|Year : 2015 | Volume
| Issue : 3 | Page : 360-363
Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial
Manal M Kamal MD , Mahmoud Hassan
Department of Anesthesia and Intensive Care, Ain Shams University, Cairo, Egypt
|Date of Submission||06-Aug-2014|
|Date of Acceptance||08-Dec-2014|
|Date of Web Publication||29-Jul-2015|
Manal M Kamal
, 8 Elemdad and El Tamween Buildings, El Nasr Road, Nasr City, Cairo
Source of Support: None, Conflict of Interest: None
This study was designed as a randomized comparison of postoperative pain after inguinal herniotomy in patients treated with intravenous esmolol and others treated with ropivacaine abdominal wound infiltration.
Patients and methods
Sixty American Society of Anesthesiologists physical status I-II patients undergoing herniotomy and anesthetized with isoflurane were randomized into one of two groups. Group R received 20 ml of ropivacaine 0.75% in 20 ml of saline 0.9% preincisional wound infiltration and group E patients received a bolus of esmolol 0.5 mg/kg intravenous at induction followed by an infusion of 5-15 mg/kg/min. After surgery, a bolus of pethidine was given according to visual analogue scale for pain intensity.
Patients in group E had lower pain scores than patients in group R. Median consumption of pethidine was higher in group R than in group E.
Intravenous esmolol reduces pethidine consumption and provides more analgesia compared with preincisional ropivacaine infiltration in patients undergoing herniotomy.
Keywords: esmolol, herniotomy, inguinal, isoflurane, pethidine, ropivacaine
|How to cite this article:|
Kamal MM, Hassan M. Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial. Ain-Shams J Anaesthesiol 2015;8:360-3
|How to cite this URL:|
Kamal MM, Hassan M. Intravenous esmolol versus ropivacaine abdominal wound infiltration for postoperative analgesia after inguinal herniotomy: a randomized controlled trial. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2022 Jan 27];8:360-3. Available from: http://www.asja.eg.net/text.asp?2015/8/3/360/161701
| Introduction|| |
Inguinal hernia repair is an operation frequently associated with moderate to severe pain after operation , , which can delay discharge and cause persistent distress  .
Typically, postherniorrhaphy pain is treated by opioids combined with a NSAID. Local anesthetic is often administered at the end of surgery .
However, the treatment designed to prevent pain in advance of surgical trauma may be more effective than the given analgesic therapy in response to pain after surgery  .
Such 'prophylactic analgesia' prevents central sensitization and hyperexcitability of neurons. Pre-emptive treatment with local anesthetics has been proposed as a method of inhibiting transmission of noxious stimuli thereby preventing central sensitization , .
b-Adrenergic blocking drugs have been shown to reduce postoperative opioids requirements, suggesting an antinociceptive effect of these agents ,,, .
A previous study on patients undergoing laparoscopic cholecystectomy showed that esmolol and not remifentanil was associated with reduced postoperative fentanyl requirements  .
This randomized study compared the postoperative pain intensity and pethidine consumption after inguinal herniotomy in patients treated with intravenous esmolol versus others treated with pre-emptive ropivacaine abdominal wound infiltration.
| Patients and methods|| |
Sixty American Society of Anesthesiologists (ASA) physical status I-II patients aged 18-45 years scheduled for herniotomy in El-Demerdash Hospital gave written informed consents to participate in the present study. The written informed consent was obtained on the day of surgery by the anesthesiologist. This study was approved by the ethics committee, Faculty of Medicine, Ain Shams University. This study was carried out from January to August 2013.
Exclusion criteria included patients with a known history of hypertension, chronic pain syndrome, renal or hepatic insufficiency, heart disease, chronic treatment with b-blockers, drug abuse, or allergy to any of the study drugs.
Noninvasive arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO 2 ) were monitored in the operation room.
Using random selection of sealed envelopes, patients were randomized into one of two groups (30 patients each). Sealed envelopes were prepared by an anesthesia technician who was not involved in the study.
After induction of anesthesia using 5 mg/kg thiopental sodium, fentanyl 1 mg/kg, and atracurium 0.5 mg/kg, endotracheal intubation was performed. Patients were divided into two groups: Group R (n = 30) received 20 ml of ropivacaine 0.75% in 20 ml normal saline preincisional wound infiltration and group E (n = 30) received a bolus of esmolol 0.5 mg/kg intravenously followed by an infusion of 5-15 mg/kg/min. Anesthesia was maintained with 1.2% isoflurane and a mixture of oxygen and air. At the end of the operation, neuromuscular blockade was reversed by intravenous neostigmine 0.04 mg/kg and intravenous atropine 0.02 mg/kg. Anesthesia was discontinued and the tracheal tube was removed when airway reflexes had recovered. Heart rate, pulse oximeter oxygen saturation, and mean arterial pressure were recorded at 10, 20, and 30 min after surgery and at 1, 2, and 3 h postoperatively. Pain scores were evaluated by a blind observer at the time of arrival in the postanesthesia care unit, at 10, 20, and 30 min after surgery, and at 1, 2, 3, 6, and 9 h postoperatively using a visual analogue scale (0-10 cm; 0 = no pain, 10 = the worst pain imaginable). If the visual analogue scale score was greater than 4 cm, 0.4 mg/kg pethidine was given intravenously. If the score did not decrease within 10 min, an additional 0.2 mg/kg pethidine was given. Time to first need for pethidine and total pethidine consumption were recorded. Nausea and vomiting were recorded during the postoperative period. All data were recorded by a blind observer.
