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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 170-174

An audit to study pain after laparoscopic cholecystectomy with the use of nonopioid analgesics


1 Department of Anaesthesiology, SGPGIMS, Lucknow, Uttar Pradesh, India
2 Department of Surgical Gastroenterology, SGPGIMS, Lucknow, Uttar Pradesh, India

Date of Web Publication18-Jan-2018

Correspondence Address:
Amit Rastogi
Department of Anaesthesiology, A Block, SGPGIMS, Lucknow 226014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_52_17

Clinical trial registration CTRI/2016/10/007362

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  Abstract 


Back ground: An Audit to study pain after laparoscopic cholecystectomy with the use of non-opioid analgesics. Patient and Methods: Hundred and nine patients were enrolled in this study that underwent elective laparoscopic cholecystectomy. Aged between 20 – 55 years, patients of either gender were enrolled in this prospective observational study. Seven patients were excluded from the study because of the conversion of laparoscopic procedure to open cholecystectomy and two patients were lost to follow-up. These patients were instructed and taught how to use the Numerical Pain Rating Scale (NPRS) for assessment of pain at rest, during deep breath and on movement. Pain score at rest, deep breath and movement including (Mild, Moderate and Severe pain), dynamic pain, breakthrough episodes of pain and time to discharge post surgery were recorded. Results: We found that none of the patients had severe pain at rest at any time interval. Only 1 patient had severe pain with deep breath at 2 hours and 2 patients had severe pain with deep breath at 6 hours after surgery. 2 patients had severe pain with movement at 2 hours and 6 patients had severe pain with movement at 6 hours after surgery. The dynamic pain was present in 12% patients (12) at 2 hours after surgery, which progressively declined to 4% (4) at 12 hours post surgery. The total number of breakthrough episodes was higher in patients having dynamic-pain at 2 hours. Conclusion: Maximum pain scores were found at 6 hours. Patients having higher dynamic pain score values at 2 hours have frequent breakthrough episodes (p value < 0.05) so an optimal analgesic control is warranted in such subset of patients. The time to discharge of patients was positively correlated to the pain scores of postoperative day 1.


How to cite this article:
Sarkar S, Rastogi A, Haldar R, Kumar A, Singh S. An audit to study pain after laparoscopic cholecystectomy with the use of nonopioid analgesics. Indian J Pain 2017;31:170-4

How to cite this URL:
Sarkar S, Rastogi A, Haldar R, Kumar A, Singh S. An audit to study pain after laparoscopic cholecystectomy with the use of nonopioid analgesics. Indian J Pain [serial online] 2017 [cited 2019 Dec 6];31:170-4. Available from: http://www.indianjpain.org/text.asp?2017/31/3/170/223668




  Introduction Top


Laparoscopic cholecystectomy is a commonly performed procedure for the treatment of cholelithiasis. Pain after laparoscopic cholecystectomy has several origins: incisional, local visceral, peritoneal, and referred. Rapid distension of the peritoneum with gas may be associated with pressure over the blood vessels, and traumatic nerve traction releases inflammatory mediators causing pain.[1] The residual carbon dioxide in the peritoneal cavity following insufflations can produce shoulder tip pain in the postoperative period, suggesting phrenic nerve irritation.[2] The trocar insertion site also contributes to the postoperative pain after cholecystectomy.

Previous studies have shown that preemptive analgesia attenuates signals entering the spinal cord, which has comparatively better efficacy in controlling pain after surgical stimulus.[3] In this context, various pain-relieving strategies have been described for the management of postoperative pain, e.g., multimodal analgesia approach. Adequate postoperative pain control allows early mobilization in laparoscopic cholecystectomy and contributes to early discharge. It can only be achieved by having adequate information about the postoperative pain pattern in laparoscopic cholecystectomy. Use of opioids in the postoperative period may also contribute to the delay in discharge. We studied the postoperative pain patterns in patients who underwent laparoscopic cholecystectomy under balanced anesthesia techniques. The postoperative pain following laparoscopic cholecystectomy in these patients was managed with nonopioid techniques.


  Patients and Methods Top


This study was approved by the Institutional Ethical Committee (IEC Code: 2015-78-MD-85) and Clinical Trial Registry India (CTRI/2016/10/007362). A total of 109 patients posted for laparoscopic cholecystectomy belonging to the American Society of Anesthesiologists (ASA) physical status II, aged between 20 and 55 years, were enrolled in this prospective observational study. Patients using steroids within 1 month of surgery, having opioid-dependent chronic pain, with history of allergy to any of the study medications, immunosuppressed, diabetes mellitus, renal disease (serum creatinine >1.6mg/dL), liver disease (liver enzymes more than two times of normal values), and psychiatric disorder were excluded from the study. If the surgery was converted from laparoscopic cholecystectomy to open procedure, the patient was excluded from the study.

