Bloqueio modificado dos nervos toracoabdominais por meio de abordagem pericondral (M TAPA) guiado por ultrassonografia em pacientes submetidos a gastroplastia vertical laparoscópica. Estudo prospectivo, duplo encoberto e randomizado.
Arquivos
Data
2024-04-26
Autores
Lima, Roclides Castro de 
Orientadores
Sakata, Rioko Kimiko
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A analgesia pós operatória adequada por um intervalo de tempo satisfatório para pacientes submetidos à gastroplastia vertical laparoscópica (GVL) é um desafio, principalmente nas primeiras horas após a cirurgia. Para fornecer um melhor conforto no período pós operatório, recomenda se o uso de analgesia multimodal, que inclui analgésicos simples, infiltração de anestésico local em portais laparoscópicos e bloqueios nervosos da parede abdominal. O bloqueio modificado dos nervos toracoabdominais por abordagem pericondral (M TAPA), surge como uma forma promissora de aliviar a dor pós operatória em cirurgias abdominais, incluindo a GVL. Devido à escassez de estudos a respeito desse bloqueio é importante elucidar os efeitos do M TAPA bem como suas diferenças em relação a versão inicial. Objetivo: O objetivo do estudo é avaliar a eficácia do M TAPA como analgesia pós operatória para pacientes submetidos à GVL. Método: Trata se de um estudo prospectivo, controlado, randomizado e duplo cego. Foi realizado no Hospital São Domingos, localizado em São Luís – MA, onde 100 pacientes submetidos a GVL, com pontuação ASA de 2 a 3, foram alocados em dois grupos: grupo com bloqueio com ropivacaína (GR) e grupo com solução salina (GS). Os pacientes do GR receberam injeção de 30 mL de ropivacaína a 0,2% bilateralmente (60 mL ao todo) após indução anestésica e intubação orotraqueal e o GS recebeu solução salina a 0,9% em igual volume. O desfecho primário do estudo foi avaliar a intensidade da dor pós operatória após o bloqueio modificado dos nervos toracoabdominais. Os desfechos secundários foram a avaliação da qualidade da recuperação pós operatória através da pontuação obtida no questionário Quality of Recovery (QoR 15); o consumo de opioides pós operatório e os efeitos adversos destes; a avaliação da duração da analgesia pós operatória e os níveis de interleucinas 6 e 8. Resultados: O estudo demonstrou uma menor intensidade da dor pós operatória em repouso, no T6 e T12 com diferença estatística com o grupo GR menor quando comparado ao GS, com valores de p=0,015 e p=0,041. A intensidade da dor pós operatória em movimento no T4, T6 e T12 no grupo GR foi menor quando comparado ao GS, com valores de p=0,021, p=0,006 e p=0,002. O critério confiança para ir de alta hospitalar no GR foi maior e com diferença estatística em relação ao GS (p=0,009). A análise da qualidade de recuperação pós anestésica pelo questionário QoR 15, por meio da mediana do escore do questionário, demonstrou diferença com significância estatística entre os grupos (p=0,042): 125 (recuperação boa) no GR, contra 118 (recuperação moderada) no GS. Não houve diferença no consumo de morfina em 24 horas entre os grupos, assim como na primeira solicitação de dose da morfina e efeitos adversos. O nível de interleucina 8 foi menor no tempo pós operatório de 24 horas (p=0,003) no grupo GR. Conclusão: o M TAPA proporcionou menor dor pós operatória e uma melhor qualidade de recuperação pós anestésica.
