Subarachnoid Block Research Articles

Comparison of Intrathecal Hyperbaric Bupivacaine Alone and Hyperbaric Bupivacaine with Fentanyl in Lower Limb Surgery

Introduction: Subarachnoid block is the preferred anaesthetic technique used for lower limb surgeries because of its rapid and profound sensory and motor blockade. Opioids are widely used in conjunction with local anaesthetics in neuraxial blocks for their property of improving the quality and prolonging the duration of local anaesthetics for surgical anaesthesia, as well as post-operative analgesia. Objectives: Objective of this study was to compare the duration of two segment regression, motor blockade and sensory analgesia, with intrathecal hyperbaric Bupivacaine alone and with Fentanyl added. Method: In this study, 80 patients above 15 years with ASA (American Society of Anaesthesiologist) physical status I and II, undergoing subarachnoid block for various lower limb surgeries were studied in a double-blinded, randomized prospective manner. Patients were divided into two equal groups - Group B (n= 40) received hyperbaric bupivacaine 15 mcg, and Group BF received hyperbaric bupivacaine 12.5 mg with fentanyl 25 mcg, making a total volume of 3 ml in both the groups. Patients were compared intraoperatively and postoperatively for the duration of motor blockade, time for two segment regression and duration of sensory analgesia and complications. Results: The time for two segment regressions, time for sensory analgesia, duration of motor blockade, was significantly higher in group BF i.e., 119 ±19 mins, 310 ±20 mins and 236±17 mins respectively, as compared to group B i.e., 83 ±20, 223 ± 22, 186 ±19 minutes respectively. Both the groups were comparable with demographic profile and hemodynamic parameters. Conclusion: The addition of fentanyl 25 mcg prolongs the time for two segment regression and duration of sensory analgesia for lower limb surgeries.

Comparison of Low-dose Diluted Hyperbaric Bupivacaine and Standard Hyperbaric Bupivacaine in Subarachnoid Block for Ambulatory Endovenous Laser Ablation of Varicose Vein: A Randomized Controlled Trial

Abstract Background: Low-dose spinal anesthesia represents a highly coveted anesthetic technique for patients undergoing endovenous laser ablation of varicose veins in a day-care setting, given its prompt onset, reliable anesthesia, brief turnover time, and cost-effectiveness. Given that intense motor block is not required for this procedure, this trial compared the efficacy of low-dose diluted hyperbaric bupivacaine with standard hyperbaric bupivacaine in the subarachnoid block for endovenous laser ablation of varicose veins. Methodology: A prospective, randomized controlled trial at a tertiary care hospital, Tamil Nadu, South India. Sixty individuals with varicose veins requiring endovenous laser ablation surgery were split at random into two groups. Group A (n = 30) got 0.5% hyperbaric bupivacaine 10 mg (2 ml), Group B (n = 30) got diluted hyperbaric bupivacaine 5 mg (1 ml of 0.5% hyperbaric bupivacaine diluted with an equivalent volume of normal saline) intrathecally. This study evaluated the time to surgical readiness, peak sensory block level, motor block grade, sensory block level at the completion of surgery, duration of motor and sensory blocks, and timing of discharge. Results: The median peak sensory block level for Group A was T6 (T8–T6), whereas for Group B it was T8 (T10–T6), with a P = 0.03. At the conclusion of surgery, the median sensory block level was T6 (T6–T8) for Group A and T8 (T7–T10) for Group B. No patients in either group needed a rescue analgesic. The average timing of discharge for Group B was shorter (P = 0.00002). Conclusion: For patients receiving endovenous laser ablation therapy for varicose veins, subarachnoid blockade with low-dose diluted hyperbaric bupivacaine (5 mg) offers an effective anesthesia, the best recovery profile, and early hospital discharge.

Do Previous Multiple Scorpion Bites Produce Resistance to Local Anesthetics Administered Via Repeated Subarachnoid and Epidural Blocks? A Case Report and Review of Available Evidence

