Dural Puncture Epidural Anesthesia versus Traditional Spinal Anesthesia for Rigid Cystoscopy: A Randomized Controlled Trial

BACKGROUNDRepeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys. The dural puncture epidural (DPE) technique provides faster and more effective analgesia for labor, but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.AIMTo determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.METHODSPatients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia (EA) groups. A 25-G spinal needle was used for dural puncture via a 19-G epidural needle. The patients in the two groups were injected with 5 mL of 2% lidocaine followed by 15 mL of a mixture of 1% lidocaine + 0.5% ropivacaine as the epidural dosage. The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.RESULTSA total of 115 women were included (EA: 57, DPE: 58). The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group (14.7 min vs 16.6 min; 95% confidence interval, 13.9 to 15.4 vs 15.8 to 17.4; P = 0.001). The cranial sensory block level was significantly higher at 5, 10, and 15 min after the initial dose in the DPE group than in the EA group (P < 0.05). The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point (P < 0.05). Adverse effects and neonatal outcomes were comparable between the two groups (P > 0.05).CONCLUSIONThe DPE technique provided higher-quality anesthesia than the EA technique, with a rapid onset of surgical anesthesia, better cranial and sacral sensory block spread and a higher motor block degree, without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Background and Aims: The peribulbar block for cataract surgery is commonly used. Fentanyl as an adjuvant enhances the anaesthesia provided by local anaesthetics. This study was designed to assess the effect of fentanyl on peribulbar block performed with a combination of 0.75% ropivacaine and 2% lidocaine in patients undergoing cataract surgery. Methodology: This prospective, randomised study included 100 patients undergoing cataract surgery. Patients were randomised into two groups: Group RF (n=50) received 0.75% ropivacaine, 2% lidocaine, and 25 mcg of fentanyl, while Group RS (n=50) received 0.75% ropivacaine, 2% lidocaine, and 0.9% normal saline. The study assessed the onset of sensory and motor blockade, the duration of sensory blockade, postoperative analgesia, and the need for rescue analgesia. Results: The onset of sensory and motor blockade was faster in group RF than in group RS (Sensory block: 2.38 ± 0.5 vs. 3.26 ± 0.69 min, p&lt;0.001), (Motor block: 7.24 ± 1.1 vs. 7.8 ± 1.12 min, p&lt;0.015). Group RF had prolonged sensory blockade (315.4 ± 9.45 vs. 272.8 ± 10.5 min, p&lt;0.001). At 6 and 12 h post-surgery, pain scores were lower in Group RF (p&lt;0.001). The changes in haemodynamic parameters and requirement of rescue analgesia were similar in both groups. Conclusion: Adding fentanyl to ropivacaine and lidocaine for peribulbar block in cataract surgery results in a faster onset, longer duration of anaesthesia, and improved postoperative analgesia, without affecting hemodynamic stability.

SP68 Dural puncture epidural: a ‘hole’ lot better? Is this the happy medium we were hoping for?

Background: Dural puncture epidural (DPE) is a method in which a dural hole is created prior to epidural injection. This study was planned to evaluate whether dural puncture improves onset and duration of labor analgesia when compared to conventional epidural technique. Methods and Materials: Sixty term primigravida parturients of ASA grade I and II were randomly assigned to two groups of 30 each (Group E for conventional epidural and Group DE for dural puncture epidural). In group E, epidural space was identified and 18-gauge multi-orifice catheter was threaded 5 cm into the epidural space. In group DE, dura was punctured using the combines spinal epidural (CSE) spinal needle and epidural catheter threaded as in group E followed by 10 ml of injection of Ropivacaine (0.2%) with 20 mcg of Fentanyl (2 mcg/ml) in fractions of 2.5 ml. Later, Ropivacaine 10 ml was given as a top-up on patient request. Onset, visual analouge scale (VAS), sensory and motor block, haemodynamic variables, duration of analgesia of initial dose were noted along with mode of delivery and the neonatal outcome. Results: Six parturients in group DE achieved adequate analgesia in 5 minutes while none of those in group E (P 0.05). Conclusions: Both techniques of labor analgesia are efficacious; dural puncture epidural has the potential to fasten onset and improve quality of labor analgesia when compared with conventional epidural technique.

