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A clinical study of effect of field block on inguinal herniorrhaphy in an outpatient surgery.

INTRODUCTION

Herniorrhaphy is one of the most commonly performed surgery, the aim of day care anaesthesia with field block is early ambulation, cost effectiveness, to reduce polypharmacy, post-operative pain relief, to reduce morbidity and infective complications. The essential criteria for anaesthetic technique of choice for a given surgery is patient's safety and surgeons comfort. These are not provided by SAB or GA. Hence to meet above requirement, the present study was undertaken. (1,2)

MATERIAL AND METHODS

After ethics committee approval, ASA class I and II patients aged between 18-60 years, with an escort at home as well as at the hospital. Pre-anaesthetic evaluation done on prior day of surgery with routine investigations such as Hb%, bleeding time, clotting time, blood urea, serum creatinine, fasting blood sugar, urine routine examination, ECG and screening chest, advised to take Tab alprazolam 0.25mg and Tab pantoprazole 40mg on previous night. On the day of surgery Midazolam 1mg given IV just before instituting field block.

Patients were given field block using 1% lignocaine with adrenaline, 15ml of the solution was injected at 1.5cm medial and superior to anterior superior iliac spine, 5ml injected at mid inguinal point, 5ml at pubic tubercle, about 10ml injected along the line of incision. If patient complains of pain, then additional 2ml injected at the neck of the inguinal hernial sac. If patient still complains of pain then pethidine 50mg given. The following scale was adopted to grade relaxation and analgesia.

EXELLENT

Patient comfortable with good surgical relaxation and analgesia.

GOOD

Patients requiring supplemental local anaesthesia at the neck of sac FAIR: Patients requiring supplemental local plus narcotic supplementation.

POOR

Inadequate anaesthesia requires GA. (3) Pulse, BP, ECG, SPO2 Monitored, then patients were shifted to post-surgical intensive care annexure where;

I. Recovery were assessed by using modified Aldrete post-anaesthetic recovery score. (1,2)

II. The postoperative pain relief and post-anaesthetic complications monitored. Using the following.

RESULTS

Modified Aldrete post anaesthetic. (1) recovery score parameters--total score

STATISTICAL METHOD

Normally distributed continuous data were analyzed using students t-test, continuous data not normally distributed were analyzed by Mann-Whitney U-test. Categorical data were analyzed using the [X.sup.2] test or Fisher's exact test where appropriate. Data presented as mean with standard deviation, median values with interquartile ranges, numbers or percentages (%). (3)

DISCUSSION

The safety and effectiveness of hernia repair using local anaesthesia is more in teaching hospitals, because there is no need for admission so it avoids hospital stay as well as low cost to the patients. (4)

The advantages of local anaesthesia are safety, simplicity effectiveness, cost effectiveness, low rate of recurrence and infection. It is a method of choice in outpatient surgery and for minimising the cost of surgery. (2,5,6)

Many authors have used lignocaine alone for inguinal filed block (Prevoznik). (7) but it is short acting.

Catherine J, et al. (8) Using the above combination for institution of block found that there was an improvement in quality and duration of block.

Dosage and Concentration of Lignocaine with Epinephrine

Dierking et al. (10) used 1% lignocaine with epinephrine because epinephrine reduces plasma concentration of lignocaine and minimizes toxicity and prolonged post-operative pain relief. We have also used 1% lignocaine with epinephrine. It has been suggested that upper limit for lignocaine with epinephrine 7mg/kg. As a fairly large volume of drug required for the block the concentration kept at 1% for lignocaine in our study. As the mean weight of our patients 61.3kg and mean volume used 35.3ml, it became clear that the total dose of the lignocaine employed by us was well within the upper recommended limit.

Quality of Analgesia and Relaxation

Most of the authors have not commented regarding the quality of analgesia in field block even though they carried out surgery under local anaesthesia. Reid MF, et al. (11) demonstrated good quality analgesia could be achieved by ilio-inguinal nerve block. Costa E. Silva classified the quality of analgesia as good, regular or bad, in the present study we graded 80% patients had excellent analgesia and relaxation. Only 15 patients had good analgesia and mild discomfort during sac manipulation which required supplementation.

