Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 252-258

Different local anesthetic technique for postoperative analgesia in open cholecystectomy


Department of Anesthesiology, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt

Date of Submission26-Nov-2014
Date of Acceptance04-Jun-2015
Date of Web Publication8-May-2015

Correspondence Address:
Mohamed Lofty
Department of Anesthesiology, Faculty of Medicine, Tanta University Hospital, Tanta 01111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.156704

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  Abstract 

Background
Paravertebral block is the technique of injecting a local anesthetic (LA) solution alongside the vertebral column close to the emergence of the spinal nerves. Infiltration of LAs into the surgical wound is a simple, safe, and low-cost technique for postoperative analgesia.
Patients and methods
Patients with physical status ASA I-II aged 20-45 years of both sexes and scheduled for an elective open cholecystectomy with subcostal incision were included in this study. Patients were classified randomly using sealed envelopes into three equal groups of 60 patients each. At the end of the surgical procedures, for all the patients of the study, a continuous wound catheter (CWC) and a continuous paravertebral catheter were inserted: group I (CWC), group II (continuous paravertebral catheter), and group III (control group). Anesthesia was induced with an intravenous fentanyl injection (1.5 µg/kg), propofol (1.5 mg/kg), followed by cis-atracurium (0.15 mg/kg), and then the patient was intubated after 3 min. Maintenance of anesthesia was by isoflurane with minimal alveolar concentration (1.5) with additional doses of cis-atracurium (0.04 mg/kg) when needed.
Results
A total of 120 patients were included in the study, with 40 patients randomized to each group. There were no significant differences in demographic data.
For mean arterial blood pressure, heart rate, and respiratory rate, there were no significant differences between the groups, except 30 min after extubation, when there was a significant increase in group III compared with the other two groups. For SpO 2 , there was no significant difference between the three groups. In terms of pain assessment using visual analogue scale, there was a significant decrease at all time points in the values of group II compared with the other two groups and in group I compared with group III.
Conclusion
We conclude that paravertebral block with a continuous infusion is more effective than a CWC infusion in postoperative pain management after surgeries with subcostal incisions, although both techniques showed a significant improvement compared with the control group.

Keywords: analgesia, open cholecystectomy, postoperative


How to cite this article:
Eldaba A, Lofty M. Different local anesthetic technique for postoperative analgesia in open cholecystectomy. Ain-Shams J Anaesthesiol 2015;8:252-8

How to cite this URL:
Eldaba A, Lofty M. Different local anesthetic technique for postoperative analgesia in open cholecystectomy. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Oct 24];8:252-8. Available from: http://www.asja.eg.net/text.asp?2015/8/2/252/156704


  Introduction Top


A number of postoperative dysfunctions are related directly to postoperative pain. The most important of these are pulmonary, circulatory, gastrointestinal, and urinary dysfunction. Thus, it is possible for acute severe unrelieved pain to result in significant morbidity and even mortality [1] .

The use of successful postoperative analgesia in patients may accelerate recovery and decrease morbidity by blunting autonomic, somatic, and endocrine reflexes [2] .

Paravertebral block (PVB) is an established technique for providing analgesia in which a local anesthetic (LA) solution is injected alongside the vertebral column close to the exit of the spinal nerves from the spinal column.

As the spinal nerve exits out the intervertebral foramen, it lacks both the epineurium and part of the perineurium of the peripheral nerve and has only a thin membranous root sheath [3] .

Surgical wound infiltration with LAs is a technique for postoperative analgesia and has the advantages of being easy, safe, and inexpensive. This local application reduces pain transmission from the wound and suppresses the local inflammation that may occur in response to the injury. LAs can be administered at the end of the surgical procedure to infuse the wound through catheters and/or as single-dose infiltrations [4] .

The introduction of wound infiltration with LAs not only provides this much-needed alternative analgesia but, in fact, in some cases, provides superior analgesia [5] .

In this study, we aimed to compare PVB and continuous wound catheter (CWC) infusion for postoperative analgesia in surgeries with a subcostal incision.