Introduction:Spinal anesthesia is a widely used technique providing faster onset with effective and uniformly distributed sensory and motor block. Due to decreased cardiovascular and central nervous system toxicity, levobupivacaine is a good alternative for spinal anesthesia. Dexmedetomidine when used intrathecally is associated with prolonged motor and sensory block, hemodynamic stability, and less requirement of rescue analgesia in 24 h.Materials and Methods:A prospective, randomized study was carried out which included 60 adult patients between the age group of 20 and 65 years of physical status American Society of Anesthesiologists Classes I and II who underwent infraumbilical surgeries. Group L patients received 3 ml (15 mg) of 0.5% isobaric levobupivacaine + 0.3 ml normal saline while Group LD patients received 3 ml (15 mg) of 0.5% isobaric levobupivacaine + 0.3 ml (3 μg) dexmedetomidine. The two groups were compared with respect to the onset and duration of sensory and motor block and hemodynamic stability.Results:The mean duration of sensory block in Group L was 199.50 ± 7.96 min while in Group LD was 340.20 ± 11.78 min. All the differences were statistically highly significant between the two groups (P < 0.001). Mean duration of motor block in Group L and LD was 150.83 ± 9.17 min and 190.20 ± 9.61 min, respectively. Both the differences were highly significant (P < 0.001).Conclusion:It is concluded that Group LD has early-onset and prolonged duration of sensory and motor block and longer duration of postoperative analgesia than Group L.

Background: Alpha-2 agonists are added to local anesthetic agents to extend the duration of peripheral nerve blocks. Objective: We evaluated the effect of combining dexmedetomidine with levobupivacine with respect to duration of motor and sensory block and duration of analgesia. In our study, while the onset time of both sensory and motor blocks were shortened in the drug group, the duration of analgesia was significantly prolonged. Materials and Methods: Sixty patients of ASA grade I or II aged between 18-60 years, posted for elective upper limb surgeries were enrolled for a prospective, randomized, double-blind study. Patients were divided into two groups, the control group B and the study group BD. In group B (n = 30), 30 ml of 0.325% levobupivacaine; and in group BD (n = 30), 30 ml of 0.325% levobupivacaine + 1 µg/kg dexmedetomidine were given for ultrasound guided supraclavicular brachial plexus block. Duration of motor and sensory block and time to first rescue analgesia were recorded. Results: Demographic profile and surgical characteristics were similar in both groups. The onset times for sensory and motor blocks were significantly shorter in BD group (p &lt; 0.05), while the duration of sensory and motor blocks and duration of analgesia (DOA) was significantly longer in BD group. Heart rate level and SBP and DBP levels in group BD were significantly lower 15-20 min after block (p&lt; 0.05). Bradycardia was observed in two patients in the group BD. No other adverse effects were observed in either of the groups. Conclusion: Dexmedetomidine added as an adjuvant to levobupivacaine for supraclavicular brachial plexus block significantly shortens the onset time and prolongs the duration of sensory and motor blocks and duration of analgesia.

