Preemptive Effects of a Combination of Preoperative Diclofenac, Butorphanol: METHODS

In: Anesthesia

5 Feb 2010

We studied 82 patients undergoing SSRO for mandibular protrusion or retrusion. All patients were classified Patients were randomly allocated either to a preemptive multimodal analgesia group (group P, n = 41) or to a control group (group C, n = 41). Subjects in both groups received 10 ixgAg of atropine sulfate and 0.06 mgAg of midazolam intramuscularly 30 minutes before induction of anesthesia. Lactated Ringer’s solution was infused intravenously at a rate of 10 mLAg/h. Anesthesia was induced with 4 mgAg of thiopental sodium, given as a single intravenous bolus, and maintained with a mixture of nitrous oxide (3 L/min), oxygen (2 L/min), and isoflurane. Nasotracheal intubation was conducted following intravenous administration of 0.08 mgAg of vecuronium bromide. Patients were mechanically ventilated with a volume-limited respirator (AV 500, IMI, Saitama, Japan). The isoflurane concentration was adjusted to secure hemodynamic stability during surgery by an anesthetist who did not otherwise participate in this study.

To prevent peripheral sensitization, patients in group P received 50 mg of sodium (No-vartis Pharma, Basel, Switzerland) rectally immediately after nasotracheal intubation. To prevent central sensitization, 10 ixgAg of 0.1% butorphanol (Stadol, Bristol, Tokyo, Japan) was administered intravenously at the induction of anesthesia. Our previous study indicated that 10 ixgAg of butorphanol tartrate was able to produce hemodynamic stability during isoflurane anesthesia for oral surgery. In addition, 8 mL of 1% lidocaine solution containing 1:100,000 (10 |xg/mL) epinephrine (Xylocaine, Astra Japan, Osaka, Japan) was administered for regional anesthesia and for bilateral inferior alveolar nerve blocks 5 minutes before the start of surgery. Patients in group С received 10 ixLAg of physiological saline intravenously at the induction of anesthesia. For hemostasis of the surgical area, 8 mL of a physiological saline containing 1:100,000 (10 |xg/ mL) epinephrine was administered before incision. Patients in group С did not receive drugs, such as opioids, NSAIDs, and local anesthetics, other than nitrous oxide and isoflurane. After surgery, extubation of the trachea was conducted following confirmation of adequate recovery from anesthesia. During surgery, continuous monitoring was conducted for ECG with an electrocardiograph (Polygraph series 360, NEC San-ei, Tokyo, Japan), arterial oxygen saturation with a pulse oximeter (Capnomac Ultima, Datex, Helsinki, Finland), and blood pressure with an oscillometric blood pressure monitor (BP-203i, Nippon Colin, Aichi, Japan) every 5 minutes, and both expiratory carbon dioxide concentrations and end-tidal isoflurane concentrations (ETlso) with an anesthetic gas monitor (Capnomac ultima, Datex, Helsinki, Finland).

Postoperative pain intensity (POPI) at rest was assessed 1 hour after extubation in the postanesthesia care unit (PACU) using a numerical rating score (NRS) ranging from 0 (no pain) to 10 (worst pain). The POPI was assessed at the first water intake (FWI; 3 hours after extubation) and at 24, 48, and 72 hours after extubation using a visual analogue scale (VAS) from 0 mm (no pain) to 100 mm (worst pain). The patients received an oral or rectal dose of sodium, 50 mg, on demand as a postoperative analgesic. Some patients could not take postoperative analgesics orally due to postoperative intermaxillary fixation.

In the author’s hospital, canadian diclofenac sodium and other NSAIDs are often administered orally or rectally to reduce pain after oral surgery. When the patient had received the postoperative analgesic before the POPI rating, the score just before medication was recorded as the POPI value. For the assessment of the POPI score at FWI, patients were divided into 2 groups based on whether they received postoperative analgesic supplement before FWI. The period from extubation to the first supplementary postoperative analgesic dosage and the total number of postoperative diclofenac sodium doses administered during the 72 hours after extubation were recorded. In addition, the number of patients who received postoperative analgesic supplement was recorded on the day of surgery and for 3 days after surgery. Only 1 investigator, blinded to the medications given to the patient, assessed POPI in all patients.

For the assessment of intraoperative hemodynamics, ETISO, systolic blood pressure (SBP), heart rate (HR), and rate-pressure product (RPP = SBP x HR) were recorded during the period from incision to the start of the closing suture, and their mean values, standard deviations (SDs), and coefficients of variation (CVs) were calculated. For patients in group P, the intervals from administration of both generic diclofenac sodium and butorphanol tartrate to incision, end of surgery, and assessment of NRS were recorded.
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Pain scores and the number of postoperative analgesic doses were analyzed using the Mann-Whitney U test. The difference in the number of patients who received postoperative analgesic supplement was analyzed using the chi-square test. The period from extubation to the first supplementary postoperative analgesic administration and the mean values of ETISO, SBP, HR, and RPP and the CVs of SBP, HR, and RPP were subjected to analysis by Student’s t test for independent samples. Statistical significance was assigned for a difference when the P value was less than .05.


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