Effects of levobupivacaine infiltration on postoperative analgesia and stress response in children following inguinal hernia repair:

Post-operative Pain Control: A Comparison between Bupivacaine and Tramadol Local Wound Infiltration in Children Undergoing Herniotomy and Orchidopexy

BACKGROUND

Post-operative pain control improves patient's satisfaction and affects the period of admission. Local wound infiltration following hernia surgery using xylocaine or bupivacaine has been a common practice. The use of tramadol for such infiltration is relatively new and has not been studied in our environment. This study compared the efficacy of post-operative pain control between Bupivacaine and Tramadol wound infiltration in children who underwent herniotomy and orchidopexy.

MATERIALS AND METHODS

This was a prospective randomised study involving 104 patients. A simple random method was used to allocate the study group into two equal groups (A, n = 52 and B, n = 52) using sealed envelopes with contents labelled A or B. Pre- and post-operative respiratory rate, heart rate, and C-reactive protein (CRP) were all recorded. Time to first and subsequent analgesia was determined using face, legs, activity, cry, consolability (FLACC) pain score.

RESULTS

Fifteen patients in Group A and 18 patients in Group B received each two doses of supplemental analgesia within the first 24 h, ( P = 0.527). Time to first analgesia was significantly different between the two groups, (6.93 ± 0.80 h and 6.11 ± 1.08 h, P = 0.020). The mean FLACC pain score at the time of first analgesia in hours was 4.93 ± 0.59 and 4.72 ± 0.67 for Group A and B, respectively, P = 0.350. The changes in CRP were not different in the two groups, ( P = 0.665). Four patients in Group A, but none in Group B had an episode each of post-operative vomiting.

CONCLUSION

Tramadol showed comparable efficacy with bupivacaine in post-operative pain control by wound infiltration in children who had unilateral herniotomy or orchidopexy. Tramadol, however, achieves a longer duration of action before rescue analgesic is required. Caution is necessary to avoid post-operative vomiting.

Analgesic Effects of Regional Analgesic Techniques in Pediatric Inguinal Surgeries: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Various regional analgesic techniques have been used in pediatric inguinal surgery to facilitate postoperative recovery. However, each technique's relative performance was undetermined owing to the lack of quantitative analysis.

METHODS

We systematically searched MEDLINE, Cochrane Library, EMBASE, and Web of Science for randomized controlled trials that compared regional analgesia in pediatric inguinal surgeries. After critical study screening and selection, a random-effects network meta-analysis was performed. The primary outcome was the time to the first rescue analgesic after surgery, and the secondary outcomes were the number of patients requiring rescue analgesics after surgery, postoperative pain scores, incidence of postoperative nausea and vomiting, and other adverse events.

RESULTS

This network meta-analysis included 69 randomized controlled trials (4636 patients) that compared 10 regional analgesic techniques. Our study revealed that the quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic after pediatric inguinal surgeries, by 7.7 hours (95% confidence interval [CI], 5.0-10.3) and 6.0 hours (95% CI, 3.9-8.2) when compared with the control group, respectively. In the subgroup involving only inguinal hernia repair, the quadratus lumborum block significantly prolonged the time to the first rescue analgesic than all other regional analgesics. In contrast, in the subgroup involving orchidopexies, only the caudal block significantly prolonged the time to the first rescue analgesic when compared with the control group (4.1 hours; 95% CI, 0.7-7.5). Wound infiltration and landmark-based ilioinguinal-iliohypogastric block had relatively poor analgesic effects than other regional analgesics. No serious adverse effects related to the regional analgesic techniques were reported in any of the included studies.

CONCLUSIONS

The quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic and the least rescue analgesic requirement for pediatric inguinal surgeries. Specifically, the quadratus lumborum block had the longest analgesic duration in inguinal hernia repair, and the caudal block was found to be the only regional analgesia that extended the time to the first rescue analgesic in pediatric orchidopexy. Most included randomized controlled trials had some concern or a high risk of bias, and future studies should focus on providing high-quality evidence to further clarify the analgesic effects of regional analgesia for pediatric inguinal surgeries.

Rectus sheath block versus local anesthetic infiltration in pediatric laparoscopic inguinal hernia repair: a randomized controlled trial

BACKGROUND

Rectus sheath block (RSB) and local anesthetic infiltration (LAI) are used for postoperative analgesia in pediatric laparoscopic inguinal hernia repair. However, whether the analgesic effect of RSB is superior to LAI remains unclear. The authors hypothesized that RSB would reduce opioid consumption in patients.

METHODS

Patients aged 3-14 years scheduled for laparoscopic inguinal hernia repair were randomly allocated to the RSB, local anesthetic infiltration high concentration (LAIHC), local anesthetic infiltration low concentration (LAILC), or control groups. Preoperatively, they received 0.4 ml/kg of 0.25% ropivacaine (RSB), 0.4 ml/kg of 0.25% ropivacaine (LAILC), or 0.2 ml/kg of 0.5% ropivacaine(LAIHC), and 0.2 ml/kg of normal saline (control). The primary outcome was equivalent morphine consumption.

