Cardioprotective effects of thoracic paravertebral blocks in acute blunt thoracic injuries of varying severity

O.Yu. Muryzina, E.N. Klygunenko

Abstract


Background. Analgesia adequacy in severe blunt thoracic trauma (BTT) is provided by regional anesthesia techniques, one of which is thoracic paravertebral block (TPVB) with proved effectiveness. However, there is no stu­dies of TPVB influence on heart traumatic injuries after BTT. The purpose of the study was to identify TPVB impact in the acute period of BTT, on primary and secondary traumatic injuries of the heart. Materials and methods. The controlled, prospective, non-randomized study is based on the analysis of treatment of 82 patients with BTT: 70 (85.4 %) men and 12 (14.6 %) women, aged 53 years old. Criteria for inclusion were following: blust chest injury with fractures of ribs on one or both sides, offset or no offset debris, the concussion development or non-fatal heart injury. Exclusion criteria: fatal injuries, heart attack, the severity of injuries over 27 scores by the ISS, the very severe condition of the patient, brain contusion II–III degree, acute respiratory failure, artificial lung ventilation. The groups were formed according to BTT severity; in subgroups (a, b) the effectiveness of systemic analgesia (NSAIDs and opioid) and TPVB conducted in the acute period of injury, and within 4–5 days was compared. Group 1: ISS (injury severity score) 16.0 ± 4.4 scores, APACHE II 11.7 ± 3.6; group 2: ISS 17.1 ± 3.9 scores, APACHE II 13.8 ± 4.1; group 3: ISS 18.5 ± 4.9 scores, APACHE II 14.5 ± 2.3. Results. BTT (ISS 18 [14, 20] scores) with lung contusion I and II degree in 62 (76 %) patients (in 22 % patients it was detected on the 1st day, in 79 % — in 2–3 days) was complicated with brain commotion or heart contusion in 70 % of cases, post-traumatic myocardial dystrophy in early and recovery period, almost in all patients. All the patients were admitted in intensive care unit in a state of shock: compensated in patients of group 1 and the maximum decompensated in groups 2 and 3. Systolic blood pressure in group 1 was 143 ± 22 (100 ¸ 180) mmHg, in group 2 — 132 ± 29 (80 ¸ 160), in group 3 125 ± 21 (70 ¸ 150). All the patients had damaged musculoskeletal frame of chest and thoracic organs with early complications: 56 (68 %) had small or mode­rate hemopneumothorax, 16 (32 %) patients closed pneumothorax. All of them underwent urgent closed drainage of pleural cavity. In each subgroup there was only one patient with fractures of the sternum — totally 5 (6.1 %) patients, 3 patients without displacement of fragments, and 2 patients had inconsiderable displacement. The ECG indices were the following: subendocardial and subepicardial changes, tachycardia, extrasystoles, non-specific changes in the final part of ventricular complex, signs of myocardial infarction, traumatic nature, as well as type II, due to bleeding (2 patients). There were no differences between the ECG signs of hemodynamically stable and unstable patients. The use of NSAIDs and opioids (n = 43; the subgroup «a») did not sufficiently reduced pain (Visual Analog Scale (VАS) on the 2nd day — 8 [7, 8] points, on the 3rd day VАS was 7 [6, 7]) and hypo­xemia PaO2/FiO2 295 ± 27 (p = 0.38,), blood oxygen saturation (SрО2) 90.1 ± 1.8 % (р = 0.12), remained peripheral vasospasm (PR 1987 ± 159 din/s · cm2), tachycardia (86 ± 13 · min–1), cardiac reduction (CI 2.71 ± 0.27 l/m2 · min). TPVB performed (n = 39, subgroup “b”) immediately reduced pain by 68 ± 7 %, contributing to better SpO2 (95.6 ± 1.7 vs. 94.1 ± 1.5 %), PaO2/FіO2 340 ± 25 vs. 312 ± 50 in “a” subgroup, decreased tachycardia (80 ± 7 · min–1) and vascular resistance (PR 1692 ± 157 din/s · cm2; p = 0.01), while the favorable increase in cardiac activity (CI 3.10 ± 0.17 l/m2 · min). On the 5th day against TPVB PaO2/FiO2 was greater than in “a” subgroups: 380 ± 28 % vs. 362 ± 27 %; SpO2 96.8 ± 0.7 vs. 95.1 ± 1.1 % (p = 0.02). The manifestations of post-traumatic myocardial dystrophy was observed for 14 days. The ECG re­gistered non-specific ST changes in the form of a slight depression, smoothing of T wave, sometimes spread of P wave, single beats, which did not require additional treatment. TPVB demonstrated evident cardioprotective properties to improve the clinical course of primary and secondary traumatic injuries of the heart. Conclusions. TPVB carried out immediately in the acute period of BTT, due to the pain and hypoxemia reduction has cardioprotective effect, which manifests by in anti-ischemic and anti-arrhythmic effect; allows avoid the complicated concussion and heart contusion, reduces the symptoms of primary and secondary myocardial dystrophy.


Keywords


blunt thoracic trauma; post-traumatic cardiac injury; thoracic paravertebral blockade

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DOI: https://doi.org/10.22141/2224-0586.5.84.2017.109363

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