Pethidine Infiltration in Intra Fascial Layer After Abdominal Hysterectomy

Introduction: multimodal analgesia regimen has a cornerstone component involving local wound infiltration with analgesic agents to manage and enhance post-operative pain to increase patient satisfaction. Aim: assessment and evaluation of effectiveness of local pethidine infiltration as a local analgesic in total abdominal hysterectomy. Methodology: A cohort of 151 cases that have undergone abdominal hysterectomy have been categorized randomly into two research groups research group I (n=74 cases), involved women that were administered both wound infiltration and IM pethidine; and research group II (n=77 cases), involving women that were administered IM pethidine. Results: The median 10-cm VAS for postoperative pain was significantly lower in women who received both WI and IM pethidine when compared to women who received only IM pethidine, 1 hour, 6 hours, 12 hours and 24 hours postoperatively. The mean total morphine consumption was lower in women who received both WI and IM pethidine when compared to women who received only IM pethidine. Conclusion: Pethidine when administered in a simultaneous manner intrafascially and intramuscularly in cases undergoing total abdominal hysterectomy is more effective in reducing post-operative pain levels


Introduction
Post-operative pain management in cases undergoing total abdominal hysterectomy is considered a major challenge for both gynecologists and anesthesiologists aiming for enhancing patient satisfaction and level of health care service requiring multidisciplinary management and planning regarding the pathway of pain management of pain [1,2]. Despite the fact that epidural form of analgesia is an efficient mode of managing post-operative pain in abdominal surgeries however less invasive forms are considered more practical and applicable for many health care systems [3,4].
Local analgesia infiltration is considered a simple and efficient mode of pain management that has reduced costs in comparison to epidural analgesia. Advancing the pain management protocols could enhance patient post-operative recovery and improve clinical outcomes [5,6]. A widely implemented synthetic opioid known as pethidine causes its analgesic action by Functioning as an agonist on opioid receptors, furthermore it has been revealed and displayed to exert a local anesthetic impact chiefly via Linked to its interfaces with sodium-ion Channels that are voltage-dependent. peripheral nerve conduction blockage action has been revealed and displayed widely in various in vivo and in vitro experimental animal research studies that makes its applicability in clinical practice in humans a promising protocol of management [7,8].
Furthermore, pethidine has been shown to block conductivity in both motor and sensory neural systems via electrophysiological research studies making this issue a matter of interest to investigate its impact on patients undergoing abdominal surgeries via research studies aiming to merge from them evidence-based protocols in practice [9,10]. The privilege of local anesthetic agents' infiltration interestingly has revealed that there are no local anesthetic toxicity issues arise if properly administered in a professional manner, no wound infection or healing issues due to usage of this form of analgesia making it an attractive mode for postoperative pain management for both gynecologists and anesthesiologists [11,12].

Aim of the Study
Assessment and evaluation of effectiveness of local pethidine infiltration as a local analgesic administered intrafascially in total abdominal hysterectomy.

Ethical approval
The research study had approval from the Ethical Committee of

Sample size justification
Data from a previous study Stamatakis et al. [12] showed that the mean values for 24-hour total morphine consumption in cases who received wound infiltration and in those who received intramuscular pethidine were 11.33 ± 8.3 mg and 15.56 ± 9.69 mg, consecutively (p<0.05). Calculation according to these values, setting the type-1 error (α) at 0.05 and the power (1-β) at 0.8, produced a minimal sample size of 72 women in each group.
Assuming a drop-out rate of 5%, a total number of 154 cases were needed to be randomized into two groups.

Statistical methods
Statistical analysis was performed using Microsoft Excel version 2016 and SPSS for Windows version 22.0. Data were presented as range, mean and standard deviation (for normally distributed data); range, median and interquartile range (for discrete or skewed data); or number (percentage) for categorical data. Difference between the two groups was analyzed using independent student's t-test (for normally distributed data); Mann-Whitney's U-test (for discrete or skewed data); or chi-squared test for categorical data.
The mean differences and risk ratios were presented with their 95% confidence intervals, as well. Significance level was set at 0.05.  Figure 1). The mean total morphine consumption was lower in women who received both WI and IM pethidine when compared to women who received only IM pethidine ( Table 3). As regards the pethidine-related adverse effects, the rates of nausea/ vomiting were comparable in both groups of women. The median sedation score was, however, significantly higher in women who received both WI and IM pethidine when compared to women who received only IM pethidine (Table 4). MD (95% CI) mean difference and its 95% confidence interval 1 Analysis using Mann-Whitney's U-test Table 2 reveals and displays interestingly a statistically significant difference as regards VAS scoring between group I and group II at 1,6,12,24 (at rest), 24 (with cough) (p values <0.001) being lower in research group I (wound infiltration +IM).

Discussion
Infiltrative form of analgesia locally acts by blockage of pain transmission due to triggering of voltage-dependent sodium channels, and additionally, sensitizes noci receptors by decreasing inflammatory mediators release responsible for pain [13,14].  Concerning pain levels estimated by using VAS scoring system  As regards morphine consumption that is an issue of concern for clinicians and surgeons due to the fear of possible clinical side effects Table 3  in that study came to the conclusion that local wound infiltration with pethidine after total abdominal hysterectomy did not decrease the total morphine consumption levels within the first 24 hours postoperatively that shows great contradiction to the current research study findings [12].
As a sole agent pethidine, was displayed by prior research team of investigators to be efficient and effective in accomplishing a successful transversus abdominis blockage during conductance laparoscopic cholecystectomy [2,4,15]. Furthermore, there are numerous research studies assessing the local analgesic effectiveness of pethidine, particularly in performing peripheral blockage action. Additionally, in orthopedic surgery research wound infiltration analgesia implementing pethidine causes a postoperative analgesic impact in cases undergoing total hip replacement, chiefly by blockage voltage-activated sodium channels present within the nerve endings and by interaction with opioid receptors [6,8]. Contradicting with the current research study findings it was revealed priorly that pethidine showed failure to control pain by wound infiltration after performance of laparoscopic tubal ligation. The finding was justified by the research team due to the dosage used, and to the issue that the visceral pain experienced by the cases was more overriding, in comparison with the pain correlated to the wound due to trocar insertion, where the infiltration was conducted. Furthermore, contradicting with the current research study in a similar fashion it was shown that wound infiltration using a local anesthetic had no opioid-sparing impact after performing total abdominal hysterectomy, as regards morphine consumption levels [10].

Conclusion
Pethidine when administered in a simultaneous manner intrafascially and intramuscularly in cases undergoing total abdominal hysterectomy is more effective in reducing post-