A Double‐Blind, Randomized Controlled Trial of Pre‐incision Wound Infiltration Using Diclofenac Versus Bupivacaine for Post‐operative Pain Relief in Open Thyroid and Parathyroid Surgery

Abstract

Background Pre‐incision wound infiltration using NSAID is an alternative method to manage post‐operative pain in surgery. It is postulated that NSAID delivered peripherally exerts efficient analgesic and anti‐inflammatory effect with minimal systemic complication. This study explored the efficacy of using diclofenac for wound infiltration in open thyroidectomy and parathyroidectomy as compared to conventional agent, bupivacaine. Methodology The study was designed as a double‐blind, randomized controlled trial involving 94 patients who underwent open thyroidectomy or parathyroidectomy in Hospital Pulau Pinang, Malaysia, from November 2015 to November 2016. The study compared the efficacy of pre‐incision wound infiltration of diclofenac (n = 47) versus bupivacaine (n = 47) in post‐operative pain relief. Wound infiltration is given prior to skin incision. Mean pain score at designated time interval within the 24‐h post‐operative period, time to first analgesia, total analgesic usage and total analgesic cost were assessed. Results Ninety‐four patients were recruited with no dropouts. Mean age was 49.3 (SD = 14.2) with majority being female (74.5%). Ethnic distribution recorded 42.6% Chinese, 38.3% Malay, followed by 19.1% Indian. Mean duration of surgery was 123.8 min (SD = 56.5), and mean length of hospital stay was 4.7 days (SD = 1.8). The characteristics of patient in both groups were generally comparable except that there were more cases of total thyroidectomy in the diclofenac group (n = 31) as compared to the bupivacaine group (n = 16). Mean pain score peaked at immediate post‐operative period (post‐operative 0.5 h) with a score of 3.5 out of 10 and the level decreased steadily over the next 20 h starting from 4 h post‐operatively. Pre‐incision wound infiltration using diclofenac had better pain control as compared to bupivacaine at all time interval assessed. In the resting state, the mean post‐operative pain score difference was statistically significant at 2 h [2.1 (SD = 1.5) vs. 2.8 (SD = 1.8), p = 0.04]. During neck movement, the dynamic pain score difference was statistically significant at post‐operative 1 h [2.7 (SD = 1.9) vs. 3.7 (SD = 2.1), p = 0.02]; 2 h [2.7 (SD = 1.6) vs. 3.7 (SD = 2.0), p = 0.01]; 4 h [2.2 (SD = 1.5) vs. 2.9 (SD = 1.7), p = 0.04], 6 h [1.9 (SD = 1.4) vs. 2.5 (SD = 1.6), p = 0.04] and 12 h [1.5 (SD = 1.5) vs. 2.2 (SD = 1.4), p = 0.03]. Mean dose of tramadol used as rescue analgesia in 24 h duration was lower in the diclofenac group as compared to bupivacaine group [13.8 mg (SD = 24.9) vs. 36.2 mg (SD = 45.1), p = 0.01]. The total cost of analgesia used was significantly cheaper in diclofenac group as compared to bupivacaine group [RM 3.47 (SD = 1.51) vs. RM 13.43 (SD = 1.68), p < 0.01] or [USD 0.83 (SD = 0.36) vs. USD 3.21 (SD = 0.40), p < 0.01]. Conclusion Pre‐incision wound infiltration using diclofenac provides better post‐operative pain relief compared to bupivacaine for patient who had underwent open thyroidectomy or parathyroidectomy. Diclofenac is cheap and easily a...

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

“…Other medications used off-label for CWI, alone or as adjuncts to LA include alpha-2agonists [47,48], tramadol [49], nonsteroidal anti-inflammatory drugs (NSAIDs) [50][51][52][53] and NMDA antagonist [54]. Of note, studies using adjuvants rarely compare the adjuvant given intravenously in the same dose in order to assess the systemic vs. local effect of the adjuvant [48,50].…”

“…The addition of NSAIDs like lornoxicam (8 mg) to ropivacaine (0.75%) improved postoperative pain control and patient comfort and decreased the need for postoperative opioids during 4 postoperative hours compared with ropivacaine and lornoxicam alone, and 12 h compared to placebo [51]. WI with diclofenac (50 mg) reduced pain scores and rescue analgesic (tramadol) use during the first 24 h postoperatively compared to bupivacaine (0.25%, 10 mL) [52]. Although superficial cervical plexus block is the most frequently used regional technique, bilaterally performed WI has similar efficacy with lower incidence of transient mild adverse events during 24 h [201,202].…”

Ketamine infiltration decreases the need for opioids after thyroid surgery

“…Diclofenac has also been reported as an effective molecule to infiltrate the wound before surgery compared to Bupivacaine in reducing postoperative pain. 11 However, the use of ropivacaine was not associated with an analgesic effect. 12 Ketamine also belongs to the molecules whose local wound analgesic effect has been studied.…”

“…6,7 In the current literature, different anesthetic agents for thyroid surgery wound infiltration were studied, including bupivacaine, diclofenac, ropivacaine, and, more rarely, ketamine. [9][10][11][12] Ketamine has a high affinity for N-methyl-D-aspartate receptors; it can also bind to opioid mu and sigma receptors that provide central and peripheral analgesic effects. 13 The purpose of this study was to assess the impact of local wound infiltration using ketamine at the end of thyroid surgery on postoperative pain and opioid requirement.…”

Efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia: A meta‐analysis with trial sequential analysis of 23 randomised controlled trials

“…CWI has been shown to be effective but has also been found to be associated with increased difficulty in postoperative care, catheter detachment, and fluid leakage 3,4 . While LWI with a single local anaesthetic can be used to overcome these complications, the analgesic time is unsatisfactory 5,6 . By increasing the duration of action, dexmedetomidine (DEX), an α2‐agonist, may help avoiding the need for catheters insertions 7 …”