Level Of Sensory Block Research Articles

Observation of single spinal anesthesia by 25G needle puncture through a lateral crypt for hip surgery in elderly patients.

Background:Lumbar spine hyperosteogeny and ligament calcification are common in the elderly and anesthesia puncture through the conventional approach is difficult in this age group, and repeated puncture can increase the risk of spinal hematoma and nerve injury. This study aimed to observe the feasibility and safety of single spinal anesthesia administered with 25G needle through the lateral crypt for lower-extremity fracture surgery in elderly patients.Methods:The subjects were 60 elderly patients in our hospital (aged 65–80 years; ASA grades I and II) scheduled for lower-extremity fracture surgery (procedure was predicted to last within 2 h) under single spinal anesthesia by different approaches through L3–4. They were randomly divided into 2 groups: in the first group, 25G needle was used in a vertical approach (group C, n=30); in the second, 25G needle was passed through the inner edge of the small joints of L3–4 to the lateral crypt (group L, n=30). After successful completion of the puncture procedure, 2.5 mL of 0.5% hyperbaric ropivacaine was used for spinal anesthesia. We then recorded the puncture times, sensory block level, and adverse reactions (e.g., headache, lumbago, and lower limb pain).Results:No significant differences in onset time, sensory block level and adverse reaction were noted between the 2 groups. The puncture success rate in group L was not significantly higher and the number of attempts per puncture was not significantly less than that in group C (93.3% vs 70%) (P = .063). Nerve-root irritation was more frequent in group L than in group C but with no significant difference (P > .05).Conclusion:Single spinal anesthesia through the lateral crypt approach is safe and effective for lower-extremity fracture surgery in elderly patients. Thus, this approach is a feasible alternative when the conventional approach fails.

Labor Epidural Analgesia to Cesarean Section Anesthetic Conversion Failure: A National Survey.

Background If conversion of labor epidural analgesia to cesarean delivery anesthesia fails, the anesthesiologist can be confronted with a challenging clinical dilemma. Optimal management of a failed epidural top up continues to be debated in the absence of best practice guidelines. Method All members of the Obstetric Anaesthetists' Association in the United Kingdom were emailed an online survey in May 2017. It obtained information on factors influencing the decision to utilize an existing labor epidural for cesarean section and, if epidural top up resulted in no objective sensory block, bilateral T10 sensory block, or unilateral T6 sensory block, factors influencing the management and selection of anesthetic technique. Differences in management options between respondents were compared using the chi-squared test. Results We received 710 survey questionnaires with an overall response rate of 41%. Most respondents (89%) would consider topping up an existing labor epidural for a category-one cesarean section. In evaluating whether or not to top up an existing labor epidural, the factors influencing decision-making were how effective the epidural had been for labor pain (99%), category of cesarean section (73%), and dermatomal level of blockade (61%). In the setting of a failed epidural top up, the most influential factors determining further anesthetic management were the category of cesarean section (92%), dermatomal level of blockade (78%), and the assessment of maternal airway. Spinal anesthesia was commonly preferred if an epidural top up resulted in no objective sensory block (74%), bilateral T10 sensory block (57%), or unilateral T6 sensory block (45%). If the sensory block level was higher or unilateral, then a lower dose of intrathecal local anesthetic was selected and alternative options such as combined-spinal epidural and general anesthesia were increasingly favored. Discussion Our survey revealed variations in the clinical management of a failed epidural top up for cesarean delivery, suggesting guidelines to aid decision-making are needed.

Height-based dosing algorithm of bupivacaine in spinal anaesthesia for decreasing maternal hypotension in caesarean section without prophylactic fluid preloading and vasopressors: study protocol for a randomised controlled non-inferiority trial

IntroductionEffectively preventing or treating spinal-induced maternal hypotension is considered to be the Holy Grail of obstetric anaesthesia. Prophylactic fluid preloading and vasopressors decrease hypotension but may aggravate heart load, induce...

Unilateral Epidural Blockade for Lower Limb Fracture Surgery: Parasagittal Epidural Versus Midline Epidural Anesthesia.

