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Category: Volume 07 Issue 11 November 2019
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Title: Effectiveness of Preoperative Eutectic Mixture of Local Anaesthetic [EMLA] Application and Postoperative Wound Infiltration of Ropivacaine in Patients Undergoing Modified Radical Mastectomy [MRM]: A Randomised Single Blind trial

Authors: Dr Kurian Cherian, Dr Hereen Antony, Dr Rachel Cherian Koshy

 DOI: https://dx.doi.org/10.18535/jmscr/v7i11.121

Abstract

Aims: To assess analgesic efficacy of preoperative EMLA cream and postoperative wound infiltration with ropivacaine in modified radical mastectomy.

Method: This is a prospective randomised single blind trial done in ASA-PS 1 and 2 for unilateral MRM aged between 18-60 years. 60 patients are randomised into four groups. First group, preoperatively EMLA cream is applied over the incision. In second group, preoperative EMLA cream with postoperative infiltration with ropivacaine. Third group, only postoperative wound infiltration with ropivacaine. In the fourth group no such interventions. All patients are operated under general anaesthesia. Intraoperatively heart rate variability (HRV) and blood pressure variability (BPV) and postoperatively VAS at rest and movement, degree of arm movement, opioid requirement are noted to assess analgesic efficacy. Statistical analyses is performed by using a statistical software package SPSS, version 20.0

Results: Time to the initial dose of paracetamol and rescue fentanyl dose requirement is significantly lower in groups 2 and 3. HRV and BPV at the time of incision was more in group 3 and 4, so also the intra-operative analgesia. VAS at rest, at 0 hour, at discharge and drain removal was significantly low with group 2 and 3.Similarly VAS on movement, significantly reduced  in group 2 and 3 at the time of discharge and drain removal. There was significant increase in degree of arm movement in group 2 and 3.

Conclusion: Our study showed postoperative wound infiltration with ropivacaine provided superior analgesia and preoperative EMLA favourable intraoperative hemodynamics.

Keywords: EMLA, Postoperative Wound Infiltration of Ropivacaine.

References

  1. Preetu Nair, Cancer Incident Rate Highest in Kerala, Times of India (News paper), Sept 19, 2018
  2. Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E: Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol 1995, 6:453-9.
  3. Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H: Preevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 2009, 302:1985-92.
  4. Martin JL, Koodie L, Krishnan AG, Charboneau R, Barke RA, Roy S. Chronic morphine administration delays wound healing by inhibiting immune cell recruitment to the wound site. Am J Pathol. 2010;176:786–99.
  5. Snyder GL, Greenberg S. Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth. 2010;105:106–15.
  6. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105:660–4.
  7. Fodale V, D'Arrigo MG, Triolo S, Mondello S, La Torre D. Anesthetic techniques and cancer recurrence after surgery. Scientific World Journal. 2014;2014 Article ID 328513.
  8. Patil SK, Anitescu M. Opioid-free perioperative analgesia for hemicolectomy in a patient with opioid-induced delirium: A case report and review of the analgesic efficacy of the alpha-2 agonist agents. Pain Pract. 2012;12:656–62.
  9. Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: A systematic review and a meta-analysis. Br J Anaesth. 2014;112:991–1004.
  10. Scott NB: Wound infiltration for surgery. Anaesthesia 2010, 65S:67-75.
  11. Moiniche S, Mikkelsen S, Wetterslev J, Dahl JB: A systematic review ofincisional local anaesthesia for postoperative pain after abdominal operations. Brit J Anaesth 1998, 81:377-83
  12. Scott DB, Lee A, Fagan D, et al. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;69: 563–9.
  13. Valenzuela C, Delpon E, Franqueza L, et al. Effects of ropivacaine on a potassium channel (hKv1.5) cloned from human ventricle. Anesthesiology 1997;86:718 –28.
  14. Kopacz DJ, Carpenter RL, Mackey DC. Effect of ropivacaine on cutaneous capillary blood flow in pigs. Anesthesiology 1989;71: 69–74.
  15. Martinsson T, Oda T, Fernvik E, et al. Ropivacaine inhibits leukocyte rolling, adhesion and CD11b/CD18 expression. J Pharmacol Exp Ther 1997;283:59–65.
  16. [Akan A et al: A randomized, placebo controlled study - EMLA in minor breast surgery, Minerva Medica Chirurgica 2012, 67:181-5
  17. Ka-Wai Tam et al. Effect of wound infiltration with ropivacaine or bupivacaine analgesia in breast cancer surgery: A meta-analysis of randomized contolled trials, In. Jt of Surgery, 22 (2015) 79-85
  18. Axelle Vigneau et. al, A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection, BMC Anesthesiology
  19. Taddio A., Stevens B, Craig K. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J. Med. 1997;24:1197-201
  20. Fassoulaki A, Sarantopoulos C, Melemeni A. EMLA reduces acute and chronic pain after breast surgery for cancer. Reg Anesth Pain Med 2000; 4:337-9.

Corresponding Author

Dr Hereen Antony

Dept. of Anaesthesiology, Govt. Medical College, Tivandum 695011, India