COMPARISON OF DICLOFENAC SUPPOSITORIES ALONE AND ITS COMBINATION WITH PARACETAMOL INFUSION FOR THE MANAGEMENT OF POST OPERATIVE PAIN FOLLOWING MYOMECTOMY DONE UNDER SPINAL ANAESTHESIA.

Abstract

Myomectomy could either be open or laparoscopic with pain being a major
complaint by patients who had open procedure as compared with those who had laparoscopy.
Post myomectomy pain is a form of acute pain which results from noxious stimulation due to
injury from muscle or viscera. The use of multimodal protocol is central in the management
of acute postoperative pain and is being advocated for. Paracetamol given as an infusion
alone or as part of a multimodal therapy had been shown to be safe and effective in managing
acute postoperative pain.
The recent increase in the number of myomectomies performed in our centre has
raised the need for adequate postoperative pain management. It was hypothesized therefore,
that the inclusion of rectal diclofenac and paracetamol infusion in multimodal pain
management for post myomectomy pain will provide adequate post operative analgesia. The
study was therefore undertaken to determine the analgesic efficacy of a combination of
infusion paracetamol and rectal diclofenac.
Sixty two patients of the American Society of Anaesthesiologists (ASA) I or II
physical status were recruited for this study. Fifty six patients completed the study. All the
patients received 3ml of 0.5% hyperbaric bupivacaine and 10mg of pethidine for the
induction of spinal anaesthesia. At skin closure, they were randomly allocated into two
groups. Group P received 100mg of rectal diclofenac and 100ml infusion of paracetamol 1g
while group S received 100mg of rectal diclofenac and 100ml of saline to serve as a placebo.
Numerical Rating Scale pain scores were recorded at 30mins, every hour up to 6hrs and then
at the 12th and 24th hour. The primary outcome was the time to first analgesic request.
Secondary outcomes were total analgesic consumption, pain score on request for analgesia
and side effect profile.
Socio demographic characteristics were comparable in the two groups. The baseline
vital signs including pulse rate, respiratory rate, blood pressure, and oxygen saturation (SpO2)
were also comparable in both groups.
The time from intrathecal injection of bupivacaine to first request for analgesia was
319.129.56 minutes in the paracetamol group as against 213.299.53 in the saline group.
This difference was significant (P=0.001, t-test). The time to first request for analgesia from
administration of infusion paracetamol was 207.1217.10 minutes in the paracetamol group
compared to 107.967.05 minutes in the saline group (P=0.001, t-test).
Pain scores were lower in the paracetamol group in the first 3hours and on request for
analgesia. Total analgesic consumption was 52.5826.17mg of pentazocine in the
paracetamol group as against 80.1934.60mg in the saline group in the first 24hours. Side
effects profile was similar in both groups. More patients in Group P, 66.2%, rated their
satisfaction as excellent or very good compared to the patients in the saline group where only
23.2% rated their satisfaction with pain relief as excellent or very good.( p=0.036, chisquare
test)
This study has shown that a combination of rectal diclofenac and paracetamol
infusion (Perfalgan®) has analgesic efficacy in the management of post myomectomy pain. It
is therefore recommended as part of a multimodal strategy for post operative pain following
myomectomy.