Diclofenac Is Superior to Paracetamol in Postoperative Pain Scores and Analgesic Consumption in Supratentorial Craniotomy With No Difference in Platelet and Clot Function: A Prospective Randomized Controlled Trial

Abstract

Background: The use of nonsteroidal anti-inflammatory drugs in neurosurgery remains controversial because of potential risk of hematoma formation secondary to platelet dysfunction. This study aimed to investigate the efficacy and safety of diclofenac compared with paracetamol for the management of postcraniotomy pain. Methods: In all, 110 adult patients undergoing craniotomy for supratentorial tumors were randomized to receive either intravenous paracetamol (15 mg/kg) or intravenous diclofenac sodium (1.5 mg/kg) 30 minutes before the end of surgery and postoperatively at 12-hour intervals up to 48 hours. The analgesic efficacy of diclofenac and paracetamol was assessed using the Numerical Rating Scale (NRS) score at 12, 24, and 48 hours after surgery. We also examined the need for rescue analgesia, coagulation profiles using a Sonoclot analyzer, and incidence of intracranial hematoma formation. Results: At 24 hours postsurgery, NRS scores were lower in group D than in group P; median (interquartile range) and mean rank NRS score in group D was 3.00 (1.0), 43.71, respectively, compared with 3.00 (1.0), 59.29 in group P (P=0.004). Patients in group P received more rescue analgesia than those in group D. Coagulation profiles were similar between groups at 24 hours. Activated clotting time was longer in group D (128.76±12.61 s) than in group P (123.84±09.77 s; P=0.03) at 48 hours, although remained within normal limits in both groups; clot rate and platelet function were similar at 48 hours. There was no difference in the incidence of postoperative tumor bed hematoma. Conclusion: Compared with paracetamol, diclofenac sodium provided more effective postoperative analgesia at 24 hours with no evidence of adverse effects on coagulation profiles in patients undergoing craniotomy for supratentorial tumors.

Post-craniotomy Pain: An Update

“…They also found no differences in ACT, clot rate, and platelet function when analyzed using a Sonoclot analyzer, 24 hours after surgery in patients receiving diclofenac, and no patient had evidence of significant tumor bed hematoma on CT scan at 24 and 48 hours postoperatively. 59 NSAIDs have also been implicated as a common cause of renal failure in the postoperative period. This may be due to renal blood flow becoming 'prostaglandin-dependent' in the state of hypovolemia as well as in the presence of high concentrations of circulating vasoconstrictors.…”

Pain management after elective craniotomy

“…15,21 Five out of six studies showed positive analgesic effects compared with placebo 15,17,18,20,21 and an opioid-sparing effect was demonstrated in four studies. [18][19][20][21] Except for one study, 15 all provided paracetamol as basic analgesic and four studies used either scalp infiltration 15,17,20 or SNB 19 and still showed an analgesic effect of NSAIDs, except for the studies using SNB. Used as premedication, single-dose intra-operatively or postoperatively on a scheduled basis, diclofenac and dexketoprofen reduced postoperative pain scores.…”

“…Used as premedication, single-dose intra-operatively or postoperatively on a scheduled basis, diclofenac and dexketoprofen reduced postoperative pain scores. [18][19][20][21] A single intra-operative dose of parecoxib also provided significant analgesia but no opioid-sparing effect. 17 Included RCTs reported no difference in opioid-related events and adverse events, 15,[17][18][19][20][21] including postoperative bleeding.…”

“…[18][19][20][21] A single intra-operative dose of parecoxib also provided significant analgesia but no opioid-sparing effect. 17 Included RCTs reported no difference in opioid-related events and adverse events, 15,[17][18][19][20][21] including postoperative bleeding. 20,21 A systematic review and a meta-analysis evaluated the analgesic effects of NSAIDs in brain surgery.…”

“…Six RCTs evaluated the efficacy of NSAIDs in craniotomy. One RCT compared NSAIDs with placebo, 17 two with paracetamol 18,19 and one with control (no medication) 20 . Two studies compared different analgesics (dexketoprofen-metamizole-paracetamol and diclofenac-flupirtine) with each other and with placebo 15,21 .…”