Perihan EKMEKÇİ, Ali Abbas YILMAZ, Enver ÖZGENCİL, Menekşe HASDOĞAN, Özay AKAN, Feyhan ÖKTEN

Total diz artroplastisi yapılan hastalarda postoperatif ağrı tedavisi amacı ile femoral sinir bloğunda sürekli infüzyon yöntemi ile ropivakaine adjuvan tramadol etkisi

Amaç: Total diz artroplastisi sonrası ağrı tedavisinde periferik sinir blokları kolay, maliyeti ve komplikasyon oranı düşük yöntemler olup yüksek hasta memnuniyeti, erken mobilizasyon ve taburculuk gibi avantajlara sahiptir. Periferik sinir bloklarında lokal anestezik ajanların etkinliğini arttırmak için farklı kombinasyonlar uygulanmaktadır. Bu çalışmada, total diz artroplastisi yapılan hastalarda preemptif "3-in-1" femoral blokta, sürekli infüzyon yöntemiyle ropivakaine tramadol ilavesinin etkisi araştırıldı. Yöntem: Total diz artroplastisi planlanan 60 hasta çalışmaya dahil edildi. Cerrahi öncesi, tüm hastalara periferik sinir stimülatörü kullanılarak % 0,5 ropivakain 0,3 mL kg-1 uygulandı. Hastalar üç gruba ayrıldı ve tüm hastalara genel anestezi uygulandı. Grup I’de cerrahi bitiminde hasta kontrollü analjezi (HKA) yöntemiyle 48 saat boyunca % 0,2 ropivakain 0,1 mL kg-1st -1 uygulandı. Grup II’de % 0,2 ropivakaine 1 mg mL-1 tramadol, Grup III’de % 0,2 ropivakaine 2 mg mL-1 tramadol eklendi. Cerrahi bitiminde VAS, motor blok ve yan etkiler değerlendirildikten sonra HKA başlandı. VAS>40 olan hastalara ek analjezik olarak diklofenak sodyum 75 mg intramusküler uygulandı. Postoperatif 0., 2., 4., 6., 12., 24 ve 48. saatlerde istirahat VAS değerleri, ek analjezik ihtiyacı, kan basıncı, kalp hızı ve yan etkiler kaydedildi. Bulgular: Her üç grupta da 48 saatlik VAS

The effect of tramadol adjunct to ropivacaine in continuous femoral nerve block in patients undergoing total knee arthroplasty for postoperative pain treatment

Objective: The use of peripheral nerve blockade following total knee arthroplasty is a simple and effective method with lesser cost and complications. Besides, this method causes good patient satisfaction, early mobilization and a short period of hospitalization. In the present study we evaluated the effectiveness of tramadol added to ropivacaine during preemptive femoral blockade in patients under going total knee arthroplasty. Method: Sixty patients undergoing total knee arthroplasty were included to the study. In all groups general anesthesia was performed and before the surgery femoral blockade with ropivacaine 0.5 % (0.3 mL kg-1 ) was done. In group I, ropivacaine 0.2 % was infused at a rate of 0.1 mL kg-1 hr-1 for 48 hours. In group II tramadol 1 mg mL-1 and in group III 2 mg mL-1 was added to ropivacaine infusion. At the end of surgery VAS, motor blockade and side effects were evaluated and PCA was done as continous infusion. As additional analgesic, intramuscular diclofenac 75 mg was done in patients with VAS values >40. VAS values, additional analgesic consumptions, blood pressures, heart rates and side effects were recorded at the postoperative 0, 2, 4, 6, 12, 24 and 48th hours. Results: VAS scores for 48 hours were <40 in three groups and was lower in Group III than in Group I and II although it was not statistically significant. Addition of tramadol did not lower additional analgesic requirement but increased analgesia time and quality. The incidence of side effects was higher in Group III (p<0.05). Conclusion: The effect of adding tramadol as an adjuvant to local anesthetics in "3-in-1" femoral block in postoperative anal- gesia was investigated and it was found that although not statistically significant, it increased the duration and quality of analge- sia. However, postoperative additional analgesic requirement was higher in group II and incidence of side effects was higher in group III and this lowers the beneficial effect of adding tramadol to local anesthetics in lower extremity blocks and limits its usage.