With additional infiltration around neck of the sac with lignocaine 1% with epinephrine. Two (2%) patients had analgesia graded as fair with mild pain during surgery. These patients were given pethidine 50mg to alleviate pain. Those had severe intolerable pain during surgery (3%) requiring conversion to general anaesthesia. It has been observed by various authors that at the time of pulling of the sac, patients often complain of discomfort. (9)

This finding was observed in 15 patients in the present clinical study. Some authors used narcotic for pain relief during surgery. In the present study two patients required narcotic in addition to local anaesthetic supplementation.

As per Marshall et al. (12) use of sedative dose of propofol has advantage of less nausea and vomiting, because of antiemetic action which in turn results faster discharge and cost effectiveness. In our study, we used propofol at a dose of 25-35mg at the time of Herniorrhaphy.

Callesen et al. (13,14) studied 400 hernia patients who underwent surgery under local anaesthesia in whom 0-5% were converted to general anaesthesia. In our study, three patients (3%) required general anaesthesia.

Present study is similar to that of Mark Tverskoy. (15) in this respect.

DC moore. (16) stated that duration of analgesia with lignocaine can prolong up to 180 mins with adrenaline solution. As per Covino et al. (17) duration of analgesic effect of lignocaine is 195+25 mins for brachial plexus block for local infiltration 35340 mins, duration can be prolonged up to 200% by addition of epinephrine. In the present study, mean duration of analgesia was 212 minutes (160 minutes to 280 minutes). So the present study correlates with the studies done by Covino et al. (17)

After shifting patients from operation theatre to postsurgical ICU annexure, the post anaesthetic recovery is assessed by using modified Aldrete Post Anaesthetic Recovery (PAR) score. (1,2)

The following are the studies done by various authors for hernia repair. Under filed block or monitored anaesthesia care as a day care anaesthesia.

With respect to activity our study correlates with the study done by A E Kark, et al. (6)

Only three patients complained of pain and were managed with oral analgesics in our study, so it correlates with the study of G W Dierking et al. (10)

The mean ambulation score was 1.06 at 90 mins, 1.68 at 120 mins, 1.94 at 150 mins.

The mean score for the ability to drink fluid was 1.04 at 60 mins and 1.56 at 90 mins so it correlates with the study of Hangama et al. (3)

At 90 mins 64 patients were fit for discharge, at 120 mins 86 patients fit for discharge, at 150 mins almost all patients became fit for discharge.

So it correlates with the study done by Hangama et al. (3)

CONCLUSION

Lignocaine with adrenaline is effective for carrying out field block for outpatient anaesthesia and provides long duration of post-operative pain relief in comparison to general anaesthesia with mean duration of 212 mins.

Field block fulfils the requirements of surgical anaesthesia.

Field block is best method for outpatient anaesthesia because fit for discharge achieved early compared to general or spinal anaesthesia.

Outpatient anesthesia with field block avoids polypharmacy, is safe and economical because it avoids hospital stay.

REFERENCES

(1.) Aldrette JA. The post anaesthesia recovery score revisited: Journal of Clini anaesthesia, 1995;7(1):89-91.

(2.) Ian S, Text book of day care anaesthesia, BMJ books, 2000: pp 1-34, 105-106, 120-121, 139-140, 180-206.

(3.) Hongama, Tang J, White PF, Zaentz A, Ronald H, Winder, et al. Perioperative Rofecoxib improves early recovery after outpatients herniorrhaphy, Anaesthesia Analgesia 2004;98:970-975.

(4.) Gianetta E, Cuneo S, Brunovitale, Camerini G, Marino P and Stella M. Anterior tension free repair of recurrent inguinal hernia under local anaesthesia, Annals of surgery 2000;231(1):132-136.

(5.) Amid PK, Shulman AG, Lichstein H. Local anaesthesia for inguinal hernia repair step by step procedure, Annals of surgery 2004;220(6):730-737.

(6.) Kark AE, Kurzer M, Waters KJ. Tension free mesh hernia repair; review of 1098 cases using local anaesthesia in a day unit, Ann R Coll Surg Engl 1995;77:299-304.

