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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianournalofAnesthesiaandAnalgesia

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AimsandScope The Indian Journal of Anesthesia and Analgesia (IJAA) is ofcial peer-reviewed scientic journal addresses all aspectsofanesthesiapractice,includinganestheticadministration,pharmacokinetics,preoperativeandpostoperative considerations,coexistingdiseaseandothercomplicatingfactors,costissues,andsimilarconcernsanesthesiologists contendwithdaily.TheJournalseeksabalancebetweenoutstandingbasicscienticreportsanddenitiveclinicaland managementinvestigations.TheJournalwelcomesmanuscriptsreectingrigorousanalysis,evenifunusualinstyle andfocus. Readership:Anesthesiologists,CriticalCarePhysiciansandSurgeons.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 INDIANONAOFANESTESIAANDANAESIA

SeptemberOctober VolumeNumberPartI

Contents

OriginalResearchArticles

ToComparetheAntiemeticEfficacyDurationofActionandSideEffectsofPalonosetron OndansetronandranisetronforAntiemeticProphylaisofPostoperatieNauseaand VomitinginPatientsndergoingaparoscopicAbdominalSurgeries Aishwaryaandewar,ShwetaNaik,Manishokne StudyonranisetronOndansetronandPalonosetrontoPreentPostoperatieNauseaand VomitingafteraparoscopicSurgeries AppaRaoMekala,MekalaDheerajAnirudh,MekalaRoshanAbhinav ComparatieEaluationofNalbuphineandTramadolasanAduanttoBupiacaine inSupraclaicularBrachialPleusBlock haviniShah,GuneetChadha,Ashwinihamborkar,RakeshD,Shwetairajdar,ShreyankSolanki AComparatieStudybeteenopiacaineithClonidineandBupiacaineithClonidine inBrachialPleusBlocksinpperimb DPavanumar,VinayDandemmanavar,ASowmya AetrospectieStudyofPredictorsofMortalityinNInfluenaAssociatedDeathsina TertiaryCareospital Mohandeepaur,SeemaWasnik,DhirVinodbala,S.eerthana,JainSaumya,kaurarmanpreet, anojiaAkash,Nidhiumari FactorsConsideredbyFinalYearMBBSStudentsinSelectingAnesthesiaasaCareerChoice: AuestionnaireBasedStudy Lohitondikar,Vishwanath,ShrutiGhatapanadi,ShridharNEkbote,alarajuTC AssessmentofnoledgeandAttituteToardsaborAnalgesiaamongPregnantWoman inMNMedicalCollegeandospital PramodPundlikraohanapurkar,NenavathSudheerumarNaik EffectofMidaolamPremedicationonInductionDoseofPropofolinAdultPatientsin ElectieSurgery AherPranjali,SangaleSwapnilV,SubhedharRajesh,MurugrajShivkumar,SelvarajanN etamineasanAdunctithBupiacaineinSuidedParaertebralAnalgesiafor ModifiedadicalMastectomy RajeevPrajapat,OmPrakashSuthar,MLTak AnObserationalStudyofSmallDosePropofolandMidaolamasCoinductionAgents toPropofol Sandeephandelwal,NitinSharma EffectsofDemedetomidineInfusiononemodynamicStressesponseSedationand PostoperatieAnalgesiceuirementinPatientsndergoingaparoscopicCholecystectomy SaradaRojaMadhuri,illuhagyalakshmi,MalapoluNeeraja EffectienessofDemedetomidinetoeduceBleedingDuringTympanoplastyandFunctional EndoscopicSinusSurgeryFESS:AnInterentionalStudy SumaV,dayahaskar,RVRSantoshNaidu PerioperatieighSensitieCreactieProteinforPredictionofCardioascularEentsafter CoronaryArteryBypassraftingSurgeryineftVentricularDysfunctionPatients: AProspectieObserationalStudy arshilJoshi,Vijayaumara,GuruprasadRai,RajkamalVishnu AComparatieStudyofeobupiacaineithFentanylVersusopiacaine ithFentanylforContinuousEpiduralaborAnalgesia MahalakshmiAnnadurai,SaravananRavi,GayathriRamanathan,arthikMani

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1496 IndianJournalofAnesthesiaandAnalgesia

EfficacyofIntraenousParacetamolforAttenuatingemodynamicesponsetoaryngoscopy andIntubation:AProspectieandomiedStudy MonmyDeka,TridipJyotiorah,NilotpalDas AComparatieStudyontheEndotrachealTubeCuffPressureChangesbeteenSupineand ProneinPatientsndergoingPronePositionSurgeries AMurshidAhamed,Sureshumar,Salasubramanian,SuneethPLazarus,VidjaiVikramS, RajprasathRajprasath ComparisonofBolusDosesofBronchodilatorandAdrenergiconIntraoperatieypotensie EpisodesthroughoutCaesareanbeneathSpinalAnesthesia NeelamGupta,AkhileshMishra PreentionofPostoperatieNauseaandVomitinginaparoscopicCholecystectomy: AComparisonofMetoclopramideandOndansetron Preetveenaur,IbalSingh,GeetanjaliPushkarna,SaruSingh,Gaganjotaur,Jasleenaur StudyofClonidinesFentanylIntrathecallyithBupiacaineinVaginalysterectomy: AComparatieStudy GaneshLaxmanhandarkar,PradnyaMilindhalerao,RajashekarS oleofPerfusionIndeasaToolforAcutePostoperatiePainAssessment: AnObserationalStudy Sanjeevumar,Mumtazussain,JayPrakash,PremPrakash,Raghwendra ComparisonbeteenopiacaineandopiacainePlusTramodolinWoundInfiltration asanAnalgesicafterOpenCholecystectomySurgeriesforPostoperatieAnalgesia SaurinPanchal,VatsalCPatel,TarakModi ComparisonofocalInfiltrationithModifiedPectoralisBlockforPostoperatieAnalgesia afterModifiedadicalMastectomy:AnOpenabelandomiedTrial ShwetaMahajan,Sonaliaushal OutcomeofOralabapentininTotalAbdominalysterectomiesonPostoperatie EpiduralAnalgesia ThomasPGeorge,ironG,JoeJoseph SafetyandSuccessofltrasounduidedInterscaleneandCericalPleusBlockasaSole AnesthesiaMethodforAcromioclaicularointFiation:Aetrospectie ObserationalStudy SureshRajkumar,Variabu EaluationofTransdermalFentanylforPostoperatiePainelief VipinumarVarshney,arshasliwal,MMNeema EaluationinSupraclaicularBrachialPleusBlockbeteenDemedetomidineand deamethasoneasanAduanttoocalAnesthetic:ADoubleBlindProspectieStudy ThomasPGeorge,iranumarT,JoeJoseph uidelinesforAuthors

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1497-1504 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.1

To Compare the Antiemetic Efficacy Duration of Action and Side Effects of Palonosetron Ondansetron and ranisetron for Antiemetic ProphylaisofPostoperatieNauseaandVomitinginPatientsndergoing aparoscopicAbdominalSurgeries

AisharyaBandearShetaNaikManishokne

1AssistantProfessor,2SenoirResident,DepartmentofAnaesthesia,MGMMedicalCollege,amothe,NaviMumbai,Maharashtra 410209,India.AssistantProfessor,DepartmentofPharmacology,TMedicalCollege,Mumbai,Maharashtra400056,India.

Abstract

AimsandObjectives:Theaimofthestudywastocomparetheanti-emeticefficacy,durationofaction,and side effects of Palonosetron, Ondansetron, and Granisetron for anti-emetic prophylaxis of post-operative nauseaandvomiting.Methodology:Weconductedaprospective,randomized,doubleblindstudyonpatients undergoing laparoscopic abdominal surgeries. The total 120 patients were divided into three groups of 40patients.PatientsofgroupAweregiveninjectionpalonosetron(0.075mg),groupweregiveninjection ondansetron (4 mg), and group C were given injection granisetron (1 mg), intravenously along with premedication,fifteenminutespriortoinductionofgeneralanaesthesia.Weanalyzedtheanti-emeticefficacy, durationofaction,andsideeffectsofpalonosetron,ondansetron,andgranisetron.Results:Totalincidenceof nauseaandvomitingwasmaximuminondansetrongroupwithtotalof74comparedto6ingranisetronand 12inpalonosetrongroup,consideringoveralappingdatainalltimeintervalsandthisdifferencewasfoundto bestatisticallymajor.Inondansetrongroup18patientshadcompleteresponse,whilecompleteresponsewas higheringranisetrongroup(24)andhighestwith28patientsinpalonosetrongroupandthisdifferencewas statisticallysubstantial.(p0.05).eadacheandsedationwasfoundinondansetrongroupin2and4patients respectivelywhileonly1patienthadheadacheinpalonosetrongroup,7patientscomplainedofheadachein granisetrongroup.Conclusion:Weconcludethatpalonosetronismoreeffectiveincomparisontogranisetron andondansetroninthepreventionofPONVinpatientsundergoingelectiveabdominallaproscopicsurgeries. eyords:Ondansetron;Granisetronandpalonosetronanti-emeticprophylaxis.

otocitethisarticle: Aishwaryaandewar,ShwetaNaik,Manishokne.ToComparetheAnti-emeticEfficacy,DurationofAction,andSideEffects ofPalonosetron,Ondansetron,andGranisetronforAnti-emeticProphylaxisofPost-operativeNauseaandVomitinginPatients ndergoingLaparoscopicAbdominalSurgeries.IndianJAnesthAnalg.2019;6(5Part-1):1497-1504.

Introduction risk groups.1 Withthe adventand usageof lesser emetogenic anaesthesia techniues and discovery The incidence of PONV is 0–40 in a normal of newer anti-emetogenic drugs for the post- populationwithatopmostof75–80insomehigh- operative nausea and vomiting prophylaxis, the

CorrespondingAuthor:ShetaNaik,SenoirResident,DepartmentofAnaesthesia,MGMMedicalCollege,amothe,NaviMumbai, Maharashtra410209,India. Email:[email protected] eceiedon08.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1498 IndianJournalofAnesthesiaandAnalgesia prevalenceofPONVhasreducedsignicantlyby The total 120 patients were correspondingly about50. divided into three groups of 40 patients each Post-operativenauseaandvomitingisbydenition according toacomputer-generatedrandom table. termedasnauseaandvomitingwhichoccurswithin Thestudydrugpreparationwasdonebyanassistant 24 hours after surgery. Patients clinical status, the whowasuninformedofourstudyprotocolandit form of surgical procedure, length of anaesthesia was done inidentical2.5 mlvolumewithnormal and surgery are few of the vital risk factors in saline to ensure blinding ofthe anaesthesiologist. determiningofPONV.Itinvolvesthreenervesand ThesamewasadministeredIVbeforeinductionof seven neurotransmitters for activation of vomiting anaesthesia.Therandomizedprocesswasblinded centre,whichmakestheprophylaxisandtreatment from the patients, the anaesthesiologist, and the a tedious and complex process. Premedicating the investigators, who collected post-operative data. patientwithanti-emeticscanreducetherateofpost- Patients of either sex aged 18–55 years, ASA I–II operativenauseaandvomitingsignicantly.Various and posted for elective abdominal laparoscopic pharmacological agents, regimens, and practises surgeries were included in the study. Patients weredevelopedoveraperiodoftime,buttheyhave with prior history of post-operative nausea and restrictedefciencyduetonumeroussideeffects.2 vomiting, complains of motion sickness in the past or at present. istory of gastroeseophageal Five-hydroxytryptamine subtype (5-T) reux disease, systemic hypertension, endocrine receptor antagonist are considered as one of the or metabolic disorders, hepatic or renal disease, utmosteffectiveanti-emetogenicagentswithbetter cardio-pulmonary dysfunction, gastrointestinal safety and lesser side effects as they deprived disorders, psychiatric diseases, taken any of potential side effects of commonly used anti- anti-emetic 24 hours former to the surgery and emetogenicagentssuchassedation,dysphoriaand morbidly obese patients and pregnant females extra-pyramidaladverseeffects. wereexcluded. The present study was a randomized double- Thorough investigations include haemoglobin, blind, prospective study to compare the anti- completebloodcount,bleedingtime,clottingtime, emetic efcacy, duration of action, and side fastingbloodsugarlevel,chest-ray,urineroutine effects of intravenous palonosetron, ondansetron, and microscopic examination, serum creatinine, and granisetron for anti-emetic prophylaxis of liverfunctiontests. post-operative nausea and vomiting in patients undergoing elective laparoscopic abdominal Patients were randomly divided into three surgeriesundergeneralanaesthesia. groupsasdescribedbelow:

Group1 PatientsreceivingIVOndansetron(4mg) AimsandObjectives Group2 PatientsreceivingIVGranisetron(1mg) Group PatientsreceivingIVPalonosetron(0.075mg) To compare the anti-emetic efcacy, duration of Informed consent of the patients were taken. action,andsideeffectsofintravenous-palonosetron, All the patients were asked to fast overnight. All ondansetron, and granisetron for anti-emetic patientsweregivenananti-anxietymedicationin prophylaxisofpost-operativenauseaandvomiting theformoftabalprazolam0.25mgandanantacid in patients undergoing elective laparoscopic intheformoftabranitidine150mg,thenightprior abdominalsurgeriesundergeneralanaesthesia. to surgery and were kept fasting for si to eight hoursbefore thesurgery. On arrivalto operation- MaterialsandMethods theatre,routinemonitoringofheartrate,systemic

arterial blood pressure, pulse oximetry (SpO2), After approval by the Institutional Ethical electrocardiogram (ECG) was initiated. After Committee and taking written informed consent securing intravenous line, an infusion of Ringer from the patient, 120 adult patients of American lactate uid was started. Patients were given Society of Anesthesiologist physical status I and premedicationwithintravenousmidazolam(1mg), -1 II,agedbetween18and58yearsofeithergender, fentanyl (2 g g ), and glycopyrrolate (0.2 mg) postedforelectivelaparoscopicabdominalsurgery trailedbystudymedicationaccordingtoourgroup under general anaesthesia from Jan 2017 to June allocation, fteen minutes prior to induction of 2018 in a tertiary care hospital were enrolled for generalanaesthesia. current study. All the patients were undergo After pre-oxygenation, induction was done pre-anaestheticassessmentbeforeenrollment. withpropofol(2mgg-1),andtrachealintubation IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ToComparetheAnti-emeticEfficacy,DurationofAction,andSideEffectsofPalonosetron, 1499 Ondansetron,andGranisetronforAnti-emeticProphylaxisofPost-operativeNausea andVomitinginPatientsndergoingLaparoscopicAbdominalSurgeries was enabled with vecuronium bromide was metoclopramide 10 mg which was given 0.08 mgg-1. Anaesthesia was maintained with intravenousifreuired. isoflurane, N2O (60) in oxygen. All patients were ventilated mechanically to maintain an StatisticalAnalysis EtCO2between5and40mmg.Supplementary analgesiaduringthesurgerywasattainedwith All the collected data was entered in Microsoft fentanyl(25 g). Attheconclusion of surgery, ExcelsheetandthentransferredtoSPSSsoftware the residual neuromuscular blockade was ver.17foranalysis.ualitativedatawaspresented antagonizedwithsuitabledosesofneostigmine asfreuencyandpercentagesandanalyzedusing (0.05 mgg-1) and glycopyrrolate (0.01 mgg-1). chi-suaretest.uantitativedatawaspresentedas Extubation was accomplished when the meanandSDandcomparisonofvariablesinmore respirationwasadeuateandpatientwasableto than2groupswasdonebyANOVAtest.p-value obeysimplecommands. 0.05wastakenaslevelofsignicance. The reference line systemic arterial blood pressure,pulserate,andSpO2wererecordedasa esults baselineparameterfollowingpremedication,after inductionandthenatveminintervalstillonehour Allthethreegroupswerecomparableasfarasage, andthenatevery15mintilltheendofsurgery.They weightandNPO(nilperoral)statuswasconcerned. werewatchedforanyhypotension,hypertension, Thethreegroupswerealsocomparableforduration arrhythmias, hypoxemia, and bronchial spasm. of anaesthesia and surgery, pre-operative pulse emodynamic variations occurring during study period were managed with volume expansion, rate, systolic P and diastolic P wereconcerned vasopressororatropine,ifreuired. (p0.05)(shownasinTable). Post-operatively,nauseaoremeticepisodeswere In ondansetron group 16 patients complained documented by the resident doctors without the of nausea, 8 patients complained of nausea in information of which group of anti-emetic drug granisetron group and 5 patients of palonosetron wasgiventowhichofthepatients.Thesideeffects groupin0–4hours.14patientsgrievedfromnausea like headache, dizziness, and drowsiness were inondansetronand6patientsingranisetrongroup also noted. Post-operatively, patients were given sufferedwithnauseawithinsametimeframeand intravenous injection of paracetamol (1 gm) for 2 patients in palonosetron group suffered nausea analgesiapurpose. during4–8hour.11patientssufferedfromnausea inondansetronand5patientsingranisetrongroup Patientswereaskedaboutnauseaandvomiting sufferedwithnauseawithinsametimeframeand at 2 4 and 12 hours by direct uestioning of 0 patients in palonosetron group suffered nausea theanaesthesiologist,blindedtowhichtreatment during8–12hour.Therewasstatisticallysubstantial thepatienthasreceived.Completeresponsewas differenceinallthreegroups(shownasinTable). dened as no nausea, retching or vomiting and no need of rescue medication within 12 hours In ondansetron group, a total of 1 patients in the post-operative period. At the end of each complained of vomiting while 7 patients interval, an anaesthesiologist registered whether complainedofvomitingingranisetrongroupand vomiting had occurred and asked the patients 4 patients of palonosetron group in 0–4 hours. accordingly. Rescue medication in our study 11patientsgrievedfromvomitinginondansetron

Table:Generalcharacteristicsamongthethreegroups

eneralcharacteristics Ondansetron ranisetron Palonosetron alue Age .881.1 2.169.1 1.18.8 0.499 Weight 51.75.1 51.104.2 50.2.7 0.07 NPO 11.20.7 10.90.5 11.10.7 0.107 Durationofsurgery 59.1716.7 58.616.1 57.215.5 0.85 Durationofanaesthesia 9.520.2 92.619.9 91.518.8 0.92 PulseRate(min) 86.1.1 85.1.2 84.8. 0.16 SystolicP(mmg) 1145.6 115.4 1125.1 0.25 DiastolicP(mmg) 82.5.1 82.14.9 80.64. 0.22

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1500 IndianJournalofAnesthesiaandAnalgesia and6patientsingranisetrongroupsufferedwith inpalonosetrongroupandthisvariancewasfound vomiting within same time frame and 1 patients to be statistically substantial during 8–12 hour in palonosetron group suffered vomiting during shownasinTable. 4–8 hour. 9 patients suffered from vomiting In ondansetron group, total 18 patients had in ondansetron and 4 patients in granisetron complete response, while complete response was group suffered with vomiting within same time higher in granisetron group which were 24 and frame and 0 patients in palonosetron group highestwith28patientsinpalonosetrongroupand suffered vomiting during 8–12 hour. There was thisdifferencewasstatisticallynoteworthy(p-0.04) statisticallynoteworthyvarianceinallthreegroups showninTable,also(showninFig). (showninTable). eadacheandsedationwasfoundinondansetron Total incidence of nausea and vomiting was groupin2and4patientsrespectively.Whileonly maximum in ondansetron group with total 1 patient had headache in palonosetron group, of 29 compared to 15 in granisetron and 9 in 7 patients complained of headache in granisetron palonosetrongroupandthisdifferencewasfound group(showninFig. tobestatisticallymomentousduring0–4hour,total incidenceofnauseaandvomitingwasmaximumin There was very less alteration in number ondansetrongroupwithtotalof25comparedto12 of patients who needed rescue medication in ingranisetronandinpalonosetrongroupandthis all the three groups. Among three groups 7, 5 differencewasfoundtobestatisticallynoteworthy and 2 patients reuired rescue medication in during 4–8 hour, total incidence of nausea and ondansetron,granisetronandpalonosetrongroup vomiting was maximum in ondansetron group respectively. withtotalof20comparedto9ingranisetronand0

Table : Number of patients with post-operative nausea (PON) and post-operative vomiting in different groupsinstudypopulation.