Objective:To compare the efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches for epidural block in patients with lower limb orthopedic surgery. Methods:This double-blind randomized clinical trial was performed on 40 patients undergoing tibial shaft fracture surgery. In PIL group, an 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L2-3 or L3-4 intervertebral spaces and pushed forward in a posteroanterior (PA) direction vertical to the body surface. After determining the most lateral place for needle arrival in an anteroposterior (AP) view, needle was pushed forward into the epidural space. For the MIL group, needle was pushed forward from the midline interspinous space with the same method. After confirmation of needle position, 1 mL of contrast was injected to confirm the epidural space distribution and then 15 ml lidocaine 2% was injected. The sensory and motor block level, onset, duration, heart rate (HR), mean arterial pressure (MAP), and arterial oxygen saturation (SPO2), and success rate were recorded. Results:Mean patients’ baseline characteristics showed no statistically significant difference between the two groups.p>0.05). Outcome measures were statistically different and significantly higher in PIL group (p-values for sensory block level <0.001, motor block level <0.001, duration of sensory block: <0.001 and duration of motor block <0.001 and success rate: <0.001). Hemodynamic variables didn’t show statistically significant difference between the two groups (p-values for Systolic pressure: 0.997, diastolic pressure:0.579, MAP:0.585, HR:0.710).Conclusion:Epidural anesthesia with parasagittal interlaminar approach provide deep motor block, high sensory level block, and hemodynamic stability.Clinical trial registry: IRCT2017041615515N2

A comparison of intrathecal dexmedetomidine and fentanyl as an adjuvant to isobaric levobupivacaine for lower limb orthopaedic surgery

Introduction: Levobupivacaine is cardiostable. Fentanyl and dexmedetomidine as adjuvant to improve quality of block. Aim: To compare the efficacy and safety of 25 mcg of fentanyl vs 5 mcg dexmedetomidine as an adjuvant in 0.5% of 3ml of isobaric levobupivacaine in lower limb orthopaedic surgery. Objectives: Onset and duration of sensory block, maximum sensory block. Onset and duration of motor block, maximum motor block, time to regress sensory and motor block, postoperative analgesia. Level of sedation, hemodynamic changes, side effects. Materials and Methods Group A: 0.5% isobaric levobupivacaine 3ml +0.5 ml of NS =3.5ml. Group F: 0.5% isobaric levobupivacaine 3ml+25 mcg fentanyl diluted with NS =3.5ml. Group D: 0.5% isobaric levobupivacaine 3ml + 5 mcg dexmedetomidine diluted with NS =3.5ml. Subarachnoid block were achieved in L3-L4 interspaces. Parameters like pulse, SBP, DBP, MAP, SPO2, RR, level of sensory block, grade of motor block, sedation scale were recorded every min for 5 min, every 5 min till 30 min, every 15 min till 2 hr, every 30 min till end of surgery Intraoperatively side effects were recorded and treated. In postoperative period total analgesic, antiemetic requirement, sedation scale checked. Result: onset of sensory block was earlier in group F. maximum sensory block was in group D. Motor block regress faster in group A. postoperative analgesia was more in group D and side effects were less. Conclusion: Dexmedetomidine group has longer onset of and duration of sensory block and effective postoperative analgesia and fewer side effect as compared to fentanyl group. Keywords: Subarachanoid block, Levobupivacaine.

The effects of uterine size with or without abdominal obesity on spinal block level and vasopressor requirement in elective cesarean section: a prospective observational study

Background/aim Hypotension is a serious complication caused by spinal anesthesia that places both the mother and fetus at increased risk. We aimed to investigate the effects of uterine size with or without abdominal obesity on sensory block level of pregnant women receiving spinal anesthesia. Materials and methodsThis study included 125 term parturients who underwent cesarean section. Motor and sensory block characteristics, the distance between the symphysis pubis and the fundus (SPF), the distance between the symphysis pubis and the xiphoid (SPX), newborn and placental weights, adverse effects, and doses of ephedrine were recorded. Results Sensory block level and ephedrine dose were significantly correlated with the SPX and the combined newborn and placenta weights (P < 0.05). The incidence of hypotension was related to the SPX and the combined newborn and placenta weight (P < 0.05). There was no correlation between the SPF and sensory block level or ephedrine dose. The sensory block level was higher for patients who had greater SPX values and higher combined newborn and placenta weights. The incidence of hypotension and the ephedrine dose were also higher in these subjects. Conclusion SPX values and combined newborn and placenta weights are more predictive of sensory block level than SPF values in parturients receiving spinal anesthesia.

