The Effects of Tramadol and Levobupivacaine Infiltration on Postoperative Analgesia in Functional Endoscopic Sinus Surgery and Septorhinoplasty

Abstract

Objective: The aim of this prospective, randomized, double-blind study was to investigate the postoperative analgesic effects of levobupivacaine or tramadol infiltration administered prior to surgery in septorhinoplasty (SRP) or endoscopic sinus surgery (ESS). Material and Methods: Sixty ASA class I-III adult patients electively undergoing SRP or ESC were included the study. Induction of anesthesia was performed with propofol 2-2.5 mg/kg, rocuronium bromide 0.6 mg/kg and fentanyl 1 μg/kg i.v. Sevoflurane 2% with an N2O/O2 mixture (FiO2: 35%) was used for maintenance. Tramadol 0.5 mg/kg (Group T: n=20), levobupivacaine 0.25% (Group L: n=20) and lidocaine 1% (Group C: n=20) in a 1/200,000 adrenaline solution was infiltrated into the surgical area 10 min before the operation (5 mL for ESS and 10 mL for SRP). All patients received fentanyl (bolus dose: 15 μg and lockout interval: 10 min) with a patient-controlled analgesia device during the postoperative period. Pain was assessed using an 11-point visual analogue scale (VAS) every 4 h for the first 24 h. Analgesic requirements, opioid consumption and side effects in the postoperative period were recorded. Results: There was a statistically significant decrease in postoperative fentanyl demand and consumption in patients receiving tramadol. Fentanyl doses in the 24 h period were 345.2±168.8 μg, 221.1±120.6 μg and 184.1±130.3 μg (p=0.002) for the Groups C, L and T, respectively. There were statistically significant differences in fentanyl requirements between the tramadol and control groups at the 16, 20 and 24 h time points (p=0.012, p=0.004 and p=0.002, respectively). The side effect profiles were similar. Conclusions: Our study indicates that the preemptive tramadol infiltration technique is an efficient, practical and safe alternative to levobupivacaine in ESS or SRP operations. Turkish Başlık: Endoskopik Sinüs Cerrahisi ve Septorinoplastide Tramadol ve Levobupivakain İnfiltrasyonunun Postoperatif Analjezi üzerine Etkileri Anahtar Kelimeler: İnfiltrasyon, levobupivakain, tramadol, postoperatif analjezi, hasta kontrollü analjezi Amaç: Prospektif, randomize ve çilf kör çalışmada septorinoplasti (SRP) ve endoskopik sinus cerrahisi (ESC) ameliyatlarından sonra levobupivakain ve tramadol infiltrasyonunun postoperatif analjezik etkilerinin araştırılması amaçlandı. Gereç ve Yöntemler: Çalışmaya elektif olarak ESC ve SRP operasyonları gerirecek ASA I-III sınıfı altmış erişkin hasta alındı. Anestezi indüksiyonu intravenöz propofol 2-2.5 mg/kg-1, roküronyum bromid 0.6 mg/kg-1, and fentanil 1 μg/kg-1 ile gerçekleştirildi. İdame %2 sevofluran ile N2O/O2 karışımı (FiO2: 35%) ile sağlandı. Operasyondan 10 dakika önce cerrahi sahaya tramadol 0.5 mg/kg-1(Group T: n= 20), levobupivakain %0.25(Group L: n= 20), ve lidokainin %1(Group C: n= 20) adrenaline solüsyonu 1/200000 infiltre edildi (ESC için 5 mL ve SRP için10 mL). Postoperatif dönemde hastaların tümüne hasta kontrollü analjezi cihazı ile fentanil uygulandı (bolus doz: 15 μg ve kilit aralığı:10 dak). Ağrı postoperative ilk 24 saatte 11 dereceli vizüel analog skala (VAS) ile 4 saat ara ile değerlendirildi. Postoperatif dönemde analjezik gereksinim, opioid tüketimi ve yan etkiler belirlenerek kaydedildi. Bulgular: Tramadol verilen grubun fentanil gereksinim ve tüketimi istatistiksel açıdan farklı bulundu. 24 saatlik fentanyl dozları Grup C, L ve T için sırası ile 345.2 ± 168.8,6 μg, 221.1 ± 120.6 μg; and 184.1 ± 130,3 μg (p= 0.002) olarak belirlendi. Tramadol ve kontrol grubunun fentanil gereksinimlerinde 16, 20 ve 24. saat peryotlarda (p= 0.012, p= 0.004. ve p= 0.002) farklılık saptandı. Yan etki profili benzerdi. Sonuç: Bulgularımız ESC ve SRP operasyonlarından önce preemptif tramadol infiltrasyonunun levobupivakainin etkili, pratik ve güvenli bir alternatifi olduğunu düşündürmektedir.

