Öz
In this study, it was aimed to determine the effects of preemptive intravenous, spinal and epidural morphine on analgesic consumption, and stress response in the early postoperative period. Sixty ASA I-II patients who were undergoing lower abdominal surgery were randomly divided into three groups. Group I patients were admisnistered 5 mg iv morphine 5 minutes before induction, Grup II patients were administered 0.5 mg of intrathecal morphine 5 minutes before induction, Group III patients were administered 5 mg epidural morphine 30 min before induction of anesthesia. Induction of anesthesia, was performed with 0.1 mg kg fentanyl and 4-7 mg kgthiopental sodium. For muscle relaxation 0.1 mg kg vecuronium were given. Anaesthesia was maintained with 1-2% sevoflurane and 50% NO. Pre and postoperative hemodynamic parameters, VAS (Visual Analog Pain Scale) scores, time to first analgesic requirement, total analgesic consumption were recorded. In addition, to evaluate the stress response blood samples were taken three times before the administration of preoperative medications, preoperative 30th minute, and postoperative and 2nd hour. In our study, postoperative VAS scores between groups was significantly different at all times for the iv group and the spinal group and iv group and epidural group (P<0.05). In terms of time to first analgesic requirement, total analgesic consumption of group iv and iv with a group of spinal epidural group and the difference between groups was significant (P<0.05). Operative in terms of prolactin and ACTH between groups was significantly different at all times for the iv group and the spinal group and iv group and epidural group (P<0.05). Cortisol, glucose, and insulin levels postoperatively for 2. hour intravenous group and the spinal epidural group and iv group and the difference between groups was significant (P<0.05). As a result of preemptive spinal and epidural morphine in relieving postoperative pain and suppress the stress response was found to be effective in group iv.
Anahtar Kelimeler
Preemptive analgesia morphine spinal analgesia epidural analgesia intravenous analgesia stress response
Kaynakça
- Kissin I. Preemptive Analgesia. Anesthesiology 2000; 93: 1138-43.
- Katz J, McCartney CJ. Current status of preemptive analgesia. Curr Opin Anaesthesiol 2002; 15: 435-41.
- Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. American Family Physician 2001; 63: 1979-84.
- Woolf CJ. Recent advances in the pathophysiology of acute pain. Br J Anaesth 1989; 63: 139-46.
- Wall PD. The prevention of postoperative pain. Pain 1988; 33: 289-90.
- Woolf CJ, Chong MS. Preemptive analgesia--treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993; 77: 362-7
- Dahl JB, Erichsen CJ, Fuglsang-Frederiksen A, Kehlet H. Pain sensation and nociceptive reflex excitability in surgical patients and human volunteers. Br J Anesth 1992; 69: 117-21.
- Schulze S, Sommer P, Bigler D, Honnens M, Shenkin A, Cruickshank AM, Bukhave K, Kehlet H. Effect of combined prednisolone, epidural analgesia, and indomethacin on the systemic response after colonic surgery. Arch Surg 1992; 127: 325-31.
- Bent JM, Paterson JL, Mashiter K, Hall GM. Effects of high-dose fentanyl anaesthesia on the established metabolic and endocrine response to surgery. Anaesthesia 1978; 39: 19-23.
- Collis R, Brandner B, Bromley LM, Woolf CJ. Is there any clinical advantage of increasing the pre-emptive dose of morphine or combining pre-incisional with postoperative morphine administration? Br J Anaesth 1995; 74: 396-9.
- Niv D, Wolman I, Yashar T, Varrassi G, Rudick V, Geller E. Epidural morphine pretreatment for postepisiotomy pain. Clin J Pain 1994; 10; 319-23.
- Wilson RJ, Leith S, Jackson IJ, Hunter D. Pre-emptive analgesia from intravenous administration of opioids. No effect with alfentanil. Anaesthesia 1994; 49: 591-3.
- Fassoulaki A, Sarantopoulos C, Zotou M, Papoulia D. Preemptive opioid analgesia does not influence pain after abdominal hysterectomy. Can J Anaesth 1995; 42: 109-13.
- Rawal N, Arnér S, Gustafsson LL, Allvin R. Present state of extradural and intrathecal opioid analgesia in Sweden. A nationwide follow-up survey. Br J Anaesth 1987; 59: 791-9.
- Baraka A, Jabbour S, Ghabash M, Nader A, Khoury G, Sibai A. A comparison of epidural tramadol and epidural morphine for postoperative analgesia. Can J Anaesth 1993; 40: 308-13.
