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Comparison of preoperative with postoperative lignocaine infiltration on postoperative analgesic requirements
British Journal of Anaesthesia 1994; 72: 541-543
Comparison of preoperative with postoperative lignocaine infiltration on postoperative analgesic requirements G. A. TURNER AND G. CHALKIADIS
PATIENTS AND METHODS
SUMMARY
KEY WORDS Analgesia: pre-emptive. Analgesic techniques;
infiltration.
The concept of pre-emptive analgesia has been suggested recently as another technique in the treatment of postoperative pain. A recent review by Dahl and Kehlet [1] outlined the basic neurophysiology and reviewed the studies which have attempted to demonstrate the value of pre-emptive analgesia. However, there have been few randomized clinical studies where identical analgesic techniques have been applied, both pre- and post-incision. These have produced conflicting results with respect to the benefit on postoperative analgesia [2-4]. Furthermore, the amount of postoperative pain was not determined by the use of both pain scores and a patient-controlled analgesia system (PCAS), which has become a widely accepted method for comparing analgesic techniques. We conducted a pilot study in which we compared local anaesthetic infiltration before operation with a local anaesthetic after operation and a normal saline group. We found no difference between pre-incision local anaesthetic infiltration and the normal saline group, but less pethidine was required after operation by the postoperative infiltration group [5]. However, postoperative analgesic requirements were determined by intermittent i.m. opioids in this study. Therefore, we performed a similar study using PCA.
After obtaining approval from the hospital Ethics Committee and informed written patient consent, we studied 90 ASA I and II patients undergoing appendicectomy. Patients were allocated randomly to one of three treatment groups according to a computer generated random sequence. In the preincision group, 1.5% lignocaine 7.5 ml with adrenaline 1:200000 was infiltrated into the skin and subcutaneous tissues along the proposed wound line after induction of anaesthesia, 3 min before incision. Another 7.5 ml of local anaesthetic solution was infiltrated into the muscle layer before incision. In the post-incision group, 1.5 % lignocaine 7.5 ml with adrenaline 1:200 000 was infiltrated into the muscle layers at wound closure and another 7.5 ml infiltrated into the skin and subcutaneous tissue when these layers were closed. The control group received no wound infiltration. All infiltrations were administered by the surgeon. As these patients were emergency cases, all had appropriate analgesia before surgery. Further premedication was at the discretion of the anaesthetist with regard to the need for analgesia. It was not possible to standardize premedication as some patients had received opioid analgesia recently whereas others were in pain and needed appropriate analgesia. Anaesthesia was induced with thiopentone and maintained with nitrous oxide, oxygen and a volatile agent after tracheal intubation facilitated by suxamethonium. Neuromuscular block was continued with vecuronium for the duration of the procedure. Fentanyl i.v. was used for intraoperative analgesia. At surgery, the severity of the appendix was graded by the surgeon as either: 1 = white, no inflammation present; 2 = red and inflamed; 3 = inflamed with free pus present. All patients were given a PCAS (after instruction in its use before operation) set for a bolus dose of pethidine 10 mg, a 5-min lockout period with no 4-h dose limit. The cumulative dose of pethidine used was recorded at 12, 24, 36 and 48 h after operation. Linear analogue pain scores were assessed while the patients were lying supine and on moving from a supine to a sitting position at 24 and 48 h after operation. G. A. TURNER, M.B., B.S., F.R.C.A., F.A.N.Z.C.A., G. CHALKIADIS,
M.B., B.S., D.A., Royal Perth Hospital, Perth, Western Australia. Accepted for Publication: November 11, 1993.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
Ninety patients undergoing appendicectomy were allocated randomly to receive 1.5% lignocaine 15 ml with adrenaline infiltrated into the proposed wound line 3 min before incision, lignocaine 15 ml with adrenaline infiltrated into the wound on closure or no wound infiltration. After operation, all patients received pethidine by patient-controlled analgesia. Pain scores were assessed while supine and sitting on day 1 and 2 and the cumulative pethidine dose administered was recorded at 12, 24, 36 and 48 h after operation. There were no significant differences in the cumulative dose of pethidine required or pain scores between the three groups at any time point after operation. We conclude that pre-incisional infiltration with 1.5% lignocaine had no advantage compared with infiltration at wound closure or no wound infiltration in reducing postoperative analgesic requirements or pain scores after appendicectomy. (Br. J. Anaesth. 1994; 72:541-543)
BRITISH JOURNAL OF ANAESTHESIA
542
TABLE I. Patient characteristics (mean (range) or number)
Age (yr) Sex (M/F) Condition of appendix White Inflamed Free pus
Control group
Pre-incision group
Post-incision group
25.3(16-47) 21/8
31.3(16-76) 14/15
24.5 (13-53 16/16
7 6 15
7 6 15
7 15 9
0.038 >0.05 >0.1
scores, both at rest and while sitting, did not differ significantly between the three groups on day 1 or day 2 (table III). In all groups, pain scores while sitting were greater than those at rest.