(7.) Prevoznik. Useful blocks in outpatient anaesthesia. International Anaesthesiology Clinic. Kurt F Schmidt, ed (1976); 14(2):91-95.

(8.) Sinnot J, Catherine BA, Cogswell P, Lawrence, Anthony JBS, Strichart RG; on mechanism by which epinephrine potentiates lidocaines peripheral nerve block, Anaesthesiology 2003; 98:181-188.

(9.) Scott E. A local anaesthesia for inguinal herniorrhaphy, survey of 50 patients. Am Jour of Surg 1960; 100:782-786.

(10.) Dierjing G, Dahl JB, et al. Effect of pre vs postoperative inguinal field block on postoperative pain after herniorrhaphy, BJA, 1992; 68:344-348.

(11.) Reid MF, Harris R, et al. Day care herniotomy in children, comparison of ilioinguinal nerve block and wound infiltration for postoperative analgesia; Anaesthesia 1987;42(6):658-661.

(12.) Scott IM, Chung, Frances. Discharge criteria and complications after ambulatory surgery. Anaesthesia analg; 1999;88:508-517.

(13.) Callesen T, Bech K, et al. The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Anaesthesia 1998;54:31-35.

(14.) Callesen T, et al. Post herniorrhaphy pain. Anaesthesiology 1997;87(5):1219-1225.

(15.) Tverskoy M, Cozacovc, et al. Postoperative pain after inguinal herniorrhaphy with different types of anaesthesia; anaesthesia analgesia; 1990;70:29-35.

(16.) Moore DC. Regional block, 4th edition, Springfield 1973, p 167.

(17.) Barash GP, Cullen F, Bruce, et al. Clinical anaesthesia 3rd edition 1997 pp 413-440, 4th edition pp1217-1238.

(18.) Ding Y, White PF. Post herniorrhaphy pain in outpatients after pre-incisional ilioinguinal and iliohypogastric nerve block during monitored anaesthesia care. Canadian Journal of Anaesthesia 1995;42(1):12-16.

(19.) Apfelbaum JI, et al. Eliminating intensive postoperative care in same day surgery patients using short acting anaesthetics, Anaesthesiology 2002;97:66-74.

Velagalaburre Yalappa Srinivasa [1], Thuraganur Kapanigowda Shashikaia [2]

[1] Associate Professor, Department of Anaesthesiology, K. R. Hospital, Mysore Medical College and Research Institute, Mysore.

[2] Associate Professor, Department of Anaesthesiology, K. R. Hospital, Mysore Medical College and Research Institute, Mysore.

Financial or Other, Competing Interest: None.

Submission 14-12-2015, Peer Review 16-12-2015, Acceptance 30-12-2015, Published 01-01-2016.

Corresponding Author:

Dr. Velagalaburre Yalappa Srinivasa, Associate Professor, Department of Anaesthesiology, Stone Building, K R Hospital, Mysore Medical College and Research Institute, Mysore.

E-mail: drsrinivasvy@gmail.com

D0I:10.14260/jemds/2016/6
Table 1: Total score-20 Fit for discharge score more than 18
Modified Aldrete Post-Anaesthetic Recovery (PAR) score for
patients having ambulatory anaesthesia. (1,2)

                                                                Score

                   Able to move 4 extremities voluntarily or      2
                                  on command
Activity           Able to move 2 extremities voluntarily or      1
                                  on command
                   Unable to move extremities voluntarily or      0
                                  on command

                    Able to breathe deeply and cough freely       2
Respiration              Dyspnoea or limited breathing            1
                                    Apnoeic                       0

                      BP+/- 20% of pre-anaesthetic level          2
Circulation          BP+/- 20-49% of pre-anaesthetic level        1
                      BP+/- 50% of pre-anaesthetic level          0

                                  Fully awake                     2
Consciousness                Arousable on calling                 1
                                Not responding                    0

                   Able to maintain saturation > 92% on room      2
                                      air
Oxygenation        Needs oxygen to maintain saturation >90%       1
                       Saturation <90% even with oxygen           0

                                 Dry and clean                    2
Wound dressing          Wet or marked but area constant           1
                            Growing area of wetness               0