RESULTS

The authors analyzed 136 patients (RSB, 33; LAIHC, 34; LAILC, 35; control, 34). Intraoperative morphine equivalent consumption was lower in the RSB group [0.115 (0.107-0.123)] than in the LAIHC [0.144 (0.137-0.151)], LAILC [0.141 (0.134-0.149)], and control [0.160 (0.151-0.170)] groups ( P <0.001). In the post-anesthesia care unit, morphine equivalent consumption differed between the RSB [0.018 (0.010-0.027)], LAIHC [0.038 (0.028-0.049)], LAILC [0.056 (0.044-0.067)], and control [0.074 (0.063-0.084)] groups ( P <0.001). The rescue morphine equivalent consumption did not differ significantly between the RSB [0.015 (0.007-0.023)] and LAIHC [0.019 (0.010-0.029)] groups, which were lower than that in the control group [0.037 (0.029-0.045)] ( P =0.001).

CONCLUSIONS

RSB can provide effective analgesia for pediatric laparoscopic inguinal hernia repair, with better effectiveness than that of LAI at the same dose.

HYR-PB21-LA, a potential extended-release bupivacaine formulation, produces long-lasting local anesthesia in rats and guinea pigs

BACKGROUND

Effective postoperative pain management plays a key role in enhancing recovery of patients after surgery. Bupivacaine hydrochloride is one of the most commonly local anesthetics used for the postoperative pain control. However, the relatively short anesthesia duration of bupivacaine preparations limited their clinical application.

METHODS

Both guinea pig pin-prick study and rat tail-flick test were performed to evaluate the local anesthesia efficacy of HYR-PB21-LA, a new microparticle suspension injection of bupivacaine pamoate.

RESULTS

In the pin-prick test, the complete cutaneous trunci muscle reflex inhibitions were observed at 30 min in all treatment groups containing bupivacaine. In comparison with 6.7 mg/mL HYR-PB21-LA, both 10 and 20 mg/mL HYR-PB21-LA groups had significantly higher area under effect time curve (AUEC) values (p<0.001 and p<0.0001) and slower offset time (p<0.0001). Significantly higher AUEC (p<0.0001) and slower offset time (p<0.0001) were also found in 10 mg/mL HYR-PB21-LA treatment group compared with bupivacaine liposome injectable suspension (liposomal bupivacaine). In the rat tail-flick test, significantly increased local anesthesia effect was lasted for 5 hours after 2.5 mg/mL HYR-PB21-LA administration, which was fivefold longer than bupivacaine hydrochloride. The longer lasted efficacy of significantly increased local anesthesia was also observed in 5 mg/mLHYR-PB21-LA than those in liposomal bupivacaine (8 hour vs 1 hour).

CONCLUSIONS

The results demonstrated that the HYR-PB21-LA produced longer local anesthesia effect than current clinical preparations of bupivacaine in two animal models. These findings raise the potential clinical value of HYR-PB21-LA as a long-lasting local anesthesia for controlling postsurgical pain in humans.

Comparison Between the Effects of Intravenous Morphine, Tramadol, and Ketorolac on Stress and Immune Responses in Patients Undergoing Modified Radical Mastectomy

OBJECTIVES

Analgesics had been suspected of impairing various immune functions either directly or indirectly. Our primary objective was to compare the effects of intravenous (IV) morphine, tramadol, and ketorolac on stress and immune responses in patients who underwent modified radical mastectomy.

PATIENTS

Sixty patients randomly assigned to receive IV morphine 5 mg (group M, n=20), tramadol 100 mg (group T, n=20), or ketorolac 60 mg (group K, n=20) at the end of surgery.

METHODS

Serum cortisol, prolactin were measured immediately, 40 minutes, and 24 hours postoperatively. Expressions of peripheral T lymphocytes (CD3, CD3CD4, CD3CD8) and natural killer cells (CD3, CD56) were measured as percentages of total lymphocytes by flow cytometry immediately, 90 minutes, and 24 hours postoperatively.

RESULTS

After 40 minutes, cortisol level increased but prolactin decreased significantly (P=0.001), then both decreased after 24 hours (P=0.001) compared with baseline within the 3 groups. CD3, CD4, CD8, and CD56 significantly decreased at 90 minutes and 24 hours (P≤0.033) compared with baseline in the 3 groups. CD4, CD8, and CD56 significantly decreased in group M, compared with group T and K (P≤0.016) and CD3, CD8, and CD56 in group T compared with group K at 90 minutes (P≤0.024) postoperatively. After 24 hours, CD4, and CD8 decreased in group M compared with group T (P≤0.048) and CD4 and CD56 in groups M and T compared with group K (P≤0.049).

CONCLUSIONS

IV morphine, tramadol, and ketorolac suppressed stress and immune responses. Ketorolac was the least immunosuppressive among the 3 drugs.

