|Year : 2017 | Volume
| Issue : 3 | Page : 115-118
Premedication with oral gabapentin versus intravenous paracetamol for post-operative analgesia after tibial fracture surgery
Mohammad Khalili1, Hesameddin Modir1, Afsaneh Norouzi1, Abolfazl Mohammadbeigi2, Seyed Arash Bagherinejad Somesara3
1 Departments of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
2 Neurology and Neurosciences Research Center, Department of Epidemiology, Qom University of Medical Sciences, Qom, Iran
3 General Practitioner, Arak University of Medical Sciences, Arak, Iran
|Date of Web Publication||15-Sep-2017|
Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak
Source of Support: None, Conflict of Interest: None
Introduction: Much attention has been devoted to the management of post-operative pain. Pain reduction brings more comfort and leads to faster recovery and mobilisation of a patient. In addition, it reduces thromboembolic events and eventually the length of hospital stay and cost of treatment. This study was conducted to compare the efficacy of gabapentin versus paracetamol for post-operative analgesia after tibial fracture surgery. Materials and Methods: This study was designed as a randomised, controlled clinical trial, in which 96 patients undergoing elective tibial fracture surgery under general anaesthesia were divided into three groups (gabapentin, paracetamol and placebo). Half an hour before induction of anaesthesia, patients received 300 mg oral gabapentin or 1000 mg paracetamol or 100 ml normal saline (these two latter as intravenous infusions) according to their groups. Surgery was performed under general anaesthesia, with similar anaesthetic regimen for all patients. The pain intensity was measured using a visual analogue scale ruler at 2, 4 and 6 h after operation. Collected data were recorded then and analysed using the statistical software SPSS. Results: At 2, 4 and 6 h after surgery, no significant differences were observed between the two paracetamol and gabapentin groups in terms of pain intensity. Pain intensity in the placebo group was significantly higher than the two case groups. Mean opioid consumption as a rescue intervention was not significantly different between the three groups. However, the placebo group included a larger number of patients requiring opioid analgesics, which was significantly different. Conclusion: A significant pain reduction was observed in both case groups as compared to placebo. Gabapentin and paracetamol had similar efficacies in post-operative analgesia after tibial fracture surgery. No difference was found between the three groups in terms of mean opioid analgesic requirements.
Keywords: Analgesia, gabapentin, intravenous paracetamol, tibial fracture
|How to cite this article:|
Khalili M, Modir H, Norouzi A, Mohammadbeigi A, Somesara SA. Premedication with oral gabapentin versus intravenous paracetamol for post-operative analgesia after tibial fracture surgery. Adv Hum Biol 2017;7:115-8
|How to cite this URL:|
Khalili M, Modir H, Norouzi A, Mohammadbeigi A, Somesara SA. Premedication with oral gabapentin versus intravenous paracetamol for post-operative analgesia after tibial fracture surgery. Adv Hum Biol [serial online] 2017 [cited 2020 May 28];7:115-8. Available from: http://www.aihbonline.com/text.asp?2017/7/3/115/214891
| Introduction|| |
Post-operative pain is a major concern for both patients and physicians, which, when reduced, not only promotes comfort and recovery of the patient but also leads to a faster return to normal life, reduced length of stay and cost of treatment., Furthermore, patients with reduced post-operative pain have better pulmonary function tests. The classic method of using opioids to control pain during and after surgery is associated with a number of dose-related side effects (respiratory depression as the most important), which can be reduced with the co-administration of non-opioid analgesics to lower the opioid dosage.
According to recent findings, aspirin and acetaminophen (paracetamol) are among the non-steroidal anti-inflammatory drugs (NSAIDs) that are probably more effective (either alone or in combination with opioids) than were previously considered., Gabapentin is another compound recently used in pain management studies. It is a structural analogue of γ-aminobutyric acid which acts through central and peripheral mechanisms. Gabapentin has been used orally in many studies to reduce post-operative pain.,,,,, Hassani et al. found that paracetamol 30 mg/kg intravenous (IV) before the induction of anaesthesia could reduce the opioid doses for pain control, both during and after upper limb surgeries. Moreover, Montazeri et al. showed that receiving 300 mg gabapentin had a lower visual analogue scale (VAS) score and less analgesic requirements after lower extremity orthopaedic surgery than those in the placebo group. Another study evaluated the efficacy of oral gabapentin premedication in preventing post-operative pain after thoracotomy and showed that administration of a single dose of 600 mg oral gabapentin before thoracotomy can significantly reduce post-operative pain scores during the recovery time. Finally, in comparing the efficacy of oral gabapentin versus paracetamol in controlling pain after adenotonsillectomy in children, Amin and Amr found that post-operative pain scores in the gabapentin group are significantly lower than those in the paracetamol group.