Using Statistical Program of Social Science (SPSS) for sample size calculation, it was calculated that a sample size of 27 per group will achieve 80% power to detect a difference of 50% difference in analgesic requirements at the first 6 postoperative hours between the two groups, with a significance level (α) of 0.05 using a two-sided two-sample t-test. A total of 30 patients per group were included to replace any dropouts.
The collected data were coded, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 17.0 (SPSS Inc., Chicago, Illinois, USA).
Data were expressed as mean value ± SD for numerical parametric data and numbers (%) for categorical data. Student's t-test was used to analyze the parametric data, and discrete (categorical) variables were analyzed using the χ2 -test, with P-values less than 0.05 considered statistically significant.
| Results|| |
No patients in group E suffered from nausea or vomiting; no patients in group R suffered from nausea, whereas one patient in group R suffered from vomiting.
| Discussion|| |
These study results showed that a continuous intraoperative infusion of esmolol (5-15 μg/kg/min) reduces postoperative pain after herniotomy compared with preincisional ropivacaine infiltration. It also delayed the first request for analgesic for 6 h postoperatively, whereas ropivacaine infiltration gave this effect only for 3 h postoperatively.
The purposes of pre-emptive analgesia are first to inhibit or reduce the development of any memory of pain stimulus in the central nervous system and second to diminish analgesic requirements as a consequence , . The pre-emptive blockade of initial nociceptive different input to the spinal cord may inhibit the development of long-term changes in the excitability of central neurons and accordingly prevent both peripheral and central nociceptive processing, thereby producing long-lasting antinociceptive effects , .
The mechanism underlying these noncardiovascular effects of b-blockers is controversial. Some studies show synergism with the hypnotic effect, whereas others disregard this action ,, . The antinociceptive effect of esmolol is also controversial. Although experimental and clinical observation point to an analgesic effect associated with the involvement of the sympathetic nervous system in nociception ,,, , this effect, however, is not universally confirmed.
The benefit of local anesthetic field block before hernia surgery has previously been investigated by Tverskoy et al.  . In that study, pain was less severe for 48 h after surgery in patients who received a postoperative field block with bupivacaine compared with patients who received no local anesthetic at all. The less duration of effect in our study may be related to differences in study design.
Chia et al.  compared the use of esmolol with a control group of patients who received saline. They noticed a decrease in intraoperative requirements for fentanyl and reduced consumption of morphine during the first 3 days after surgery. They proposed that attenuation of the intraoperative nociceptive stimulation of esmolol reduces the consequences of adrenergic dysregulation. White et al.  compared three different analgesic protocols in patients undergoing gynecologic laparoscopy: a group managed with esmolol alone, a group managed with nicardipine combined with esmolol, and a control group managed with saline. Their results showed that 80% of patients in the control group required postoperative analgesia compared with 47% of patients in the esmolol group and 40% of patients in the esmolol-nicardipine group. Servando et al. compared the use of esmolol infusion versus ketamine-remifentanil infusion for early postoperative analgesia after laparoscopic cholecystectomy. Their results showed that intraoperative infusion of esmolol reduces opioid requirements and improves postoperative analgesia  .
It is necessary to emphasize that, in this study, we only recorded the total consumption of pethidine in the first 9 h postoperatively. Therefore, our results cannot document whether this effect was prolonged to the late postoperative period. We were unable to record the patient need for analgesia during the late postoperative period as it was not possible to contact the patient at home, which could be carried out in further studies [Table 1] [Table 2] [Table 3] [Table 4] [Table 5] and [Figure 1].
|Figure 1: The middle line in each box represents the median; the outer margins of the box represents the interquartile range; and the whiskers are minimum and maximum. Visual analogue scale (VAS) scores were signifi cantly lower in the esmolol group compared with the ropivacaine group in the first 9 h postoperatively.|
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| Conclusion|| |
This study shows that intraoperative infusion of esmolol in patients undergoing herniotomy is associated with reduced pain scores and analgesic use in the first 9 h postoperatively compared with preoperative ropivacaine abdominal wound infiltration.
| Acknowledgements|| |
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]