Bilgin DALKILINÇ, Ersel GÜLEÇ, Özgür SÜRMELİOĞLU, Yasemin GÜNEŞ, Geylan IŞIK

Çocuklarda Peritonsiller Levobupivakaine Eklenen İntravenöz ve Peritonsiller Deksametazonun Etkilerinin Karşılaştırılması

Amaç: Çalışmamızda, çocuklarda tonsillektomilerde, peritonsiller levobupivakaine eklenen i.v. (intravenöz) deksametazon ve peritonsiller deksametazonun postoperatif ağrı, kanama, bulantı ve kusma üzerine etkisinin değerlendirilmesi amaçlandı. Gereç ve Yöntem: Çalışmaya Çukurova Üniversitesi Tıp Fakültesi Hastanesi Etik Kurul Onayı ve ailelerin yazılı onamı alındıktan sonra, elektif tonsillektomi veya adenotonsillektomi operasyonu yapılması planlanan 3-12 yaş arası ASA (American Society of Anesthesiologist) I- II toplam 60 hasta dahil edildi. Operasyona alınan tüm hastalar randomize olarak 3 gruba ayrıldı. Anestezi indüksiyonu sonrası cerrahi başlamadan önce Grup Ι"de (n=20) olgulara, her bir tonsile % 0,5 levobupivakain 0,4 mg/kg (maximum 4"er ml) ile peritonsiller infiltrasyon yapıldı. Grup II"de levobupivakaine ek olarak (n=20) 0.25 mg/kg i.v. deksametazon, Grup III"deki olgulara ise levobupivakaine ek olarak peritonsiller 4 mg deksametazon uygulandı. Her üç gruba da postoperatif analjezik olarak 1 mg/kg i.v. tramadol uygulandı. Preoperatif ve ilaçların enjeksiyonunu takiben hemodinamik parametreler kaydedildi. Postoperatif dönemde, uyanma odasında 1 saat (erken dönem) ve sonraki 24 saat (geç dönem) veya taburcu olana kadar bulantı ve kusma sıklığı, analjezi düzeyleri, ilk analjeziğe gereksinim zamanı, ağrı düzeyi (VAS;Vizüel Analog Skala ve CHEOPS;Children"s Hospital of Eastern Ontorio Pain Scale) 10, 20, 30 ve 45. dakikalar ile 1, 2, 4, 6 ve 24. saatlerde kaydedildi. Postoperatif erken ve geç dönemde kanama olup olmadığı kaydedildi. Bulgular: Grupların demografik verileri ve hemodinamik parametrelerinin benzer olduğu ve aralarında istatistiksel olarak anlamlı bir fark bulunmadığı belirlendi. Grup I"de bulantı, kusma yüzdesinin daha yüksek olduğu saptandı. Ek analjezik başlama süresi Grup I"de 3,15±0,88 saat, Grup II"de 4,85±1,09 saat ve Grup III"de 5±1,21 saat olup istatistiksel olarak anlamlı bulundu (p

Anahtar Kelimeler:

Deksametazon, Levobupivakain, Peritonsiler tutulum, Postoperatif analjezi, Postoperatif bulantı ve kusma, Kanama

Comparison of the Effects of Intravenous and Peritonsillar Dexamethasone Plus Levopubivacaine in Children

Purpose: We aimed to investigate the effects of intravenous and peritonsillar dexamethasone plus levopubivacaine on postoperative pain, bleeding, nausea and vomiting in children undergoing tonsillectomy or adenotonsillectomy. Methods: After obtaining the approval of Ethics Committee of Çukurova University Medical Faculty Hospital and the patients were given informed consent, 60 patients of ASA (American Society of Anesthesiologist) class I- II between ages 3-12 which were planned to be undergone elective tonsillectomy or adenotonsillectomy were included. All patients were randomised and divided into 3 groups. After anesthesia induction, Group I (n=20) patients received 0.4 mg/kg %0.5 levobupivacaine for each tonsil at the dose of max. 4 ml with peritonsillar infiltration after before tonsillectomy. While Group II (n=20) and Group III (n=20) received levobupivacaine via the same route, Group II received i.v. (intravenous) dexamethasone 0.25 mg/kg and Group III 4 mg dexamethasone with peritonsillar infiltration additionally. All groups were administrated 1mg/kg tramadol iv as postoperative analgesic. Hemodynamic parameters were recorded after drug injections. Frequency of nausea and vomiting and analgesic requirements determined with Visual Analog Scale (VAS) and CHEOPS (Children"s Hospital of Eastern Ontario Pain Scale) at first, 10th, 20th, 30th, 45th minutes and first, 2nd, 4th, 6th and 24th hours were recorded. Postoperative bleeding were recorded at early and late periods. Results: The hemodynamic parameters and demographic data of groups were similar. The insidance of nausea and vomiting was statistically higher in Group I compared to Group II and III. First analgesic administered time was 3.15±0.88 in Group I, 4.85±1.09 in Group II and 5±1.21 in Group III and the difference was found significant. At postoperative period, VAS and CHEOPS scores were lower in group II than the other groups. Bleeding or other complications did not recorded. Conclusion: In concluded that, intravenous and peritonsillary dexamethasone prolonged the first analgesic administered time and decreased pain, nausea and vomiting compared to peritonsillar levobupivacaine alone in children undergoing tonsillectomy or adenotonsillectomy. However, dexamethasone did not increase postoperative bleeding after tonsillectomy.

