COMPARISON OF BUPIVACAINE–FENTANYL AND BUPIVACAINE-ALFENTANIL USED INTRATHECALLY IN LAPAROSCOPIC APPENDECTOMY SURGERY

Year 2021, , 414 - 421, 04.08.2021

Mehtap Balcı Fatih Balcı Emre Atay , Erhan Bozkurt , Ayşe Ertekin

https://doi.org/10.18229/kocatepetip.835963

Abstract

OBJECTIVE: Acute appendicitis, which is the most common cause of acute abdominal pain, is an acute inflammation of appendix vermiformis. Spinal anesthesia is one of the most used regional anesthesia technique nowadays, and it is the temporary interruption of nerve conduction by local anesthetic solution injected into the cerebrospinal fluid. In this study we created multimodal analgesia by giving various opioid agent (fentanyl and alfentanil) intrathecally with local anesthetic. The aim of this study is to compare bupivacaine-fentanyl and bupivacaine-alfentanil that are used intrathecally to create motor and sensory block.
MATERIAL AND METHODS: This study was planned as a clinical study using the random sampling method in a tertiary care hospital. 50 voluntary patients who were diagnosed with appendicitis by laboratory tests and clinical diagnosis methods in the general surgery clinic were included in the study. The patients were randomly assigned into two group, Group I (10 mg hyperbaric bupivacaine (2cc) and 25 mcg fentanyl (0.5 cc)) and Group II (10 mg hyperbaric bupivacaine (2 cc) and 250 mcg alfentanil (0.5 cc)). The patients were randomly assigned into two group, Group I and Group II. Before the operation, each patient was informed about the use of the patient-controlled analgesia system and visual pain scale (VPS) for pain scoring. It was compared the postoperative analgesic needs of patients who underwent multimodal spinal anesthesia with different opiates. Sensorial block levels were measured by pinprick test every 2 minutes in the first 10 minutes and every 5 minutes in later periods. It was recorded mean arterial pressure at the beginning of the surgery at 0th minute and at 5-10-30th minutes during the surgery. In addition, mean arterial pressure and heart rate were recorded at 1-2-6-12-24th hours postoperatively.
RESULTS: Postoperative first analgesic requirement time of Group I was found to be late than Group II. Postoperative 6th, 12th and 24th hours visual pain scales were found to be significantly lower in Group I than Group II. But 2nd and 6th hours heart rates were found higher in Group I than Group II.
CONCLUSIONS: It was shown that the duration of analgesia was longer and postoperative first analgesia requirements time were so late in patients who were given bupivacaine–fentanyl than the patients given bupivacaine–alfentanil

Keywords

alfentanil, analgesia, intrathecally fentanyl, visual pain scale

LAPAROSKOPİK APENDEKTOMİ CERRAHİSİNDE İNTRATEKAL OLARAK KULLANILAN BUPİVAKAİN-FENTANİL VE BUPİVAKAİN-ALFENTANİLİN KARŞILAŞTIRILMASI

