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"Latar Belakang: Laparoskopi nefrektomi merupakan teknik pembedahan pilihan untuk pasien donor ginjal di RSCM karena memiliki beberapa keunggulan dibandingkan laparotomi. Pembedahan akan mengaktivasi respon stress yang mempengaruhi perubahan hemodinamik intraoperatif. Kombinasi anestesi regional epidural dengan anestesi umum dapat mengurangi respon stress intraoperatif. Teknik yang digunakan adalah epidural. Blok Quadratus Lumborum (QL) merupakan blok interfasia efektif sebagai analgesia pasca bedah abdomen. Penelitian ini bertujuan untuk menilai respon stress hemodinamik intraoperatif antara blok QL dan epidural pada pasien laparoskopi nefrektomi. Parameter yang dinilai adalah tekanan arteri rata-rata (MAP), laju nadi, indeks kardiak (CI), dan gula darah. Kebutuhan fentanyl intraoperatif juga turut dinilai. Metode: Penelitian ini adalah uji klinis acak tidak tersamar terhadap pasien donor ginjal yang menjalani laparoskopi nefrektomi di RSCM selama bulan Juni hingga September 2018. Dilakukan randomisasi sebanyak 36 subjek menjadi 2 kelompok. Setelah induksi, kelompok epidural diberikan epidural kontinyu bupivacain 0.25% sebanyak 6 ml/jam dan pada kelompok QL diberikan 20 ml bupivacain 0.25% secara bilateral. Variabel MAP, laju nadi, CI, gula darah dan kebutuhan fentanyl intraoperatif dicatat. Analisis data dilakukan melalui uji bivariat t-test tidak berpasangan, Mann-Whitney serta uji multivariat general linear model. Hasil: Perubahan MAP pada kelompok QL lebih baik secara signifikan dibandingkan dengan epidural. Tidak terdapat perbedaan yang bermakna pada variabel laju nadi, CI, gula darah dan kebutuhan fentanyl intraoperatif. Kesimpulan: Blok QL tidak lebih baik dari epidural dalam menurunkan respon stress intraoperatif pada laparoskopi nefrektomi. Akan tetapi perubahan MAP pada blok QL lebih stabil.

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Background: Laparoscopic nephrectomy is a surgical technique preferred for renal donor in RSCM because of its advantages over laparotomy. Surgery activated stress responses thus affected intraoperative hemodynamics. Regional epidural anesthesia often combined with general anesthesia to reduce stress responses. Quadratus Lumborum (QL) block is an interfacial block and effective as abdominal surgery analgesia. This study was aimed to assess intraoperative hemodynamic stress response between QL and epidural block in laparoscopic nephrectomy patients. Mean arterial pressure (MAP), pulse rate, cardiac index (CI), and blood sugar was collected. Intraoperative fentanyl consumption also noted.

Methods: This was a randomized clinical trial of renal donor patients who underwent laparoscopic nephrectomy at RSCM during June to September 2018. A total of 36 subjects were randomized into 2 groups. After induction of general anesthesia, the epidural group received continuous epidural infusion of 0.25% 6 ml / hour of bupivacaine and QL group received 20 ml of 0.25% bupivacaine. MAP variables, pulse rate, CI, blood sugar and intraoperative fentanyl consumption were recorded in both groups. Data was analyzed with bivariate paired t-test, Mann-Whitney and multivariate general linear model test.

Results: MAP changes in QL group is significantly better than epidural group. There was no difference in heart rate, CI, blood glucose and fentanyl consumption intraoperative between two groups.

Conclusion : QL block compared to epidural did not have better result in reducing intraoperative stress response. However, MAP changes in QL group have better stability than epidural group."