Background: Spinal anesthesia has always had problems with the timing of the onset and the length of the motor and sensory block. By combining local anesthetics with an adjuvant, one can lengthen the block's effect and lessen its side effects. In this study, patients undergoing elective infra-umbilical surgeries were given 25mcg/50mcg of neostigmine in addition to bupivacaine and the efficacy was studied. Aims: The assessment and comparison of: Onset of the Sensory Blockade Duration of the Sensory Blockade, Onset of the motor blockade, Duration of the motor blockade, Adverse effects. Materials and Methods: About 60 patients scheduled for elective infra-umbilical surgeries under spinal anesthesia were enrolled in our study. One of the three groups (each with 20 patients) was randomly assigned to patients: Group BS: Hyperbaric 0.5% Bupivacaine 3ml+0.5mL Normal Saline, Group BN 25: Hyperbaric 0.5% Bupivacaine 3mL+25mcg Neostigmine (0.5 mL), Group BN 50: Hyperbaric 0.5% Bupivacaine 3mL+50mcg Neostigmine (0.5 mL). The onset of anesthesia, duration of postoperative analgesia, time to use first rescue analgesia, overall, 24-hr VAS pain scores, are recorded for 24-hr post drug administration. Intra operative and postoperative blood pressure, heart rate, oxygen saturation, incidence of adverse effects and the total amount of analgesic consumed in overall 24-hr were recorded. Results: The duration of sensory and motor block was significantly prolonged with addition of 25mcg/50 mcg neostigmine to Bupivacaine for patients undergoing infra-umbilical surgeries under spinal anesthesia. It might cause a delay in attaining the discharge criteria in day care surgeries and there was a dose-dependent increase in the severity of nausea, vomiting with the highest PONV score in the group of patients who received 50mcg of neostigmine along with Bupivacaine intrathecally. Conclusion: Intrathecally administered doses of 25mcg or 50mcg neostigmine and Bupivacaine increased the duration of sensory and motor block, reduced the need for rescue analgesia and delayed postoperative pain for 5–6hours.Hense we recommend the addition of 25mcg of Neostigmine to Bupivacaine for Spinal anesthesia with minimal adverse effects.

Background: Alpha-2 agonists are added to local anesthetic agents to extend the duration of peripheral nerve blocks. Objective: We evaluated the effect of combining dexmedetomidine with levobupivacine with respect to duration of motor and sensory block and duration of analgesia. Material and Methods: Sixty patients of ASA grade I or II aged between 18-60 years, posted for elective upper limb surgeries were enrolled for a prospective, randomized, double-blind study. Patients were divided into two groups, the control group B and the study group BD. In group B (n = 30), 30 ml of 0.325% levobupivacaine + normal saline; and in group BD (n = 30), 30 ml of 0.325% levobupivacaine + 1μ/kg dexmedetomidine were given for ultrasound guided supraclavicular brachial plexus block. Duration of motor and sensory block and time to first rescue analgesia were recorded.. Results: Demographic profile and surgical characteristics were similar in both groups. The onset times for sensory and motor blocks were significantly shorter in BD group (p < 0.05), while the duration of sensory and motor blocks and duration of analgesia (DOA) was significantly longer in BD group. Heart rate level and SBP and DBP levels in group BD were significantly lower 15-20 min after block (p < 0.05). Bradycardia was observed in two patients in the group BD. No other adverse effects were observed in either of the groups. Conclusion: Dexmedetomidine added as an adjuvant to levobupivacaine for supraclavicular brachial plexus block significantly shortens the onset time and prolongs the duration of sensory and motor blocks and duration of analgesia.

Introduction: Peripheral nerve block leads to effective pain control. Peripheral nerve blocks are used both in general anaesthesia and as regional anaesthesia alone. The aim of this study was to compare the characteristics of the supraclavicular block with bupivacaine (0.5%) in combination with dexmedetomidine, granisetron and magnesium sulphate in upper-limb orthopaedic surgery. Materials and Methods: This double-blind clinical trial was carried out on 105 patients who were candidates for upper-limb orthopaedic surgery in Valiasr Hospital in Arak. The patients were divided into three equal groups (dexmedetomidine, granisetron and magnesium sulphate) using the block method for randomisation. Mean arterial pressure, heart rate and arterial oxygen saturation every 5 min until the end of the surgery, onset and duration of sensory and motor block, mean opioid consumption in 24 h and post-operative pain during recovery and 2 h after surgery at 4, 8, 12 and 24 h were recorded. Data were analysed by SPSS.22 software. Results: The lowest heart rate at all times and the lowest blood pressure from 40 min to the end of surgery were observed in the dexmedetomidine group (P &lt; 0.05). The time to the onset of sensory block and the time to the onset of motor block were shorter in the magnesium sulphate and dexmedetomidine groups, respectively. Moreover, the duration of the sensory and motor block was longer in the dexmedetomidine group (P = 0.0001). In addition, pain and amount of opioid consumption were lower in the dexmedetomidine group (P = 0.0001). Conclusion: Magnesium sulphate caused earlier onset of sensory block, while dexmedetomidine increased the duration of sensory and motor block. In the dexmedetomidine group, haemodynamic changes were made in the form of a decrease in heart rate and blood pressure, which, of course, did not require special treatment. As such, magnesium sulphate as an adjuvant is recommended to be used in cases where there is a requirement for the rapid onset of sensory block. Meanwhile, dexmedetomidine should be used as an adjuvant for the rapid onset of motor block and increase of the duration of sensory and motor block when taking into account the patients' physical conditions and the anaesthesiologist's discretion.

