Nghiên cứu hiệu quả vô cảm trong mổ và giảm đau sau mổ của gây tê đám rối thần kinh cánh tay bằng hỗn hợp bupivacain dexmedetomidin trong kết hợp xương chi trên tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES --- TRAN THI CAM NHUNG RESEARCH ON EFFICACY OF INTRAOPERATIVE ANES

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

-

TRAN THI CAM NHUNG

RESEARCH ON EFFICACY OF INTRAOPERATIVE ANESTHESIA AND POSTOPERATIVE ANALGESIA BY MIXTURE OF BUPIVACAINE WITH DEXMEDETOMIDINE

IN BRACHIAL PLEXUS BLOCK FOR UPPER EXTREMITY BONE SURGERY

Speciality: Anesthesiology Code: 62720122

ABSTRACT OF MEDICAL DISSERTATION

Hanoi - 2020

THE THESIS HAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Supervisors:

1 Prof Dr Nguyen Van Chung

2 Dr.Tong Xuan Hung

Reviewers:

1 Prof Dr Nguyen Huu Tu

2 Ass Prof Dr Bui Van Manh

3 Ass Prof Dr Le Van Doan

Archives:

1 National Library of Vietnam

2 Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences

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INTRODUCTION

Upper extremity fractures are a common and they appear in every subject According to statistics of Nguyen Duc Chinh et al from 2016 to 2018, 90011 patients of accidents at Viet Duc Hospital, the proportion of this cases had accounted for 53.2% with lower and upper extremity injuries The study of Karl in the United States, the epidemiology of upper extremity fractures accounted for 677/100000 patients in 2009 Among anesthesia methods for upper extremity surgery, brachial plexus block is usual technique due to simple but highly effective anesthesia for this surgery

To reduce dose of local anesthetic, increase effect this anesthetic in brachial plexus block, prolong the analgesic effect after surgery, many authors have had researches adding local anesthetics with drug such as sufentanil, fentanyl, morphine, dexamethasone, ketorolac, clonidine, or dexmedetomidine In Viet Nam, there has been no any research on a combination of local anesthetic with dexmedetomidine, so we have conducted a project "Research on efficacy of intraoperative anesthesia and postoperative analgesia by mixture of bupivacaine with dexmedetomidine in brachial plexus block for upper extremity bone surgery”, following two objectives:

1 To compare intraoperative anesthetic and postoperative analgesic efficacy of 75mg bupivacaine and 100mcg dexmedetomidine mixture with bupivacaine alone by brachial plexus block for upper extremity bone surgery

2 To evaluate on blood pressure, heart rate, sedative effect and some adverse effects of 75mg bupivacaine and 100mcg dexmedetomidine mixture by brachial plexus block for upper extremity bone surgery

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Chapter 1 OVERVIEW 1.1 Upper extremity fracture

Causes of the upper extremity fractures are popular due to domestic accidents, machinery, playground injury or road traffic accidents In particular, the author Rubin and his colleagues reported

103465 cases of traffic accidents which had 17263 situations of upper extremity fractures, the ratio of open fractures accounted for 16.7%, about 18.1% at adults and 13.2.% at children In the Netherlands, the frequency of upper extremity fractures had accounted about 824/100 000 people for 9 years from 2004 to 2012 and tended to grow up following next time, more regularly in a group

of 16-35 years old, more man than female

1.2 Anesthetic techniques for upper extremity bone surgery

There are many anesthetic techniques for upper extremity surgeries, such as intravenous regional anesthesia (Bier block), brachial plexus block, general anesthesia

Advantages of brachial plexus block are not only simple technique, but also reducing or losing provisional sensation and movement of upper extremity Patients still awaken, recovery early, lessen caring of health care staff and family’patient Especially, it is lower cost than general anesthesia

1.3 Brachial plexus block

The brachial plexus is formed from five roots, the anterior rami

of the spinal nerves from C5 - T1, they connect together to form 3 trunks, after the roots pass between the scalene muscles they meet the subclavicular artery and divide into divisions

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In the three trunks, the superior trunk arises from the union of the C5 - C6 root The middle trunk is formed by the C7 root The inferior trunk is formed by the C8 - T1 root Each trunk continues to divide into two: the anterior and posterior division After that, six dividions connect together and form three cords The lateral cord is formed from connection of two anterior divisions from the superior trunk and the middle trunk The medial cord is an anterior division of the inferior trunk and the posterior cord is composed of three posterior divisions The three cords give rise to major nerves which control sensation and movement of upper extremity, are musculocutaneous nerve, radial nerve, median nerve and ulnar nerve The benefit of supraclavicular brachial plexus block is to anesthetize whole upper extremity Thus, it should be considered

"spinal block for upper extremity", and indicated for arm, elbow, forearm and hand surgeries Because almost the brachial plexus merges into a mass, blocking this position can do anesthesia for all branches and rapid onset time of sensory block due to small nerves and minimum local anesthetic

