.paper.final-1.pptxComparitive study on analgesia and anaesthesia effect caused by intrathecal bupivacaine

Comparitive study on analgesia and anaesthesia effect caused by intrathecal bupivacaine , bupivacaine + clonidine ,bupivacaine + dexmeditomeditine in spinal anaesthesia

1. “A COMPARATIVE STUDY ON THE ANALGESIA AND ANAESTHESIA EFFECTS CAUSED BY INTRATHECAL BUPIVACAINE,BUPIVACAINE PLUS CLONIDINE AND BUPIVACAINE PLUS DEXMEDETOMIDINE IN SPINAL ANAESTHESIA” Dr. SINGARAVELAN M (Postgraduate, Anaesthesia) Dr. BRINDHA (Professor & HOD, Anaesthesia) Dr. SABAPATHY V A (Professor, Anaesthesia) DR.PREM KUMAR (Assistant professor, Anaesthesia)

2. INTRODUCTION Spinal anesthesia is typically used for procedures affecting the lower abdominal region, perineum and lower limbs. Because of its rapid onset, superior blockage, lower risk of infection, lower rates of failure and cost- effectiveness, spinal block is still the first option but has the disadvantages of shorter block length and less postoperative analgesia(1). Uncontrolled postoperative pain may stimulate and activate the sympathetic nervous system leading to increased morbidity or mortality(2). Attenuation of perioperative pain by optimizing perioperative analgesia can decrease complications and promote recovery not only during the immediate postoperative period but also after hospital discharge(3). Most local anesthetic adjuvants have been intrathecally used to enhance the quality of intraoperative analgesia and extend it in the postoperative period. Bupivacaine and tetracaine are the local anesthetics most frequently used for long-duration spinal anesthesia (4), produces slightly more intense sensory Anesthesia than tetracaine (4). 0.5% Hyperbaric Bupivacaine is extensively used. It's disadvantages are slow onset of action and decreased motor block(5). Intrathecal clonidine is widely evaluated as an alternative to neuraxial opioids for pain control and has been shown to be a potent analgesic. Clonidine prolongs the sensory and motor block as alpha 2 agonist increases sedation, and can potentiate hypotension and bradycardia(6). Dexmedetomidine, a new, highly specific, effective and selective a2- adrenergic agonist used as adjuvants as it offers stable hemodynamic conditions and good quality postoperative analgesia with minimal side effects(7). This study is been undertaken to compare the synergistic effect of the addition of clonidine and dexmedetomidine to intrathecal hyperbaric bupivacaine with respect to duration of analgesia, motor and sensory blockade and the intraoperative hemodynamic profile when mixed with Bupivacaine. This study also aims to ascertain the safety of these drugs for use in routine practice in the hospital.

3. AIM & OBJECTIVE S 1. To study and compare the effectiveness of Dexmedetomidine and clonidine as adjuvants with Bupivacaine in terms of duration of analgesia, motor and sensory blockade and the intraoperative hemodynamic profile among patients undergoing lower limb orthopaedic surgeries. 2. To study the adverse effects of these drugs.

4. MATERIALS AND METHODS STUDY DESIGN : Comparative study STUDY PLACE : Vinayaka Mission’s Kirupananda Variyar Medical College & Hospital, Salem STUDY SAMPLE size : 90 patients ; 30 in each group STUDY DURATION : 4 months from the date of approval INCLUSION CRITERIA : 1) Physical status under ASA 1&2 2) Aged between 18 and 55 years 3)Patients Undergoing lower limb orthopaedic procedures under spinal anaesthesia. EXCLUSION CRITERIA : 1 )Patient not willing for the study. 2) Physical status under ASA 3&4 3) Pregnant women 4) Patients who are allergic to study drugs 5) Contraindications to Spinal anaesthesia 6) Duration of surgery more than 2hours. 7) Patients with thyroid disease,addisons disease,Raynauds syndrome,cardiopu cardiopulmonary,liver,renal disease. History of convulsions/epilepsy,Bronchial Asthma,patient with enlarged prostate or urinary retention problems. 8) use of sedative hypnotic agents,antid antidepressant therapy like monoamine oxidase inhibitors,selective serotonin reuptake inhibitors,vasodilators,benzodiazepines. 9)Initial body temperature <36.0 or >37.5 c 10)Any need for blood transfusion during intraoperative period.