  Patients and methods Top


Patients with ASA I-II physical status and aged 20-45 years of both sexes who were scheduled for an elective open cholecystectomy with subcostal incision were included in our study after obtaining approval from the ethics committee and written informed consent from each patient. This study was carried out in Tanta University Hospital from March 2013 till December 2013.

Cardiac, respiratory, and hepatic patients, patients with bleeding disorders, patients with a history of relevant drug allergy, morbid obesity, mental dysfunction, history of substance abuse, and chronic analgesic use were excluded from the study.

Anesthetic technique

Preoperative

The following procedures were carried out for every patient included in this study:

Medical and surgical histories of the patient were evaluated. Clinical examination of the patient was performed. Routine laboratory investigations were assessed including complete blood picture, prothrombin time and activity, liver functions, and renal functions. An intravenous 18 G cannula was inserted. 10 ml/kg intravenous crystalloids were administered as maintenance fluid.

Intraoperative

In the operative room, routine monitoring of heart rate (HR) and rhythm by ECG, arterial blood pressure by noninvasive blood pressure including systolic, diastolic, and mean arterial blood pressure (MAP), peripheral oxygen saturation (SpO 2 ) using a pulse oxymeter, and measurement of end tidal CO 2 by capnogram were performed. Preoxygenation with 100% O 2 for 3-5 min was carried out. Anesthesia was induced with an intravenous fentanyl injection (1.5 µg/kg), propofol (1.5 mg/kg), followed by cis-atracurium (0.15 mg/kg), and then the patient was intubated after 3 min. Anesthesia was maintained by isoflurane with minimal alveolar concentration (1.5) with additional doses of cis-atracurium (0.04 mg/kg) when needed. At the end of the surgical procedures, for all the patients of the study, a CWC and a continuous paravertebral catheter were inserted.

Continuous wound infusion

One multiholed catheter was inserted along the entire length of the wound at the end of the surgery. After closure of the transversus abdominis muscle (deep muscular layer), the catheter was placed superior to the transversus abdominis muscle and below the oblique muscles (both the internal and the external).

Continuous paravertebral block

At the end of the surgery, the patient was turned to the lateral position, allowing the side to be operated and blocked upwards. At the level of the seventh thoracic vertebra, a 22-G (8-10 cm) epidural needle was inserted 2.5-3 cm lateral to the spinous process of the thoracic vertebra and advanced perpendicular to the skin in all planes to contact the transverse process at a variable depth (2-4 cm) according to each individual's body built.

The needle was withdrawn and redirected in the cephalic direction to walk above the transverse process and gradually advanced until a subtle click was felt as a result of penetration of the superior costotransverse ligament and feeling that resistance to air or saline was lost, and then a catheter was inserted so that not more than 4 cm of the catheter length was within the paravertebral space. The technique was performed only on the side of the operation.

At the end of the surgery and the study procedures, each patient was recovered gradually.

Patients were classified randomly using computer-generated random numbers and sealed envelopes into three equal groups of 40 patients each.

Group I (continuous wound catheter group)

They received 20 ml of plain bupivacaine 0.5% (single shot) in the wound catheter as a loading dose, followed by a continuous infusion of plain bupivacaine 0.5% for 24 h through the catheter at a rate of 5 ml/h.

They received 20 ml of normal saline 0.9% (single shot) in the paravertebral catheter, followed by a continuous infusion of normal saline 0.9% (5 ml/h) for 24 h through the catheter.

Group II (paravertebral block group)

They received 20 ml normal saline 0.9% (single shot) in the wound catheter as a loading dose, followed by a continuous infusion of normal saline 0.9% (5 ml/h) for 24 h through the catheter.

They received 20 ml plain bupivacaine 0.5% (single shot) in the paravertebral catheter as a loading dose, followed by a continuous infusion of plain bupivacaine 0.5% (5 ml/h) for 24 h through the catheter.