Effects of bupivacaine or levobupivacaine on cerebral oxygenation during spinal anesthesia in elderly patients undergoing orthopedic surgery for hip fracture: a randomized controlled trial

BackgroundBupivacaine and levobupivacaine have similar pharmacokinetic and pharmacodynamic characteristics, and are used regularly in spinal anesthesia. Whether potential differences in their hemodynamic and anesthetic profiles could determine a differential risk of complications in elderly subjects, is controversial. The main objective was to compare the effects of intrathecally administered levobupivacaine (LB) versus bupivacaine (B), on regional cerebral O2 saturation during spinal anesthesia, cognitive status and neurological complications in elderly patients undergoing surgery for hip fracture.MethodsThis was a randomized, controlled, single blind study. 58 patients aged 70 or older undergoing surgery for hip fracture with spinal anesthesia were allocated with a 1:1 ratio to receive LB or B, combined with fentanyl 15 μg, by intrathecal route. The primary outcome was the proportion of intraoperative time with regional cerebral desaturation (≥20% reduction in regional cerebral oxygen saturation from baseline), monitored by near –infrared spectroscopy. Secondary endpoints included hemodynamic parameters, level of sensory and motor block, changes in Short Portable Mental Status Questionnaire (SPMSQ), and neurological complications.ResultsThe mean percentage of intraoperative time with desaturation in the B group was 6.1% (SD: 17.5) and 4.7% (SD: 11.9) in the left and right hemisphere respectively; in the LB group the mean was 4.8% (SD: 11.4) in the left hemisphere and 2.4% (SD: 8.3) in the right one. No statistically significant differences were found between treatment groups. The level of sensory block at the start of surgery was lower for LB than for B (Th10 vs Th8, p:0.047) and motor block at 15 min was lower for LB (2.5 vs 3, p:0.009). No differences in postoperative SPMSQ were observed. Neurological complications such as confusional state, agitation or disorientation were reported in 50% of patients in the B group and 21.4% of patients in the LB group, p = 0.05.ConclusionsNo statistically significant differences in regional cerebral oxygen saturation or hemodynamic parameters were observed between both treatment groups. Bupivacaine and levobupivacaine differed in sensory and motor block achieved. While no differences were observed in cognitive impairment measured by the SPMSQ between treatment groups neurological complications reported by the physician were more frequent with bupivacaine.Trial registrationEuropean Union Clinical Trials Register (EudraCT 2013–000846 -20) (April 9th, 2013).ClinicalTrials.gov (NCT01960543) (September 23rd, 2013).

Spinal Anaesthesia for Infra-umbilical Surgeries - A Prospective Randomized Study to evaluate the effectiveness of Dexmedetomidine as an adjuvant to Bupivacaine.

Background: Spinal anesthesia is commonly used anesthetic modality worldwide but with the limitation of relatively short duration of action and complain of post-operative pain. However, the addition of adjuvants have intensified and increased the duration of sensory block with concommitent prolongation of the duration of postoperative analgesia.&#x0D; Study design and settings: This prospective randomized study was conducted in the Department of Anesthesia, Pain and Critical Care at the University Teaching Hospital.&#x0D; Methods: 60 patients irrespective of their age and gender were randomized equally into two groups, and received 3ml of total drug volume intrathecally (IT) viz 2.5 ml of hyperbaric bupivacaine 0.5% mixed with 0.5 ml of normal saline in Group I and 0.5 ml of 5 mcg of Dexmedetomidine in Group II respectively.&#x0D; Results: The maximum height of sensory block achieved were dermatomes T 6.5 ± 1.43 in Group I, and T 6.20 ± 1.28 in Group II (P value, 0.794 &gt; 0.05) with time required to reach T10 sensory block level was 6.70 ± 0.98 min. in Group I and 5.50 ± 1.00 min. in Group II (P value, 0.001) The time to reach Bromage scale 3 was 15.70 ± 2.56 min. in Group I and 8.55 ± 1.67min. in Group II (P value, &lt; 0.001) The time of first rescue dose requested by patient was 196.75 ± 15.16 min. in Group I, and 359.50 ± 49.79 min. in Group II (P value, 0.01) &#x0D; Conclusions: Dexmedetomidine in doses of 5 µg as adjuvants to hyperbaric 0.5% bupivacaine intrathecally produced a significantly quick onset and longer duration of motor and sensory block with benefit prolonged postoperative analgesia. JMS 2018: 21 (2):95-100

Effect of nonpharmacological methods on incidence of postspinal hypotension during cesarean delivery