In orthopaedic surgeries, post-operative analgesia helps in early patient mobilisation and this in turn helps reduce deep vein thrombosis and pulmonary embolism episodes. Considering above, this study was aimed to compare the effects of gabapentin versus IV paracetamol for post-operative analgesia after tibial fracture surgery, which has not been examined so far.
| Materials and Methods|| |
This study was designed as a randomised double-blind, controlled clinical trial, in which 96 patients undergoing tibial fracture surgery under general anaesthesia were randomly allocated into three groups (gabapentin, paracetamol and placebo) with 32 patients in each group, using block model. The study population consisted of patients scheduled for tibial fracture surgery, which was performed in Valiasr Hospital affiliated to Arak University of Medical Sciences. Inclusion criteria were age of 15–60 years, body mass index between 20 and 35, American Society of Anesthesiologists Class I and II, fractures only in the leg area and filling and signing the written consent form. Non-inclusion criteria were the underlying diseases that affect consciousness (psychosis, Alzheimer's disease, epilepsy and cognitive disorders), addiction to alcohol, narcotics and psychiatric drugs, use of NSAIDs, a history of allergy, pregnancy, hepatic and renal disorders, gastritis, peptic ulcer and diabetes. After selection of the patients, the demographic information of each participant was recorded in the data collection form. Then, patients were randomly assigned to three groups according to the blocking model. Half an hour before surgery, a 300 mg capsule was administered with 100 ml of water to patients in the gabapentin group. In the paracetamol group, 1000 mg paracetamol was infused IV at the same time in 100 ml of normal saline.
With regard to blindness of the study, a placebo capsule was orally administered to the patients half an hour before surgery in the paracetamol and placebo groups. Furthermore, 100 ml of normal saline was infused in the gabapentin and placebo groups. Surgery was performed under general anaesthesia with a standardised anaesthesia drug regimen in all three groups. After administration of 0.4 mg/kg midazolam and 2.5 μg/kg fentanyl as premedication, patients were oxygenated for 3 min with 100% oxygen. Then, all of them received 2 mg/kg propofol and 0.5 mg/kg atracurium for induction of anaesthesia. A laryngeal mask airway of appropriate size (3 or 4) was used for airway control. All patients were mechanically ventilated and an O2/N2O mixture of 50/50 was used along with a propofol infusion of 40–80 μg/kg/min for the maintenance of anaesthesia. The monitoring protocol contained pulse oximetry, electrocardiogram and non-invasive blood pressure.
Patients requiring additional opioids during surgery and those experiencing more than 1.5 h of surgery were excluded from the study. After the end of surgery, the pain intensity was measured at 2, 4 and 6 h post-operatively using the VAS ruler and was recorded in a separate data collection form, together with all possible side effects such as hypotension, headache, nausea and double vision.
Fifty milligrammes meperidine (as rescue medication) was administered intramuscularly if a patient complained of intolerable pain. In these cases, pain severity measurement was not performed thereafter, but the total dose of the opioid used during the first post-operative 6 h was recorded and analysed. All data were analysed using the statistical software SPSS (Chicago, IL, USA).
| Results|| |
The Chi-square test and one-way ANOVA were used to assess the homogeneity of the groups in terms of age, gender and mean pre-anaesthesia systolic and diastolic blood pressures. There was no statistically significant difference between the three groups in this regard (P > 0.05).
One-way ANOVA showed a statistically significant difference between the groups in terms of pain intensity at 2, 4 and 6 h after surgery, with P = 0.004, 0.001 and 0.001, respectively [Table 1].
