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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 59-61

Effect of nebulized versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery


Department of Anesthesia, Gandhi Medical College, Bhopal, Madhya Pradesh, India

Date of Submission26-Feb-2020
Date of Decision09-Mar-2020
Date of Acceptance18-Mar-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. D Premkumar
No. 59, Kidwai Road, Shahjahanabad, Bhopal - 462 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_14_20

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  Abstract 

Background: This study was aimed to compare the effect of nebulized fentanyl versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery. Patients and Methods: A total of sixty patients scheduled for unilateral femur interlock surgery under subarachnoid block were enrolled in the study and were randomly divided into two groups. Group I included thirty patients who received 2 μg/kg of fentanyl intravenously, and Group N included thirty patients who received 4 μg/kg of fentanyl nebulization using a standard venturi mask. In the postoperative period, whenever the Visual Analog Scale ≥4, patients received the analgesic corresponding to their respective groups. The data obtained were statistically analyzed using IBM SPSS software. Results: There was no significant difference in the demographic characteristics, duration of surgery, the number of patients who required rescue analgesia, and the onset of analgesia in Group N in comparison with Group I. The duration of analgesia was significantly longer in Group N in comparison to Group I. In Group I, the rise in Ramsay sedation score was faster and peaked at 5 min. In Group N, however, it was lesser than that of Group I. Side effects in Group N were significantly lesser compared to Group I. Conclusion: Nebulization with fentanyl is a good alternative to intravenous fentanyl for adequate postoperative pain relief with fewer side effects.

Keywords: Analgesia, femur interlock surgery, fentanyl, nebulized, postoperative


How to cite this article:
Singh J, Premkumar D, Agarwal A. Effect of nebulized versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery. Bali J Anaesthesiol 2020;4:59-61

How to cite this URL:
Singh J, Premkumar D, Agarwal A. Effect of nebulized versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Jul 9];4:59-61. Available from: http://www.bjoaonline.com/text.asp?2020/4/2/59/284174


  Introduction Top


Intravenous route for fentanyl administration has been the most preferred route of administration for anesthesia and analgesia for surgical procedures and intensive care unit sedation.[1] However, it is associated with several side effects such as nausea, vomiting, sedation, hypotension, bradycardia, pruritis, and respiratory depression.[2]

Fentanyl is a highly lipophilic drug that can be administered through several routes such as subcutaneous, transdermal, sublingual, and nasal spray. One of the rarely used routes of fentanyl administration is inhalational drug delivery.[3] This study was aimed to compare the effect of nebulized fentanyl versus intravenous fentanyl for postoperative analgesia after unilateral femur interlock surgery.


  Patients and Methods Top


This prospective double-blinded randomized comparative clinical study was conducted from January 2019 to January 2020. After obtaining institutional ethical committee clearance and informed consent, sixty patients of 20–50 years old with the American society of anesthesiologists (ASA) Grade I and II posted for elective unilateral femur interlock surgery under subarachnoid block were enrolled for the study. The sixty patients were divided into two equal groups of thirty patients each by sealed envelope method.

Exclusion criteria include those who refused to take part in the study, patients with renal, cardiac, and hepatic impairment and bleeding diathesis, pregnant and breastfeeding women, patients with hypersensitivity to opioids, patients taking drugs that have interactions with fentanyl, patients with body mass index >30 kg/m[2], patients with neuropsychiatric disorders, and patients who were receiving sedatives or any other narcotic drugs.

The sixty patients were randomly divided into two groups of thirty patients each by sealed envelope method. Group I included thirty patients who received 2 μg/kg of fentanyl diluted in 10 ml of normal saline with 5 ml of normal saline nebulized using a nebulizer through standard venturi mask at 8–10 L/min flow of oxygen for 10 min. Group N included thirty patients who received 10 ml of normal saline with 4 μg/kg of fentanyl in 5 ml of normal saline, nebulized using a nebulizer through standard venturi mask at 8–10 L/min flow of oxygen for 10 min.

In the operation theater, all patients received standard premedication with ondansetron 0.15 mg/kg and ranitidine 150 mg. The subarachnoid block was carried out with 17.5 mg bupivacaine (heavy) through a 25G spinal needle. The target block level was kept between T8 and T10. Standard ASA monitoring was applied. Patients were kept in the postanesthesia care unit for 24 h after the end of surgery for observation. The intensity of postoperative pain was recorded for all patients using the Visual Analog Scale (VAS) after surgery. Both the groups received the analgesic drug by a blinded observer through either intravenous or nebulization routes.

The following parameters were recorded: duration of surgery (time from skin incision to the removal of drapes), the onset of analgesia (time from the admission of the analgesic until the VAS score becomes ≤2), duration of analgesia (time from the onset of analgesia until the VAS score becomes greater ≥ 4), level of sedation using Ramsay sedation scale (every 5 min up to 30 min and then at intervals of 15 min up to 2 h), number of patients with inadequate analgesia, and signs of opioid side effects.

The sample size was estimated based on a pilot study. The data obtained were statistically analyzed using IBM SPSS software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, version 25.0. Armonk, NY: IBM Corp.). Qualitative data were analyzed using the Chi-square test and Z-test. Quantitative data were analyzed using the Student's t-test. P < 0.05 was considered statistically significant.