Introduction Hypotension is caused by upward spread of anesthetic into the subarachnoid space; this results in venous pooling in the capacitance vessels of the lower limbs as a result of block of sympathetic tone and unopposed activity of parasympathetic tone. It also may be caused by aorto-caval syndrome and is accompanied by bradycardia, nausea, and vomiting. Hypotension may have deleterious effects on mother and fetus and may result in uteroplacental hypoperfusion, as placental perfusion is pressure dependent, and lack of autoregulation of placental blood vessels, if persisted, may threaten the life of the fetus. Aim The primary aim of the work is to compare incidence of intraoperative hypotension between the three groups. The secondary outcome is to assess Appearance, Pulse, Grimace, Activity, Respiration (Apgar) score, vasopressor consumption, and occurrence of complications (nausea, vomiting, and bradycardia). Patients and methods A total of 150 patients undergoing cesarean delivery under spinal anesthesia were included. Patients were divided into three equal groups, using simple randomization method, with 50 patients each: group S, in which the patient will sit for 1 min after induction of spinal anesthesia and then will lie down; group E, in which patient's legs will be elevated to 30° from the horizontal plane; and group C in which the patient will lie down immediately after induction of spinal anesthesia as a control group. Then, heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure were measured every 2 min until delivery of fetus and then every 5 min until the end of surgery. Sensory level was assessed before start of surgery, subsequently after lying down, and every 1 min using hot and cold test until it reaches T6 sensory level. Fetal well-being was assessed by Appearance, Pulse, Grimace, Activity, Respiration (Apgar) score measured by a pediatrician blinded to the study protocol at 1 and 5 min after delivery. Incidence of hypotension is defined as ‘at least one episode of decrease in systolic blood pressure to less than 90 mmHg or decrease in systolic pressure more than 20% from the baseline till the end of surgery’. It was treated immediately by 200 ml intravenous bolus fluids and injection of 5 mg ephedrine intravenous bolus every 2 min until elevation of blood pressure, and the total of ephedrine consumption was calculated. Duration of surgery and intraoperative complications was recorded as bradycardia, defined by heart rate below 60 beats/min, which was treated by 0.5 mg atropine sulfate, and nausea and vomiting, which were treated by ondansetron intravenous 4 mg after correction of hypotension. Results A total of 150 cesarean delivery patients between 22 and 34 years of age were included in the study. Regarding basic clinical and demographic data, it was found that the median age of all cesarean delivery patients was 30 years. The median BMI of all cesarean delivery patients was 32.5. Regarding the surgery duration, the median surgery duration of all cesarean delivery patients was 40 min. Regarding level of sensory block, most patients had sensory block at T6 (70%), and 30% at T4 in groups C, E, and S, correspondingly. Regarding primary outcome (incidence of hypotension mean arterial blood pressuer (MAP)&lt;70 mmHg), there was a highly significant increase in incidence of hypotension in group C compared with other groups of patients, with highly significant statistical difference (P=0.0092). The incidence of hypotension in group C was 70%, in group E was 50%, whereas in group S was 40% (P=0.0092). Regarding secondary outcomes (ephedrine consumption, Apgar scores, and complications), there was a highly significant increase in ephedrine consumption in group C compared with other groups (P=0.000002). The median value of ephedrine consumption in group C was 7.5 mg, in group E was 2.5 mg, whereas no ephedrine was consumed in group S (P=0.000002). Moreover, there was a nonsignificant difference regarding Apgar score at 1 min (P&gt;0.05). There was a highly significant increase in Apgar score at 5 min in group S compared with other groups (P=0.0047). There was a highly significant increase in bradycardia in group C compared with the other groups (P=0.0015). There was a highly significant increase in nausea in group C compared with the other groups (P=0.0008). There was a highly significant increase in vomiting in group C compared with the other groups (P=0.0008). Conclusion Incidence of hypotension in patients undergoing cesarean delivery under spinal anesthesia markedly decreased in patients who sat for 1 min after induction of spinal anesthesia and then lied down (group S) compared with patients who lied down immediately after induction of spinal anesthesia.

Intrathecal 1% 2-Chloroprocaine with Fentanyl in Comparison with Ropivacaine (0.5%) with Fentanyl in Day Care Perianal Surgery: Prospective Randomized Comparative Study.

Background:Spinal anesthesia is a reliable and safe technique for perianal surgeries; the changing trend of surgical practice from an inpatient to outpatient has urged us to use lower dose of local anesthetic providing segmental block with adjuvants such as opioids. Ropivacaine is a long acting; amide local anesthetic, with greater sensory motor differentiation. Chloroprocaine (CP) is an amino-ester local anesthetic with a very short half-life. This study was designed to compare CP with ropivacaine for spinal anesthesia in an elective ambulatory setting.Methods:This prospective, randomized, comparative study included 60 adult patients scheduled to undergo perianal surgeries under subarachnoid block with intrathecal 3.0 mL of 1% CP with 12.5 μg fentanyl (Group C) or 1.5 mL of 0.5% ropivacaine with 12.5 μg fentanyl (Group R).Statistical Analysis:Chi-square test used to assess significance for qualitative data, independent t-test for significance of the mean difference between two quantitative variables.Results:Meantime of onset of sensory block at T10 in both the groups were comparable (Group C – 4.7 min, Group R – 4.8 min). Maximum upper level of sensory block was at T8 in both the groups, time for regression of sensory level to L1 was significantly longer with ropivacaine (Group R – 135 min, Group C – 76 min, P < 0.0001), and the duration of motor blockade (Group C – 81 min, Group R – 145 min P < 0.0001) was significantly short in the Group C with early ambulation (160 min).Conclusion:CP provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal ropivacaine.

