Reachout Orthopedics - Issue 2

it can improve postoperative quality of recov- ery through mood improvement that can be helpful in the postoperative period [12]. Another group of analgesics is the non- steroidal anti-inflammatory drugs (NSAIDs) which are used for acute pain management. It has pain-relieving, antipyretic, and anti-in- flammatory properties [13]. It’s thought that its analgesic effect is caused by suppression of cyclooxygenase (COX) thus it inhibits the synthesis of PGs [14]. However, being non- selective in inhibition of COX1 and COX2; several adverse effects can appear [15]. It is thought that the therapeutic activity of NSAIDs is due to the inhibition of COX-2, whereas the adverse effects results from in- hibition of COX-1 [16]. Thus, many studies show that the selective COX-2 inhibitors have a great role in reducing the postoperative pain and reducing the dose of postoperative opioid consumption [17–19]. Etoricoxib is more highly selective of COX-2 over COX-1 than celecoxib [20], and characterized by longer duration of action ranging 22–24 h. In addition, it is absorbed rapidly after oral intake so the peak plasma concentrations are reached after 1 h [21]. It was examined preoperatively by different studies and revealed efficacy in providing postoperative analgesia after abdominal [17], laparoscopic [19], gynecological [22] and orthopedic procedures [18, 23]. However, additive or synergistic interactions can be detected when two analgesics are adminis- tered together at the same time [24]. In cases of synergistic interaction, we can use smaller doses of each drug to achieve good analgesia with fewer adverse effects derived from indi- vidual compounds [4]. The main objective of the present study was to examine perioperatively the analgesic efficacy with the combination of duloxetine and etoricoxib on postoperative pain and itsopioid-sparing properties when given as part of a multimodal pain strategy in patients undergoing surgery on the lumbar spine. In addition to evaluating the patient’s satisfac- tion and the adverse effects related to the combination of both medications. Methods After institutional Ethics Committee approv- al, this prospective double-blind, randomized, controlled study was started in November 2015 at the department of anesthesia and intensive care unit; El-Minia University Hospital. The study involved 120 adult pa- tients of both genders aging between 18 and 70 years of age with an ASA physical status of I, II and III,who were scheduled for single level lumbar spinal disc prolapse surgery. All patients gave written informed consent. Exclusion criteria involved patients with history of allergic reaction to any of the study drugs, history of drug or alcohol abuse, and abnormal renal or liver function tests. Patients using antidepressants had to stop taking them 2 weeks before surgery. Also, Patients with previous cervical surger- ies, psychiatric disorders and patients receiv- ing opioid analgesic medications within 24 h preoperatively were excluded. We asked the patients to visit the outpa- tient clinic 1 day before surgery for assessment and performing laboratory investigations. We also explained to them the study protocols, including analgesic administration and the 11-point numeric rating scale (NRS) where 0 being ‘no pain’ and ‘10’ being the maximal worst pain [25]. Study Design The patients admitted to the hospital were randomized according to the computer- generated random numbers with closed- sealed envelopes into one of the four groups 30 patients each. The study medications were prepared by the pharmacy of the hospital and given to the patients by an investigator not involved in the study. They were duloxetine 60 mg capsules (Cymbalta; Eli Lilly & Company, Indiana, USA), etoricoxib 60 mg film coated tablets (Arcoxia; Merck Sharp & Dohme Limited, Hertford road, Hoddesdon, Hertfordshire, UK), and placebo capsules that matched the duloxetine capsules or etoricoxib tablet in color and size. All drugs were given 1 h before surgery and repeated after 24 h. 1. The Group P (Placebo) received placebo capsule + two placebo tablet 2. The Group E (etoricoxib) received placebo capsule + two etoricoxib tablet 60 mg 3. The Group D (duloxetine) received dulox- etine capsule 60 mg+two placebo tablet 4. The Group DC (duloxetine + etoricoxib) received duloxetine 60 mg capsules + two etoricoxib tablets 90 mg On arrival to the operating room, stand- ard intraoperative monitoring included elec- trocardiogram (ECG), heart rate (HR), mean arterial blood pressure (MABP), oxygen saturation (SPO2) and end tidal CO2 were recorded and subsequent measurements were recorded every 5 min till the end of the operation using a multiparameter monitor (Mindray iMEC12, Hi-tech industrial Park, Nanshan, Shenzhen, china). General anesthesia was induced by (1.5 μg/kg) fentanyl IV, (2 mg/kg) propofol IV, and endotracheal intubation was performed with (0.5 mg/kg) IV atracurium. Maintenance of anesthesia was done through inhalation of a mixture of oxygen (3 L/min) (1–2%) isoflu- rane and (0.05 mg/kg) atracurium as intermit- tent dose of muscle relaxant to ensure proper muscle relaxation during the procedure. An anesthetist who was blinded to the groups took all the measurements. Their goal was to adjust the anesthetics concentration to keep the heart rate and blood pressure within 20% of the base line value throughout the an- esthesia period.At the end of surgery, the first dose of paracetamol 1000 mg/100 ml intrave- nously (Medalgesic; ARABCOMED, Cairo, Egypt) was given to all patients before extuba- tion. Then, reversal of neuromuscular block- ade was performed with atropine (0.01 mg/kg) and neostigmine (0.05 mg/kg) given intra- venously. After tracheal extubation, patients were transferred to the post-anesthetic care unit (PACU) where vital parameters were re- corded every 1/2 h till complete recovery. During the first 48 h, a standard analgesic regimen of paracetamol 1 g was given intra- venously every 6 h to all patients. In addition, pain assessment in the ward was performed by nurses every 2 h and titrated doses of mor- phine (2 mg bolus at 10 min intervals) were given if patients reported pain (NRS was ≥3). The postoperative data were collected by a senior resident (blinded to the study). The NRS pain scores was recorded at 30 min after the end of anesthesia (time =0), all patients were able to answer questions and Selective COX-2 inhibitors have a great role in reducing the postoperative pain and reducing the dose of postoperative opioid consumption. 13 reachOut Orthopedics