STUDY ON THE COMPARISION OF INTRAPERITONEAL INSTILLATION OF BUPIVACAINE,ROPIVACAINE AND SALINE FOR POST OPERATIVE PAIN RELIEF AFTER LAPAROSCOPIC INTRA ABDOMINAL SURGERIES.

Aim: To evaluate the efficacy of intraperitoneal instillation of local anaesthetics for postoperative pain relief after laparoscopic abdominal surgeries and compare the efficacy of two differernt local anaesthetics-Bupivacaine vs Ropivacine. Materials and methods: This study is a prospective, randomized, comparitive study for evaluating the efficacy of intraperitoneal instillation of bupivacine0.5%vs Ropivacaine0.5% for postoperative pain relief after elective laparoscopic abdominal surgeries. institutional ethical committee approval was obtained.Totally90 patients were selected. After getting the informed consent from the patients they were randomly allocated into 3 groups, group B(Bupivacine),group R(Ropivacine),and group C(Control). Result: Durationof post operative pain relief after intraperitoneal instillation of Bupivacaine a It the the use parentral and NSAIDs This was done to compare the analgesic Bupivacaine Ropivacaine , which were instilled intraperitoneally , with a control group.


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The mechanism of analgesia is by blocking the visceral nociceptors,therby,decreasing the visceral pain in laparoscopic surgeries.It also has anti inflammatory action and prevents peritonitis and bowel adhesion.
Creation of pneumoperitoneum can cause various physiological changes. Respiratory changes include Impaired ventilation ,absorption of CO2 from the peritoneum,V/Q mismatch and patient positioning.Wgen intra-abdominal pressure raises >10 mmhg there is significant reduction in cardiac output;also there will be increase in intrathoracic pressure ,which increases the peripheral vascular resistance.Venous stasis may lead to deep vein thrombosis.There is also reduction in renal blood flow,glomerular filtration and urine output.

Aim And Objective:-
To evaluate the efficacy of intraperitoneal instillation of local anaesthetics for post operative pain relief after laparoscopic abdominal surgeries and compare the efficacy of two differernt local anaesthetics-Bupivacaine vs ropivacine.

Materials And Methods:-
This study is a prospective,randomized,comparitive study for evaluating the efficacy of intraperitoneal instillation of bupivacine0.5%vs Ropivacaine0.5% for postoperative pain relief after elective laparoscopic abdominal surgeries. institutional ethical committee approval was obtained.Totally90 patients were selected. After getting the informed consent from the patients they were randomly allocated into 3 groups,

Anaesthesia And Surgery:-
After getting the informed consent ,height and weght were measured;patients were shifted to theatre.local anaesthesia test dose were given.After confirming the absence of allegic reaction,monitors were connected(ECG,NIBP,PR,SPO2,ETCO2).Basal parameters were noted.patients were preoxygenated with 100%O2 for 3min with bag and mask.induction was carried out with inj.fentanyl 2mc/kg,inj.thiopentone 5mg/kg and intubated with an approvated size endo tracheal tube after a loading dose of inj.atracurium(0.5 mg/kg),maintanence of anaesthesia was with N20:02 2:1,Sevoflurane 1-2%,inj atracurium 0.1 mg/kg.No extra dose of analgesia was given intraoperatively All the surgeries were done by trained surgeons.after skin incision 11mm trocar is introduced via umbilical port,abdomen is inflated with C02 1lit/min intra abdominal pressure kept around 12-14 mmhg in all patients After the procedure gets over,abdomen was thoroughly washed to remove the blood clots and debris.Inj.Bupivacaine 0.5%with 10 ml distilled water/Inj.Ropivacaine 0.5% with 10 ml distilled water /30 ml of normal saline is instilled intra peritoneally under vision.after the removal of trocar,CO2 gas was completely evacuated from the abdomen.patients were kept in trendelenberg position for 10 mins.If abdominal drain was present it was 1378 clamped.4ml of 2% Lignocaine was infiltrated into the skin.During the surgery ETCO2 value was maintained between 25-35mmhg.
Post operatively all the patients were shifted to pacu for observation.primary and secondrary outcomes were measured.vas score at 0,1,2,3,4,5,6,10,12,24 hrs were noted.inj.fentanyl 1mc/kg iv given as the rescue analgesia whenever the vas score was more than 3.total dose of fentanyl required was noted in these patients.time of the first rescue analgesic requirement was noted.presence of complications was noted.

Discussion:-
Rescue Analgesia Timing:- Table 1:-Bupivacaine provided adequate analgesia for the first 6 hrs when compared to Ropivacaine, which provided adequate analgesia for about 4 hrs 24 mins Vas Score:-When compared with control group, Bupivacaine and Ropivacaine both group had less VAS score.
Pain threshold was maximum in the first hour and it was minimal in the sixth hour irrespective of the groups. These type of laparoscopic surgeries required higher analgesics upto six hours post operatively. After six hours the analgesic requirements were found to be minimal. Laparoscopic techniques have gained popularity in the recent years mainly because of the facts that it involves small incision, short hospital stay and early ambulation though it has got various advantages on its own , the peritoneal stretching due to the insufflation of gases results in excessive pain post operatively. Various modes of providing analgesia were tried. The techniques that can be used for providing pain relief in laparoscopic surgeries include 1379 surgery under subarachnoid block, parentral opioid and NSAIDs , instillation of local anesthetics intraperitoneally etc., Instillation of local anesthetics solution intraperitoneally, as a mode of providing postoperative analgesia , has been studied extensively . It has the added advantage of early ambulation, reduced incidence of postoperative nausea, vomiting and reduces the use of parentral opioids and NSAIDs . This study was done to compare the analgesic efficacy of Bupivacaine and Ropivacaine , which were instilled intraperitoneally , with a control group.
In our study it was found that the total dose of opioid required in the postoperative period was significantly less in both groups. Out of these two groups Bupivacaine group needed less fentanyl 74 ± 25.24µg, when compared with Ropivacaine group which needed 92.33±34.81µg, though the difference was found to be statistically insignificant. In our study the median VAS score for Bupivacaine group was 2.82 over 24 hours and in Ropivacaine group was 3.15, which was found to be statistically significant.
Intraperitoneal instillation of Bupivacaine or Ropivacaine at the end of the surgery provided analgesia for 355 min and 264.33 min compared with saline group which was about 13 min, which was found to be statistically significant.
Summary:-From this prospective, randomised, comparative, double blinded, case control study which evaluated the effectiveness of intraperitoneal instillation of Bupivacine compared with Ropivacaine for post operative pain relief after laparoscopic abdominal surgeries.
The following observation were noted…. 1. The demographic profiles like Age, Sex, BMI, ASA status were comparable in all the groups. 2. Duration of postoperative pain relief after intraperitoneal instillation of Bupivacaine was longer than Ropivacaine. 3. The VAS score was lower in Bupivacaine and Ropivacaine group when compared with saline group over the first 6 hours post operatively. 4. Total Fentanyl requirement was lower in Bupivacaine and Ropivacaine group compared with compared with saline group. 5. Postoperative nausea and vomiting was significantly lower in both Ropivacaine and Bopivacaine group when compared to control group are. 6. Duration of surgery, hemodynamic parameters and complications were comparable in all groups.