Patients were instructed and taught how to use the Numerical Pain Rating Scale (NPRS) for assessment of pain at rest, during deep breath, and on movement (an 11-point ordinal scale, with 0 indicating no pain and 10 indicating worst pain imaginable).

All patients were premedicated with Tab. ranitidine 150mg and Tab. lorazepam 0.04mg/kg night prior to surgery. Five-lead electrocardiography, pulse oximetry, noninvasive blood pressure, temperature, and end-tidal CO2 were monitored. All patients received dexamethasone (8mg) given over 60s intravenously just prior to the induction of anesthesia. Balanced anesthesia technique was used, and patients were induced with fentanyl 2 μg/kg, midazolam 0.05mg/kg, and propofol 0.5–1.5mg/kg. Endotracheal intubation was facilitated with vecuronium 0.1mg/kg. Anesthesia was maintained with sevoflurane (1–2%) with O2 in air (FiO2 of 0.5) and intermittent doses of vecuronium. Ondansetron 4mg was administered intravenously as antiemetic half an hour before commencement of surgery. Intravenous paracetamol 1g was administered slowly 20min before the end of surgery. Following surgery, the trocar incision sites were infiltrated with 10mL of 0.25% bupivacaine, and residual muscle paralysis was reversed. All patients received postoperative analgesia by intravenous paracetamol 1g, which was given 6 hourly on the day of surgery. In case of breakthrough pain (defined as NPRS score > 3), intravenous ketorolac 30mg was administered as a rescue analgesic.

All patients were interrogated for acute pain for the postoperative pain score at rest, deep breathing, and movement at 2, 6, and 12h on the first day of surgery according to the NPRS.

The pain was also classified into mild, moderate, and severe at rest, deep breath, and movement, respectively, at 2, 6, and 12h on the first day of surgery (no pain, NPRS = 0; mild pain, NPRS = 1–3; moderate pain, NPRS = 4–6; and severe pain, NPRS = 7–10).

Dynamic pain was defined as the difference in the NPRS scores between rest and deep breathing, which is >2 points. The timing of first episode of breakthrough pain and number of episodes of breakthrough pain on postoperative day 1 and time to discharge from the day of surgery were recorded.

Statistical Analysis

The statistical analysis was performed using SPSS software, version 20. Quantitative data (age, height, weight, body mass index [BMI], intraoperative fentanyl use, duration of surgery, pain at rest, with deep breath and movement, timing of the first breakthrough episode, number of breakthrough episodes, total dose of rescue analgesic used, time to discharge postsurgery) were presented as mean ± SD. Number of breakthrough episodes, total dose of rescue analgesic used, and time to discharge postsurgery are presented as frequency and percentage. The statistical analysis of quantitative data (mean ± SD) between the groups was performed using Mann–Whitney U-test as the data were not normally distributed. Qualitative data regarding the number of patients with no, mild, moderate, and severe pain at different time periods were presented as frequency and percentage. The correlation between various parameters was determined using Pearson correlation coefficient. A P value of <0.05 was considered to be statistically significant.


  Results Top


In this study, 109 patients were enrolled, who underwent elective laparoscopic cholecystectomy. Seven patients were excluded from the study because of the conversion of laparoscopic procedure to open cholecystectomy, and two patients were lost to follow-up (see the following flow chart). Mean age of patients was 47.79±13.05 years, and mean BMI of the patients was 24.37±3.31 Kg/metre2.



The mean duration of surgery in all patients was 91.49±19.28min, and mean total dose of fentanyl used intraoperatively was 208.75±44.43μg. Mean time of last dose of opioid used before extubation was 31.95±14.41min. Maximum pain score at rest observed at 6h (2.21±1.05) was found to be higher than the pain scores at rest at 2h (1.01±1.14). Thereafter, pain scores at rest decreased at 12h (1.84±0.81) and even further on postoperative day 1 (1.48±0.89).

Maximum score with deep breathing was found at 6h after surgery (3.08±1.47), and minimum score with deep breathing was found at 2h after surgery (1.72±1.48). Average pain score with deep breathing on postoperative day 1 was 2.16±1.21.

