Hakan EMİRKADI, Hüseyin ŞEN, GÜNER DAĞLI, BULAT AYTEK ŞIK, Yaşam Kemal AKPAK

Jinekolojik cerrahide postoperatif uygulanan intravenöz tramadolün ve tramadole deksmedetomidin ilavesinin analjezi ve hemodinamik parametreler üzerine etkileri: Prospektif (çift kör) randomize kontrollü çalışma

Amaç: Bu çalışmada Pfannenstiel kesisi yapılan jinekolojik prosedürlerde postoperatif ağrı tedavisinde intravenöz tramadol ile intravenöz tramadole ilave deksmedetomidinin analjezi ve hemodinamik parametreler üzerine etkilerinin karşılaştırılması amaçlanmıştır. Yöntemler: Genel anestezi altında elektif Pfannenstiel kesisi uygulanarak jinekolojik operasyon planlanan ASA I-II grubuna dahil 60 hasta randomize olarak iki gruba ayrıldı (Grup C (Tramadol grubu) ve Grup D Tramadol + Deksmedetomidin). Operasyon sonrası derlenme odasına alınan her iki gruptaki hastalara ameliyat sonrası 24 saat boyunca hasta kontrollu analjezi (HKA) uygulandı (Grup C için 20 dk kilitli kalma süresi ile 20 mg tramadol bolus doz, Grup D için ilk 4 saat 20 mg tramadol+10mcg deksmedetomidin bolus doz, daha sonra 20 mg tramadol bolus doz). Postoperatif değerlendirmede, sözel ağrı skoru, sedasyon skoru, bulantı ve kusma skoru, tramadol kullanımı ile hemodinamik parametreler ve hasta memnuniyeti kaydedildi. Bulgular: Postoperatif ağrı skorları Grup D'de, Grup C'ye göre anlamlı olarak düşüktü ve hasta kontrollü analjezi tramadol kullanımı Grup D'de anlamlı olarak azaldı. Toplam PCA tramadol kullanımı Grup D'de Grup C ile karşılaştırıldığında % 27 azaldı (p=0,001). Ağrı tedavisi ile hasta memnuniyeti Grup D'de Grup C'ye göre anlamlı olarak yükseldi (p=0,001). Grup D'de 1, 2 ve 4 saatte sedasyon skorlarında anlamlı bir artış gözlendi. Kalp hızı, Grup D'de postoperatif 1, 2 ve 4 saatte daha düşüktü (sırası ile p=0,001, p=0,001 and p=0,01, respectively). Bulantı ve kusma skoru Grup D'de daha düşüktü (hepsi için p<0,05). Sonuç: Deksmedetomidinin PCA yöntemiyle tramadole eklenmesi, tramadol tüketimini önemli ölçüde azaltmakta ve jinekolojik operasyonlarda analjezi düzeyini ve hasta memnuniyetini artırmaktadır.

Anahtar Kelimeler:

Deksmedetomidin, jinekolojik ameliyatlar, hasta kontrollü analjezi, postoperative ağrı, tramadol

Effects of postoperative intravenous infusion of tramadol and addition of dexmedetomidine to tramadol on analgesia and hemodynamic parameters in gynecologic surgery: A prospective (double blind) randomised controlled trial

Aim: We designed this double-blind study to test and compare the effects of intravenous tramadol and intravenous tramadol plus dexmedetomidine on analgesia and hemodynamic parameters for treatment of postoperative pain in gynecologic surgeries with Pfannenstiel incision. Methods: Sixty patients undergoing total abdominal hysterectomy with Pfannenstiel incision under general anesthesia were randomly allocated into two groups. Group C (Tramadol) and Group D (Tramadol + Dexmedetomidin). The anesthetic technique was standardized. Postoperatively, the patients in both groups received patient controlled analgesia during 24 hours after surgery (tramadol 20 mg bolus for Group C, tramadol 20 mg+dexmedetomidine 10 mg first four hours, then tramadol 20 mg for Group D with a lock-out time of 15 minutes). Postoperative assessment included verbal pain score, sedation score, nausea and vomiting score, consumption of tramadol, hemodynamic parameters and patient’s satisfaction. Results: Postoperative pain scores were significantly lower in Group D compared with Group C and patient-controlled analgesia tramadol use was significantly reduced in Group D. Total PCA tramadol use was decreased by 27% in Group D compared with Group C (p=0.001). Patient satisfaction with pain treatment was significantly improved in Group D compared with Group C (p=0.001). A significant increase in sedation scores at the 1st, 2nd and 4th hours were observed in Group D. Heart rate was lower in Group D at the 1st, 2nd and 4th hours postoperatively (p=0.001, p=0.001 and p=0.01, respectively). Nausea and vomiting score was lower in Group D (p<0.05 for all). Conclusion: The addition of dexmedetomidine to tramadol by patient controlled analgesia method significantly reduces tramadol consumption and increases analgesia level and patient satisfaction in gynecological operations.

