Randomized Controlled Trial to Evaluate the Efficacy of Intrathecal Dexmedetomidine to Low dose hyperbaric 0.5% Bupivacaine in Elective Lower Segment Caesarean Section

Introduction: Dexmedetomidine has been safely used as an adjuvant for subarachnoid block in obstetric as well as non-obstetric surgeries and was found to be effective without adverse effects. Hence, this study was conducted to determine the efficacy of intrathecal Dexmedetomidine for elective lower segment caesarean sections with reduction of local anesthetic dose. Objectives: This double blinded, randomized controlled study was designed to compare the effects of addition of Dexmedetomidine on 1) Sensory and motor block 2) Maternal hemodynamics 3) Post-operative analgesia and 4) Neonatal outcome. Methods: Eighty parturients were enrolled in study and randomized into two groups as of 40 each and named as Group D and Group B. Group D received 0.5% Hyperbaric Bupivacaine 9mg (1.8ml) + Dexmedetomidine 5µg (0.2ml of 25 µg per ml ) and for Group B received 0.5% Hyperbaric Bupivacaine 10mg (2ml) . Characteristics of block, maternal hemodynamics and neonatal outcome were recorded. P value <0.05 was considered as significant. Results: Sensory onset was rapid in D group as compared to B group (3.7 ± 1.1vs 4.5±1.2) and motor onset was also rapid in D group (3.8±2.0 vs 4.9 ±1.9) with 95% CI. Duration of analgesia was also significantly high in Group D (230.5±40.5 vs 145.1±28.5). No adverse maternal and fetal outcomes were reported. Conclusion: Intrathecal Dexmedetomidine with low dose bupivacaine for cesarean section hastens the sensory as well as motor onset without adversely affecting mother and neonate.

COMPARISON OF HAEMODYNAMIC STABILITY WITH 0.5% AND 0.75% HYPERBARIC BUPIVACAINE DURING SPINAL ANAESTHESIA IN WOMEN UNDERGOING CAESAREAN SECTION

Objective: To compare the effect of 0.5% and 0.75% hyperbaric Bupivacaine on haemodynamic stability in terms of mean systolic blood pressure and heart rate recorded at 4 min in patients undergoing caesarian section in spinal anesthesia. Study Design: Quasi experimental study. Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital, Malir, from Jul to Dec 2018. Methodology: The patients were assigned in two groups (A and B) using lottery method. Group A received 0.5% hyperbaric Bupivacaine solution. Group B received 0.5% hyperbaric Bupivacaine solution. Spinal anaesthesia was given, blood pressure and heart rate were recorded. Data were analyzed in SPSS version 23. Both groups were compared for mean systolic blood pressure and heart rate by using independent sample t-test. Results: The mean age of patients was 29.62 ± 6.21 years in 0.75% Bupivacaine group while 29.31 ± 6.20 years in 0.5% Bupivacaine group. The mean systolic blood pressure of patients was 111.63 ± 5.96 mmHg in 0.75% Bupivacaine group while 117.16 ± 7.12 mmHg in 0.5% Bupivacaine group. The difference was significant in both groups (p-value <0.05). The mean heart rate of patients was 92.27 ± 4.71 beats per min (bpm) in 0.75% Bupivacaine group while 97.68 ± 4.58 bpm in 0.5% Bupivacaine group. The difference was significant in both groups (p-value <0.05). Conclusion: 0.5% hyperbaric Bupivacaine was better than 0.75% hyperbaric Bupivacaine solution in spinal anaesthesia during caesarean section.

A Comparative Study between Analgesic Efficacy of Intrathecal Buprenorphine and USG-Guided Transversus Abdominis Plane Block in Patients Undergoing Cesarean Section under Spinal Anesthesia

Objective The aim of this study was to evaluate and compare the postoperative analgesic efficacy of intrathecal buprenorphine with ultrasonography (USG)-guided transversus abdominis plane (TAP) block in patients of cesarean section. Materials and Methods: Sixty American Society of Anesthesiologists grade I and II pregnant women aged between 20 and 40 years requiring lower segment cesarean section were included in this study. Study Design A prospective randomized comparative study. Study Groups Group A received intrathecal hyperbaric bupivacaine 0.5% 1.8 mL with 60 µg buprenorphine. Group B received intrathecal hyperbaric bupivacaine 0.5% 1.8 mL with 0.2 mL sterile normal saline and at the end of surgery USG-guided bilateral TAP block was given with 20 mL 0.25% bupivacaine on each side of abdomen. Results The mean ± standard deviation of time to first rescue analgesia in Group A and group B was 9.17 ± 0.64 hours and 5.59 ± 0.50 hours, respectively. Distribution of mean time to first rescue analgesia among the cases studied is significantly higher in group A compared with group B. The distribution of paracetamol and tramadol requirement in first 24 hours among the cases studied was significantly higher in group B compared with group A. Conclusion The addition of buprenorphine to intrathecal hyperbaric bupivacaine has advantages over USG-guided TAP block for postoperative analgesia after cesarean section—longer duration of postoperative analgesia, lower analgesic requirements over first 24 hours, and cost–effectiveness.