Time Ondansetron ranisetron Palonosetron alue Post-perative 0–4hour 16(25) 8(20) 5(12.5) 0.04 nausea 4–8hour 14(15) 6(10) 2(10) 0.002 8–12hour 11(12.5) 5(5) 0(7.5) 0.001 Total 40(100) 40(100) 40(100) Post-operative 0–4hour 1(25) 7(20) 4(12.5) 0.0 vomiting 4–8hour 11(15) 6(10) 1(10) 0.007 8–12hour 9(12.5) 4(5) 0(7.5) 0.005 Total 40(100) 40(100) 40(100)

Table : Number of patients with total post-operative nausea and vomiting (TPNV) in different groups in studypopulation.

Time Ondansetron ranisetron Palonosetron alue 0–4hour 29(25) 15(20) 9(12.5) 0.001 4–8hour 25(15) 12(10) (10) 0.001 8–12hour 20(12.5) 9(5) 0(7.5) 0.001 Total 40(100) 40(100) 40(100)

Table:Numberofpatientswithcompleteresponse(CR)ie.,freefrombothnauseaandvomitingthroughout intra-operativeandpost-operativeperiod.

roups TNV C Total Ondansetron 22(55) 18(45) 40(100) Granisetron 16(41) 24(59) 40(100) Palonosetron 12(1) 28(69) 40(100)

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ToComparetheAnti-emeticEfficacy,DurationofAction,andSideEffectsofPalonosetron, 1501 Ondansetron,andGranisetronforAnti-emeticProphylaxisofPost-operativeNausea andVomitinginPatientsndergoingLaparoscopicAbdominalSurgeries

Fig:Numberofpatientswithcompleteresponse(CRie.,freefrombothnauseaandvomitingthroughout intra-operativeandpost-operativeperiod.

Fig:Sideeffectsexperiencedbynumberofpatientsindifferentgroups

Discussion antagonistsarehighlyspecicandselectiveforits actionagainstnauseaandvomitingbybindingto The aetiology of the PONV is intricate and theserotonin5-Treceptorinthechemoreceptor multifactorial. Pre-operative anxiety, positive trigger zone (CT) and at vagal efferent in the 6,7 pressure ventilation, inhalational anaesthetic gastrointestinaltracts. agents,andnitrousoxideincreasethejeopardyof In the current study, as per the demographic PONV. Anaesthetic agents initiate the vomiting dataobtainedthemeanageofstudypopulationin reex by stimulating the central 5-T receptors ondansetron group was .88 1.1, granisetron onthechemoreceptortriggerzone(CT).PONVis groupwas2.169.1andinpalonosetrongroup morecommoninyoungeragegroupandinobese was 1.1 8.8 and there was no noteworthy patients.,4Apfeletal2004consideredlaparoscopic variancebetweenallgroups.Obesityisusuallyseen surgery,femalegender,non-smokers,ahistoryof tobeassociatedwithincreasedincidenceofPONV. PONV,motionsickness,andpost-operativeopioid Inourstudythemeanweightwas5.75.1g,51.10 therapy as important independent causal factors 4.2g,49.2.7ginondansetron,granisetron 5 forPONV. and in palonosetron group and the episodes of Anti-emeticdrugsinclinetohavemorenoticeable PONV was non-pointedly higherin ondansetron, actionatoneortworeceptorswhile5-Treceptor granisetronascomparedtopalonosetron.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1502 IndianJournalofAnesthesiaandAnalgesia

TheoccurrenceofPONVmaybelinkedwithmany vomiting during 4–8 hour. 9 patients suffered featuresincluding:Ageandgender(femalegender from vomiting in ondansetron and 4 patients in andyoungeragethanadulthoodincreasetherisk granisetrongroupagonizedwithvomitingwithin ofPONV);previoushistoryofmotionsicknessor same time frame and 0 patients in palonosetron PONV;smokingstatus(smokingdecreasestherisk group grieved vomiting during 8–12 hour. There of PONV); post-operative opioid use; nature and was statistically noteworthy variance in all three length of surgery; anaesthesia and ambulation.8–10 groups. This ndings is in arrangement with the In the current study, the mean duration of study shown by Neha Sharma et al nausea was anesthesia and surgery were almost comparable detected in 18 patients, 10 patients, patients of withnosubstantialstatisticalvarianceinallthree ondansetron,granisetronandpalonosetrongroup groups. In the study, directed by Sukhminderjit respectively and this difference was statistically Singh ajwa et al 2011, the mean duration of substantial.11 Similarly in the study, directed by surgeryinondansetrongroupwas27.864.68and umkumGuptaetal2014,25patientsagonized in palonosetron group was 29.24 .88 and the fromvomitinginondansetrongroup,5patients meandurationofanaesthesiainondansetrongroup in palonosetron group within 0–4 hrs. There was 6.42 2.58 and in palonosetron group was was statistically momentous variance in all two 8.262.96.7Inthecurrentstudy,pre-operatively groups.12 Comparable ndings were observed the mean pulse rate, SP, DP in all the groups in the study led by Park et al 2011 in which showed no substantial alteration. This ndings is palonosetron was superior to ondansetron for in arrangement with the study directed by Neha controlofpost-operativenauseaandvomiting.1 Sharmaetaltherewasnosubstantialchangesin Inthecurrentstudy,totaloccurrenceofnausea systolicanddiastolicpressureamongthegroupsof andvomitingwasmaximuminondansetrongroup 11 studiedpatients. with total of 29 compared to 15 in granisetron In the current study, in ondansetron group, a and 9 in palonosetron group and this difference total of 16 patients grieved of nausea, 8 patients was found to be statistically noteworthy during complained of nausea in granisetron group and 0–2hour,totaloccurrenceofnauseaandvomiting 5 patients of palonosetron group in 0–4 hours. was extreme in ondansetron group with total 14 patients grieved from nausea in ondansetron of 25 compared to 12 in granisetron and in and6patientsingranisetrongroupagonisedwith palonosetrongroupandthisvariancewasfoundto nausea within same time frame and 2 patients bestatisticallymomentousduring4–8hour.Total in palonosetron group agonized nausea during occurrenceofnauseaandvomitingwasall-outin 4–8 hour. 11 patients grieved from nausea in ondansetron group with total of 20 compared to ondansetron and 5 patients in granisetron group 9ingranisetronand0inpalonosetrongroupand agonized with nausea within same time frame this transformation was found to be statistically and 0 patients in palonosetron group suffered importantduring8–12hour. nausea during 8–12 hour. There was statistically In the current study, in ondansetron group 18 noteworthy difference in all three groups. patients had complete response, while complete Thisndingsisincontractwiththestudyshown responsewashigheringranisetrongroup(24)and by Neha Sharma et al nausea was observed in highest with 28 patients in palonosetron group 18patients,10patients,patientsofondansetron, and this difference was statistically signicant. granisetron and palonosetron group respectively (p0.05).Thisndingsisinarrangementwiththe andthisdifferencewasstatisticallymomentous.11 studydirectedbyNehaSharmaetalpalonosetron Similarly in the study conducted by umkum was linked with greater patients gratication Guptaetal2014,0patientsgrievedfromnausea than granisetron and ondansetron 69, 59 inondansetrongroup,5patientsinpalonosetron and 45 of patients, respectively (p 0.02) and group within 0–4 hrs. There was statistically this modication was found to be statistically 12 substantialmodicationinalltwogroups. unimportant.11 Palonosteron was further more In the current study, in ondansetron group, effectiveatdroppingPONVratesthangranisetron a total of 1 patients complained of vomiting, and ondansetron. This could reect the high 7 patients complained of vomiting in granisetron receptor afnity of palonosetron for 5-T, with group and 4 patients of palonosetron group in a low afnity established for other receptors 0–4 hours. 11 patients grieved from vomiting in including5-T1A,5-T1D,5-T2Aand5-T2C, ondansetron and 6 patients in granisetron group andthelongerdurationofaction.14,15Palonosetron grieved with vomiting within same time frame was superior to ondansetron in reducing and 1 patients in palonosetron group agonized overallPONV.16 IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ToComparetheAnti-emeticEfficacy,DurationofAction,andSideEffectsofPalonosetron, 150 Ondansetron,andGranisetronforAnti-emeticProphylaxisofPost-operativeNausea andVomitinginPatientsndergoingLaparoscopicAbdominalSurgeries Inthecurrentstudy,headacheandsedationwas palonosetron were comparable in the prevention observedinondansetrongroupin2and4patients ofearlyPONV,butpalonosetronwasmuchmore respectively. While only 1 patient had headache operational in the prevention of delayed PONV in palonosetron group, 7 patients complained of accordingtoourstudy. headache in granisetron group. Likewise in the studydirectedbyParketal2011inwhichheadache eferences was observed in 8.9 and 6.7 while dizziness was present in 11.1 and 11.1 of ondansetron andpalonosetron group correspondingly (though 1. Islam S, Jain PN. Post-operative nausea and statisticallynotnoteworthy).1 vomiting (PONV): A review article. Indian J Anaesth2004;48:25–8. Inthecurrentstudy,therewasverylessvariance 2. Gan TJ, Meyer T, Apfel CC, et al Consensus in number of patients who reuired rescue guidelines for managing post-operative nausea medicationinallthethreegroups.Metoclopramide andvomiting.AnesthAnalg.200;97:62–71. wasusedasourrescuemedication.Itisaprokinetic . Pierre S, Como G, enais , Apfel CC. A risk drugthatstimulatesthemusclesofGITcounting score-dependentanti-emeticapproacheffectively muscles of lower esophageal sphincter, stomach, reduces post-operative nausea and vomiting: A and small intestine by networking withreceptors continuousualityimprovementinitiative.CanJ foracetylcholineanddopamineongastrointestinal Anesth.2004;51:20–25. muscles and nerves. It reduced the reux of 4. Leslie , MylesPS, ChanMT, et alRisk factors gastricacidbystrengtheningthemusclesoflower for severe post-operative nausea and vomiting esophageal sphincter. Amongst three groups 7, in a randomized trial of nitrous Oxide-based 5 and 2 patients needed rescue medication in vs. nitrous oxide-free anesthesia. r J Anaesth ondansetron,granisetron and palonosetron group 2008;101:498–505. individually.Thisndingsisincovenantwiththe 5. ApfelCC,orttila,AbdallaM,etalAfactorial studyshownbyNehaSharmaetalinwhichneed trial of six interventions for the prevention of for additional rescue anti-emetic medication was post-operative nausea and vomiting. N Engl J reuired in 1. of patients with palonosetron, Med.2004;50:2441–451. 0.0withgranisetronand46.7withondansetron 6. GrallaR,LichinisterM,VanDerVS.Palonosetron (p 0.02) in this study.11 Likewise in the study improves prevention of chemotherapy-induced shown by Park et al in which rescue medication nausea and vomiting following moderately in was used in 15.6 and 17.8 of palonosetron Emetogenic chemotherapy: Results of double- and ondensetron group correspondingly though blindrandomizedPhaseIIItrialcomparingsingle doses of palanosetron with ondansetron. Ann statisticallynotimportant.1 Oncol.200;14:1570–577. oth palonosetron and granisetron are 5-T 7. ajwaSS,ajwaS,aurJ,etalPalonosetron:A antagonists;however,palonosetronhasasuperior novelapproachtocontrolpost-operativenausea bindingafnityandalengthierbiologicalhalf-life andvomitingindaycaresurgery.SaudiJAnaesth. whenmatchedtoolder5-Tantagonistssuchas 2011;5:19–24. granisetron and interrelateswith 5-T receptors 8. Watcha MF. Post-operative nausea and emesis: inanallosteric,positivelyco-operativemanner at AnesthClinNorthAmerica.2002;20():471–84. othersites,leadingtolong-lastingeffectsonreceptor 9. Sinclair DR, Chung F, Mezei G. Can post- 17,18 ligand binding and functional responses. This operative nausea and vomiting be predicted could be the reason for the improved control of Anesthesiology.1999;91:109 lateonsetPONV(nausea2–48h,p0.07)inthe 10. oivuranta M, Lr E, Snre L, Alahuhta S. A palonosetron group compared to the granisetron survey of postoperative nausea and vomiting. groupeventhoughthendingsofthetwodrugs Anaesthesia.1997;52:44–49. werealmostanalogousinearlyonsetPONV. 11. Sharma N, hargava M, Chaudhary V, et al Comparison of anti-emetic efficacy of Conclusion palonosetron, ondansetron and granisetron in prevention of post-operative nausea and vomiting.IntSurgJ.2015;2:549–55. Palonosetron is more effective in comparison to 12. Gupta,SinghI,GuptaP,etalPalonosetron, granisetron andondansetroninthepreventionof Ondansetron, and Granisetron for anti-emetic post-operative nausea and vomiting in patients prophylaxis of post-operative nausea and undergoing elective abdominal laproscopic vomiting: A comparative evaluation. Anesth surgeries. Ondansetron, granisetron and EssaysRes.2014;8:197–201.

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1. ParkS,ChoEJ.Arandomized,double-blindtrial 16. Tramer MR, Reynolds DJ, Moore RA. Efficacy, of palonosetron compared with ondansetron in dose-response, and safety of ondansetron preventing post-operative nausea and vomiting in prevention of post–operative nausea and after gynaecological laparoscopic surgery. J Int vomiting: A uantitative systematic review MedRes.2011;9:99–407. of randomized placebo-controlled trials. 14. Wong E, Clark R, Leung E. The interaction of Anesthesiology.1997;87:1277–289. RS25259–197,apotentandselectiveantagonist, 17. Aapro MS. Palonosetron as an anti-emetic and with 5-T receptors, in vitro. r J Pharmacol. anti-nausea agent in oncology. Ther Clin Risk 1995;114:851–59. Manag.2007;:1009–1020. 15. NewberryNR,WatkinsCJ,SprosenTS.RL46470 18. RojasC,StathisM,ThomasAG,etalPalonosetron potently antagonizes neural responses activated exhibits uniue molecular interactions with the by 5-T receptors. Neuropharmacology. 5-Treceptor.AnesthAnalg.2008;107:469–78. 199;2:729–5.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1505-1510 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.2

Study on ranisetron Ondansetron and Palonosetron to Preent PostoperatieNauseaandVomitingafteraparoscopicSurgeries

AppaaoMekalaMekalaDheeraAnirudhMekalaoshanAbhina

1AssistantProfessor,2FinalearMS,DepartmentofAnaesthesiology,GandhiMedicalCollege,Secunderabad.Telangana50000, India.FinalearMS,ouseSurgeon,OsmaniaMedicalCollege,oti,yderabad,500095,India.