[Table 2] shows a comparison between the two case groups (gabapentin and paracetamol) in terms of pain intensity at 2, 4 and 6 h after surgery using the t-test for independent groups. There was no statistically significant difference between the two groups in this regard (P > 0.05).
|Table 2: Post hoc comparison of post-operative pain intensity in the gabapentin and paracetamol groups |
Click here to view
One-way ANOVA showed [Table 3] no statistically significant difference between the three groups in terms of mean consumption of meperidine. However, in comparison with the other two groups, the placebo group included a greater number of patients requiring analgesics and this difference was statistically significant (P = 0.049). Meperidine was used for 50%, 43.7% and 71.9% of the patients in the gabapentin, paracetamol and placebo groups, respectively (P = 0.049). Moreover, no serious side effects have been reported in the cases. Mild side effects (such as headache and nausea) were reported in a limited number of patients. [Chart 1] compares the pain intensity of the three groups, at different times post-operatively.
|Table 3: The percentage of patients with need to pethidine and the average dosage of pethidine after surgery |
Click here to view
| Discussion|| |
Our study revealed that gabapentin premedication was as effective as paracetamol in producing analgesia after tibial fracture surgery. Pain scores in both gabapentin and paracetamol groups were significantly lower at 2nd, 4th and 6th post-operative hours, compared to placebo. There was no statistically significant difference between gabapentin and paracetamol regarding to pain reduction and consumption of meperidine.
The statistical test of one-way ANOVA showed no significant differences between the three groups in terms of mean consumption of meperidine. All three groups were similar in this regard. However, in the placebo group, a greater proportion of patients required rescue opioid injection, indicating a statistically significant difference.
The effects of IV paracetamol at different doses on opioid sparing during and after upper limb surgery were examined in a study by Hassani et al. They found that paracetamol with a dose of 30 mg/kg (and not 15 mg/kg) could reduce the dose of opioids needed for pain control during and after upper limb surgery. This is consistent with our study, in which paracetamol (with a dose of 14–20 mg/kg) could not reduce the dose of post-operative opioids.
The study performed by Pandey et al. (2004) on the pre-emptive use of gabapentin in reducing post-operative pain and rescue analgesic requirements in laparoscopic cholecystectomy showed that in the group receiving 300 mg gabapentin, pain scores were significantly lower than those in the tramadol or placebo group. In a study on the efficacy of preoperative gabapentin in reducing pain and nausea after laparoscopic cholecystectomy, Alamshahi et al. concluded that gabapentin can be effective in reducing pain and nausea after that type of surgery.
Montazeri et al. also found that patients receiving 300 mg gabapentin had lower pain scores than those receiving placebo, but the gabapentin group required lower doses of opioids than the placebo group. This latter finding was inconsistent with our study. In a study measuring the efficacy of oral gabapentin as premedication to prevent post-operative pain, Imani et al. concluded that a single dose of 600 mg oral gabapentin before thoracotomy can significantly reduce post-operative pain during the recovery stay and the first post-operative hour. In addition, the total amount of morphine administration during the first post-operative 24 h was reduced. In our study, there was no difference between gabapentin and placebo in terms of the need for opioids. This difference in narcotic requirements may be attributed to the higher doses of gabapentin used in Imani's study.
In a study to compare the efficacy of oral gabapentin versus paracetamol in pain control after adenotonsillectomy in children, Amin et al. found that post-operative pain in the gabapentin group was significantly lower than the paracetamol group. This was inconsistent with our study, where no differences were observed between gabapentin and paracetamol in post-operative analgesia. The study performed by Chandrasekharan et al. on the pre-emptive use of gabapentin to reduce post-operative pain and rescue analgesic requirements in laparoscopic cholecystectomy showed that in the group receiving 300 mg gabapentin, pain scores were significantly lower than those in the tramadol or placebo group, which was consistent with our study.,
In a study on the efficacy of 300 mg preoperative oral gabapentin in reducing pain and nausea after laparoscopic cholecystectomy, Alamshahi et al. found that gabapentin, compared to placebo, was effective in reducing post-operative pain, which was consistent with our study. They also reported a reduction in the need for post-operative analgesics in the gabapentin group, which was inconsistent with our study.
| Conclusion|| |
Based on the results of this study, gabapentin and paracetamol can be recommended for pain reduction after tibial fracture surgery. However, the similar results of the two drugs on the post-operative analgesic requirements mandate further studies with more samples to determine any possible differences in this regard.
