Muhittin YAPRAK, Volkan DOĞRU, Ayhan MESCİ, Mert AKBAŞ

Laparoskopik Kolesistektomi Sonrası Ağrı Yönetimi

Amaç: Ağrı algısı sadece duyusal bir uyarıcı değil, aynı zamanda motivasyonel durum ve duygu durumu ile yakından ilgilidir ve kültürel öğrenme, geçmiş deneyimler, kaygı ve depresyon ile şekillenir. Çalışmada laparoskopik kolesistektomi için uygulanan postoperatif analjezi protokollerindeki opioid tüketimini azaltabilecek yardımcı ajanları belirlemek amaçlanmıştır. Gereç ve Yöntemler: Nonsteroidal antienflamatuar bir ilaç olan Dexketoprofen ve zayıf bir opioid olan Tramadol’u içeren standart bir postoperatif yatan hasta ağrı yönetimi protokolü alan hastalarımız içinde bir anksiyolitik olan Alprazolam'ın preoperatif uygulanmasının n=12 opioid ihtiyacı üzerine etkisi istatistiksel analizlerle incelendi . Kontrol grubu n=81 , sadece standart protokole bağlı kalanları içermekteydi. Lokal anestezik Bupivakainʼin adjuvan kullanımı, kesi yerine infiltrasyonu n=23 ile opioid ihtiyacı arasındaki ilişki ayrıca analiz edildi.Bulgular: Ameliyat öncesi Alprazolam verilen ve kesi yerlerine Bupivakain Hidroklorür enjeksiyonu yapılan grupların ilk 24 saatlik opioid gereksinimi kontrol grubuna göre anlamlı derecede düşüktü sırasıyla p=0,019 ve p=0,033 . Toplam opioid tüketimi, sadece lokal anestezi grubunda kontrol grubuna göre anlamlı derecede düşüktü p=0,045 . Alprazolam grubunda, kontrol grubuna göre ilk 24 saatten sonra opioid talep etme riskinin önemli ölçüde arttığı gözlendi. Odds ratio 4,0 %95 Cl, 1,00 ila 15,99; p=0,038 idi.Sonuç: Bupivakain, Alprazolam ve Tramadol, P450 sisteminin aynı alt birimi ile metabolize edilir; CYP3A4 enzimi. Bu nedenle, bu ilaçların eliminasyonu sırasında enzim için yarışma gerçekleşip vücutta bu duruma bağlı ilaç toksisiteleri gelişebilir. Öyle ki, çalışmada preoperatif Alprazolam alan hastalarda ameliyat sonrası ilk günden sonra Tramadol HCl için artmış ilaç arama davranışı gözlemlenmiştir. Bu durum opioid toksisitesi riski için anlamlı bir ipucu olarak değerlendirilebilir

Anahtar Kelimeler:

Laparoskopik kolesistektomi, Ağrı, Analjezi

Pain Management After Laparoscopic Cholecystectomy

Objective: The perception of pain is not only a sensorial stimulus, but it is closely related with motivational state and affect and it is shaped with cultural learning, past experiences, anxiety and depression. Common postoperative analgesia protocols for laparoscopic cholecystectomy are scrutinized to identify adjunctive agents reducing weak opioid consumption.Material and Methods: Preoperative administration of an anxiolytic, Alprazolam n=12 , was analyzed among patients who received a standardized postoperative inpatient pain management protocol including a nonsteroidal anti-inflammatory drug, Dexketoprofen, and a weak opioid, Tramadol. The control group n=81 included those who adhered to the standardized protocol only. Adjunctive use of the local anesthetic Bupivacaine, by means of wound infiltration n=23 was analyzed separately to compare the analgesic outcome.Results: The first 24-hour weak opioid requirement was significantly lower in the Bupivacaine Hydrochloride wound infiltration group and Alprazolam groups when compared with the control group p=0.019 and p=0.033, respectively . Total weak opioid consumption was significantly lower in the only local anesthesia group when compared with the control group p=0.045 . Alprazolam group had a significantly higher risk of demanding weak opioids with respect to the control group after the first 24 hours. Odds ratio was 4.0 95% Cl, 1.00 to 15.99; p=0.038 . Conclusion: Bupivacaine, Alprazolam and Tramadol are metabolized by the same subunit of the P450 system, the CYP3A4 enzyme. Thus, their elimination is subject to possible competition and related toxicity. So much so that after the first postoperative day, increased drug seeking behavior for Tramadol HCl was observed with preoperative alprazolam in the study. This can be considered as a significant clue for the risk of opioid toxicity

Keywords:

