Ain-Shams Journal of Anaesthesiology

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 8  |  Issue : 3  |  Page : 360--363

Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial


Manal M Kamal, Mahmoud Hassan 
 Department of Anesthesia and Intensive Care, Ain Shams University, Cairo, Egypt

Correspondence Address:
Manal M Kamal
, 8 Elemdad and El Tamween Buildings, El Nasr Road, Nasr City, Cairo
Egypt

Abstract

Objectives This study was designed as a randomized comparison of postoperative pain after inguinal herniotomy in patients treated with intravenous esmolol and others treated with ropivacaine abdominal wound infiltration. Patients and methods Sixty American Society of Anesthesiologists physical status I-II patients undergoing herniotomy and anesthetized with isoflurane were randomized into one of two groups. Group R received 20 ml of ropivacaine 0.75% in 20 ml of saline 0.9% preincisional wound infiltration and group E patients received a bolus of esmolol 0.5 mg/kg intravenous at induction followed by an infusion of 5-15 mg/kg/min. After surgery, a bolus of pethidine was given according to visual analogue scale for pain intensity. Results Patients in group E had lower pain scores than patients in group R. Median consumption of pethidine was higher in group R than in group E. Conclusion Intravenous esmolol reduces pethidine consumption and provides more analgesia compared with preincisional ropivacaine infiltration in patients undergoing herniotomy.



How to cite this article:
Kamal MM, Hassan M. Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial.Ain-Shams J Anaesthesiol 2015;8:360-363


How to cite this URL:
Kamal MM, Hassan M. Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Sep 17 ];8:360-363
Available from: http://www.asja.eg.net/text.asp?2015/8/3/360/161701


Full Text

 Introduction



Inguinal hernia repair is an operation frequently associated with moderate to severe pain after operation [1],[2] , which can delay discharge and cause persistent distress [3] .

Typically, postherniorrhaphy pain is treated by opioids combined with a NSAID. Local anesthetic is often administered at the end of surgery [1].

However, the treatment designed to prevent pain in advance of surgical trauma may be more effective than the given analgesic therapy in response to pain after surgery [4] .

Such 'prophylactic analgesia' prevents central sensitization and hyperexcitability of neurons. Pre-emptive treatment with local anesthetics has been proposed as a method of inhibiting transmission of noxious stimuli thereby preventing central sensitization [4],[5] .

b-Adrenergic blocking drugs have been shown to reduce postoperative opioids requirements, suggesting an antinociceptive effect of these agents [6],[7],[8],[9] .

A previous study on patients undergoing laparoscopic cholecystectomy showed that esmolol and not remifentanil was associated with reduced postoperative fentanyl requirements [10] .

This randomized study compared the postoperative pain intensity and pethidine consumption after inguinal herniotomy in patients treated with intravenous esmolol versus others treated with pre-emptive ropivacaine abdominal wound infiltration.

 Patients and methods



Sixty American Society of Anesthesiologists (ASA) physical status I-II patients aged 18-45 years scheduled for herniotomy in El-Demerdash Hospital gave written informed consents to participate in the present study. The written informed consent was obtained on the day of surgery by the anesthesiologist. This study was approved by the ethics committee, Faculty of Medicine, Ain Shams University. This study was carried out from January to August 2013.

Exclusion criteria included patients with a known history of hypertension, chronic pain syndrome, renal or hepatic insufficiency, heart disease, chronic treatment with b-blockers, drug abuse, or allergy to any of the study drugs.

Noninvasive arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO 2 ) were monitored in the operation room.

Using random selection of sealed envelopes, patients were randomized into one of two groups (30 patients each). Sealed envelopes were prepared by an anesthesia technician who was not involved in the study.

