Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 531-535

Intraperitoneal bupivacaine plus fentanyl after laparoscopic pyeloplasty


Department of Anaesthesiology, Ain Shams University, Cairo, Egypt

Date of Submission18-Sep-2015
Date of Acceptance22-May-2016
Date of Web Publication12-Jan-2017

Correspondence Address:
Hoda Shokri
Department of Anaesthesiology, Ain Shams University, Abbassya Square, 11772 Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.197570

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  Abstract 

Objective
Laparoscopic surgery has decreased the severity of postoperative pain. However, patients often experience abdominal and shoulder pain, requiring significant amounts of opioids and potentially prolonging their hospitalization. This study was conducted to assess the effectiveness of intraperitoneal bupivacaine plus fentanyl in reducing postoperative pain without incidence of postoperative complications in patients undergoing laparoscopic pyeloplasty.
Patients and methods
After hospital ethics committee approval and obtaining written informed consent, 50 consecutive patients undergoing unilateral laparoscopic pyeloplasty were enrolled in this prospective randomized trial. Patients were randomly divided into two groups using the sealed envelope technique: the BF group (25 patients) received induction with 30 ml of bupivacaine (0.25%) plus fentanyl (20 μg) intraperitoneally just before trocar removal, and the saline group (25 patients) received induction with saline (30 ml). Pain scores, time to first analgesic requirement, postoperative opioid requirements, and occurrence of adverse effects were all recorded.
Results
There was a significant reduction in 24 h of postoperative opioid utilization and visual analog scale scores in the BF group compared with the saline group at all time points. The time to first opioid consumption was significantly longer in the BF group compared with the saline group. The incidence of complications was not significantly different between the study groups. Systolic and diastolic blood pressures were significantly lower in the BF group compared with the saline group.
Conclusion
The administration of intraperitoneal bupivacaine plus fentanyl just before trocar removal appears to be a simple, effective, and low-cost method to reduce postoperative pain in adults undergoing laparoscopic pyeloplasty.

Keywords: bupivacaine, fentanyl, intraperitoneal instillation, laparoscopic pyeloplasty, postoperative pain


How to cite this article:
Shokri H. Intraperitoneal bupivacaine plus fentanyl after laparoscopic pyeloplasty. Ain-Shams J Anaesthesiol 2016;9:531-5

How to cite this URL:
Shokri H. Intraperitoneal bupivacaine plus fentanyl after laparoscopic pyeloplasty. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Jun 28];9:531-5. Available from: http://www.asja.eg.net/text.asp?2016/9/4/531/197570


  Introduction Top


Laparoscopic operative procedures make a kind of revolution in surgical practice, with many advantages such as smaller and more cosmetic incision, reduced blood loss, and reduced postoperative stay and pain, which cut down on hospital cost. However, patients undergoing laparoscopic procedures experience postoperative pain, especially in the abdomen, back, and shoulder region, which requires proper attention. Pain intensity usually peaks during the first postoperative hours [1].

Different regimens have been proposed to relieve pain after laparoscopy surgery, such as NSAIDs, opioids, local wound infiltration, intraperitoneal saline, and opioid. Opioids provide effective analgesia but can increase the incidence of side effects such as nausea and vomiting after surgery and produce excessive sedation, which can delay the discharge. NSAIDs may provide a rational approach because they not only prevent the side effects of opioids but also because of treatment of peritoneal inflammation after pneumoperitoneum. Infiltration of local anesthetics decreases scapular pain. Visceral pain has its maximum intensity during the first hour and is exacerbated by coughing, respiratory movements, and mobilization [2].

The aim of choosing the intraperitoneal route is to block the visceral afferent signals and potentially modify visceral nociception and provide analgesia. The local anesthetic inhibits nociception by affecting nerve membrane-associated proteins and by inhibiting the release and action of prostaglandins and other agents that sensitize or stimulate the nociceptors and contribute to inflammation [3]. However, absorption from large peritoneal surface may also occur, which may be a further mechanism of analgesia.

This prospective study was conducted to evaluate the analgesic efficacy of intraperitoneal bupivacaine and fentanyl after laparoscopic pyeloplasty surgeries.