Introduction: Adequate postoperative analgesia for a satisfactory period of time for patients undergoing laparoscopic sleeve gastroplasty (GVL) is a challenge, especially in the first hours after surgery. To provide better comfort in the postoperative period, the use of multimodal analgesia is recommended, which includes simple analgesics, local anesthetic infiltration into laparoscopic portals and abdominal wall nerve blocks. Modified thoracoabdominal nerve block using a perichondral approach (M TAPA) appears as a promising way to alleviate postoperative pain in abdominal surgeries, including GVL. Due to the scarcity of studies regarding this blockade, it is important to elucidate the effects of M TAPA as well as its differences in relation to the initial version. Objective: The aim of the study is to evaluate the effectiveness of M TAPA as postoperative analgesia for patients undergoing GVL. Method: this is a prospective, controlled, randomized and double blind study. It was carried out at Hospital São Domingos, located in São Luís – MA, where 100 patients undergoing GVL, with an ASA score of 2 to 3, were allocated into two groups: group with ropivacaine blockade (GR) and group with saline solution (GS). The RG patients received an injection of 30 ml of 0.2% ropivacaine bilaterally (60 mL in total) after anesthetic induction and orotracheal intubation and the GS received 0.9% saline solution in the same volume. The primary outcome of the study was to evaluate the intensity of postoperative pain after modified thoracoabdominal nerve block. The secondary outcomes were the assessment of the quality of postoperative recovery through the score obtained in the Quality of Recovery questionnaire (QoR 15); the consumption of postoperative opioids and their adverse effects; assessment of the duration of postoperative analgesia and levels of interleukins 6 and 8. Results: The study demonstrated a lower intensity of postoperative pain at rest, at T6 and T12, with a smaller statistical difference with the GR group when compared to the GS, with values of p=0.015 and p=0.041. The intensity of postoperative pain during movement at T4, T6 and T12 in the GR group was lower when compared to the GS, with values of p=0.021, p=0.006 and p=0.002. The confidence criterion for being discharged from hospital in GR was higher and with a statistical difference in relation to GS (p=0.009). The analysis of the quality of post anesthesia recovery using the QoR 15 questionnaire, using the median of the questionnaire score, demonstrated a statistically significant difference between the groups (p=0.042): 125 (good recovery) in the GR, against 118 (recovery moderate) in GS. There was no difference in morphine consumption in 24 hours between the groups, as well as in the first morphine dose request and adverse effects. The level of interleukin 8 was lower 24 hours postoperatively (p=0.003) in the GR group. Conclusion: M TAPA provided less postoperative pain and a better quality of post anesthesia recovery.
Introduction: Adequate postoperative analgesia for a satisfactory period of time for patients undergoing laparoscopic sleeve gastroplasty (GVL) is a challenge, especially in the first hours after surgery. To provide better comfort in the postoperative period, the use of multimodal analgesia is recommended, which includes simple analgesics, local anesthetic infiltration into laparoscopic portals and abdominal wall nerve blocks. Modified thoracoabdominal nerve block using a perichondral approach (M TAPA) appears as a promising way to alleviate postoperative pain in abdominal surgeries, including GVL. Due to the scarcity of studies regarding this blockade, it is important to elucidate the effects of M TAPA as well as its differences in relation to the initial version. Objective: The aim of the study is to evaluate the effectiveness of M TAPA as postoperative analgesia for patients undergoing GVL. Method: this is a prospective, controlled, randomized and double blind study. It was carried out at Hospital São Domingos, located in São Luís – MA, where 100 patients undergoing GVL, with an ASA score of 2 to 3, were allocated into two groups: group with ropivacaine blockade (GR) and group with saline solution (GS). The RG patients received an injection of 30 ml of 0.2% ropivacaine bilaterally (60 mL in total) after anesthetic induction and orotracheal intubation and the GS received 0.9% saline solution in the same volume. The primary outcome of the study was to evaluate the intensity of postoperative pain after modified thoracoabdominal nerve block. The secondary outcomes were the assessment of the quality of postoperative recovery through the score obtained in the Quality of Recovery questionnaire (QoR 15); the consumption of postoperative opioids and their adverse effects; assessment of the duration of postoperative analgesia and levels of interleukins 6 and 8. Results: The study demonstrated a lower intensity of postoperative pain at rest, at T6 and T12, with a smaller statistical difference with the GR group when compared to the GS, with values of p=0.015 and p=0.041. The intensity of postoperative pain during movement at T4, T6 and T12 in the GR group was lower when compared to the GS, with values of p=0.021, p=0.006 and p=0.002. The confidence criterion for being discharged from hospital in GR was higher and with a statistical difference in relation to GS (p=0.009). The analysis of the quality of post anesthesia recovery using the QoR 15 questionnaire, using the median of the questionnaire score, demonstrated a statistically significant difference between the groups (p=0.042): 125 (good recovery) in the GR, against 118 (recovery moderate) in GS. There was no difference in morphine consumption in 24 hours between the groups, as well as in the first morphine dose request and adverse effects. The level of interleukin 8 was lower 24 hours postoperatively (p=0.003) in the GR group. Conclusion: M TAPA provided less postoperative pain and a better quality of post anesthesia recovery.
Descrição
Citação
LIMA, Roclides Castro de. Bloqueio modificado dos nervos toracoabdominais por meio de abordagem pericondral (M TAPA) guiado por ultrassonografia em pacientes submetidos a gastroplastia vertical laparoscópica. Estudo prospectivo, duplo encoberto e randomizado.. 2024. Tese (Doutorado em Ciência Cirúrgica Interdisciplinar) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). São Paulo, 2024.