Introduction: Failure to achieve a subarachnoid block, even after a second attempt, and the inability to activate epidural analgesia, despite a properly placed catheter, can be both frustrating and perplexing. This case presents a situation where these incidents occurred, and two well-conducted attempts at a subarachnoid block and a properly placed epidural catheter block were unable to produce surgical anesthesia. Case Presentation: A 55-year-old female, classified as American Society of Anesthesiologists (ASA) grade II, was scheduled for a total abdominal hysterectomy with bilateral salpingo-oophorectomy. After adequate pre-operative preparation, an epidural catheter was inserted on the morning of surgery, followed by a subarachnoid block with all the proper precautions, which completely failed. After waiting for 10 minutes, the epidural block was activated with a local anesthetic mixture. To our surprise, it also did not produce any desirable effect, so the subarachnoid block was repeated, which again failed to produce any clinical block. Consequently, the surgery had to be conducted under balanced general anesthesia. Recalling previous experience and evidence, a history of scorpion bites was elicited. The patient had a history of multiple encounters (five) and was from a geographical area known to be endemic for scorpions. Conclusions: This case represents another instance of developing resistance to the effects of local anesthetics after exposure to scorpion venom. We believe there is a strong correlation between previous scorpion bites, the number of bites, and the duration between the most recent bite and the development of resistance to local anesthetic agents (LAAs). From a detailed search, it was evident that enough clinical evidence has emerged to irrefutably support this proposal.

A double blinded randomized prospective trial of comparison between control and study group, nefopam versus tramadol on shivering scores after spinal anesthesia in patients undergoing Transurethral resection of prostate

IntroductionShivering is a common and distressing complication that can occur after subarachnoid block (SAB) in patients, particularly those undergoing transurethral resection of the prostate (TURP) due to the use of irrigating fluid and older age group. This study aims to compare the effectiveness of nefopam and tramadol in reducing intraoperative shivering compared to a control group, in Indian patients. MethodologyThis study is a double-blinded randomized control trial with a total of 99 patients undergoing elective TURP under SAB were enrolled. The patients were randomly divided into three groups (GT, GN, and GC): GT received tramadol (0.5 mg kg-1) and GN received nefopam (0.15 mg kg-1). Both tramadol and nefopam were premixed into 100 ml of normal saline (NS) and GC received 100 ml NS, given over 15 min just before SAB. The induction protocol was the same for all groups, and shivering score, hemodynamic parameters, and body temperature (BT) were recorded. ResultsThe overall incidence of shivering was 29.67 % (27/91), with the lowest incidence being in GN (16.67 %, 5/30), followed by GT (22.58 %, 7/31) and GC (50 %, 15/30). Both nefopam and tramadol resulted in a significant (p < 0.05) decrease in the incidence of shivering compared to control. Among the hemodynamic parameters and BT, no significant difference was seen between GT, GN, and GC (p > 0.05). ConclusionBoth nefopam and tramadol were effective in reducing the incidence but the severity was controlled better with nefopam during TURP under SAB.

Comparative Analysis of Intrathecal Bupivacaine With Fentanyl Versus Intrathecal Bupivacaine With Midazolam in Lower Abdominal and Lower Limb Surgeries.

Many different adjuvants are added intrathecally along with local anaesthetics to prolong intraoperative and postoperative analgesia. Hence, this study aimed to compare intrathecal bupivacaine with fentanyl and bupivacaine with midazolam in lower abdominal and lower limb surgeries. Following permission from the Hospital Ethical Committee (Research Protocol No.: IESC/PGS/2022/143), the study was conducted on a sample of 60 patients, divided into two groups, Group F and Group M, with 30 patients each, representing the American Society of Anaesthesiologist's (ASA) grades I and II. The patients were between the ages of 18 and 60 and featured both males and females, scheduled to undergo elective surgical procedures on the lower abdomen and lower limbs via spinal anaesthesia. Group "F": 3 ml of 0.5% hyperbaric bupivacaine hydrochloride with 0.5 ml (25 mcg) of fentanyl (preservative-free) intrathecally. Group "M": 3 ml of 0.5% hyperbaric bupivacaine hydrochloride with 0.5 ml (2.5 mg) of midazolam (preservative-free) intrathecally. The primary aim was to study the onset of motor and sensory block and duration of analgesia with the addition of midazolam or fentanyl to 0.5% heavy bupivacaine in the sub-arachnoid block. A secondary aim was to evaluate the quality of anaesthesia and postoperative analgesia, determine the haemodynamic stability in the intraoperative and postoperative period in the two study groups, andobserve any adverse effects of study drugs. Group F exhibited a substantially longer duration for both sensory (211.5 vs. 154.4 min) and motor blockade (269.8 vs. 214.6 min) compared to Group M, as well as a rapid onset time for both sensory (2.6 vs. 3.3 min) and motor blockade (3.1 vs. 3.9 min). Also, Group F had a significantly longer duration of effective analgesia compared to Group M (266 ± 15.9 vs. 197.6 ± 13.7 minutes). The addition of 0.5 ml (2.5 mg) Midazolam with 0.5% hyperbaric Bupivacaine intrathecally prolonged the duration of anaesthesia and postoperative analgesia; however, fentanyl 0.5 ml (25 mcg) has a more prolonged duration of intraoperative and postoperative analgesia.

