Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 334-340

Efficacy of systemic lidocaine infusion compared with systemic ketorolac infusion in improvement of recovery after laparoscopic bariatric surgery


1 Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University; Ahmad Maher Teaching Hospital, Ministry of Health, Cairo, Egypt

Date of Submission22-Sep-2014
Date of Acceptance25-Feb-2015
Date of Web Publication29-Jul-2015

Correspondence Address:
Hesham F Soliman
Alnoor Specialist Hospital, PO Box 6251, Makkah 21955
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.161695

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  Abstract 

Background
Obese patients are at a high risk for both aspiration and acute airway obstruction after tracheal extubation. Thus, rapid recovery is desirable to ensure early efficient coughing and to decrease the rate of postoperative respiratory complications.
Patients and methods
Sixty patients who were assigned for elective laparoscopic bariatric surgery were divided into three equal groups. Lidocaine group, in which the patients received intravenous (i.v.) lidocaine (1.5 mg/kg bolus, followed by a 2 mg/kg/h infusion until the end of surgery); ketorolac group, in which the patients received i.v. ketorolac (30 mg i.v. as a bolus over 15-30 s, followed by a continuous i.v. infusion of ketorolac 0.5 mg/kg/h until the end of surgery); and the control group, in which participants received an i.v. infusion (normal saline) of the same volume as the drug groups. Immediate recovery from anesthesia was assessed on the basis of the time to eye opening, extubation, and orientation from the time of discontinuation of inhalation agents and reversal of neuromuscular block. Postoperative pain was assessed using a pain numeric scale, and postoperative nausea and vomiting were documented.
Results
No significant difference was found between the groups studied in terms of patient characteristics, type, and duration surgery, but there was a significant decrease in the intraoperative bispectral index value of the control group compared with the lidocaine and ketorolac groups (61.35 ± 4.54 vs. 63.35 ± 4.0 and 66.60 ± 7.19, respectively). The lidocaine group had a better postoperative mobility score, less nausea and vomiting, good incentive spirometry, greater patient satisfaction, low total fentanyl dose, and low postoperative pain at all the time points studied. The difference was statistically significant.
Conclusion
Lidocaine i.v. infusion was found to be an effective and safe adjuvant for the rapid recovery of obese patients following bariatric surgery. Ketorolac led to better outcome than that in the control group, but was less effective compared with lidocaine.

Keywords: bariatric surgery, ketorolac, laparoscopic, lidocaine


How to cite this article:
Soliman HF, Gharbiya AR. Efficacy of systemic lidocaine infusion compared with systemic ketorolac infusion in improvement of recovery after laparoscopic bariatric surgery. Ain-Shams J Anaesthesiol 2015;8:334-40

How to cite this URL:
Soliman HF, Gharbiya AR. Efficacy of systemic lidocaine infusion compared with systemic ketorolac infusion in improvement of recovery after laparoscopic bariatric surgery. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jul 16];8:334-40. Available from: http://www.asja.eg.net/text.asp?2015/8/3/334/161695


  Introduction Top


Obesity is considered an epidemic nowadays. Worldwide, the prevalence of obesity has almost doubled since 1980 and in 2008, more than 1.4 billion adults, 20 years and older, were overweight. Of these, over 200 million men and almost 300 million women were obese. It is estimated that 65% of the world's population live in countries where being overweight and obese results in mortality than being underweight [1] .

Laparoscopy has revolutionized the field of bariatric surgery. Studies to date show several advantages of this type of approach in comparison with open surgery [2] . Prompt recovery of protective airway reflexes, absence of pain, ability to maintain respiratory physical therapy, early ambulation and discharge from the postanesthesia care unit (PACU), coupled with a stable intraoperative environment, have been the desired goals of anesthetic management of morbidly obese patients [3] .

Postoperative nausea and vomiting (PONV) usually occur after laparoscopic bariatric surgery. In previous studies, the incidence of PONV in patients who did not receive antiemetic prophylaxis was as high as 70-80% [4] .

Pain management in bariatric surgical patients should be opioid sparing or free because of a well-documented risk of sedation and severe respiratory depression from neuraxially or intravenously (i.v.) administered opioids, particularly in obese patients with obstructive sleep apnea (OSA), in addition to opioid-related side effects, including pruritus, nausea, vomiting, and delayed bowel function. Multimodal analgesic strategies using multiple nonopioid analgesics and local anesthetics, whenever possible, can lead to the achievement of this important goal. Successful strategies include the use of NSAIDs such as ketorolac in a variety of dosing schemes [3],[5],[6] , and local anesthetic port and wound infiltration or infusion [7],[8] . Ketamine, clonidine, dexmedetomidine, magnesium sulfate, methyl-prednisolone, and i.v. lidocaine have been studied less in bariatric surgical patients [9],[10] .