- Kundra P, Gurnani A, Bhattacharya A. Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy. Anesth Analg 1997; 85: 135
- Kayhan Z. Klinik Anestezi. II. Baskı. Logos Yayıncılık. İstanbul. 1997; 373: 544
- Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85; 109-17.
- Sarantopoulos CD, Fassoulaki A.When is preemptive analgesia truly preemptive? Anesthesiology 2001; 95: 565-7.
- Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: A meta-analysis. Anesth Analg 2005; 100: 757-3.
- Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474-506.
- Ünlügenç H, Özalevli M, Güneş Y, Güler T, Işık G. Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery. Br J Anaesth 2003; 91: 209-13.
- Richmond CE, Bromley LM, Woolf CJ. Preoperative morphine pre-empts postoperative pain. Lancet 1993; 10: 73-5.
- Aida S, Baba H, Yamakura T, Taga K, Fukuda S, Shimoji K. The effectiveness of preemptive analgesia varies according to the type of surgery: a randomized, double-blind study. Anesth Analg 1999; 89: 711-6.
- Bugedo GJ, Cárcamo CR, Mertens RA, Dagnino JA, Muñoz HR. Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy pain management in adults. Reg Anaesth 1990; 15: 130-3. Techanivate A, Kiatgungwanglia P, Yingsakmongkol W. Spinal morphine for post-operative analgesia after lumbar laminectomy with fusion. J Med Assoc Thai 2003; 86: 262-9.
- Özdilmaç İ, Altıntaş F, Salihoğlu Z, Demiroluk Ş, Aydın S, Uzun H. Alt batın cerrahisinde genel anestezi ile epidural-genel anestezi uygulamasının stres yanıta etkileri. Anestezi dergisi 2003; 11; 195-200.
- Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001; 87; 47-61.
- Miller RD. Anesthesia. Churchill, Livigstone 2000; 2323-43; 2192-6.
- Kurşun S, Çelebi H, Bozkırlı F, Elbek Ş. Midazolam-alfentanil ile TİVA ve halotan ile inhalasyon anestezisinin stresle oluşan endokrin ve metabolik yanıt üzerine etkileri. Türk Anest Rean Cem Mecmuası 1999; 27; 164-70.
- Grossi EA, Zakow PK, Ribakove G, Kallenbach K, Ursomanno P, Gradek CE, Baumann FG, Colvin SB, Galloway AC Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients. Eur J Cardiothorac Surg 1999; 16; S39-42.
- Desborough JP, Hall GM. Modification of the hormonal and metabolic response to surgery bynarcotics and general anaesthesia. Clin Anaesthesiol 1989; 3; 317
- Lacoumenta S, Yeo TH, Burrin JM, Bloom SR, Paterson JL, Hall GM. Fentanyl and the beta-endorphin, ACTH and glucoregulatory hormonal response to surgery. Br J Anaesth 1987; 59; 713-20.
- Kılıçkan L, Toker K. The effect of preemptive intravenous morphine on postoperative analgesia and surgical stress response. Panminerva Med 2001; 43; 171Kılıçkan L, Toker K. The effects of preemptive intravenous versus preemptive epidural morphine on postoperative analgesia and surgical stress response after orthopaedic procedures. Minerva Anesthesiol 2000; 66; 649-55.
- Engquist A, Brandt MR, Fernandes A, Kehlet H. The blocking effect of epidural analgesia on the adrenocortical and hyperglycemic responses to surgery. Acta Anaesthesiol Scand 1977; 231: 330-5.
- Breslow MJ, Jordan DA, Christopherson R, Rosenfeld B, Miller CF, Hanley DF, Beattie C, Traystman RJ, Rogers MC. Epidural morphine decreases postoperative hypertension by attenuating sympathetic nervous system hyperactivity. JAMA 1989; 261: 3577-81.
