Postoperative Pain Management After Supratentorial Craniotomy

Abstract

The aim of this study was to compare the analgesic efficacy of three different postoperative treatments after supratentorial craniotomy. Sixty-four patients were allocated prospectively and randomly into three groups: paracetamol (the P group, n = 8), paracetamol and tramadol (the PT group, n = 29), and paracetamol and nalbuphine (the PN group, n = 27). General anesthesia was standardized with propofol and remifentanil using atracurium as the muscle relaxant. One hour before the end of surgery, all patients received 30 mg/kg propacetamol intravenously then 30 mg/kg every 6 hours. Patients in the PT group received 1.5 mg/kg tramadol 1 hour before the end of surgery. For patients in the PN group, 0.15 mg/kg nalbuphine was injected after discontinuation of remifentanil, because of its mu-antagonist effect. Postoperative pain was assessed in the fully awake patient after extubation (hour 0) and at 1, 2, 4, 8, and 24 hours using a visual analog scale (VAS). Additional tramadol (1.5 mg/kg) or 0.15 mg/kg nalbuphine was administered when the VAS score was > or = 30 mm. Analgesia was compared using the Mantha and Kaplan-Meier methods. Adverse effects of the drugs were also measured. The three groups were similar with respect to the total dose of remifentanil received (0.27 +/- 0.1 mircog/kg/min). In all patients, extubation was obtained within 6 +/- 3 minutes after remifentanil administration. Postoperative analgesia was ineffective in the P group; therefore, inclusions in this group were stopped after the eighth patient. Postoperative analgesia was effective in the two remaining groups because VAS scores were similar, except at hour 1, when nalbuphine was more effective (P = .001). Nevertheless, acquiring such a result demanded significantly more tramadol than nalbuphine (P < .05). More cases of nausea and vomiting were observed in the PT group but the difference was not significant (P < .06). In conclusion, pain after supratentorial neurosurgery must be taken into account, and paracetamol alone is insufficient in bringing relief to the patient. Addition of either tramadol or nalbuphine to paracetamol seems necessary to achieve adequate analgesia, with, nevertheless, a larger dose of tramadol to fulfill this objective.

Comparison of the analgesic efficacy and respiratory effects of morphine, tramadol and codeine after craniotomy*

“…Ten percent of craniotomy patients had severe postoperative pain or required more than 10 mg of morphine in the postanaesthetic care unit. Most recent reports have suggested that pain is a greater problem than previously considered, with 40-60% of patients having moderate to excruciating pain [3][4][5][6]. A recent review article [7] identified acute postoperative pain as an important clinical problem which has been comparatively neglected, and found that chronic pain resulting from intracranial surgery has received scant attention, with a paucity of data on its incidence and management.…”

Anesthesiologic Management for Awake Craniotomy

“…In this case the addition of tramadol or nalbuphine to paracetamol seems to be necessary, with the drawback of a greater incidence of nausea and vomiting 44 .…”

The Perioperative Management of Pain from Intracranial Surgery

“…Certainly, for supratentorial craniotomy using a propofol-remifentanil anesthetic, acetaminophen alone is inadequate [106], but when combined with tramadol or nalbuphine administered on an ''as needed'' (PRN) basis both combinations were equally effective, resulting in mild pain for the first 24 postoperative hours. Several studies have compared intramuscular codeine phosphate with morphine sulfate.…”