Laparoskopik Kolesistektomi Sonrası Ağrı Yönetimi

Abstract

Amaç: Ağrı algısı sadece duyusal bir uyarıcı değil, aynı zamanda motivasyonel durum ve duygu durumu ile yakından ilgilidir ve kültürel öğrenme, geçmiş deneyimler, kaygı ve depresyon ile şekillenir. Çalışmada laparoskopik kolesistektomi için uygulanan postoperatif analjezi protokollerindeki opioid tüketimini azaltabilecek yardımcı ajanları belirlemek amaçlanmıştır. Gereç ve Yöntemler: Nonsteroidal antienflamatuar bir ilaç olan Dexketoprofen ve zayıf bir opioid olan Tramadol’u içeren standart bir postoperatif yatan hasta ağrı yönetimi protokolü alan hastalarımız içinde bir anksiyolitik olan Alprazolam'ın preoperatif uygulanmasının n=12 opioid ihtiyacı üzerine etkisi istatistiksel analizlerle incelendi . Kontrol grubu n=81 , sadece standart protokole bağlı kalanları içermekteydi. Lokal anestezik Bupivakainʼin adjuvan kullanımı, kesi yerine infiltrasyonu n=23 ile opioid ihtiyacı arasındaki ilişki ayrıca analiz edildi.Bulgular: Ameliyat öncesi Alprazolam verilen ve kesi yerlerine Bupivakain Hidroklorür enjeksiyonu yapılan grupların ilk 24 saatlik opioid gereksinimi kontrol grubuna göre anlamlı derecede düşüktü sırasıyla p=0,019 ve p=0,033 . Toplam opioid tüketimi, sadece lokal anestezi grubunda kontrol grubuna göre anlamlı derecede düşüktü p=0,045 . Alprazolam grubunda, kontrol grubuna göre ilk 24 saatten sonra opioid talep etme riskinin önemli ölçüde arttığı gözlendi. Odds ratio 4,0 %95 Cl, 1,00 ila 15,99; p=0,038 idi.Sonuç: Bupivakain, Alprazolam ve Tramadol, P450 sisteminin aynı alt birimi ile metabolize edilir; CYP3A4 enzimi. Bu nedenle, bu ilaçların eliminasyonu sırasında enzim için yarışma gerçekleşip vücutta bu duruma bağlı ilaç toksisiteleri gelişebilir. Öyle ki, çalışmada preoperatif Alprazolam alan hastalarda ameliyat sonrası ilk günden sonra Tramadol HCl için artmış ilaç arama davranışı gözlemlenmiştir. Bu durum opioid toksisitesi riski için anlamlı bir ipucu olarak değerlendirilebilir

Keywords

• Laparoskopik kolesistektomi, Ağrı, Analjezi

Pain Management After Laparoscopic Cholecystectomy

Abstract

Objective: The perception of pain is not only a sensorial stimulus, but it is closely related with motivational state and affect and it is shaped with cultural learning, past experiences, anxiety and depression. Common postoperative analgesia protocols for laparoscopic cholecystectomy are scrutinized to identify adjunctive agents reducing weak opioid consumption.Material and Methods: Preoperative administration of an anxiolytic, Alprazolam n=12 , was analyzed among patients who received a standardized postoperative inpatient pain management protocol including a nonsteroidal anti-inflammatory drug, Dexketoprofen, and a weak opioid, Tramadol. The control group n=81 included those who adhered to the standardized protocol only. Adjunctive use of the local anesthetic Bupivacaine, by means of wound infiltration n=23 was analyzed separately to compare the analgesic outcome.Results: The first 24-hour weak opioid requirement was significantly lower in the Bupivacaine Hydrochloride wound infiltration group and Alprazolam groups when compared with the control group p=0.019 and p=0.033, respectively . Total weak opioid consumption was significantly lower in the only local anesthesia group when compared with the control group p=0.045 . Alprazolam group had a significantly higher risk of demanding weak opioids with respect to the control group after the first 24 hours. Odds ratio was 4.0 95% Cl, 1.00 to 15.99; p=0.038 . Conclusion: Bupivacaine, Alprazolam and Tramadol are metabolized by the same subunit of the P450 system, the CYP3A4 enzyme. Thus, their elimination is subject to possible competition and related toxicity. So much so that after the first postoperative day, increased drug seeking behavior for Tramadol HCl was observed with preoperative alprazolam in the study. This can be considered as a significant clue for the risk of opioid toxicity

Keywords

• Laparoscopic cholecystectomy, Pain, Analgesia

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