Evaluation of postoperative analgesia with intraperitoneal ropivacaine instillation in videolaparoscopic cholecystectomy

ORIGINAL ARTICLE Rev Dor. São Paulo, 2016 apr-jun;17(2):117-20 Evaluation of postoperative analgesia with intraperitoneal ropivacaine instillation in videolaparoscopic cholecystectomy Avaliação da analgesia pós-operatória com instilação de ropivacaína intraperitoneal em colecistectomia videolaparoscópica Thiago Lucena César de Albuquerque1, Monique Ferro Bezerra1, Cíntia Cibelly Paz Zuzu Schots1, Ana Karla Arraes Von Sohsten2, Jane Auxiliadora Amorim2, Otávio Damázio Filho2 DOI 10.5935/1806-0013.20160027 ABSTRACT RESUMO BACKGROUND AND OBJECTIVES: This study aimed at evaluating postoperative analgesia with ropivacaine instillation inside the peritoneal cavity in videolaparoscopic cholecystectomy. METHODS: This is a randomized clinical trial with 60 patients. The intervention group (RP, n = 30) received 0.5% ropivacaine instillation in right and left subdiaphragmatic regions and in gallbladder bed in equal volumes of 10 mL. The control group (SS, n = 30) received 0.9% saline solution instillation. Patients of both groups received multimodal analgesia. Scores of abdominal pain and referred pain in shoulder were evaluated at emergence and after 1, 2, 4, 12 and 24 hours, in addition to the need for rescue analgesia, opioid consumption and adverse events, considering statistically significant p<0.05. RESULTS: There has been no statistical difference between groups with regard to demographic data and anesthetic-surgical time. The intervention group had lower and statistically significant pain scores as compared to control group at emergence (p=0.001), 1 (p=0.019) and 2 (p=0.04) postoperative hours, in addition to lower opioid consumption at emergence (p=0.022) and in total in the first 24 hours (p=0.001). Time for first request for rescue analgesia was longer in the intervention group (p=0.001). CONCLUSION: Ropivacaine instillation inside the peritoneal cavity has decreased pain scores in the first 2 hours and postoperative opioid consumption. Keywords: Analgesia, Laparoscopic cholecystectomy, Local anesthetics, Postoperative pain, Ropivacaine. JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi avaliar a analgesia pós-operatória com instilação de solução de ropivacaína dentro da cavidade peritoneal em colecistectomia videolaparoscópica. MÉTODOS: Trata-se de um ensaio clinico randomizado com 60 pacientes. No grupo intervenção (RP, n=30) foi realizada instilação de solução de ropivacaína a 0,5% nas regiões subdiafragmáticas direita e esquerda e no leito da vesícula biliar em iguais volumes de 10 mL. No grupo controle (SF, n =30) foi realizada instilação de solução fisiológica a 0,9%. Os pacientes de ambos os grupos receberam analgesia multimodal. No período pós-operatório foram avaliados os escores de dor abdominal e referida no ombro ao despertar e após 1, 2, 4, 6, 12 e 24 horas, além da necessidade de analgesia de resgate, consumo de opioide e eventos adversos. Foi considerado estatisticamente significativo o valor de p<0,05. RESULTADOS: Não houve diferença estatística entre os grupos em relação a dados demográficos e tempo anestésico-cirúrgico. O grupo intervenção apresentou escores de dor menores e estatisticamente significativos comparado ao grupo controle ao despertar (p=0,001), com 1 hora (p=0,019) e 2 horas (p=0,04) de pósoperatório, bem como menor consumo de opioide ao despertar (p=0,022) e no total nas primeiras 24 horas (p=0,001). O tempo para necessidade da primeira analgesia de resgate foi maior no grupo intervenção (p=0,001). CONCLUSÃO: A instilação de ropivacaína dentro da cavidade peritoneal reduziu os escores de dor nas primeiras duas horas e o consumo de opioide no pós-operatório. Descritores: Analgesia, Anestésicos locais, Colecistectomia laparoscópica, Dor pós-operatória, Ropivacaína. INTRODUCTION 1. Universidade de Pernambuco, Recife, PE, Brasil. 2. Hospital da Restauração, Hospital Getúlio Vargas, Hospital Universitário Oswaldo Cruz, Recife, PE, Brasil. Submitted in February 15, 2016. Accepted for publication in May 27, 2016. Conflict of interests: none – Sponsoring sources: none. Correspondence to: Rua Arnóbio Marquês, 310 - Santo Amaro 50100-130 Recife, PE, Brasil. E-mail: © Sociedade Brasileira para o Estudo da Dor Videolaparoscopic cholecystectomy (VC) is the golden standard for gallbladder removal and the laparoscopic procedure more performed worldwide1. According to Datasus, 58,663 surgeries were performed in Brazil in 20142. For being a minimally invasive procedure, laparoscopy induces the wrong perception that it is also minimally painful; however pain has been mentioned as major complaint and a reason for delayed postoperative recovery. Post-VC pain has three components: incisional, visceral and 117 Rev Dor. São Paulo, 2016 apr-jun;17(2):117-20 Albuquerque TL, Bezerra MF, Schots CC, Sohsten AK, Amorim JA and Damázio Filho O referred, the latter in general in the shoulder3. In addition to discomfort and postoperative physiological repercussions, such as respiratory restriction, tachycardia and hypertension, pain delays early ambulation and hospital discharge4,5. Multimodal analgesia has been used to minimize post-VC pain, including the perioperative use of non-steroid anti-inflammatory drugs (NSAIDs), opioids, N-methyl D-aspartate receptor inhibitors (NMDA), anticonvulsants and local anesthetic infiltration in the surgical wound. In this context, intraperitoneal ropivacaine instillation has been suggested by some authors as a feasible and easy resource to control postvideolaparoscopic cholecystectomy pain6-9. This study aimed at evaluating postoperative analgesia with intraperitoneal ropivacaine instillation for VC. METHODS Participated in this analytical, randomized and double-blind study 60 patients of both genders, aged 18 years or above, physical status ASA I, II and III, according to the American Society of Anesthesiology, submitted to elective VC under balanced general anesthesia in the Hospital Universitário Oswaldo Cruz (HUOC), Recife, PE, between July and September 2015. Exclusion criteria were patients weighing less than 50kg, with acute pancreatitis, preoperative abdominal or shoulder pain, being treated for chronic pain, in antiepileptic therapy, alcohol or drug addicts, with liver or kidney dysfunction, allergy or sensitivity to drugs used in this study, cognitive deficiency, pregnant or breastfeeding women and when the surgical technique had to be changed to conventional. During preanesthetic evaluation and after signing the Free and Informed Consent Term (FICT), patients were divided in two groups of 30 individuals: Group RP (intervention), who received intraperitoneal instillation of 30mL of 0.5% ropivacaine, and Group SS (control) who received 30mL of 0.9% saline solution. This was a convenience sample, considering the approximate number of available patients in the service in one time unit. We decided to use a minimum of 30 patients per group to allow the use of parametric tests. All patients had venous access a (...truncated)