RESULTS
Several experimental studies have shown that preinjury blocks with local anaesthetic or opioids may provide a prolonged post-injury analgesic effect [6, 7], but there have been few studies demonstrating this phenomenon in clinical practice. In this study, we found no difference in pain scores or postoperative opioid requirements between patients receiving lignocaine infiltration either pre- or postappendicectomy and those having no infiltration. This is in accordance with other studies [2,3], reporting no benefit from pre-incisional inguinal field block or preoperative extradural block compared with postoperative block. There has only been one study demonstrating a beneficial effect of pre-incisional local anaesthetic infiltration when compared directly with the same local anaesthetic block given after operation [4]. That study demonstrated no difference in pain scores for the first 6 h after operation and an increase in time to request of first analgesia in the pre-incisional group. However, the study lasted for only 6 h after operation and the use of on demand oral analgesics is a less precise measure of postoperative analgesic requirements than PCAS. Several studies have compared local anaesthetic infiltration either before or after operation with either no treatment or normal saline infiltration [8-14]. In almost all of these, there has been some benefit with regard to analgesia in the active treatment group. However, the absence of an identically matched treatment group performed on the pre- or post-incision prevents any conclusions with respect to pre-emptive analgesia. We failed to demonstrate any benefit of the local anaesthetic infiltrations over the control group, in contrast with many other studies. It is possible that the main cause of pain in our patients was peritoneal irritation which was not blocked by local anaesthetic infiltration. This may have contributed also to our failure to detect a difference between the pre- and post-incisional local anaesthetic groups. While this study rejects the hypothesis that preincisional infiltration of local anaesthetic provides improved postoperative pain relief because of the large range of pethidine required after operation, the power to accept the alternative hypothesis that there was no value in pre-incisional infiltration was only
There were 32 patients in the post-incision group and 29 patients in the control and pre-incision groups, respectively. There was no statistically significant difference between the groups in the condition of the appendix at the time of surgery and the ratio of males to females (table I). However, mean age of the patients in the pre-incision group was significantly greater compared with the other groups {P < 0.05). The pattern of premedication was similar in the three groups. No premedication was prescribed for 76 % of the control patients, 66 % and 62.5 % of the pre- and post-incision groups, respectively. Opioid premedication—analgesia was given within 2 h of surgery to 17% of the control patients, 34% of the pre-incision patients and 25 % of the post-incision patients. The remaining patients received oral temazepam as premedication (7%, 0% and 12.5%, respectively; P> 0.2). Mean (SD) dose of fentanyl given during operation was 117.86 (51.75), 140.5 (72.7) and 115.8 (68.7), respectively (P > 0.2). The cumulative dose of pethidine used by PCA over the first 48 h after operation did not differ significantly between the three groups (table II). Similarly, there was no difference between the three groups at 12, 24 and 36 h after operation. Pain TABLE II. Mean (SD) cumulative dose of pethidine in the three groups Time after op. 12h 24 h 36 h 48 h
Control group 216(88) 431 (158) 567 (225) 662(313)
TABLE III.