PDF

___

1. Bonica J. Postoperative pain. In: Bonica J. The management of pain 2nd ed. Philadelphia: Lea & Febiger, 1990: 461-80.
2. Ferrante FM, Orav EJ, Rocco AG, Gallo J. A statistical model for pain in patient-controlled analgesia and conventional intramuscular opioid regimens. Anesth Analg 1988; 67: 457-61.
3. Baker MW, Tullos HS, Bryan WJ, Oxspring H. The use of epidural morphine in patients undergoing total knee arthroplasty. J Arthroplasty 1989; 4: 157-61.
4. Ilahi OA, Davidson JP, Tullos HS. Continuous epidural analgesia using fentanyl and bupivacaine after total knee artroplasty. Clin Orthop 1994; 299: 44-52.
5. Schultz P, Anker-Moller E, Dahl JB, et al. Postoperative pain treatment after open knee surgery: continuous lumbar plexus block with bupivacaine versus epidural morphine. Reg Anesth 1991; 16: 34-7.
6. Edwards ND, Wright EM. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg 1992; 75: 265-7.
7. Nielsen KC, Klein SM, Steele SM. Techniques in Regional Anesthesia & Pain Management 2003; 1(7): 1-18.
8. Capdevila X, Barthelet Y, Biboulet P, et al. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91: 8-15.
9. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the "3-in-1 block". Anesth Analg 1973; 52: 989-96.
10. Fattorini F, Pascarella MA, Benvenuti SG, et al. Use of ropivaca- ine in axillary plexus block. Clin Ter 1997; 148: 527-30.
11. Bernard JM, Macaire P. Dose-range effects of clonidine added to lidocaine for brachial plexus block. Anesthesiology 1997; 87: 277-84.
12. Martin R, Martin G, Martin D, et al. Effects of CO2 and epinephrine on lidocaine 1 % in axillary block. Ann Fr Anesth Reanim 1997; 16: 479-82.
13. Bazin JE, Massoni C, Bruelle P, et al. The addition of opioids to local anaesthetics in brachial plexus block: the comparative effects of morphine, buprenorphine and sufentanil. Anesthesia 1997; 52: 858-62.
14. Dayer P, Collart L, Desmeules J. The pharmacology of tramadol. Drugs 1994; 47: 3-7.
15. Lehmann KA. Tramadol in acute pain. Drugs 1997; 53: 25-33.
16. Besson JM. The place of tramadol in the therapy of pain. Drugs 1997; 53: 65-6.
17. Kehlet H. Surgical stress: the role of pain and analgesia. Br J Anaesth 1989; 85: 189-95.
18. Singeleyn FJ, Deyaert M, Jorist D, et al. Effects of intavenous patient–controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88-92.
19. Kaya K, Doral MN, Mahli A, Karadenizli Y. Alt ekstremite ameliyatlarında iskiadik ve femoral sinir bloklarının kombinasyonu. Türk Anesteziyoloji ve Reanimasyon Cemiyeti Mecmuası 1989; 17: 297-300.
20. Allen HW, Liu SS, Ware PD, et al. Peripheral nevre blocks improve analgesia after total knee replacement surgery. Anesth Analg 1998; 87: 93-7.
21. Elmas C, Elmas Y, Gautschi P, Uehlinger P. Kombinierter ischiadicus 3-in-1 block: Anwendung bei orthopadischen Operationen im Unterschenkelbereich. Anaesthesist 1992; 41: 639-43.
22. Spillane WF. 3-in-1 blocks and continuous 3-in-1 blocks. Reg Anesth 1992; 17: 175-6.
23. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989; 69: 705-13.
24. Seeberger MD, Urwyler A. Paravascular lumbar plexus block: block extension after femoral nerve stimulation and injection of 20 vs. 40 ml mepivacaine 10 mg/ml. Acta Anaesthesiol Scand 1995; 39: 769-73.
25. Singeleyn FJ, Gouverneur JM. Postoperative analgesia after open knee surgery: comparison between continuous 3-in-1 block and continuous epidural analgesia. Anesthesiology 1999; 87: A803.
26. Cuvillon P, Ripart J, Lalaursey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: Bacterial colo- nization, infectious rate and adverse effect. Anesth Analg 2001; 93: 1045-9.
27. Vaghadia H, Chan V, Ganapathy S, et al. A multicentre trial of ropivacaine 7.5 mg/ml vs bupivacaine 5 mg/ml for supra clavicular brachial plexus anesthesia. Can J Anaesth 1999; 46: 946-51.
28. Casati A, Fanelli G, Albertin A, et al. Interscalene brachial plexus anesthesia with either 0.5 % ropivacaine or 0.5 % bupivacaine. Minerva Anestesiol 2000; 66: 39-44.
29. Singeleyn FJ, Vandewalle F, Gouverneur JM. Effect of pre vs postoperative continuous "3-in-1" block (CB) on postoperative pain after elective total hip replacement (THR). Anesthesiology 1993: 79: A900.