scholarly journals A comparison of intrathecal 0.5% hyperbaric ropivacaine with 0.5% hyperbaric bupivacaine for elective surgery: a prospective, randomized, double-blind, controlled study

2021 ◽  
Vol 9 (2) ◽  
pp. 471
Author(s):  
Pallavi Amol Kharat ◽  
Rajshree Chandrashekhar Deopujari
Keyword(s):  
Lower Limb ◽  
Motor Block ◽  
Elective Surgery ◽  
Sensory Block ◽  
Controlled Study ◽  
Complete Regression ◽  
Hyperbaric Bupivacaine ◽  
Duration Of Action ◽  
Significant Difference ◽  
Group B

Background: To compare the onset of action, intensity and duration of motor block of 0.5% hyperbaric ropivacaine with 0.5% hyperbaric bupivacaine for elective lower abdominal, perineal and lower-limb surgeries.Methods: 70 patients undergoing elective lower abdominal, perineal and lower limb surgery receiving spinal anesthesia were divided randomly into two groups, Group B, (bupivacaine 5 mg/ml with glucose 80 mg/ml;4 ml, and Group R, (ropivacaine 5 mg/ml with glucose 80 mg/ml; 4 ml).Results: The results were analyzed and compared using Chi-square test, student ‘s t-test and Fisher’s exact tests. The onset of sensory block was more rapid with bupivacaine (p<0.05). The maximum cephalad spread was similar in both groups. However, the time required to maximum extent of cephalic spread was less in Group B (p<0.05). Motor block 3 according to modified bromage scale was obtained in both groups and the time to achieve the same was not significant. The duration of motor blockade i.e., time to complete regression of motor block was significantly greater with Group B than with Group R (0.0001). We found that there was no significant difference in the time taken to achieve grade 3 motor block but ropivacaine gave a lesser degree of motor block which regressed faster than bupivacaine (118 min versus 156 min; p<0.0001). There was no significant difference in hemodynamic parameters except that diastolic and mean pressures remained on lower side in group B (p<0.05).Conclusions: We conclude that 0.5% hyperbaric ropivacaine provides a sensory block of similar onset and extent, shorter duration of action and less frequency of hypotension as compared to 0.5% hyperbaric bupivacaine.

scholarly journals Comparison between isobaric levobupivacaine 0.5% and hyperbaric bupivacaine 0.5% in spinal anesthesia in lower limb surgeries and lower abdominal surgeries in adult patients

2021 ◽  
Vol 9 (2) ◽  
pp. 418
Author(s):  
Preeti Parashar ◽  
Anisha Singh ◽  
Manoj Kumar Sharma ◽  
Dipak L. Raval
Keyword(s):  
Blood Pressure ◽  
Lower Limb ◽  
Motor Block ◽  
Total Duration ◽  
Sensory Block ◽  
Hyperbaric Bupivacaine ◽  
Significant Difference ◽  
The Mean ◽  
Group B ◽  
Mean Time

 Background: The aim of our study was to compare sensory and motor block characteristics and hemodynamic changes following intrathecal hyperbaric bupivacaine (0.5%) and isobaric levobupivacaine (0.5%) in elective lower limb and lower abdominal surgeries.Methods: 60 patients of either sex, aged 18-60 years, ASA grade I or II scheduled for elective lower abdominal and lower limb surgeries were randomized into two groups, group B (n=30) and group L (n=30) and received either 3 ml of intrathecal hyperbaric bupivacaine or isobaric levobupivacaine intrathecally.Results: The mean time of onset of sensory block at shin of tibia in both the groups was comparable i.e. levobupivacaine (1.19±0.2 minutes) and bupivacaine (1.1+0.2 minutes). The mean time for total duration of sensory block was 211.1±8.2 minutes in group L, while 193.13±13.7 minutes in group B. Time for total duration of motor block in group L was 198.76±8.428 minutes and in group B was 182.6±13.989 minutes. Statistically significant difference was observed in total duration of sensory and motor block in both levobupivaciane and bupivacaine group (p<0.0001). Patients in group L were hemodynamically more stable with significantly less decrease in pulse rate, systolic blood pressure and diastolic blood pressure as compared to group B.Conclusions: We observed that 0.5% isobaric levobupivacaine provided better hemodynamic stability, longer duration of sensory and motor block as compared to bupivacaine. 