Comparision of dexmedetomidine and clonidine with hyperbaric bupivacain in spinal anaesthesia

Background: Alpha-2 adrenergic agonists used as adjuvant to spinal anaesthesia produce substantial sensory and motor blockade of bupivacaine. This study was planned to compare the sensory and motor blockade characteristics of intrathecal combinations of adjuvants dexmedetomidine and clonidine with hyperbaric bupivacaine in the cases who underwent lower limb surgery under spinal anaesthesia.Methods: This was prospective, randomized, double blind study. 90 patients of age group between 18-60 years, ASA grade I and II were allotted into 3 equal groups. Group B received 15 mg bupivacaine plain, group BD and BC received dexmedetomidine (5mcg) and clonidine (50mcg) as adjuvants to bupivacaine respectively.Results: The duration of 2 dermatome regression time, sensory blockade and motor blockade were longest in dexmedetomidine group (129.37±4.87; 386±58.43; 353±48.87) in compared to clonidine (109.77±5.95; 296.53±57.19; 269.7±51.2) and bupivacaine group (81.03±6.83; 211.1± 30.47;181.03±20.8). Both drugs do not affect the peak level of sensory blockade, sensory block onset and motor block onset time. Dexmedetomidine and clonidine do not cause sedation in intraoperative and postoperative period.Conclusions: We conclude that addition of dexmedetomidine and clonidine in spinal anesthesia with hyperbaric bupivacaine increase the duration of ‘2 dermatome regression’ time, sensory and motor blockade and both are more with dexmedetomidine than with clonidine.

Spontaneous Termination of Spinal Myoclonus after Spinal Anesthesia: A Case Report

Spinal myoclonus following neuraxial anesthesia isextremely rare. Herein, wereport onacase of spinal myoclonus after spinal anesthesia for elective colpocleisis with perineorrhaphy, in a 71-year-old woman. Sudden, brief, repetitive, and rhythmic hyperkinetic movement in both legs developed two hours after spinal injection with hyperbaric bupivacaine; which then spontaneously resolved after 45 minutes without leaving any neurologic deficit.

COMPARISONS OF EFFECTS OF DIFFERENT DOSES OF DEXMEDETOMIDINE AS ADDITIVE IN INTRATHECAL BLOCKADE WITH 0.5% HYPERBARIC BUPIVACAINE IN LOWER LIMB ORTHOPEDIC SURGERIES

INTRODUCTION Lower limb surgeries may be performed under local, regional (spinal or epidural) or general anaesthesia, but neuraxial blockade is the preferred mode of anaesthesia. Spinal block is still therst choice because of its rapid onset, superior blockade, low risk of infection as from catheter in situ, 1 less failure rates and cost-effectiveness. Intrathecal local anaesthesia alone is associated with relatively short duration of action and thus early analgesic intervention is needed in post-operative period. AIMS AND OBJECTIVES With use of dexmedetomidine in 3 different graded doses with hyperbaric bupivacaine intrathecally as regional anaesthesia for lower limb surgeries. MATERIALS AND METHODOLOGY This Prospective double blinded randomized controlled study. The study will be conducted in adult patients aged between 18-50 years undergoing lower limb surgeries under spinal anaesthesia in orthopedic OT, dept. of Anaethesiology, Medical college & hospital, Kolkata. Duration of the study One year (9 months for data collection & 3 months for data analysis, review& report writing). Total 63 patients in our study. RESULTS We found the mean of two segment regression time from highest sensory level in Group B was 130.56min; in group C was 171.34min; ingroup D was 217.85min So, block regression was signicantly slower with the addition of intrathecal dexmedetomidine (Group D) as compared to group C & B ( P < 0.0001) The mean regression time to S1 from highest sensory level for Group Bwas 289.43 min ( SD- 12.43) For Group C, the mean regression time to S1 from highest sensory level was 402.71 min ( SD- 28.60) For Group D, the mean regression time to S1 from highest sensory level was 584.43min ( SD- 38.92) Overall the mean regression time to S1 from highest sensory level was 425.52 min ( SD- 125.71) The sensory regression time to S1 from highest sensory level was signicantly higher with increasing dose of dexmedetomidine i. e. D>C>B . (P< 0.0001). CONCLUSION We recommend the use of 10mcg of intrathecal dexmedetomidine as an adjuvant to bupivacaine as it seems to be a good alternative to other additives for long duration surgical procedures due to its profound intrathecal anesthetic and analgesic properties. It provides good quality of intraoperative analgesia, thermodynamically stable conditions, minimal side effects, and excellent quality of postoperative analgesia.