Abstract

AMAÇ: Akut karın ağrısının en sık nedeni olan akut apandisit, apendiks vermiformisin akut enflamasyonudur. Spinal anestezi günümüzde en çok kullanılan bölgesel anestezi tekniklerinden biri olup, beyin omurilik sıvısına enjekte edilen lokal anestezik solüsyon ile sinir iletiminin geçici olarak kesilmesidir. Bu çalışmada çeşitli opioid ajanların (fentanil ve alfentanil) intratekal olarak lokal anesteziyle verilmesi sonucu multimodal analjezi oluşturuldu. Bu çalışmanın amacı, motor ve duyusal blok oluşturmak için intratekal olarak kullanılan bupivakain-fentanil ve bupivakain-alfentanili karşılaştırmaktır.
GEREÇ VE YÖNTEM: Bu çalışma bir üçüncü basamak sağlık kuruluşunda rastgele örneklem yöntemi ile klinik bir çalışma olarak planlandı. Çalışmaya genel cerrahi kliniğinde laboratuvar testleri ve klinik tanı yöntemleri ile apandisit tanısı almış 50 gönüllü hasta dahil edildi. Hastalar rastgele Grup I (10 mg hiperbarik bupivakain (2cc) ve 25 mcg fentanil (0.5 cc)) ve Grup II (10 mg hiperbarik bupivakain (2 cc) ve 250 mcg alfentanil (0.5 cc)) olmak üzere ikiye ayrıldı. Operasyon öncesinde her hastaya ağrı skorlaması için hasta kontrollü analjezi sistemi ve Görsel Analog Skala (GAS) kullanımı hakkında bilgi verildi. Farklı opiyatlarla multimodal spinal anestezi uygulanan hastaların postoperatif analjezik ihtiyaçları karşılaştırıldı. Duyusal blok seviyeleri ilk 10 dakikada 2 dakikada bir, sonraki dönemlerde 5 dakikada bir iğne testi ile ölçüldü. Ameliyat başlangıcında 0. dakikada ve ameliyat sırasında 5-10-30. dakikalarda ortalama arter basıncı kaydedildi. Ayrıca postoperatif 1-2-6-12-24. saatlerde ortalama arter basıncı ve kalp hızı kaydedildi.
BULGULAR: Grup I'in postoperatif ilk analjezik gereksinim zamanı, Grup II'ye göre gecikti. Postoperatif 6., 12. ve 24. saat GAS ölçekleri Grup I'de Grup II'ye göre anlamlı olarak düşük bulundu. Ancak 2. ve 6. saat kalp hızları Grup I'de Grup II'den daha yüksek bulundu.
SONUÇ: Bupivakain-fentanil verilen hastalarda, bupivakain-alfentanil verilen hastalara göre analjezi süresinin daha uzun olduğu ve ameliyat sonrası ilk analjezi gereksinim süresinin çok geç kaldığı gösterilmiştir.