  Aim Top


The aim of this study was to evaluate the effectiveness of systemic lidocaine infusion compared with systemic ketorolac infusion in postoperative pain, nausea, and vomiting after bariatric surgery.


  Patients and methods Top


This prospective, randomized, double-blind, and controlled study included 60 patients who were assigned for elective laparoscopic bariatric surgery. This study was carried out in Ahmad Maher Teaching Hospital, Cairo, from June 2012 to January 2014. Approval from the Institutional Review Board was obtained, and all patients signed an informed consent.

Patients were divided randomly (each patient was assigned a number included in an enclosed envelope that was opened directly before the surgical intervention by a nurse who was not part of the study protocol) into three equal groups.

  1. Lidocaine group: patients received i.v. lidocaine (1.5 mg/kg bolus, followed by a 2 mg/kg/h infusion until the end of the surgical procedure (Xylocaine 2%; AstraZeneca, 600 Capability Green, Luton, LU1 3LU, UK).
  2. Ketorolac group: patients received i.v. ketorolac (30 mg i.v. as a bolus over 15-30 s, followed by a continuous i.v. infusion of ketorolac 0.5 mg/kg/h infusion until the end of the surgical procedure) (Ketorolac Tromethamine; Hospira Inc., Lake Forest, Illinois, USA).
  3. Control group: patients received an i.v. infusion of the same volume of normal saline as the lidocaine and ketorolac groups.
The perfusor (Alaris CC for a 50 ml syringe; Cardinal Health, Dublin, Ireland) with the studied agent was prepared by an independent contributor.

Inclusion criteria were as follows:

  1. Obese male or female patients with BMI (35-55 kg/m 2 ).
  2. Assigned for laparoscopic bariatric surgery.
Exclusion criteria included the following:

  1. Chronic aspirin or NSAID intake.
  2. Known allergy to aspirin and/or NSAIDs, or lidocaine.
  3. History of bronchial asthma requiring intubation.
  4. Peptic ulceration.
  5. Coagulopathy.
  6. Renal insufficiency.
  7. Opioid abuse.
  8. Pregnancy.
  9. Conversion from laparoscopic to open surgery.
All patients were subjected to a standard anesthetic plane as follows:

  1. Premedication: 0.04 mg/kg i.v. midazolam on arrival to the holding area.
  2. Induction of anesthesia was carried out using propofol 1-2 mg/kg, fentanyl 2 mcg/kg, and rocuronium 0.8 mg/kg.
  3. Maintenance: sevoflurane 2 MAC, rocuronium 0.1 mg/kg/20 min.
  4. The laparoscopic ports were infiltrated with 0.25% bupivacaine preemptively. Neostigmine was administered to antagonize residual neuromuscular block at the end of the surgery.
  5. Intraoperative stability and depth of anesthesia were assessed on the basis of variations in blood pressure, pulse rate, and bispectral index score (BIS) values. Postanesthesia recovery was assessed using objective endpoints.
All medications in the study protocol were dosed on the basis of the following dosing body weight formula: ideal body weight (IBW) +0.4 × (actual body weight−IBW) [11] .

Patient assessment

Immediate recovery from anesthesia was assessed on the basis of the time to eye opening, extubation, and orientation starting from the time of discontinuation of inhalation agents and reversal of neuromuscular block. The patient's ability to move from the operating room table to the bed was assessed using a five-point scale (0 = needs help, no movement; 1 = moves only the head; 2 = moves the head and one leg; 3 = moves the head and both legs; 4 = able to move alone). The patients were transported to PACU in a semirecumbent position breathing oxygen through a face mask at 4-6 l/min [3] . Patients were asked by an anesthesiologist blinded to the treatment group to rate their pain upon arrival to PACU and at regular intervals (10 min) on a 0-10 pain numeric rating scale (NRS), and then at 2, 4, 8, 12, 18, and 24 h after PACU discharge, where 0 indicates no pain and 10 indicates the worst pain imaginable. Fentanyl 10-20 mcg was administered every 10 min (if needed) to maintain the pain score less than 4.