Keywords:

Dexamethasone, Levobupivacaine, Peritonsillar infiltration, Postoperative analgesy, Postoperative nausea and vomiting, Bleeding,

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McNeill RA., RA . "A History of Tonsillectomy: Two Millenia of Trauma, Hæmorrhage and Controversy". Ulser Medical Journal. 1960; 29: 59–63.
Younis RT, Rande HL. History and Current Practice of Tonsillectomy. Laryngoscope. 2002; 112: 3-5.
Shaikh W, Vayda E, Feldman W. A systematic review of the literature on evaluative studies of tonsillectomy and adenoidectomy. Pediatrics. 1976; 57:401–407.
Johnson LB, Elluru RG, Myer CM, 3rd. Complications of adenotonsillectomy. Laryngoscope. 2002; 112:35-36.
Patel RI, Hannallah RS. Anesthetic complications following pediatric ambulatory surgery: a 3-yr study. Anesthesiology. 1988; 69:1009-12.
Hamid SK, Selby IR, Sikich N, et al. Vomiting after adenotonsillectomy in children: a comparison of ondansetron, dimenhydrinate, and placebo. Anesth Analg. 1998; 86: 496-500.
Anderson BJ, Ralph CJ, Stewart AW, et al. The dose-effect relationship for morphine and vomiting after day-stay tonsillectomy in children.Anaesth Intensive Care. 2000; 28(2):155-60
Splinter WM, Rhine EJ. Low-dose ondansetron with dexamethasone more effectively decreases vomiting after strabismus surgery in children than does highdose ondansetron. Anesthesiology. 1998; 88: 72-5
Broadman LM, Patel RI, Feldman BA, et al. The effects of peritonsillar infiltration on the reduction of intraoperative blood loss and post-tonsillectomy pain in children.Laryngoscope. 1989; 99:578-81.
Campbell JC. Clinical note on the use of a long acting local anesthetic agent in the control of pain following tonsillectomy. J.Laryngol Otol.1953; 67:372-4
Jebeles JA Reilly JS, Gutierrez JF, et al. Tonsillectomy and adenoidectomy pain reduction by local bupivacaine infiltration in children. Int J Pediatric Otorhinolaringology. 1993; 25:149-54.
Schoem SR Watkins GL, Kuhn JJ, et al. Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993; 72:560-3
Sun J, Wu X, Meng Y, et al. Bupivacaine versus normal salin for relief of post-adenotonsillectomy pain in children:a meta-analysis. Int J Pediatr Otorhinolaryngol. 2010; 74:369-73.
April MM, Callan ND, Nowak DM, et al . The effect of intravenous dexamethasone in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg. 1996; 122:117-20.
Ohlms LA, Wilder RT, Weston B. Use of intraoperative corticosteroids in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 1995; 121:737-42.
Lee WC,Sharp JF. Complications of paediatrics tonsillectomy post discharge. J Laryngol Otol. 1996; 110:136-40.
Leone S, Di Cianni S, Casati A, et al.Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed. 2008; 79:92-105.
Kasapoğlu F , Kaya FN, Tüzümen G et al. Comparison of peritonsillar levobupivacaine and bupivacaine infiltration for post-tonsillectomy pain relief in children: Placebo-controlled clinical study. Int J Paediatr Otorhinolaryngol. 2011; 75: 322-326.
Foulkes GD, Robinso JS Jr. Intraoperative dexamethesone irrigation in lumbar micrdiskectomy. Cli Ortop. 1990; 261: 224-28.
Kaygusuz I, Susaman N. The effects of dexamethasone, bupivacaine and topical lidocaine spray on pain after tonsillectomy. Int J Pediatr Otorhinolaryngol. 2003; 67:737-42.
Montazeri K, Okhovat A., Homardand A, et al. Preincisional infiltration of tonsils with dexamethasone dose not reduce posttonsillectomy vomiting and pain in children. Saudi J Anaesth. 2009; 3: 53-56.
Kaan MN, Odabasi O, Gezer E et al. The effect of preoperative dexamethasone on earyl oral intake, vomiting and pain after tonsillectomy. Int J Pediatr Otorhinolaryngol. 2006; 70:73-9
Tzeng JI, Hsing CH, Chu CC, et al. Low dose dexamethasone reduces nause and vomiting after epidural morphine: a comparison of metoclopramide with saline. J Clin Anesth. 2002 ;14:19-23.
Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg. 1996; 83: 913-6.
Rich WM, Apdulhayoğlu G, Disaia PJ. Methylprednisolone as an antiemetic drug during cancer chemotherapy a pilot study. Gynecol Oncol. 1980; 9:193-198.
Harris AL. Cytotoxic-therapy-induced vomiting is mediated via enkephalin pathways. Lancet. 1982; 1:714-6.
Madan R, Bhatia A, Chakithandy S, et al. Prophylactic dexamethasone for postoperative nausea and vomiting in pediatric strabismus surgery: a dose ranging and safety evaluation study. Anesth Analg. 2005; 100:1622-6.
Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011; 10: CD003997.
Doshi J, Damadora M, Gregory S, et al. Posttonsillectomy morbidity statistics: are they underestimated? J Laryngol Otol. 2008;122:374-7.
Güneş Y. Çocuklarda tonsillektomi sonrası görülen bulantı ve kusmada ondansetron, deksametazon ve droperidolün etkinliğinin karşılaştırılması. Çukurova Üniversitesi Tıp Fakültesi Dergisi. 2002; 27:13-19.
Brigger MT, Cuningham MJ, Hardnick CJ. Dexamethasone administration and postoperative bleeding risk in children undergoing tonsillectomy. Otolaryngol Head Neck Surgery. 2010; 136:766-72.
Shakeel M, Trinidade A, Al-Adhami A, et al. Intraoperative dexamethasone and the risk of secondary posttonsillectomy hemorrhage. J Otolaryngol Head Neck Surg. 2010; 39:732-6.
Czarnetzki C, Elia N, Lysakowski C et al. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children:a randomized trial. JAMA. 2010; 300:2621-30.