Background General anesthesia has a lot of complications, so alternative procedures like combined spinal-epidural anesthesia (CSEA) are better but with their adverse effects on cardiovascular and pulmonary functions. New era tend toward ultrasound (US) guidance and nerve stimulator for nerve block to ensure better effects without any complications.Aim The aim of this study was to compare CSEA versus femoral/sciatic nerve block (FSNB) by US guidance and nerve stimulator as anesthetic technique for patients with both-bone leg (BBL) fractures.Patients and methods Ninety adult patients, ASA I–II, scheduled for fracture BBL were included in the study. Patients were randomized into two equal groups. Group I CSEA received intrathecal 5 mg of hyperbaric bupivacaine 0.5+15% μg fentanyl, and then 7 ml of epidural (0.375% of plain bupivacaine+fentanyl 2 μg/ml) was injected as a loading dose. Finally, an additional epidural of 4 ml of 2% lidocaine was given if the desired sensory level was not reached till after 20 min or the operation lasted more than 80 min. Group II underwent FSNB by using US guidance and nerve stimulator. We first blocked the sciatic nerve by injection of 15 ml of 0.25% bupivacaine and 10 ml of 1% lidocaine. Then femoral nerve block was done by injection of 20 ml of bupivacaine 0.25% and 10 ml of 1% lidocaine.Results There was no significant difference between both groups in demographic data and failure rate. The onset of sensory and motor block was shorter in CSEA group, but the duration of sensory and motor block was prolonged in FSNB group. First dose of analgesia required was earlier in CSEA group. Heart rate and mean arterial blood pressure showed significant decrease in CSEA group at 5, 15, and 30 min intraoperatively. Visual analogue pain scale was higher and need for rescue analgesia was earlier in CSEA group.Conclusion FSNB by US guidance nerve stimulation technique provides better block characteristics, longer duration of analgesic, better intraoperative hemodynamics, and decreased the need for postoperative rescue analgesia in comparison with CSEA in patients with BBL fractures.

PurposeThis study aimed to establish the 90% effective interval time for programmed intermittent epidural bolus (PIEB) following dural puncture epidural (DPE) analgesia with a dexmedetomidine ropivacaine combination for primiparas in the first stage of labor.Patients and MethodsThis biased coin up and down sequential allocation trial enrolled 40 nulliparous women requesting labor analgesia. After an initial loading dose, analgesia was maintained with PIEB of a fixed volume of 8 mL of the same solution, starting 1 hour later. The initial PIEB interval was set at 60 minutes for the first patient and subsequently adjusted by ± 5 minutes based on the outcome of the previous patient, following the biased-coin design. A successful interval was defined as no requirement for supplemental analgesia. The primary outcome was the 90% effective PIEB interval (ED90) for the first stage of labor. Secondary outcomes included patient satisfaction, the incidence of motor and sensory block, and adverse events.ResultsIsotonic regression analysis estimated the 90% effective PIEB interval as 34.5 min (95% confidence interval: 31.0–37.0 min). All patients reported a very high level of satisfaction. The incidence of motor block was 10%, while 37.5% of patients achieved the highest sensory block at the T6 level or above. Notably, no cases of excessive sedation, hypotension, or bradycardia.ConclusionFor DPE labor analgesia using 8 mL of 0.075% ropivacaine combined with 0.4 μg/mL dexmedetomidine, the optimal PIEB interval is approximately 35 min. This interval can reduce breakthrough pain and the need for rescue analgesia. This finding provides a practical, evidence-based reference for optimizing PIEB regimens in clinical labor analgesia, contributing to improved maternal comfort and labor experience while ensuring safety.