5. SAMPLING TECHNIQUE: Convinent sampling. STUDY TOOLS: The following equipments,drugs and monitors were used DRUGS: 1) Inj.Dexmedetomidine 10 mcg 2) Inj.Clonidine 30 mcg 3) Inj.Ondansetron 8 mg 4) 3.0 ml of 0.5% hyperbaric bupivacaine 5)2ml of 2% lignocaine for local infiltration. MONITORS: A multiparameter monitor with following is made available Electrocardiography,non invasive blood pressure,pulse oximetry,thermometer to measure axillary temperature. ETHICAL APPROVAL: Obtained. CONSENT: An informed consent was obtained from participants after explaining the study procedure to them.

6. On the previous day of surgery all patients underwent routine pre operative assessment. Then the patients were randomly allocated into three groups (group B,group C and group D). Drugs received by three groups are : Group B received 3.0 ml of 0.5% bupivacaine (heavy).intrathecally Group C received 3.0 ml of 0.5% Bupivacaine (heavy) mixed with Clonidine 30 mcg.intrathecally Group D received 3.0 ml of 0.5% bupivacaine (heavy) mixed with 10mcg Dexmedetomidine.intrathecally Anaesthesia machine was checked, pipeline and emergency oxygen supply kept ready. Working laryngoscope with medium and large size blades, endotracheal tube of appropriate size, oropharyngeal airways and working suction apparatus were kept ready. Emergency drugs and general anaesthesia drugs were kept ready. Before shifting the patient to operation theatre, IV access was secured with 18 gauge cannula and IV fluids started . Patients placed in sitting position and under aseptic precautions spinal block was performed at level of L3-L4 through a midline approach using 25G Quincke Babcock spinal needle and study drug injected .patient was made to supine posture immediately and supplemental oxygen given. Continuous monitoring of Non invasive blood pressure(NIBP), heart rate(HR), electrocardiography(ECG) and oxygen saturation(SpO2) was done .Pain assessed using Visual analog score (VAS) score. Patients heart rate,blood pressure,oxygen saturation will be recorded at every 5 minutes till end of surgery.

7. The following parameters were recorded: Onset of sensory blockade and motor blockade. Total duration of Rescue Analgesia. Total duration of analgesia Total duration of sensory blockade and motor blockade Adverse effects- Hypotension and bradycardia.

8. RESULTS The three groups were compared for their efficacy to achieve maximum sensory and motor blockage, time taken to achieve designated level of blockage, success in achieving designated level of blockage and like variables including intraoperative and postoperative complications and use of analgesics. Data entered in MS excel and analysed using SPSS version 23.0. Chi-square/ Fischer exact test, ANOVA, Post hoc analysis was used for Univariate analysis. P value less than 0.05 was considered significant. Tables and graphs were used wherever necessary.

9.   GROUPB GROUP C GROUP D F VALUE P VALUE MEAN SD MEAN SD MEAN SD MEAN ± SD    2.933 0.6915  1.467 0.5074  1.2333  0.5040  77.232  0.000

10.   GROUPB GROUP C GROUP D F VALUE P VALUE MEAN SD MEAN SD MEAN SD MEAN ± SD     4 . 1 6 7   . 6 9   1 . 7 3 3   . 5 8   1 . 2 6 7   . 5 2   1 9 8 . 3 9   .

11.   RESCUE ANALGESIA IN MINS GROUPB GROUP C GROUP D F VALUE P VALUE MEAN SD MEAN SD MEAN SD MEAN ± SD    234.667   2 .674  392.333  22.03  432  24.16  655.032   .