Group III (control group)

They received 20 ml normal saline 0.9% (single shot) in the wound catheter, followed by a continuous infusion of normal saline 0.9% (5 ml/h) for 24 h through the catheter.

They received 20 ml normal saline (single shot) in the paravertebral catheter, followed by a continuous infusion of normal saline (5 ml/h) for 24 h through the catheter.

The loading doses for all groups were injected just after insertion of the catheters and before recovery from anesthesia.

Postoperative intravenous paracetamol (10 mg/kg) infusion, together with an intravenous ketorolac ampoule (15 mg) injection, was administered when needed [when visual analogue scale (VAS) score³4].

Postoperative measurements

In all groups the following parameters were measured postoperatively:

The MAP, HR, and respiratory rate (RR) were measured and recorded before induction of anesthesia (baseline), 30 min after extubation (when the patient became fully awake), and 3, 6, 12, and 24 h after recovery. Pain assessment using a VAS was performed at 30 min after extubation (when the patient became fully awake) and 3, 6, 12, and 24 h after recovery. For the first 24 h, time to first analgesic request after recovery of anesthesia and postoperative analgesic consumption were recorded. The occurrence of nausea and vomiting for 24 h postoperatively, duration of hospital stay, and the occurrence of postoperative wound infection were recorded for 1 month.

Statistical analysis

Sample size calculation was carried out using VAS of postoperative pain as the main response variable. Thirty-five patients per group were required as identified by power analysis to detect a 15% difference with a power of 80% and a significance level of 0.05%. Quantitative data were presented as means and SD and qualitative data were presented as frequency and percentages. To compare between groups, the Student t-test was used. P value less than 0.05 was considered significant. To analyze data, the SPSS (version 11; SPSS Inc., Chicago, Illinois, USA) software program was used.


  Results Top


In our study, 120 patients were included; 40 patients were randomized to each group. No significant differences in demographic data were detected ([Table 1]).
Table 1 Demographic data

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For MAP, HR, and RR ([Table 2] [Table 3] [Table 4] and [Figure 1] [Figure 2] [Figure 3]), no significant differences were detected between groups, except 30 min after extubation, when readings in group III were significantly higher than those of the other two groups. For SpO 2 , no significant differences were detected between the three groups.
Figure 1: Comparison between the three groups in postoperative mean arterial blood pressure. Data are expressed as mean ± SD .

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Figure 2: Comparison between the three groups in postoperative heart rate. Data are expressed as mean ± S D.

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Figure 3: Comparison between the three groups in postoperative respiratory rate. Data are expressed as mean ± S D.

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Table 2 Comparison between the three groups in postoperative mean arterial blood pressure

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Table 3 Comparison between the three groups in postoperative heart rate

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Table 4 Comparison between the three groups in postoperative respiratory rate

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In terms of pain assessment using VAS, there was a significant decrease at all time points in the values of group II compared with the other two groups and in group I compared with group III ([Table 5]).
Table 5 Comparison between the three groups in postoperative pain (visual analogue scale)

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Postoperative analgesic consumption (paracetamol

and ketorolac) was significantly less in groups I and II compared with the control group ([Table 6] and [Figure 4]). Also, it was significantly higher in group I compared with group II. Postoperative hospital stay (days) was significantly less in group II compared with other groups ([Table 7] and [Figure 5]).
Table 6 Comparison between the three groups in the total postoperative analgesic consumption per first 24 h (mg)

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Table 7 Comparison between the three groups in the total postoperative hospital stay

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There was one case of postoperative nausea and vomiting (PONV) in group I and another one in group II and three cases in group III. There was no postoperative wound infection in any of the groups for one month.
Figure 4: Comparison between the three groups in the total postoperative analgesic consumption per first 24 h. Data are expressed as mean ± SD.

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Figure 5: Comparison between the three groups in the total postoperative hospital stay. Data are expressed as mean ± SD.