Keywords

• Infiltration, levobupivacaine, tramadol, postoperative analgesia, patient-controlled analgesia

The Effects of Tramadol and Levobupivacaine Infiltration on Postoperative Analgesia in Functional Endoscopic Sinus Surgery and Septorhinoplasty

Öz

References

1. Vadivelu N, Mitra S, Narayan D. Recent advances in postopera- tive pain management. Yale J Biol Med 2010;83:11-25.
2. Pyati S, Gan TJ. Perioperative pain management. CNS Drugs 2007;21:185-211. [CrossRef]
3. Ground S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet 2004;43:879-923. [CrossRef]
4. Raffa RB, Nayak RK, Liao S, Minn FL. The mechanisms of action and pharmocokinetics of tramadol hydrochloride. Rev Contemp Pharmacother 1995;6:485-97.
5. Scott LJ, Perry CM. Tramadol: a review of its use in perioperative pain. Drugs 2000;60:139-76. [CrossRef]
6. Altunkaya H, Ozer Y, Kargi E, Babuccu O. Comparison of local anaesthetic effects of tramadol with prilocaine for minor surgical procedures. Br J Anaesth 2003;90:320-2. [CrossRef]
7. Altunkaya H, Ozer Y, Kargi E, Ozkocak I, Hosnuter M, Demirel CB, Babuccu O. The postoperative analgesic effects of trama- dol when used as subcutaneous local anesthetic. Anesth Analg 2004;99:1461-4. [CrossRef]
8. Atef A, Fawaz AA. Peritonsillar infiltration with tramadol im- proves pediatric tonsillectomy pain. Eur Arch Otorhinolaryngol 2008;265:571-4. [CrossRef]

9. Ugur MB, Yilmaz M, Altunkaya H, Cinar F, Ozer Y, Beder L. Effects of intramuscular and peritonsillar injection of tramadol before ton- sillectomy: a double blind, randomized, placebo-controlled clinical trial. Int J Pediatr Otorhinolaryngol 2008;72:241-8. [CrossRef]
10. Akkaya T, Bedirli N, Ceylan T, Matkap E, Gülen G, Elverici O, et al. Comparison of intravenous and peritonsillar infiltration of tramadol for postoperative pain relief in children following ad- enotonsillectomy. Eur J Anaesth 2009;26:333-8. [CrossRef]
11. Huang Y, Pryor M, Mather L, Veering B. Cardiovascular and cen- tral nervous system effects of intravenous levobupivacaine and bupivacaine in sheep. Anesth Analg 1998;86:797-804. [CrossRef]
12. Bardsley H, Gristwood R, Baker H, Watson N, Nimmo W. A com- parison of the cardiovascular effects of levobupivacaine and rac- bupivacaine following intravenous administration to healthy vol- unteers. Br J Clin Pharmacol 1998;46:245-9. [CrossRef]
13. Demiraran Y, Ozturk O, Guclu E, Iskender A, Ergin MH, Tokmak A. Vasoconstriction and analgesic efficacy of locally infiltrated levobupi- vacaine for nasal surgery. Anesth Analg 2008;106:1008-11. [CrossRef]
14. Huizing EH. Functional surgery in inflammation of the nose and paranasal sinuses. Rhinol Suppl 1988;5:5-15.
15. Friedman M, Venkatesan TK, Lang D, Caldarelli DD. Bupivacaine for postoperative analgesia following endoscopic sinus surgery. Laryngoscope 1996;106:1382-5. [CrossRef]
16. Leykin Y, Casati A, Rapotec A, Dal Sasso M, Barzan L, Fanelli G, et al. A prospective, randomized, double-blind comparison be- tween parecoxib and ketorolac for early postoperative analgesia following nasal surgery. Minerva Anestesiol 2008;74:475-9.
17. Church CA, Stewart C, O-Lee TJ, Wallace D. Rofecoxib versus hy- drocodone/acetaminophen for postoperative analgesia in functional endoscopic sinus surgery. Laryngoscope 2006;116:602-6. [CrossRef]
18. Buccellati C, Sala A, Ballerio R, Bianchib M. Tramadol anti-in- flammatory activity is not related to a direct inhibitory action on prostaglandin endoperoxide synthases. Eur J Pain 2000;4:413-5. [CrossRef]
19. Bianchi M, Martucci C, Ferrario P, Franchi S, Sacerdote P. Increased tumor necrosis factor-α and prostaglandin E2 concentrations in the cerebrospinal fluid of rats with inflammatory hyperalgesia. The ef- fects of analgesic drugs. Anesth Analg 2007;104:949-54. [CrossRef]
20. Foster RH, Markham A. Levobupivacaine: a review of its phar- macology and use as a local anaesthetic. Drugs 2000;59:551-79. [CrossRef]
21. McLeod OA, Burke D. Review Article: Levobupivacaine. Anaes- thesia 2001;56:331-41. [CrossRef]
22. Power I, Barratt S. Analgesic agents for the postoperative period: nonopioids. Surg Clin North Am 1999;79:275-95. [CrossRef]