scholarly journals A Comparative Study of Isobaric Levobupivacaine 0.5% versus Isobaric Levobupivacaine 0.5% with 3µg Dexmeditomidine in Spinal Anaesthesia in Patients Undergoing Effective Lower Limb Surgeries

2020 ◽  
Vol 5 (1) ◽  
pp. 84-90
Author(s):  
Spoorthy Uppuleti ◽  
Kuppannagari Subba Reddy
Keyword(s):  
Adverse Effects ◽  
Spinal Anaesthesia ◽  
Motor Block ◽  
Onset Time ◽  
Sensory Block ◽  
Complete Regression ◽  
Time Block ◽  
Duration Of Action ◽  
Randomized Controlled ◽  
Significant Difference

Background: Intrathecal apha-2 agonists prolong the duration of action of local anesthetics and reduce the required dose. Dexmedetomidine is a 2 receptor agonist and its 2/1selectivity is 8 times higher than that of clonidine. Aim: In this study, we aimed to investigate the effect of adding 3µg dexmedetomidine to Intrathecal Isobariclevobupivacaine0.5% on the onset time and duration of motor and Sensory blocks.Study design: Randomized controlled study.Subjects and Methods:Patients were randomly assigned into two groups. Group L (n=30) patients received 3 mL (15mg) of 0.5% levobupivacaine+0.3mL normal saline and Group LD(n=30) patients received 3mL(15mg)of0.5%levobupivacaine+0.3mL (3mcg dexmedetomidine). Sensory block onset time, block reaching time to T10dermatome, the most elevated dermatome level, two dermatome regression time, sensory block complete regression time as well as motor block on a set time, reaching Bromage3and regressing to Bromage 0 were recorded.Results:Sensory and motor block onset times were shorter in Group LD than in Group L (p<0.001).The regression of the sensory block to S1dermatome andBromage0 was Longer in Group LD than Group L (p<0.001).The two dermatome regression time was Longer in Group LD than Group L (p<0.001). There were no statistically significant Differences between groups in blood pressure and hear trate.There was no statistically Significant difference between groups when adverse effects were compared.Conclusion:We conclude that intrathecal dexmedetomidine addition to Isobaric levobupivacaine 0.5%for spinal anaesthesia shortens sensory and motor block onset time and prolongs Block duration without any significant adverse effects.

scholarly journals COMPARISON OF INTRATHECAL DEXMEDETOMIDINE AND MAGNESIUM SULPHATE AS AN ADJUVANT TO 0.5% HYPERBARIC BUPIVACAINE IN LOWER LIMB SURGERY

2021 ◽  
pp. 1-3
Author(s):  
Shaheer Ahmed Siddiqui ◽  
Kapil Rastogi ◽  
Aamir Laique Khan
Keyword(s):  
Magnesium Sulfate ◽  
Postoperative Analgesia ◽  
Lower Limb ◽  
Motor Block ◽  
Onset Time ◽  
Sensory Block ◽  
Hyperbaric Bupivacaine ◽  
Block Level ◽  
Lower Limb Surgery ◽  
Group B

Background: Epidural anesthesia is commonly used for perioperative as well as postoperative analgesia in lower limb surgeries. Adjuvant in spinal anesthesia prolongs the duration of anesthesia as well as postoperative analgesia. In this study we evaluate the effects of intrathecal dexmedetomidine and magnesium sulfate as an adjuvant to 0.5% hyperbaric bupivacaine in lower limb surgeries. Methods: Total 60 patients belonging to ASA I or II aged 24 to 57 years of either sex were included in this study and randomly distributed into two groups. Group (B+M) received intrathecal 100mg magnesium sulfate and Group (B+D) received intrathecal 5.0 mcg dexmedetomidine with hyperbaric bupivacaine 15mg (3ml of 0.5%). Onset and duration of sensory and motor block, duration of analgesia, hemodynamic changes and complications were recorded. Results: The mean Onset time of sensory block at T10 (min.), Time to maximum sensory block level (min.), Time in minutes for complete motor block (min.), Time for Motor Emergence from Bromage 3 (min.), Time for Sensory Emergence and Time for first analgesia (min) were significantly different between groups. Conclusion: The dexmedetomidine as an adjuvant with hyperbaric bupivacaine leads to earlier onset and prolonged duration of both sensory and motor block as compared to magnesium sulfate.