Abstract

ntroduction: Post-operative nausea and vomiting (POVN) is a common condition and causes much discomforttothepatient.Itisnotonlyunpleasantbutalsocanhaveseriousconseuenceslikethatofgastric contentaspiration,ruptureofesophagus,openingupofwounds,subcutaneousemphysema,orpneumothorax. Aimofthetudy:Tocomparetheanti-emeticeffectsofintravenousgranisetron,ondansetronandpalonosetron forprophylaxisofpost-operativenauseaandvomitingafterlaparoscopicsurgeriesundergeneralanesthesia. MaterialsandMethods:Thiswasaprospective, randomized,double-blinded,comparativestudy. Atotalof 75patientsweredividedrandomlyintothreegroupseachhaving25subjects.Group-Areceivedondansetron 8mg,Group-receivedGranisetron2.5mgandGroup-CreceivedPalonosetron0.75ug.othmaleandfemale patients,ASAI–IIwithagerangingfrom18–65 yearsandwhounderwentelectivelaparoscopicsurgeries undergeneralanesthesiawereselected.Theincidenceofpost-operative;nausea,retchingandvomitingwere studied.ObservationsandResults:Age,genderandweightwereinsignificantinalltheGroups.Groups-A/C wasfoundtobestatisticallysignificant(p0.05)in24–48andalso12–24hours.Retchingwassignificantly lessinGroup-Cwhencomparedtoothertwogroups.IncidenceofvomitingwassignificantlylessinGroup-C when compared to Group-A and . The p-value between Group–A and C was found to be statistically significant (p 0.05) in 24–48 hours. Conclusion:Prophylactictherapy withpalonosetron is more effective than prophylactictherapywithondansetron and granisetron for thelong-termprevention of PONVafter laparoscopicsurgery. eyords:Granisetron;Ondansetron;Palonosetron;PONV;Laparoscopicsurgeries.

otocitethisarticle: AppaRaoMekala,MekalaDheerajAnirudh,MekalaRoshanAbhinav.StudyonGranisetron,OndansetronandPalonosetron toPreventPost-operativeNauseaandVomitingafterLaparoscopicSurgeries.IndianJAnesthAnalg.2019;6(5Part-1):1505-1510.

Introduction nausea, retching and vomiting individually or in combination are identied as sickness and Pain and vomiting/emesis are common after each symptom is considered a separate entity. anesthesia and surgery. They cause anxiety Post-operative nausea and vomiting (PONV) has and distress to the patients. Post-operative been characterized as big little problem and is

CorrespondingAuthor:MekalaDheeraAnirudh,FinalearMS,OsmaniaMedicalCollege,oti,yderabad,500095,India. Email:[email protected] eceiedon08.05.2019,Acceptedon08.06.2019

RedFlowerPublicationPvt.Ltd. 1506 IndianJournalofAnesthesiaandAnalgesia a freuent complication for both inpatients and the patients werepostedforelectivelaparoscopic outpatients undergoing virtually all types of surgeries under general anesthesia and were surgicalprocedures.Earlier,intheEtherErathe randomly allotted to the groups, each containing incidenceofPONVwashighandwasabout75to twenty-vepatients. 80.Inthepresentscenario,itiscomparativelyless andisabout22to0inadultpatients. clusionCriteria According totheliterature,incidenceofPONV Patients with known gastrointestinal disease, ranges from 25 to 55 in inpatients who have smokers,patientswithhistoryofmotionsickness, undergonesurgeryand8to47inoutpatients.1 post-operative nausea and vomiting, pregnant Itwasobservedthat patientsareconcernedmore womenandmenstruatingwomenwereexcluded. about post-operative nausea and vomiting which Also thosewhohadtakenanti-emetic medication canbeuitedistressing.PONVwhensevereand/or withinpast24hourswereexcluded. prolonged,canleadtowounddehiscence,bleeding sing computer generated randomization from operative sites, venous hypertension, tears techniue these patients were divided into three orruptureintheesophagus,ifsevereitmaycause groups each containing 25 individuals. Group-A fractureintheribs,herniationofstomachandalso received ondansetron 8 mg, Group- received muscular fatigue. Persistent PONV is especially Granisetron 2.5 mg and Group-C received dangerous in post-operative neurosurgical cases Palonosetron 0.75 ug along with premedication, where it can lead to raised intracranial pressure immediately before induction of general and also predispose to pulmonary aspiration. anesthesia.Normalsalinewasaddedtobringthe In the paediatric population, persistent vomiting totalinjectablevolumeto2.5mlineachgroup.Two cancausedetrimentaldehydrationandelectrolyte theatre assistants were used for group allotment imbalance.2 of the patients and to prepare the study drugs. AddressingthecomplicationsofPONVresultsin owever,bothwereunawareofthestudyprotocol increasedcosttothepatient,longerrecoverytime, andwereuninvolvedinanyfurtherevaluationof extended bed occupancy in the hospital, added thepatients. attention and time constraints for the nurses and Allpatientswerekeptnilorallyaftermidnight. physicians and also inconvenience to the family In the operation room, routine monitoring (ECG, as a whole. Patients undergoing laparoscopic pulseoximetry,NIP)wereattachedandbaseline surgeries are more likely to encounter PONV. vitalparameterslikeheartrate(R),bloodpressure In laparascopic surgeries due to the presence of (systolic, diastolic and mean) and arterial oxygen pneumo-peritoneum, the mechano receptors in saturation(SpO )werenoted.Anintravenousline thegutarestimulatedmuchmore,therebyleading 2 was secured. Allpatients were premediated with toPONV. inj.Glycopyrrolate0.2mg,inj.Midazolam0.0mg The commonly used anti-emetic drugs like g,inj.Tramadol2mggintravenously. anti-histaminic, anti-cholinergics and dopamine Afterpre-oxygenationforminutes,inductionof receptorantagonistshaveclinicallysignicantside anesthesiawasdonewith inj.Thiopental5mgg. effects, such as sedation, dry mouth, dysphoria Patientswereintubatedwithinj.Succinyl choline and extra pyramidal symptoms. 5T receptor 2 mgg with appropriate size endotracheal tube. antagonists are potent anti- emetics. The present Anesthesiawasmaintainedwithoxygen,nitrous study was done to compare anti-emetic effects oxide67.Musclerelaxationwasmaintainedwith of intravenously administered granisetron, inj.Vecuroniumbromideandsupplementedwith ondansetron and palonosetron for prophylactic Isourane. Mechanical ventilation was used to PONV in patients undergoing laparoscopic keep EtCO2 between 2–5 mm g. The stomach surgeriesundergeneralanesthesia. contents were emptied by a nasogastric tube. For the laparoscopic procedure, the peritoneal MaterialsandMethods cavity was insufated with carbondioxide. Intra- abdominalpressurewaskept14mmg.Atthe This was a prospective, randomized, double- endofsurgicalprocedure,residualneuromuscular blinded, comparative study approved by the blockwas adeuatelyreversed using intravenous institution ethical committee. Informed consent glycopyrrolate 1 ugg and neostigmine 0.05 mg was obtained from all the patients. The study gand then extubation wasdone. eforetracheal group consisted of 75 ASA I–II male and female extubation, post-operative analgesia, injection patientswithagerangingfrom18to5years.All diclofenacsodium-75mgintramuscularwasgiven IJAA/Volume6Number5(Part-I)/Sep-Oct2019 StudyonGranisetron,OndansetronandPalonosetrontoPrevent 1507 Post-operativeNauseaandVomitingafterLaparoscopicSurgeries whenpainscorewas4VisualAnalogScore(VAS). Theincidenceofnauseawassignicantlylessin Residentdoctorswhowereunawareofthestudy Group-CascomparedtoGroup-AandGroup-. drug observed all the patients post-operatively and noted the ndings. Patients were transferred Table:Correlationofnauseainthreegroupsinfirst48hours to post-anesthesia care unit and vitals were roup Interalalue alue monitored.AllepisodesofPONV(nausea,retching A/C 0–hrs 0.60 andvomiting)wererecordedatintervalsof6,12,24 –12hrs 0.60 and48hoursinpost-operativeward. 12–24hrs 0.04* Nauseawasdenedasanunpleasantsensation 24–48hrs 0.02* with an urge to vomit. Retching was dened as A/B 0–hrs 0.60 the labored, spastic, rhythmic contraction of the –12hrs 1.00 12–24hrs 0.49 respiratory muscles without the actual emesis. 24–48hrs 0.23 Completeresponse(freefromemesis)wasdened B/C 0hrs 1.0 asnoPONVandnoneedforanyrescuemedication. –12hrs 1.0 Injection metoclopramide 10 mg IV was given as 12–24hrs 0.34 rescuemedicationiftheyvomitedmorethantwice. 24–48hrs 0.46 Attheendofeachtimeintervalitwasrecorded,if The p – value between Groups-A and C was thepatienthadvomitingoranysensationofnausea found to be statistically signicant (p 0.05) in orretching. 24–48hoursandalso12–24hours.Thep-valuewas Theresultwasscoredasnausea-1,retching-2,and statisticallyinsignicant(p0.05)inallothercases. vomiting-andstatisticalanalysiswasperformed with the SPSS 17.0 for Windows Software. The Table:Incidenceofretchingamongthethreegroupsinfirst normally distributed data were compared using 48hours Students ttest. For comparison of skewed data, roup 0hrs 2hrs 22hrs 2hrs Mann-Whitney u-test was applied. ualitative or A 1 2 5 categoricalvariablesweredescribedasfreuencies 0 1 2 and compared with Chi-suare or Fishers exact C 0 1 1 2 test whichever was applicable. p values were corrected by the onferroni method and p 0.05 Table:Correlationofretchingamongthethreegroupsinfirst wasconsideredstatisticallysignicant. 48hours roup Interal alue esults A/C 0–hrs 1.0 –12hrs 1.0 12–24hrs 0.60 A total of 75 ASA grade I–II male and female 24–48hrs 0.42 patients,aged18–5yearswerestudiedforPONV A/B 0–hrs 1.0 following elective laparoscopic surgeries under –12hrs 1.0 generalanesthesia,(TablesandFig). 12–24hrs 1.0 24–48hrs 0.70 B/C 0–hrs 1.0 Table:Demographicdatainstudy –12hrs 1.0 roup Ageinyears Weight Female Male 12–24hrs 1.0 A 28.729.91 51.25.5 18 7 24–48hrs 1.0 0.512.8 50.645.9 17 8 The incidence of retching was signicantly C 0.18.99 50.65.28 18 7 less in Group-C as compared to Group-A and All the groups are similar with regard to age, Group-.Thep-valuesamongallthegroupswere weightandgender. statisticallyinsignicant(p0.05).

Table:Incidenceofnauseaamongthethreegroupsinfirst48 Table:Incidenceofvomitingamongthethreegroupsinfirst hours 48hours

roup 0hrs 2hrs 22hrs 2hrs roup 0hrs 2hrs 22hrs 2hrs A 7 11 A 2 5 11 1 2 4 6 1 2 5 6 C 1 1 1 C 0 1 2

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1508 IndianJournalofAnesthesiaandAnalgesia

Fig:Incidenceofnausea,retchingandvomitinginthethreegroups (Pl.useNdashinrsRange)

Table:Correlationofvomitingamongthethreegroupsinfirst freuently listed among the most important pre- 48hours operativeconcernsapartfrompain.Withchanging roup Interal alue trendsofincreasedoutpatientofcebasedmedical/ A/C 0–hrs 0.4 surgical environment, more emphasis is focused –12hrs 0.60 onthethebiglittleproblemofPONVfollowing 12–24hrs 0.412 generalanesthesia. 24–48hrs 0.02* In spite of much advancement in the A/B 0–hrs 1.0 managementofPONVwiththeinventionofnew –12hrs 1.0 drugs, multimodal approaches of management 12–24hrs 1.0 like administering multimodal approaches of 24–48hrs 0.13 managementlikeadministeringmultipledifferent B/C 0–hrs 1.0 anti-emeticmedications,lessemetogenic-anesthetic –12hrs 1.0 techniues, adeuate intravenous hydration, 12–24hrs 0.417 adeuate pain control etc., the incidence of post- 24–48hrs 0.70 operativenauseaandvomitingremainsstillhigh, rangingfrom25–55followinginpatientsurgery Incidence of vomiting was signicantly less in and8–47followingoutpatientsurgery.4 Group-CwhencomparedtoGroupAand.The An effective anti-emetic that could be used to p-valuebetweenGroup-AandCwasstatistically treat nausea and vomiting without extending signicant(p0.05)in24–48hours.Thep-value recoverytimeandthatremaineffectivefor48hours wasnotstatisticallysignicant(p0.05)inallother following treatment would be signicant asset to cases. the anesthesiologists armamentarium, especially Incidence was less in group C (Palonosetron) in settings like ofce based anesthesia where the whencomparedtogroupAand. patients is admitted for day care surgery and is discharged on the same day. Drugs acting for longerdurationalsohaveanadvantageinsurgeries Discussion wheretheincidenceofpost-operativenauseaand vomiting is very high like laparoscopic surgery, Nauseaandvomitingfollowinggeneralanesthesia middle ear surgery, tonsillectomy, laparotomy, areadistressingproblemforthepatientsandare strabismussurgery,orchidopexy,etc.4,5

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 StudyonGranisetron,OndansetronandPalonosetrontoPrevent 1509 Post-operativeNauseaandVomitingafterLaparoscopicSurgeries

nfortunately, commonly used anti-emetic half-life than older 5-T receptor antagonists. medications like antihistamines, anticholinergics, The proposed mechanism of palonosetronis that gastroprokinetic, butyrophenones cause itfunctions via theareapostrema whichcontains undesirable side effects like sedation, dysphoria, many 5-T receptors. Therefore, granisetron and restlessness and extrapyramidal symptoms. palonosetron may have similar mechanisms to To overcome this later serotonin antagonists like exertanti-emeticeffectinpreventingPONV.7 ondansetron, tropisetron, dolasetron, granisetron Forchemotherapyrelatednauseaandvomiting and palonosetron were introduced for treatment theeffectivedoseofgranisetronis40–80ug.Adose of nausea and vomiting. They were primarily of granisetron 2.5 mg (approximately 45 ug/g) used in treating chemotherapy induced vomiting wasusedinthisstudyastheeffectivedoserange withminimalandclinicallyacceptablesideeffects. is (40–80). owever, the dose of palnonosetron Themostdistressingandintolerableemesisinduced forthepreventionofPONVisnotestablishedbut by anti-malignant medication is better controlled was extrapolated from the dose used in clinical withthese5Tantagonistsandtheyprovedtohave trials.ovacLAandcolleaguesdemonstratedthat apromisingroleintheeldofoncology.Abundant palonosetron75ugisthemoreeffectivedoseforthe research inoncology demonstrates the efcacy of preventionofPONVaftermajorgynecologicaland these drugs. owever, there were many reports laparoscopicsurgerythan25ugand50ug. in the literature about their role in prevention of post-operativenauseaandvomiting. In our study, we compared the anti-emetic efciency of ondansetron, granisetron and Post-operative period has variable incidence palonosetron post-operatively for laparoscopic of nausea and vomiting. PONV depends on the surgeriesinrst48hours.Ourstudydemonstrates duration ofsurgery, thetypeofanesthetic agents that in the rst 12 hours anti-emetic efciency of used (dose, inhalational drugs, opioids), smoking all three drugs (ondansetron, granisetron and habits,etc.Vomitingreexesareinitiatedby5-T palonosetron) is similar and the difference is receptor stimulation. The vagus nerve terminals statisticallynotsignicant. bear these receptors and they are also present centrallyonthechemoreceptortriggerzone(CT) Palonosetronismoreeffectivethanondansetron oftheareapostrema.Anestheticagentsinitiatethe and granisetron for getting complete response vomiting reex as they stimulatethe central5T (no PONV, no rescue medication reuired) for receptors on the CT. These agents also release 24–48hoursandthep-value0.05)isstatistically serotonin from the enterochromafn cells of the signicantbetweenondansetronandpalonosetron small intestine and cause stimulation of 5-T groupsin24to48hours receptorsonafferentbersofvagusnerve.6 This suggests that palonosetron has longer The incidence of PONV after laparoscopic lasting anti-emetic effect as compared to the surgery is high (40–75). The etiology of PONV other two drugs. The variable effectiveness of after laparoscopic surgery is complex and is these drugs could be related to their half-lives dependent on patient age, body weight, history (ondansetron–4hours,granistron8–hours,versus ofpreviousPONV,thetypeofsurgicalprocedure palonosetron40hours.)Itcouldalsobeduetothe and techniue of administration of anesthesia. In binding afnities of 5-T receptor antagonists as the present study, however, all the groups were palonosetron interacts with 5-T receptors in an comparablewithrespecttopatientdemographics, allosteric, positive manner at sites different from anesthesia and analgesics used post-operatively. thoseofondansetronandgranisetron. Therefore,thedifferenceinacompleteresponse(on hattacharya et al8reported that granisetron is PONV,norescuemedication)betweenthegroups superiortoondansetronforpreventionofPONV. canbeattributedtothestudydrug. TheyobservedthatincidenceofPONVwaslesswith Emesisrelatedtocancerchemotherapyresponds granisetronwhencomparedtoondansetronwithin well to Granisetron. The exact mechanism of rsthourspost-operativelyinpatientsundergoing action ofgranisetronis unclear, butitis proposed daycaregynecologicallaparoscopy.Thesendings that granisertron may act on sites containing areinagreementwithourstudywhereincidenceof 5-T receptors with demonstrated anti-emetic PONVwaslesswithondansetronandgranisetron effects. Palonosetron is a uniue 5-T receptor inrsthours. antagonist and is widely used for the prevention hattacharjeeetal5reportedthattheincidenceof of chemotherapy related nausea and vomiting. It PONVwaslesswithpalonosetronwhencompared hasagreaterbindingafnityandlongerbiological with granisetron within 24–48 hours in patients

