Control
of Post-Thyroidectomy Pain: A Comparison between Local Wound Infiltration and
Bilateral Superficial Cervical Plexus Block.
Masoud A.
Lfeituri,* Mohamed M. Gaber,* Amer E. Ben-Irhuma,**
Saad S.
El-Taleb,*** Abdul Mutaleb B. Issa.****
Abstract:
Background: Regional anesthesia for post-thyroidectomy pain
management has recently become as a new trend that provides a good quality of
analgesia with more prolonged duration and lesser side effects than IV
analgesia.
Aim of the study: We aimed to assess the bilateral superficial cervical plexus block
(BSCB) versus local wound infiltration (LWI) after thyroid surgery with regard
to postoperative analgesic efficacy.
Patients & Methods: Sixty adult patients of
both sexes scheduled for elective thyroid surgery were randomly categorized into three equal groups. In
the first group no regional block was performed (group-C), in the second group
(group-L) the wound was infiltrated with 0.5% bupivacaine at the end of
surgery, and the third group (group-B) received BSCB immediately after the
induction of general anesthesia. Pain intensity was evaluated by the
eleven-category numerical rating scale (NRS) and the four-category verbal
rating scale (VRS) at the first hour after surgery, and then every 4 hours for the
24 hours postoperatively.
Results: NRS and VRS mean scores were significantly lower in
groups (L) and (B) compared with the (C) group. The mean (± SD) of
postoperative NRS scores was 3.82 (± 0.65), 2.01 (± 0.61), and 1.36 (± 0.70) in
the (C), (L), and (B) groups respectively. The corresponding values measured by
VRS were 2.49 (± 0.20), 1.71 (± 0.22), and 1.55 (± 0.23).
Conclusion: Although
both techniques are effective for post-thyroidectomy pain management during the
first postoperative 24 hours, BSCB provides a better analgesia and effectively
decreases postoperative pethidine consumption more than LWI.
Introduction:
Post-thyroidectomy acute pain should be controlled
especially during the first post-operative day.1 Many surgeons are reluctant to
use non steroidal anti-inflammatory drugs soon after this type of surgery
because of fear of bleeding complications.2 Also,
opioids are not a good choice as they may promote postoperative nausea and
vomiting, which are already frequent after this type of surgery.3,4
Therefore, regional anesthesia for thyroid surgery has recently become
as a new trend that provides a good quality of postoperative analgesia with
more prolonged duration and lesser incidence of side effects. Other advantages
of regional anesthesia include its sparing effect on the intra- and
postoperative analgesic requirements, and lightening of the level of general
anesthesia.5, 6
Superficial, deep or combined superficial and deep
bilateral cervical plexus blocks have all been used to decrease the postoperative
pain and opioid requirements after neck surgery.5-7 However, deep
cervical plexus blocks is associated with many complications including hemi-diaphragmatic
dysfunction.8
Local wound infiltration (LWI) with local anesthetics (LA) is a simple
and safe alternative approach for postoperative pain relief. It has been used
in different types of surgery, and found to be more efficient in superficial
and minor short-lasting procedures,9, 10 than major
visceral operations.11, 12
The aim of this study was to assess the bilateral
superficial cervical plexus block (BSCB) versus LWI after thyroid
surgery with regard to postoperative analgesic efficacy.
*) Department of Surgery, unit
of anesthesia and intensive care, Faculty of Medicine, Arab Medical
University
**) Department of Surgery, Faculty of Medicine, Sebha University ,
Sebha -Libya
***) Department
of Surgery, Faculty of Medicine, Arab
Medical University
****) Department of Anesthesia,
Tripoli Medical Centre. Tripoli-Libya.
Patients and Methods:
This study was carried out on 60 adult patients of
both sexes undergoing elective thyroid surgery. Only euthyroid patients with physical
status of ASA-I or ASA-II were included in the study. An informed consent was
taken from every patient representing his approval of the study. Exclusion
criteria included huge goiter, recent use of analgesics or steroids, history of
allergy to LA, patient with coagulopathy or receiving anticoagulants, and
patients who were unstable, psychiatric or unable to use numerical rating scale
(NRS) or four-category verbal rating scale (VRS) for pain
assessment.
Patients were randomly categorized into three equal groups,
each group included 20 patients. The first group received no regional block
(control or group-C), in the second group LWI was administered at the end of
surgery (group-L), and in the third group BSCB was performed immediately after
induction of general anesthesia (group-B).
All patients were premedicated
with IV midazolam (0.03-0.05 mg/kg within an hour (hr) preoperatively).