Background: In this study, we have compared the addition of fentanyl 25 mcg and dexmedetomidine 5 mcg to 15 mg of 0.5% hyperbaric bupivacaine for spinal anesthesia separately for patient undergoing lower limb orthopedic surgery. Dexmedetomidine is an α-2 adrenoreceptor agonist and it can prolong the motor and sensory block for long spinal anesthesia. It act by binding to presynaptic C-fiber and postsynaptic dorsal horn neurons. The analgesic action is a result of depression of release of C-fiber transmitters and hyperpolarization of postsynaptic dorsal horn neurons. Aims and Objectives: The present study compares the onset, duration of sensory and motor block, postoperative analgesia, hemodynamic changes, and adverse effects of intrathecal dexmedetomidine and intrathecal fentanyl as an adjuvant to bupivacaine during spinal anesthesia for lower limb orthopedic surgery. Materials and Methods: Patient was randomly grouped by close-envelope technique into the three equal group of 30 in each group. Total 90 patients were including in this study. The blind nature of the study was maintained and the study drug is given according as, Group-1: 15 mg of 0.5% hyperbaric bupivacaine. (Control group), Group-2: 15 mg of 0.5% hyperbaric bupivacaine with 25 mcg of fentanyl, and Group-3: 15 mg of 0.5% hyperbaric bupivacaine with 5 mcg dexmedetomidine for spinal anesthesia. Results: Patients in dexmedetomidine Group-3 had a significantly longer sensory (160±18.5 min) and motor block (242±22 min) time as compared to patients in fentanyl and control group (P&lt;0.001). The time to first request of analgesic in the post-operative period was also longer in dexmedetomidine group (245±3.6 min) when compared to bupivacaine and fentanyl in which it was 125±1.0 min and 220±2.5 min, respectively (P&lt;0.001). Conclusion: We concluded that intrathecal dexmedetomidine with bupivacaine for spinal anesthesia is associated with prolong motor and sensory block then fentanyl 25 μg with bupivacaine and bupivacaine alone.

Background: To assess the effects of combining Tramadol and Dexamethasone with Bupivacaine in supraclavicular brachial plexus block for upper limb surgeries. Material and Methods: A clinical research was performed with sixty patients who received upper limb surgery with a supraclavicular brachial plexus block. The study encompassed a total of 60 patients who were divided into two groups, with 30 patients in each group. Group D was administered a blend of Bupivacaine and Dexamethasone, whilst Group T was given a mixture of Bupivacaine and Tramadol, resulting in a combined amount of 25 ml. The study recorded the beginning and length of the sensory and motor block. We meticulously observed the hemodynamic variables throughout the research, until the administration of the first rescue analgesic. Results: In group D, the mean time for motor block to occur was 5.10±0.92 minutes, whereas in group T, it took 7.93±0.98 minutes. Group D had an average sensory block onset time of 8.23±1.22 minutes, whereas Group T had a slightly longer average onset time of 10.97±1.22 minutes. Group D had an average motor block duration of 560.53±24.46 minutes, whereas group T had a duration of 358.93±20.85 minutes. Group D had a mean duration of sensory block of 745.17±32.81 minutes, whereas group T had a slightly shorter duration of 457.07±16.36 minutes. In group D, the average time for the first rescue analgesia was 961.50±32.94 minutes, whereas in group T, it was 524.17±16.46 minutes. Conclusion: Inclusion of Dexamethasone led to a noticeably quicker onset of motor and sensory block in comparison to Tramadol. In a recent study, researchers discovered that when Dexamethasone was added to the mix, it had a notable impact on the duration of both motor and sensory block. The effects were significant and promising. When Dexamethasone was added, it noticeably increased the duration until the first rescue analgesia, in comparison to Tramadol.