12.   GROUPB GROUP C GROUP D F VALUE P VALUE MEAN SD MEAN SD MEAN SD MEAN ± SD     1 6 9 . 3 3   2 . 7 9   3 3 9   4 9 . 7 1   3 6 5 . 6 7   3 9 . 2 7   3 7 4 . 6 6 7   .

13.   GROUPB GROUP C GROUP D NO OF PTS % NO OF PTS % NO OF PTS % PRESENT    1  3.33  5  16.67  8  26.67 ABSENT 29 96.67 25 83.33 22 73.33 TOTAL 30 100 30 100 30 100

14.   GROUPB GROUP C GROUP D NO OF PTS % NO OF PTS % NO OF PTS % PRESENT    0  0  4  13.33  5  16.67 ABSENT 30 100 26 86.67 25 83.33 TOTAL 30 100 30 100 30 100

15. DISCUSSION All the three groups are more or less equal in attainment of maximum sensory level. In Group D the time taken for sensory onset (1.23 mins) is less compared to other groups and in Group B the time taken (2.9 mins) is too high. In Group D the time taken for motor onset (1.2 mins) is less compared to other groups and in Group B the time taken (4.16 mins) is too high. In Group D the time taken for sensory blockade (5.17 mins) is less compared to other groups and in Group B the time taken (7.5 mins) is too high. In Group D the time taken for motor blockade (5.26 mins) is less compared to other groups and in Group B the time taken (6.76 mins) is too high. The mean duration for analgesia is high (365 mins) in group D when compared to other groups. When compared to group B and group C, group D has higher occurrence of hypotension. Group B has lesser occurrence of hypotension. Group D has higher occurrence of bradycardia whereas group B has no occurrence of bradycardia.

16. CONCLUSION In this study, the efficacy of intrathecal dexmedetomidine and clonidine was compared and we found that intrathecal dexmedetomidine was better than clonidine in terms of the onset and duration of both sensory and motor blockade as well as analgesic duration. Bradycardia and hypotension were seen in few patients which was managed on time. Other side effects like respiratory distress, vomiting and CVS problems were not noticed. Thus intrathecal use of dexmedetomidine is effective than clonidine.

17. REFERENCES 1 .Singh AK, Kumar A, Kumar A, Prasad BK, Tiwary PK, Kumar R. A Comparison of Intrathecal Dexmedetomidine and Neostigmine as Adjuvant to Ropivacaine for Lower Limb Surgeries: A Double-blind Randomized Controlled Study. Anesth Essays Res. 2017;11(4):987-992. doi:10.4103/aer.AER_62_17 2 .Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology. 1995;82:1474 MD 3 .Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87:62. 4 .BrownDL.Spinal, epidural and caudal anesthesia. 6th ed. Chapter43. In: Miller's Anesthesia, Miller RD, ed. Philadelphia: Elsevier Churchill Livingstone; 2005. 5 .Srinivasan K, Sekaran N. Effect of intrathecal hyperbaric bupivacaine with midazolam and hyperbaric bupivacaine alone in lower limb and lower abdominal surgeries for post operativeanaelgesia. Int J Modn Res Revs [Internet]. 2016;4(9):1262-68. Available from: http://journalijmrr.com/wp- content/uploads/2016/10/IJMRR-308.pdf 8. 6 .Whizar-Lugo V, Flores-Carrillo J, Preciado-Ramirez S. Intrathecal Clonidine as Spinal Anaesthesia Adjuvant Is there a Magical Dose?. Topics in Spinal Anaesthesia [Internet]. 2014;. Available from: https://www.intechopen.com/books/topics-in-spinal-anaesthesia/intrathecal- clonidine-as-spinal-anaesthesia-adjuvant-is-there-a-magical-dose - 7 Kanazi GE, Aouad MT, Jabbour-Khoury SI, Al Jazzar MD, Alameddine MM , A l - Yaman R, et al. Effect of low-dose dexmedetomidine or clonidine on the characteristics o f BUPIVACAine Spinal b l o c k . A c t a a n a e s t h e s i o l S c a n d 2 6 ; 5 : 2 2 2 - 7 .

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