On arrival to the
operating room all patients were connected to a multi-channel monitor for
continuous display of ECG, heart rate, non-invasive blood pressure and
peripheral oxygen saturation. Anesthesia was induced with IV fentanyl (3-4
µg/kg) and IV propofol (2–3 mg/kg). Endotracheal intubation was facilitated by
the administration of IV atracurium (0.5 mg/kg). Anesthesia was maintained by
50% of nitrous oxide in oxygen, with halothane (0.4–0.8%). Supplemental atracurium
(0.15 mg/kg) was given every 15 to 25 min.
After induction of general anesthesia, and after local
sterilization, the superficial block of cervical plexus was performed bilaterally
by injecting 15 ml of 0.5% R-bupivacaine (Laboratoire Delmas, Lyon-France) just
subcutaneously at each side using a 23-gauge needle, which was inserted at the
midpoint of the posterior border of the sternocleidomastoid muscle in three
directions; 5 ml were injected up (cephalic) and 5 ml down (caudad)
along the posterior border of the sternocleidomastoid, and 5 ml were injected
horizontally above the muscle.
Local infiltration of the wound was performed by the
surgeon at the end of surgery just before wound closure. A 23-gauge
needle was inserted along the incision line and 20 ml of 0.5% R-bupivacaine
(Laboratoire Delmas, Lyon-France) were infiltrated in the subcutaneous layers.
Redivac surgical drain of size 10 or 12 was inserted in all patients.
Postoperatively, all patients were transferred to the post-anesthetic
care unit (PACU) where they stayed for at least 1 hr, and then they were transferred
to the ward.
Pain assessment was done postoperatively on the first
hr, and then every 4 hrs until 24 hrs after the end of surgery. Pain
intensity was evaluated by the eleven-category NRS (with 0 representing no pain
and 10 representing the worst imaginable pain) and by the
four-category VRS (no pain (I), mild pain (II), moderate pain (III),
and severe pain (IV)).
Postoperative pain management was standardized in all
groups by giving 50 mg of pethidine intramuscularly if the NRS score was ≥ 4
or VRS ≥ 3.
Prophylactic antiemetics (metoclopramide)
were not administered.
Postoperative pethidine consumption, nausea, vomiting,
and metoclopramide requirements were fully recorded during the first
postoperative 24 hrs.
Values are presented as mean ± standard deviation
(SD). One way ANOVA test was used for normally distributed variables, and the
Bonferroni post-hoc test was used for multiple comparisons to determine the
significance of differences in means. Kruskal-Wallis ANOVA was used
for non-normally distributed data. P<0.05 was considered
statistically significant.
Results:
Demographic characteristics and surgical data were
comparable (P>0.05) in all groups (Tables 1).
During the first postoperative 24 hrs, NRS mean scores
were significantly lower in groups (L) (P<0.05) and (B) (P<0.001)
compared with the control (C) group (Figure 1).
The corresponding VRS scores were also significantly
lower (P<0.001) in groups (L) and (B) than the control group (Figure 2).
By measuring the differences between (C) and (L)
groups at each interval, the NRS pain scores were only significantly different
at 1st, 4th, 8th (P<0.001), and 12th
(P<0.05) intervals, whereas the significant differences between the
(C) and (B) groups were at the 1st, 4th, 8th,
12th, 16th (P<0.001), and 20th (P<0.05)
intervals, (Figure 1).
Table-1: Demographic
characteristics and surgical data of patients in the three studied groups.
|
|
Group (C)
|
Group (L)
|
Group (B)
|
P value
|
|
Age (years):
|
38.9 ± 12.6
|
35.4 ± 10.7
|
33.7 ± 9.2
|
0.321
|
|
Weight (kg):
|
73.1 ± 12.1
|
72.7 ± 11.3
|
69.5 ± 11.6
|
0.564
|
|
Height (cm):
|
167.2 ± 4.97
|
167.8 ± 3.69
|
168.8 ± 5.68
|
0.587
|
|
Gender: M/F
|
2/18
|
1/19
|
2/18
|
--
|
|
ASA I/II:
|
15/5
|
15/5
|
14/6
|
--
|
|
Duration of surgery (min):
|
88.3 ± 30.6
|
80.45 ± 28.9
|
84.6 ± 35.6
|
0.742
|
|
Unilateral/bilateral lobectomy:
|
3/17
|
3/17
|
2/18
|
--
|
Values are expressed as total numbers or mean ± SD.