Pre-emptif uygulanan intravenöz, spinal ve epidural morfinin erken postoperatif analjezi ve stres yanıt üzerine etkileri
Öz
Bu çalışmada, preemptif uygulanan iv, spinal ve epidural morfinin erken postoperatif dönemdeki
analjezik tüketimi ve stres yanıt üzerine etkilerini belirlemek amaçlandı. Alt batın operasyonu
uygulanacak ASA I-II grubuna giren 60 hasta rasgele üç gruba ayrıldı. Grup I’e indüksiyondan 5
dk. önce 5 mg iv morfin, Grup II’ye indüksiyondan 5 dk önce 0,5 mg intratekal morfin, Grup III’e
indüksiyondan 30dk önce 5mg epidural morfin uygulandı. Anestezi indüksiyonu 0,1 µg kg-1
fentanil ve 4-7 mg kg-1 tiopental sodyum ile sağlandı. Kas gevşemesi ise 0,1mg/kg vekuronyum ile
sağlandı. İdamede %1-2 sevofluran ve %50 N2O kullanıldı. Pre ve postoperatif dönemde hastaların
hemodinamik parametreleri ve postoperatif dönemde hemodinamik parametreler, VAS (Visual
Analog Ağrı Skala) değerleri, ilk analjezik ihtiyaç zamanları ve total analjezik tüketimi kaydedildi.
Ayrıca stres yanıtı değerlendirmek için preoperatif dönemde ilaçlar uygulanmadan önce,
peroperatif 30’uncu dakika ve postoperatif 2’nci saatte olmak üzere üç kan örneği alındı.
Çalışmamızda VAS değerleri açısından postoperatif tüm zamanlarda iv grup ile spinal grup ve iv
grup ile epidural grup arasındaki farklılık anlamlı (P < 0.05). İlk analjezik ihtiyaç zamanı ve total
analjezik tüketimi açısından iv grup ile spinal grup ve iv grup ile epidural grup arasındaki farklılık
anlamlı bulundu (P < 0.05). Prolaktin ve ACTH değerleri açısından perop. 30 dk. ve postop. 2’nci
saatte iv grup ile spinal grup ve iv grup ile epidural grup arasındaki farklılık anlamlı bulundu
(P < 0.05). Kortizol, glukoz ve insülin değerleri açısından postop; 2’nci saatte iv grup ile spinal
grup ve iv grup ile epidural grup arasındaki farklılık anlamlı bulundu (P < 0.05). Sonuç olarak
preemptif uygulanan spinal ve epidural morfinin postoperatif ağrıyı gidermede ve stres yanıtı
baskılamada iv gruba göre etkili oldukları tesbit edildi.
Anahtar Kelimeler
Preemptif analjezi morfin spinal analjezi epidural analjezi iv analjezi stres yanıt
Kaynakça
- Kissin I. Preemptive Analgesia. Anesthesiology 2000; 93: 1138-43.
- Katz J, McCartney CJ. Current status of preemptive analgesia. Curr Opin Anaesthesiol 2002; 15: 435-41.
- Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. American Family Physician 2001; 63: 1979-84.
- Woolf CJ. Recent advances in the pathophysiology of acute pain. Br J Anaesth 1989; 63: 139-46.
- Wall PD. The prevention of postoperative pain. Pain 1988; 33: 289-90.
- Woolf CJ, Chong MS. Preemptive analgesia--treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993; 77: 362-7
- Dahl JB, Erichsen CJ, Fuglsang-Frederiksen A, Kehlet H. Pain sensation and nociceptive reflex excitability in surgical patients and human volunteers. Br J Anesth 1992; 69: 117-21.
- Schulze S, Sommer P, Bigler D, Honnens M, Shenkin A, Cruickshank AM, Bukhave K, Kehlet H. Effect of combined prednisolone, epidural analgesia, and indomethacin on the systemic response after colonic surgery. Arch Surg 1992; 127: 325-31.
- Bent JM, Paterson JL, Mashiter K, Hall GM. Effects of high-dose fentanyl anaesthesia on the established metabolic and endocrine response to surgery. Anaesthesia 1978; 39: 19-23.
- Collis R, Brandner B, Bromley LM, Woolf CJ. Is there any clinical advantage of increasing the pre-emptive dose of morphine or combining pre-incisional with postoperative morphine administration? Br J Anaesth 1995; 74: 396-9.
- Niv D, Wolman I, Yashar T, Varrassi G, Rudick V, Geller E. Epidural morphine pretreatment for postepisiotomy pain. Clin J Pain 1994; 10; 319-23.
- Wilson RJ, Leith S, Jackson IJ, Hunter D. Pre-emptive analgesia from intravenous administration of opioids. No effect with alfentanil. Anaesthesia 1994; 49: 591-3.
- Fassoulaki A, Sarantopoulos C, Zotou M, Papoulia D. Preemptive opioid analgesia does not influence pain after abdominal hysterectomy. Can J Anaesth 1995; 42: 109-13.
- Rawal N, Arnér S, Gustafsson LL, Allvin R. Present state of extradural and intrathecal opioid analgesia in Sweden. A nationwide follow-up survey. Br J Anaesth 1987; 59: 791-9.