Financial support and sponsorship
The study was supported by Arak University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pandey CK, Singhal V, Kumar M, Lakra A, Ranjan R, Pal R, et al.
Gabapentin provides effective postoperative analgesia whether administered pre-emptively or post-incision. Can J Anaesth 2005;52:827-31.
Durmus M, Kadir But A, Saricicek V, Ilksen Toprak H, Ozcan Ersoy M. The post-operative analgesic effects of a combination of gabapentin and paracetamol in patients undergoing abdominal hysterectomy: A randomized clinical trial. Acta Anaesthesiol Scand 2007;51:299-304.
Rawal N, Berggren L. Organization of acute pain services: A low-cost model. Pain 1994;57:117-23.
Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, et al.
The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998;86:598-612.
Miller RD. Anesthesia. Philadelphia: Churchil Livingstone; 2005.
Cook RJ, Sackett DL. The number needed to treat: A clinically useful measure of treatment effect. BMJ 1995;310:452-4.
Mackaness CR, Hussain SK, Hobbs GJ, Spendlove JL, Majeed A. Effect of general anaesthesia and surgery on the kinetics of intravenous propacetamol. Br J Anaesth 1999;82:121-6.
Chandrasekharan NV, Dai H, Roos KL, Evanson NK, Tomsik J, Elton TS, et al.
COX-3, a cyclooxygenase-1 variant inhibited by acetaminophen and other analgesic/antipyretic drugs: Cloning, structure, and expression. Proc Natl Acad Sci U S A 2002;99:13926-31.
Maneuf YP, Gonzalez MI, Sutton KS, Chung FZ, Pinnock RD, Lee K. Cellular and molecular action of the putative GABA-mimetic, gabapentin. Cell Mol Life Sci 2003;60:742-50.
Katzung BG, Masters SB, Trevor AJ. Basic & Clinical Pharmacology. New York: McGraw-Hill Medical; 2011.
Amin SM, Amr YM. Comparison between preemptive gabapentin and paracetamol for pain control after adenotonsillectomy in children. Anesth Essays Res 2011;5:167-70. [Full text]
Hassani V, Manoochehripour M, Nojoomi M. Study of the effects of intravenous paracetamol with different doses on opioid sparing during and after upper limb surgeries. Razi J Med Sci 2008;15:109-15.
Imani F, Hasani V, Bazargani B, Entezari S, Mirdehghan M. Evaluation of oral gabapentin premedication on postoperative pain after thoracotomy. Razi J Med Sci 2009;16:73-9.
Montazeri K, Kashefi P, Honarmand A. Pre-emptive gabapentin significantly reduces postoperative pain and morphine demand following lower extremity orthopaedic surgery. Singapore Med J 2007;48:748-51.
Pandey CK, Priye S, Singh S, Singh U, Singh RB, Singh PK. Preemptive use of gabapentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anaesth 2004;51:358-63.
Alamshahi F, Fateh A, Talebi H, Norouzi A, Fateh S. Effect of preoperative gabapentin in reducing pain after laparoscopic cholecystectomy. Anesth Pain 2012;3:16-0.
Gousheh SM, Nesioonpour S, Javaher Foroosh F, Akhondzadeh R, Sahafi SA, Alizadeh Z. Intravenous paracetamol for postoperative analgesia in laparoscopic cholecystectomy. Anesth Pain Med 2013;3:214-8.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||A Double-Blind, Randomized Controlled Trial of Gabapentin vs. Placebo for Acute Pain Management in Critically Ill Patients with Rib Fractures
| ||Eliza E. Moskowitz,Lucin Garabedian,Kimberly Harden,Emily Perkins-Pride,Menilik Asfaw,Candice Preslaski,Kiara N. Liasia,Ryan Lawless,Clay Cothren Burlew,Fredric Pieracci |
| ||Injury. 2018; |
|[Pubmed] | [DOI]|