Comparative Analysis of Oral Clonidine Versus Oral Gabapentin on Subarachnoid Block Duration and Postoperative Analgesic Needs.

Pain, an inherently subjective experience, plays a pivotal role in the body's defence mechanism by signalling tissue damage or potential harm. Thus, optimal postoperative pain management is a cornerstone of modern surgical practice, essential for improving recovery outcomes and overall patient well-being. In this study, a total of 60 patients were randomly assigned to two groups of 30 each: Group C (clonidine) and Group G (gabapentin). Group C received oral clonidine 100 mcg and Group G received oral gabapentin600 mg one hour prior to the subarachnoid block. Duration of sensory and motor block, hemodynamic parameters, Visual Analog Scale (VAS) scores, time to rescue analgesia and any side effect of both drugs were assessed in both groups. The duration of motor and sensory blockade, as well as intraoperative hemodynamics and respiratory rates, were comparable between the two groups. Group G exhibited significantly lower VAS scores from 150 minutes postoperatively up to 12 hours (p < 0.001). Additionally, Group G experienced longer duration of postoperative analgesia (16.8±3.9 hours) compared to Group C (9.27±1.7 hours). About 26.6% of the patients in Group C and 6.7% of the patients in Group G presented with postoperative nausea and vomiting (PONV). Oral gabapentin at a dosage of 600 mg demonstrates superior efficacy as a premedication compared to oral clonidine 100 mcg for patients undergoing lower abdominal and lower limb surgeries under spinal anesthesia. Group G demonstrated extended postoperative analgesia, lower VASscores, and a reduced incidence of PONV, indicating its superiority over clonidine as an analgesic adjunct.

Intrathecal Dexmedetomidine as an Adjuvant to Low Dose Hyperbaric 0.5% Bupivacaine on Haemodynamic Parameters in Patients Undergoing Transurethral Resection of Prostate.

To determine the role of dexmedetomidine in potentiating the local anaesthetic efficacy of a low dose of bupivacaine when used as an adjuvant. A prospective, double-blind, randomised study. Place and Duration of the Study: Department of Anaesthesia, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from July 2021 to February 2022. One hundred and eight patients of ASA physical class I-III undergoing transurethral resection of the prostate (TURP) under sub-arachnoid block (SAB) were enroled and distributed into two equal groups. Group BUPIPURE (BP) was given 7.5 mg of pure 0.5% hyperbaric bupivacain whereas group BUPIDEX (BD) was given 6 mg of 0.5% hyperbaric bupivacain with 3 μg dexmedetomidine intrathecally. The effects in Both groups were compared using chi-square and unpaired t-tests. A significance level of p <0.05 was used to evaluate the statistical significance. Both groups demonstrated a steady decrease in mean heart rate (mean HR 98.9-62.7 per minute as compared to 79.1-59.4 per minute in groups BP and BD, respectively), however, no patient reached to HR <50/min. Group BP had a higher HR variability than group BD. The two groups' median peak sensory levels were similar. However, a statistically significant difference was revealed in the time taken for 2-segment regression (87.5 ± 11.3 min vs. 115.5 ± 6.2 min p <0.001 in BP and BD), as well as the time to reach T10 sensory level (13.56 ± 2.5 min vs. 10.9 ± 3.0 min p <0.001). In patients having TURP, intrathecal dexmedetomidine combined with low-dose bupivacaine results in a quicker start, extended sensory and motor block, and a decreased need for rescue analgesics. Adjuvants, Dexmedetomidine, Spinal anaesthesia, Transurethral Resection of Prostate.