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1510 IndianJournalofAnesthesiaandAnalgesia undergoing laparoscopic cholecystectomy. These of post-operative nausea and vomiting. Can J ndingsaresimilartoourobservations. Anesth.2000;47:1008–18. Mehta et al9 compared ondansetron and 2. Wang SM, ain N. Pre-operative anxiety granisetron for prevention of PONV following and post-operative nausea and vomiting in children: Is there an association Anesth Analg. electivecaesareansectionandconcludedthatboththe 2000;90:571–75. drugshadsignicantlyreducedPONV.Ourstudy correlateswellwiththeirstudyinearlyprevention . o,GanTJ.Pharmacology,pharmacogenetics, and clinical efficacy of 5-hydroxytryptamine ofPONVwithondansetronandgranisetron. type receptor antagonists for post-operative Tahir et al10 did study on palonosetron in the nausea and vomiting. Curr Opin Anesthesiol. preventionandtreatmentofPONVandfoundthat 2006;19:606–11. palonosetron is effective in preventing delayed 4. SwailkaS,PalA,ChaterjeeS,etalOndansetron, periodofPONVupto24–72hours.Ourstudyconcurs Ramosetron, or Palonosetron: Which is a better withtheirstudyinthepreventionoflateperiodof choice of anti-emetic to prevent post-operative PONV(24–48hours)withpalonosetron. nausea and vomiting in patients undergoing laparoscopiccholecystectomyAnestEssaysRes. 11 Sarbarietal studiedtheefcacyofRamosetron, 2011;182–6. PalonosetronandOndansetronforpreventingpost 5. hattacharjee DP, Dawn S, Nayak S, et al A operativenauseaandvomitinginfemalepatients comparative study between palonosetron and undergoing laparoscopic cholecystectomy, the granisetrontopreventpost-operativenauseaand incidenceofpost-operativenauseaandvomitingwas vomiting after laparoscopic cholecystectomy. J 4.5,62.1and65.5respectively,representing AnaesthClinPharmacol.2010;26:480–8. asignicantoveralldifference(p0.04)aswellas 6. Gan TJ. Selective serotonin 5-T receptor betweenRamosetronandOndansetron(p0.05). antagonists for post-operative nausea and Ramosetronwaslabeledtobeabetterprophylactic vomiting: Are they all the same CNS Drugs. anti-emetic than Palonosetron or Ondansetron in 2005;19:225–8. femalepatientsundergeneralanesthesia. 7. asuA,SahaD,embromP,etalComparison We did not include a control group receiving of palonosetron, granisetron and ondansetron as anti-emetics for prevention of post-operative placebo in our study. Aspinall and Goodman12 nausea and vomiting in patients undergoing have suggested that if active drugs are available middle ear surgery. J Indian Med Assoc. thenplacebocontrolledtrialsshouldnotbedoneas 2011;109:27–29. itwouldbeunethical becausePONVcausemuch 8. hattacharya D, anerjee A. Comparison of anxietyanddistresstothepatients. ondansetron and granisetron for prevention of nausea and vomiting following day care Conclusion gynaecological laparoscopy. Indian J Anaesth. 200;47:279–82. We conclude that anti-emetic prophylaxis with 9. MehtaP,VaghelaA,Soni,etalAComparative 5-hydroxytryptaminesubtype(5-T)antagonists StudyEfficacyofOndansetronversusGranisetron provides clinically effective prevention of post- to Prevent Peri-operative Nausea and Vomiting among Patients undergoing Gynecological operative nausea and vomiting. These drugs have Surgery under Spinal Anesthesia in a Tertiary statistically signicant difference in their efcacy CareospitalofWesternIndia:NationalJournal and duration of action. Palonosetron is a better ofMedicalResearch.2018:8(2):54–57. drug for anti-emetic prophylaxis of PONV in 10. Tahir S, Mir AA, ameed A. Comparison of patients undergoing laparoscopic surgery under PalonosetronwithGranisetronforPreventionof generalanesthesiaascomparedtoondansetronand Post-operativeNauseaandVomitinginPatients granisetronasithasprolongeddurationandminimal ndergoing Laparoscopic Abdominal Surgery. sideeffects.Prophylactictherapywithpalonosetron AnesthessaysRes.2018;12():66–4. is more effective than prophylactic therapy with 11. Sadhasivam S, Saxena A, athirvel S, et al The ondansetron and granisetron for the long-term safety and efficacy of prophylactic ondansetron preventionofPONVafterlaparoscopicsurgery. in patients undergoing modified radical mastectomy.AnesthAnalg.1999;89:140–57. eferences 12. Aspinall RL, Goodman NW. Denial of effective treatmentandpoorualityofclinicalinformation in placebo controlled trials of ondansetron for 1. Loewen PS, Marra CA, ed PJ. 5-T receptor post-operativenauseaandvomiting.Areviewof antagonistvstraditionalagentsfortheprophylaxis publishedtrials.MJ.1995;11:844–46.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1511-1516 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.

ComparatieEaluationofNalbuphineandTramadolasanAduantto BupiacaineinSupraclaicularBrachialPleusBlock

Bhaini Shah uneet Chadha Ashini hamborkar akesh D Sheta Biradar ShreyankSolanki

1AssociateProfessor,2AssistantProfessor,rdyearPGResident,42ndyearPGResident,52ndyearPGResident,6rdyearPGResident. Department of Anaesthesiology, Dr. D.. Patil Medical College, ospital and Research Centre, Pimpri, Pune. Dr. D.. Patil Vidyapeeth,Pune,Maharashtra411018,India.

Abstract

acground: rachial plexus block is a reliable, regional anesthetic techniue for upper arm surgeries. Opioidagonist-antagonistsareusedasadjuvanttoenhancetheanalgesiaofbupivacaine.Thepresentstudy wasaimedtocomparetheanalgesicefficacyandsafetyofnalbuphineandtramadolasanadjuvantto0.5 bupivacaineforbrachialplexusblock.MaterialsandMethods:ThirtyadultpatientsofASAIandIIofboth genderswererandomizedintotwoGroupsoffifteenpatients,GroupTreceive28mlof0.5bupivacaine with2mloftramadolandGroupNreceive28mlof0.5bupivacainewith2mlofnalbuphine20mgfor supraclavicularbrachialplexusblock.Patientswereobservedforonsetanddurationofsensoryandmotor blockwithdurationofpainreliefasprimaryendpointswhileoccurrenceofanyadverseeffectduetotechniue ornalbuphinewasnotedassecondaryoutcome. Results:InGroupN,therewasastatisticallysignificant shortertimetoonsetofsensoryblockade(10.461.5minvs1.662.5min,p0.001),shorteronsettimeto achievemotorblock(14.42.5minvs.18.46.5min,p0.001),longerdurationofmotorblock(291.4minvs 6.07min,p0.001),andprolongedanalgesia(456minvs409.1min,p0.00).Nosignificantsideeffects wereseeninanyofthegroups.Conclusion:Additionofnalbuphineto0.5bupivacaineinsupraclavicular brachialplexusblocksignificantlyhastenstheonset,andprolongsthedurationofsensorimotorblockadeand analgesiawhencomparedwithtramadolasanadditive.oththedrugswerecomparableintermsofsafety. eyords:rachialplexusblock;upivacaine;Nalbuphine;Tramadol;Additive.

otocitethisarticle: haviniShah,GuneetChadha,Ashwinihamborkar.ComparativeEvaluationofNalbuphineandTramadolasanAdjuvantto 0.5upivacaineinSupraclavicularrachialPlexuslock.IndianJAnesthAnalg.2019;6(5Part-1):1511-1516.

Introduction oflaryngoscopy.Thepost-operativeperiodisalso freefrom pain, nausea, vomiting, andrespiratory depression.Thesupraclavicularapproachischosen Thesupraclavicularblockisoftencalledthespinal forbrachialplexusblockashereitisenclosedina anesthesia of the upper extremity because of its fascialsheaththatextendsfromnecktotheaxilla.1 ubiuitousapplicationforupperextremitysurgery. Thesuccessofbrachialplexusblockreliesonnerve It is a reliable, alternative to general anesthesia localization, needle placement, and deposition of for certain group of patients as it is devoid of localanestheticsolutionatrightplacebyasingle undesired effects of generalanesthesia and stress injection of local anesthetic.1 Nerve stimulatorare

Corresponding Author: Ashini hamborkar, rd year PG Resident, Department of Anaesthesiology, Dr. D.. Patil Medical College,ospitalandResearchCentre,Pimpri,Pune.Dr.D..PatilVidyapeeth,Pune,Maharashtra411018,India. Email:[email protected] eceiedon1.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1512 IndianJournalofAnesthesiaandAnalgesia better than blind techniue as they not only tramadolversusnalbuphineasanadjuvantto0.5 increase the accuracy but also prevent several bupivacaine for supraclavicular brachial plexus complicationthatmayariseduetoblindtechniue. block.Theprimaryaimofthisstudywastocompare It also minimizes the local anesthetic volume, tramadolversusnalbuphineasanadjuvantto0.5 thereby reducing the incidences of their systemic bupivacaine in supraclavicular brachial plexus toxicity.2,upivacainerelievespainbyblockingthe blocksintermsofonsetofblock,durationofsensory transmissionofpainsignalstothedorsalhorn,but andmotorblockadeandpost-operativedurationof ithasdeniterisksofsystemictoxicity,especially analgesiaandsecondaryaimistocomparesafety withbrachialplexusblock.Variousadjuvantslike ofthetwodrugsintheformofsideeffectprole. opioids,clonidine,dexmeditomedineareaddedin peripheralnerveblockstoincreasespeedofonset, MaterialsandMethods durationofaction,improveualityoftheblockand to reduce toxicity of local anesthetics.4 owever, they are associated with side effects like heavy AfterapprovaloftheInstitutionalEthicsCommittee sedation and respiratory depression. Therefore, and obtaining written informed consent from there is always look out for drugs with minimal each patient, thirty patients of American Society sideeffects.Opioidshaveananti-nociceptiveeffect of Anesthesiologists (ASA) physical status I to atthecentralorspinalcordlevels.Stimulationof II of both gender, aged 18–0 years, scheduled opioid receptors on neurons of central nervous for elective elbow, forearm and hand surgeries systems leads to the inhibition of neuronal in orthopedic operation theatres, were enrolled serotonin uptake which leads to augmentation of for this prospective, randomized comparative spinalinhibitorypainpathways;however,itisstill controlstudy. unclearwhetherfunctionalopioidreceptorsexistin Patientswithclinicallysignicantcoagulopathy, peripheraltissue.5Manyopioidssuchastramadol infection at the injection site, allergy to local andfentanylhavebeenaddedasadjuvantstolocal anesthetics, pre-existing neuromuscular diseases, anesthetics by different routes, including brachial severecardiovascularorpulmonarydisease,renal plexus block, to enhance the analgesic efcacy. or hepatic disorder, refusal to techniue, unco- Effectsofopioidsareeitherbytheiractiononopioid operative or failure of block were excluded from receptors or by systemic absorption. Tramadol is thestudy.Patientsonanyopioidsoranysedative ananalgesicwithmixedopioidandnon-opioid medications in the week prior to the surgery activity.Itinhibitsthereuptakeofnorepinephrine werealsoexcludedfromthestudy.Visualanalog (NE) and serotonin from the nerve endings and scale(VAS)wasexplainedtoallpatientswhere0 potentiates the effects of local anesthetics when correspondstonopainand10indicatestheworst mixedtogetherinperipheralregionalnerveblock. unbearablepain. Ithaslessrespiratorydepressanteffectduetoweak 6 Patients were randomized according to receptorafnity. computer-generated random number table into Nalbuphine hydrochloride, a potent analgesic,7 twoeual groupsoffteenpatientseach,Group acts as a appa agonist and partial mu T (upivacaine with tramadol) and Group N antagonist.7,8,10 Its afnity to -opioid receptors (upivacainewithnalbuphine).PatientsofGroup results in sedation, analgesia, and cardiovascular T received28ml of0.5bupivacainewith2ml stabilitywithminimalrespiratorydepression.7,10 (100 mg) of tramadol and patients of Group N Itmaypotentiatelocalanestheticactionthrough received28mlof0.5bupivacainewith2ml(20 central opioid receptor-mediated analgesia by mg)ofnalbuphineforbrachialplexusblockadeby peripheral uptake of nalbuphine to systemic supraclavicularapproach. circulation.It is widely studiedasanadjuvant to Thestudydrugsolutionswereinsimilarvolume localanestheticsincentralneuraxialtechniuesby of 0 ml, to maintain the blindness of study and epidural,caudal,andintrathecalroutes.11owever, were prepared by an anesthetist who was not after researchinliterature, we did notndmuch involved for data collection of the patients. The publisheddatastudyingtheeffectofnalbuphineas anesthetistperformingtheblockwasalsoblinded anadjuvanttolocalanestheticsinperipheralnerve tothestudygroups,andallobservationsweredone blockshowever,wearecommonlyusingtramadol bythesameinvestigator. asanadjuvanttolocalanestheticinourinstitute. All patients were admitted before the day ence, the present study was undertaken of surgery, and fasting of 8 hours was ensured. to compare the clinical efcacy and safety of On arrival in the operation theatre, intravenous

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparativeEvaluationofNalbuphineandTramadolasanAdjuvant 151 to0.5upivacaineinSupraclavicularrachialPlexuslock access was established and lactated ringer lactate withtime0minbeingthetimeofcompletionofthe solution was infused at the rate of –8 mlg injection. and monitors for non-invasive blood pressure, Intra-operative vital parameters of blood heart rate, electrocardiogram (ECG), and pulse pressure,heartrate,respiratoryrate,andperipheral oximetry (SpO ) were commenced to monitor 2 oxygensaturationweremonitoredinitiallyat5min the peri-operative vital parameters of patients. intervaluntil15minandthenat15minintervaluntil Patientsliedownsupinewithheadturned45to completion of surgery. The uality of analgesia thecontralateralsidewithadductionofipsilateral was assessed every hour post-operatively for arm.Asmallbolsterwasplacedbetweenshoulder 24hoursintherecoveryroomandinsurgicalward bladestomaketheplexustaut.Thesupraclavicular by attending nurse using VAS scale (1–10): zero brachialplexusblockwasperformedusingaVygon was considered asnopain,1– asmildpain,4–6 nervestimulatorwith 22g 5cminsulatedneedle asmoderatepain,and7–10asseverepain.Atthe for precise location of brachial plexus. nder all scoreof4,nursingstaffwasdirectedtoadminister aseptic precautions, a skin wheal was raised in injectiondiclofenacsodium75mgintramuscularly. thesupraclavicularregion,1cmabovethemedial Duration of analgesia was calculated from the twothirdandthelateralonethirdoftheclavicle. timeoflocalanestheticinjectiontothetimeofrst Subclavian artery is usually palpable on this site. analgesicreuirement.Allpatientswereobserved Nerve stimulator freuency was set at 2 and for any side effects such as nausea, vomiting, intensity of stimulating current was initially set bradycardia and hypotension and complications to deliver 1 mA for 01 ms. Insulated needle was of supraclavicular block like pneumothorax, inserted through the skin wheal in a posterior, hematoma, Local anesthesia toxicity, and post caudal and medial direction until a distal motor block neuropathy in the intra and post-operative responsewaselicited.Asthenervewasapproached, periodsandtreatedaccordingly. movement of the wrist or ngers were identied andthecurrentwasgraduallyreducedto05mA. Positionofneedlewasconsideredacceptablewhen esults an output current 05 mA elicited a distal motor response.Atthispointafternegativeaspirationfor Patients of both groups were comparable with blood,amixtureoflocalanestheticandadjuvantas respect to the demographic prole for age, sex perthegroupallottedwasgiven.Allpatientswere distribution,ASAphysicalstatus.Thebaselinevital givensupplementaloxygenusingventimask.The parametersofheartrate,systemicbloodpressure, onset of sensory block was assessed by pinprick and oxygen saturation were comparable between method. The onset time of sensory block wasthe the groups. Intra-operatively, hemodynamic timefromcompletionoftheinjectiontorstlossof changes did not reveal any signicant difference pinpricksensation. between the groups and all patients remained Motor weakness was assessed by hand grip hemodynamically stable throughout the surgery. and movement at the elbow, wrist and ngers, Onsettimeofsensoryblock(10415minvs.1 usingamodiedromagescale(Grade0-normal 25min)andmotorblock(14425minvs.184 motorfunction,ableto raisetheextended arm to 5min)inGroupNwassignicantlyfasterthan 0;Grade1-abletoextheelbowandmovethe GroupT(p0.001),showedasin(Table),along ngersbutunabletoraisetheextendedarm;Grade with(raphicsand). 2- unable toex theelbowbutable tomovethe ngers;Grade-completemotorblock).Theonset Table: timeofmotorblockwasthetimefromcompletion Onsetofsensory Onsetofmotor of the injection to reduction of muscle force to blockade blockade Grade2.Motorblockwasalsoassessedbythumb GroupT 1.66/-2.5 18.46/-.5 abduction (radial nerve), thumb adduction (ulnar GroupN 10.46/-1.5 14.4/-2.5 nerve), and thumb opposition (median nerve). Totaldurationof Totaldurationof Durationofmotorblockwastakenfromonsetof motorblockade analgesia motor block to complete recovery of full muscle GroupT 07min05hrs 401min8hrs powerandwasdeterminedbyaskingthepatients GroupN 214min48hrs 4500min7hrs tonotethetimewhentheycouldrstmovetheir Themeandurationofmotorblockwas214min ngersofblockedlimb.Patientswereassessedfor inpatientsofGroupNwhencomparedtoGroup onsetofsensoryandmotorblockadeatevery2min T(07min)andthedifferencewasstatistically interval till desired surgical anesthesia achieved

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1514 IndianJournalofAnesthesiaandAnalgesia

OnsetofSensorylock OnsetofMotorlock

raph:

TotalDurationof TotalDuration Motorlockade ofAnalgesia raph:

signicant(p0.001).Thedurationofanalgesiain of regional anesthesia over general anesthesia patientsofGroupNwas4500minandinpatients in terms of safety, effective pain relief, and early ofGroupTwas401minwithp–value0.00. discharge from the recovery room. owever, NosideeffectwasseenineitherGroup. additionalanalgesicsarereuiredforrelievingthe post-operativepain,12,1,14,15asthedurationofaction Discussion of currently available Local anesthetic agent is short.IncreasingthedoseofLocalanestheticagents mayprolongtheDurationofaction16butmayalso rachial plexusblockadeiscommonly performed increasetheriskofLAsystemictoxicity.17 regional anesthetic techniue for forearm and hand surgeries, and its blockage provides good Different opioids have been added to local surgical anesthesia. There are several advantages anesthetic to improve the uality and duration

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparativeEvaluationofNalbuphineandTramadolasanAdjuvant 1515 to0.5upivacaineinSupraclavicularrachialPlexuslock of post-operative analgesia of peripheral nerve Conclusion blocks.18Manypreviousstudieshaveattemptedto determinewhethertheadditionofopioidtolocal Nalbuphine is superior to tramadol in terms of anestheticswould improve the clinicalefcacy of onset of action, duration of motor blockade and peripheral nerve blocks and demonstrated that post-operative duration of analgesia when added different types of opioids act well on peripheral as an additive to bupivacaine in supraclavicular nervethroughstimulationofopioidreceptor, but brachialplexusblock. they were associated with unacceptable adverse effects. Tramadol and fentanyl were commonly inancialsupportandsponsorship:Nil. used as adjuvant to local anesthetic drug in Conicts of interest: There are no conicts of brachialplexusblock.19Systemicreviewofvarious interest. adjuvants for brachial plexus block suggested that the nalbuphine appeared to possess greater eferences analgesicefcacywithminimaladverseeffects.

