Anesthesiological management of thyroidectomy in patients with thyrotoxicosis: the introduction of a multimodal balanced analgesia

Аim ? implementation of a multimodal balanced analgesia (MMBA) in a complex of anesthetic management of patients undergoing thyroidectomy in a specialized centre of endocrine surgery. Materiаls and methods. Patients in the study were divided into 2 groups: in the group of balanced analgesia (BA) 52 patients with thyrotoxicosis were included, in whom the multimodal balanced analgesia approach was used and the control group (C) which consisted of 71 patients with thyrotoxicosis in whom the traditional anesthesia approach was used. Evaluation of, the pain level by visual analog score (VAS), the use of narcotic and non-narcotic analgesics, the frequency and severity of postoperative nausea and vomiting (PONV) during the first 24 hours of postoperative (post-op) period was performed. Results and discussion. Total fentanyl consumption in the operation was the lowest in subgroup BA-S (303,4+-14,4) mcg, the highest in the subgroup C-P (443,7+-19,0) mcg and had a significant difference between other subgroups(p <0,05). The combination of the bilateral BSCP with sevoflurane anesthesia reduces opioid requirement and consumption in the intraoperative period. In subgroups BA-S and BA-P the use of narcotic analgesics was not necessary in the post-op period unlike subgroups C-S and C-P, where narcotic analgesics were used in 94,9% and 93,7% patients respectively due to the fact that bilateral BSCP provides higher efficiency of post-op analgesia for a long time. Dexketoprofen consumption was significantly lower in the subgroups BA-S (100,0+-4,8) mg and BA-P (100,0+-4,6) mg compared to the control subgroups, where dexketoprofen consumption was (112,8+_3,5) mg and (112,5+_3,8) mg in the subgroups C-S and C-P respectively. Due to the good anesthetic and analgesic effects of bilateral BSCP we didn't have to combine dexketoprofen with COX-3 inhibitors in subgroups BA-S and BA-P. According to VAS the level of pain in subgroups BA-S and BA-P was evaluated as weak pain and was significantly lower compared to the subgroups C-S and C-P(p <0,05). The use of multimodal balanced analgesia approach with basic anesthesia by sevoflurane in the subgroup BA-S provides the intraoperative opioid sparing effect, which resulted in decreased intraoperative fentanyl consumption (303,4+_14,4) mcg per operation, which was significantly lower by 19,5%, 20,5% and 31,6% than in subgroups C-S, BA-P and C-P respectively. The use of MMBA approach allowed us to significantly decrease patients without PONV(p <0,05), number of patients without PONV was 46,2% and 50,0% in the subgroups C-S and C-P, respectively, and 73,3% and 77,3% in subgroups BA-S and BA-P. Significant decline was acheieved (p<0,05) in the total score on the PONV scale in subgroups BA-P upto 0,36+_0,11, that was 60,6% and 55,2% less than in the subgroups C-S and C-P. For the subgroup BA-S, this indicator was 0,43+_0,11 and was 53,1% and 46,7% significantly (p <0,05) lower than in the subgroups C-S and C-P. Conclusions. The introduction ofthe MMBA complex into anesthetic management of patients with thyrotoxicosis undergoing thyroidectomy, in the form of bilateral blockade of superficial cervical plexus (BSCP) by 0,5% bupivacaine solution with the addition of IV dexamethasone 4?8 mg and IV 50 mg dexketoprofen before induction of anesthesia provided a high level of analgesia in post-op period in both the subgroups: with baseline inhalation anesthesia with sevoflurane and TIVA with propofol; provided opioid-sparing effect in post-op period which resulted in no necessity for the use of narcotic analgesics; reduced post-operative pain and the frequency and severity of PONV, NSAIDs consumption.