Comparison Of Ketorolac Versus Ibuprofen For Postoperative Pain Management In Total Abdominal Hystrectomy Surgeries

Background - Postoperative pain management is crucial for ensuring patient comfort and promoting faster recovery. Pharmacological interventions, such as NSAIDs, play an essential role in reducing pain intensity while minimizing opioid-related side effects. Ketorolac, a potent NSAID, and ibuprofen are both commonly used for pain relief. This study focuses on comparing the efficacy of these two drugs for pain management in total abdominal hysterectomy surgeries. Aim -To assess and compare the effects of intravenous ketorolac and intravenous ibuprofen on postoperative pain management in total abdominal hysterectomy patients. Materials and Methods: A randomized single-blind study was conducted on 30 patients, divided into two groups (Group K: ketorolac, Group I: ibuprofen). Various parameters, including VAS pain scores, sedation, time for rescue analgesia, and the number of rescue analgesics, were compared. Participants: 30 patients undergoing total abdominal hysterectomy, randomized into two groups (Group K: ketorolac, Group I: ibuprofen). Inclusion Criteria: Patients between 18 and 65 years of age undergoing elective surgery, ASA grade I or II. Exclusion Criteria: Patients with NSAID hypersensitivity, coagulation disorders, bronchial asthma, hepatic or renal failure, and peptic ulcers. Methodology: Patients received lumbar subarachnoid block, followed by either 30 mg of ketorolac or 800 mg of ibuprofen postoperatively. Rescue analgesics were provided if needed. Results: The postoperative pain scores were significantly lower in the ibuprofen group. Time for first rescue analgesia and the total number of rescue analgesics required were also lower in the ibuprofen group

Cesarean Section under General Anesthesia over 10 Years at Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction: The global surge in cesarean deliveries necessitates safe anesthetic practices to optimize outcomes. While the neuraxial block is the preferred method, specific conditions warrant general anesthesia. This study is aimed to determine the prevalence of cesarean sections under general anesthesia at a tertiary care center. Methods: A descriptive cross-sectional study was conducted on cesarean sections performed between April 14, 2013, and April 13, 2023, at a tertiary care center. Ethical approval was obtained from the Institutional Review Committee (Reference number: 20092023/01). Total sampling was done. Data for the past ten years were manually collected from hospital records using a self-structured proforma and analyzed using Microsoft Excel 2018 and IBM SPSS version 26. The point estimate and 95% confidence interval were calculated for the study. Results: In this study, there were 216 (2.98%) (95% CI: 2.59-3.38%) cesarean sections under general anesthesia in 10 years. Notably, among them, there were 103 (47.69%) primigravida, nullipara 130 (60.19%), 135 (62.50%) with no living children, and 161 (74.54%) without any past abortions. In most cases, 182 (84.26%) were emergency procedures and 34 (15.74%) were elective. Fetal bradycardia with distress was the primary indication observed in 121 (56.02%) cases, followed by 32 (14.81%) maternal requests. Additionally, twenty-one cases were found initially planned as cesarean sections under subarachnoid block but were converted to general anesthesia. The prevalence in this study was found within the recommended limits.Conclusions: The findings highlight that the majority of these procedures were emergency cases, predominantly due to fetal distress, with a notable proportion involving primigravida and nulliparous women.

Efficacy of combined lumbar plexus and parasacral sciatic nerve block in elderly patients undergoing hip fracture surgery: a retrospective analysis

Aims: Hip fractures are a major cause of morbidity and mortality in the elderly population. Anesthesia management significantly affects outcomes in elderly patients. In recent years, peripheral nerve blocks acquired importance, especially in patients where subarachnoid blocks are contraindicated or in patients with severe pulmonary or cardiac diseases. This study aimed to retrospectively evaluate the efficacy of combined lumbar plexus block and parasacral sciatic nerve block in geriatric populations. Methods: Data from patients over 70 years of age (ASA III) who underwent surgery for hip fracture and received combined lumbar plexus and parasacral sciatic nerve blocks between 2014 and 2024 were retrospectively analyzed. The efficacy of anesthesia, the need for intraoperative rescue anesthesia, and hemodynamic parameters were evaluated. Results: The mean age of the 98 patients included in the study was 79.81 ± 8.94 years. Most patients had concomitant chronic diseases. A total of 19 (19.94%) patients were administered Fentanyl 50 mcg and Propofol 0.5 mg/kg for pain at the beginning of surgery, and none of the patients who received sedoanalgesia experienced severe respiratory distress or low oxygen saturation. Anesthesia and analgesia were effectively administered, and the need for intraoperative rescue anesthesia was low. Hemodynamic parameters remained stable. Conclusion: Combined lumbar plexus and parasacral sciatic nerve block is an effective anesthetic method for hip surgery in elderly patients with comorbidities. This method reduces the need for general anesthesia, provides comprehensive analgesia, and maintains hemodynamic stability.

