Journal of Pain Research Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Effects of Adding a Combined Infraorbital and Infratrochlear Nerve Block to General Anaesthesia in Septorhinoplasty This article was published in the following Dove Press journal: Journal of Pain Research Cem Kıvılcım Kaçar Purpose: In this study, we evaluated the hypothesis that preoperative bilateral infraoptic Osman Uzundere nerve (ION) and infratrochlear nerve (ITN) blocks under general anesthesia with sevoflurane Fikret Salık and remifentanil reduced the incidence of emergence agitation (EA), pain scores, and the Mesut Akgündüz analgesic consumption after the septorhinoplasty. Esra Aktiz Bıçak Patients and Methods: Our study was conducted as a prospective randomized, double-sided blind study. Fifty-two patients whose septorhinoplasty operation was planned under general Abdulkadir Yektaş anesthesia were included in the study. Patients were randomly distributed to either the ION and Anaesthesiology and Reanimation Clinic, ITN blocks were performed. Group 1: Bilateral ION and ITN blocks were performed; Group 2: Gazi Yaşargil Education and Research Hospital, TR Health Sciences University, ION and ITN blocks were not performed. Duration of the surgery and anesthesia, Riker Diyarbakır, Turkey Sedation-Agitation Scale (RSAS) score, EA presence, duration of postoperative analgesia, numerical rating scale (NRS) scores, and cumulative dexketoprofen consumption were recorded. Results: The RSAS score, NRS score and cumulative dexketoprofen consumption of the patients in Group 1 were statistically significantly lower than the patients in Group 2 (p<0.05). It was also found that patients in Group 1 (n: 8/26) had less EA compared to patients in Group 2 (n: 16/26) and this difference was statistically significant (p: 0.026). Postoperative analgesia duration of patients in Group 1 was found to be statistically sig­ nificantly higher than patients in Group 2 (p: <0.001). In addition, the number of patients given postoperative dexketoprofen in Group 1 (n: 8/26) was found to be statistically significantly lower than patients in Group 2 (n: 25/26). (p: <0.001). Conclusion: Bilateral ION and ITN blocks in septorhinoplasty operation is an effective, reliable and simple technique in the treatment of postoperative pain. Keywords: emergence agitation, infraorbital nerve block, infratrochlear nerve block, postoperative pain, septorhinoplasty Introduction Pain management is a crucial component of postoperative care.1 Pain cannot be managed well in approximately 80% of postoperative patients.2 Inadequate post­ operative pain management may increase thromboembolic and pulmonary compli­ cations, length of hospital stay, opioid use, recovery time, development of chronic 1–3 Correspondence: Abdulkadir Yektaş pain, mortality, and morbidity. More so, inadequate pain management directly Anaesthesiology and Reanimation Clinic, affects the success of the surgical procedure and creates an uncomfortable morbid Gazi Yaşargil Education and Research 3,4 Hospital, TR Health Sciences University, condition during the postoperative period. Diyarbakır, Turkey Septorhinoplasty is one of the most frequently used nasal surgical procedures.3 Tel/Fax +90-412-258 00 60 ext 3148 Email [email protected] Severe pain may occur in the postoperative period of septorhinoplasty due to soft submit your manuscript | www.dovepress.com Journal of Pain Research 2020:13 2599–2607 2599 DovePress © 2020 Kaçar et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php http://doi.org/10.2147/JPR.S255720 and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Kaçar et al Dovepress tissue injury and osteotomies.5 On a numerical rating scale incidence of EA, pain scores, and the analgesic consump­ (NRS)6 from 0 to 10, a pain score of >3 in 45% of patients tion after the septorhinoplasty. and a pain score of >6 in almost 30% of patients were 7 reported after a septorhinoplasty operation. In their study Patients and Methods examining the postoperative pain of patients undergoing rhinoplasty operation, Demir et al accepted patients with Patients Our study was conducted as a prospective randomized, an NRS score of ≥5 as patients with postoperative pain and double-sided blind study between February 2020 and applied analgesics to them.8 The latest practice guidelines April 2020 in the operating room of the Diyarbakır Gazi published by the American Society of Anesthesiologists Yaşargil Training and Research Hospital at the University (ASA) for perioperative acute pain management recom­ of Health Sciences. We started the study after getting mend the use of multimodal analgesia and regional approval (422/2020) from the ethics committee of our hos­ blockages where possible.9 The use of opioid analgesics in pital. Our study was conducted by the 2008 Helsinki the recovery room is very effective for pain management in Declaration and written informed consent was obtained these patients but has negative effects such as sedation, from all patients. Fifty-two patients between the ages respiratory depression, nausea and vomiting.10,11 Also, the 18–65 who had ASA physical status18 I–II and whose side effects of opioid analgesics may delay the patient’s septorhinoplasty operation was planned under general discharge.11 Peripheral nerve blocks are increasingly used anesthesia were included in the study. Pregnancy, cancer, for postoperative analgesia. Peripheral nerve blocks offer known local anesthetic drug allergy, preoperative chronic advantages of less tissue edema, a wider area of anesthesia pain, inability to provide informed consent, body mass and lower pain in the surgical site.12 index (BMI) 35 > kg/m2 and coagulopathy were considered The infraorbital nerve (ION) is a branch of the max­ as exclusion criteria. Patients were randomly distributed to illary part of the trigeminal nerve. This nerve innervates either the ION and ITN blocks were performed. Group 1: the skin of the nose and septum mobile nasi. The infratro­ ION and ITN blocks were performed; Group 2: ION and chlear nerve (ITN) innervates the root of the nose and is an ITN blocks were not performed. The randomization extraconal branch of the nasociliary nerve, which is a sequence was generated by a computerized random number branch of the ophthalmic portion of the trigeminal nerve.13 generator and sealed in numbered envelopes. The anesthe­ Together with general anesthesia, these two peripheral siologist who performed nerve blocks and the anesthesiol­ nerve blocks have been reported to facilitate pain manage­ ogist who performed extubation and postoperative care ment, reduce complications, and reduce anesthetic agent were different. consumption after nasal procedures.7,12,14 Emergence agitation (EA) is a clinical condition char­ acterized by agitation, confusion, disorientation and General Anesthesia Maintenance aggressive behavior in the early stage of recovery from After the patients were taken to the operating room, general anesthesia.15 Although the etiology of EA is not venous cannulation was performed on the back of the well understood, known risk factors are age (young), sex hand with an 18G intravenous (IV) cannula. 10 mL/kg/h (male), smoking history, benzodiazepine premedication, IV isotonic NaCl 0.9% infusion was started. 5 mg IV sevoflurane anesthesia, postoperative pain, tracheal tube dexamethasone (Dekort, Deva, Istanbul, Turkey) was and/or urinary catheter.13 The incidence of EA can reach administered to prevent postoperative nausea and vomiting up to 55.4% in adults after ear, nose and throat surgery.15 (PONV) and surgical edema and ecchymosis. The patients EA can lead to serious consequences such as various were continuously monitored with electrocardiography, injuries, self-extubation, hemorrhage, increased pain, pulse oximeter and noninvasive blood pressure measure­ removal of catheters, respiratory depression, nausea/ ments recorded every 5 minutes. Preoxygenation was done vomiting, increased blood pressure/heart rate (HR), and with a facemask for three minutes. 2–2.5 mg/kg IV pro­ myocardial oxygen consumption.16 Pain management can pofol (Propofol 1% Fresenius®; Fresenius Kabi Medicine, be an effective preventive measure for EA.17 Istanbul, Turkey), 0.6 mg/kg IV rocuronium (Esmeron®, In this study, we evaluated the hypothesis that preo­ Merck Sharpoo Dohme (MSD) Pharmaceuticals Ltd., perative bilateral ION and ITN blocks under general Germany), and 1 µg/kg IV fentanyl (Talinat, Vem, anesthesia with sevoflurane and remifentanil reduced the Istanbul, Turkey) was administered in anesthesia 2600 submit your manuscript | www.dovepress.com J ournal of Pain Resear ch 2020:13 DovePress Dovepress Kaçar et al induction. For all patients in our study, we used Dräger epinephrine for local anesthesia and decrease intraopera­ Primus (Dräger AG, Lübeck, Germany) as the anesthesia tive bleeding. Septorhinoplasty was performed by open device and monitor and Sevoflurane vaporizer (Drager approach. Bone