Laparoscopic cholecystectomy, Pain, Analgesia,

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Mitko J, Main W, Hussain L, Meister K, Kerlakian G, Tymitz K. Laparoscopic versus Robotic Cholecystectomy in the obese population: Is there a preferred approach? Surgery for Obesity and Related Diseases 2016; 12:114-5.
Dey A, Malik VK. Shoulder tip pain following laparoscopic cholecystectomy-a randomized control study to determine the cause. Indian J Surg 2015; 77:381-4.
Snell RS. The spinal cord and the ascending and descending Tracts. In: Snell RS, ed. Clinical neuroanatomy. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:132-85.
Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther 2011; 91:700-11.
Mitra S, Khandelwal P, Roberts K, Kumar S, Vadivelu N. Pain relief in laparoscopic cholecystectomy-a review of the current options. Pain Pract 2012; 12:485-96.
Alkhamesi NA, Peck DH, Lomax D, Darzi AW. Intraperitoneal aerosolization of bupivacaine reduces postoperative pain in laparoscopic surgery: A randomized prospective controlled double-blinded clinical trial. Surg Endosc 2007; 21:602-6.
Loizides S, Gurusamy KS, Nagendran M, Rossi M, Guerrini GP, Davidson BR. Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2014; 3:CD007049.
Anand LK, Sandhu M, Singh J, Mitra S. Evaluation of analgesic efficacy of pregabalin for postoperative pain relief after laparoscopic cholecystectomy: A double blind study. Anesth Pain & Intensive Care 2017;21:174-80.
Peng K, Ji F, Liu H, Wu S. Ultrasound-Guided transversus abdominis plane block for analgesia in laparoscopic cholecystectomy: A systematic review and meta-analysis. Princ Pract 2016; 25:237-46.
O’Connor K, Renfrew C. Subcostal transversus abdominis plane block. Anaesthesia 2010;65:91–2.
Ma J, Jiang Y, Tang S, Wang B, Lian Q, Xie Z, Li J. Analgesic efficacy of ultrasound-guided subcostal transversus abdominis plane block. Medicine (Baltimore) 2017; 96:e6309.
Iwata M, Kuzumoto N, Akasaki Y, Morioka M, Nakayama K, Matsuzawa N, Kimoto K, Shimomura T. The ultrasound-guided nerve blocks of abdominal wall contributed to anesthetic management of cholecystectomy in a patient with Becker muscular dystrophy without using muscle relaxants. JA Clin Rep 2017; 3:64.
Kimura F, Oishi M, Yakoshi C, Ogasawara C, Ishihara H, Hirota K. Rectus sheath block and transversus abdominis plane block for a patient with Lambert-Eaton myasthenic syndrome undergoing low anterior resection. Masui 2013; 62:989-91.
Joseph TT, Krishna HM, Kamath S. Premedication with gabapentin, alprazolam or a placebo for abdominal hysterectomy: Effect on pre-operative anxiety, post- operative pain and morphine consumption. Indian J Anaesth 2014; 58:693-9.
Chouinard G. Issues in the clinical use of benzodiazepines: potency, withdrawal, and rebound. Eur Neuropsychopharmacol 2004; 65:7-12.
Coda BA, Mackie A, Hill HF. Influence of alprazolam on opioid analgesia and side effects during steady-state morphine infusions. Pain 1992; 50:309-16
Egan KJ, Ready LB, Nessly M, Greer BE. Self- administration of midazolam for postoperative anxiety: A double-blinded study. Pain 1992; 49:3-8.
Fernandez F, Adams F, Holmes VF. Analgesic effect of alprazolam in patients with chronic, organic pain of malignant origin. J Clin Psychopharmacol 1987;7:167-9.
Jann M, Kennedy WK, Lopez G. Benzodiazepines: A major component in unintentional prescription drug overdoses with opioid analgesics. J Pharm Pract 2014; 27:5-16.
Yuan R, Flockhart DA, Balain JD. Pharmacokinetic and pharmacodynamic consequences of metabolism-based drug interactions with alprazolam, midazolam, and triazolam. J Clin Pharmacol 1999; 39:1109-25.
Miotto K, Cho AK, Khalil MA, Blanco K, Sasaki JD, Rawson R. Trends in tramadol: Pharmacology, metabolism, and misuse. Anesth Analg 2017; 124:44-51.
Dziewit JA, Elkassabany NM. Drug-drug intreactions involving local anesthetics: Perfect storm? Fatal forty DDI: omeprol, nicardipine, diltiazem, bupivacaine, CYP3A4, CYP2C19, CYP2D6. In: Marcucci C, Hutchens MP, Wittwer ED, Weingarten TN, Sprung J, Nicholson WT, Lalwani K, Metro DG, Dull RO, Swide CE, Seagull FJ, Kirsch JR, Sandson NB, eds. A case approach to perioperative drug-drug interactions. 1st ed. New York: Springer, 2015:215-8.
Scully C. Perioperative care. In: Scully C, ed. Scully’s Medical problems in dentistry. 7th ed. London: Churchill Livingstone, 2014:51-96.
Malamed SF. Oral, rectal and intramuscular sedation. In: Malamed SF, ed. Sedation: A guide to patient management. 6th ed. Saint Louis: Elsevier/Mosby, 2018:94-163.
Faria J, Barbosa J, Moreira R, Queirós O, Carvalho F, Dinis-Oliveira RJ. Comparative pharmacology and toxicology of tramadol and tapentadol. Eur J Pain 2018; 22:827-44.
Hain E, Maggiori L, Prost À la Denise J, Panis Y. Transversus abdominis plane (tap) block in laparoscopic colorectal surgery improves postoperative pain management: A meta-analysis. Colorectal Dis 2018; 20:279-87.