Comparing the Efficacy of Landmark-Based Fascia Iliaca Compartment Block and Pericapsular Nerve Group Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Surgery for Hip Fractures: A Randomized Controlled Trial.

Subarachnoid block is the most common anesthetic technique for patients having corrective hip surgeries. However, adequate positioning for a successful subarachnoid block is a major challenge in this particular population of patients, owing to the site of fracture. Regional anesthesia, in the form of nerve blocks, is an effective means of alleviating such constraints and gives an added benefit of prolonged postoperative analgesia. The pericapsular nerve group (PENG) block and the fascia iliaca compartment block (FICB), under ultrasonography guidance, are a few examples of the commonly performed peripheral nerve blocks in such settings. However, the landmark-based techniques of nerve blockade still hold good in many resource poor settings, given the lack of ultrasonography facilities. To compare the ease of spinal positioning using the patient sitting satisfaction score between the landmark-guided FICBand PENG block. This study was done on 80 patients of the American Society of Anesthesiology (ASA) grade I or II with intertrochantericfractures of the hip joint scheduled for proximal femoral nailing. Patients were allocated into two groups of 40 each through computer generated random numbers, to receive 30 ml of 0.5% ropivacaine via the landmark-guided technique of FICB in Group F and peripheral nerve stimulator assisted landmark-guided PENG block in Group P, 30 minutes prior to spinal positioning. Time to passive leg raise (PLR) to 15 degrees and time to PLR to 30 degrees with a standard goniometer guidance at visual analogue scale (VAS) score < 4 and ease of spinal positioning through the sitting satisfaction score at the 30th minute were assessed. Any adverse effects and events of failure were noted. The duration of postoperative analgesia was measured through the time to the first dose of paracetamol on arrival at the post-anesthesia care unit. Statistical analysis was done using JASP version (0.18.3.0) using the independent samples t-test and significance was taken when p value was < 0.001. The time to PLR to 15 degrees and 30 degrees were achieved faster in the patients who received the PENG block in comparison to the patients who received the FICB, and the average patient sitting satisfaction score was significantly higher in Group P as compared to Group F (p < 0.001). While the overall amount of analgesics used in both groups was similar, the overall period of postoperative analgesia was prolonged in Group F compared to Group P (p < 0.001). The landmark guided PENG block is feasible and superior to the landmark-guided FICB for preoperative positioning and analgesia. The FICB provides a longer duration of postoperative analgesia for patients with intertrochanteric fractures.

A comparative evaluation of dexamethasone and MgSO4 as an adjuvant to ropivacaine in transversus abdominis plane block for post operative analgesia in patients undergoing elective cesarean section, a triple blinded randomised controlled trial

: In regional blocks, dexamethasone and magnesium sulphate (MgSO4) have been used as an adjunct to local anesthesia. But more research needs to be done on each one's effectiveness. This study aims to assess the efficacy of dexamethasone 4mg and MgSO4 150mg as an adjunct to ropivacaine 0.375% in transversus abdominis plane (TAP) block for postoperative analgesia in patients undergoing cesarean section under subarachnoid block (SAB).: Ninety patients undergoing cesarean section under SAB belonging to American Society of Anesthesiologists physical status I or II, were recruited and randomised in three groups. Each group comprised of 30 patients. Group RS received 20ml 0.375% ropivacaine with 2 ml normal saline, Group RD received 20ml 0.375% ropivacaine with 4 mg dexamethasone and Group RM received 20ml 0.375% ropivacaine with 150 mg MgSO4.Time to first analgesic request, VAS score at rest and movement, patient satisfaction score, hemodynamic parameters and side effects were recorded in each group post-TAP block for 24 hours. Time to first analgesic request was significantly longer in group RD (814.0± 277.3 min) compared to group RM (606.5 ± 279.9 min) and group RS (545.5 ± 254.3 min) (p = 0.001). The mean value of tramadol requirement was statistically higher in Group RS compared to Group RD and Group RM (p&amp;#60;0.001). The mean differences in VAS score at rest and movement at 6 &amp; 8 h was significantly lower in dexamethasone and MgSO4 compared to control group p=0.001. The addition of dexamethasone to ropivacaine in TAP block significantly prolonged the duration of analgesia, reducing the need for systemic analgesia with minimal side effects.