  Results Top


There was no significant difference in the demographic characteristics, duration of surgery, and the number of patients who required rescue analgesia, as displayed in [Table 1]. There was no significant delay in the onset of analgesia in Group N in comparison with Group I, and also, the duration of analgesia was significantly longer in Group N in comparison to Group I.
Table 1: Demographic characteristics, duration of surgery, and onset and duration of analgesia

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In Group I, the rise in Ramsay sedation [Table 2] score was faster and peaked at 5 min. Side effects in Group N were significantly lesser compared to Group I [Table 3].
Table 2: Ramsay sedation score

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Table 3: Side effect comparison

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  Discussion Top


This study of comparison of the effect of nebulized fentanyl (4 mg/kg) versus intravenous fentanyl (2 mg/kg) was based on a study conducted by Abd El-Hamid et al.,[3] the result of which was that nebulized fentanyl produced more extended analgesia than intravenous fentanyl with fewer side effects.

Furthermore, previously, Farahmand et al. had compared the effectiveness of nebulized fentanyl with intravenous morphine in the management of acute limb pain and proposed that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients.[4],[5],[6]

Furyk et al. also compared the efficacy of nebulized fentanyl with intravenous morphine in pediatric patients presenting to the emergency department with clinically suspected limb fractures and found that nebulized fentanyl at a dose of 4 μg/kg provided a clinically significant improvement in pain scores, comparable to that of intravenous morphine.[7] Several studies have documented the effectiveness of nebulized fentanyl compared with intravenous fentanyl.[2],[3],[6],[7],[8],[9],[10],[11],[12],[13]

In this study, we found that there was no significant delay in the onset of analgesia in Group N in comparison with Group I. In contrast, the duration of analgesia was significantly longer in Group N in comparison with Group I. This was in contrary to the study conducted by Abd El-Hamid et al.[3] Several studies reported that nebulization with fentanyl had fewer side effects.[2],[3],[4],[6],[8] The limitation of the study was that serum fentanyl levels were not taken into account.


  Conclusion Top


Nebulization with fentanyl is a good alternative to intravenous fentanyl for adequate postoperative pain relief with fewer side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gourlay GK, Kowalski SR, Plummer JL, Cousins MJ, Armstrong PJ. Fentanyl blood concentration-analgesic response relationship in the treatment of postoperative pain. Anesth Analg 1988;67:329-37.  Back to cited text no. 1
    
2.
Singh AP, Jena SS, Meena RK, Tewari M, Rastogi V. Nebulised fentanyl for post-operative pain relief, a prospective double-blind controlled randomised clinical trial. Indian J Anaesth 2013;57:583-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Abd El-Hamid AM, Elrabeie MA, Afifi EE. Nebulized versus intravenous fentanyl for postoperative analgesia after unilateral arthroscopic anterior cruciate ligament reconstruction surgery: A prospective, randomized, comparative trial. Ain-Shams J Anaesthesiol 2015;8:316-9.  Back to cited text no. 3
    
4.
Worsley MH, MacLeod AD, Brodie MJ, Asbury AJ, Clark C. Inhaled fentanyl as a method of analgesia. Anaesthesia 1990;45:449-51.  Back to cited text no. 4
    
5.
Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-9.  Back to cited text no. 5
    
6.
Farahmand S, Shiralizadeh S, Talebian MT, Bagheri-Hariri S, Arbab M, Basirghafouri H, et al. Nebulized fentanyl versus intravenous morphine for ED patients with acute limb pain: A randomized clinical trial. Am J Emerg Med 2014;32:1011-5.  Back to cited text no. 6
    
7.
Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: A randomized controlled trial. Emerg Med Australas 2009;21:203-9.  Back to cited text no. 7
    
8.
Bartfield JM, Flint RD, McErlean M, Broderick J. Nebulized fentanyl for relief of abdominal pain. Acad Emerg Med 2003;10:215-8.  Back to cited text no. 8
    
9.
Kissin I. Preemptive analgesia. Anesthesiology 2000;93:1138-43.  Back to cited text no. 9
    
10.
Higgins MJ, Asbury AJ, Brodie MJ. Inhaled nebulised fentanyl for postoperative analgesia. Anaesthesia 1991;46:973-6.  Back to cited text no. 10
    
11.
Macleod DB, Habib AS, Ikeda K, Spyker DA, Cassella JV, Ho KY, et al. Inhaled fentanyl aerosol in healthy volunteers: Pharmacokinetics and pharmacodynamics. Anesth Analg 2012;115:1071-7.  Back to cited text no. 11
    
12.
Miner JR, Kletti C, Herold M, Hubbard D, Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med 2007;14:895-8.  Back to cited text no. 12
    
13.
Mather LE, Woodhouse A, Ward ME, Farr SJ, Rubsamen RA, Eltherington LG. Pulmonary administration of aerosolised fentanyl: Pharmacokinetic analysis of systemic delivery. Br J Clin Pharmacol 1998;46:37-43.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Patients and Methods
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