scholarly journals Effectiveness of Hyperbaric Ropivacaine over Hyperbaric Bupivacaine in Spinal Anaesthesia

2019 ◽  
Vol 1 (1) ◽  
pp. 10-15 ◽  
Author(s):  
Ramesh Ghimire ◽  
Madhu Gyawali
Keyword(s):  
Motor Block ◽  
Body Wall ◽  
Sensory Block ◽  
Complete Regression ◽  
Hyperbaric Bupivacaine ◽  
Subarachnoid Block ◽  
Hemodynamic Variables ◽  
Block Level ◽  
Group B ◽  
Time To Onset

Introduction: Spinal anesthesia is widely recognized as an alternative to general anesthesia for the surgery in lower extremities, perineum, or lower body wall.  The aim of the study was to compare the effectiveness and safety of hyperbaric Bupivacaine over hyperbaric Ropivacaine. Materials and Methods: We enrolled 60 patients of either sex, ASA grade I &II who were randomly allocated in two groups. Group-B received 3 ml of 0.5% hyperbaric Bupivacaine with glucose 8% and Group-R received 3ml of 0.5% hyperbaric Ropivacaine glucose 8.33%. The various parameters of the subarachnoid block, hemodynamic variables, recovery from sensory and motor blockade, and side effects were studied. Result: The time to onset of maximum sensory block level was faster in Bupivacaine (9.10±3.90min) than in Ropivacaine (10.87±5.37min) and statistically not significant. The time to 5 segments regression was faster in Ropivacaine (116.00±29.72min) than Bupivacaine (143.50±18.76min) and the time to S2 level regression of sensory block was faster in Ropivacaine (154.00±27.84min) than Bupivacaine (186.00±18.73min). The time to onset of the maximum motor was faster with Bupivacaine (8.70±3.19min) as compared to Ropivacaine (13.10±4.40min) The time to regression of motor block by 1 grade was faster with Ropivacaine (97.00±26.64min) than Bupivacaine (146.50±23.53min) and the time to complete regression of motor block was faster with Ropivacaine (149.00±30.75min) than Bupivacaine (183.50±19.96min). Conclusion: The hyperbaric Ropivacaine (3ml, 0.5%) provides a reliable subarachnoid block of shorter duration than hyperbaric Bupivacaine (3ml, 0.5%) with stable hemodynamic parameters. Keywords: Hyperbaric Ropivacaine, Hyperbaric Bupivacaine, Motor, and Sensory Block, ASA

A COMPARATIVE STUDY OF 0.5 % BUPIVACAINE WITH FENTANYL VERSUS 0.75% ROPIVACAINE WITH FENTANYL IN EPIDURALANESTHESIA FOR ABDOMINAL HYSTERECTOMY

2021 ◽  
pp. 71-73
Author(s):  
Pravin Vijayan ◽  
Debarshi Jana
Keyword(s):  
Motor Block ◽  
Sensory Block ◽  
Local Anaesthetics ◽  
Abdominal Hysterectomy ◽  
Controlled Study ◽  
Rescue Analgesia ◽  
Study Results ◽  
Duration Of Surgery ◽  
Group B ◽  
Time To Onset