The patient's ability to cooperate with respiratory physical therapy, as evidenced by incentive spirometry, was assessed using a five-point scale (0 = drowsy, unable to cooperate; 1, 2, 3, 4 = able to cooperate, but in severe, moderate, mild, and almost no pain, respectively). Duration of stay in the PACU, incidence of PONV, fentanyl requirements for postoperative analgesia over 24 h, and overall patient satisfaction at the end of 24 h were recorded [3] .

Statistical analysis

Sample size was calculated according to the following equation: n (group)=[(Z0α + Zβ) 2 × 2 × p (P0−1)]/d2 , where n is the number of each group; Zα is 1.96 at α = 0.05 and 95% CI; is 0.84 at 80% statistical power; d is the required difference; p is the percentage; and by application where percentage needed is 0.7 and difference = 0.4. The required number in each group was 20.

The collected data were organized, tabulated, and analyzed statistically using the statistical package for the social sciences (SPSS, version 16; SPSS Inc., Chicago, Illinois, USA). Quantitative data were represented as mean ± SD; minimum and maximum were presented. Qualitative data were represented as relative frequency and percent distribution. One-way analysis of variance and χ2 -tests were used to compare the quantitative and qualitative variables between the studied groups, respectively. For comparison between two means, the Student t-test was used. P value less than 0.05 was considered significant.


  Results Top


Patient characteristics are presented in [Table 1]; the patients ranged in age from 22 to 46 years, with the majority being women. The BMI of the patients ranged from 36.76 to 52.12 kg/m 2 ; the majority of cases were American Society of Anesthesiologists class III. OSA was reported in about 40% of cases. There was no significant difference between the groups studied in any of the patient characteristics.
Table 1: Patient characteristics

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In the present study, the surgical procedure was in the form of a Roux-in-Y bypass in 30, 50, and 35% of the patients in the lidocaine, ketorolac, and control groups, respectively, and gastric sleeve in the rest of the cases; the duration of surgery ranged from 120 to 158 min and there was no significant difference between the groups studied. Furthermore, there was a significant decrease in intraoperative BIS in the control group compared with the lidocaine and ketorolac groups (61.35 ± 4.54 vs. 63.35 ± 4.0 and 66.60 ± 7.19, respectively). However, at extubation, the BIS was significantly decreased in the lidocaine group compared with the ketorolac and control groups (91.15 ± 2.73 vs. 93.65±1.49 and 94.70 ± 3.52, respectively). Finally, the patients in the lidocaine group showed significantly early recovery compared with the ketorolac or control groups [Table 2]. [Table 3] shows that the lidocaine group had a better postoperative mobility score, less nausea and vomiting, good incentive spirometry, greater patient satisfaction, requirement of a low total fentanyl dose, and low postoperative pain at all the time points studied. The difference was statistically significant.
Table 2: Intraoperative data of the cases studied

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Table 3: Postoperative data in the cases studied

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  Discussion Top


Obese patients are at a high risk for both aspiration and acute airway obstruction after tracheal extubation. Thus, rapid recovery is desirable to ensure early efficient coughing and to decrease the rate of postoperative respiratory complications [12] .

The present study was designed to compare between lidocaine and ketorolac in terms of the outcomes of postbariatric surgery (e.g. postoperative pain, PONV, need for postoperative analgesia, and patient satisfaction).

In the present study, OSA was reported in 40% of cases, which is less than that reported in the literature, where sleep-disordered breathing syndromes include OSA and obesity hypoventilation syndrome, which some consider as an extension of OSA. Obesity is a major risk/causative factor for both entities. More than 70% of patients presenting for bariatric procedures have OSA, the predominant form of sleep-disordered breathing in these patients [13],[14] .

The results showed that lidocaine was associated with better outcome as it decreased postoperative pain during the first 24 h, decreased PONV, decreased the total dose of fentanyl, and resulted in increased patient satisfaction. The difference was significant compared with the ketorolac and control groups. In addition, the ketorolac group showed a significantly better outcome compared with the control group.

