Laparoskopik Kolesistektomide Port Sahasına %0.25 Bupivakain İnfiltrasyonuna Adjuvan Olarak Eklenen Deksmedetomidinin Postoperatif Analjezi Kalitesi ve Süresine Etkisi

Amaç: Laparoskopik kolesistektomi (LK), teknik açıdan, ASA III hastaların bile dışlanmadığı günü- birlik bir işlem haline gelmiştir. Ağrı, beklenmedik gece hastanede yatış nedenlerinden biridir. PROSPECT (PROcedure SPECific Postoperative Pain Management) çalışma grubu, NSAİİ’lar ve parasetamol ile port sahası infiltrasyonunu laparoskopik kolesistektomi için tercih edilen analjezi şekli olarak önermektedir. Buradan yola çıkarak, laparoskopik kolesistektomi yapılan hastalarda, port sahasına yara yeri infiltrasyonunda bupivakaine adjuvan olarak eklenen deksmedetomidinin etkinliğini çalıştık. Yöntem: LK planlanan 120 ASA I-II hasta rastgele iki gruba ayrıldı. Grup A’ya 24 mL %0.25 bupi- vakain ve 2 mcg kg -1 deksmedetomidin ile, Grup B’ye 24 mL % 0.25 bupivakain ile yara infiltras- yonu dört laparoskopik port bölgesi için eşit olarak bölünmüş dozda uygulandı. Tüm hastalarda standart bir genel anestezi tekniği kullanıldı. Cilt insizyonundan 30 dk önce parasetamol 1 g iv ile pre-emptif analjezi uygulandı. Tramadol 1 mg kg -1 ve ketorolak 0.5 mg kg -1 iv ile kurtarıcı analjezi sağlandı. Postoperatif ağrı skoru, etkili analjezi süresi, kurtarıcı analjezik ihtiyacı, ile mobilizasyon ve taburculuk zamanları kaydedildi. Bulgular: Deksmedetomidin grubunda, ağrı skoru daha iyi, etkili analjezi süresi daha uzun, kurta- rıcı analjezik gerektiren hasta oranı daha düşük ve mobilizasyon ve taburculuk daha erkendi. Sonuç: 2 μg kg -1 deksmedetomidinin, laparoskopik kolesistektomiyi takiben postoperatif analjezi kalitesi ve süresi açısından port sahası yara infiltrasyonu için etkili bir bupivakain adjuvanı olduğu sonucuna vardık.

Effect of Dexmedetomidine as an Adjuvant to 0.25% Bupivacaine for Local Infiltration of Port Site in Laparoscopic Cholecystectomy in Terms of Quality and Duration of Post-op Analgesia

Objective: Laparoscopic cholecystectomy (LC) technically has evolved as a day case procedureeven to a extent that ASA III patients are also not a exclusion. Pain is one of the cause for unex-pected overnight hospital stay. The recent PROSPECT (PROcedure SPECific Postoperative PainManagement) working Group has recommended port site infiltration along with NSAIDS andparacetamol as the preferred mode of analgesia for laparoscopic cholecystectomy. Hence, westudied about efficacy of dexmedetomidine as an adjuvant for local anesthetic portsite woundinfiltration with bupivacaine in patients undergoing laparoscopic cholecystectomy.Methods: 120 patients of ASA I-II scheduled for LC were randomly allotted to two groups. GroupA received port site wound infiltration with 24 mL of 0.25% bupivacaine and dexmedetomidine 2μg kg -1 while Group B received wound infiltration with 24 mL of 0.25% bupivacaine dividedequally for all the four laparoscopic port sites. A standard general anesthesia technique was usedin all the patients. Pre-emptive analgesia with paracetamol 1 g IV given 30 minutes before skinincision. Tramadol 1 mg kg -1 and ketorolac 0.5 mg kg -1 IV infusion was administered as rescueanalgesic. Postoperative pain score, duration of effective analgesia, need for rescue analgesic,time of ambulation and hospital discharge was recorded.Results: Dexmedetomidine group has better pain score, longer duration of effective analgesia,lower percentage of patients requiring rescue analgesic, and earlier ambulation and hospitaldischarge.Conclusion: We conclude that dexmedetomidine 2 μg kg -1 is an effective adjuvant to bupivacainefor port site wound infiltration in terms of quality and duration of postoperative analgesia follow-ing laparoscopic cholecystectomy.

PDF

___

Barazanchi AWH, MacFater WS, Rahiri JL, Tutone S, Hill AG, Joshi GP; PROSPECT collaboration. Evidence-based management of pain after laparoscopic cholecystec- tomy: a PROSPECT review update. Br J Anaesth. 2018;121:787-803.
Whiteman A, Bajaj S, Hasan M. Novel techniques of local anaesthetic infiltration. Continuing Education in Anaesthesia Critical Care & Pain. 2011;11:167-71. https://doi.org/10.1093/bjaceaccp/mkr026
Peng K, Ji FH, Liu HY, et al. Effects of perioperative dex- medetomidine on postoperative mortality and morbi- dity: A systematic review and meta-analysis. Clin Ther. 2019;41:138-54.
Vorobeichik L, Brull R, Abdallah FW. Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. British Journal of Anaesthesia. 2017;118:167- 81.
Solodkyy A, Hakeem AR, Oswald N, et al. ‘True Day Case’ Laparoscopic cholecystectomy in a high-volume specialist unit and review of factors contributing to unexpected overnight stay. Minim Invasive Surg. 2018;2018:1260358.
Loizides S, Gurusamy KS, Nagendran M, Rossi M, Guerrini GP, Davidson BR. Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2014;3:CD007049.
Swati Singh, Chandrakant Prasad. Post-operative anal- gesic effect of dexmedetomidine administration in wound infiltration for abdominal hysterectomy: A ran- domised control study. Indian J Anaesth. 2017;61:494-8.
Luan H, Zhu P, Zhang X, et al. Effect of dexmedetomidi- ne as an adjuvant to ropivacaine for wound infiltration in patients undergoing open gastrectomy A prospecti- ve randomized controlled trial. Medicine (Baltimore). 2017;96:e7950.
Yu JM, Sun H, Wu C, Dong CS, Lu Y, Zhang Y. The anal- gesic effect of ropivacaine combined with dexmedeto- midine for incision infiltration after laparoscopic cho- lecystectomy. Surg Laparosc Endosc Percutan Tech. 2016;26:449-54. https://doi.org/10.1097/SLE.0000000000000325
Joris J, Thiry E, Paris P, Weerts J, Lamy M. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg. 1995;81:379-84.