Keywords:

Dexmedetomidine, gynecological operations, patient controlled analgesia, postoperative pain, tramadol,

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1. Saygı Aİ, Özdamar Ö, Gün İ, Emirkadı H, Müngen E, Akpak YK. Comparison of maternal and fetal outcomes among patients undergoing cesarean section under general andspinal anesthesia: a randomized clinical trial. Sao Paulo Med J. 2015;133:227-34.
2. Schnabel A, Meyer-Frießem CH, Reichl SU, Zahn PK, Pogatzki-Zahn EM. Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials. Pain. 2013;154:1140-9.
3. Cruickshank M, Henderson L, MacLennan G, Fraser C, Campbell M, Blackwood B, et al. Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review. Health Technol Assess. 2016; 20:v-xx, 1-117.
4. Falzone E1, Hoffmann C, Keita H. Postoperative analgesia in elderly patients. Drugs Aging. 2013;30:81-90.
5. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000;93:382-94.
6. Fairbanks CA, Kitto KF, Nguyen HO, Stone LS, Wilcox GL. Clonidine and dexmedetomidine produce antinociceptive synergy in mouse spinal cord. Anesthesiology. 2009;110:638-47.
7. Gil DW, Cheevers CV, Kedzie KM, Kedzie KM, Manlapaz CA, Rao S, et al. Alpha-1-adrenergic receptor agonist activity of clinical alpha-adrenergic receptor agonists interferes with alpha-2-mediated analgesia. Anesthesiology. 2009;110:401-17.
8. Grosu I, Lavand'homme P. Use of dexmedetomidine for pain control. F1000 Med Rep. 2010;2:90.
9. Blaudszun G, Lysakowski C, Elia N, Tramer MR. Effect of perioperative systemic alpha2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116:1312-22.
10. Nelson S, Muzyk AJ, Bucklin MH, Brudney S, Gagliardi JP. Defining the Role of Dexmedetomidine in the Prevention of Delirium in the Intensive Care Unit.Biomed Res Int. 2015;2015:635737.
11. Peng K, Jin XH, Liu SL, Ji FH. Effect of Intraoperative Dexmedetomidine on Post-Craniotomy Pain. Clin Ther. 2015;37:1114-21.
12. Zhang X, Wang R, Lu J, Jin W, Qian Y, Huang P, et al. Effects of different doses of dexmedetomidine on heart rate and blood pressure in intensive care unit patients. Exp Ther Med. 2016;11:360-6.
13. Ickeringill M, Shehabi Y, Adamson H, Ruettimann U. Dexmedetomidine infusion without loading dose in surgical patients requiring mechanical ventilation: hemodynamic effects and efficacy. Anaesth Intensive Care 2004;32:741-5.
14. Wang G, Zhang L, Lou S, Chen Y, Cao Y, Wang R, et al. Effect of Dexmedetomidine in Preventing Postoperative Side Effects for Laparoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials and Trial Sequential Analysis (PRISMA). Medicine (Baltimore). 2016;95:e2927.
15. Cormack JR, Orme RM, Costello TG, The role of alpha–2-agonists in neurosurgery. J Clin Neurosci. 2005;12:375-8.
16. Cortinez LI, Hsu YW, Sum-Ping ST, Young C, Keifer JC, Macleod D. Dexmedetomidine pharmacodynamics: Part II: Crossover comparison of the analgesic effect of dexmedetomidine and remifentanil in healthy volunteers. Anesthesiology. 2004;101:1077-83.
17. Massad IM, Mohsen WA, Basha AS, Al-Zaben KR, Al-Mustafa MM, Alghanem SM. A balanced anesthesia with dexmedetomidine decreases postoperative nausea and vomiting after laparoscopic surgery. Saudi Med J. 2009;30:1537-41.
18. Al-Zaben KR, Qudaisat IY, Al-Ghanem SM, Massad IM, Al-Mustafa MM, Al-Oweidi AS, et al. Intraoperative administration of dexmedetomidine reduces the analgesic requirements for children undergoing hypospadius surgery. Eur J Anaesthesiol. 2010;27:247-52.
19. Gandhi KA, Panda NB, Vellaichamy A, Mathew PJ, Sahni N, Batra YK. Intraoperative and Postoperative Administration of Dexmedetomidine Reduces Anesthetic and PostoperativeAnalgesic Requirements in Patients Undergoing Cervical Spine Surgeries. J Neurosurg Anesthesiol. 2016 Mar 31. [Epub ahead of print]
20. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg. 2000;90:699-705.
21. Hall JE, Uhrich TD, Ebert TJ. Sedative, analgesic and cognitive effects of clonidine infusions in humans. Br J Anaesth. 2001;86:5-11.
22. Arain SR, Ruehlow RM, Uhrich TD, Ebert TJ. The efficacy of dexmedetomidine versus morphine for postoperative analgesia after major ınpatient surgery. Anesth Analg. 2004;98:153-8.
23. Lin TF, Yeh YC, Lin FS, Wang YP, Lin CJ, Sun WZ, et al. Effect of combining dexmedetomidine and morphine for intravenous patient-controlled analgesia. Br J Anaesth. 2009;102:117-22.
24. Unlugenc H, Gunduz M, Guler T, Yagmur O, Isik G. The effect of pre-anaesthetic administration of intravenous dexmedetomidine on postoperative pain in patients receiving patient-controlled morphine. Eur J Anaesthesiol. 2005;22:386-91.
25. Venn RM, Bradshaw CJ, Spencer R, Brealey D, Caudwell E, Naughton C. Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit, Anaesthesia. 1999;54:1136-42.
26. De Kock MF, Pichon G, Scholtes JL. Intraoperative clonidine enhances postoperative morphine patient-controlled analgesia. Can J Anaesth. 1992;39:537-44.
27. Arain SR, Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesth Analg. 2002;95:461-6.
28. Whittington RA, Virág L. Dexmedetomidine-induced decreases in accumbal dopamine in the rat are partly mediated via the locus ceruleus. Anesth Analg. 2006;102:448-55.
29. Abdelmageed WM, Elquesny KM, Shabana RI, Abushama HM, Nassar AM. Analgesic properties of a dexmedetomidine infusion after uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Saudi J Anaesth. 2011; 5: 150-6.
30. Goksu S, Arik H, Demiryurek S, Mumbuc S, Oner U, Demiryurek AT. Effects of dexmedetomidine infusion in patients undergoing functional endoscopic sinus surgery under local anaesthesia. Eur J Anaesthesiol. 2008;25:22-8.