Diclophenac/orphenadrine decreases tramadol consumption and incidence of nausea and vomiting (PONV) after laparoscopic cholecystectomy

Irina Grecu¹, A.E. Nicolau², Daniela Ologoiu¹1, Mirela Nicolau¹, Ioana Grinţescu¹

1 Clinica ATI, Spitalul Clinic de Urgenţă Bucureşti
2 Clinica de Chirurgie, Spitalul Clinic de Urgenţă Bucureşti

Abstract

Introduction. NSAID’s as part of multimodal analgesia after laparoscopic surgery are very popular. Still, many patients need rescue analgesics, i.e. weak opioids in the first 24 hours after surgery. These may have some side effects that preclude early mobilization and discharge. Our study hypothesis was that a combination of a NSAID with a muscle relaxant could decrease the dose of tramadol consumption after laparoscopic cholecystectomy.

Material and methods. After Hospital Ethical Board approval and patient informed consent, 65 patients scheduled for laparoscopic cholecystectomy performed by the same surgeon were enrolled in a randomized, double-blind, controlled trial, over a 5 months period (Feb-June 2007). Prior to general anes­thesia induction, an i.v. infusion of diclophenac 75 mg + orphenadrine 30 mg (group N, 32 patients) or saline (group C, 33 patients) was started and repeated after 12 hs. All patients received the same scheme of gene­ral anesthesia and 4 g of i.v. paracetamol in the first 24 hs, starting immediately after surgery. Tramadol boluses of 100 mg (up to 400 mg/d) were used as rescue analgesic. Primary objectives were postope­rative analgesia (VAS at mobilization, 0-100 mm) at 0, 2, 6, 12 and 24 hs, tramadol consumption, incidence of PONV and hospital length of stay (LOS). Secondary objectives were incidence of gastrointestinal symptoms, postoperative blood loss. Statistics was done with SPSS 16.0.

Results. We found no differences regarding demographics, postoperative gastrointestinal symptoms, postoperative blood loss and length of hospital stay. VAS was significantly lower in group N vs C at 0, 2, 6 and 12 hs (p < 0.05), as well as the incidence of PONV (5 vs 12 pts, respectively, p < 0.05). The number of tramadol boluses (1.07 ± 0.75 vs 3.75 ± 1.24, p < 0.001) and also the number of patients requiring rescue analgesic (6 vs 21, p < 0.01) was lower in group N vs C, respectively.

Conclusions. Diclophenac/orphenadrine and paracetamol provides better analgesia after lapa­ro­scopic cholecystectomy than paracetamol alone. The combination also decreases tramadol consumption and the incidence of PONV.

Keywords: multimodal analgesia, nausea, vomiting, postoperative