Preemptive, preventive, multimodal analgesia: what do they really mean?

SUMMARY

To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.

The Effects of Preincisional Levobupivacaine Infiltration on Extubation Comfort, Postoperative Recovery and Visual Analogue Scale in Appendectomy Patients

OBJECTIVE

The aim of our study was to determine the effect of preincisional 0.25% levobupivacaine infiltration on extubation comfort, postoperative recovery and visual analogue scale (VAS) in appendectomy patients.

METHODS

Forty 15-60-year-old patients at American Society of Anaesthesiologists (ASA) physical status I-II, scheduled for appendectomy were included in the study. After routine monitorisation, anaesthesia induction was performed with propofol, fentanyl and rocuronium; later, maintenance was continued with sevoflurane. Patients were divided into two groups randomly. A total 20 mL of 0.25% (50 mg) levobupivacaine was injected around the incision line as a rectangle in Group 1. Levobupivacaine was not administered in Group 2 patients. Heart rate, peripheral oxygen saturation, additional fentanyl requirement and mean blood pressure were recorded during the operation. All patients were evaluated according to difficulties encountered during extubation.

RESULTS

Discharge time, necessity of diclofenac and postoperative VAS values at 0-1 hours were statistically lower in Group 1 patients than the Group 2 patients (p<0.05). Difficulties, like straining, cough, laryngo-bronchospasm, vomiting and nausea during extubation, were 5% and 25% in Group 1 and Group 2, respectively, but these differences were not statistically significant (p=0.077).

CONCLUSION

Infiltration of 0.25% of levobupivacaine as a rectangle which included the incision line before surgery decreases discharge time, provides analgesia well in the early postoperative period and diminishes the requirement of analgesics in appendectomy patients.

Comparison of the effects of bupivacaine, lidocaine, and tramadol infiltration on wound healing in rats

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the effects of saline solution, bupivacaine, lidocaine and tramadol infiltration on wound healing in rats.

METHOD

Thirty-two male Wistar Albino rats were randomly separated into four groups, receiving 3 mL saline solution in control group (Group C, n=8), 3 mL of 2% lidocaine in lidocaine group (Group L, n=8), 3 mL of 0.5% bupivacaine in bupivacaine group (Group B, n=8), and 3 mL of 5% tramadol in tramadol group (Group T, n=8). Breaking-strength measurements, collagen bundle counting, and histopathologic evaluation were evaluated in the tissue samples taken from the rats.

RESULTS

Comparing the control group with the groups where bupivacaine and lidocaine were used for wound infiltration, collagen production was lower, breaking-strength measurements showed reduced resistance while significantly high edema, vascularity, inflammation scores were found (p<0.0125). Between the control and the tramadol group there were no significant differences in collagen production, breaking-strength measurements, and edema, vascularity, inflammation scores (p>0.0125).

CONCLUSION

In our study, we found bupivacaine and lidocaine reduced the collagen production, wound breaking strength, and caused significantly high scores for edema, vascularity, and inflammation when compared to the control group. There was no significant difference between the control and the tramadol group. Results of this experimental preliminary study on rats support the idea that tramadol can be used for wound infiltration anesthesia without adverse effect on the surgical healing process. These results need to be verified in humans.

Effects of levobupivacaine on wound healing

BACKGROUND

Local anesthetic infiltration along the incision may be used to provide surgical anesthesia or postoperative analgesia. However, the effect of local anesthetics on wound healing remains controversial. In this investigation, we evaluated the effects of levobupivacaine on wound healing.

METHODS

Sixty Wistar albino female rats weighing 230±20 g were included, with 10 rats in each group: group early c (early control): 3 mL isotonic saline; group early l1.25 (early levobupivacaine 1.25): 1.25 mg/kg per 3 mL levobupivacaine; group early l2.5 (early levobupivacaine 2.5): 2.5 mg/kg per 3 mL levobupivacaine; group late c (late control): 3 mL isotonic saline; group late l1.25 (late levobupivacaine 1.25): 1.25 mg/kg per 3 mL levobupivacaine; and group late l2.5 (late levobupivacaine 2.5): 2.5 mg/kg per 3 mL levobupivacaine. Rats in groups early c to early l2.5 were euthanized on the 8th day. Rats in groups late c to late l2.5 were euthanized on the 21st day. Wound tension strength, tissue hydroxyproline, and fibrotic index levels of the tissue samples from the early c and early l2.5 and late c and late l2.5 groups, respectively, on the 8th and 21st days were examined.

RESULTS

Levobupivacaine decreased wound tension strength on the 8th day, especially a 2.5 mg/kg dose (P<0.001), and increased it on the 21st day (P<0.001). It also increased the inflammatory response (P<0.001) and collagen synthesis (8th day, P=0.109; 21st day, P=0.103) on both the 8th and 21st days.

CONCLUSIONS

While levobupivacaine had a positive effect on wound healing during the early period, negative effects were observed thereafter. Additional studies at the molecular level are necessary to determine the cause of these apparently opposite effects.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.