INTRODUCTION Abdominal hysterectomy (AH) is a quite common gynaecological surgical procedure and electively done under central neuraxial blockade. AH is performed for malignant as well as benign indications such as uterine leiomyoma, persistent vaginal bleeding, or pelvic organ prolapse. AIMS AND OBJECTIVES Compare the onset of motor and sensory block. Find out the duration of the sensory and motor blockade. Observe intraoperative hemodynamic changes and assess post-operative analgesia requirements in 24 hour. Duration of analgesia assessed by requirement of rst rescue analgesic. Observe any untoward incident during intraoperative and post-operative period and managed accordingly MATERIALS AND METHODS Study Area: Department of Anesthesiology & critical care, DARBHANGAMEDICALCOLLEGE AND HOSPITAL. Study Population: Adult patients (30- 65 years) undergoing elective abdominal hysterectomy with regional anaesthesia were included for this study. Study Period:January 2019 to March 2020 Sample Design: Subjects were divided into two groups (n=35) equal in numbers and they sampled as per computerized randomization chart. These patients were divided into two groups, group B (with epidural 0.5% bupivacaine and 100g fentanyl) and group R (with epidural 0.75% ropivavaine and 100g fentanyl). Study Design: Prospective, open, randomized, controlled study. RESULTS: In Our study showed that 3.38kg/m2 and 24.86 3.60 kg/m2in group B and R respectively. The duration of surgery was 100.86 9.35minutes and 98.86 8.32 minutes and the duration of stay, was4.86 0.81days and 4.60 0.914 days in group B and group R respectively. Now with comparison of both groups, time to onset of sensory block (uptoT6) has signicant variation. But the other parameters namely, time to onset of motor block, two segment regression or duration of sensory block, rescue analgesia timing and complete motor recovery time were comparable and not signicant statistically in both groups. SUMMARY & CONCLUSIONS To conclude that in the present study using 0.5% bupivacaine with fentanyl and 0.75% ropivacaine with fentanyl epidurally, ropivacaine produced an earlier onset but similar duration of sensory block. The onset, quality and duration of motor block werecomparable in both the groups. It is important that new local anaesthetics with lower cardiotoxic property are adopted to ensure that regional techniques using large amounts of local anaesthetics remain safe with minimal complications. The recovery prole of ropivacaine may be useful where prompt mobilization is require

scholarly journals Comparison of Intrathecal Fentanyl and Butorphanol as an Adjuvant to Intrathecal Bupivacaine 0.5% in Infraumbilical Surgeries- A Randomised Double Blind Study

2020 ◽  
Author(s):  
Sandip Roy Basunia ◽  
Prosenjit Mukherjee ◽  
Md Bakir Hossain Munshi
Keyword(s):  
Spinal Anaesthesia ◽  
Motor Block ◽  
Controlled Trial ◽  
Sensory Block ◽  
P Value ◽  
Double Blind Study ◽  
Hyperbaric Bupivacaine ◽  
Double Blind ◽  
Group A ◽  
Group B

Introduction: Neuraxial opioids are widely used as adjuvants to local anaesthetic as they improve quality and duration of block. Neuraxial opioids like Butorphanol and Fentanyl allow prolonged analgesia in the postoperative period and faster recovery from spinal anaesthesia. Aim: To compare the safety and efficacy of Butorphanol and Fentanyl combined with bupivacaine for spinal anaesthesia in infraumbilical surgeries. Materials and Methods: The present study was a randomised controlled trial in which 110, ASA I and II patients of either sex who underwent elective infraumbilical surgeries under spinal anaesthesia were selected. Patients were allocated randomly into two groups A (n=55) and B (n=55). Group A (F) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with fentanyl 25 microgram (0.5 mL) to make it total 3.5 mL. Group B (B) received intrathecal 0.5% hyperbaric bupivacaine 12.5 mg (3 mL) with butorphanol 250 microgram (0.25 mL) and Normal Saline (NS) 0.25 mL to make it total 3.5 mL. Heart Rate (HR), Systolic and Diastolic Blood Pressure (SBP, DBP), two segment regression time of sensory block, motor block were assessed at preset intervals. Chi-square test or Fischer’s-exact test were used and a p-value ≤0.05 was considered as statistically significant. Results: Mean of two segment sensory regression time of Group A was 41.94±1.73 minutes and Group B was 50.56±4.43 minutes (p<0.0001). Time to onset of motor block in Group A was 5.28±.32 minutes and Group B was 5.27±.32 minutes (p=0.96). Mean duration of motor block in Group A was 81.23±4.87 minutes and Group B was 109.83±2.61 minutes (p<0.0001). Time to rescue analgesic was 289.27±7.37 minutes in Group A and 378.41±10.25 minutes in Group B (p<0.0001). HR, SBP and DBP were comparable among the groups. Conclusion: Intrathecal bupivacaine-butorphanol mixture was clinically better as it provided longer duration of analgesia with lesser incidences of pruritus and nausea/vomiting compared to intrathecal fentanyl-bupivacaine mixture.

scholarly journals A COMPARATIVE STUDY OF CLONIDINE VERSUS NALBUPHINE AS INTRATHECAL ADJUVANTS TO 0.5% HYPERBARIC BUPIVACAINE DURING LOWER ABDOMINAL SURGERIES – A RANDOMIZED DOUBLE BLIND INTERVENTIONAL STUDY.