  Patients and methods Top


A total of 50 patients with physical status I and II according to the American Society of Anesthesiologists (ASA) between 18 and 25 years of age who were scheduled for laparoscopic pyeloplasty surgery were enrolled in a randomized double-blind parallel group prospective study after the hospital ethics committee approval and obtaining written informed consent from all patients. This study was carried out between December 2013 and April 2015 at Ain Shams University Hospital. The study exclusion criteria included use of opioid during 24 h before the study, drug or alcohol abuse, allergy to any of the study drug, and chronic pain syndrome when pain evaluation was judged unreliable because of neurological disease or treatment with steroids before surgery. Preanesthetic evaluation was carried out on the night of surgery. In the preparation room, the anesthesiologist secured an 18-G cannula and administered midazolam 0.05 mg/kg, intravenous, to all patients before transfer to the operating room where standard monitoring devices such as ECG, noninvasive blood pressure, and pulse oximetry were placed.

A conventional balanced general anesthesia was administered. The induction protocol was standard for all patients and consisted of intravenous administration of fentanyl (2 μg/kg), thiopentone sodium (3–5 mg/kg), and atracurium (0.5 mg/kg). Anesthesia was maintained with oxygen 100%, isoflurane, and supplements of atracurium. Volume-controlled ventilation (tidal volume: 10 ml/kg) was adjusted to maintain end-tidal carbon dioxide between 35 and 40 mmHg. Patients were placed in Trendelenburg position during laparoscopy, and intra-abdominal pressure was maintained between 12 and 14 mmHg. At the end of the procedure, those patients who were allocated to group BF (n = 25) received 30 ml of 0.25% bupivacaine and 20 μg of fentanyl intraperitoneally. A total volume of 7 ml each was instilled on the inferior aspect of each diaphragm, and remaining 23 ml was instilled on the operative site through the umbilical port site with the patient in supine position (after peritoneal wash and suctioning), followed by clamping of the drainage tube for 40 min. In the saline group (n = 25), 30 ml of saline was instilled. Carbon dioxide was then evacuated from the peritoneal cavity and skin incision was sutured.

Anesthesia was discontinued and neuromuscular blockade was antagonized with neostigmine, intravenous (0.05 mg/kg) and atropine, intravenous (0.03 mg/kg) at appropriate doses. Patients were extubated and shifted to the postanesthesia care unit.

Patients were randomized into two groups using the closed envelope technique. A drug solution was prepared by a doctor who had not participated in the study, and the drug was filled in precoded syringes and given to the surgeon. The surgeon and anesthetist in the postanesthetic care unit were unaware of the treatment for which the patient was randomized.

Before induction of anesthesia, patients were instructed on how to use a 100 cm visual analog scale (VAS with the 0 end labeled ‘no pain’ and 100 labeled as ‘worst conceivable pain’). The degree of postoperative pain was assessed at 1, 4, 8, 12, 18, and 24 h using the VAS score, which was used as a primary outcome measure. Postoperative analgesia regimen was standard in all groups. When the VAS score was greater than 40, patients were given pethidine (50 mg, intravenous). The time to first analgesic dose from the end of surgery throughout the 24-h postoperative period, total analgesic requirement during the 24-h postoperative period, and systolic and diastolic blood pressures at 1, 4, 8, 12, 18, and 24 h postoperatively were recorded, and the occurrence of adverse events such as vomiting, pruritus, and sedation, which were used as secondary outcome measures, were also recorded.


  Statistical methods Top


Sample size justification

Epi Info (version 17.0; SPSS Inc., Chicago, Illinois, USA) was used for calculations of sample size, based on 95% confidence interval, 80% power, and α error of 5%. A previous study [4] had shown a significant reduction in pain scores at 1 h (P < 0.01) and 2 h (P < 0.05) between the intraperitoneal bupivacaine group and the saline group. On the basis of that study we assumed that a minimal sample size of 50 cases was enough to find such a difference. Assuming a dropout ratio of 5%, the sample size was determined at 25 cases in each group.

Statistical analysis

The collected data were coded, tabulated, and statistically analyzed using statistical package for the social sciences (SPSS; version 17.0; SPSS Inc.) software.

Visual analog scores were presented as median. They were compared between study groups using the Mann–Whitney test.

The time to the first analgesic dose and total dose of rescue analgesic were presented as mean ± SD; they were compared using t-test. Incidence of complications was compared using the x2-test.