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  Discussion Top


In this study, PVB and CWC infusion led to significant control of postoperative pain after surgeries with a subcostal incision. PVB showed better control compared with CWC infusion. Both PVB and CWC infusion reduced postoperative total analgesic consumption per first 24 h. PVB reduced postoperative hospital stay. There were no significant differences in adverse effects.

In agreement with our study, the analgesic effect provided by the paravertebral technique is better than that of other types of analgesia and local wound infiltration after inguinal herniorrhaphy [6],[7],[22],[23] . PVB can also improve early ambulation, decrease the analgesic requirements, reduce postoperative nausea and vomiting, and lead to earlier discharge from hospital [8],[9] .

Naja et al. [6],[7] used a nerve stimulator technique to detect the paravertebral space and compared the outcome of their block with systemic analgesia in inguinal hernia repair. With the use of the PVB, pain scores were reduced significantly, consumption of systemic analgesia was less, and the rates of discharge were increased. Also, greater surgeon satisfaction was achieved with this technique [6],[7] .

Richardson et al. [10] reported a series of eight patients undergoing abdominal vascular surgical procedures. Following induction of general anesthesia, bilateral PVBs with catheters at T10 were placed and their use was continued after surgery for 4 days with other analgesia such as diclofenac and patient-controlled analgesia with morphine. There was no need for additional intraoperative opioids or neuromuscular blockers and excellent postoperative analgesia was provided. No complications were detected because of the PVB [11],[12] .

Wound infiltration with a LA was described for the first time in 1935 by Capelle. Afterwards, Blades and Ford used this technique for gynecological procedures, reporting a decrease in opioid requirements [13] .

Hopf et al. [13] confirmed that the reduction in pain caused by local infiltration reduces the decreased wound perfusion and oxygenation induced by inflammatory response and increased catecholamines, thus improving wound healing, and this was observed in this study as no cases of postoperative wound infection were recorded within 1 month [13],[14] .

In a systematic review performed by Liu et al. [4] , the usefulness of this analgesic method was confirmed during several painful surgical procedures, such as thoracic, cardiac, gynecological, or spinal surgeries. The success of this technique may be related to the nature of surgery and also to the level of tissue where the infiltration takes place. In particular, if the catheter is placed subcutaneously, there may be some improvement in postoperative pain scores [4] .

In agreement with this study, Forastiere et al. [15] studied the efficacy of 0.5% ropivacaine as a continuous wound infusion by the ON-Q system for postoperative pain after open nephrectomy, showing that compared with placebo, it decreases pain and the requirement for narcotics [15] .

In Sidiropoulou et al.'s [16] study, the catheter was not only placed in the subcutaneous tissue but also near the intercostal nerve bundle for adequate management of pain.

Several studies comparing boluses with a continuous infusion for the maintenance of PVB confirmed that a continuous infusion is associated with lower pain score and opioid requirement.

A study carried out by Wheatley et al. [17] reported a reduction in patients' pain after thoracotomy when local surgical infiltration by the ON-Q Pain Relief System was compared with a single-shot epidural analgesia in combination with ON-Q with a continuous epidural infusion. The Wheatley et al.'s [17] study concluded that 0.25% bupivacaine administered by a continuous infusion (4 ml/h) through an ON-Q elastomeric infusion pump is a safe and efficient adjunct in the management of postoperative pain following thoracotomy. Use of the ON-Q Pain Relief System enables reductions in narcotic use and yields pain scores compared with a continuous epidural infusion [17] ; similar results were also obtained in our study.

In agreement with this research, a meta-analysis of 10 randomized studies reported that thoracic paravertebral block (TPVB) produced pain relief comparable with that of thoracic epidural following thoracic surgery. Also, the results showed that a TPVB resulted in an improved side-effect profile (hypotension, urine retention, PONV, pulmonary complications) and decreased rates of pulmonary complications and block failure. Therefore, TPVB is currently recommended for thoracic surgery [17],[18] .

