Arzu MERCAN, Hatice TÜRE, Levent ELEMAN, M. Murat SAYIN, Selami SÖZÜBİR, Bora AYKAÇ

Çocuklarda kaudal bloğa ek olarak uygulanan intravenöz parasetamolün zamanlamasının postoperatif analjeziye katkısı

Amaç: Bu çalışmada; kaudal bloğa adjuvan olarak, kaudal bloğu takiben 3. ve 4. saatlerde uygulanan intravenöz parasetamolün postoperatif analjezik etkinliğe katkısının karşılaştırılması amaçlanmıştır. Yöntem: ASA I, vücut ağırlığı 33 kg ve üzeri olan, inguinal ve genital cerrahi geçirecek olan 97 hasta rastgele olarak 4 gruba ayrıldı. Tüm hastalara postoperatif analjezi amacı ile kaudal blok uygulandı. Kontrol grubunda (grup K, n=24) kaudal bloğa ek olarak başka bir analjezik uygulanmaz iken; grup P3’de (n=23) kaudal enjeksiyonu takiben 3. saatte; grup P4’de (n=24) 4. saatte 15 mg kg-1 parasetamol ‹V ve grup RP’de (n=26) ise kaudal enjeksiyonu takiben 3. saatte 20 mg kg-1 parasetamol rektal olarak uygulandı. Vizüel analog skala ile ağrı değeri 4 veya daha yüksek olduğunda, ‹V meperidin uygulandı. Postoperatif 10 saat boyunca tüm hastaların ağrı skorları ve ek analjezik gereksinimleri kaydedildi. Bulgular: Demografik veriler ve cerrahi süreler bakımından gruplar arasında fark yokken, analjezik gereksinimi olan hasta sayısı 6. saatte grup K’da diğer üç gruptan, ağrı skorları da 8. ve 10. saatlerde grup K ve P3’de diğer iki gruptan yüksek bulundu. Sonuç: Çocuklarda inguinal ve genital cerrahi sonrası analjezide, kaudal bloğa ek olarak verilen intravenöz parasetamolün 4. saatte uygulanmasının 3. saatte uygulanmasına göre postoperatif analjezi süresini ve kalitesini daha çok arttırdığı kanısına varılmıştır.

Timing intravenous paracetamol application for postoperative analgesia with caudal blockade in children

Objective: The aim of this study was to investigate whether a supplemental dose of intravenous paracetamol at the third or fourth hour would enhance the quality of the analgesia provided by caudal blockade in children. Methods: Ninety seven, ASA I, inguinal and genital surgery patients weighing over 33 kg were randomized into four groups. Patients in group K (n=24) did not receive any analgesia except for caudal blockade. Paracetamol (15 mg kg-1 ) was given intravenously at the third hour of caudal injection to the group P3 (n=23) patients and at the fourth hour of caudal injection to the group P4 (n=24) patients and rectal paracetamol (20 mg kg-1 ) to the group RP (n=26) patients at the third hour of caudal injection. Pain scores and additional analgesic requirements were recorded for 10 hours postoperatively. Results: The groups were comparable with respect to demographic data. A significantly higher number of patients required relief analgesic at the 6th postoperative hour in group K and higher levels of pain scores were recorded in groups K and P3 at the 8th and 10th postoperative hours. Conclusion: Supplemental intravenous paracetamol at the fourth hour of caudal blockade enhances the duration and the quality of postoperative analgesia better than its application at the third hour in children undergoing inguinal and genital surgery.