1: 1: 2: 2:
supine sitting supine sitting
228(123) 427 (229) 569(305) 640(361)
255(159) 480 (302) 631 (417) 724(502)
P 0.48 0.63 0.69 0.70
Mean (SD) pain scores forthe three groups Control group
Day Day Day Day
Pre-incision Post-incision group group
2.52(1.6) 5.8(1.7) 1.42(1.1) 4.4 (2.4)
Pre-incision Post-incision group group 2.92 (2.2) 6.0 (2.8) 1.6(1.9) 4.7 (2.6)
3.2(1.9) 6.3 (2.2) 1.8(2.1) 4.1 (2.5)
P 0.39 0.71 0.74 0.72
DISCUSSION
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
All patients and observers were blinded with regard to patient grouping and the patients were monitored by the hospital's acute pain service. All data were analysed using one-way ANOVA for parametric data and chi-square tests for nonparametric data.
PREOPERATIVE VS POSTOPERATIVE LOCAL ANAESTHETIC INFILTRATION 14 %. Therefore, further larger studies are warranted to enable us to accept this hypothesis with more confidence.
7. Dickenson A, Sullivan A. Subcutaneous formalin-induced activity of dorsal horn neurones in the rat: Differential response to an intrathecal opiate administered pre or post formalin. Pain 1987; 30: 349-360. 8. Hashemi K, Middleton MD. Subcutaneous bupivacaine for postoperative analgesia after herniorrhaphy. Annals of the Royal College of Surgeons 1983; 65: 38-39. 9. Owen H, Galloway DJ, Mitchell KG. Analgesia by wound infiltration after surgical excision of benign breast lumps. Annals of the Royal College of Surgeons 1985; 67: 114-115. 10. Sinclair R, Cassulto J, Hogstrom S, Linden I, Faxen A, Hedner T, Ekman R. Topical anesthesia with lidocaine aerosol in the control of postoperative pain. Anesthesiology 1988; 68: 895-901. 11. Thomas DFM, Lambert WG, Williams KL. The direct perfusion of surgical wounds with local anaesthetic solution: an approach to postoperative pain? Annals of the Royal College of Surgeons 1983; 65: 226-229. 12. Bugedo GJ, Carcamo CR, Mertens RA, Dagnino JA, Munoz HR. Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5 % bupivacaine for posthemiorrhaphy pain management in adults. Regional Analgesia 1990; 15: 130-133. 13. Jebeles JA, Reilly JS, Gutierrez JF, Bradley EL, Kissin I. The effect of pre-incisional infiltration of tonsils with bupivacaine on the pain following tonsillectomy under general anaesthesia. Pain 1991; 47: 305-308. 14. Tverskoy M, Cozacov C, Ayache M, Bradley EL, Kissin I. Postoperative pain after inguinal herniorrhaphy with different types of anesthesia. Anesthesia and Analgesia 1990; 70: 29-35.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
REFERENCES 1. Dahl JB, Kehlet H. The value of pre-emptive analgesia in the treatment of postoperative pain. British Journal of Anaesthesia 1993; 70: 434-439. 2. Dierking GW, Dahl JB, Kanstrup J, Dahl A, Kehlet H. Effe« of pre- vs postoperative inguinal field block on postoperative pain after herniorrhaphy. British Journal of Anaesthesia 1992; 68: 344-348. 3. Dahl JB, Hansen BL, Hjortso NC, Erichsen CJ, Moiniche S, Kehlet H. Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery. British Journal of Anaesthesia 1992; 69: 4-8. 4. Ejlersen E, Andersen HB, Eliasen K, Mogensen T. A comparison between preincisional and postincisional lidocaine infiltration and postoperative pain. Anesthesia and Analgesia 1992; 74: 495-498. 5. Chalkiadis G, Goucke C, Sims C, Turner G. A comparison of the effects of bupivacaine infiltration pre and post surgery on postoperative analgesia. Anaesthesia and Intensive Care 1992; 20: 113. 6. Woolf CJ, Wall PD. Morphine-sensitive and morphineinsensitive actions of C-fibre input on the rat spinal cord. Neuroscience Letters 1986; 64: 221-225.