2020 ◽  
Vol 4 (3) ◽  
Author(s):  
Trishala Jain ◽  
Jaipal .
Keyword(s):  
Motor Block ◽  
Sensory Block ◽  
Double Blind Study ◽  
Hyperbaric Bupivacaine ◽  
Double Blind ◽  
Rescue Analgesia ◽  
Institutional Ethics ◽  
Group A ◽  
Group B ◽  
Intrathecal Clonidine

Background: Regional anesthesia techniques for gynecological procedures are on increasing trends due to their advantage of postoperative analgesia owing to intrathecal adjuvants. The present study was aimed to comparatively evaluate the clinical efficacy of clonidine with nalbuphine when co-administered intrathecally with 0.5% hyperbaric bupivacaine for Lower abdominal surgeries in Gynecology. Methods: With institutional ethics committee clearance No. 193MC/EC/2018, randomized, double blind study was conducted. After obtaining informed written consent total of 84 patients scheduled for lower abdominal surgeries were randomly allocated into two groups: Group A (n=42) - Inj.  3.5 ml Bupivacaine 0.5% + 0.2 ml Clonidine(30µg) intrathecally.  Group B (n=42) - Inj.3.5 ml Bupivacaine 0.5%+0.2 ml Nalbuphine(2mg) intrathecally. The characteristics of sensory and motor block, hemodynamic data, side effects were recorded. Results: The onset of sensory block was earlier in Group B than Group A (3.08±0.52 min vs 4.00±0.54 min, p<0.001 ). The onset of motor block was also earlier in Group B than Group A (7.78±0.80 min vs 8.80±0.95min, p<0.001). The time to first rescue analgesia in patients receiving intrathecal clonidine was significantly delayed than patients receiving intrathecal nalbuphine (284.95 ± 12.93 min vs 211.52 ± 15.92 min, p<0.001). Introperative hemodynamic changes were comparable and none of the patient suffered from respiratory depression except very little cases of shivering which are not significant. Conclusions: Intrathecal clonidine as adjuvant to bupivacaine provided was clinically more effective than nalbuphine for prolonging the duration of analgesia for gynecological procedures. Keywords: Bupivacaine, Clonidine, Lower abdominal surgeries in gynecology, Nalbuphine, Subarachnoid block.

scholarly journals Comparison of Racemic Bupivacaine and Levobupivacaine; combined with low dose Fentanyl, through Intrathecal Route for Transurethral Resection of Prostate

2018 ◽  
Vol 4 (3) ◽  
pp. 10-13
Author(s):  
Debalpana Chandra ◽  
Subir Kumar Brahma
Keyword(s):  
Transurethral Resection ◽  
Motor Block ◽  
Onset Time ◽  
Sensory Block ◽  
Racemic Mixture ◽  
Transurethral Resection Of Prostate ◽  
Complete Regression ◽  
Central Nervous System Toxicity ◽  
Suitable Alternative ◽  
Significant Difference

Background and Objectives:  Bupivacaine is available as a racemic mixture of dextro and levobupivacaine. Many studies show that dextrobupivacaine has greater cardiovascular and central nervous system toxicity than levobupivacaine. The objectives of the present study were to compare the effects of racemic Bupivacaine + Fentanyl and Levobupivacaine + Fentanyl on the complete regression of motor block, onset time to reach T10 level sensory block, duration of T10 level sensory block, onset time of motor block, duration of sensory block.Materials and Method: The study was conducted in 100 patients undergoing transurethral resection of prostate operation, who received either 1.75 ml Bupivacaine (0.5%) + 25 µg Fentanyl (Gr A) or 1.75 ml Levobupivacaine (0.5%) + 25 µg Fentanyl (Gr B) intrathecally.Results: Time to complete regression of motor block, onset time toT10 level sensory block were significantly prolonged in Gr A compared to Gr B. The onset time of motor block was significantly shorter in Gr A compared to Gr B. There was no statistically significant difference between the two groups in respect to the duration of T10 level sensory block, duration of sensory block.Conclusion: Intrathecal Levobupivacaine + Fentanyl used in the present study can be considered as a suitable alternative to Bupivacaine + Fentanyl for spinal anaesthesia in elective TURP surgery.