- Baraka A, Jabbour S, Ghabash M, Nader A, Khoury G, Sibai A. A comparison of epidural tramadol and epidural morphine for postoperative analgesia. Can J Anaesth 1993; 40: 308-13.
- Kundra P, Gurnani A, Bhattacharya A. Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy. Anesth Analg 1997; 85: 135
- Kayhan Z. Klinik Anestezi. II. Baskı. Logos Yayıncılık. İstanbul. 1997; 373: 544
- Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85; 109-17.
- Sarantopoulos CD, Fassoulaki A.When is preemptive analgesia truly preemptive? Anesthesiology 2001; 95: 565-7.
- Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: A meta-analysis. Anesth Analg 2005; 100: 757-3.
- Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474-506.
- Ünlügenç H, Özalevli M, Güneş Y, Güler T, Işık G. Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery. Br J Anaesth 2003; 91: 209-13.
- Richmond CE, Bromley LM, Woolf CJ. Preoperative morphine pre-empts postoperative pain. Lancet 1993; 10: 73-5.
- Aida S, Baba H, Yamakura T, Taga K, Fukuda S, Shimoji K. The effectiveness of preemptive analgesia varies according to the type of surgery: a randomized, double-blind study. Anesth Analg 1999; 89: 711-6.
- Bugedo GJ, Cárcamo CR, Mertens RA, Dagnino JA, Muñoz HR. Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy pain management in adults. Reg Anaesth 1990; 15: 130-3. Techanivate A, Kiatgungwanglia P, Yingsakmongkol W. Spinal morphine for post-operative analgesia after lumbar laminectomy with fusion. J Med Assoc Thai 2003; 86: 262-9.
- Özdilmaç İ, Altıntaş F, Salihoğlu Z, Demiroluk Ş, Aydın S, Uzun H. Alt batın cerrahisinde genel anestezi ile epidural-genel anestezi uygulamasının stres yanıta etkileri. Anestezi dergisi 2003; 11; 195-200.
- Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001; 87; 47-61.
- Miller RD. Anesthesia. Churchill, Livigstone 2000; 2323-43; 2192-6.
- Kurşun S, Çelebi H, Bozkırlı F, Elbek Ş. Midazolam-alfentanil ile TİVA ve halotan ile inhalasyon anestezisinin stresle oluşan endokrin ve metabolik yanıt üzerine etkileri. Türk Anest Rean Cem Mecmuası 1999; 27; 164-70.
- Grossi EA, Zakow PK, Ribakove G, Kallenbach K, Ursomanno P, Gradek CE, Baumann FG, Colvin SB, Galloway AC Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients. Eur J Cardiothorac Surg 1999; 16; S39-42.
- Desborough JP, Hall GM. Modification of the hormonal and metabolic response to surgery bynarcotics and general anaesthesia. Clin Anaesthesiol 1989; 3; 317
- Lacoumenta S, Yeo TH, Burrin JM, Bloom SR, Paterson JL, Hall GM. Fentanyl and the beta-endorphin, ACTH and glucoregulatory hormonal response to surgery. Br J Anaesth 1987; 59; 713-20.
- Kılıçkan L, Toker K. The effect of preemptive intravenous morphine on postoperative analgesia and surgical stress response. Panminerva Med 2001; 43; 171Kılıçkan L, Toker K. The effects of preemptive intravenous versus preemptive epidural morphine on postoperative analgesia and surgical stress response after orthopaedic procedures. Minerva Anesthesiol 2000; 66; 649-55.
- Engquist A, Brandt MR, Fernandes A, Kehlet H. The blocking effect of epidural analgesia on the adrenocortical and hyperglycemic responses to surgery. Acta Anaesthesiol Scand 1977; 231: 330-5.
- Breslow MJ, Jordan DA, Christopherson R, Rosenfeld B, Miller CF, Hanley DF, Beattie C, Traystman RJ, Rogers MC. Epidural morphine decreases postoperative hypertension by attenuating sympathetic nervous system hyperactivity. JAMA 1989; 261: 3577-81.
Ayrıntılar
| Birincil Dil | Türkçe |
|---|---|
| Bölüm | Cerrahi Tıp Bilimleri Araştırma Yazıları |
| Yazarlar | |
| Yayımlanma Tarihi | 27 Mart 2013 |
| Yayımlandığı Sayı | Yıl 2013Cilt: 35 Sayı: 3 |