Indian Journal of Anesthesia

8/18/2019 Indian Journal of Anesthesia

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INDIAN JOURNAL OFANESTHESIA

A prospective randomised double blind studyof intrathecal fentanyl and dexmedetomidineadded to low dose bupivacaine for spinal

anesthesia for lower abdominal surgeries


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Background and Aims: The potentiating eect of short actinglipophilic opioid fentanyl and a more selectiveα2 agonist dexmedetomidine is used to reduce

the dose requirement of bupivacaine and its

adverse eects and also to prolong analgesia.n this study! we aimed to "nd out whetherquality of anaesthesia is better with low dosebupivacaine and fentanyl or with low dose

bupivacaine and dexmedetomidine.


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Me!od

#rospective randomised double$blindedstudy

%n &'( patients of both sex aged

between &) and *( years American +ociety of Anaesthesiologists

,A+A- physical status rade and undergoing elective lower abdominalsurgeries , urological and general surgicalprocedures- under spinal anaesthesia


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Me!od

&.roup / 0 fentanyl group

2.roup 1 0 dexmedetomidine group ' patients in each group and informed

consent was obtained.


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Me!od

ntrathecal drugs were prepared by ananaesthesiologist not involved in thestudy and were administered by another

anaesthesiologist who was blinded andperformed spinal anaesthesia.


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Me!od

+pinal anaesthesia was performed in allpatients in the lateral decubitus positionwith operating table tilted '$&(3 in

Trendelenberg position! using 2'4uinc5e needle mid$line spinal puncturewas performed at 62$67 level.


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Me!od

n roup /! in8ection bupivacaine (.'9 ,(.) ml- : fentanyl (.'ml ,2' ;g- : normal saline (.7 ml! ,for a final concentrationof (.2'9 and volume of &.* ml of bupivacaine- wasadministered intrathecally.

n roup 1! dexmedetomidine was "rst diluted in normalsaline to obtain a dose of ' ;g in (.' ml. Then! in8ectionbupivacaine (.'9 ,(.) ml- : dexmedetomidine (.' ml ,' ;g-: normal saline (.7 ml ,for a "nal concentration of (.2'9 andvolume of &.* ml of bupivacaine- was administeredintrathecally.

1rug was administered over &( seconds ,s- using 2 ccsyringes with cephalad orientation of the spinal needle bevel. The patients were turned supine immediately after thein8ection of the drug. The completion of the in8ection wasta5en as


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Me!od

The degree of motor bloc5ade at the time of pea5sensory bloc5 was scored using a modi"ed =romagescale ,>=+-

,&- ?omplete motor bloc5!

,2- Almost complete motor bloc5! patient is able tomove only feet!

,7- #artial motor bloc5! patient is able to move the5nees!

,@- 1etectable wea5ness of hip exion! patient is ableto raise the leg but is unable to 5eep it raised! ,'- Bo detectable wea5ness of hip exion! patient is

able to 5eep the leg raised for &(s at least! ,*- Bo wea5ness at all-.


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Me!od

The quality of anaesthesia was assessedas C

&.Dxcellent ,no discomfort or pain-

2.ood ,mild pain or discomfort and noneed for additional analgesics-

7./air ,pain that required analgesics-

@.#oor ,severe pain that requiredanalgesics-


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"ua#i$ o% anaes!esia


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+ystolic blood pressure ,+=#-! diastolicblood pressure ,1=#-! and heart rate ,EF-were recorded every ' min up to &' minand then every &' min up to G( minirrespective of the duration of surgery


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Me!od

The demographic pro"le! which includedpatients age! sex! weight! height and A+Agrading were similar and no signi"cant

dierence was observed between thegroups.

A P H (.(' was considered as statisticallysigni"cant.


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n our study! the time to reach pea5sensory bloc5 ,in min- was higher in roup1 ,&2.G2 I 7.&7& vs. &&.)) I 2.&'*C P H(.('- compared to roup /. +ince! therewas no signi"cant dierence in time toreach T&( ,in min- ,roup / J '.&2 I (.)2K

roup 1 J @.G* I (.G2CP L (.('- andthere was a signi"cant dierence in #+=6

,roup / J T*$T&(K roup 1 J T@0 T&(C PJ(.(((-! the signi"cant dierence in

time to reach #+=6 can be accepted.


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The higher motor bloc5ade seen in roup 1 ,P J(.(@- may be because of the tendency of α2 receptor

agonists to bind with motor neurons in the dorsalhorn of the spinal cord.