"Teknik anestesia yang adekuat menghasilkan analgesia pascabedah yang cukup dan menurunkan respon stres pasien. Hal ini dapat menurunkan morbiditas dan mortalitas yang berhubungan dengan gangguan imunologis, seperti infeksi, penyembuhan luka berkepanjangan, dan sepsis. Studi ini bertujuan untuk membandingkan derajat nyeri pascabedah, kadar interleukin-6 (IL-6) dan C-reactive protein (CRP) sebagai marker respon stress, dan durasi pemakaian kateter urin antara epidural kontinu dan blok Quadratus Lumborum (QL) sebagai teknik analgesia pascabedah pada donor ginjal. Enam puluh dua pasien dibagi secara acak menjadi dua kelompok sama rata: epidural kontinu dan blok QL. Grup blok QL mendapatkan bupivakain 0,25% sebanyak 20 ml dan grup epidural mendapatkan bupivakain 0,25% 6 ml/jam kontinu melalui kateter. Menjelang ekstubasi, grup blok QL mendapatkan blok QL bilateral dengan dosis yang sama sedangkan grup epidural mendapatkan bupivakain 0,125% 6 ml/jam kontinu melalui kateter. Sampel darah diambil untuk membandingkan kadar IL-6 dan CRP setelah intubasi (preoperatif), segera setelah operasi, 24 jam serta 48 jam setelah operasi. Nyeri pascabedah diukur menggunakan numerical rating scale (NRS) di ruang pulih dan 24 jam pascabedah. Kebutuhan morfin dan durasi pemakaian kateter juga dicatat pascabedah. Efek samping yang muncul selama 24 jam dicatat. Data dianalisis menggunakan uji t tidak berpasangan atau uji Mann-Whitney. Tidak ada perbedaan yang ditemukan antarkelompok pada derajat nyeri pasca bedah, kadar plasma IL-6 setelah operasi atau 24 jam setelah operasi (p= 0,785 dan p=0,361, secara berurutan) meskipun rerata kadar IL-6 24 jam setelah operasi lebih rendah pada grup blok QL dibandingkan kelompok epidural kontinu. Durasi pemakaian kateter urin pada blok QL lebih singkat daripada epidural. Kadar CRP tidak berbeda signifikan antara kedua kelompok baik setelah operasi maupun 48 jam setelah operasi (p=0,805 dan p=0,636, secara berurutan). Durasi pemakaian kateter urin pada blok QL lebih singkat daripada epidural. Kedua teknik epidural kontinu dan blok QL menunjukkan analgesia pascabedah yang sebanding pada pasien donor ginjal yang menjalani laparoskopi nefrektomi.

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An adequate anesthesia technique generates appropriate postoperative analgesic properties and decreases the patient’s stress response. This will lead to decreased morbidity and mortality associated with immunology disturbances, such as infection, prolonged wound healing, and sepsis. The aim of this study was to compare postoperative pain level, interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, as the markers of the stress response, and duration of catheter usage between continuous epidural and quadratus lumborum (QL) block as postoperative analgesia techniques among living kidney donors. Sixty-two patients were randomly divided into two equal groups: continuous epidural and QL block. A group received bilateral QL block with 20 mL of bupivacaine 0.25% and the other received 6 mL/hour of bupivacaine 0.25% continuously via an epidural catheter. Prior to extubation, the QL block group received bilateral QL block with the same dose and the continuous epidural group was administered with 6 mL/hour of bupivacaine 0.125%. Blood samples were drawn to compare IL-6 and CRP concentrations after intubation (preoperatively), directly after surgery, 24 hours postoperatively, and 48 hours postoperatively. Postoperative pain was measured with the numerical rating scale (NRS). Morphine requirement and duration of catheter usage were also measured porsoperatively. Side effects within 24 hours postoperatively were noted. Data were analyzed with independent t-test or Mann-Whitney test. No difference was observed between the groups in the postoperative pain level, plasma concentration of IL-6 either after surgery or 24 hours postoperatively (p= 0.785 and p=0.361, respectively) although the mean IL-6 concentration 24 hours postoperatively was lower in the QL block group than in the continuous epidural group. CRP concentration was not significantly different between the groups either after surgery or 48 hours postoperatively (p=0.805 and p=0.636, respectively). The duration of catheter usage is significantly shorter in QL Block. Both continuous epidural and QL block techniques showed comparable postoperative analgesic properties among living kidney donors undergoing laparoscopic nephrectomy."