Supraclavicular brachial plexus block may have some complications such as about 0.04 - 1% pneumothorax, subclavicular artery puncture, Claude Bernard Horner syndrome, phrenic nerve block rarely

1.4 Using drug in brachial plexus block of our study

Bupivacaine which is local anesthetic, is exerted to block recoverable conduction of nerve impulse, through mechanism to inhibit depolarization of neural membrane by preventing of Na+ to pass this membrane Bupivacaine inhibits stronger sensory fibers than motor fibers, because motor fibers have myelin sheath and

It is important that high doses of dexmedetomidine has not affected the histopathology of the neural axon and myelin which were monitored at 24 hours and 14 days

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Chapter 2 SUBJECTS AND METHODS 2.1 STUDYING SUBJECTS

Male and female patients, who had been undergone elective surgeries of arm or/and forearm fracture by supraclavicular brachial plexus block

2.1.1 Selection criteria for study patients

Patients who agreed to participate in the study, aged 15-75 years, ASA grade I – III

2.1.2 Exclusive criteria

- Patients had disorder of atrial-ventricular conduction, bradycardia < 50beats/minute Psychiatric disorder, epilepsy, neuromuscular diseases Renal or hepatic failure

- History of allergy local anesthetics, alcoholism or drug abuse

- Pregnancy or lactating women, patient’s weigh < 35 kg

2.1.3 Rejective criteria from study

Patient had multiple injuries, combined upper extremity surgery with other surgeries, surgical complication or not collected enough data

2.2 TIME AND LOCATION OF STUDY

The study was practiced from February, 2016 to May, 2017 at Anesthesia and Orthopedic Department in Can Tho Central General Clinic Hospital

2.3 RESEACH METHODOLOGY

2.3.1 Study Design: It was a controlled, randomized, interventional

prospective clinical study

2.3.2 Sample size and division of patient group

Using the test formula for comparison of two average numbers

Filling this parameters into this formula, and calculating n = 49.1 Therefore, we selected 54 patients for each group

2.3.3 Devices, facilities and drugs of research

- Ultrasound machine with linear probe, frequency 6 - 12MHz of Ezono AG company

- Stimuplex A needle for brachial plexus block of B Braun company

- VAS (Visual Analog Scale) ruler

- Multi-parameters monitoring of Nihon Kohden company

- Bupivacaine Aguettant 20 ml 0.5% of Delpharm Tours, France

- Dexmedetomidine (PrecedexR), 200mcg/2ml of Hospira.Inc, North Chicago

- Emergency drugs: atropine, ephedrine, adrenaline, noradrenaline, intralipid 20%

- Kinds of infusion: lactate ringer, sodium chloride 0.9%,

2 3.4 Study procedure

2.3.4.1 Preoperative period

The day before surgery: examined and measured height,

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weight, and classified ASA Instruct patients to identify pain level on VAS ruler Explain to the patient about the technique of anesthesia and some possible adverse-effects If the patient agreed to participate

in this study, he/she would sign a consent form and be drawn to the study subgroup No one is used analgesic at the surgerical morning

2.3.4.2 At the operating room

Patients would be watched for ECG, HA, breathing rate, SpO2

by monitoring and recorded these indexes at that time of study Administer 3liter/min oxygen through the nasal tube Doing intravenous line with 18G needle, and infusing ringer lactate about

30 drops/min

To prepare 30 ml mixture of local anesthetics:

+ B Group: 15 ml of bupivacaine 0.5% plus 15 ml of 0.9% sodium chloride to obtain 30 ml of bupivacaine 0.25%

+ BD group: 15 ml of bupivacaine 0.5% plus 100mcg /1ml of dexmedetomidine, and 14ml of 0.9% natricloride to get 30ml mixture of bupivacaine 0.25% and 100mcg dexmedetomidine

2.3.4.3 Practice by supraclavicular brachial plexus block via ultrasound guidance

The patient's position was lying on an operative table, injuried hand was closed to body, his head was faced to the opposite side of brachial plexus block An anesthesiologist used an ultrasound probe

to determine location of the brachial plexus where is above the clavical bone Holding the transducer plane in a direction that was parallel to body's axis, so that ultrasound beam crossed the brachial plexus and subclavicular artery located on the first rib Once the brachial plexus was adequately identification of the neural structures

as round or oval multiple hypoechoic structures, next to the

To monitor the patient in 30 minutes after brachial plexus block: if the patient had completed pain sensory blockage, surgery would be performed If the patient was still moderate pain, we would give them fentanyl 1-2 mcg/kg, and/or midazolam 0.02 - 0.04 mg/kg

by intravenous injection in case of anxiety Continuing this evaluation after 5 minutes, if the patient was still severe pain, we would change to general anesthesia All patients in both groups are given paracetamol 1g/100ml at the end of the surgery