Comparative study of morphine or dexmedetomidine as intrathecal adjuvants to 0.5% hyperbaric bupivacaine in infraumbilical surgeries

Background: Morphine and Dexmedetomidine have been used with subarachnoid block for postoperative pain relief, sedation and analgesia. In higher doses, it may produce adverse effect on haemodynamics. Aim and Objective: This study compares the block characteristics and side effects effects of morphine and intrathecal Dexmedetomidine, given with intrathecal bupivacaine. Materials and Methods: A prospective, randomised, double-blinded study was conducted in department of anaesthesiology at a tertiary referral hospital. Eighty patients with American Society of Anaesthesiologists Status I and II were randomly allocated to receive either dexmedetomidine (5 μg) or Morphine (200 mcg) with or 0.5% hyperbaric bupivacaine. Results: Time to first dose of rescue analgesia was significantly more with dexmedetomidine (386.75102.27 min) as compared to Morphine (232.5045.45 min). Duration of motor block was also significantly longer with dexmedetomidine (192.3836.50) than Morphine (155.488.66). There was no significant difference between the two groups in relation to onset of sensory or motor block, time to reach maximum level of sensory block, and the time for two segment regression. Conclusion: Intrathecal dexmedetomidine as compared to Morphine as an adjuvant to intrathecal bupivacaine prolonged the time to first rescue analgesia, without any significant adverse effect.

Comparison between epidural ropivacaine and ropivacaine–clonidine combination for infraumbilical surgeries: A randomized clinical study

Introduction: Lower abdominal and lower limb surgeries may be performed under local, regional (spinal or epidural) or general anaesthesia, but neuraxial blockade is preferred mode of anaesthesia. Major advantage of epidural anaesthesia over spinal anaesthesia is the ability to titrate the extent and duration of anaesthesia. Aims and Objective: The primary outcome of the study was to measure the duration of sensory analgesia. The secondary outcomes were onset of sensory block, onset of motor block, highest level of sensory block, degree of motor block, duration of motor block, and quality of sensory blockage as measured by visual analog scale. Material and Methods: After getting institutional ethical clearance from our institute and proper written consent from each patient a total of 80 patients who underwent infraumbilical surgeries. A total of 80 patients who underwent infraumbilical surgeries were included randomly into two clinical study groups comprising 40 patients in each study group. Epidural anaesthesia was administered with 20ml of Ropivacaine 0.75% (GROUP-R) and 20 ml of epidural Ropivacaine 0.75% and Clonidine 75mcg combination (GROUP-RC). Statistical Analysis: Statistical comparison was made by comparison between groups by applying chi-square test to a contingency table for categorical data and two sample t–test and independent t-test for numerical data. Result: A total of 102 patients were assessed for eligibility, of which 16 patients did not meet the inclusion criteria and 6 patients were excluded during the study period. The groups was comparable with regard to demographic data and incidences of side effects except for the higher incidence of dry mouth in patients of RC group. Onset of analgesia was much shorter in RC group with prolonged duration of analgesia. The incidence of bradycardia and hypotension was more in RC group as compared to R group which was statistically significant. Conclusion: The addition of 75mcg clonidine to isobaric epidural ropivacaine results in longer, complete and effective analgesia with similar block properties and helped to reduce the effective dose of ropivacaine when compared with plain ropivacaine for infraumbilical surgery

Correlation of Symphysiofundal Height and Abdominal Girth with the Incidence of Hypotension in Cesarean Section Under Spinal Anesthesia using Bupivacaine with Fentanyl as Adjuvant: A Clinical Study.