Naja et al. [19] and Lönnqvist et al. [20] reported a 6.1% rate of overall technical failure during PVB (performed in 620 adults and 42 children). Recorded complications were inadvertent vascular puncture in 6.8%, epidural spread signs in 1.0%, and pleural puncture in 0.8% (five patients); three of these patients (nearly 0.5%) developed pneumothorax subsequently. Also, in terms of feasibility, in an older study of Lönnqvist et al. [20] , TPVB was reported to yield a 10.1% overall failure rate, with complications such as hypotension in 4.6%, vascular puncture in 3.8%, pleural puncture in 1.1%, and pneumothorax in 0.5% of patients.

The data of the research seem to show the safety of TPVB in terms of adverse effects: respiratory, infectious, or hemodynamic. Furthermore, there is no need for any specific monitoring for TPVB over the usual follow-up of patients in the postoperative period and there is also no need for hospitalization in the ICU.

The results of the research were supported by those of Zohar et al., who proved that with CWC, the requirement of morphine was significantly lower after total abdominal hysterectomy. Liu et al. [4] confirmed these findings in a systematic review in which it was shown that the use of CWCs provided better analgesia at rest and after mobilization, and a decrease in morphine use and related adverse effects; also, it was associated with higher patient satisfaction and a trend toward reduced hospitalization period. Notably, in the review performed by Liu et al. [4] , these benefits were observed in large numbers of various surgical procedures (cardiac, thoracic, abdominal, gynecological, and orthopedic) [21] . Failure of CWC to provide effective analgesia may be attributed to the pain resulting from drains (placed at a distance from the main incision). However, this was not observed in the study because of the absence of a postoperative wound drain.

Finally, the CWC technique is feasible in anesthetized patients and is uncomplicated and rapid to put in place. At the end of the procedure, the catheter is placed near or on the wound under direct visual control. There is almost no need for handling by nurses in CWC; thus, the risk of infections is limited. Therefore, the equipment is essential and the complication and risks are minimal, allowing patients to stay in conventional care units during the postoperative phase, with no need for admission to the ICU. CWC has a very low cost because of its simplicity, rapidity, and ease of use. To date, there are no reports of toxicity events with LAs.

The limitations of this study include fixed doses of LA and the use of no adjuvants, which may increase the analgesic effect of both the TPVB and the CWC infusions, different positions of CWC, and different sizes of incisions.

Large-scale CWC investigations are required to identify the ideal catheter positions, doses, volumes, and LA concentrations. Analgesic efficiency of this technique could be improved by adjuvant therapy (e.g. clonidine or morphine), as could epidural analgesia associations.

Finally, we conclude that PVB with a continuous infusion is more effective than CWC infusion in the management of postoperative pain after surgeries with subcostal incisions, although both techniques showed significant efficacy compared with the control group. Also, both techniques reduced postoperative analgesic requirements, with no significant differences in adverse effects. PVB reduced the duration of postoperative hospital stay.[24]


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

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Naja ZM, Raf M, El Rajab M, Ziade FM, Al Tannir MA, Lönnqvist PA. Nerve stimulator-guided paravertebral blockade combined with sevoflurane sedation versus general anesthesia with systemic analgesia for postherniorrhaphy pain relief in children: a prospective randomized trial. Anesthesiology 2005; 103:600-605.  Back to cited text no. 6
    
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Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH III, Jensen JA, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 1997; 132: 997-1004.  Back to cited text no. 13
    
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Forastiere E, Sofra M, Giannarelli D, Fabrizi L, Simone G. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. Br J Anaesth 2008; 101:841-847.  Back to cited text no. 15
    
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Sidiropoulou T, Buonomo O, Fabbi E, Silvi MB, Kostopanagiotou G, Sabato AF, Dauri M A prospective comparison of continuous wound infiltration with ropivacaine versus single-injection paravertebral block after modified radical mastectomy. Anesth Analg 2008; 106: 997-1001.  Back to cited text no. 16
    
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Wheatley GH III, Rosenbaum DH, Paul MC, Dine AP, Wait MA, Meyer DM, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg 2005; 130:464-468.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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