9 Nalbuphine hydrochloride, a potent analgesic, 1. Neal JM, Gerancher JC, ebl JR, et al pper acts as a appa agonist and partial mu extremity regional anesthesia: Essentials of our antagonist.9,10,11 Its afnity to -opioid receptors current understanding, 2008. Reg Anesth Pain results in sedation, analgesia, and cardiovascular Med.2009;4:14–170. stabilitywithminimalrespiratorydepression.9,10 2. ChoyceA,ChanVES,MiddletonWJ,etalWhat Tramadol is an analgesic with mixed opioid is the relationship between paresthesia and nerve stimulation for axillary brachial plexus and non-opioid activity. It inhibits the reuptake block Regional anesthesia and pain medicine. of norepinephrine (NE) and serotonin from the 2001;26:100–104. nerve endings and potentiates the effects of local . DugganE,Eleheiry,PerlasA,etalMinimum anesthetics when mixed together in peripheral effectivevolumeoflocalanestheticforultrasound- regional nerve block. It has less respiratory guidedsupraclavicularbrachialplexusblock.Reg depressanteffectduetoweakreceptorafnity.6 AnesthPainMed.2009;4:215–18. oussef and Elayyat20 compared the effect 4. Frster JG, Rosenberg P. Clinically useful of nalbuphine with tramadol as adjuvants to adjuvants in regional anesthesia. Curr Opin lidocaine in intravenous regional anesthesia and Anesthesiol.200;16:477–86. concludedthatbothnalbuphineandtramadolwere 5. Fields L, Emson PC, Leigh , et al Multiple comparable, but nalbuphine was more effective opiate receptor sites on primary afferent fibres. thantramadolforprolongingthedurationofpost- Nature.1980;284:51–5. operativeanalgesia. 6. Chatopadhyays, Mira LG, iswas N, et al Tramadol as an adjuvant for brachial plexus 21 Abdelha and Elramely also used 20 mg block.JAnesthClinpharmacol.2007;2:187–89. nalbuphineasadjuvantto25mlof0.5bupivacaine 7. GunionMW,MarchionneAM,AndersonTM.se forsupraclavicularbrachialplexusblockforupper of the mixed agonist-antagonist nalbuphine in armsurgeriesandconcludedthatnalbuphinehas opioidbasedanalgesia.Acutepain.2004;6:29–9. signicantlyincreasedthedurationofbothsensory 8. Errick J, eel RC. Nalbuphine: A preliminary and motor block along with prolonged post- review of its pharmacological properties and operativeanalgesia. therapeuticefficacy.Drugs.198;26:191–211. Inthepresentstudy,weobservedthestatistically 9. Schmidt W, Tam SW, Shotzberger GS, et al signicant enhanced onset of action, enhanced Nalbuphine.DrugAlcoholDepend.1985;14:9–62. duration of motor block along with duration of 10. De Souza E, Schmidt W, uhar MJ. analgesia with addition of nalbuphine to 0.5 Nalbuphine:Anautoradiographicopioidreceptor bupivacaine as compared to tramadol in brachial bindingprofilein the centralnervoussystemof plexusblock.Thisprolongationofanestheticeffect anagonist/antagonistanalgesic.JPharmacolExp andanalgesiacouldbesecondarytothestimulation Ther.1988;244:91–402. of kappa receptors by nalbuphine, which inhibits 11. MukherjeeA,PalA,AgrawalJ,etalIntrathecal release of neurotransmitters for pain such as nalbuphineasanadjuvanttosubarachnoidblock: What is the most effective dose Anesth Essays substance P. Thebenets ofnalbuphine were not Res.2011;5:171–75. associated with any hemodynamic variability or anyadverseevent. 12. Liu SS, Strodtbeck WM, Richman JM, et al A comparisonofregionalversusgeneralanesthesia IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1516 IndianJournalofAnesthesiaandAnalgesia

for ambulatory anesthesia: A meta-analysis of 17. ScottD,LeeA,FaganD,etalAcutetoxicityof randomized controlled trials. Anesth Analg. ropivacaine compared withthatof bupivacaine. 2005;101:164–642. AnesthAnalg.1989;69:56–69. 1. LiuSS,WuCL.Theeffectofanalgesictechniue 18. aabachiO,OueziniR,oubaaW,etalTramadol on post-operative patient-reported outcomes as an adjuvant to lidocaine for axillary brachial includinganalgesia:Asystematicreview.Anesth plexusblock.AnesthAnalg.2009;108:67–70. Analg.2007;105:789–808. 19. Saryazdi , azdani A, Sajedi P, et al 14. McCartneyCJ,rullR,ChanVW,etalEarlybut Comparative evaluation of adding different no long-term benefitofregionalcompared with opiates (morphine, meperidine, buprenorphine, generalanesthesiaforambulatoryhandsurgery. orfentanyl)tolidocaineindurationandualityof Anesthesiology.2004;101:461–67. axillarybrachialplexusblock. AdviomedRes. 15. CovinoJ,WildsmithJA.Clinicalpharmacology 2015;4:22. of local anesthetic agents. In: Cousins MJ, 20. oussefMM,ElayyatNS.Lidocaine-nalbuphine ridenbaugh PO, editors. Neural lockade in versus lidocaine-tramadol for intravenous Clinical Anesthesia and Management of Pain. regional anesthesia. Ain Shams J Anesthesiol. Philadelphia, PA: Lippincott-Raven; 1998. pp. 2014;7:198–204. 97–128. 21. AbdelhaMM,ElramelyMA.Effectofnalbuphine 16. SchoenmakersP,WegenerJT,StienstraR.Effect asadjuvanttobupivacaineforultrasound-guided of local anesthetic volume (15 vs 40 ml) on the supraclavicular brachial plexus block. Open J durationofultrasound-guidedsingleshotaxillary Anesthesiol.2016;6:20-26. brachialplexusblock:Aprospectiverandomized, observer-blinded trial. Reg Anesth Pain Med. 2012;7:242–47.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1517-1522 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.4

A Comparatie Study beteen opiacaine ith Clonidine and BupiacaineithClonidineinBrachialPleusBlocksinpperimb

DPaanumarVinayDandemmanaarASomya

1,2AssistantProfessor,Dept.ofAnesthesia,amineniInstituteofMedicalSciences,Narketpally,NalgondaDist,Telangana508254, India.MDPharmacology,urnoolMedicalCollege,urnool,AndhraPradesh518002,India.

Abstract

ntroduction:Thesupraclavicularbrachialplexusblockprovidesanaesthesiaofentireupperextremityin mostconsistentmanner.rachialplexusblockadeforupperlimbsurgeriesisadvantageousastheeffectof drugislimitedtothepartofthebodytobeoperatedupon.MaterialsandMethods:Thepresentstudytitled AcomparativestudyofRopivacaineClonidinewithupivacaineClonidineinsupraclavicularbrachial plexus block was carried out at amineni Institute of Medical Sciences, Narketpally, Nalgonda District, TelanganaState.Itwasaprospectiveandrandomizedstudy.Sixtypatientsofagegroupbetween 18and 70yearsadmittedbetweenAugust2018andovember2018wereselectedforthestudy.Thesepatientswere undergoingelectiveoperativeproceduresforupperlimbsurgeries(i.e.,elbow,forearmandhandsurgeries). Exclusioncriteriaincludedpatientsrefusal,historyofbleedingdisordersorpatientsonanticoagulanttherapy, peripheralneuropathy,localinfection,respiratorydisease,orknownallergytolocalanestheticdrugs.Each patient was visited pre-operatively and the procedure was explained and informed written consent was obtained.Investigationslikeemoglobin,leedingtime,Clottingtime,bloodgrouping,randombloodsugar, bloodurea,serumcreatinine,bleedingtime,clottingtime,chestx-ray,ECGweredone.Results:Thepresent studywasconductedon60consentingpatientsagedbetween18and70years.GroupRCreceived0mlof 0.5Ropivacaineclonidine(0mcg).GroupCreceived0mlof0.5upivacaineclonidine(0mcg) forbrachialplexusblockbysupraclavicularapproach.Theminimumageinbothgroupswas18years.The maximumageinbothgroupswas0yearsand5yearsrespectively.ThemeanageingroupCwere1.20 12.59andRCwere2.001.17respectively.Therewasnosignificantdifferenceintheageofpatientsbetween theGroupCandGroupRC.othgroupsweresimilarwithrespecttoagedistribution(p0.05).Conclusion: Fromourstudy,weconcludedthatadditionofClonidine(2gg)to0.5Ropivacaineinsupraclavicular brachialplexusblockhasadvantagescomparetobupivacainewithclonidineFasteronsetofanalgesia,sensory andmotorblockade. eyords:Supraclavicularbrachialplexusblock;Ropivacaine;Clonidine.

otocitethisarticle: D. Pavan umar, Vinay Dandemmanavar, A. Sowmya. A Comparative Study between Ropivacaine with Clonidine and upivacainewithClonidineinrachialPlexuslocksinpperLimb.IndianJAnesthAnalg.2019;6(5Part-1):1517-1522.

Introduction of drug is limited to the part of the body to be operatedupon.1 Thesupraclavicularbrachialplexusblockprovides A commonly used drug for this techniue is anesthesia of entire upper extremity in most bupivacaine 0.5 which is a well-established consistent manner. rachial plexus blockade for long acting local anesthetic, which like all amide upperlimbsurgeriesisadvantageousastheeffect anestheticshasbeenassociatedwithcardiotoxicity

Corresponding Author: Vinay Dandemmanaar, Assistant Professor, amineni Institute of Medical Sciences, Narketpally, NalgondaDist,Telangana508254,India. Email:[email protected] eceiedon08.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1518 IndianJournalofAnesthesiaandAnalgesia when used in high concentration or when was carried out at amineni Institute of Medical accidentallyadministeredintravascularly.2 Sciences,Narketpally,NalgondaDistrict,Telangana As with other elds, regional anesthesia too, State.Itwasaprospectiveandrandomizedstudy. has undergone major developments, both in Sixty patients of age group between 18 and techniuesanddrugavailability.Ropivacainewas 70 years admitted between August 2018 and thusdevelopedafteritwasnotedthatbupivacaine ovember 2018wereselected for the study. These wasassociatedwithsignicantnumberofcardiac patients were undergoing elective operative arrests. Ropivacaine is a new long acting local procedures for upper limb surgeries (ie., elbow, anesthetic drug belonging to the amino amide forearmandhandsurgeries). group. Ropivacaine and bupivacine belong to Exclusion criteria included patients refusal, pipecoloxylididesgroupoflocalanesthetics.Itisa history of bleeding disorders or patients on pureS(-)enantiomer,unlikeupivacaine,whichis anticoagulanttherapy,peripheralneuropathy,local aracemate,developedforthepurposeofreducing infection,respiratorydisease,orknownallergyto potential toxicity and improving relative sensory localanestheticdrugs. andmotorblockproles.,4 Each patient was visited pre-operatively and Additionofadjuvantdrugstothelocalanesthetic the procedure was explained and informed mightimproveuality,onsetanddurationofblock written consent was obtained. Investigations like anddecreasepost-operativeanalgesicreuirement emoglobin, leeding time, Clotting time, blood and systemic side effects.2 Opioids, clonidine, grouping,randombloodsugar,bloodurea,serum ketamineandprostigminehavebeenaddedtolocal creatinine,bleedingtime,clottingtime,chest-ray, anestheticsandinjectedextradurally,intrathecally ECGweredone. or in nerve plexuses for a more intense and prolonged analgesia.5–8 Opioids are commonly Each patient was randomly assigned to one of added to local anesthetic solutions to increase the two groups of 0 patients each, Group D or intensity and duration of anesthesia by acting on GroupRDbyacomputerizedrandomization. 9,10 opioidreceptorspresentonthenerveterminals. Group – C ie., 0 ml of upivacaine group owever,fentanylhassomesideeffectsasvomiting received 0.5 upivacaine according to body 7 andrespiratorydepression. Clonidineisaselective weightclonidine(0mcg). Alpha-2 adrenergic agonist with some Alpha-1 agonist property. In clinical studies, the addition Group – RC ie., 0 ml of Ropivacaine group ofclonidinetolocalanestheticsolutionimproved received 0.5 Ropivacaine according to body peripheralnerveblocksbyreducingtheonsettime weightclonidine(0mcg). improvingtheefcacyoftheblockduringsurgery Each patient wasmade to liesupine withouta andextendingpost-operativeanalgesia. pillow, arms at the side, head turned slightly to the opposite side with the shoulders depressed AimsandObjectives posteriorly and downward by moulding the shouldersoverarollplacedbetweenthescapulae. Thesupraclavicularareawasasepticallyprepared Thepresentstudyisaimedtocomparetheeffects and draped. The anesthesiologist stands on the of 0.5 Ropivacaine with clonidine (0 mcg) side of the patient to be blocked. The patients and 0.5 upivacaine with clonidine (0 mcg) in were administered brachial plexus block by supraclavicularbrachialplexusblockintermsof: supraclavicular approach under strict aseptic The onset of blockade–sensory and motor precautions.Theinjectionsitewasinltratedwith blockade 1 ml of lidocaine 2 subcutaneously. A nerve Durationoftheblockade–sensoryandmotor stimulatorwith50mmstimuplexneedleisusedto blockade locatebrachialplexus.Thelocationendpointbeing adistalresponsewithanoutputof0.4mA.During ualityoftheblock injection,negativeaspirationwasperformedevery –7 ml to avoid intravascular injection. A -min MaterialsandMethods massagewasperformedtofacilitateanevendrug distribution. The present study titled A comparative study Time of onset of sensory block was recorded of Ropivacaine Clonidine with upivacaine using pinprick in skin dermatomes C4-T2. The Clonidineinsupraclavicularbrachialplexusblock same observer assessed the motor block at the

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudybetweenRopivacainewithClonidineandupivacaine 1519 withClonidineinrachialPlexuslocksinpperLimb sametime. (0 mcg). Group C received 0 ml of 0.5 Onset of sensory block was from the time of upivacaineclonidine(0mcg)forbrachialplexus injectionofdrugtotimeoflossofpainonpinprick. blockbysupraclavicularapproach. Onsetofmotorblockwasfromthetimeofinjection totimeofcompletelossofmovement. Table:Agedistributionofpatients Sensory block was assessedby pinprick witha roupBCBupiacaine roupCopiacaine shortbevelled2Gneedleas: Agein Clonidine Clonidine Years Numberof Numberof Percent Percent Grade0–Sharppinprickfelt. Patients Patients 18–24 5 16.67 10 .() Grade1–Analgesia,dullsensationfelt. 25–1 12 40 10 .() Grade2–Anesthesia,nosensationfelt. 2–8 6 20 2 6.67() 9–45 2 6.67 2 6.67() Motor block was graded according to the 46–52 2 6.67 10.00() modiedromagescale: 5–59 1 . 1 .() Grade 0 – Normal motor function with full 60–66 2 6.67 2 6.67() extensionandexionofelbow,wrist,andngers. Total 0 100.00 0 100.00() MeanSD 1.2012.59 2.001.17 Grade1–Decreasedmotorstrength,withability Minimum 18 18 tomoveonlyngers. Maximum 60 65 Grade2–Completemotorblockwithinabilityto 22.48,p0.8850 moveelbow,wrist,andngers. Tableshowninagedistributionofthepatients Duration of sensory blockade was the time inboththegroups.Theminimumageinbothgroups in minutes from the onset of analgesia to the was18years.Themaximumageinbothgroupswas recurrenceofpaintopinprick.Durationofmotor 0yearsand5yearsrespectively.Themeanagein blockadewasthetimeinminutesfromtheonsetof group Cwere 1.2012.59and RCwere 2.00 paresistotherecurrenceofmotormovements. 1.17respectively.Therewasnosignicantdifference in the age of patients between the Group C and Theualityoftheblockwasgradedaccordingto GroupRC.othgroupsweresimilarwithrespectto whetheropioidswereusedduringintraoperative agedistribution(p0.05)shownasin(Tables). period(GradeII)orifadjuvantsofanykindwere not used throughout the surgery (Grade I). For the patients who were anxious and perturbed by Table:Distributionofpatientsaccordingtheirsex the sensation of touch on the operating limb, Inj. roupBC roupC Fentanyl50mcgIVwas administered.Theblocks Se Numberof Numberof Percent Percent thatreuiredconversiontogeneralanesthesiawere Patients Patients excludedfromthestudy. Male 18 60.00 21 70.00 Female 12 40.00 9 0.00 The heart rate, oxygen saturation and mean arterial pressure were recorded. Patients were Total 0 100.00 0 100.00 watched for complications such as bradycardia, 20.08208,p0.7745 convulsions, restlessness, disorientation or No signicant difference was observed in sex drowsiness.Allthevalueswereexpressedasmean distribution of the cases between two groups standard deviation. Statistical comparison was (p0.05). performedbystudentsttestandChi-Suaretest. A p - value of 0.05 was considered to be Table:Showingtheweightdistributionineachgroup statistically not signicant, a p - value 0.05 as roupBC roupC statistically signicant, a p - value of 0.01 as Weight Numberof Numberof Percent Percent statistically highly signicant and a p - value of Patients Patients 0.001asstatisticallyveryhighlysignicant. 40–49 12 40 9 0() 50–59 11 6.67 15 50() 60–69 7 2. 6 20() esults Total 0 100 0 100() MeanSD 52.96.52 5.75.45 Thepresentstudywasconductedon60consenting Minimum 40 42 patientsagedbetween18and70years.GroupRC Maximum 68 62 21.121,p0.5710 received 0 ml of 0.5 Ropivacaine clonidine

