Patients undergoing bariatric surgery have high prevalence of obstructive sleep apnea with or without obesity hypoventilation syndrome. Thus they are at increased risk of respiratory complications related to opioid analgesia. The latter also contributes to postoperative nausea and vomiting (PNV) which delays oral intake. Acetaminophen and Nonsteroidal anti-inflammatory drugs (NSAIDS) have been used as a part of multimodal analgesia regimen for postoperative pain control in an attempt to reduce opioid use and reduce PNV. Few studies have indicated a decrease in opioid requirement and nausea after bariatric surgery. We investigated perioperative use of intravenous ibuprofen in a prospective, randomized, double blind controlled trial in bariatric patients.
A total of 85 patients undergoing laparoscopic bariatric surgery at a single institution were randomized to receive 800 mg intravenous ibuprofen or a placebo. Both were provided by the pharmacy in an identical 500 ml bag with the patient name and protocol number. Patients received medications starting preoperatively and repeated every 6 hours for 24 hours postoperatively. No additional NSAIDS or acetaminophen were used during anesthesia. Primary end point was monitoring opioid requirement and secondary outcomes were visual analogue pain scores at rest (VASr) and cough (VASc), pressure pain thresholds (PPT).
There were 42 patients in Ibuprofen and 43 in placebo group. There were no significant differences in 2 groups. 69 patients were females. Age (mean, 95% confidence interval, and standard deviation) was 34 years, 29.8-33.5 and 10.9. 79 patients underwent sleeve gastrectomy and 6 had Roux-En-Y gastric bypass. Mean weight was 123.9 Kg (115.4-132.3, 95% CI). Median BMI was 44(IQR 40-48). One patient in the ibuprofen group had postoperative bleeding prompting re-exploration. 24 hour morphine use was 32.9 mg (27.6-38.6, 95% CI) (Ibuprofen) versus 31.3 mg (26.9-35.8,95% CI), p=0.609. VASr was 37.7 (32.8-41.5) versus 45.4 (39.5-45.6), p=0.055. VASc was 52.7 (47.6-57.7) versus 54.4 (48.6-60.2), p=0.666. Postoperative PPT decreased with no intergroup difference, p=0.708. Posthoc ANOVA hour after dose effect was present only in the ibuprofen group, p=0.003. VASr at 8-24 hours was reduced by 9.3 (17.5 to 0.7), p=0.034.
Use of intravenous Ibuprofen is safe in bariatric surgery. Standard intravenous dose of ibuprofen does not achieve sustained analgesic and morphine sparing effects in bariatric population but may decrease pain at rest after repeated doses. Further studies are needed to see if higher or more frequent dosing are necessary to achieve therapeutic concentration in bariatric patients.