"Pendahuluan: Nefrektomi donor hidup perlaparoskopi adalah pendekatan standar emas untuk bedah ginjal donor hidup dikaitkan dengan nyeri pascabedah yang lebih ringan. RSUPN Dr. Cipto Mangunkusumo merupakan pusat transplantasi ginjal terbesar di Indonesia. Saat ini pembedahan donor ginjal hidup dilakukan dengan menggunakan pendekatan transperitoneum menjadi retroperitoneum untuk mengurangi komplikasi berupa cidera organ viseral. Perubahan ini menyebabkan teknik blok tranverse abdominis plane (TAP) dan blok quadratus lumborum (QL) pendekatan anterior dianggap tidak memadai sebagai suplementasi analgesia intraoperatif, teknik anestesi regional yang dianggap tepat untuk pendekatan retroperitoneal adalah teknik blok erector spinae plane (ESP) dan blok QL pendekatan anterior subcostal yang terletak lebih posterior. Brief Pain Inventory (BPI) merupakan salah satu instrumen yang dapat menilai derajat nyeri dan gangguan nyeri kronik terhadap kegiatan sehari-hari yang digunakan dalam penelitian ini.Metode: Penelitian dilakukan dengan desain kohort retrospektif untuk analisis insiden dan derajat nyeri kronik terhadap teknik blok ESP dan blok QL pada pasien laparoskopik donor ginjal hidup dengan teknik retroperitoneum di RSUPN Dr. Cipto Mangunkusumo. Sampel yang akan diambil di penelitian ini adalah semua pasien laparaskopi donor ginjal hidup teknik retroperitoneal minimal tiga bulan pascabedah sampai bulan Oktober 2022 dengan jumlah sampel 138 orang. Dilakukan juga analisa hubungan antara teknik blok dengan derajat akut, hubungan derajat nyeri akut, konsumsi opioid intraoperatif dan jenis analgesia pascabedah terhadap nyeri kronik dan hubungan karakteristik pasien terhadap nyeri kronik. Hasil: Teknik blok ESP dan blok QL tidak berbeda bermakna terhadap insiden (p=0,317) dan derajat nyeri kronik (p=1,000) pascabedah. Insiden nyeri kronik pascabedah laparaskopi donor hidup teknik retroperitoneal adalah 41 orang (27,7%) dengan karakteristik nyeri kronik derajat ringan 39 orang (95,2%). Teknik blok ESP dan blok QL berbeda bermakna terhadap derajat nyeri akut H-0 (p=0,045) dan derajat nyeri akut pascabedah bermakna terhadap insiden nyeri kronik pascabedah (p=0,04). Terdapat hubungan bermakna antara karakteristik pasien pada status pekerjaan (p=0,032) dan jangka waktu pascabedah (p=0,05) terhadap insiden nyeri kronik pada pasien laparoskopik donor ginjal hidup teknik retroperitoneum. Kesimpulan: Teknik blok ESP dan blok QL tidak berbeda bermakna terhadap insiden dan derajat nyeri kronik pascabedah.

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Introduction: Laparoscopic living donor nephrectomy is the gold standard approach for living donor kidney surgery associated with less postoperative pain. RSUPN Dr. Cipto Mangunkusumo is the largest kidney transplant center in Indonesia. Currently living kidney donor surgery is performed using a transperitoneal approach to retroperitoneum in order to reduce complications of visceral organ injury. This change causes the transverse abdominis plane (TAP) block technique and the anterior approach of quadratus lumborum (QL) block technique to be considered inadequate as a supplement for intraoperative analgesia, regional anesthetic techniques that are considered appropriate for the retroperitoneal approach are the erector spinae plane (ESP) block technique and the QL block approach more posteriorly. The Brief Pain Inventory (BPI) is an instrument that can assess the pain severity and pain interferences in daily activities used in this study.

Methods: This study was conducted with a retrospective cohort design to analyze the incidence and severity of chronic pain using the ESP block and QL block in living kidney donor laparoscopic patients using retroperitoneum technique at RSUPN Dr. Cipto Mangunkusumo. Samples taken in this study were all living kidney donor laparoscopic patients with retroperitoneal technique for at least three months postoperatively until October 2022 with a total sample of 138 people. Assessment of the correlation between block technique and acute pain severity was also carried out, the correlation between acute pain severity, intraoperative opioid consumption and types of postoperative analgesia to chronic pain and the correlation between patient characteristics and chronic pain.

Results: ESP block technique and QL block technique were not significantly different on the incidence (p=0,317) and the severity of chronic pain after surgery (p=1,000). The incidence of chronic pain after laparoscopic living donor retroperitoneal surgery was 41 people (27,7%) with mild chronic pain of 39 people (95,2%). The ESP block technique and QL block technique differed significantly on the degree of acute pain H-0 (p=0,045). The degree of acute postoperative pain was significant to the incidence of postoperative chronic pain (p=0,04) and there was a significant correlation between patient characteristics in occupational status (p=0,032) and the postoperative period to chronic pain (p=0,05).

Conclusion: The technique of ESP block and QL block did not differ significantly on the incidence and severity of postoperative chronic pain."