Tesis

Perbandingan kombinasi blok pleksus servikal superfisial dan supraorbital dengan blok skalp pada kraniotomi: kajian penggunaan opioid dan penekanan respon hemodinamik = A comparative analysis of combined superficial cervical plexus and supraorbital blocks in conjunction with scalp blocks during craniotomy: a review of opioid consumption and the suppression of hemodynamic responses.

Latar Belakang: Manajemen nyeri perioperatif pada kraniotomi memerlukan teknik anestesi regional yang efektif untuk mengurangi penggunaan opioid sistemik dan mengoptimalkan kontrol hemodinamik. Blok skalp selama ini mampu menekan respon hemodinamik namun pelaksanaannya melibatkan titik penyuntikan yang cukup banyak (6 saraf yang harus diblok bilateral, total 12 titik penyuntikan) dan kemungkinan tidak semua saraf terblok dengan baik. Sementara itu, blok pleksus servikal superfisial dan supraorbital tidak terlalu banyak titik penyuntikan (2 saraf di blok bilateral, total 4 titik penyuntikan) dengan area analgesia yang mungkin cukup memfasilitasi operasi kraniotomi termasuk saat pemasangan pin Mayfield yang hanya terdiri d ari tiga pin dimana area pemasangan pin tidak terlalu banyak. Penelitian ini bertujuan membandingkan efikasi kombinasi blok pleksus servikal superfisial dan supraorbital dengan blok skalp dalam mengurangi penggunaan opioid intraoperatif dan mengontrol respon hemodinamik pada operasi kraniotomi. Metode: Penelitian uji klinis acak terkontrol dengan tersamar tunggal melibatkan 42 subjek yang menjalani kraniotomi. Satu subjek mengalami drop out, sehingga 41 subjek masuk dalam analisis per protokol. Subjek dibagi menjadi dua kelompok secara acak: kelompok kombinasi blok pleksus servikal superfisial dan supraorbital, serta kelompok blok skalp. Paramater yang dievaluasi meliputi konsumsi Remifentanil operatif, perubahan mean arterial pressure (MAP) dan laju nadi pada empat tahap operasi (pemasangan pin, insisi kulit, manipulasi periosteum, dan jahit kulit). Analisis statistik menggunakan uji Friedman dan Mann-Whitney U dengan koreksi Bonferroni (p < 0,0125) Hasil: Blok kombinasi pleksus servikal superfisial dan supraorbital menunjukkan efikasi superior dalam mengurangi penggunaan Remifentanil intraoperatif dibandingkan blok skalp, dengan penurunan konsumsi sebesar 18% (4,4 vs 5,35 mcg/kgbb/jam, p=0,037). Kedua teknik menunjukkan ekuivalensi dalam mengontrol respon hemodinamik, tidak terdapat perbedaan yang signifikan secara statistik pada perubahan MAP dan laju nadi di semua tahap operasi antara kedua kelompok (p > 0,0125), namun blok kombinasi dengan konsistensi penekanan respon hemodinamik yang lebih baik. Simpulan: Blok pleksus servikal superfisial dan supraorbital dapat menekan lebih baik dalam penggunaan opioid dan respon hemodinamik dibandingkan blok skalp selama pasien menjalani operasi kraniotomi.
Kata kunci: blok pleksus servikal superfisial, blok supraorbital, blok skalp, kraniotomi, Remifentanil, anestesi regional


Background: Perioperative pain management in craniotomy requires the administration of effective regional anesthetic techniques to reduce the use of systemic opioids and optimize hemodynamic control. Scalp block has been demonstrated to suppress hemodynamic response; however, its implementation generally involves a large number of injection points (six nerves that must be blocked bilaterally, resulting in a total of 12 injection points) and the possibility that not all nerve points are adequately blocked. Meanwhile, superficial cervical plexus and supraorbital block involves fewer injection points (two nerves to be blocked bilaterally, for a total of four injection points) with an analgesia area that may be sufficient to facilitate craniotomy surgery, including the insertion of Mayfield pins, consisting of only three pins, where the pin insertion area is not too large. The objective of this study is to compare the efficacy of combined superficial cervical plexus and supraorbital block with scalp block in reducing intraoperative opioid consumption and controlling hemodynamic response in craniotomy surgery. Methods: The randomized controlled clinical trial study included 42 subjects who underwent craniotomy. Due to the dropout of one subject, the final analysis included 41 subjects, as per the protocol. The subjects were randomly divided into two groups: a combined superficial cervical and supraorbital plexus block group and a scalp block group. The following parameters were the focus of the evaluation: operative remifentanil consumption, changes in mean arterial pressure (MAP), and pulse rate at specific stages of the surgical procedure. These stages included pinning, skin incision, periosteum manipulation, and skin suturing. A statistical analysis was conducted using the Friedman and Mann-Whitney U test with Bonferroni correction (p < 0.0125) using SPSS 25. Results: The combination of superficial cervical plexus and supraorbital block demonstrated superior efficacy in reducing intraoperative Remifentanil consumption when compared with scalp block, resulting in an 18% reduction in consumption (4.4 vs. 5.35 mcg/kgbb/hr, p=0.037). The investigation revealed that both techniques demonstrated equivalent efficacy in controlling the haemodynamic response, exhibiting no statistically significant difference in changes in mean arterial pressure (MAP) and pulse rate at any stage of the surgical procedure between the two groups (p > 0.0125). Notably, the combination block resulted in superior consistency in the suppression of the haemodynamic response. Conclusion: It has been demonstrated that superficial cervical plexus and supraorbital block can suppress opioid use and haemodynamic response to a greater effect than scalp block during craniotomy surgery.
Keywords: superficial cervical plexus block, supraorbital nerve block, scalp block, craniotomy, remifentanil, regional anesthesia