AnesthesiaWeb - Literature Review- Part Two of a Two-Part Series on Multi-Modal Analgesia after Laparoscopic Surgery

February 1, 2001
PART TWO OF A TWO-PART SERIES ON MULTI-MODAL ANALGESIA AFTER LAPAROSCOPIC SURGERY

An Assessment of the Value of Intraperitoneal Meperidine for Analgesia Postlaparoscipic Tubal Ligation.

Colbert ST, Moran K, O’Hanlon DM, Chambers F, McKenna P, Moriarty DC,
Blunnie WP.
Anesth Analg 2000;91:667-70.

Commentary by Beverly Philip, M.D.

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see abstract below

Although laparoscopic surgery is associated with significantly less pain than other surgical techniques, these patients do experience postoperative pain especially in the abdomen, back and shoulders. Pain after laparoscopy results from stretching of the intra-abdominal cavity, peritoneal inflammation, and phrenic nerve irritation caused by residual carbon dioxide in the peritoneal cavity. The intraperitoneal (IP) delivery of drugs could be a simple and effective method of reducing the intensity of postlaparoscopic pain, but studies with IP local anesthetics alone have been equivocal. Meperidine is an analgesic which has local anesthetic effects both in vitro and in vivo. Therefore, IP meperidine may have the potential to provide additional analgesic benefits because of its combined opioid and local anesthetic properties. These authors studied the effect of intraperitoneal bupivacaine and meperidine on pain following tubal ligation performed with Filshie clips.

ASA I patients undergoing laparoscopic tubal ligation were recruited into the study. They were randomly assigned to group B/S, who received IP bupivacaine and IP saline, with IM meperidine, or to group B/M who received IP bupivacaine and IP meperidine, with IM saline. No premedication was used. Anesthesia was induced with propofol 2.5– 3 mg/kg and fentanyl 2 ug/kg IV, and maintained using a mixture of 1.5% - 2% isoflurane and 66% nitrous oxide in oxygen. Tracheal intubation was facilitated with atracurium. No opioids were administered during the maintenance. All patients receive ondansetron 8 mg IV and diclofenac [an NSAID] 100 mg rectally after the induction of anesthesia.

At the end of the operation, the patients allocated to group B/S received 80 ml 0.125% bupivacaine with 1:200,000 epinephrine and 10 ml saline instilled into the peritoneal cavity under direct vision via the umbilical port, and 50 mg (1 ml) IM meperidine. Patients in group B/M received 80 ml of 1.25% bupivacaine with epinephrine and 50 mg meperidine (mixed up to 10ml) instilled into the peritoneal cavity, and 1 ml of IM saline. CO2 was then evacuated from the peritoneal cavity. The surgical wounds were not infiltrated with local anesthetic.

Postoperative pain was assessed both at rest and on movement, by asking patients to move from supine to sitting position. Patients rated the severity of their pain via a visual analog scale (VAS), from ‘no pain’ to ‘worst possible pain’ (0-10 cm). A similar scale was used to rate nausea. Measurements were taken at 30 minutes and 2, 4 and 6 hours postoperatively; preop scores were not done. A standard postop analgesic regimen was used, with 0.5 to 1 mg/kg IM meperidine or oral acetaminophen (500 mg). The time to first analgesia administration, total analgesic requirements in the first 6 h, nausea scores, and the occurrence of vomiting were recorded.

One hundred patients completed this study. Demographics were similar in both groups: age approximately 37 yr, weight approx. 63 kg, duration of pneumoperitoneum approx. 11 min, and duration of surgery approx. 22 minutes. At all postoperative times, the pain scores were significantly lower in group B/M, both at rest and with movement. The greatest difference was seen at 2 hours postop: the pain scores were 1.8 � 1.8 vs 0.76 � 0.6 (B/S vs B/M, p<.0001). The pain scores with movement at 2 hr were 2.3 � 1.9 vs 1.0 � 0.9 (B/S vs B/M, p<.0001). Overall, highest pain scores were recorded in both groups at the 30 minute assessment time, when pain scores at rest were 2.4 � 1.8 vs 1.5 � 0.9 (B/S vs B/M, p<.01); scores with movement at 30 minutes were 2.9 � 2.1 vs 2.0 � 1.1, (B/S vs B/M, p< .05). There was no significant difference between groups in time to first analgesia (78 vs 60 minutes, B/S vs B/M) nor in the percentage of patients requiring additional analgesic (59% vs 39%, B/S vs B/M). There were no differences in the nausea scores or in the number of patients who vomited.

This study used a multimodal analgesic approach with rectal diclofenac (an NSAID) and IP bupivacaine and meperidine. Pain scores were low overall in this study, but significant differences were observed. The authors believe that these differences are clinically relevant since pain scores were more that halved at some time periods. Since this study essentially compared the analgesic effects produced by equivalent doses of meperidine administered IM or IP, the results suggest that the observed differences in analgesia may be produced by the local effects of meperidine itself. One might expect that the pain scores in this study would have been lower yet had additional multimodal analgesia been included in the study protocol. Specifically, analgesia may be enhanced by the use of local anesthesia infiltration into the surgical wounds. A considerable advantage of the technique proposed by these authors is its ease of implementation.

In conclusion, the combination of IP bupivacaine and IP meperidine was better than the combination of IP bupivacaine and IM meperidine for the relief of postoperative pain in patients undergoing laparascopic tubal ligation with Filshie clips. IP meperidine reduced pain scores both at rest and on movement at each time period studied, compared with the same dose administered IM. The use of IP meperidine for patients undergoing laparascopic surgical procedures may warrant further study.

ABSTRACT

An Assessment of the Value of Intraperitoneal Meperidine for Analgesia Postlaparoscipic Tubal Ligation

AUTHORS:
Colbert ST, Moran K, O’Hanlon DM, Chambers F, McKenna P, Moriarty DC, Blunnie WP.

SOURCE:
Anesth Analg 2000;91:667-70.

ABSTRACT:
Patients undergoing laparoscopic procedures may experience postoperative pain. The intraperitoneal (IP) administration of drugs is controversial but has proven effective in some studies for the relief of postoperative pain. However, some investigators have not been able to confirm the analgesic efficacy of IP local anesthetics. The administration of IP opioids for the relief of postoperative pain has received little attention. At the end of laparoscopic tubal ligation, 100 patients received 80 mL of 0.125% bupivacaine with 1:200,000 epinephrine IP and 50 mg of meperidine either IP or IM. Postoperative pain scores were measured at rest and with movement. Pain scores were significantly lower in the group receiving the IP meperidine both at rest (P: < 0.01) and with movement (P: <0.05). We conclude that the combination of intraperitoneal bupivacaine and intraperitoneal meperidine was better than the combination of IP bupivacaine and IM meperidine for postoperative analgesia in patients undergoing laparoscopic tubal ligation. IMPLICATIONS: The combination of bupivacaine and meperidine delivered to the intraperitoneal cavity proved superior to equivalent doses of intraperitoneal bupivacaine and IM meperidine for postoperative pain relief in patients undergoing laparoscopic tubal ligation. Intraperitoneal delivery of analgesia proved effective in this study and merits further study and more widespread use.