Systolic and diastolic blood pressures were presented as mean ± SD; they were compared using t-test.

A P value less than 0.05 was considered significant.


  Results Top


All patients completed the study.

The study groups were similar as regards age, weight, sex, and duration of surgery ([Table 1]).
Table 1: Demographic data

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Pain scores were significantly lower in group BF when compared with the saline group at all time intervals ([Table 2]).
Table 2: Visual analog scores among study groups

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Time to the first dose of rescue analgesia was longer in the BF group, indicating better and longer pain relief in the BF group compared with the saline group ([Table 3]).
Table 3: Comparison of the time to first analgesic dose, total dose of rescue analgesic, and incidence of complications

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Total postoperative analgesic consumption was significantly lower in the BF group compared with the saline group ([Table 3]).

No patient in group BF and two patients in the saline group complained of vomiting ([Table 3]) (nonsignificant difference between study groups).

There was no significant difference as regards incidence of pruritus or sedation among study groups ([Table 3]).

Systolic blood pressures were significantly lower in the FB group compared with the saline group at all time points ([Table 4]).
Table 4: Systolic blood pressures among study groups

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Diastolic blood pressures were significantly lower in the FB group compared with the saline group at all time points ([Table 5]).
Table 5: Diastolic blood pressures among study groups

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  Discussion Top


Laparoscopic urologic surgery being a minimally invasive procedure provides many valuable advantages to the patients and hospital services. It reduces the hospital stay, expenses, and cosmetic disfigurement [1].

Intraperitoneal injection of bupivacaine fentanyl for laparoscopic pyeloplasty resulted in significant analgesia, less total dose of postoperative analgesic requirements with longer time to first analgesic requirement, lower systolic and diastolic blood pressures, and dramatically fewer side effects according to this randomized controlled study.

Chundrigar et al. [4] and Szem et al. [5] showed similar results, with mean duration of analgesia lasting for 2–8 h only, which corresponds to pharmacological profile of the drug. Moreover, Malhotra et al. [6] found that 100 mg of intraperitoneal bupivacaine provides pain relief for a longer duration (8 h) compared with 50 mg of drug (4–6 h). Analgesic requirement was also less in the 100 mg group after laparoscopy gynecological surgery [6].

There was a significant reduction in postoperative opioid utilization when bupivacaine was administered at the beginning of the surgery (0.1 vs. 0.4 mg/kg; P = 0.04), but not at the end (0.3 mg/kg; P = 0.25), as compared with controls. All patients receiving aerosolized bupivacaine had a significantly shorter time in hospital (2.4 vs. 1.4 days; P ≤ 0.01) [7].

This is not in agreement with our study as study drug was given at the end of surgery and resulted in significant analgesia.

Hernández-Palazón et al. [8] concluded that pain scores were significantly lower for patients receiving intraperitoneal bupivacaine plus intravenous morphine (P < 0.05) during the first 2 h postoperatively and also postoperative consumption of metamizol was significantly lower (P < 0.05) during the first 6 h after surgery [8].

This is not in agreement with the findings of our study, which showed lower pain scores for longer time period.

Butala et al. [9] showed that pain scores were significantly lower in patients receiving intraperitoneal instillation of bupivacaine and morphine immediately postoperatively and during the first 4 h after surgery. The time to administration of first rescue analgesic was significantly higher (6.15 h). Total dose of rescue analgesic was significantly lower in the intraperitoneal instillation group [9].

Shukla et al. [10] showed that VAS scores were significantly lower in patients receiving intraperitoneal instillation of bupivacaine plus dexmedetomidine; the time to first analgesic requirement was longer and total dose of rescue analgesics was significantly lower after intraperitoneal instillation of bupivacaine plus dexmedetomidine.

Maharjan and Shrestha [11] showed that rescue analgesic requirements were significantly less in patients receiving intraperitoneal injection of bupivacaine following laparoscopic cholyecystectomy, but there was no statistically significant difference in pain scores postoperatively.

Narchi et al. [12] found that intraperitoneal infiltration of bupivacaine and lignocaine is effective in reducing postoperative shoulder pain for 24 h postoperatively.

Danny et al. [13] concluded that there was a significant decrease in VAS scores until the end of the study (48 h). No statistically significant was found in postoperative analgesic requirements or incidence of postoperative complications at any time point in patients receiving intraperitoneal bupivacaine in a continuous manner through ON-Q pump following laparoscopic band surgery [13].