The Causes of Intraoperative Pain among Elective Caesarean Section Patients under Sub-Arachnoid Block at the Tamale Teaching Hospital

Background: Intraoperative pain is a possible complication of neuraxial anaesthesia for caesarean delivery. Possible causes of intraoperative pain following caesarean section under spinal anaesthesia have been proposed. The potential consequences include inadequate anaesthesia, nerve injury during needle insertion, manipulation of internal organs during surgery, and psychological factors such as anxiety and fear. This study was conducted to assess the causes of intraoperative pain among patients undergoing elective caesarean section under sub-arachnoid block at the Tamale Teaching Hospital. Methods: A descriptive cross-sectional research design was employed in this study. A total of 55 women who have had elective caesarean section under sub-arachnoid block were selected for the study. Data was collected using a structured questionnaire and analysed with the SPSS. Results: Findings from the study showed a high incidence of intraoperative pain among women during elective caesarean section under sub-arachnoid block (96.4%). These were mainly sharp and aching pain. However, the levels of the pain experienced intraoperative were mild (52.7%) and moderate (43.6%). Increased length of time spent during surgery and ineffectiveness of medications/ injections given to prevent pain were the main factors contributing to intraoperative pain among patients during elective caesarean section under sub-arachnoid block. Conclusions: The study found a substantial incidence of intraoperative pain during caesarean delivery. To mitigate intraoperative discomfort and enhance the overall surgical experience for patients having elective CS, it is crucial to address these issues by employing optimised anaesthesia techniques, implementing effective pain management measures, and utilising preoperative psychological therapies.

Prevention of post-anaesthetic shivering under subarachnoid block for lower limb surgeries: A randomised controlled study comparing nefopam and tramadol

Prevention of post-anaesthetic shivering under subarachnoid block for lower limb surgeries: A randomised controlled study comparing nefopam and tramadol

Effect of Ketamine as an Adjuvant to Bupivacaine in Ilioinguinal and Iliohypogastric Nerve Block for Postoperative Analgesia after Inguinal Hernia Repair

Ilioinguinal and Iliohypogastric nerve block is one of the methods exercised widely to reduce postoperative pain after inguinal hernia repair. Several initiatives are ongoing to prolong the duration of postoperative analgesia by adding various adjuvants to the local anaesthetic agents in different nerve blocks. In this study ketamine has been added as an adjuvant to local anaesthetic bupivacaine in Ilioinguinal and Iliohypogastric nerve blocks. Our study aims to evaluate the effect of adding ketamine to local anaesthetic bupivacaine in ultrasound guided Ilioinguinal and Iliohypogastric nerve block in patient scheduled for inguinal hernia repair under subarachnoid block. This randomized control trial was carried out among 94 patients scheduled for elective inguinal hernia repair under subarachnoid block in Dhaka Medical College Hospital, Dhaka, Bangladesh. Two nerves, Ilioinguinal and Iliohypogastric were blocked by 0.25% bupivacaine under ultrasound guidance after the completion of surgery for postoperative analgesia. The study population was divided equally into two groups having 47 patients in each. Patients of group-A was received 20 ml of 0.25% bupivacaine and 2ml normal saline in the block procedure. Another group, group B patients received 20ml of 0.25% bupivacaine and 1mg/kg of ketamine in the same nerve block. Demographic profiles had no significant differences between two groups (p&gt;0.05). Mean duration of the analgesia or the time of first rescue analgesic requirement were significantly higher in ketamine group (595.24±15.90 minutes) than normal saline group (226.4±20.6 minutes). (p&lt;0.05); Postoperative total analgesic (pethidine) requirement within first 24 hours (178.3±18.3 vs. 92.3±15.3) milligrams, (p&lt;0.05) was higher in normal saline group. Our data suggests that ketamine when used as an adjuvant to bupivacaine for ilioinguinal and iliohypogastric nerve block prolongs the time to first analgesic request as well as decreases the analgesic requirement during postoperative period. CBMJ 2024 July: vol. 13 no. 02 P: 203-212

Outcome of Subarachnoid Block with Low Dose Bupivacaine and Fentanyl for Lower Limb Vascular Surgeries in Patients with Coronary Artery Disease