543
Comparison of preoperative with postoperative lignocaine infiltration on postoperative analgesic requirements G. A. TURNER AND G. CHALKIADIS
PATIENTS AND METHODS
SUMMARY
KEY WORDS Analgesia: pre-emptive. Analgesic techniques;
infiltration.
The concept of pre-emptive analgesia has been suggested recently as another technique in the treatment of postoperative pain. A recent review by Dahl and Kehlet [1] outlined the basic neurophysiology and reviewed the studies which have attempted to demonstrate the value of pre-emptive analgesia. However, there have been few randomized clinical studies where identical analgesic techniques have been applied, both pre- and post-incision. These have produced conflicting results with respect to the benefit on postoperative analgesia [2-4]. Furthermore, the amount of postoperative pain was not determined by the use of both pain scores and a patient-controlled analgesia system (PCAS), which has become a widely accepted method for comparing analgesic techniques. We conducted a pilot study in which we compared local anaesthetic infiltration before operation with a local anaesthetic after operation and a normal saline group. We found no difference between pre-incision local anaesthetic infiltration and the normal saline group, but less pethidine was required after operation by the postoperative infiltration group [5]. However, postoperative analgesic requirements were determined by intermittent i.m. opioids in this study. Therefore, we performed a similar study using PCA.
After obtaining approval from the hospital Ethics Committee and informed written patient consent, we studied 90 ASA I and II patients undergoing appendicectomy. Patients were allocated randomly to one of three treatment groups according to a computer generated random sequence. In the preincision group, 1.5% lignocaine 7.5 ml with adrenaline 1:200000 was infiltrated into the skin and subcutaneous tissues along the proposed wound line after induction of anaesthesia, 3 min before incision. Another 7.5 ml of local anaesthetic solution was infiltrated into the muscle layer before incision. In the post-incision group, 1.5 % lignocaine 7.5 ml with adrenaline 1:200 000 was infiltrated into the muscle layers at wound closure and another 7.5 ml infiltrated into the skin and subcutaneous tissue when these layers were closed. The control group received no wound infiltration. All infiltrations were administered by the surgeon. As these patients were emergency cases, all had appropriate analgesia before surgery. Further premedication was at the discretion of the anaesthetist with regard to the need for analgesia. It was not possible to standardize premedication as some patients had received opioid analgesia recently whereas others were in pain and needed appropriate analgesia. Anaesthesia was induced with thiopentone and maintained with nitrous oxide, oxygen and a volatile agent after tracheal intubation facilitated by suxamethonium. Neuromuscular block was continued with vecuronium for the duration of the procedure. Fentanyl i.v. was used for intraoperative analgesia. At surgery, the severity of the appendix was graded by the surgeon as either: 1 = white, no inflammation present; 2 = red and inflamed; 3 = inflamed with free pus present. All patients were given a PCAS (after instruction in its use before operation) set for a bolus dose of pethidine 10 mg, a 5-min lockout period with no 4-h dose limit. The cumulative dose of pethidine used was recorded at 12, 24, 36 and 48 h after operation. Linear analogue pain scores were assessed while the patients were lying supine and on moving from a supine to a sitting position at 24 and 48 h after operation. G. A. TURNER, M.B., B.S., F.R.C.A., F.A.N.Z.C.A., G. CHALKIADIS,
M.B., B.S., D.A., Royal Perth Hospital, Perth, Western Australia. Accepted for Publication: November 11, 1993.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
Ninety patients undergoing appendicectomy were allocated randomly to receive 1.5% lignocaine 15 ml with adrenaline infiltrated into the proposed wound line 3 min before incision, lignocaine 15 ml with adrenaline infiltrated into the wound on closure or no wound infiltration. After operation, all patients received pethidine by patient-controlled analgesia. Pain scores were assessed while supine and sitting on day 1 and 2 and the cumulative pethidine dose administered was recorded at 12, 24, 36 and 48 h after operation. There were no significant differences in the cumulative dose of pethidine required or pain scores between the three groups at any time point after operation. We conclude that pre-incisional infiltration with 1.5% lignocaine had no advantage compared with infiltration at wound closure or no wound infiltration in reducing postoperative analgesic requirements or pain scores after appendicectomy. (Br. J. Anaesth. 1994; 72:541-543)
BRITISH JOURNAL OF ANAESTHESIA
542
TABLE I. Patient characteristics (mean (range) or number)
Age (yr) Sex (M/F) Condition of appendix White Inflamed Free pus
Control group
Pre-incision group
Post-incision group
25.3(16-47) 21/8
31.3(16-76) 14/15
24.5 (13-53 16/16
7 6 15
7 6 15
7 15 9
0.038 >0.05 >0.1
scores, both at rest and while sitting, did not differ significantly between the three groups on day 1 or day 2 (table III). In all groups, pain scores while sitting were greater than those at rest.