Schulte et al. [14] found that 0.25% bupivacaine or 0.005% morphine given intraperitoneally was ineffective for pain analgesia following laparoscopic cholecystectomy; it might be attributed to inadequate dose or rapid dilution of the drugs.

This study findings are in disagreement with our findings as there was a significant decrease in pain scores in the study group [14].


  Conclusion Top


The administration of intraperitoneal bupivacaine plus fentanyl just before trocar removal appears to be a simple, effective, and low-cost method to reduce postoperative pain in adults undergoing laparoscopic pyeloplasty.

Acknowledgements

This work was supported by both, the Department of Urologic Surgery and the Department of Anaesthesiology at Ain Shams University, Cairo, Egypt.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Joris J, Thiry E, Paris P, Weerts J, Lamy M. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg 1995; 81:379-384.  Back to cited text no. 1
    
2.
Hernandez-Palazon J, Tortosa JA, Nuño de la RosaV, Gimenez-Viudes J, Ramírez G, Robles R. Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy. Eur J Anaesthesiol 2003; 20:891-896.  Back to cited text no. 2
    
3.
Liu SS, Hodgson PS. Local anaesthetics. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical anaesthesia. 4th ed. Philadelphia, PA: Lippicott Williams and Wilkins; 2001. 449-469.  Back to cited text no. 3
    
4.
Chundrigar T, Hedges AR, Morris R, Stamatakis JD. Intraperitoneal bupivacaine for effective pain relief after laparoscopic cholecystectomy. Ann R Coll Surg Engl 1993; 75:437-439.  Back to cited text no. 4
    
5.
Szem JW, Hydo L, Barie PS. A double blind evaluation of intraperitoneal bupivacaine V/S saline for post operative pain and nausea after laparoscopic cholecystectomy. Surg Endosc 1996; 10:44-48.  Back to cited text no. 5
    
6.
Malhotra N, Chanana C, Roy KK, Kumar S, Rewari V, Sharma JB. To compare the efficacy of two doses of intraperitoneal bupivacaine for pain relief after operative laparoscopy in gynecology. Arch Gynecol Obstet 2007; 276:323-326.  Back to cited text no. 6
    
7.
Freilich DA, Houck CS, Meier PM, Passerotti CC, Retik AB, Nguyen HT. The effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children undergoing robotic-assisted laparoscopic pyeloplasty. J Pediatr Urol 2008; 4:337-340.  Back to cited text no. 7
    
8.
Hernandez-Palazon J, Tortosa JA, Nuño de la Rosa V, Gimenez-Viudes J, Ramírez G, Robles R. Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy. Eur J Anaesthesiol 2003; 20:891-896.  Back to cited text no. 8
    
9.
Butala BP, Shah VR, Nived K. Randomized double blind trial of intraperitoneal instillation of bupivacaine and morphine for pain relief after laparoscopic gynecological surgeries. Saudi J Anaesth 2013; 7:18-23.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Shukla U, Prabhakar T, Malhotra K, Srivastava D. Intraperitoneal bupivacaine alone or with dexmedetomidine or tramadol for post-operative analgesia following laparoscopic cholecystectomy: a comparative evaluation. Indian J Anaesth. 2015; 59:234-239.  Back to cited text no. 10
    
11.
Maharjan SK, Shrestha S. Intraperitoneal and periportal injection of bupivacaine for pain after laparoscopic cholecystectomy. Kathmandu Univ Med J.2009; 7:50-53.  Back to cited text no. 11
    
12.
Narchi P, Benhamou D, Fernandez H. Intraperitoneal local anaesthetic for shoulder pain after day-case laparoscopy. Lancet 1991; 338:1569-1570.  Back to cited text no. 12
    
13.
Sherwinter DA, Ghaznavi AM, Spinner D, Savel RH, Macura JM, Adler H. Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized trial. Obes Surg 2008; 18:15811586.  Back to cited text no. 13
    
14.
Schulte H, Weningert E, Domimik J, Bernhard H Axel M. Intraperitoneal versus intrapleural morphine or bupivacaine for pain after laparoscopic cholecystectomy. Anesthesiology 1995; 82:634-640.  Back to cited text no. 14
    



 
 
    Tables

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



 

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