Infiltration with ropivacaine plus lornoxicam reduces postoperative pain and opioid consumption

0 Rsultats : Les scores de douleurs ont t significativement plus bas chez les patients du groupe RL que chez ceux du groupe S pendant les 12 premires heures et que chez ceux des groupes R et L pendant les quatre premires heures (P < 0,01). Le moment de la premire demande d'analgsique a t plus tardif (14,8 8,4 h vs 5,9 5,2 h ; P < 0,01), la consommation totale de pthidine a t plus basse que dans le groupe S (34,0 33,0 mg vs 78,0 29,8 mg ; P < 0,001), le retour de la fonction gastro-intestinale et de la marche a t plus prcoce, la longueur du sjour hospitalier (P < 0 ,05) plus courte et la satisfaction des patients (P < 0,01) meilleure dans le groupe RL que dans le groupe S (P < 0,05) [L'infiltration avec de la ropivacane, plus du lornoxicam, rduit la douleur postopratoire et la consommation d'opiodes] Purpose: To compare efficacy and patient outcome of wound infiltration with ropivacaine, lornoxicam, or their combination for control of pain following thyroid surgery. Methods: Eighty patients underwent thyroid surgery were randomly assigned to one of four groups. Before skin closure, local tissues were infiltrated with 12 mL saline in Group S, with 10 mL of ropivacaine 0.75% plus 2 mL saline in Group R, with 2 mL of lornoxicam (8 mg) plus 10 mL saline in Group L, and with 10 mL ropivacaine 0.75% plus 2 mL lornoxicam (8 mg) in Group RL. Pain scores, total and incremental meperidine consumption were recorded at 30 min, one, two, three, four, six, eight, 12, 18, and 24 hr postoperatively. Time to first analgesic requirement, patient satisfaction, and duration of hospital stay were also compared after surgery. Results: The pain scores in Group RL were significantly lower in the first 12 hr than in Group S, and in the first four hours than in Groups R and L (P < 0.01). The time to first analgesic requirement was significantly longer (14.8 8.4 hr vs 5.9 5.2 hr; P < 0.01), the total pethidine consumption was significantly less than Group S (34.0 33.0 mg vs 78.0 29.8 mg; P<0.001), return of gastrointestinal function, ambulation time, length of hospital stay (P < 0.05) were significantly shorter, and patient satisfaction (P < 0.01) was significantly better in Group RL than in Group S (P < 0.05). Conclusion: Wound infiltration with ropivacaine 0.75% plus lornoxicam 8 mg combination improved postoperative pain control and patient comfort, and decreased the need for opioids than the use of either drug alone. - Tduring the first day after thyroid surgery. HYROID surgery induces brief postoperative pain, requiring analgesia/therapy Post-thyroidectomy pain has frequently been treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids.1,2 Lornoxicam is a potent new NSAID of the oxicam class that has been shown to be effective and well tolerated in the treatment of postoperative pain.35 The short plasma half-life (three to five hours) of lornoxicam may provide advantages over other NSAIDs.4 Wound infiltration with local anesthetics is an alternative and acceptable method for the management of postoperative pain.6,7 The main limitation of wound infiltration is that only long-acting local anesthetics produce effective and sufficient duration of analgesia. Bupivacaine is the most preferred longacting local anesthetic and has been used successfully for local infiltration after surgery.8,9 However, large doses of bupivacaine are relatively toxic, and moderate plasma concentrations can cause catastrophic cardiotoxicity.10 Ropivacaine, a long-acting amide local anesthetic, is chemically related to bupivacaine but it has less cardiac and central nervous system toxicity.11 It produces cutaneous vasoconstriction that restricts systemic absorption of the drug and increases its local duration of action.12 Moreover, ropivacaine possesses anti-inflammatory activity that may further reduce pain when administered locally.13 The analgesic synergy of NSAID-local anestheticopioid combination was demonstrated by Visalyaputra et al.14 In a recent study, postoperative wound infiltration with levobupivacaine plus lornoxicam provided better postoperative pain relief than levobupivacaine alone after cholecystectomy.15 Further studies are needed to evaluate the analgesic efficacy of wound infiltration with another regimen of ropivacaine enriched with the NSAID lornoxicam alone on acute pain with different postoperative pain models. We therefore designed, a prospective, randomized, double-blinded, placebo-controlled study, to compare the effect of ropivacaine, lornoxicam or their combination on analgesia efficacy and patient outcome after thyroid surgery. Methods After obtaining the approval of the Institutional Ethics Committee (Trakya University, Edirne, Turkey) and written informed consent from the patients, we studied 80 patients, American Society of Anesthesiologists physical status I and II, undergoing elective partial or total thyroidectomy, in a prospective, randomized, double-blinded, placebo-controlled protocol. All patients were physiologically euthyroid. Exclusion criteria included a known allergy, sensitivity, or contraindication to opioids, local anesthetic or any NSAID, renal or liver failure, a history of peptic ulcer, a history of asthma, clotting disorder, an intrathoracic goiter, and pregnancy. In addition, patients who had previously suffered from a difficult endotracheal intubation (more than two attempts at tracheal intubation) at the induction of anesthesia were also excluded. Patients were randomly divided into four groups of 20 patients each. For premedication, midazolam 0.07 mgkg1 was administered im 45 min before the surgical procedure. In the operating room, a crystalloid infusion was started, and mean arterial blood pressure (MAP), heart rate (HR), and peripheral oxygen saturation were monitored (Cato PM 8040; Drger, Lbeck, Germany). After the administration of oxygen, anesthesia was induced with propofol (2 mgkg1 iv) and fentanyl (2 gkg1 iv). Tracheal intubation was facilitated with atracurium (0.6 mgkg1 iv). Anesthesia was maintained with 1 to 2.5% (inspired concentration) sevoflurane and 66% nitrous oxide in oxygen. Additional fentanyl boluses up to 0.2 mg iv were allowed during surgery. Ventilation was controlled mechanically (Cato; Drger, Lbeck, Germany), and adjusted to maintain end-expiratory carbon dioxide between 34 to 36 mmHg. Muscle relaxation was maintained with atracurium (0.1 mgkg1 iv) boluses as required. At the end of surgery and before skin closure, would infiltration was performed by the surgeon, who was blinded to the applied drug solution. The patients were allocated by computer randomization to receive: (Group S) 12 mL of normal saline; (Group R) 10 mL of ropivacaine 0.75% (Naropin; AstraZeneca, Milano, Italy) with 2 mL of normal saline; (Group L) 2 mL (8 mg) of lornoxicam (4 mgmL1), (Xefo; Nycomed Pharma AS, Roskilde, Denmark) with 10 mL of normal saline; (Group RL) 10 mL of ropivacaine 0.75% with 2 mL (8 mg) of lornoxicam. The thyroi (...truncated)