Subarachnoid block (SAB) with local anesthetics and opioids (fentanyl) and able to perform spinal anesthesia because of the synergistic effects and allow top use of low dose local anesthetics which results in a stable hemodynamic state. A randomized clinical trial was conducted to observe the cardiovascular effects of subarachnoid block (SAB) with low dose bupivacaine and fentanyl on patient with coronary artery disease, between January 2021 and December 2022. A total of 36 patients who had known case of coronary artery disease. All patients underwent spinal block for lower limb surgery with 7.5 mg hyperbaric bupivacaine 0.5% and 25 µg fentanyl. In each patient, 1 mg I/V midazolam was used and if needed subsequent may be given. Complications related to anesthesia such as hypotension, bradycardia, vasopressor need, and blood or volume use were recorded. Our study shows at the 90-minutes of spinal block, patients with EF ≤40% experienced a decrease of 10.5% in systolic blood pressure, while those with EF&gt;40% experienced a larger decrease of 19%. At the 90-minutes of spinal block, percentage decrease was higher in the EF&gt;40% group (19.5% vs. 14%) in diastolic blood pressure. At the 90-minutes of spinal block, patients with EF ≤ 40% experienced a decrease of 13% in MAP, while those with EF&gt;40% experienced a larger decrease of 19%. The findings demonstrate that patients with EF&gt;40% exhibited larger percentage decreases in systolic blood pressure, diastolic blood pressure, and MAP compared to those with EF ≤40%. The difference was statically significant (P&lt;0.05). Our study recommends subarachnoid block with low dose of bupivacaine and fentanyl is effective in lower limbs surgeries for patients with coronary artery disease particularly with low EF. CBMJ 2024 July: vol. 13 no. 02 P: 169-175

Comparison of the effect of intrathecal fentanyl citrate and magnesium sulfate as adjuvants to hyperbaric levobupivacaine 0.5% for spinal anesthesia in patients undergoing lower limb orthopedic surgeries

Background: Subarachnoid blockade is a safe, reliable, and inexpensive technique that provides surgical anesthesia along with prolonged post-operative analgesia. The quality of subarachnoid block is enhanced by the addition of intrathecal adjuvants, such as fentanyl citrate and magnesium sulfate to hyperbaric levobupivacaine. Aims and Objectives: The aim of this study was to compare the effects of fentanyl and magnesium sulfate as adjuvants to 0.5% hyperbaric levobupivacaine in orthopedic surgeries under subarachnoid block. Materials and Methods: This prospective randomized study included 90 American Society of Anesthesiologists Grade I and II patients aged 18–60 years undergoing orthopedic surgeries. Group LS received 3 mL 0.5% levobupivacaine heavy+0.5 mL normal saline. Group LF received 3 mL 0.5% levobupivacaine heavy+fentanyl 25 μg, and Group LM, 3 mL 0.5% levobupivacaine heavy+magnesium sulphate 50 mg+0.4 mL normal saline. The onset and duration of sensory and motor block and intraoperative hemodynamics were recorded. In the post-operative period, duration of analgesia, Visual Analog Scales scores, and side effects were observed. Results: The onset of sensory block was 4.04±0.74 min in Group LM (P&lt;0.001) as compared to Groups LF (2.01±0.23 min) and LS (2±0.24 min). The onset of motor blockade took 5±1.14 min in the control group, 7.01±0.94 in group LF, and 8.11±1.33 min in group LM (P&lt;0.001). The duration of analgesia in group LS was 183.73±12.08 min, 317±18.6 min in group LF, and 219.43±20.89 in group LM (P&lt;0.001). Conclusion: The addition of fentanyl and magnesium as adjuvants enhanced the quality of subarachnoid block when added to hyperbaric levobupivacaine. The duration of analgesia was longest in fentanyl, followed by magnesium and then control. The incidence of side effects was greatest in fentanyl, followed by control and nil in magnesium.

Effect of Abdominal Girth and Vertebral Column Length in Spread of Spinal Anesthesia for Lower Limb Surgery: A Prospective Study

Background: Subarachnoid spread of local anesthetics is quite erratic and is determined by several factors. There is a high predictive for the spread of spinal anaesthesia in terms of abdominal girth and vertebral column length. Our study is designed to determine the effect of abdominal girth and vertebral column length with cephalad spread of spinal anaesthesia for a given dose of 0.5% hyperbaric bupivacaine in Nepalese patients. Materials and Methods: In this prospective observational study, a total 100 patients of ASA PS I-II, aged16-65 years and undergoing lower extremity surgery under spinal anesthesia were enrolled. 2.8 mL of 0.5% hyperbaric bupivacaine was injected intrathecally at L3-4 interspace in sitting position. Extent of sensory blockade was assessed for 60 min. Simple linear regression, multiple linear regression and Pearson’s correlation coefficient analysis were performed to determine the correlation between patient variables viz abdominal girth, vertebral column length, height, weight, body mass index and age and maximum sensory block height. Results: Abdominal girth and vertebral column length correlated significantly with the maximal sensory block height after intrathecal administration of a fixed dose of 0.5% hyperbaric bupivacaine by all the three statistical tools used. Conclusion: Abdominal girth and vertebral column lengthcorrelate significantly with the maximal sensory block height in Nepalese patients receiving a fixed dose subarachnoid block with 0.5% hyperbaric bupivacaine

Role of Dexmedetomidine and Clonidine With Hyperbaric Ropivacaine in Subarachnoid Block: A Comprehensive Review.