2.3.5 Accessment standards of study

2.3.5.1 General characteristics of the patient and surgery

Age, gender, height, weight, historical chronic diseases, ASA classification, location and time of surgery

2.3.5.2 Comparison intraoperative anesthetic and postoperative analgesic efficacy of mixture’s bupivacaine and dexmedetomidine with bupivacaine alone by brachial plexus block

- The onset time and level of pain sensory blockage dermatomes where be controlled by radial nerve, median nerve and ulnar nerve

- The onset time and level of pain sensory blockage on

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dermatomes where be controlled by roots from C5 to T2

- The onset time and level of pain sensory blockage whole dermatomes of arm surgery

- The onset and duration time of motor blockage

- Level of motor blockage

- Intraoperative anesthetic efficiency

- Postoperative analgesic efficiency: duration time and VAS score at rest and movement, used analgesics after surgery

2.3.5.3 Evaluation on blood pressure, heart rate, sedative effects and some adverse effects mixture of bupivacaine with dexmedetomidine by brachial plexus block

- Monitor blood pressure: systolic blood pressure (SBP), diastolic blood pressure (DBP), average blood pressure (ABP), heart rate

- Sedative effect: onset and duration time, sedative level

- Monitor breathing rate and SpO2

- Adverse effects due to local anesthetic

-Adverse effects due to anesthetic technique

2.3.6 Methods of evaluation

- Evaluation of pain sensory blockage by pin-prick method: after anesthesia, we used a needle to prick test sensory pain on dermatomes where be controlled by roots from C5 to T2, and radial nerve, median nerve, ulnar nerve, compared with the opposite side

In particular, C5 dominates sensory pain of arm’s outside, C6 dominates sensory pain of forearm’s outside, C7 dominates sensory pain of the hand, C8 dominates sensory pain of the forearm’s inside, T1 dominates sensory pain of the arm’s inside and T2 dominates sensory pain of underarm The radial nerve dominates sensory pain

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on the back of the thumb and II finger, the median nerve dominates sensory pain on the palm of III and IV finger, the ulnar nerve controls sensory pain on the palm of V finger

- The level of pain sensory blockage for upper extremity during surgery was assessed following the author Agarwal’s research, divided to 3 grades, grade 0: normal sensation; grade 1: a little loss

of sensation of pin-prick (analgesia); grade 2: complete loss of pain sensation (anesthesia)

- The level of motor blockage for upper extremity was assessed

by Bromage scale, divided into 3 grades, grade 0: normal motor function with full flexion and extension of elbow, wrist, and fingers; grade 1: decreased motor strength with ability to move the fingers only; grade 2: Complete motor block with inability to move the fingers

- Intraoperative anesthetic efficiency was assessed by the author Abouleish E., divided into 4 levels, excellent: patient completely no felt pain and no supplementary drug was required; very good: patient felt mild pain and was given 50 mcg fentanyl; good: patient felt moderate pain and was given 100 mcg fentanyl, poor: patient felt severe pain and was required 100 mcg fentanyl but they could not bear pain and could be changed general anesthesia

- The level of postoperative analgesia was evaluated by VAS score, divided into 4 levels, VAS = 0: no pain, VAS = 1 - 3: mild pain, VAS = 4 - 6: moderate pain, VAS = 7 - 10: severe pain

- The level of intraoperative sedation was evaluated by OAA/S score, OAA/S = 5 score: alert; OAA/S = 4: light sleep; OAA/S = 3: moderate sleep; OAA/S = 2: deep sleep; OAA/S = 1: very deep sleep, unconscious

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2.3.7 Standards and definitions using for study

- Onset time of pain sensory blockage of each root from C5 to T2 root, radial nerve, median nerve, ulnar nerve was defined as the time from the end of local anesthetic administration until patient felt a litte loss sensory block with grade 1 according to the classification of Agarwal, unit in minutes

- Onset time of pain sensory blockage of whole upper extremity

is defined as the time from the end of local anesthetic administration until patient feel loss sensory block with grade 1 according to the classification of Agarwal, was dominated by roots from C5 to T2, and radial nerve, median nerve, ulnar nerve, unit in minutes

- Duration time of pain sensory blockage of whole upper extremity was defined as the time from patient felt loss sensory block with grade 1 until completely sensory recovery with grade 0 according to the classification of Agarwal, unit in minutes

- Onset time of motor blockage was defined as the time from the end of local anesthetic administration until patient decreased motor strength with ability to move the fingers only, grade 1 according to the classification of Bromage, unit in minutes

- Duration time of motor blockage was defined as the time from patient decreased motor strength with ability to move the fingers only (grade 1) until completely motor recovery (grade 0), unit in minutes

- Postoperative analgesic time was defined as the time from the end of the surgery to the time of pain appearance, unit in minutes

- Hypotension: systolic blood pressure (SPB) was less than 90 mmHg in a case of an initial SPB  110 mmHg, or SPB droped of more than 20% of the initial SPB = 90 - 109 mmHg