Background and Aims:A decreased lumbosacral subarachnoid space volume is a major factor in cephalad intrathecal spread of local anesthetic in term parturients due to compressive effect of the gravid uterus. The aim of this study was to assess the relationship of symphysiofundal height (SFH) and abdominal girth (AG) with the incidence of hypotension and the highest level of sensory blockade.Settings and Design:This study was a prospective observational study.Materials and Methods:Ninety parturients under the American Society of Anesthesiologists physical status class II within the age range of 20–30 years, weighing between 60 and 65 kg, and height between 150 and 155 cm were studied, and the SFH and AG of all parturients had been measured just before spinal anesthesia. Hyperbaric bupivacaine 9 mg with 12.5 μg intrathecal fentanyl was administered for subarachnoid block. The incidence of hypotension and the highest level of sensory block were assessed.Statistical Analysis:Correlation analysis (Spearman's rank test) was applied to analyze the data, and P < 0.05 was considered to be statistically significant.Results:The incidence of hypotension was higher with increasing SFH (16.9% with SFH of 30–35 cm, 78.37% with SFH of 36–40 cm; correlation coefficient ρ =0.338) and with increasing AG (5.3% with AG between 85 and 89 cm, 35.7% with AG 90–94 cm, 62.8% with AG 95–99 cm; ρ =0.341), and both were statistically significant (P < 0.001). There was a statistically significant correlation between increasing SFH and maximum sensory block achieved (ρ =0.157, P < 0.001). There was increased level of sensory blockade with increased AG but was not statistically significant (ρ =0.011, P = 0.32).Conclusion:In term parturients undergoing cesarean section under spinal anesthesia, the SFH has a significant positive correlation with the incidence of hypotension and ascent of spinal anesthesia. AG also has a positive correlation with the incidence of hypotension but is not significant with the ascent of spinal anesthesia.

Comparing Effects of Intrathecal Adjuvants Fentanyl and Dexmedetomidine with Hyperbaric Ropivacaine in Patients Undergoing Elective Infraumbilical Surgeries: A Prospective, Double-Blind, Clinical Study.

Background:Spinal anesthesia is most commonly used anesthesia technique for infraumbilical surgeries, and it is cost-effective with decreased hospital stay. Intrathecal isobaric ropivacaine has shorter duration of anesthesia than bupivacaine. By making, ropivacaine hyperbaric will help to achieve dense block with good postoperative analgesia.Materials and Methods:Ninety patients with American Society of Anesthesiologists physical status Classes I and II, aged between 18 and 60 years of either sex, undergoing for elective infraumbilical surgeries were randomly allocated into three groups 30 each (n = 30). Group Ropivacaine + Dexmedetomidine (RD) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + dexmedetomidine 10 μg (0.5 ml), Group Ropivacaine + Fentanyl (RF) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) + fentanyl 25 μg (0.5 ml), and Group Ropivacaine + Normal saline (RC) received 2.5 ml of 0.5% hyperbaric ropivacaine (15 mg) +0.5 ml of normal saline. The onset, extent, and duration of sensory and motor block, duration of rescue analgesia, hemodynamic parameters, and side effects such as nausea, vomiting, pruritus, and shivering were recorded.Results:Time of onset early in RD (1.673 ± 0.567), in RF (1.73 ± 0.520), and in RC (1.763 ± 0.420) min (P = 0.783). Time to achieve maximum level of sensory block in RD (5.94 ± 1.88), in RF (3.86 ± 1.22), and RC (5.99 ± 0.46) min (P < 0.001). The total duration of analgesia in Group RD (356.67 ± 63.022), in RF (255.10 ± 35.626), and in RC (197.67 ± 37.605) min (P < 0.001). The time onset and duration of motor block in Group RD (1.59 ± 0.59, 319.57 ± 64.752), Group RF (1.59 ± 0.53, 236.83 ± 33.797), and Group RC (2.07 ± 0.20, 183.93 ± 35.252) min both are statistically highly significant (P < 0.001).Conclusion:Addition of glucose to ropivacaine makes the block dense. Addition of adjuvants such as dexmedetomidine and fentanyl further hastens the onset; prolong the postoperative analgesia with minimal hemodynamic and other side effects.

A comparative study between the effect of intrathecal hyperbaric bupivacaine with fentanyl and hyperbaric levobupivacaine with fentanyl for knee arthroscopy

Background The use of levobupivacaine as a pure S (−) enantiomer of bupivacaine was progressively increased due to lower cardiotoxicity and neurotoxicity and shorter motor block duration. The aim of this work was to compare the effectiveness of lower-dose local anesthetics’ use together with higher opioid dose to decrease the side effects of drugs. We compared sensorial, motor block levels and side effects of equal doses of hyperbaric bupivacaine and levobupivacaine with intrathecal fentanyl addition in knee arthroscopy. Patients and methods After hospital ethics committee approval and getting written informed consent from patients, 100 patients with American Society of Anesthesiologists grade I–II, aged 18–40 years were included in the study. They were randomized to either group A receiving 7.5 mg (1.5 ml) hyperbaric levobupivacaine with 25 μg (0.5 ml) fentanyl, or group B receiving 7.5 mg (1.5 ml) hyperbaric bupivacaine with 25 μg (0.5 ml) fentanyl. Results Hemodynamic parameters such as the 45th minute mean arterial pressure of group B was found to be lower (P&lt;0.05). In group A, maximum sensorial block level and postoperative visual analog scale scores were higher (P&lt;0.05). Onset of motor block time, time to maximum motor block, time to sensorial block, reversal of two dermatome and first analgesic need were similar in both groups. Conclusion Intrathecal hyperbaric levobupivacaine–fentanyl combination is a better and good alternative to bupivacaine–fentanyl combination in knee arthroscopy, as it maintains hemodynamic stability.