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1520 IndianJournalofAnesthesiaandAnalgesia

Table:Comparisonofonsetofsensoryandmotorblockade

OnsetofBlock roupBC roupC (min) Min Ma Mean SD Min Ma Mean SD Motor 8 15 12.57 1.9205 7 1 8.07 1.5447 p0.001 Sensory 6 12 10.7 1.51 5 12 6.9 1.8557 p0.001

Table:Durationofblockade(min)

roupBC roupC DurationofBlock Min Ma Mean SD Min Ma Mean SD Motor 70 480 41. 2.56 40 480 415. 6.11 p0.07 Sensory 90 520 480. 20.1 80 500 469.67 25.15 p0.07

The two groups are compared according to Table:Meandurationofsurgeryinminutes their weight. This was statistically not signicant roupBC roupC (p0.05). Min Ma Mean SD Min Ma Mean SD Duration In Group C the mean onset time of sensory 50 10 78.41 21.10 50 10 69.5 19. blockade was 10.7 minutes and motor blockade ofSurgery were12.57minuteswhereasinGroupRC,themean p0.15 onset time of sensory blockade was 6.9 minutes IngroupC,themeandurationofsurgerywas andmotorblockadewere8.07minutes. 78.41 21.10 minutes whereas in group RC the Onsetofsensoryandmotorblockadewasearlier meandurationofsurgerywas69.519.minutes. in case of Group RC (Ropivacaine group) when The mean duration of surgery in Group C was compared with Group C (upivacaine group). similarcomparedtoGroupRC.Thep-value(0.15) The p value was 0.01 which is statistically wasalsonotstatisticallysignicant. signicant. In group C the mean duration of sensory Discussion blockade was 480. minutes and motor blockadewere41. minuteswhencompared to Regional anesthetic techniues are used for both group RC, where sensory blockade duration was operative anesthesia and for post-operative 469.67 minutes and duration of motor blockade analgesia. They are becoming more popular as 415.minutes. a result of advances in drugs, euipment, and improved techniues of anatomical localization, Thedurationofsensoryandmotorblockadewas includingnervestimulatorandultrasoniclocation.11 similarinGroupCwhencomparedtoGroupRC. Therewasnostatisticaldifferencebetweenthetwo Regional anesthetic techniues may be (p0.05). used alone or in combination with sedation or general anesthesia depending on individual 12,1 Table:ualityofblockade circumstances. The advantages of regional techniuesinclude: Class roupBC roupC Avoidanceoftheadverseeffectsofgeneral 1 20 22 anesthesia. 2 10 8 Total 0 0 Post-operativeanalgesia. Preservationofconsciousnessduringsurgery. 20.1,p0.57 Sympatheticblockadeandattenuationofthe In Group C 20 patients needed no additional stressresponsetosurgery. drug like opioids (Inj. Fentanyl 50 mcg IV) when compared with Group RC where 22 patients Improved gastrointestinal motility and didntneedanyadjuvant.Adjuvantswereusedin reducednauseaandvomiting. 10patientsingroupCwhereas8patientsneeded Simplicityofadministration. adjuvantsinGroupRC. Rapid mobilization of patient and early Thisisstatisticallynotsignicant(p0.05). dischargedecreasesDVT.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudybetweenRopivacainewithClonidineandupivacaine 1521 withClonidineinrachialPlexuslocksinpperLimb

Moreeconomicalforthepatient. alpha-2-adrenoreceptormediatedvasoconstriction, Theneteffectofthesefeaturesleadstoareduction attenuation of inammatory response and direct intheincidenceofmajorpost-operativerespiratory action on peripheral nerve. Clonidine possibly complication. The upper limb is well suited to enhancesorampliesthesodiumchannelblocking regional anesthetic techniues and these remain action of local anesthetics by opening up the among the most useful and commonly practiced potassiumchannelsresultinginhyperpolarization, peripheral regional techniues. Supraclavicular a state in which the cell is unresponsive to 20 blockoffersdenseanesthesiaofbrachialplexusfor excitatoryinput. surgicalproceduresatordistaltotheelbow.This The present study is undertaken to compare approachprovidesperhapsthebestoverallefcacy the onset, duration of sensory and motor block ofcompletearmblockfromasingleinjectionasthe andtheuality ofblockachievedby upivacaine trunks/divisionsofthebrachialplexusareclosely with clonidine and Ropivacaine with clonidine. relatedatthispoint.14,15,16 Supraclavicular brachial plexus block was For a long-time, the choice of local anesthetic administered in 60 patients selected randomly for brachial plexus block was upivacaine, a for elective and emergency surgeries. 0.5 long-acting amide local anesthetic. owever, upivacaine was administered with clonidine concerns about its high lipid solubility and high (0mcg)to0patientsselectedrandomlyand0.5 cardiotoxicity limited its use. With the advent of Ropivacaine was administered with clonidine newerandsaferlong-actingamidelocalanesthetics (0mcg)to0patientsselectedrandomly. such as Ropivacaine and Levobupivacaine, upivacainehaslargelybeenreplaced.Ropivacaine has lower lipid solubility and produces less Conclusion central nervous toxicity and cardiotoxicity than upivacaine. It has been shown that Ropivacaine From our study, we concluded that addition interfereswithmitochondrialrespirationandATP of Clonidine (0 mcg) to 0.5 Ropivacaine in synthesis less than both racemic bupivacaineand supraclavicularbrachialplexusblockhasfollowing Levobupivacaine. Ropivacaine is thus gaining advantagescomparetobupivacainewithclonidine popularity over upivacaine for peripheral nerve Faster onset of analgesia, sensory and motor blocks.17,18 blockade: There has been a search for an ideal adjuvant 1. LesscardiacToxicity. to local anesthetics for regional nerve block 2. NosignicantDifferenceinhemodynamic that prolongs the analgesia with lesser side parameters (pulse rate, lood pressure; effects. Several adjuncts have been described SpO2 and respiratory rate) and no to decrease the time of onset to the block and signicantsideeffectsandcomplications. to prolong the duration of the block. Drugs such as opioids, Dexmethasone, Tramadol, Neostigmine,Epinephrine,Dexmedetomidineand eferences Clonidine have been used as adjuncts to brachial plexusblocks.19 1. De Mey JC. The influence of sufentanil and/ Evidence regarding the analgesic benet of orclonidineonthedurationofanalgesiaaftera caudal block for hypospadias repair surgery in opioidadjuncts remainseuivocal.Thereappears children.EurJAnesthesiol.2000;17:79–82. tobenoadvantageforreducedadverseeffectsby theperipheraladministrationofopioidanalgesics. 2. Constant I,. Addition of clonidine or fentanyl to local anesthetics prolongs the duration of Nausea,vomitingandpruritisoccurredevenwith surgicalanalgesiaaftersingleshotcaudalblockin theperipheraladministrationofopioids. children.rJAnesth.1998;80:294–98. Sufcient data is not available to allow the . aris S Comparison of fentanyl-bupivacaine or recommendation of tramadol and neostigmine midazolam bupivacaine mixtures with plain as adjuncts to local anesthetics in brachial plexus bupivacaine for caudal anesthesia in children. block.Clonidineenhancesbothsensoryandmotor PediatrAnesth.200;1:126–. blockadeof neuraxialandperipheral nervesafter 4. Vercauteren M and Meert TF. Isobolographic injection of local anesthetic solutions. There have analysis of the interaction between epidural been four proposed mechanisms for the action sufentanil and bupivacaine in rats. Pharmacol of clonidine in peripheral nerve blocks. These iochemehav.1997;58:27–42. mechanisms are centrally mediated analgesia, 5. Palmer CM. upivacaine augments intrathecal IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1522 IndianJournalofAnesthesiaandAnalgesia

fentanyl for labor analgesia. Anesthesiology. of International Medical and Dental Research. 1999;91:84–89. 2016;2(1):295–00. 6. Madan R. A dose response study of clonidine 14. Chatrath V, Sharan R, heterpal R, et al withlocalanestheticmixtureforperibulbarblock: Comparative evaluation of 0.75 ropivacaine A comparison of three doses. Anesth Analg. with clonidine and 0.5 bupivacaine with 2001;9:159–597. clonidineininfraclavicularbrachialplexusblock. 7. utterworth JF and Strichartz GR. The alpha AnesthEssaysRes.2015;9(2):189–94. 2-adrenergic agonists clonidine and guanfacine 15. aj,TyagiV,ChaudhriRS,etalAcomparative produce tonic and phasic block of conduction study of effects of clonidine added to in rat sciatic nerve fibers. Anesth Analg. ropivacaine versus plain ropivacaine during 199;76:295–01. supra clavicular brachial plexus block. Journal 8. MurphyD.Novalanalgesiaadjunctsforbrachial of Evolution of Medical and Dental Sciences. plexusblock.A systemic review.Anesth Analg. 201;2(52):10228–1025. 2000;1122–128. 16. MohammadA,GoelS,SinghalA,etalClonidine 9. EisenachJC,DekockMandlimschaW.Alpha asanAdjuvanttoRopivacaineinSupraclavicular (2) adrenergic agonists for regional anesthesia. rachial Plexus lock: A randomized double A clinical review of clonidine (1984–1995). blinded prospective study. International Anesthesiology.1996;85:655–74. Journal of Contemporary Medical Research. 10. ChakrabortyS,ChakrabartiJ.MandaiMC,etal 2016;(5):129–1296. Effect of clonidine as adjuvant in bupivacaine- 17. PatelC,Parikh,havsarMM,etalClonidineas inducedsupraclavicularbrachialplexusblock:A adjuvantto0.75ropivacaineinsupraclavicular randomizedcontrolledtrial.IndianJPharmacol. brachialplexusblockforpost-operativeanalgesia: 2010;42:74–77. Asingleblindrandomizedcontrolledtrial.IJR. 11. Rohan , Singh P and Gurjeet . Addition 2014;05(05). of clonidine or lignocaine to ropivacaine 18. afna , adav N, handelwal M, et al for supraclavicular brachial plexus block: Comparison of 0.5 ropivacaine alone and in A comparative study; Singapore. Med J. 2014;55(4):229–2. combination with clonidine in supraclavicular brachial plexus block. Indian Journal of Pain. 12. Gupta S, Gadani N and Thippeswamy G. 2015;29(1):41–45. A comparative study between ropivacaine 0 ml (0.75) and ropivacaine 0 ml (0.75) 19. Routray SS, iswal D, Raut , at al. The Effects withclonidine150gasanadjuvantinbrachial of Clonidine on Ropivacaine in Supraclavicular plexus block through supraclavicular approach. rachial Plexus lock. Sch J App Med Sci. Sudan Medical Monitor. 2015 January– 201;1(6):887–9. March;10(1):11–15. 20. 20. Patil N and Singh ND. Clonidine as an 1. Raut,Pradhan,RoutraySS,etalTheEffects adjuvanttoropivacaine-inducedsupraclavicular oftwodifferentdosesofClonidineasAdjuvant brachial plexus block for upper limb surgeries. toRopivacaineinSupraclavicularrachialPlexus JournalofAnethesiologyClinicalPharmacology. lock A randomized controlled study. Annals 2015;1():65–69.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):152-150 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.5

A etrospectie Study of Predictors of Mortality in N Influena AssociatedDeathsinaTertiaryCareospital

Mohandeep aur Seema B Wasnik Dhir Vinodbala S eerthana ain Saumya kaurarmanpreetanoiaAkashNidhiumari

1ODAnaesthesia,2SeniorAnaesthesiologist,SeniorConsultantAnesthesiologist,4,5,7FirstyearPGAnaesthesia,6JuniorResident, 8SeniorResident,DepartmentofAnesthesiology,PGIMERandDrRMLospital,Delhi110001,India.

Abstract

ThisstudyaimsistoidentifythepredictorsofmortalityinSwinefluassociateddeathsandtoformulate protocolsandguidelinesforthefuture managementof Swineflupatientsincaseofinter-hospitalpatient transfer,riskstratificationandoptimizationofotherco-morbidconditions.esign:RetrospectiveDescriptive Study. Materials and Methods: Patients who were admitted in the hospital from September 2017 to March 2018 and September 2018 to March 2019 were included in the study as two separate groups. The data was retrospectively collected from the Medical Records Department (MRD). Information regarding age/ sex, clinical presentation, laboratory findings, organ failures, arterial blood gas parameters, Chest -ray, durationofICstay,needformechanicalventilationandpre-existingco-morbiditieswascollected.Analysis: Categoricalvariableswerepresentedinnumbers.ThedatawasenteredinMSExcelspreadsheetandanalysis wasdoneusingSPSSversion22.0bycalculatingpercentages.Conclusion:Oldage,presenceofco-morbidities, lateadmissiontoatertiarycarehospital,inter-hospitaltransfer,lowPao2/Fio2ratioatthetimeofadmission were identified as the key factors for early mortality in 1N1 Influenza patients. Recommendation: etter protocolsaretobeformulatedforthemanagementofSwineflupositivepatientsincasesofinter-hospital patienttransfer,riskstratificationandoptimizationofotherco-morbidconditions. eyords:Inter-hospitaltransfer;Co-morbidities;Durationofillness;-sofascore;Murrayscore.

otocitethisarticle: Mohandeepaur,SeemaWasnik,DhirVinodbalaetalARetrospectiveStudyofPredictorsofMortalityin1N1Influenza AssociatedDeathsinaTertiaryCareospital.IndianJAnesthAnalg.2019;6(5Part-1):152-150.

Introduction on mortality associated with 1N1 virus related disease in India. ence, we are conducting this We conducted our study on Swine u patients study to assess the predictors of mortality in whowereadmittedinPGIMERandRMLospital Inuenzacausedby1N1virus. earmarkedfortreatingcriticallyillpatientsofSwine ufortwoconsecutiveyearsfromeptember2017to AimsandObjectives March2018andeptember2018toMarch201. This study was conducted to understand the Aimofthestudywastoidentifythecontributing contributing factors for Swine u associated factorscommonwithmortalitycasesofSwineu mortality of patients. There are very few studies andtodoriskstraticationofthesepatientsincase

