Comparative analgesic efficacy of ultrasound-guided nerve blocks induced by three anesthetics with different duration of action in the treatment of resistant neuropathic pain in the lower extremities
Abstract
Apstrakt
Uvod/Cilj. Lečenje neuropatskog bola (NB) je veliki medicinski i socioekonomski problem. Kada se iscrpe medikamentozne metode lečenja, razvijaju se novi pravci u lečenju NB. Cilj rada bio je ispitivanje efikasnosti lečenja hroničnog, rezistentnog perifernog NB blokovima lokalnih anestetika pod kontrolom ultrazvuka. Zbog neefikasnosti konzervativnog lečenja, primenjivene su svakodnevne serije blokada tri lokalna anestetika (kratkog, srednjedugog i dugog dejstva), u istoj minimalnoj dozi. Beležene su komplikacije, neželjeni efekti, vreme potrebno za izvođenje procedure i započinjanje delovanja lokalnog anestetika. Metode. U ovom prospektivnom, randomizovanom i dvostruko-slepom istraživanju, 108 pacijenata (53 sa dijagnostikovanim dijabetesom i 55 sa radikulopatijom) sa rezistentnim i hroničnim perifernim NB u donjim ekstremitetima lečeno je serijom blokada perifernih nerava lokalnim anesteticima, pod kontrolom ultrazvuka. Konzervativno lečenje je bilo iscrpljeno. Postojanje NB je potvrđeno najmanje jednom od tri skale – the Leeds Assesment of Neuropathic Simptoms and Signs (LANSS) skala, the Dolour Neuropathic 4 questions (DN4) skala i the pain DETECT questionnaire (PD-Q) skala. Drugo lečenje nije primenjivano. Blokade nerava su davane svakodnevno do postizanja obezboljavanja [Vizuelno-analogna skala (VAS) < 30], i još dve blokade nakon toga. Primenjena su tri lokalna anestetika različite dužine dejstva u istoj minimalnoj dozi: kratkog dejstva (1% rastvor prokain-hlorida), srednjedugog dejstva (1% rastvor lidokain-hlorida) i dugog dejstva (0,25% rastvor levobupivakain-hlorida). Terapijska efikasnost je merena procentom smanjenja bola merenog VAS pre i posle lečenja i jedan mesec nakon završetka terapije: odličan rezultat > 50%; dobar rezultat 31–49%; terapija ne deluje < 30%. Beleženi su i neželjeni efekti, komplikacije, trajanje procedure, vreme potrebno za razvoj trnjenja i broj korekcija pravca igle. Rezultati. Za sve tri grupe izvođenje nervnog bloka je trajalo 5,04 ± 1,48 min (bez razlike između grupa), početak trnjenja je nastajao u proseku posle 3,75 ± 2,62 min (bez razlike između grupa), a potreba korekcije pravca igle bila je minimalna (1,03 ± 0,17 korekcije). Svi pacijenti su bili obezboljeni (VAS < 30) kada je primenjen anestetik dugog dejstva; broj potrebnih blokada za taj efekat bio je visokoznačajno (p < 0,001) manji (4,33 ± 0,63 blokada), nego u druge dve grupe, i procenat smanjenja bola bio je visokoznačajno veći (73,13%) (p < 0,001). Gubitak bola se održavao mesec dana nakon završetka lečenja bez primene bilo kakve druge terapije. Nije bilo komplikacija, niti neželjenih efekata. Zaključak. Opisana procedura je bezbedna, efikasna i laka za izvođenje, nije praćena komplikacijama niti neželjenim efektima. Obezboljavanje se postiže efikasnije i brže sa anesteticima dugog dejstva, i održava se jedan mesec bez bilo kakvog dodatnog lečenja.
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