Intrathecal Magnesium Sulfate as Analgesic and Anaesthetic Adjunct to Bupivacaine in Patients Undergoing Lower Extremity Orthopaedic Surgery

Background: Subarachnoid block is a popular mode of anesthesia for lower limb surgeries. Studies of Magnesium Sulfate (MgS04 ) as an adjuvant to intrathecal local anaesthetic are limited. The objective was to find out the analgesic and anaesthetic effect of intrathecal MgS04 added to bupivacaine for spinal anaesthesia in patients undergoing lower extremity orthopaedic surgery.Methods: Sixty ASA I or II adult patients undergoing lower extremity orthopaedic surgery were randomly allocated in a double blinded fashion into two groups of thirty each. Group A received 3.0 ml of 0.5% hyperbaric bupivacaine with 0.15 ml of 50% MgSO4. Group B received 3.0 ml of 0.5% hyperbaric bupivacaine with 0.15 ml of NS. Onset of sensory and motor block as well as time to attain highest level of sensory block were recorded. Duration of sensory and motor block along with duration of spinal anaesthesia were also assessed. Any adverse effects were noted and treated.Results: Duration of sensory and motor block along with duration of spinal anaesthesia were prolonged in patients of MgSO4 but were not statistically significant with p-value of 0.33, 0.23 and 0.68 respectively. Onset of anaesthesia, requirement of rescue analgesics, haemodynamic parameters and adverse effects were comparable between two groups.Conclusion: In patients undergoing lower extremity orthopaedic surgery the addition of 75mg of MgSO4 to intrathecal bupivacaine did not prolong the duration of sensory block, spinal anaesthesia nor decreased postoperative analgesic consumption without any additional side effects. Journal of Society of Anesthesiologists of NepalVol. 4, No. 2, 2017, Page: 74-80

Prophylactic infusion of phenylephrine increases the median effective dose of intrathecal hyperbaric bupivacaine in cesarean section: A prospective randomized study.

Background:Phenylephrine infusion to prevent spinal-induced hypotension can attenuate cephalic spread of intrathecal bupivacaine. Therefore, we suspected the intrathecal dose requirement for bupivacaine may differ when using phenylephrine infusion to prevent spinal-induced hypotension in cesarean section. We designed a prospective, randomized study to determine the ED50 of hyperbaric bupivacaine for cesarean section under combined spinal-epidural anesthesia in healthy parturients with and without prophylactic phenylephrine infusion to prevent spinal-induced hypotension.Methods:Sixty healthy parturients rated American Society for Anesthesiology status I/II undergoing elective cesarean section were enrolled in this study, which was conducted July 2016 to February 2017 in the labor and delivery department of Jiaxing University Affiliated Women and Children Hospital. After enrollment, patients were randomized into 2 groups of 30 by blinded opaque envelopes sorted by computer-generated random allocation. Solutions were prepared by an anesthesiologist not involved in outcome measurement. Patients and anesthesiologists collecting data were blinded to group allocation. Group P (phenylephrine group) parturients received prophylactic infusion of phenylephrine at the time of intrathecal injection. Group S (saline group) parturients receive the same volume of saline. Doses of intrathecal bupivacaine for each patient were determined using an up-down allocation method; initial dose was 7 mg. Effective dose was defined as bilateral T6 or above sensory block level achieved within 10 minutes of intrathecal drug administration and no additional epidural lidocaine required for intraoperative pain. The Dixon and Massey formula was used to calculate ED50 values.Results:The ED50 values for hyperbaric bupivacaine were 7.0 mg (95% confidence interval [CI]: 6.6–7.4 mg) and 4.9 mg (95% CI: 4.4–5.4 mg) for groups P and S, respectively (P < .001). There were significant differences in incidence of hypotension and pH of umbilical arterial blood between groups S and P (60% vs 10%, P = .04 and 7.31 ± 0.04 vs 7.28 ± 0.06, P = .003, respectively).Conclusion:The ED50 of intrathecal hyperbaric bupivacaine is higher when phenylephrine infusion is used to prevent spinal-induced hypotension than when it is not used.

Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial

Although several approaches for ultrasound-guided thoracic paravertebral block have been introduced, little is known regarding the differences in analgesic efficacy. We conducted this prospective randomised trial to examine whether the type of approach for ultrasound-guided thoracic paravertebral block could affect analgesic quality in thoracotomy. Patients scheduled for video-assisted thoracotomy were randomly allocated into two groups by block technique: the intercostal approach (group IC) or the paralaminar approach (group PL). At the start and end of surgery, 20mL of 0.5% ropivacaine was injected, followed by a continuous infusion of 0.2% ropivacaine at 5mL h-1 . We also started intravenous fentanyl patient-controlled analgesia at 0.5μg kg-1 h-1 and bolus dose of 15μg. The main outcome was the number of rescue fentanyl use. We also evaluated postoperative pain scores and number of blocked dermatomes showing a reduced sensation. Enrolment was ceased because of implementation of a minimally invasive surgical method. Overall, 42 subjects completed the trial for analysis. The number of rescue fentanyl use in group PL was significantly less than that in group IC at 3, 6, 12 and 24hour postoperatively. The numerical rating scale (NRS) at rest in group PL was significantly lower at 1, 3, 6, and 12hour postoperatively. Patients in Group PL developed significantly wider sensory block level (median (IQR [range]); 4 (4-5 [2-7])) than those in Group IC (3 (3-3 [2-9])). We suggested that paralaminar approach provided superior analgesia for thoracotomy rather than the intercostal approach.

Spinal anaesthesia for spine surgery in prone position

Background . There is no universal approach to spinal anaesthesia (SA) in prone position according to type, dose and baricity of local anesthetic agent. Aim of the study is to compare isobaric and hyperbaric bupivacaine for SA for lumbar spine surgery. Methods .A total of 144 patients were divided into 3 groups (48 pts in each). In the group HB5 SA with heavy bupivacaine 0,5%-3,5 ml with exposure 5 min in supine position was performed. In the group HB10 SA with the same bupivacaine but with exposure 10 min was performed. In the group IB patients were anaesthetized with isobaric bupivacaine 0,5%-3,5 ml and than turned by themselves to prone position immediately after injection. We examined the level of sensory and motor block, and hemodynamics 15 min and 3 hrs after injection of bupivacaine. Results . The level of sensory block was higher in both hyperbaric groups compared to isobaric. Anywhere it was enough for surgery L3 and lower in all cases. Motor block was Bromage3 in all groups. After 3 hours, sensory level was the highest in the group HB5, and motor block was the highest in the group HB10. The most stable hemodynamics was in in group IB, and the most unstable in the group HB10. Conclusions . Isobaric bupivacaine is preferable for SA for lumbar spine surgery that lasts for 3 hrs and less due to stable hemodynamics and early start of surgery. For longer surgery hyperbaric bupivacaine may be recommended with exposure time in supine position for 5 min.

The effects of adjuvant intrathecal fentanyl on postoperative pain and rebound pain for anorectal surgery under saddle anesthesia.

BackgroundIntrathecal opioid has been known to enhance the quality and prolong the duration of spinal anesthesia, as well as to reduce postoperative pain. The purpose of this study was to evaluate postoperative analgesic characteristics of intrathecal fentanyl for the first 48 hours after anorectal surgery under saddle anesthesia.MethodsEighty patients were recruited in our study. Forty patients were randomly allocated to group B that received 0.5% bupivacaine 5 mg with 0.3 ml normal saline. The other 40 patients were assigned to group BF which was given 0.5% bupivacaine 5 mg with fentanyl 15 μg. The primary outcome variable was a numeric rating scale (NRS) at six hours postoperatively. Secondary outcomes included changes in the NRS score between one and 48 hours postoperatively, consumption of rescue analgesics, and the frequency of rebound pain.ResultsGroup BF exhibited a lower mean NRS score at postoperative six hours compared to group B (P < 0.001). However, the mean NRS score was not different after postoperative six hours between the two groups. The median consumption of rescue analgesics in group BF was less than that of group B (P = 0.028) and the frequency of rebound pain decreased in group BF when compared to group B (P = 0.021). The levels of sensory block were S1 dermatome and motor block scores were 0 for both groups. There was no significant difference in adverse effects between the groups.ConclusionsIntrathecal fentanyl 15 μg for anorectal surgery under saddle anesthesia led to an improved pain score for the first six hours after surgery and decreased postoperative analgesic use. Rebound pain diminished with intrathecal fentanyl and adverse effects did not increase.