                                   Pain free                      2
Pain                  Mild pain managed with oral therapy         1
                   Severe pain requiring parenteral therapy       0
                                                                  2
                      Able to stand up and walk straight
Ambulation                    Vertigo when erect                  1
                             Dizziness when supine                0

                             Able to drink fluids                 2
Fasting/                           Nauseated                      1
Feeding                       Nausea and vomiting                 0

                                  Has voided                      2
Urine output            Unable to void, but comfortable           1
                       Unable to void, but uncomfortable          0

Table 2

Age Distribution

Age in Years       Number of Patients

18-25                      20
26-30                      12
31-35                      9
36-40                      17
41-45                      8
46-50                      5
51-55                      12
56-60                      17
Total                     100

Mean age distribution; 39.83 years with
standard deviation of 13.79

Table 3

Weight Distribution

Weight in KG       Number of Patients

51-60                      48
61-70                      47
71-80                       4
81-90                       1
Total                     100

Weight distribution; mean weight 61.38 kg
with standard deviation of 6.098

Table 4

Quality of Analgesia and Relaxation

                   Number of Patients

Excellent                  80
Good                       15
Fair                        2
Poor                        3
Total                     100

Quality of analgesia and relaxation;
Excellent--80, Good--15, Fair--2, Poor--3,
Success rate 97%, Failure rate 3%

Table 5

Duration of Analgesia

Time Range in Minutes      Number of Patients
No of analgesia                    3

151-160                            5
161-170                            7
171-180                            9
181-190                            4
191-200                            6
201-210                            16
210-220                            20
221-230                            9
231-240                            8
241-250                            8
251-260                            1
261-270                            2
271-280                            2
281-290                           Nil
291-300                           Nil
Total                             100

Duration of analgesia mean -212.38 mins, minimum of
160 mins and maximum of 280 mins

Table 6

Time                   Mean Score     Standard Deviation

0 minute                  15.01             1.243
30 minutes                15.44             1.249
60 minutes                16.75             0.903
90 minutes                17.59             0.985
120 minutes               18.53             1.149
150 minutes               18.92              0.8

Table 7

Concentration of Lignocaine with Epinephrine Solution

Study           Total     ASIP     MIP     PT       SC     Neck of
                Volume                                     the Sac

Scott                     5-10             3.5      5-
early. (9)     35-40ml     ml      --      ml      20ml      2ml
(1960)

                 55ml
Dirking         (15ml               5       5
et al. (10)      1%+      25ml     ml      ml     20 ml       --
(1992)           40ml
                0.5%)

Present        35-37ml    15ml      5       5      10ml      2ml
study                              ml      ml

Table 8

Duration of Analgesia and Surgery

Duration of Surgery                          Duration

G. W. Dierling et al. (1992). (10)      48(25-90) minutes
Mark Tverkoy et al. (1990). (15)           31+5 minutes
Present study                         32.58 minutes (15-60)

Table 9

Year              Study                              Result

                                  MAC          Ambulation time 86
1994          Ding, Yifing       with               +18 mins
               et al. (18)       field         Fit for discharge
                                 block          112 + 49 minutes

                                              Able to walk to room
1995           A E Kark et       Field      assisted by nurse after
                 al. (6)         block      1.5 hours but fully able
                                             to walk within 3 hours

                                               Recovery time mean
                                  Mac               90 mins
                Jetfrey l        with          Recovery range 20
2002         apfelbaum. (19)     field          mins to 210 mins
                                 block          GA ; 90 mins to
                                                    270 mins

                                             Eye opening--7+ 9mins
                                                  Responds to
                                              commands--10+ 9 mins
                                               Orientation--12+11
                                                      mins
                                 Field       Sitting up--53+27 mins
2004             al. (3)         with       Tolerate to oral fluids-
                               propofol           60+ 26 mins
                                              Standing up-101+ 39
                                                      mins
                                             Ambulating--102+ mins
                                              Home readiness--115+
                                                    43 mins
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Title Annotation:Original Article
Author:Srinivasa, Velagalaburre Yalappa; Shashikala, Thuraganur Kapanigowda
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jan 4, 2016
Words:2380
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