The TT+F ,in min- was not statistically signi"cantamong the groups ,roup / J *(.2@ I @.)GK roup 1J *&.G I '.)*C P L(.('-.

urbet et al! reported a two segment regression

time of 7* I && min! at a lower dose of bupivacaine,2.' mg- than that used in the present study.

The T/AF ,in hours- was longer in roup 1 thanroup / ,).2( I 2.) vs. *.*@ I 2.72K P J (.(((-.


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upta et al! report T/AF of ) h with ' ;g dexmedetomidineand 7 ml ropivacaine (.'9

6ee found a duration of ) h with dexmedetomidine 7 ;g Main et al! reported duration of '.'' h with 2( ;g fentanyl.

Al$hanem et al! found that &( mg plain bupivacainesupplemented with dexmedetomidine ' ;g producedprolonged motor and sensory bloc5 compared with 2' ;gfentanyl similar to the present study.

6imitations of the present study were speed of in8ection

could not be uniform! no preloading was underta5en andhence improper rehydration also might have contributed toreduction in blood pressure. 1ierent types of surgerieswere included in this study and no sedation assessmentwas done.


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Resu#s

There were no signi"cant dierencesbetween the groups in the time to reach

T&( segment bloc5 ,# L (.('- and TT+F ,#

L (.('-Ktime to reach #+=6 ,# H (.('- andmodi"ed =romage scales ,# H (.('- weresigni"cant. #+=6 ,# J (.(((- and time to"rst analgesic request ,# J (.(((- were

highly signi"cant. All patients werehaemodynamically stable and nosigni"cant dierence in adverse eectswas observed.


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Fenan$# Usage

Nim et al! observed that fentanyl beyond 2' ;gintrathecally produced no bene"t in regard tothe duration of analgesia. Eowever! fentanyl 2';g intrathecally with low dose bupivacaine

improves post$operative analgesia andhaemodynamic stability.

At the same time! fentanyl 2(;g withbupivacaine @ mg intrathecally provides spinal

anaesthesia with less hypotension! T/AF is alsoreported to be longer in groups where fentanyl2' ;g was added to low dose bupivacaine


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De&medeomidine Usage

1exmedetomidine 7 ;g with bupivacaine produced ashorter onset of motor bloc5ade! prolonged durationof motor and sensory bloc5 with haemodynamicstability and lac5 of sedation.

upta et al! observed that ' ;g dexmedetomidinewith ropivacaine provided excellent quality of post$operative analgesia with minimal side$eectsK and ';g dexmedetomidine seems to be an attractivealternative as ad8uvant to spinal bupivacaine.

ntrathecal dexmedetomidine in doses of &( ;g and&' ;g significantly prolong the anaesthetic andanalgesic eects of spinal bupivacaine in a dosedependent manner.


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Discussions

The addition of fentanyl ,2' ;g- to lowdose bupivacaine ,@ mg- has beenreported to increase the perioperative

quality of spinal bloc5s with fewercardiovascular changes! as has theaddition of dexmedetomidine ,7 ;g- incombination with low dose bupivacaine

,* mg- =ased on the above studies! we had

concluded that fentanyl 2' ;g anddexmedetomidine ' ;g would be safeand appropriate for our study


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Discussions

n this study! it was found that addition ofdexmedetomidine to low dosebupivacaine increased the level of

sensory bloc5 and post$operativeanalgesic eOcacy without signi"cantadverse eects! but with a signi"cantmotor bloc5ade


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Discussions

The density of compounds is believed to be ama8or determinant in controlling the extent ofneural bloc5.

n our study! fentanyl group consisted of

bupivacaine (.) ml! fentanyl (.' ml and normalsaline (.7 ml and dexmedetomidine groupconsisted of bupivacaine (.) ml! dexmedetomidine(.(' ml and normal saline (.' ml.

Therefore! the solution with dexmedetomidine wasdenser and this could be an explanation for theincreased level of bloc5ade in dexmedetomidinegroup as compared with the fentanyl group.


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Discussions

=en$1avid et al found that fentanyl 2( ;gwith @ mg bupivacaine provided completeand satisfactory spinal anaesthesia with

dramatically less hypotension.


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'onc#usion

/entanyl and dexmedetomidine alongwith low dose bupivacaine providedadequate anaesthesia for all lower

abdominal surgeries with haemodynamicstability. Eowever! the clinical advantageof dexmedetomidine over fentanyl is thatit facilitates the spread of the bloc5 and

oers prolonged post$operative analgesiacompared to fentanyl.

Indian Journal of Anesthesia

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