RESULTS
Several experimental studies have shown that preinjury blocks with local anaesthetic or opioids may provide a prolonged post-injury analgesic effect [6, 7], but there have been few studies demonstrating this phenomenon in clinical practice. In this study, we found no difference in pain scores or postoperative opioid requirements between patients receiving lignocaine infiltration either pre- or postappendicectomy and those having no infiltration. This is in accordance with other studies [2,3], reporting no benefit from pre-incisional inguinal field block or preoperative extradural block compared with postoperative block. There has only been one study demonstrating a beneficial effect of pre-incisional local anaesthetic infiltration when compared directly with the same local anaesthetic block given after operation [4]. That study demonstrated no difference in pain scores for the first 6 h after operation and an increase in time to request of first analgesia in the pre-incisional group. However, the study lasted for only 6 h after operation and the use of on demand oral analgesics is a less precise measure of postoperative analgesic requirements than PCAS. Several studies have compared local anaesthetic infiltration either before or after operation with either no treatment or normal saline infiltration [8-14]. In almost all of these, there has been some benefit with regard to analgesia in the active treatment group. However, the absence of an identically matched treatment group performed on the pre- or post-incision prevents any conclusions with respect to pre-emptive analgesia. We failed to demonstrate any benefit of the local anaesthetic infiltrations over the control group, in contrast with many other studies. It is possible that the main cause of pain in our patients was peritoneal irritation which was not blocked by local anaesthetic infiltration. This may have contributed also to our failure to detect a difference between the pre- and post-incisional local anaesthetic groups. While this study rejects the hypothesis that preincisional infiltration of local anaesthetic provides improved postoperative pain relief because of the large range of pethidine required after operation, the power to accept the alternative hypothesis that there was no value in pre-incisional infiltration was only
There were 32 patients in the post-incision group and 29 patients in the control and pre-incision groups, respectively. There was no statistically significant difference between the groups in the condition of the appendix at the time of surgery and the ratio of males to females (table I). However, mean age of the patients in the pre-incision group was significantly greater compared with the other groups {P < 0.05). The pattern of premedication was similar in the three groups. No premedication was prescribed for 76 % of the control patients, 66 % and 62.5 % of the pre- and post-incision groups, respectively. Opioid premedication—analgesia was given within 2 h of surgery to 17% of the control patients, 34% of the pre-incision patients and 25 % of the post-incision patients. The remaining patients received oral temazepam as premedication (7%, 0% and 12.5%, respectively; P> 0.2). Mean (SD) dose of fentanyl given during operation was 117.86 (51.75), 140.5 (72.7) and 115.8 (68.7), respectively (P > 0.2). The cumulative dose of pethidine used by PCA over the first 48 h after operation did not differ significantly between the three groups (table II). Similarly, there was no difference between the three groups at 12, 24 and 36 h after operation. Pain TABLE II. Mean (SD) cumulative dose of pethidine in the three groups Time after op. 12h 24 h 36 h 48 h
Control group 216(88) 431 (158) 567 (225) 662(313)
TABLE III.