After induction of anesthesia using 5 mg/kg thiopental sodium, fentanyl 1 mg/kg, and atracurium 0.5 mg/kg, endotracheal intubation was performed. Patients were divided into two groups: Group R (n = 30) received 20 ml of ropivacaine 0.75% in 20 ml normal saline preincisional wound infiltration and group E (n = 30) received a bolus of esmolol 0.5 mg/kg intravenously followed by an infusion of 5-15 mg/kg/min. Anesthesia was maintained with 1.2% isoflurane and a mixture of oxygen and air. At the end of the operation, neuromuscular blockade was reversed by intravenous neostigmine 0.04 mg/kg and intravenous atropine 0.02 mg/kg. Anesthesia was discontinued and the tracheal tube was removed when airway reflexes had recovered. Heart rate, pulse oximeter oxygen saturation, and mean arterial pressure were recorded at 10, 20, and 30 min after surgery and at 1, 2, and 3 h postoperatively. Pain scores were evaluated by a blind observer at the time of arrival in the postanesthesia care unit, at 10, 20, and 30 min after surgery, and at 1, 2, 3, 6, and 9 h postoperatively using a visual analogue scale (0-10 cm; 0 = no pain, 10 = the worst pain imaginable). If the visual analogue scale score was greater than 4 cm, 0.4 mg/kg pethidine was given intravenously. If the score did not decrease within 10 min, an additional 0.2 mg/kg pethidine was given. Time to first need for pethidine and total pethidine consumption were recorded. Nausea and vomiting were recorded during the postoperative period. All data were recorded by a blind observer.

Using Statistical Program of Social Science (SPSS) for sample size calculation, it was calculated that a sample size of 27 per group will achieve 80% power to detect a difference of 50% difference in analgesic requirements at the first 6 postoperative hours between the two groups, with a significance level (α) of 0.05 using a two-sided two-sample t-test. A total of 30 patients per group were included to replace any dropouts.

The collected data were coded, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 17.0 (SPSS Inc., Chicago, Illinois, USA).

Data were expressed as mean value ± SD for numerical parametric data and numbers (%) for categorical data. Student's t-test was used to analyze the parametric data, and discrete (categorical) variables were analyzed using the χ2 -test, with P-values less than 0.05 considered statistically significant.

 Results



No patients in group E suffered from nausea or vomiting; no patients in group R suffered from nausea, whereas one patient in group R suffered from vomiting.

 Discussion



These study results showed that a continuous intraoperative infusion of esmolol (5-15 μg/kg/min) reduces postoperative pain after herniotomy compared with preincisional ropivacaine infiltration. It also delayed the first request for analgesic for 6 h postoperatively, whereas ropivacaine infiltration gave this effect only for 3 h postoperatively.

The purposes of pre-emptive analgesia are first to inhibit or reduce the development of any memory of pain stimulus in the central nervous system and second to diminish analgesic requirements as a consequence [11],[12] . The pre-emptive blockade of initial nociceptive different input to the spinal cord may inhibit the development of long-term changes in the excitability of central neurons and accordingly prevent both peripheral and central nociceptive processing, thereby producing long-lasting antinociceptive effects [13],[14] .

The mechanism underlying these noncardiovascular effects of b-blockers is controversial. Some studies show synergism with the hypnotic effect, whereas others disregard this action [8],[15],[16] . The antinociceptive effect of esmolol is also controversial. Although experimental and clinical observation point to an analgesic effect associated with the involvement of the sympathetic nervous system in nociception [8],[10],[17],[18] , this effect, however, is not universally confirmed.

The benefit of local anesthetic field block before hernia surgery has previously been investigated by Tverskoy et al. [19] . In that study, pain was less severe for 48 h after surgery in patients who received a postoperative field block with bupivacaine compared with patients who received no local anesthetic at all. The less duration of effect in our study may be related to differences in study design.

Chia et al. [8] compared the use of esmolol with a control group of patients who received saline. They noticed a decrease in intraoperative requirements for fentanyl and reduced consumption of morphine during the first 3 days after surgery. They proposed that attenuation of the intraoperative nociceptive stimulation of esmolol reduces the consequences of adrenergic dysregulation. White et al. [9] compared three different analgesic protocols in patients undergoing gynecologic laparoscopy: a group managed with esmolol alone, a group managed with nicardipine combined with esmolol, and a control group managed with saline. Their results showed that 80% of patients in the control group required postoperative analgesia compared with 47% of patients in the esmolol group and 40% of patients in the esmolol-nicardipine group. Servando et al.[20] compared the use of esmolol infusion versus ketamine-remifentanil infusion for early postoperative analgesia after laparoscopic cholecystectomy. Their results showed that intraoperative infusion of esmolol reduces opioid requirements and improves postoperative analgesia [20] .

