الفهرس 
patients and methodsOnly 14 pages are availabe for public view
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Abstract
Pain is not just a sensory modality but an experience. The international association for the study of pain define pain as” an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. from this definition we can recognized on the objective, physiologic sensory aspect of pain and its subjective, emotional, and psychological components.
In recent years, the use of intrathechal/epidural narcotics has become widespread, epidural administered morphine binding with the opiate receptors of the spinal cord to provide effective and long lasting analgesia. However it is associated with nausea, vomiting, pruritus, retention of urine and, in some instances, late onset of respiratory depression.
The epidural administration of opioids is currently being investigated for relief of pain. Epidural administration of morphine sulphate has provided, long lasting relief for postoperative or chronic pain. The major advantages of selective blockage of pain by spinal opioids lie in the absence of sympathetic blockage and neuromuscular blockage allowing
easy ambulation of patients and avoidance of cardiovascular collapse or convulsions, the major complications of local anesthetic blockage. Opioids administered IV or IM for postoperative pain relief, the parturient induce potential side effects, including respiratory depression, nausea, vomiting, orthostatic hypotension and delayed gastric emptying.
Epidural administered opiates must initially cross the dura mater before exerting their effect in the substantia gelatinosa .These agents are also subject to uptake epidural plexus of veins. Uptake and distribution into plasma after epidural administration resembles that seen after intramuscular injection. The portion of the drug that is not taken in the vascular compartment is available to cross the dura. Hydrophilicity determines how much drug will cross the dura. Lipophilic agents such as fentanyl will cross the dura rapidly but also tend to retrace into the epidural space. The hydrophilic morphine crosses the dura poorly, but tends to stay subarachnoid once there. from both theoretical and clinical data it is now possible to assess the suitability of some commonly used opioids for the epidural versus the systemic route. To justify epidural versus systemic use the drug should have high dural permeability to rapidly achieve adequate cord versus systemic levels, moderate lipophilicity and high receptor affinity and activity. This would ensure a rapid onset, long duration of action and low risk of rostral transport.
Acceptance of a new technique depends not only on its efficacy, but also on the nature and incidence of side effects. The latter occur frequently after extradural opioids, and although many are regarded as being minor, they can nevertheless be very annoying to the patient. The most feared complication of spinal opioids is delayed respiratory depression. Other side effects include pruritis, nausea, vomiting, urinary retention, and constipation .
The aim of postoperative pain relief is to provide subjective comfort in addition to inhibiting trauma induced nociceptive impulses in order to blunt autonomic and somatic reflex responses to pain and subsequently to enhance restoration of function by allowing the patient to breathe, cough and move more easily.
Multimodal Pain therapy (balanced analgesia):
Sufficient pain relief, including analgesia that allows normal function, cannot be achieved after major surgery with any single analgesic, without side effects or the need for surveillance. Date on multimodal pain therapy suggests this treatment modality to be important clinically by combining NSAID and opioids for minor to moderate pain and the use of a combination of local anesthetic and opioids in extradural analgesia or there is no doubt that multimodal pain therapy is
the most important technique for the treatment of postoperative pain.
Effects on Outcome:
It has generally been assumed the adequate postoperative pain relief may reduce pulmonary, cardiovascular, thromboembolic and other complication, and improve general postoperative outcome. However, the effects of nociceptive block and pain relief on morbidity are still debated, despite the fact that pain relief with extradural or spinal local anesthetics has a pronounced inhibitory effect on the stress response in lower body operations and has beneficial effects on outcome variables such as reduction of blood loss, thromboembolic complications and pulmonary infection in these procedures. Also, multimodal pain therapy with extradural combination of opioid and local anesthetics demonstrates a major improvement in postoperative convalescence, postoperative exercise, mobilization and reduction of the hospital stay.
Tramadol is synthetic, centrally acting analgesic agent with two distinct, synergistic mechanisms of action, acting as both a weak opioids agonist with selectivity for the µ receptor and a weak inhibitor of monoamine neurotransmitter reuptake. The two enantiomers of racemic tramadol function in a complementary manner to enhance the analgesic efficacy and improve the tolerability profile of tramadol.