COMPARATIVE STUDY OF INTRATHECAL FENTANYL WITH HYPERBARIC BUPIVACAINE TO IMPROVE PERIOPERATIVE ANALGESIA IN PATIENT UNDERGOING ORTHOPEDIC SURGERY

Background: Various methods exist for treating post-operative pain which includes systemic narcotics, NSAIDS, patient-controlled analgesia, regional anaesthesia techniques, epidural local anaesthetic – narcotic mixtures, cryoanalgesia, transcutaneous electric nerve stimulation, psychological methods. Various opioides intrathecally and epidurally have been tried for post-operative analgesia. These include - morphine, pethidine, pentazocine, methadone, tramadol, Fentanyl, sufentanyl. In present study, we tried to find out analgesic effectiveness of intrathecal Fentanyl for post-operative analgesia, combined with 0.5 % Bupivacaine and side effects if any, in patients undergoing lower limb surgeries. Materials and Methods: After approval from the local ethics committee and with written informed consent from patient, a randomized controlled prospective study is carried out in the medical college and hospital.100 patients belonging to American Society of Anesthesiologists (ASA)classification I &amp; II, aged between 18-60 years, posted for elective lower limb surgeries, were randomly allocated for the study. Group-I: 50 patients received intrathecal 3 ml of 0.5 % hyperbaric Bupivacaine only. Group-II : 50 patients received intrathecal 3 ml of 0.5% hyperbaric Bupivacaine and Fentanyl 25 mcg.The patients studied across the group did not vary much with respect to age,height, weight and sex distribution. Results: The onset of sensory blockade was faster by 1.27 min in Group-BF. The perioperative and postoperative hemodynamic parameters were comparable in both the groups. The sensory analgesia in Group II was significantly prolonged by 159 mins, thus increasing the duration of analgesia. The time of first request of analgesics by the patients in group-II is prolonged compared to group-I thus prolonging the duration of analgesia. Analgesic requirement is also reduced in study group in early post-operative period. The onset of motor block was faster when Fentanyl was added to intrathecal Bupivacaine and it was 1.1 min earlier in study group. The duration of motor block to Bromage III was prolonged by almost 22 min in study group as compare to control group. Visual analogue scores were significantly lower in group-II compared to group-I after two hours of surgery thus reducing the frequency of supplemental postoperative analgesics. Conclusion: With the present study we can summarize that intrathecal Fentanyl potentiates the action of Bupivacaine thereby bringing about better quality and longer duration of analgesia, intense motor block, no hemodynamic disturbance and better postoperative outcome with/ minimum side effects.

Correlation between anthropometric measurements and sensory block level of spinal anesthesia for cesarean section

Background: When performing spinal anesthesia for cesarean section, it is important to determine the appropriate anesthetic dose as well as to predict the level of spinal anesthesia. In this study, it was hypothesized that some anthropometric measurements may be related to maximum sensory block and hemodynamic changes. Objectives: The aim of this study are to find maternal anthropometric values that are correlate with the level of spinal anesthesia. Methods: Maternal anthropometric measurements, including height, weight, supine and standing abdominal circumference (AC), and hip circumference, were recorded before spinal anesthesia for cesarean section. Spinal anesthesia was induced by administering 8 mg of 0.5% hyperbaric bupivacaine and 20 μg of fentanyl at the L3-L4 interspace. The level of sensory block was determined using pin-prick at 1, 5, 10, and 15 minutes after spinal anesthesia. The sensory block level and hemodynamic adverse events were analyzed in relationship to anthropometric measurements. Results: The supine AC/height ratios significantly correlate with the maximal sensory block level at 5, 10, and 15 minutes after the injection of spinal anesthetic (p = 0.001, p < 0.001 and p < 0.001, respectively). Further, there were significant correlations between body mass index (BMI) and sensory block level at every assessment (p = 0.041, p = 0.002, p = 0.001 and p < 0.001, respectively). When comparing the groups with and without hypotension, BMI, weight, and supine AC/height ratio were found to be significantly higher in the group with hypotension (p = 0.002, p = 0.004 and p = 0.006, respectively). Conclusions: We conclude that BMI and AC/height ratio correlate with the sensory block level of spinal anesthesia for cesarean section.