1: 1: 2: 2:
supine sitting supine sitting
228(123) 427 (229) 569(305) 640(361)
255(159) 480 (302) 631 (417) 724(502)
P 0.48 0.63 0.69 0.70
Mean (SD) pain scores forthe three groups Control group
Day Day Day Day
Pre-incision Post-incision group group
2.52(1.6) 5.8(1.7) 1.42(1.1) 4.4 (2.4)
Pre-incision Post-incision group group 2.92 (2.2) 6.0 (2.8) 1.6(1.9) 4.7 (2.6)
3.2(1.9) 6.3 (2.2) 1.8(2.1) 4.1 (2.5)
P 0.39 0.71 0.74 0.72
DISCUSSION
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
All patients and observers were blinded with regard to patient grouping and the patients were monitored by the hospital's acute pain service. All data were analysed using one-way ANOVA for parametric data and chi-square tests for nonparametric data.
PREOPERATIVE VS POSTOPERATIVE LOCAL ANAESTHETIC INFILTRATION 14 %. Therefore, further larger studies are warranted to enable us to accept this hypothesis with more confidence.
7. Dickenson A, Sullivan A. Subcutaneous formalin-induced activity of dorsal horn neurones in the rat: Differential response to an intrathecal opiate administered pre or post formalin. Pain 1987; 30: 349-360. 8. Hashemi K, Middleton MD. Subcutaneous bupivacaine for postoperative analgesia after herniorrhaphy. Annals of the Royal College of Surgeons 1983; 65: 38-39. 9. Owen H, Galloway DJ, Mitchell KG. Analgesia by wound infiltration after surgical excision of benign breast lumps. Annals of the Royal College of Surgeons 1985; 67: 114-115. 10. Sinclair R, Cassulto J, Hogstrom S, Linden I, Faxen A, Hedner T, Ekman R. Topical anesthesia with lidocaine aerosol in the control of postoperative pain. Anesthesiology 1988; 68: 895-901. 11. Thomas DFM, Lambert WG, Williams KL. The direct perfusion of surgical wounds with local anaesthetic solution: an approach to postoperative pain? Annals of the Royal College of Surgeons 1983; 65: 226-229. 12. Bugedo GJ, Carcamo CR, Mertens RA, Dagnino JA, Munoz HR. Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5 % bupivacaine for posthemiorrhaphy pain management in adults. Regional Analgesia 1990; 15: 130-133. 13. Jebeles JA, Reilly JS, Gutierrez JF, Bradley EL, Kissin I. The effect of pre-incisional infiltration of tonsils with bupivacaine on the pain following tonsillectomy under general anaesthesia. Pain 1991; 47: 305-308. 14. Tverskoy M, Cozacov C, Ayache M, Bradley EL, Kissin I. Postoperative pain after inguinal herniorrhaphy with different types of anesthesia. Anesthesia and Analgesia 1990; 70: 29-35.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 15, 2015
REFERENCES 1. Dahl JB, Kehlet H. The value of pre-emptive analgesia in the treatment of postoperative pain. British Journal of Anaesthesia 1993; 70: 434-439. 2. Dierking GW, Dahl JB, Kanstrup J, Dahl A, Kehlet H. Effe« of pre- vs postoperative inguinal field block on postoperative pain after herniorrhaphy. British Journal of Anaesthesia 1992; 68: 344-348. 3. Dahl JB, Hansen BL, Hjortso NC, Erichsen CJ, Moiniche S, Kehlet H. Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery. British Journal of Anaesthesia 1992; 69: 4-8. 4. Ejlersen E, Andersen HB, Eliasen K, Mogensen T. A comparison between preincisional and postincisional lidocaine infiltration and postoperative pain. Anesthesia and Analgesia 1992; 74: 495-498. 5. Chalkiadis G, Goucke C, Sims C, Turner G. A comparison of the effects of bupivacaine infiltration pre and post surgery on postoperative analgesia. Anaesthesia and Intensive Care 1992; 20: 113. 6. Woolf CJ, Wall PD. Morphine-sensitive and morphineinsensitive actions of C-fibre input on the rat spinal cord. Neuroscience Letters 1986; 64: 221-225.
543