Figure-1: Mean numerical rating scale (NRS) pain scores in the
control (C), local wound infiltration (L) and bilateral superficial cervical
plexus (B) groups during the first 24 hours after surgery.
Vertical bars are standard
deviation. Pain scores were significantly lower in (L)
and (B) groups when compared
with (C) group.
Using the VRS, the inter-interval significant
differences in pain scores between (C) and (L) groups were at the 1st,
4th, 8th (P<0.001), 12th, 16th,
and 20th (P<0.01) intervals, whereas the significant
differences between the (C) and (B) groups were at all the studied intervals [1st,
4th, 8th, 12th, 16th (P<0.001),
20th (P<0.01), and 24th (P<0.05)], (Figure
2).
The mean (±SD) of postoperative pain scores using the
NRS was 3.82 (± 0.65), 2.01 (± 0.61), and 1.36 (± 0.70) in the (C), (L), and (B)
groups respectively. The corresponding values measured by VRS were 2.49 (± 0.20),
1.71 (± 0.22), and 1.55 (± 0.23).
The proportion of patients with a NRS score ≥ 4 at any
time-interval was significantly smaller in the (L) (P<0.05)
and (B) groups (P<0.01) when compared with the control group (Table 2).
The categorical VRS occasions at which patients
reporting no, mild, moderate, and/or severe pain at any time are
presented table 3. Severe pain was completely abolished in the treatment
groups.
Number of patients required postoperative pethidine,
and the total amount of pethidine consumption were significantly smaller
(P<0.001) in the (L) and (B) groups than the (C) group. The time to
first analgesic requirement was also significantly longer (P<0.001)
in group (L) and (B) than for the control group (Table 4).
Regarding the incidence of postoperative nausea and
vomiting, and the number of patients received metoclopramide, no significant
statistical differences between the groups were found. Postoperative nausea was experienced by 11
(55%), 6 (30), and 5 (25%) patients (P= 0.144), and vomiting by 8 (40%),
4 (20%), and 3 (15%) patients (P= 0.16) in the (C), (L), and (B) groups
respectively. Metoclopramide was given to 10 (50%), 4 (20%), and 3 (15%)
patients of the corresponding groups (P= 0.091).
No related complications were reported in our studied
patients.
Table-2: Number (and percentage) of patients with NRS
≥ 4 at all studied intervals.
|
|
Group (C)
|
Group (L)
|
Group (B)
|
|
1 hr
|
14 (70%)
|
0 ***
|
0 ***
|
|
4 hr
|
15 (75%)
|
2 (10%) ***
|
0 ***
|
|
8 hr
|
11 (55%)
|
1 (5%) ***
|
1 (5%) ***
|
|
12 hr
|
8 (40%)
|
2 (10%) **
|
0 ***
|
|
16 hr
|
10 (50%)
|
7 (35%)
|
2 (10%) **
|
|
20 hr
|
8 (40%)
|
4 (20%) *
|
2 (10%) **
|
|
24 hr
|
5 (25%)
|
1 (5%) *
|
3 (15%)
|
The statistical
differences between the control (C) and the treatment (L) and (B) groups
are indicated by small
stars when they are significant (* = (P<0.05), ** = (P< 0.01),
and *** = (P< 0.001)).
Figure-2:
Mean verbal rating scale (VRS) pain scores in the control (C), local wound
infiltration (L) and bilateral superficial cervical plexus (B) groups during
the first 24 hours after surgery. Vertical bars are standard deviation. Pain scores were significantly lower in (L)
and (B) groups when compared with (C) group.
Table-3: Sum (and percentage) of pain occasions for
each categorical VRS measured
at all studied intervals.
|
|
Group (C)
|
Group (L)
|
Group (B)
|
|
No pain (grade I)
|
2 (1.4 %)
|
56 (40 %)
|
65 (46.4 %)
|
|
Mild pain (grade II)
|
76 (54 %)
|
68 (48.5%)
|
67 (47.8 %)
|
|
Moderate pain (grade III)
|
54 (38.5 %)
|
16 (10.7 %)
|
8 (5.7 %)
|
|
Severe pain (grade IV)
|
8 (5.7 %)
|
0 %
|
0 %
|
Severe pain was
completely abolished in group (L) and group (B).