Maximum pain scores with movement were recorded at 6h after surgery (3.61±1.59), and minimum pain scores with movement were recorded at 2h after surgery (2.25±1.72) [Table 1].
Table 1: Pain score at rest, deep breath, and movement

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Forty-four patients had no pain at rest at 2h after surgery, whereas only two had no pain after 6h. None of the patients had severe pain at rest at any point of time.

Only 1% (1) of patients had severe pain at deep breath at 2h, and 2% (2) of patients had severe pain at deep breath at 6h after surgery.

The maximum number of patients, i.e., 41% (41), had moderate pain with movement at 6h after surgery, which reduced to 29% (29) at 12h after surgery. At 6h after surgery, 6% (6) of patients had severe pain with movement, but at 12h after surgery, none of the patients had severe pain [see [Table 2].
Table 2: Mild, moderate, and severe pain at rest, deep breath, and movement

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Twelve patients had dynamic pain at 2h after surgery, which gradually decreased with time. Only four patients had dynamic pain on postoperative day 1 [Table 3].
Table 3: Distribution of dynamic pain at different time intervals

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The timing of first breakthrough episode and total number of breakthrough episodes were compared in patients grouped according to the presence/absence of dynamic pain [Table 4]. The total number of breakthrough episodes was significantly higher in patients having dynamic pain at all time periods with P value of <0.05. The average total dose of rescue analgesic was 34.20±44.72. The average time to discharge after surgery was 2.22±0.50 days. The time to discharge of patients was positively correlated to the pain scores of postoperative day 1 with P value of <0.05 [Table 5]. The highest positive correlation was observed with average pain score with movement (0.601).
Table 4: Comparison of breakthrough episodes and dynamic pain

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Table 5: Correlation between pain scores on postoperative day 1 and time to discharge

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  Discussion Top


Laparoscopic cholecystectomy is one of the most common elective surgical procedures. Despite of clear benefits of this approach, pain is still considered as the most common complaint and the reason of prolonged hospital stay.[4],[5],[6] Duration of convalescence after noncomplicated laparoscopic cholecystectomy may depend on several factors, of which pain, fatigue, and sociocultural factors are the most important ones.[7],[8] Pain and fatigue are most intense on the day of operation and the following day.[7],[8],[9] Nausea and vomiting occur mainly on the day of operation and only rarely contribute to prolonged convalescence.[7]

After laparoscopic cholecystectomy, patients usually complain of pain from the skin incision, visceral pain, and shoulder pain, which is usually caused by diaphragmatic irritation.[9] Because pain is caused by various reasons, a range of treatment methods has been introduced for the reduction of pain.[1],[9]

Local anesthetic infiltration at the incision area is an established pain management method in laparoscopic cholecystectomy.[10],[11],[12] Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to be used before surgery or even during surgery and for 3–4days after surgery.[11] There are also reports that CO2 remaining in the abdominal cavity is related to postoperative pain so thorough removal of the gas is recommended.[1] Recently a multimodal analgesic method that combines and utilizes aforementioned methods is recommended.[11]

In our study, we have used the NPRS for the assessment of pain after surgery. We recorded pain scores associated with deep breath and with movement and included the concept of dynamic pain unlike previous studies. We have used balanced anesthesia technique uniformly in all patients. We did not use opioids as a component of rescue analgesia treatment because data from routine use of NSAIDs or cyclooxygenase-2 (COX-2) inhibitors and acetaminophen suggested hastened and higher quality of recovery along with reduced use of opioids in cholecystectomy and other minor surgeries.[11]

In our study, the average pain score at rest was highest at 6h (2.21±1.05), which gradually decreased to 1.48±0.89 on postoperative day 1. An important finding was that none of the patients had severe pain at rest.

In our study, maximum average score with deep breath was found at 6h after surgery (3.08±1.47) and minimum average score with deep breath was found at 2h after surgery (1.72±1.48). The average pain score with deep breath at 12h was found to be 2.57±1.21. Only one patient had severe pain with deep breath at 2h, and two patients had severe pain with deep breath at 6h after surgery.

Maximum pain scores with movement was recorded at 6h after surgery (3.61±1.59), and minimum pain scores with movement were recorded at 2h after surgery (2.25±1.72). Average scores with movement at 12h after surgery were 3.04±1.14.

After classifying the pain scores into mild, moderate, and severe, we found that none of the patients had severe pain at rest at any time interval. Only one patient had severe pain with deep breath at 2h, and two patients had severe pain with deep breath at 6h after surgery. Two patients had severe pain with movement at 2h, and six patients had severe pain with movement at 6h after surgery.