Background Intrathecal α2 agonists prolong the duration of action of local anesthetics and reduce the required dose. Dexmedetomidine is an α2 receptor agonist, and its α2/α1 selectivity is eight times higher than that of clonidine. Aim The aim of this study was to determine the effect of adding dexmedetomidine and fentanyl to intrathecal bupivacaine on the onset time and duration and intensity of motor and sensory blocks for cesarean section. Patients and methods The study was carried out on 40 adult female patients who were randomly classified using closed envelope method into two equal groups, with 20 patients in each: group D patients received intrathecally 2.5 ml volume of 10 mg (2 ml) 0.5% hyperbaric bupivacaine and 10 µg dexmedetomidine in 0.5 ml (prepared by diluting 1 ml dexmedetomidine in 5 ml of normal saline), and group F patients received intrathecally 2.5 ml volume of 10 mg (2 ml) 0.5% hyperbaric bupivacaine and 20 µg fentanyl in 0.5 ml (prepared by diluting 2 ml fentanyl in 2.5 ml of normal saline). The aim was to evaluate motor and sensory block. Sensory block assessment: the onset and duration of sensory block was assessed by ice cube method, and time taken from intrathecal injection to the highest level of sensory block and sensory regression to the L1 dermatome were recorded. On achieving T7 sensory blockade level, surgery was allowed. Motor block assessment: onset and degree of motor block was assessed by Bromage scale: 0, no paralysis; 1, inability to raise extended leg; 2, inability to flex the knee; and 3, inability to flex the ankle (complete motor block). Results Sensory and motor block onset times were shorter in group D than in group F. The regression of the sensory block to S1 dermatome and Bromage 0 were longer in group D than group F. The two-dermatome regression time was longer in group D than group F. There was a statistically significant decrease in group F regarding systolic, diastolic, and mean arterial blood pressures and heart rate than group D. There was no statistically significant difference among the two groups regarding arterial oxygen saturation and respiratory rate. Neonatal outcome was normal in all groups. Conclusion Intrathecal dexmedetomidine addition to bupivacaine for spinal anesthesia synergistically increases block duration and shortens sensory and motor block onset time without any significant adverse effects.

Background: Upper extremity surgeries are commonly performed under regional anaesthesia. Regional anaesthesia of the upper extremity has several advantages over general anaesthesia such as improved postoperative pain management, decreased postoperative narcotic consumption, and reduced recovery time. Objectives: The aim of the study was to compare between dexamethasone and magnesium sulphate as adjuvants in supraclavicular brachial plexus block as regards the onset and duration of sensory and motor block as well as side effects. Patients and Methods: This prospective double-blinded comparative study was carried out in Faculty of Medicine, Ain-Shams University Hospital on 120 adult patients between 21-50 years of both sexes with ASA classification 1&amp;2 who were scheduled for elective upper limb orthopaedic surgeries. A written informed consent was obtained from all patients. Every patient received an explanation about the purpose of the study. Procedures had been approved by the institutional and the regional ethical committee. Total 120 patients are enrolled in the study and divided into 3 groups A and B and C (40 for each one). Results From aspect of increasing the duration of sensory &amp;motor block magnesium sulphate group (group A) showed higher prolongation of sensory &amp; motor block with recovery of pin prick sensation in median time 313 mins ± when compared with group B &amp;C even with longer time taken for patient to request rescue analgesia after 5 hours. In group (B) by adding dexamethasone with bupivacaine the blood pressure rate are increased after 20 min of injection and return normal after 240 min, heart rate are normal, but in case of sensory and motor block about 77.5% of study patient in this group have full motor and sensory block, in case of increasing time of motor and sensory block the dexamethasone success increasing time for motor and sensory block to reach 278 min sensory and 314 min in motor block, first call of Analgesic are after 4 hr. Conclusion: Group A (Magnesium sulphate with bupivacaine) were more effective and increasing affected time in motor and sensory block than Group B (Dexamethasone with Bupivacaine) and Group C (Control).