PDF

___

1. Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioral changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997; 52: 970-6.
2. Ozbek H, Bilen A, Ozcengiz D, Gunes Y, Ozalevli M, Akman H. The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children. Paediatr Anaesth 2002; 12: 610-6.
3. Tsui BC, Berde CB. Caudal analgesia and anaesthesia techniques in children. Curr Opin Anaesthesiol 2005; 18: 283-8.
4. Samuel M, Evans DH, Cunnington P. Prospective to a randomized double-blind controlled trial to assess efficacy of double caudal analgesia in hypospadias repair. J Ped Surg 2002; 37: 168-74.
5. Ozcengiz D, Gunduz M, Ozbek H, Isik G. Comparison of caudal morphine and tramodol for postoperative pain control in children undergoing inguinal herniography. Paediatr Anaesth 2001; 11: 459-64.
6. Ansermino M, Basu R, Vandebeek C, Montgomery C. Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review. Paediatr Anaesth 2003; 13: 561-73.
7. Ozkan S, Pocan S, Bahar A, Cakır O, Gokben M. The effect of caudal bupivacaine versus tramadol in postoperative analgesia for paediatric patients. J Int Med Res 2003; 31: 467-502.
8. Birmingham PK, Tobin MJ, Fisher DM, Henthorn TK, Hall SC, Cote CJ. Initial and subsequent dosing of rectal acetaminophen in children. Anesthesiology 2001; 94: 385-9.
9. Ozyuvaci E, Altan A, Yucel M, Yenmez K. Evaluation of adding preoperative or postoperative rectal paracetamol to caudal bupivacaine for postoperative analgesia in children. Pediatr Anesth 2004; 14: 661-5.
10. Anderson BJ. What we don’t know about paracetamol in children. Paediatr Anaesth 1998; 8: 451-60.
11. Hansen TG, O’Brien K, Morton NS, Rasmussen SN. Plasma paracetamol concentrations and pharmacokinetics following rectal administration in neonates and young infants. Acta Anaesthesiol Scand 1999; 43: 855-9.
12. Lin YC, Susman HH, Benitz WE. Plasma concentrations after rectal administration of acetaminophen in preterm neonates. Paediatr Anaesth 1997; 7: 457-9.
13. Anderson BJ, Holford NH, Woollard GA. Paracetamol kinetics in neonates. Anaesth Intens Care 1997; 25: 721-2.
14. Granry JC, Rod B, Monrigal JP, et al. The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopedic surgery. Paediatr Anaesth 1997; 7: 445-9.
15. Murat I, Baujard C, Foussat C, Guyot E, Petel H, Rod B, Ricard C. Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair. Pediatr Anesth 2005; 15: 663-70.
16. Granry JC, Rod B, Boccard E, et al. Pharmacokinetics and antipyretic effects of an injectable pro-drug of paracetamol (proparacetamol) in children. Paediatr Aaesth 1992; 2: 291-5.
17. Akbaş M. Çocuklarda postoperatif rejyonel analjezi yöntemleri. Türkiye Klinikleri J Anest Reanim 2007; 5: 31-8.
18. European Commission Enterprise Directorate-Genereal. Better Medicines for children: proposed regulatory actions on pediatric medicinal products. Consultation Document. Int J Pharm Med 2002; 16: 25-9.
19. Levy G. Pharmacokinetic analysis and analgesic effect of a single dose of acetaminophen in humans. J Pharmaceut Sci 1987; 76: 88-9.
20. Hahn TW, Henneberg SW, Holm-Knudsen RJ, Eriksen K, Rasmussen SN, Rasmussen M. Pharmacokinetics of rectal paracetamol after repeated dosing in children. Br J Anaesth 2000; 85: 512-9.
21. Montgomery CJ, McCormack JP, Reichert CC, Marsland CP. Plasma concentrations after high-dose (45 mg.kg-1) rectal acetaminophen in children. Can J Anaesth 1995; 42: 982-6.
22. Hahn TW, Mogensen T, Lund C, Schouenborg L, Rasmussen M. High dose rectal and oral acetaminophen in postoperative patients-serum saliva concentrations. Acta Anaesthesiol Scand 2000; 44: 302-6.
23. Birmingham PK, Tobin MJ, Henthorn TK, et al. Twenty-four hour pharmacokinetics of rectal acetaminophen in children. An old drug with new recommendations. Anesthesiology 1997; 87: 244-52.
24. Anderson BJ, Woolard GA, Holford NH. Pharmacokinetics of rectal paracetamol after major surgery in children. Paediatr Anaesth 1995; 5: 237-2.
25. Gazzard BG, Ford-Hutchinson AW, Smith MJ, Williams R. The binding of paracetamol to plasma proteins of man and pig. J Pharm Pharmacol 1973; 25: 964-7.
26. Anderson BJ, Holford NH, Woollard GA et al. Perioperative pharmacodynamics of acetaminophen analgesia in children. Anesthesiology 1999; 90: 411-21.
27. Mercan A, Sayın M, Saydam S, Ozmert S, Tiryaki T. When to add rectal paracetamol for postoperative analgesia with caudal bupivacaine in children? A prospective, double-blind, randomized study. Pediatr Anesth Early Online Issue (baskıda).
28. Allegaert K, Van der Marel CD, Debeer A et al. Pharmacokinetics of single dose intravenous proparacetamol in neonates: effect of gestational age. Arch Dis Child Fetal Neonatol Ed 2004; 89: F25-8.
29. Autret E, Dutertre JP, Breteau M, Jonville AP, Furet Y, Laugier J.et al. Pharmacokinetics of paracetamol in the neonate and infant after administration of proparacetamol chlorhydrate. Dev Pharmacol Ther 1993; 20: 129-34.
30. Depre M, van Hecken A, Verbesselt R, Tjandra-Maga TB, Gerin M, de Schepper PJ. Tolerance and pharmacokinetics proparacetamol, a paracetamol formulation for intravenous use. Fundam Clin Pharmacol 1992; 6: 259-62.
31. Allegaert K, Anderson BJ, Naulaers G et al. Intravenous paracetamol (proparacetamol) pharmacokinetics in term and preterm infants. Eur J Clin Pharmacol 2004; 60: 191-7.
32. Anderson BJ, Pons G, Autret E, Allegaert K, Boccard E. Pediatric intravenous paracetamol (proparacetamol) pharmacokinetics: a population analysis. Pediatr Anesth 2005; 15: 282-92.
33. Anderson BJ, Woolard GA, Holford NH. Acetaminophen analgesia in children: placebo effect and pain resolution after tonsillectomy. Eur J Clin Pharmacol 2001; 57: 559-69.