Subarachnoid block (SAB), a fundamental technique in regional anesthesia, offers efficient anesthesia for various surgical procedures with advantages including rapid onset, reliable anesthesia, and reduced systemic effects compared to general anesthesia. Hyperbaric ropivacaine, a long-acting local anesthetic, has gained popularity due to its favorable pharmacokinetic profile and safety profile. However, to extend the duration and enhance the quality of anesthesia provided by hyperbaric ropivacaine, adjuvants such as dexmedetomidine and clonidine are frequently employed. This comprehensive review explores the roles of dexmedetomidine and clonidine as adjuvants to hyperbaric ropivacaine in SAB. It examines their pharmacological mechanisms, clinical efficacy, safety profiles, and comparative effectiveness in prolonging analgesia and enhancing anesthesia. The review synthesizes evidence from clinical studies to delineate the synergistic effects of these adjuvants, their impact on patient outcomes, and their potential advantages over traditional anesthesia techniques. Through a detailed analysis of current literature and clinical practices, this review aims to provide insights into optimizing the use of dexmedetomidine and clonidine in SAB protocols. It discusses clinical implications, offers recommendations for practice, and identifies future research directions to further enhance the efficacy and safety of SAB using these adjuvants.

Assessment of the Efficacy of Nalbuphine as an Adjuvant to Intrathecal Bupivacaine in Endoscopic Urological Surgeries for the Prolongation of Postoperative Analgesia.

Background In anaesthesiology, intrathecal drugs play pivotal roles in spinal anaesthesia. Despite their ability to induce a high sensory block, bupivacaine alone may not be adequate for postoperative analgesia. It often requires a substantial dose of postoperative rescue analgesia to manage pain effectively. Thus, we studied the efficacy of nalbuphine 1.5 mg injected intrathecally as an adjuvant in endoscopic urological surgery. Materials and methods Sixty patients undergoing endoscopic urological surgery were equally divided into two study groups: group B (injection 0.5% hyperbaric bupivacaine 15 mg (3 ml) plus sterile NS 0.15 ml) and group N (injection 0.5% hyperbaric bupivacaine 15 mg (3 ml)+nalbuphine 1.5 mg (0.15 ml)). The first appearance of the sensory and motor blockages and duration required to attain complete sensory and motor threshold was noted. All vitals were recorded. After surgery, it was recorded when the patient first needed rescue analgesia (injection paracetamol 1 gm IV). Any adverse effects were recorded and addressed. The statistical analysis was conducted using IBM SPSS Statistics for Windows, V. 22.0 (IBM Corp., Armonk, NY), with p<0.05 indicating significance in both groups' operations. Results Intrathecal nalbuphine as an adjuvant caused an earlier onset of sensory and motor inhibition, delayed two-segment regression, and prolonged postoperative anaesthesia. The control group experienced sensory block at 3.33±0.61 minutes, while the nalbuphine group had a mean onset of 2.66±0.92 minutes (p=0.001). The patient who received nalbuphine had a mean regression time of 119.60±14.549 minutes, whereas the bupivacaine group had a mean regression time of 88.43±17.196 minutes. Group N had a considerably longer duration of postoperative analgesia, lasting 264.97 minutes, compared to group B's 198.50 minutes (p<0.001). Intrathecal nalbuphine did not influence vital indicators such as heart rate, respiration rate, and oxygen saturation. Conclusion To conclude, endoscopic urological surgery patients who received a subarachnoid block with 1.5 mg (0.15 ml) of nalbuphine hydrochloride with 0.5% hyperbaric bupivacaine 15 mg (3 ml) had longer postoperative pain relief than those who received 3 ml of intrathecal bupivacaine (15 mg). Urinary retention and pruritus were absent. Intrathecal nalbuphine with hyperbaric 0.5% bupivacaine is deemed safe with minimal side effects in endoscopic urology surgery.