Keywords

alfentanil, analjezi, görsel analog skala, intratekal fentanil

References

• 1. Fitz RH. Perforating inflammation of the vermiform appendix: with special reference to its earlydiagnosis and treatment. Am J Med Sci. 1886;(92):321-46.
• 2. Brunicardi FC, Andersen DK, Billiar TR (Editor). Schwartz's principles of surgery. In: Chapter 30: The Appendix. 8th edition. New York, NY: McGraw-Hill Companies. 2005;(111) 9-37.
• 3. Jaschinski T,Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol. 2015;15:48.
• 4. Addiss DG, Shaffer N, Foweler BS, Tauxe R. The epidemiology of appendicitis and apendicectomy in the United States. Am J Epidemiology.1990;(132):910–25.
• 5. Seem K. Endoscopic appendectomy. Endoscopy. 1983;(15):59–64.
• 6. Wei HB, Huang JL, Zheng ZH, et al. Laparoscopic versus open appendectomy: a prospective randomized comparison. Surg Endosc. 2010;24(2):266-69.
• 7. Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis. J Am Coll Surg. 2007;205(1):60-5.
• 8. Woodham BL, Cox MR, Eslick GD. Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis. Surg Endosc. 2012;26(9):2566-70.
• 9. Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012;99(11):1470-78.
• 10. Collins JV (Editor). Spinal anesthesia principles of anesthesiology. 3rd edition. Philadelphia: Lea and Febiger. 1993;(54):1445-93.
• 11. Erdine S (Editör). Rejyonel anestezi. İstanbul:Nobel Tıp Kitabevleri, 2005;159.
• 12. Tuckley JM. The pharmacology of local anaesthetic agents. Update in Anaesthesia 1994; e-library-03 Basic science: Pharmacology:1-6.
• 13. Quinones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15(2):167-84.
• 14. Miller RD (Editor). Anaesthesia. 5th edition, New York, NY: Churcill Livingstone. 2000;(1):273-77.
• 15. Kitahata LM, Collins JG. Spinal action of narcotic analgesics. Anesthesiology.1981;54(2):153-63.
• 16. Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, VolpinetG. Mini dose bupivacaine fentanyl spinal anesthesia for surgical repair of hip fracture in the aged. Anesthesiology. 2000;92(1):6–10.
• 17. Butterworth J. Physiology of spinal anesthesia: what are the implications for management? Reg Anesth Pain Med. 1998;23(4):370-373; discussion 384-87.
• 18. Seewal R, Shende D, Kashvap L, Mohan V. Effect of addition of various doses of fentanyl intrathecally to 0.5% hyperbaric bupivacaine on perioperative analgesia and subarachnoid- block characteristics in lower abdominal surgery: a dose-response study. Reg Anesth Pain Med. 2007; 32(1):20-6.
• 19. White PF, Coe V, Shafer A, Sung ML. Comparison of alfentanil with fentanyl for outpatient anesthesia. Anesthesiology. 1986;64(1):99-106.
• 20. Staats SP, Dougherty MP (Editor). Practical management of pain. In: P Prithvi Raj. Spinal Analgesics: Present and future. 3rd edition, St Louis, Missouri: Mosby. 2000;513-28.
• 21. Uyar M (Editör). Postoperatif ağrılı hastanın değerlendirilmesi ve ağrı ölçümü. In: Yücel A. Postoperatif analjezi. 1. baskı, İstanbul: Mavimer Matbacılık Yayıncılık, 2004;27-36.
• 22. Goodwin SA. A review of preemptive analgesia. J Perianesth Nurs. 1998;13(2):109-14.
• 23. Klamt JG, Garcia LV, Prado WA. Analgesic and adverse effects of a low dose of intrathecally administered hyperbaric neostigmine alone or combined with morphine in patients submitted to spinal anaesthesia: pilot studies. Anaesthesia. 1999;54(1):27-31.
• 24. Kang H, Ha YC, Kim JY, et al. Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. J Bone Joint Surg Am. 2013;95(4):291-96.
• 25. Cohen SM. Extended pain relief trial utilizing infiltration of Exparel, a long-acting multivesicular liposome formulation of bupivacaine: a Phase IV health economic trial in adult patients undergoing open colectomy. J Pain Res. 2012;5:567-72.
• 26. Tejwani GA, Rattan AK, McDonald JS. Role of spinal opioid receptor in the antinociceptive interactions between intrathecal morphine and bupivacaine. Anesth Analg. 1992;74(5):726–34.
• 27. Ben-David B, Levin H, Salomon E, Admoni H, Vaida S. Spinal bupivacaine in ambulatory surgery: the effect of saline dilution. Anesth Analg. 1996;83(4):716–20.
• 28. Sıddık-Sayyid SM, Aouad MT, Jalbout MI, et al. Intrathecal versus intravenous fentanyl for supplementation of subarachnoid block during cesarean delivery. Anesth Analg. 2002;95(1):209-13.
• 29. Cooper DW, Ryall DM, Desira WR. Extradural fentanyl for postoperative analgesia: predominant spinal or systemic action? Br J Anaesth. 1995;74(2):184-87.
• 30. Scholz J, Steinfathl M, Schulz M. Clinical pharmacokinetics of alfentanil, fentanyl and sufentanil an update. Clin Pharmacokinet. 1996;31(4):275-92.
• 31. Shafer SL, Varvel JR. Pharmacokinetics, pharmacodynamics and rational opioid selection. Anesthesiology. 1991;74(1):53-63.
• 32. Shafer SL, Stanski DR. Improving the clinical utility of anesthetic drug pharmacokinetics. Anesthesiology. 1992;76(3):327-30.
• 33. Youngs EJ, Shafer SL. Pharmacokinetic parameters relevant to recovery from opioids. Anesthesiology. 1994;81(4):833-42.
• 34. Hughes MA, Glass PSA, Jacobs JR. Context-sensitive half-time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology. 1992;76(3):334-41.
• 35. Cooper RA, Devlin E, Boyd TH, Bali IM. Epidural analgesia for labour using a continuous infusion of bupivacaine and alfentanil. Eur J Anaesthesiol. 1993;10(3):183-87.
• 36. Bader AM, Ray N, Datta S. Continuous epidural infusion of alfentanil and bupivacaine for labor and delivery. Int J Obstet Anesth. 1992;1(4):187-90.
• 37. Chauvin M, Salbaing J, Perrin D, Levron JC, Viars P. Clinical assessment and plasma pharmacokinetics associated with intramuscular or extradural alfentanil. Br J Anaesth. 1985;57(9):886-91.
• 38. Mark JB, Steele SM. Cardiovascular effects of spinal anesthesia. Int Anesthesic Clin.1989;27(1):31-9.
• 39. Morgan GE, Mikhail MS, Murray MJ, Larson CP (Editor). Clinical Anesthesiology (Anesthesia for Patients with Endocrine Disease). 3rd edition, United States of America: Lange Medical Books. 2002;36:747-48.
• 40. Tarkkila PJ, Kaukinen S. Complications during spinal anesthesia a prospective study. Reg Anesth. 1991;16(2):100-6.