From the aforementioned scores at different time periods, we observed that the severity of pain gradually increased to a peak at 6h after surgery and then declined until postoperative day 1 following laparoscopic cholecystectomy. J.J. Alexander stated in a review article that reporting of pain is greatest after operation, which decreases to a low level within 24h but increases to a second or third peak later.[1],[12],[13] The presence of dynamic pain was observed in 12% patients at 2h after surgery, which progressively declined to only 4% at 12h after surgery.

The timing of first breakthrough episode and total number of breakthrough episodes were compared in patients by grouping them according to the presence of dynamic pain. We found that the total number of breakthrough episodes were higher in patients having dynamic pain at 2h, which was significant (P < 0.05). Such a subset of patients in which dynamic pain was present at 2h have higher breakthrough episodes, so in these patients aggressive postoperative analgesia is required to control further dynamic pain and reduce breakthrough episodes.

The average time to discharge after surgery was 2.22±0.50 days, which was consistent with the findings of Bisgaard et al.[7],[8],[9] who studied the period of convalescence after laparoscopic cholecystectomy.

The correlation between pain scores on postoperative day 1 and the time to discharge was calculated and showed a positive correlation between the two, which was statistically significant.


  Conclusion Top


Maximum pain scores at rest, with movement, and with deep breath were found at 6h after surgery, so adequate pain control must be given at this time period, and patients have high dynamic pain scores and have higher breakthrough episodes, which can impede early discharge.

The timing of the first breakthrough episode and the total number of breakthrough episodes were compared in patients by grouping them according to the presence of dynamic pain. We found that the total number of breakthrough episodes was higher in patients having dynamic pain and it was significant.

The time to discharge was positively correlated to the pain scores on postoperative day 1, so lowering the average pain scores at day 1 will facilitate early discharge.

The limitations of our study were that it was an observational study conducted to study postoperative pain pattern in laparoscopic cholecystectomy with a sample size of 100 patients. Our study population was limited to ASA physical status I and II. We could not include patients with ASA physical status III and beyond in view of ethical issue as well as limitations arising due to fixed intraoperative balanced anesthetic technique.

Financial support and sponsorship

Nil.

Conflicts of interest

None.



 
  References Top

1.
Alexander JJ. Pain after laparoscopy. Br J Anaesth 1997;79:369-78.  Back to cited text no. 1
    
2.
Golubovic S, Golubovic V, Cindric-Stancin M, Tokmadzic VS. Intraperitoneal analgesia for laparoscopic cholecystectomy: bupivacaine versus bupivacaine with tramadol. Coll Antropol 2009;33:299-302.  Back to cited text no. 2
    
3.
Nesioonpour S, Akhondzadeh R, Pipelzadeh MR, Rezaee S, Nazaree E, Soleymani M. The effect of preemptive analgesia with bupivacaine on postoperative pain of inguinal hernia repair under spinal anesthesia: a randomized clinical trial. Hernia 2013;17:465-70.  Back to cited text no. 3
    
4.
Hessami MA, Yari M. Granisetron versus dexamethasone in prophylaxis of nausea and vomiting after laparoscopic cholecystectomy. Anesth Pain Med 2012;2:81-4.  Back to cited text no. 4
    
5.
Lepner U, Goroshina J, Samarutel J. Postoperative pain relief after laparoscopic cholecystectomy: A randomised prospective double-blind clinical trial. Scand J Surg 2003;92:121-4.  Back to cited text no. 5
    
6.
Sarvestani AS, Amini S, Kalhor M, Roshanravan R, Mohammadi M, Lebaschi AH. Intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy. Saudi J Anaesth 2013;7:14-17.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg 2001;136:917-21.  Back to cited text no. 7
    
8.
Bisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg 2001;167:84-96.  Back to cited text no. 8
    
9.
Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Characteristics and prediction of early pain after laparoscopic cholecystectomy. Pain 2001;90:261-9.  Back to cited text no. 9
    
10.
Lee IO, Kim SH, Kong MH, Lee MK, Kim NS, Choi YS, et al. Pain after laparoscopic cholecystectomy: The effect and timing of incisional and intraperitoneal bupivacaine. Can J Anaesth 2001;48:545-50.  Back to cited text no. 10
    
11.
Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evidence. Anesthesiology 2006;104:835-46.  Back to cited text no. 11
    
12.
Elhakim M, Elkott M, Ali NM, Tahoun HM. Intraperitoneal lidocaine for postoperative pain after laparoscopy. Acta Anaesthesiol Scand 2000;44:280-4.  Back to cited text no. 12
    
13.
Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy. Ann Surg 2003;238:651-60.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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