Effectiveness of Intrathecal Administration of Bupivacaine with Fentanyl versus Nalbuphine for Elective Cesarean Section

Background Spinal anesthesia is the most popular procedure in the field of anesthesiology. Subarachnoid block is the preferred anesthetic technique for cesarean section, being simple to perform and economical with rapid onset. Lower incidence of failed block, less drug doses, minimal neonatal depression and decreased incidence of aspiration pneumonitis are added advantages of spinal anesthesia. Objectives The study aims to compare the postoperative analgesic efficacy of Fentanyl versus Nalbuphine when used with intrathecal injection of 0.5% hyperbaric bupivacaine in spinal anesthesia in patients undergoing cesarean section as the primary objective and compare intraoperative hemodynamic changes and postoperative pruritus and shivering as the secondary objectives. Methods and material After Approval was obtained from the research ethics committee of faculty of medicine, Ain Shams University and after obtaining a written informed consent. Fifty adult females underwent elective cesarean section with spinal anesthesia, their ages ranged between 18-45 years old and classified as ASA I and II were enrolled in the study at obstetrics and gynecology Ain Shams university hospital over 4 months. The patients were randomly divided using computer generated randomization into two groups 25patients in each (n = 25), Group A received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml fentanyl (25 μg); Group B received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml nalbuphine (0.8 mg) Results The main significant findings in this study was that fentanyl has a more rapid onset of motor block (5.63±0.25 minute in fentanyl group versus 5.88±0.19 minute in nalbuphine group), while nalbuphine produces less perioperative side effects as: shivering (7 patients in fentanyl group versus 1 patient in nalbuphine group), pruritis (6 patients in fentanyl group versus 1 patient in nalbuphine group), nausea and vomiting (5 patients in fentanyl group versus 1 patient in nalbuphine group). Regarding perioperative hemodynamic parameters and postoperative analgesia, they were comparable between the 2 groups. Conclusions We concluded that either intrathecal nalbuphine (0.8 mg) combined with (10 mg) Bupivacaine or intrathecal fentanyl (25 µg) combined with (10 mg) Bupivacaine improves intraoperative analgesia and prolongs early postoperative analgesia in cesarean section with significantly lower incidence of side effects as shivering, pruritis, nausea and vomiting in Nalbuphine.

Addition of intrathecal atropine for prevention of postoperative nausea and vomiting in patients received intrathecal bupivacaine / morphine in lower limb surgeries

Background Intrathecal opioids administration is an attractive analgesic technique since the opioids is injected directly into the cerebrospinal fluid providing safe and effective postoperative analgesia for up to 24 hours. The most common adverse effects after intrathecal morphine are postoperative nausea, vomiting and pruritus. We evaluated the effect of intrathecal atropine on prevention of postoperative nausea and vomiting in patients receiving intrathecal hyperbaric bupivacaine and morphine in lower limb surgeries and on its effect on duration of postoperative analgesia. Methods 80 patients undergoing lower limb surgeries under spinal anesthesia were randomized into two groups. BM group Received spinal anesthesia with 15 mg of 0.5% hyperbaric bupivacaine (3ml) + 200 mcg of preservative-free morphine sulphate (0.2ml) + Normal saline (0.1ml). BMA group received spinal anesthesia with 15 mg of 0.5% hyperbaric bupivacaine (3ml) + 200 mcg of preservative-free morphine sulphate (0.2ml) + 100 mcg preservative-free atropine sulphate (0.1ml). Follow-up of both nausea and vomiting episodes was done during the first 24 hours postoperatively. Results Nausea and vomiting were noticed in 17 patients (42.5%) in group BM and 7 patients (17.5%) in group BMA, with significant differences (p = 0.015). As regards postoperative analgesia, there was no significant differences between BM and BMA group. Conclusions Intrathecal atropine has antiemetic effect after spinal anesthesia using bupivacaine and morphine for lower limb surgeries without affecting postoperative analgesia.