacientes submetidos a toracotomia.
In spite of the increasing use of minimal invasive techniques in the approach of thoracic diseases, the thoracotomy remains an irreplaceable access in many situations. The patients most frequent complaint is pain, either in the early postoperative as well in the postoperative follow-up. Several attempts have been made to attenuate this symptom, such as, epidural thoracic anesthesia and variations on surgical technique, however the outcomes are unsatisfactory. The purpose of this study is to evaluate if the dissection of the neurovascular bundle, prior to the positioning of the Finochietto retractor and avoid the intercostal nerve crush(subperiostal suture)while closing the thoracotomy, are effective in decreasing pain during the intrahospital postoperative (up to five days postoperative). There were 40 patients elected to thoracotomy, at Thoracic Division of Escola Paulista de Medicina, randomized into two groups of 20 patients each, one group to be submitted to a conventional thoracotomy without the protection of the neurovascular bundle and 20 patients whose the bundle was protected. All the patients were operated with a muscle-sparing thoracotomy and an epidural cateter was placed, and was removed on the third postoperative day. Pain is a subjective symptom and its quite difficult to evaluate on postoperative period. We chose the use of Visual Analogic Scale (VAS) and the measurement of the analgesic consumption on postoperative (tramadol chlorhydrate and sodium dipirone). The study shows that the protection of the neurovascular bundle was effective decreasing pain, the comparison on VAS scores, on the fifth postoperative day achieved statistical significance (3,29- conventional group x1.50-preserved group p=0.04). When analgesic consumption was measured, it was similar into the two groups, either to tramadol chlorhydrate (1025mg x 834.09mg p =0.22) or to sodium dipirone (16.67g x 15.71g p=0.98). We conclude that protecting the neurovascular bunble prior to the posiotioning of the retractor and being careful to protect the bundle when closing the thoracotomy, are a simple and fast method that may decrease pain on intrahospital postoperative period in patients submited to a thoracotomy.
In spite of the increasing use of minimal invasive techniques in the approach of thoracic diseases, the thoracotomy remains an irreplaceable access in many situations. The patients most frequent complaint is pain, either in the early postoperative as well in the postoperative follow-up. Several attempts have been made to attenuate this symptom, such as, epidural thoracic anesthesia and variations on surgical technique, however the outcomes are unsatisfactory. The purpose of this study is to evaluate if the dissection of the neurovascular bundle, prior to the positioning of the Finochietto retractor and avoid the intercostal nerve crush(subperiostal suture)while closing the thoracotomy, are effective in decreasing pain during the intrahospital postoperative (up to five days postoperative). There were 40 patients elected to thoracotomy, at Thoracic Division of Escola Paulista de Medicina, randomized into two groups of 20 patients each, one group to be submitted to a conventional thoracotomy without the protection of the neurovascular bundle and 20 patients whose the bundle was protected. All the patients were operated with a muscle-sparing thoracotomy and an epidural cateter was placed, and was removed on the third postoperative day. Pain is a subjective symptom and its quite difficult to evaluate on postoperative period. We chose the use of Visual Analogic Scale (VAS) and the measurement of the analgesic consumption on postoperative (tramadol chlorhydrate and sodium dipirone). The study shows that the protection of the neurovascular bundle was effective decreasing pain, the comparison on VAS scores, on the fifth postoperative day achieved statistical significance (3,29- conventional group x1.50-preserved group p=0.04). When analgesic consumption was measured, it was similar into the two groups, either to tramadol chlorhydrate (1025mg x 834.09mg p =0.22) or to sodium dipirone (16.67g x 15.71g p=0.98). We conclude that protecting the neurovascular bunble prior to the posiotioning of the retractor and being careful to protect the bundle when closing the thoracotomy, are a simple and fast method that may decrease pain on intrahospital postoperative period in patients submited to a thoracotomy.
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MARCHETTI FILHO, Marco Aurélio. O papel da preservação do nervo intercostal no controle da dor aguda pós-toracotomia. 2013. 86 f. Tese (Doutorado em Ciências) – Escola Paulista de Medicina, Universidade Federal de São Paulo. São Paulo, 2013.