To the best of our knowledge, the present study is the first to compare both the drugs. The literature includes many studies comparing different drugs, with control groups or other drugs, aiming at decreasing postoperative pain and PONV. The results of our study showed the superiority of lidocaine over ketorolac in achieving low postoperative pain and PONV. In addition to the results of the present study, it has been reported that lidocaine exerts an opioids-sparing effect of systemic infusion when used in patients undergoing laparoscopic bariatric surgery [15] . Lidocaine has been shown to have opioid-sparing properties in other patient populations undergoing different surgical procedures [16] . The lower prevalence of nausea and vomiting in the lidocaine group likely results from the lower opioid consumption in PACU by the lidocaine group. Several mechanisms have been proposed to explain the opioid-sparing effects of perioperative systemic lidocaine. First, systemic lidocaine has anti-inflammatory properties that can minimize the pain caused by surgical inflammation [17],[18] . Second, systemic lidocaine can also directly block sodium channels of pain-conducting nerve fibers [19] . Finally, systemic lidocaine can reduce the need for an intraoperative volatile anesthetic and/or opioid drugs, which may minimize the development of postsurgical hyperalgesia [20],[21],[22] .

However, systemic lidocaine can induce allergic reaction, arrhythmia, hypotension, drowsiness, or convulsions. Many studies show that i.v. lidocaine with a 1.5-mg/kg bolus and a 2.0-mg/kg/h infusion dose is safe and without side effects. Even a larger dose and a longer duration of administration of lidocaine did not result in toxic concentrations or cause side effects [23] . In the present study, we observed patients precisely for 24 h (the elimination half-life of lidocaine is ~90-120 min) after surgery. We did not observe any such complications, confirming the safety of the low dose used in the present work.

In agreement with the results of the present study, Kim et al. [24] used an i.v. systemic infusion of lidocaine during microdiscectomy and concluded that an intraoperative systemic infusion of lidocaine decreases pain perception during microdiscectomy, thus reducing the consumption of opioids and the severity of postoperative pain. This effect contributes toward reducing the length of hospital stay. In addition, systemic lidocaine infusion may reduce muscle damage and inflammatory reaction. In addition, Tikuisis et al. [25] concluded that perioperative continuous i.v. lidocaine infusion exerts a beneficial effect in terms of postoperative pain, restoration of bowel function, and length of hospital stay in patients who have undergone hand-assisted laparoscopic colon surgery.

The intraoperative use of opioid analgesics can improve hemodynamic stability and decrease anesthetic requirements, postoperative pain, and discomfort. However, opioid analgesics can also produce postoperative respiratory depression, drowsiness, nausea, and vomiting [26] . The need for adequate postoperative pain relief with an eye on early ambulation encouraged many studies to use NSAIDs (e.g. ketorolac, ketoprofen, diclofenac) in addition to i.v. boluses or patient controlled analgesia (PCA)-delivered morphine or fentanyl [12] .

It had been reported that perioperative prophylactic administration of ketorolac significantly reduces immediate postoperative pain, reduces opioid consumption, avoids most opioid-related complications, reduces sedation, and enables better cooperation in ambulation. Moreover, 24 h of ketorolac infusion had no major influence on endocrine-metabolic response and no negative influence on hemostatic or renal function [27] . Ketorolac has been used in lieu of narcotics during surgery for a morbidly obese patient with sleep apnea [28] , but the literature has no randomized studies on morbidly obese patients receiving ketorolac as the major analgesic during general anesthesia. Our results seem to indicate that prophylactic and continuous administration of ketorolac can provide satisfactory analgesia in patients with moderate to severe postsurgical pain. They compare favorably with the conclusions of two other studies [27],[29] and appear to be better than the results obtained by other investigators using different regimens of ketorolac administration [30] .

The results of the present study are comparable with those of Govindarajan et al. [3] , who reported that the use of intraoperative ketorolac infusion seems to provide a stable intraoperative environment and depth of anesthesia, as indicated by hemodynamic parameters and BIS readings. Intraoperative and 24-h postoperative administration of ketorolac reduces postoperative opioid consumption, avoids opioid-related side effects, reduces sedation, prevents PONV, promotes early ambulation, improves patient participation in respiratory physical therapy, and significantly reduces PACU stay.

Finally, the study design and results are in agreement with the current evidence that suggests that at least NSAIDs and a local anesthetic port or wound infiltration should be part of a multimodal postoperative pain management regimen in this patient population, unless contraindicated. However, optimal timing and dosing of NSAIDs and other potentially beneficial analgesic adjuvants as well as specific protocols have yet to be determined in addition to their impact on pain scores and opioid needs beyond the immediate (6-48 h) recovery period. A valuable addition to this evidence is that the use of lidocaine, as an i.v. infusion, was superior to NSAID (ketorolac).


  Conclusion Top


We concluded that an i.v. infusion of lidocaine was found to be an effective and safe adjuvant for the rapid recovery of obese patients following bariatric surgery. Ketorolac led to a better outcome than that in the control group, but less than that achieved with lidocaine.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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