CorrespondingAuthor:SeemaBWasnik,SeniorAnaesthesiologist,DepartmentofAnesthesiology,PGIMERandDrRMLospital, NewDelhi,India. Email:[email protected] eceiedon10.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1524 IndianJournalofAnesthesiaandAnalgesia ofinter-hospitalandintra-hospitaltransfertoIC. Guideline for Community Acuired Pneumonia Alsotondoutmodiablecontributingfactorsof (CAP)wereprescribed. mortalitytoachievereductioninmortality. CateoryC MaterialsandMethods In addition to the above signs and symptoms of CategoryAand,ifthepatienthadoneormoreof Patients reported to this hospital both from thefollowing: communityaswellasinter-hospitaltransfercases. (a) reathlessness,chestpain,drowsiness,fallin Anespeciallydedicatedfeverclinicismanagedin blood pressure, sputum mixed with blood, RMLospitaltoidentifySwineupatientsatthe bluishdiscolorationofnails. initialcourseofillness.TheannualOPDattendance (b) Childrenwithinuenzalikeillnesswhohad ofpatientswithrespiratoryillnessis2500inRML aseverediseaseasmanifestedbytheredag ospital,NewDelhi. signs(somnolence,highandpersistentfever, The patients attending fever clinic were inabilitytofeedwell,convulsions,shortness categorizedaccordingtotheguidelinesofMinistry ofbreath,difcultyinbreathing,etc.). ofealthandFamilyWelfare,IndiaforSwineu (c) Worseningofunderlyingchronicconditions. asperwhichpatientmayfallintoCategoryAtoC dependinguponthespectrumofdisease.1 AllthesepatientsmentionedaboveinCategory Creuiredtesting,immediatehospitalizationand treatment. CateoryA I. Allthecasesoffeverwithpneumoniawho Patients with mild fever plus cough, sore throat attended the fever clinic were kept under with or without headache, diarrhea, body ache, suspicionofbeingSwineupositiveunless andvomitingdidnotreuireOseltamivirandwere provennegativebylaboratoryreports.These managedsymptomaticallyathome. Notesting of patientswereshiftedtoaseparatededicated thepatientforInuenzawasreuired. ighDependencynitbytheDepartmentof Medicine.owever, thepatients whowere diagnosed Swine u positive by RT PCR Cateory test done in the laboratory and reuiring ventilatorsupportwerereferredtoSwineu 1. In addition to the signs and symptoms ICofthehospital. mentionedunderCategoryA,ifthepatient had severe sore throat and high grade II. Patientsincritical conditions referred from fever,homeisolationandOseltamivirwere other hospitals of NCR and Delhi were reuired. triaged in the casualty of RML ospital by Sofa Scoring and were sent to either 2. In addition to all the signs and symptoms the igh Dependency nit or the Swine mentioned under Category A, patients u IC depending on the SOFA.2 Score havingoneormoreofthefollowinghigh-risk uick()SOFA Score: ses three criteria, conditionsweretreatedwithOseltamivir: assigningonepointforlowloodPressure (a) Childrenwithmildillnessbutwith (SystolicloodPressure100mmg),high predisposingriskfactors. Respiratory Rate ( 22 breaths/minute) or (b) Pregnantwomen. altered mentation ( Glasgow coma scale 15).Thescorerangesfrom0–points.The (c) Personsaged5yearsorolder. presenceof2ormoreSOFApointsnearthe (d) Patients with lung diseases, heart onsetofinfection. disease, liver disease, kidney Thosereuiringinvasivemechanicalventilation disease, blood disorders, diabetes, wereshiftedtoSwineuICwhereasthosewho neurological disorders, cancer and could be managed with supplemental oxygen IV/AIDS. therapy and non-invasive methods of ventilation (e) Patients on long-term cortisone (CPAP/iPAP)weresenttotheighDependency therapy. nit(D). TestsforInuenzaarenotreuiredforCategory The Swine u IC is a six bedded IC. The (1)and(2).roadSpectrumantibioticsasperthe patients in Swine u IC were managed by IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ARetrospectiveStudyofPredictorsofMortalityin1N1 1525 InfluenzaAssociatedDeathsinaTertiaryCareospital anesthesiologiststeamofConsultantsandresident prolongedventilatorsupportandthosewithhigh doctors, nurses and technicians. On admission FiO2reuirementweretracheostomised;thosewith to IC the severity of patients lung injury was shockwerestartedoninotropes. assessedonthebasisofMurrayscoresapartfrom clinical and laboratory examination. This allowed StatisticalAnalysis the practitionerto form decision on thecourseof managementofthepatients. Categorical variables were presented in numbers. The data was retrospectively collected from The data was entered in MS Excel spread sheet the Medical Records Department (MRD). andanalysiswasdoneusingSPSSversion22.0by Patientswhowereadmittedinthehospitalfrom calculatingpercentages. eptember 2017 –March2018 and eptember 2018 – March201wereincludedinthestudy astwo yeofstudy separate groups. Information regarding age/ sex,clinicalspectrum,laboratoryndings,organ RetrospectiveDescriptiveStudy. failures, arterial blood gas parameters, chest ray,durationofICstay,needformechanical esults ventilation and pre-existing co-morbidities wascollected. Outof40conrmedcasesofSwineuwhoreuired CategoryCpatientswithInuenzalikesymptoms admission20(50) deathsoccurredintheyear of diagnosedinCasualtyorfeverclinicwereadmitted 2017–18and5outof4(81)admittedconrmed to SwineuDofRML ospital. Asampleof casesdiedintheyearof2018–1.Therewerealmost throatswabandnasalswabwascollectedforallthe eual no ofmale and female patients inboth the suspected cases of 1N1 Inuenza on the day of years.Mostofthepatientsweremorethan50years admissionbyatraineddoctorbeforeadministration ofage.Majorityofthedeathsoccurredwithin24hr oftheanti-viraldrug. of admission, ie., 40 in the year of 2017–18 and 1.4intheyear2018–1. SamleCollection Most common symptoms on presentation was A swab was inserted into one nostril straight cough(100), fever (100), breathlessness (60), back (not upwards) and horizontally to the followed by RI symptoms such as sore throat nasopharynxuptothemeasureddistanceonthe (5), headache (20), fatigue (16), common swabhandle.Theswabwasrotatedupto5times cold (12), joint pain (8). Other symptoms like andheldinplacefor5–10secondstocollectsample vomitinganddiarrhea(8.9),bleeding(5.)were material. The swab was removed and insert presentinalessernumberofpatients.Majorityof into a vial containing 1– ml of viral transport the patients (85) had more than one co-morbid media containing, protein stabilizer, antibiotics conditionslikediabetes,hypertension,pulmonary to discourage bacterial and fungal growth, and tuberculosis, coronary artery disease, chronic buffer solution. The specimens were kept at obstructive pulmonary disease, hypothyroidism. 4 degree Celsius until transported for testing. Only5ofpatientsdidnthaveanycomorbidities. The sample was transported to the designated laboratory of Microbiology Department (SL Mean duration of symptoms before admission Level 2), RML ospital or National Centre for to any hospital was 15 days. 75 of patients in DiseaseControl(NCDC)within24hourswhichis 2017–18 and 80 in 2018–19 were inter-hospital withintheacceptabledeadlineof4dayThosewho transfers. All the patients reuired mechanical wereadmittedassuspectedcasesbutcameoutto ventilation,outofwhich70reuiredPEEPmore benegativewereexcludedfromthestudy. then12.AlltheexpiredpatientshadalowPaO2/

The initial management of the conrmed cases FiO2ratio(00).60ofpatientshadacidosisat included Tablet Oseltamivir, broad spectrum thetimeofadmissionin2017–18,whereasacidosis antibiotics which were administered empirically was present in 54.2 patients in 2018–19 at the tothepatientsatthetimeofadmissionandfurther time of admission. On radiological evaluation management was done according to the culture 70 of cases had bilateral inltrate and 0 had and sensitivity reports along with the supportive unilateral inltrate in 2017–18, whereas 85 had treatment.Ventilatorysettingsweredoneasperthe bilateralinltratesand15hadunilateralinltrate protocolforARDSmanagement.Patientsreuiring in2018–19showedin(raphs

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1526 IndianJournalofAnesthesiaandAnalgesia

raph:ShowingdayofdeathduringICstay

raph:Showingco-morbiditiesassociatedwith1N1Influenza

raph:ShowingReferralsfromotherhospitalsin2017–2018

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ARetrospectiveStudyofPredictorsofMortalityin1N1 1527 InfluenzaAssociatedDeathsinaTertiaryCareospital

raph:ShowingReferralsfromotherhospitalsin2018–2019

raph:ShowingNumberofdeathsassociatedwithorganfailurein2017–2018

raph:Showingnumberofdeathsassociatedwithorganfailurein2018–2019

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1528 IndianJournalofAnesthesiaandAnalgesia

raph:PaO2/FiO2ratiodistributionin2017–2018inmortalitycases

raph:PaO2/FiO2ratiodistributionin2018–2019inmortalitycases

Discussion The average duration of symptoms before hospitaladmissionwasonetotwowees.According Westudiedtheclinicalprolesofpatientswhodied toMinistryofhealthandfamilywelfare(MOFW) guidelines,patients with symptoms suggestive of of1N1intheSwineuICandDduringthe periodofMarch–September2017–2018and2018–19 seasonalinuenzashouldhaveattendedthefever toidentifythepredictorsofmortalityinSwineu clinicimmediatelyatRMLospitalasitisthenodal patients.20deathswerereportedintheyear2017–18 centerfordiagnosisandmanagementofSwineu. outof40conrmedcasesofSwineuwhereasthere owever,inthisstudywefoundsubstantialdelay were5deathsreportedoutof4casesintheyear inadmissiontoourhospitalandthisworsenedthe 2018–1.ighestnumberofdeathsbelongedtothe prognosisofpatients.Ithasbeenfoundinprevious agegroupofmorethan 50yearsandwas eually studiesthatdelayinhospitaltransfersignicantly distributedbetweenmalesandfemalesinboththe increases mortality and morbidity of patients studyyears.Thesendingswereconsistentwitha further5 86 percent patients were referred from previousstudyonhospitalizedpatientswith1N1 privatehospitalsormanagedbylocalpractitioners inuenzaintheyear2004 initially which isnot according to guidelineslaid

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ARetrospectiveStudyofPredictorsofMortalityin1N1 1529 InfluenzaAssociatedDeathsinaTertiaryCareospital down by MOFW, Delhi. In this study, raph needstobedonetopreventtransferofpatientin and raph shows number of referral cases MODSandcriticalconditions. from otherhospitalsto RMLospital intheyear 2017–2018and2018–2019. eyessae When no improvement of the symptoms Moreemphasisshouldbeonpreventiveaspectlike was found after a few days of treatment, these public awareness about 1N1 Inuenza illness patients were referred to our center for further andwaysofpreventingitneedstobedone.There management. Inter hospital transfer plays a huge isaneedofproperco-ordinationbetweenprivate role in increasing the mortality as concluded by hospitals and Nodal centers for management of casecontrolstudyin2008,wherepatientsadmitted Swine u patients. A proper format needs to be toICfromanotherhospitalhavehigherhospital devised for inter-hospital transfer of patient. The mortalityandlongerstaythanthoseadmittedfrom formatshouldmentionthereasonfortransferand theOPDoremergencydepartment.6 conditionofpatientatthetimeoftransfer. In a single center retrospective study in 2018 it was concluded that critically ill patients may not Acnoledement benetfrominter-hospitaltransfer,insteadmaybe harmedbythepotentialcomplicationsandexpense We would like to thank Dr. Shipra, Dr. Archana, of transfer.7 Majority of these patients who were Dr, Sagari Senior Residents of Department of transferred from other hospitals were in severe Anesthesiologyfortheirguidanceandthenursing ARDS,haddevelopedsecondarybacterialinfections, staffANSsisterSaradaRavindran,sisterincharge and had worsening of underlying co-morbid JessyAntony,sisterinduAjithandSisterSudesh conditions, all of which could have contributed to bala of Swine u IC and Medical Records earlymortalityfollowingadmissiontoourhospital. DepartmentofPGIMER,DrRMLospitalfortheir cooperationandsupport. Majority ofthe patients who died of 1N1had more than one co-morbid conditions as shown ingraph , the most common onebeing diabetes eferences mellitus followed by hypertension similar to an IndianstudyonpandemicInuenzaAintheyear 8 1. GuidelinesonRiskcategorization.Availablefrom 200 Chronic pulmonary diseases like COPD, https://mohfw.gov.in/media/disease-alerts/ pulmonary tuberculosis were present in a less Seasonal-Influenza/technical-guidelines. number ofpatients incontrast to a study,9where 2. SOFA: uick sepsis related organ failure majority ofpatients admitted with Swine u had assessment, Available from; http://www.sofa. COPD and bronchial asthma. Due to underlying org2012. co-morbid conditions these patients have a . Murray JF, Matthay MA, Luce JM, et al An compromisedimmunesystemwhichwillpromote expanded definition of the adult respiratory rapid increase in viral load and hence delaying distress syndrome. Am Rev Respir Dis. response to treatment and worsening of the 1988;18:720–2. 10,11 co-morbidcondition. 4. Jain S, Schimitz AM, Louie j, et al ospitalized patients with the 2009 1N1 Influenza in Conclusion nited State, ENGl J Med. 2009 April–June;61: 195–944. More emphasis on preventive aspect like public 5. Flabouris A, art G, George C. Outcomes of patientsadmittedtotertiaryintensivecareunits awarenessabout1N1inuenzaillnessandways after interhospital transfer: Comparison with ofpreventingitneedstobedone.Needofproper patientsadmittedfromemergencydepartments. co-ordinationbetweenprivatehospitalsandNodal CritCareResusc.2008Jun;10(2):97–105. centersformanagementofSwineupatients.The 6. AnandR,GuptaA,GuptaA,etalManagementof private hospitals are accountable ininter-hospital SwineflupatientsintheIntensivecareunit;Our transfer of patients. A proper format needs to be experience; Journal of Anesthesiology Clinical devised for inter-hospital transfer of patient. The Pharmacology.2012;28(1);51–55. formatshouldmentionthereasonfortransferand 7. Jayshil JP, Jonathan , Al-Ghandour Easa, et al conditionofpatientatthetimeoftransfer.Mostof Predictors of 24 hr mortality after inter-hospital the patients are transferred because of monitory transfertoatertiarymedicalintensivecareunit. conditions of patient. A decision to subsidize the Journal of intensive care society. 2018;19(4); treatment of 1N1 patients in private hospital 19–25. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 150 IndianJournalofAnesthesiaandAnalgesia

8. Rajesh , Pramod V, Amin Chikitsa A, et al 10. ohio P, Adamson AL. Glycolytic control of Correlatesofseverediseaseinpatientsadmitted vacuolar-type ATPase activity: A mechanism with 2009 pandemic Influenza: A (1N1) to regulate Influenza viral infection. J Virology. infectioninSaurashtraregion,India.IndianJCrit 201;01–09. CareMed.2010;14():11–20. 11. ReadingPC,AllisonJ,CrouchEC,etalIncreased 9. Mcenna John J, ramley Anna M, Jacek S, susceptibilityofdiabetic micetoinfluenzavirus et al Asthma in patients hospitalized with infection: Compromise of collection-mediated pandemic Influenza: A (1N1) pdm 09 virus host defense of the lung by glucose. J Virol. infection,nitedStates.MCInfectiousDiseases. 1998;72:6884–87. 201;1:57.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):151-156 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.6

FactorsConsideredbyFinalYearMBBSStudentsinSelectingAnesthesia asaCareerChoice:AuestionnaireBasedStudy

ohitondikarVishanathShrutihatapanadiShridharNEkboteBalarauTC

1,2Assistant Professor, 1st ear Resident, 4,5Professor, Department of Anaesthesiology, Navodaya Medical College, Raichur, arnataka58410,India.

Abstract

acground:Smoothfunctioningofcountrieshealthcareservicesreuirebalanceddistributionofphysicians amongdifferentspecialities.Eachcountryneedstoexaminethefactorsinfluencingcareerspecialtypreference which will be helpful in future recruitment process. Aims: To assess the awareness and attitude towards anesthesiologyasacareeroptionandthefactorswhichinfluenceinmakingsuchachoice.Methods:Across- sectionalstudywasconductedonfinalyearMSstudentsinNavodayaMedicalCollege,Raichur.Asemi- structured,self-administereduestionnairecopywasdistributedtoatotalof11finalyearMSstudents and results were analyzed usingSPSS version IM 22. Results:The most preferred specialty was General Medicine(18.45),followedbygeneralsurgery(15.5)andorthopedics(14.56).Amongmalesthemost preferredspecialtywasgeneralmedicine(27.12)andamongfemalesobstetricsandgynecology(27.27) wasthemostpreferredspecialty.Themostcommonreasonfornotchoosinganesthesiaasacareerchoice waslackofrecognitionbypatients(24.71)andthemostcommonreasonbehindmakingacareerchoicewas personalinterest(19.42).0.8studentsfoundthatanesthesiaasaspecialtywasinterestingandlifesaving and7.5studentsfoundthatanesthesiapostingwasinterestingandimportant.Conclusion:Withonly2 studentschoosinganesthesia,itisvitaltoprovideadeuateaidsandemphasizeonthepositiveaspectsof anesthesiaamongtheundergraduatestocreateinterestinanesthesiologyasacareerchoice. eyords:Anesthesia;Careerchoice;MSstudents.

otocitethisarticle: Lohitondikar,Vishwanath,ShrutiGhatapanadi.etalFactorsConsideredbyFinalearMSStudentsinSelectingAnesthesia asaCareerChoice:AuestionnaireasedStudy.IndianJAnesthAnalg.2019;6(5Part-1):151-156.

Introduction Thechoiceofcareerspecialtymadebygraduating studentsandfactorsinvolvedin making a choice have an impact on the healthcare services of Thespecialtyofanesthesiologywhichwasconned the country. Studies on speciality preference totheoperatingroominthepasthasnowwidened are helpful to identify the possible inuencing its scope and includesIC management, trauma, factors,whichwillprovidevaluableinformationto acuteandchronicpainmanagement.Inspiteofits medicalworkforceplannersinformulatingfuture improvedscope,thenumberofstudentspreferring educationalprogrammesespecially whenthere is anesthesia as specialty is still signicantly low.1 undersupplyofdoctors.2,

CorrespondingAuthor:Vishanath,AssistantProfessor,DepartmentofAnaesthesiology,NavodayaMedicalCollege,Raichur, arnataka58410,India. Email:[email protected] eceiedon06.05.2019,Acceptedon08.06.2019

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Duringthecourseofmedicaleducation,students It included a list of 12 commonly preferred are exposed to a wide range of specialities, and specialitiesincludinganesthesia.Topthreechoices the exposure may signicantly affect the career intheorderofpreferencewereasked.Italsohad preference. Many factors inuence the choice of an option of not decided and others. The third career and include personal preferences, work part was reason for not choosing anesthesia as environment, awareness and knowledge about their preference. It had nine common reasons the scope of subject and practice hours. Gender listed and anoption to mention any otherreason is another important factor in career choice and thantheabovelisted.Thefourthpartofthestudy females usually choose pediatrics and obstetrics containedalistof14commonfactorsthatinuence andgynecology.2 the students in making a career choice. The top Thisstudyisaimedtoassesstheawarenessand threepreferredfactorswereasked.Italsoincluded attitudetowardsanesthesiologyasacareeroption anoptionoflistinganyotherfactors.Thefthpart and the factors which inuence in making such of the uestionnaire was about the perception of achoice. anesthesiabeforeandafterattendingthepostings. After collecting data from self reporting MaterialsandMethods uestionnaire,itwascodedandmanuallyentered into the computer for statistical analysis. The analysiswasdoneusingtheStatisticalPackagefor This study was conducted on nal year MS Social Sciences Software (SPSS, version IM 22). students of Navodaya Medical College, Raichur, Data analysis was performed using freuency arnataka. After obtaining approval from the anddiagrams. hospitalethicalcommittee,abrieftalkonthestudy was given to the students and informed consent wasobtained.Asemi-structured,self-administered esults uestionnaire copy was then administered to a total of 11 MS students in March 2019, who ThetotalnumberofnalyearMSstudentsinour had undergone their undergraduate training in institutewas11.Ofthis10studentsparticipated anesthesia.Theuestionnairewasdesignedtoelicit inthestudy,consistingof44females(42.71)and sociodemographiccharacteristics,preferenceabout 59 males (57.28). The mean age of respondents specialization, reason for not choosing anesthesia was21.47.Overallthemostpreferredcareerchoice asacareer,possiblefactorsthataffectedthechoice wasGeneralMedicine(19students,18.45).Itwas ofspecialityandperceptionaboutanesthesia. followedbygeneralsurgery(16students,15.5) The uestionnaire was designed in ve parts. as the second preferred choice and orthopedics The rst part included demographic data. The (15students,14.56)asthethirdpreferredchoice, second part of the uestionnaire was to nd the 7 students have not yet decided their specialty preferred speciality following their graduation. choice(Fig). Specialtychoicepreference

Notyetdecided Others Psychiatry Pulmonarymedicine ENT Ophthalmology Anesthesiology Specialtychoice(pref)

Radiology Specialtychoice(2pref) Dermatology Specialtychoice(1pref) Orthopedics Pediatrics ObstetricsandGynecology Generalmedicine Generalsurgery

0 5 10 15 20 Fig:Specialtychoicepreferences.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 FactorsConsideredbyFinalearMSStudentsinSelecting 15 AnesthesiaasaCareerChoice:AuestionnaireasedStudy

Among 59 males, 16 students (27.12) choose 24.71),followedbyitbeingadependantbranch generalmedicineasrstcareerchoicewhereasonly (16 students, 18.82) (Fig ). The most common females(6.82)choosegeneralmedicineasrst reasonbehindmakingacareerchoicewaspersonal careerchoice.12females(27.27)chooseobstetrics interest(20students,19.42),followedbyspecialty andgynecologyasrstcareerchoiceand2males recognition (1 students, 12.62) as the second (.9)chooseitasrstcareerchoice(Fig). preferred reason behind making a career choice Overallonly2(1.94)studentschooseanesthesia (Fig).2students(1.02)foundthatanesthesia asa rst career choice. Themostcommonreason asa specialty wasinteresting andlifesaving and for not choosing anesthesia as a career choice 9students(7.5)foundthat anesthesiaposting was lack of recognition by patients (21 students, wasinterestingandimportant(Table).