It is necessary to emphasize that, in this study, we only recorded the total consumption of pethidine in the first 9 h postoperatively. Therefore, our results cannot document whether this effect was prolonged to the late postoperative period. We were unable to record the patient need for analgesia during the late postoperative period as it was not possible to contact the patient at home, which could be carried out in further studies [Table 1] [Table 2] [Table 3] [Table 4] [Table 5] and [Figure 1].{Figure 1}{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

 Conclusion



This study shows that intraoperative infusion of esmolol in patients undergoing herniotomy is associated with reduced pain scores and analgesic use in the first 9 h postoperatively compared with preoperative ropivacaine abdominal wound infiltration.

 Acknowledgements



Conflicts of interest

None declared.

References

1Callesen T, Kehlet H. Postherniorrhaphy pain. Anesthesiology 1997; 87:1219-1230.
2Johansson B, Hallerbäck B, Stubberöd A, Janbu T, Edwin B, Glise H, Solhaug JH. Preoperative local infiltration with ropivacaine for postoperative pain relief after inguinal hernia repair. A randomised controlled trial. Eur J Surg 1997; 163:371-378.
3Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H. Factors affecting discharge time in adult outpatients. Anesth Analg 1998; 87:816-826.
4Woolf CJ, Chong MS. Preemptive analgesia - treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993; 77:362-379.
5Cousins MJ, Power I, Smith G. 1996 Labat lecture: pain - a persistent problem. Reg Anesth Pain Med 2000; 25:6-21.
6Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, et al. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 1999; 91:1674-1686.
7Johansen JW, Flaishon R, Sebel PS. Esmolol reduces anesthetic requirement for skin incision during propofol/nitrous oxide/morphine anesthesia. Anesthesiology 1997; 86:364-371.
8Chia YY, Chan MH, Ko NH, Liu K. Role of beta-blockade in anaesthesia and postoperative pain management after hysterectomy. Br J Anaesth 2004; 93:799-805.
9White PF, Wang B, Tang J, Wender RH, Naruse R, Sloninsky A. The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery. Anesth Analg 2003; 97:1633-1638.
10Collard V, Mistraletti G, Taqi A, Asenjo JF, Feldman LS, Fried GM, Carli F. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 2007; 105:1255-1262.
11Zahn PK, Brennan TJ. Intrathecal metabotropic glutamate receptor antagonists do not decrease mechanical hyperalgesia in a rat model of postoperative pain. Anesth Analg 1998; 87:1354-1359.
12Hudspith MJ. Glutamate: a role in normal brain function, anaesthesia, analgesia and CNS injury. Br J Anaesth 1997; 78:731-747.
13Kohrs R, Durieux ME. Ketamine: teaching an old drug new tricks. Anesth Analg 1998; 87:1186-1193.
14Chapman V, Dickenson AH. The combination of NMDA antagonism and morphine produces profound antinociception in the rat dorsal horn. Brain Res 1992; 573:321-323.
15Johansen JW, Schneider G, Windsor AM, Sebel PS. Esmolol potentiates reduction of minimum alveolar isoflurane concentration by alfentanil. Anesth Analg 1998; 87:671-676.
16Smith I, Van Hemelrijck J, White PF. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia. Anesth Analg 1991; 73:540-546.
17Davidson EM, Doursout MF, Szmuk P, Chelly JE. Antinociceptive and cardiovascular properties of esmolol following formalin injection in rats. Can J Anaesth 2001; 48:59-64.
18Zhao H, Sugawara T, Miura S, Iijima T, Kashimoto S. Intrathecal landiolol inhibits nociception and spinal c-Fos expression in the mouse formalin test. Can J Anaesth 2007; 54:201-207.
19Tverskoy M, Cozacov C, Ayache M, Bradley EL Jr, Kissin I. Postoperative pain after inguinal herniorrhaphy with different types of anesthesia. Anesth Analg 1990; 70:29-35.
20López-Álvarez S, Mayo-Moldes M, Zaballos M, Iglesias BG, Blanco-Davila R. Esmolol versus ketamine-remifentanil combination for early postoperative analgesia after laparoscopic cholecystectomy: a randomized controlled trial. Can J Anaesth 2012; 59:442-448.