Table-4: Total number (%)
of patients required analgesia, total (± SD) pethedine consumption, and first
analgesia requirement time (± SD).
|
|
Group (C)
|
Group (L)
|
Group (B)
|
|
Number of patients required analgesia:
|
15 (75%)
|
7 (35%) **
|
4 (20%) ***
|
|
Time to first analgesia (min):
|
162 ± 124
|
544 ± 320 **
|
860 ± 59 ***
|
|
Total pethedine doses (mg):
|
60 ± 44.7
|
20 ± 29.9 **
|
12.5 ± 27.5 ***
|
The degree
of significance of statistical differences between the control (C) and the
treatment (L)
and (B) groups
are indicated by small stars (** = (P< 0.01), and *** = (P< 0.001)).
Discussion:
The main outcome of this study was that the severity
of post-thyroidectomy pain can be decreased similarly by either LWI or BSCB,
although BSCB was more efficient. Accordingly, fewer patients in the treatment
groups required postoperative pethidine, which was also consumed in smaller
doses and administered after a more prolonged time.
Gozal et al.(9) studied the effectiveness of LWI after thyroid
surgery, and reported that wound infiltration with 10 ml of 0.5% bupivacaine at
the end of thyroid surgery markedly reduced the mean pain scores and
the postoperative opioid requirements during the first postoperative 24 hrs.
Similar results were obtained by another study using 12 ml of either
ropivacaine or ropivacaine mixed with lornoxicam for wound infiltration after
thyroid surgery.13
However, some literatures disputed the beneficial
effect of LWI after thyroid surgery. In one of these studies LWI was
performed with 20 ml of 0.25 % bupivacaine and found to be ineffective in
decreasing neither opioids requirements nor pain scores.14 In another study,
bupivacaine wound infiltration effectiveness was considered
disappointing when compared with two opioid regimens.4
The differences in study design, pain assessment,
perception and management, and many other factors, all may interact and produce
a wide range of discrepancy in the
results of the different studies.15-17 In many previous researches, and because the neck is a highly
vascular area, 0.25%-0.375% bupivacaine was used to avoid side effects like
systemic toxicity.1,14 In the current study, higher doses of 0.5%
bupivacaine were used for LWI (20 ml) and BSCB (30 ml) for the sake of
prolonged analgesia, and no complications were observed during the study
period.
The results of this study are consisted with that of
Dieudonne et al.1 who reported that BSCB can reduce pain
intensity scores and the amount of cumulative opioid doses after
thyroidectomy. They performed BSCB with
20 ml bupivacaine 0.25% with 1:200,000 epinephrine at the end of
surgery and found lower pain intensity scores in the early
postoperative period in the treatment group. However, a study by Eti,
et al.14 could not demonstrate any beneficial effect of BSCB
on postoperative opioid demand or pain scores although they used a
large volume (30 ml) of 0.25% bupivacaine.
In the current study, post-thyroidectomy pain could
not be completely abolished in the treatment groups as 11 (27%) patients (7
patients in (L) and 4 patients in (B) group), required additional postoperative
pethidine analgesia (Tab -4). Dieudonne et al.1 concluded that BSCB
alone can not provide optimal pain relief because still 65% of
patients needed additional analgesics. This is probably due to the
fact that the source of this type of pain has many components linked
to the intraoperative neck position, superficial and deep layers of
the wound, and wound drainage.8,16,18,19
NRS rather than VAS was chosen in this study to
measure pain intensity, because previous studies evaluating the
suitability of several pain intensity scales in this type of
surgery, reported that NRS to be convenient in the early
postoperative period more than VAS.17,20,21 VRS was chosen mainly because of its
simplicity to all categories of patients.16,18,21
The duration of postoperative effective (statistically
significant) analgesia in the (L) and (B) groups when evaluated by the NRS was
12 and 20 hrs respectively. The corresponding values when measured by the VRS
were 20 and 24 hrs. This variation could be related to VRS per se, which frequently
being described to be noncontiguous and less precise.16,18 The
current study did not evaluate the VRS, as this was beyond the scope of the
study. However VRS was actually easier to all patients to understand, and generally
it followed the trend of changes of pain scores measured by the NRS.
Although there were no significant statistical
differences between the groups regarding the incidence of postoperative nausea
and vomiting, it seems that the reduced pethidine consumption was clinically
relevant, and had an impact on decreasing the incidence of postoperative nausea
and vomiting in (L) (30%) and (B) (25%) groups when compared to the control
group (55%). This is not in accordance with the study of Dieudonne et al.1
who reported that the reduced morphine consumption in their studied groups was
less clinically relevant, as it did not result in reduced incidence of
postoperative nausea and vomiting.
Conclusion:
Although both techniques are effective for
post-thyroidectomy pain management during the first postoperative 24 hrs, BSCB
provides a better analgesia and effectively decreases postoperative pethidine
consumption more than LWI.
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