Effect of Preemptive Multimodal Analgesia Regimen on Post-operative Epidural Demand Boluses in Lower Limb Orthopaedic Surgeries

Introduction Excruciating pain is associated with lower limb orthopaedic surgeries involving femoral shaft fractures. Postoperative pain management is still ineffective in low-resource settings where the use of epidural and opioid-free analgesia is impractical. Literature is scarce with respect to the effect of a preemptive multimodal analgesia regimen on the requirement of postoperative epidural demand boluses. Hence, the present study aimed to evaluate the effect of pre-emptive multimodal analgesia in reducing the requirement of epidural demand boluses postoperatively, and to find out the time required to receive the first epidural bolus. Material and methods This double-blinded randomized control study included 48 subjects. Patients aged 18-60 years with lower limb fractures requiring surgery under combined spinal-epidural anesthesia were included. Patients were divided into two groups through random allocation. Group A: Preemptive multimodal group received intravenous paracetamol 1 g, IV diclofenac 75 mg diluted in 100ml NS, IV tramadol 50 mg diluted in 100ml NS and tab pregabalin 75 mg orally, 30 mins before surgery. Group B: Placebo group received 3 pints of 100ml NS IV and tab ranitidine 150 mg, 30 mins before surgery. Intraoperatively, combined spinal-epidural anaesthesia was administered taking all the aseptic precautions. Visual analogue scale (VAS) was recorded immediately on shifting to a postoperative room, and then at 1, 4, 8, 12, and 24 hr for both groups. Epidural boluses (10 ml of 0.125% bupivacaine with 2 μg/ml of fentanyl) were given whenever the patient’s visual analogue scale was more than 4. The time at which the first epidural bolus was required by the patient was recorded. The total number of epidural boluses given over 24 hours based on VAS was recorded for both, the preemptive and placebo groups. If the patient still complained of pain, IV diclofenac 75 mg was given if the VAS was more than 4, while IV diclofenac 75 mg along with IV tramadol 50 mg was given if the VAS was more than 6. Patient satisfaction with anesthesia care, in general, was assessed 24 hrs postoperatively. Results A total of 48 subjects were included in the study. During the immediate-postoperative period, and at 8, 12 and 24 hr, the median VAS was significantly low in group A as compared to group B. A significant increase in the demand for epidural bolus immediate-postoperatively was observed in group B (70.83%) compared to group A (4.17%) (p-value of <0.001). At 8 hr, 12hr, and 24hr, patients in group A found a significantly less need for epidural boluses compared to Group B. The mean total number of epidural boluses taken in group A was significantly less compared to group B (1.79 ± 0.41 VS 3.33 ± 0.48, p-Value <0.001). In group A, all patients reported no requirement for diclofenac and tramadol. In group B, 8.33% required diclofenac 75 mg, while the remaining 91.66% had no requirement for diclofenac and tramadol. The difference in patient satisfaction with anaesthesia care in general between the two study groups was found to be significant with a p-value of 0.027. Patients in Group A were very satisfied compared with those in group B. Conclusions The study found that the pre-emptive multimodal analgesia group had better postoperative pain control because they required fewer epidural boluses and no extra analgesics postoperatively. This group was more satisfied with the anaesthesia care in general.