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Abstract
Summary
This study was carried out on adult patients of both sexes suffering from unilateral chest trauma (multiple fracture ribs – flail chest) who were admitted in the cardio-thoracic intensive care unit in Suez Canal University Hospital.
Type of study:
This study was a comparative analytic study.
* Patients were classified into three equal groups ”16 patient each” by randomization
- Steps of the study were explained to every patient included in the study and approval consent was taken.
- All patients were encouraged to perform breathing exercises using an incentive deep breathing exerciser (Triflo II) and received regular physiotherapy.
Group I:
In this group : thoracic epidural catheter was placed in the thoracic epidural space under complete a septic condition at a level in the center between the uppermost and lowermost fractured ribs while the patient in the sitting position.
Group II:
In this group : patients undergo thoracic paravertebral block (TPVB) with insertion of a polyvinyl catheter in the paraverteberal space at the level between the uppermost and lowermost fractured ribs using an epidural set (18 G.) under complete aseptic condition, while the patient in the sitting position.
Group III: (control group)
Patients of this group received morphine for analgesia by PCA.
A bolus dose of 0.1 mg / kg of morphine was given through the intravenous route followed by PCA infusion.
-Total dose of morphine consumption was calculated after 72 hours.
Measurements
* Pain assessment :
I-By using visual analogue score (VAS):
Pain was assessed both at rest and during cough pre procedure& 30 minutes , 6 hours ,24 hours, 48 hours and 72 hours after the procedure by using visual analogue score.
II-By total morphine consumption :
Total dose of morphine consumption (in mg) was calculated in each group after 72 hours.
* Hemodynamics :
Heart rate and Blood pressure (systolic and diastolic) :
Heart rate- Blood pressure (systolic and diastolic) were measured pre procedure & 30 minutes, 6 hours, 24 hours, 48 hours and 72 hours after the procedure.
* Respiratory parameters :
I- Respiratory rate :
Respiratory rate was measured pre procedure, 30 minutes, 6 hours,24 hours 48 hours and 72 hours after the procedure.
II- Blood oxygen saturation (Sao2) :
Monitoring of blood oxygen saturation using pulse oimetry was monitored pre procedure & 30 minutes, 6 hours, 24 hours, 48 hours and 72 hours after the procedure.
* Arterial blood gases analysis :
Measurement of pH, PaO2 and PaCO2 were done pre procedure & 30 minutes, 6 hours, 24 hours, 48 hours and 72 hours after the procedure .
* Pulmonary function tests :
Measurement of FVC, FEV1, and peak expiratory flow rate was done pre procedure & 24 hours after the procedure, by using bedside spirometry.
* Recording side effects and complications in each group.
Results were as follow:
*Assessment of pain:
I- By using visual analogue pain score:
a) At rest
Pain scores were statistically significant lower in patients in the three groups. , but in groups I and II pain scores were highly statistically significant lower ( p <0.001) throughout the period of study.
b) During cough :
Pain scores were statistically significant lower in patients in the three groups, but in groups I and II pain scores were highly statistically significant lower ( p <0.001) throughout the period of study.
II- Total morphine consumption :
Significant decrease in total morphine consumption in groups I and II as compared to group III p<0.001 .
*Assessment of hemodynamics :
a) Heart rate
Significant improvement in the mean values of heart rate occurred in the three groups, but in groups I and II mean values of heart rate were highly statistically significant lower
*Assessment of respiratory parameters :
Respiratory rate :
Mean values of respiratory rate were statistically significant lower in patients in the three groups. , but in groups I and II tachypna was improved more significantly.
*Arterial blood gases analysis :
I- Blood PH and PaO2 :
mean values of blood PH and PaO2 were statistically significant higher in patients in the three groups. , but in groups I and II they were more statistically significant higher. Mean values PaCO2 were statistically significant lower in patients in the three groups. , but in groups I and II they were more statistically significant lower.
*Assessment of Pulmonary function tests :
Mean values of Forced vital capacity (FVC), Peak expiratory flow rate (PEFR) and Forced expiratory volume in one second (FEV1) were highly statistically significant higher in patients in groups I and II after 24 hours till the end of the study ( p <0.001). In group III mean values of FVC ,PEFR and FEV1 were statistically significant higher after 24 hours (p< 0.05) and highly statistically significant higher at 48 and 72 hours ( p <0.001).
*Incidence of complications and side effects
The incidence of complications and side effects in patients in the three groups expressed as percentage:
- Hypotension occurred more frequently in group I (50%) than groups II (6.25%) & III (6.25%).
- Nausea occurred more frequently in group III (56.25%) than groups II (12.5%) & I (18.75%).
-Pruritus occurred in only in group III (25%) of patients.