scholarly journals Comparison of effects of Bupivacaine and Ropivacaine in patients undergoing elective Caesarean section

2020 ◽  
Vol 4 (3) ◽  
pp. 859-863
Author(s):  
Sangeeta Subba ◽  
Arjun Arjun Chhetri ◽  
Rupak Bhattarai
Keyword(s):  
Cesarean Section ◽  
Spinal Anesthesia ◽  
Motor Block ◽  
Elective Caesarean Section ◽  
Sensory Block ◽  
Elective Cesarean Section ◽  
Hyperbaric Bupivacaine ◽  
Safe Alternative ◽  
Elective Cesarean ◽  
Group B

Introduction: Spinal anesthesia is considered a reasonable choice for cesarean section. Bupivacaine and ropivacaine have been used as intrathecal drugs alone or in combination with various opioids. Ropivacaine is considered a valid and safe alternative to bupivacaine for spinal anesthesia. Objectives: To compare the efficacy and safety of hyperbaric ropivacaine with hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. Methodology: Sixty pregnant women undergoing elective cesarean section were allocated into two groups. Group R received 3 ml of 0.5% hyperbaric ropivacaine (2 ml 0.75% plain ropivacaine mixed with 1 ml of 25 %dextrose) and Group B received 2.5 ml of 0.5% hyperbaric bupivacaine. Both the groups were compared in terms of onset of sensory and motor block, regression of sensory and motor block, duration of analgesia and side effects. Results: The onset of sensory block was comparable in both groups but was statistically insignificant. The onset of motor block in Bupivacaine(7.53 ± 1.72) min was faster when compared to Ropivacaine group(14.33 ± 6.19) min. Regression of sensory and motor block both were faster in Ropivacaine group. Duration of analgesia was longer in Bupivacaine group(131.17 ± 32.95)min than Ropivacaine group(125.33 ± 30.54)min. Conclusion: Ropivacaine can be used as an alternative to Bupivacaine for spinal anesthesia in cesarean section but has a shorter duration of sensory and motor block.

A COMPARISON BETWEEN INTRATHECAL NALBUPHINE VERSUS FENTANYL AS AN ADJUVANT WITH 0.5% HYPERBARIC BUPIVACAINE FOR POSTOPERATIVE ANALGESIA IN PATIENTS UNDERGOING LOWER SEGMENT CESAREAN SECTION

2021 ◽  
Vol 5 (8) ◽  
Author(s):  
Mukesh Choudhary ◽  
Neeti Mahla
Keyword(s):  
Cesarean Section ◽  
Postoperative Analgesia ◽  
Motor Block ◽  
Sensory Block ◽  
Hyperbaric Bupivacaine ◽  
Double Blind ◽  
Lower Segment Cesarean Section ◽  
Group A ◽  
The Mean ◽  
Group B

Background: Subarachnoid block is the preferred anesthesia for cesarean section, being simple to perform and economical with rapid onset. This study aims to compare the postoperative analgesia of intrathecal nalbuphine and fentanyl as adjuvants to bupivacaine in cesarean section. Methods: A prospective, randomized, double?blind, and comparative study was conducted on 120 patients of American Society of Anesthesiologists (ASA) physical status I and II. These patients were randomized into three groups with fifty patients in each group. Group A received 2 ml of 0.5% hyperbaric bupivacaine (10 mg) plus 0.4 ml nalbuphine (0.8 mg), Group B received 2 ml of 0.5% hyperbaric bupivacaine (10 mg) plus 0.4 ml fentanyl (20 ?g), and Group B received 2 ml of 0.5% hyperbaric bupivacaine (10 mg) plus 0.4 ml of normal saline. Results: The mean duration of sensory block was 107.32 ± 5.36 min in Group A, 111.23 ± 4.23 min in Group B, and 85.69 ± 2.31 min in Group C. The mean duration of motor block (time required for motor block to return to Bromage’s Grade 1 from the time of onset of motor block) was 152.02 ± 3.12 min in Group A, 151.69± 2.36 min in Group B, and 122.12 ± 2.32 min in Group C. Conclusion: We concluded that intrathecal nalbuphine prolongs postoperative analgesia maximally and may be used as an alternative to intrathecal fentanyl in cesarean section. Keywords: Nalbuphine, Bupivacaine, Fentanyl.

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