The use of epidural fentanyl-bupivacaine for postoperative analgesia is an effective method of providing pain relief. The opioid-related side effects of epidural fentanyl bupivacaine solutions may be reduced by decreasing the fentanyl concentrations.
The use of epidural pethidine provides effective analgesia but with relatively short duration with low incidence of side effects.
The aim of the study is to compare the efficacy of epidural morphine, tramadol, fentanyl-bupivacaine and pethidine for postoperative pain relief
This study has been conducted on eighty patients that have been subjected to lower limb orthopaedic surgery
All patients were anesthetized with spinal anesthesia after epidural catheter was inserted for postoperative analgesia.
Patients were divided into four equal groups (20 patients for each group) according to analgesic drugs injected in epidural catheter ( the volume of injected drugs were completed to 4 ml volume by saline.)
. Group I: Morphine 2 mg.
. Group II: Tramadol 20 mg
.Group III: Fentanyl 10µg and Bupivacaine ( 0.5% ) 5mg
. Group IV: Pethidine 20 mg.
Top up doses were given when the patient ask for analgesia at various time intervals 24h. postoperative.
The following parameters were recorded:
- Pain score before and every 3 hrs during the study (pain score was obtained from numerical rating scale where 0 = no pain, 10 = the worst pain imaginable
- Onset and duration of analgesia after injection of the drugs
- Number of top up doses of analgesics
- Total volume of drug injected
- MABP, HR, RR, SPO2 (before and after pain relief by analgesia)
- Side effects :
Respiratory depression (RR<10 /min. and/or SPO2 < 90%
Nausea and vomiting PONV
Pruritus and allergic effects
Urinary retention and constipation
Management of any side effect.
There was satisfactory postoperative analgesia in all patients in the four groups, as shown by gradual decrease in pain score with administration of top up doses of each drug . There was no statistically significant difference between the groups.
Onset of action of 1st dose of tested drugs of four groups of patients were nearly similar with no statistically significant difference . Onset of action of 2nd dose compared with 1st dose were statistically insignificant difference in four groups . There was statistically significant difference in onset of action ( shorter onset of action) of 3rd dose in relation to 1st dose in group I, II, III while it was statistically insignificant in group IV.
There was statistically significant increase in duration of postoperative analgesia using equipotent doses of the drugs in both group I and II morphine and tramadol compared with group III and IV fentanyl- bupivacaine and pethidine.
Number of top up doses and total volume of analgesia injected were more in group III and IV fentanyl-bupivacaine and pethidine than in group I and II morphine and tramadol.
Insignificant haemodynamic changes were observed in four groups during the 24 hr, postoperative however within each group there was a continuous but with insignificant decrease in mean arterial blood pressure and heart rate.
There was statistically insignificant difference between the four groups during the study , before and after injection of postoperative analgesia as regard respiratory rate (RR) and oxygen saturation (SPO2 )
Postoperative nausea and vomiting were more frequent with epidural tramadol 15% of cases and fentanyl-bupivacaine 15% of cases compared with 10% of cases of epidural morphine with no single cases of epidural pethidine. There was statistically insignificant difference between the four groups of study for postoperative nausea and vomiting (PONV).
Pruritus were more frequent with epidural morphine 15% of cases compared to 10% of cases of epidural pethidine and 5% of cases of epidural tramedol with no single cases in epidural fentanyl-bupivacaine. There was statistically insignificant difference between the four groups of study for postoperative pruritus.
No patient developed any sign of respiratory depression.
No statistically significant difference as regards urinary retention.
Constipation not reported during the study.
In conclusion
The need for improved postoperative pain is mandatary, with establishment of intensified collaboration between the patient, surgical nurse, surgeon and anaesthetist in order to provide and make use of the pain relief.
Epidural morphine, tramadol, fentanyl-bupivacaine and pethidine are successful analgesic models for postoperative pain relief.
Epidural administration of morphine or tramadol provide effective and long lasting analgesia without harmful side effects.
The use of epidural fentanyl-bupivacaine or pethidine for postoperative analgesia is an effective method for pain relief but with short duration of action and needs multiple injection with minimal side effects.