Fig:Specialtychoicegenderwise.

Fig:Reasonfornotchoosinganaesthesiaasacareer

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 154 IndianJournalofAnesthesiaandAnalgesia

Importnt factors in uencingcareer choice

Others FuturejobopportunityinAbroad Personalinterest Furthersuperspecializationnotreuired Genderpreferance(likeOG)

In uence offamilyandfriends pref Reuirementofspecializedskills pref2 Lowriskoflitigation Nonightcalls pref1 Lessworkinghours Fixedworkinghours Researchopportunity Intrestinteaching Specialtyrecognitionbypatients Financialremuneration 0 5 10 15 20 25 Fig:Importantfactorsinfluencingcareerchoice

Table:Importantfactorsinfluencingcareerchoice

AnesthesiaSpecialty Freuency Interestingandlifesaving 2 0.8 Challengingandupcoming 20 19.2 branch Multimodel 20 19.2 TooStressful 15 14.4 oring 8 7.7 Noidea 9 8.7 Total 104 100

Anesthesiaposting Freuency Interestingandimportant 9 7.5 Veryinformative 2 0.8 Tooshort 21 20.2 oring 12 11.5 Total 104 100

Discussion care.Thiswasattributedtolackofearlyexposure tothespecialty.4 Anesthesiologists play a very important role in Inour study wefound that themost preferred saving lives of critically ill patients by providing specialtywasgeneralmedicinefollowedbygeneral LS,ACLScare,managingcriticalpatientsinIC. surgery,orthopedicsandobstetricsandgynecology. This is in addition to its classic role of providing This was contrary to the other studies which the best and safe conditions for the performance showed general surgery was the most preferred of surgery, by doing pre-anesthetic evaluation specialty.2Inourstudy,wefoundthattherewasan andoptimisingthepatientsconditioninorderto associationbetweengenderandthechoiceoffuture reduce peri-operative morbidity and mortality, specialty.6 Among 59 males, 16 students (27.12) by providing peri-operative care.4,5 About three choosegeneralmedicineasrstcareerchoicewhere decadesago,itwasnotedthatthelackofinterest asonlyfemales(6.82)choosegeneralmedicine inanesthesiaasaspecialtywasbecauseitwasseen as rst career choice. 12 females (27.27) choose as unchallenging and lacking in primary patient obstetricsandgynecologyasrstcareerchoiceand IJAA/Volume6Number5(Part-I)/Sep-Oct2019 FactorsConsideredbyFinalearMSStudentsinSelecting 155 AnesthesiaasaCareerChoice:AuestionnaireasedStudy

2 males (.9) choose it as rst career choice.7,2 Conclusion The students cannot practice independently and hence do not have hands on experience out of Inourstudy,wehavefoundthatthemostpreferred their hospital setting, hence the surroundings in careerchoicewasgeneralmedicineandthemost whichthestudentsdotheirundergraduatestudies 7 commonreasonbehindmakingthecareerchoice inuencetheirspeciality choices. Traditionallyin was personal interest. We need to emphasise on ourcountryOGhasevolvedasafemaledominant thepositiveaspectsofanesthesiologylikesurging branchandmedicineasamaledominantbranch. trends towards intensivists and pain specialists Patientacceptanceofafemalegynecologistismore apart from the traditional subspecialties like and this is one of the reasons for less number of cardiac anesthesia, neuro anesthesia, obstetric maleschoosingOGastheirpreferredspecialty.8 anesthesia, pediatric anesthesia, bariatric Inourresearch,among10studentsonly2(2.08) anesthesia and regional anesthesia to create choose anesthesia as their rst preferred specialty interest regarding the specialty. Provision of choice. Number of students choosing anesthesia adeuate aids like manneuins and conducting as a second and third preference was more. This LS,ALStraining,simulationsandworkshopsat was consistent with studies conducted by han undergraduatelevelwillalsocreateinterestinthe et al9 On uestioning the reason for not choosing anesthesiaspecialty. anesthesia,wefoundthatthemostcommonreason SuortNil waslackofrecognitionbythepatientsfollowedby itbeingadependantbranch.Thismaybebecause, ConictsofinterestNil in developing countries like ours, there is lack ermissionsNil of awareness among patients about anesthesia.10 Whereasindevelopedcountriesthegeneralpublic eferences ismoreawareofanesthesiaandanesthesiologists.

The most common reason behind choosing 1. harS,DelA,harD,etalAnesthesiology:Asa a specialty among the undergraduate medical careerintheviewofnewpostgraduatestudents students was personal interest in the specialty pursuing this subject. International Journal of and this was consistent with ndings in study ealthSciencesandResearch.2015;5(9):15–60. 9 conducted by han et al but was in contrast to 2. hader , Al-oubi D, Amarin , et al Factors the study conducted by Dikici et al11 The second affecting medical students in formulating their factor inuencing career choice was specialty specialty preferences in Jordan. MC Medical recognitionbypatients.Thedurationofexposure Education.2008;8:2. ofundergraduatestudentstoaparticularspecialty . amat CA, Todakar M, Rangalakshmi S, varies with different institutes.4 This varied et al Awareness about scope of anesthesiology, exposure and also lack of provision of adeuate attitudestowardsthespecialityandstresslevels aids such as manneuin are all contributory amongstpostgraduatestudentsinanesthesiology. factorstotheproblemoflimitedornon-interestin A cross-sectional study. Indian J Anesth. anesthesia.4,12Thishasresultedinthediminishing 2015;59:110–17. of medical students clinical skills such as basic 4. Oku OO, OkuOA,Edentekhe T, et alSpecialty airway management, acute, and chronic pain choices among graduating medical students management,andbasiclifesupport. in niversity of Calabar, Nigeria: Implications for anesthesia practice. Ain-Shams Journal of In our study, we found that 1.02 students Anesthesiology.2014;07:485–90. thoughtanesthesiaasacareerwasimportantand 5. Smith A, Mannion S, Iohom G. Irish medical lifesavingand7.5studentsthoughtanesthesia studentsknowledgeandperceptionofanesthesia. asapostingwasimportantandinteresting. EducationinMedicineJournal.201;5(2):144. 6. Al-Nuaimi,McGroutherG,ayatA.Modernising imitations medical careers and factors influencing career choices of medical students. ritish journal of Thelimitationofourstudywasthatitwasasingle hospitalmedicine.2008;69():16–66. institute study. Compulsory Rotatory Internship 7. Alwad AAMA, han WS, AbdelrazigM, etal may change the specialty preference of the Factors considered by undergraduate medical studentsandthismaynotbeexactrepresentation students when selecting speciality of their of the career choice that will be made following future careers. Pan African Medical Journal. theirgraduation. 2015;2(102):1–6.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 156 IndianJournalofAnesthesiaandAnalgesia

8. Lefevre J, Roupret M, erneis S, et al Career based study. Indian Journal of Anesthesia and choices of medical students: A national survey Analgesia.2018;5(6):89–96. of 1780 students. Medical Education. 2010;44: 11. Dikici MF, aris F, Topseve P, et al Factors 60–12. affecting choice of specialty among first-year 9. han FA, Minai FN, Siddiui S. Anesthesia as medicalstudentsoffouruniversitiesindifferent a career choice in a developing country: Effect regionsofTurkey.CroatMedJ.2008;49:415–20. of clinical clerkship. J Park Med Association. 12. OnyekaTC,EwuzieNP.ChoiceofFutureCareer 2011;61(11):1052–56. amongst Medical Students in Enugu, Nigeria: 10. Shridhar N Ekbote, Mohan, et al Assessment Implications for anesthesia. Nigerian Journal of of patients knowledge regarding speciality of Surgery.2010;16(1,2):9–12. anesthesiaandanesthesiologists:Auestionnaire

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):157-159 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.7

AssessmentofnoledgeandAttituteToardsaborAnalgesiaamong PregnantWomaninMNMedicalCollegeandospital

PramodPundlikraohanapurkarNenaathSudheerumarNaik

1AssociateProfessor,2AssistantProfessor,DepartmentofAnesthesia,MNRMedicalCollegeandospital,Sangareddy,Telangana, 502285,India.

Abstract

ntroduction:Painduringlaborisoneofthemajordeterminantsofwomenschildbirthexperience.Epidural laboranalgesiaisthegoldstandardmethodnow-a-days,withnoharmfuleffectstotheneonatebut,beneficial effects has been observed. igh acceptance rate of labor analgesia is observed in Developed countries, therefore,theirdatafocusesonoverallbirthexperience.MaterialsandMethods:Descriptivestudywascarried outon120expectantmothersattendingtheantenatalOPDofMNRMedicalCollegeandospital,yderabad overaperiodof6months.Aftertakinginformedconsent120expectantmotherswereselectedbyconvenience samplingtechniue.nowledgewasassessedusingstructureduestionnaire.Attitudewasassessedusing pointLikertscaleconsistedof20statements.Results:Majorityofexpectantmothers,62(52)belongsto age-groupof28–1years,8(2)inage-groupof24–27years,10(8)inage-groupof20–2yearsandother 10(8)inage-groupof2–5years.Gravidadistributionofexpectantmothers,66(55)hadgravidaone, 46(8)hadgravidasecondandfew8(7)hadgravidathree.Conclusion:Mostofexpectantmothershad averagelevelofknowledgebutmajorityofhadpositiveattitude.MostoftheIndianparturientstillsufferfrom theagonyoflaborpainsduetolackofawareness,lackofavailabilityorknowledgeofavailabilityoflabor analgesiaservice.Theawarenesslevelneedstobeimproved. eyords:Laborpain;Epidurallaboranalgesia;Pregnantwomen.

otocitethisarticle: Pramod Pundlikrao. hanapurkar,Nenavath Sudheer umar Naik. Assessment of nowledge and Attitute Towards Labor AnalgesiaamongPregnantWomaninMNRMedicalCollegeandospital.IndianJAnesthAnalg.2019;6(5Part-1):157-159.

Introduction experience.8 In India, some information has been already documented to benet the pregnant Labor pain is one of the major determinants of womenabouttheuseofanalgesiaindelivery.The womens childbirth experience. Epidural labor veryfactthat,childbirthcanbeachievedwithout analgesia is the gold standard method,1,2 with no pain may seem absurd to many.9 Culture, up evidence of harm to the neonate,4 but, benecial bringing and ethnicity can inuence the attitude effects has been observed.5,6 Developed countries towards pain.10 Maternal reuest for pain relief have high acceptance rate of labor analgesia,7 sufcestheindicationforlaboranalgesiaaccording therefore, their data focuses on overall birth toAmericanSocietyofAnesthesiologists.11

CorrespondingAuthor:NenaathSudheerumarNaik,AssistantProfessor,DepartmentofAnesthesia,MNRMedicalCollegeand ospital,Sangareddy,Telangana,502285,India. Email:[email protected] eceiedon08.05.2019,Acceptedon19.06.2019

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Women who received labor analgesia were Figure2showsthat56(46.7)expectantmothers highlysatisedwithexperienceofchildbirth.12This had below average level of knowledge, 42 (5) survey, assessed the awareness and acceptance had average level of knowledge and 22 (18.) aboutlaboranalgesiaamongantenatalwomenand had good level of knowledge regarding epidural attemptedtopointoutthereasonsforimpediment analgesia.96.7hadpositiveattitudeandonly. fornotreceivinganalgesia.1 hadnegativeattitudetowardsepiduralanalgesia.

MaterialsandMethods

This study was carried out on 120 expectant mothers attending the antenatal OPD of MNR Medical College and ospital, yderabad over a period of months. Informed consent was taken and 120 expectant mothers were selected by convenience samplingtechniue. nowledgewas assessed using structured uestionnaire. Attitude wasassessedusingpointLikertscaleconsistedof 20statements. Fig:Revealsthepercentagedistributionofexpectantmothers aspertheirlevelofknowledgeregardingepiduralanalgesia InclusionCriteria Expectant mothers who were in third trimester of pregnancy attending antenatal OPD of MNR Medical College and ospital, yderabad, Telangana. Statistical analysis was done using Stata 11 software. Chi suare test was used to assessstatisticalsignicance.Ap-value0.05was consideredsignicant.

esults

Majorityofexpectantmothers,62(52)belonged toagegroupof28–1years,8(2)inagegroup of24–27years,10(8)inage-groupof20–2years Fig : Reveals that 96.70 had positive attitude ie showed willingness to opt epidural analgesia and only .0 had and other 10 (8) in age-group of 2–5 years. negativeattitudetowardsepiduralanalgesia. Distribution of expectant mothers according Thecorrelationwasstatisticallytested(r0.609) to gravida, 66 (55) subjects had gravida one, andfoundtobesignicant(p-0.001).Therewas 46(8)hadgravidasecondandfew 8(7)had moderatepositivecorrelationbetweenknowledge gravidathree(Fig.1). with attitude. ence, it can be concluded that therewaspositiveeffectofknowledgeonattitude regarding epidural analgesia among expectant mothers. There was signicant association of knowledgeandattitudewitheducation,occupation, habitat, previous knowledge regarding epidural analgesia,periodofgestationsat(p0.05)(Fig.).

Discussion

In the present study, knowledge and attitude regarding epidural analgesia among expectant mothers wasassessed. The ndings revealedthat outof120expectantmothers,56(46.7)expectant Fig:PercentagedistributionofpatientsaccordingtoGravida mothershadbelowaverage,42(5)hadaverage IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AssessmentofnowledgeandAttituteTowardsLaborAnalgesia 159 amongPregnantWomaninMNRMedicalCollegeandospital and 22 (18.) had good level of knowledge 2. Lederman RP, McCann DS, Work , et regarding epidural analgesia. Similar study al Endogenous plasma epinephrine and conducted by apadia Shital, Parmar artikeya, norepinephrine in last-trimester pregnancy and Solanki Nilesh and Patadia avita showed that labor.AmJObstetGynecol.1977;129(1):5–8. 95patients weretotally unawareoftheconcept . Shnider SM, Abboud T, Artal R, et al Maternal of labor analgesia.6 96.7 had positive attitude catecholamines decrease during labor after ie., showed willingness to opt epidural analgesia lumbarepiduralanalgesia.AmJObstetGynecol. 198;147:1–5. during delivery and only . had negative attitudetowardsepiduralanalgesia.Similarstudy 4. Lederman RP, Lederman E, Work , et al conducted by Shidhaye RV, Galande Mandar, Anxiety and epinephrine in multiparous labor: Relationship to duration of labor and angalVandSmitaJoshiresultsshowedthat69 fetal heart rate pattern. Am J Obstet Gynecol. expressed their rm willingness to get delivered 1985;15(8):870–77. without labor pains and out of them 26 were 5. Osterman MJ, Martin JA. Epidural and spinal very much eager for it, 25 showed inclination anesthesia use during labor: 27-state reporting forpainlesslaborbysayingthatthey maylikeit, area,2008.NatlVitalStatRep.2011Apr6;59(5):1- 5 whileonly6werenotatallinterested. Moderate 1,16. positivecorrelation(r0.609)betweenknowledge 6. Naithani , harwal P, Chauhan SS, et al andattitude.Asimilarstudyconductedbyanem nowledge,attitudeandacceptanceofantenatal F Mohamed in Riyadh showed that there was a women toward labor analgesia and cesarean signicant moderate correlation between parity section in a medical college hospital in India. andknowledge(r0.40,p0.000),income(r0.9, JObstetAnesthCritCare.2011;1:1–20. p0.001),education(r0.1,p0.000)andattitude 7. Shidhaye RV, Galande MV, et al Awareness (r0.1,0.000).4Therewassignicantassociationof andattitudetowards labour analgesiaofIndian knowledgeandattitudewitheducation,occupation, pregnant women. Anesth Pain and Intensive habitat, previous heard about epidural analgesia Care.2012;16(2):11–6. (p 0.05). A study conducted by Minhas MR, 8. James JN, Prakash S, Ponniah M. Awareness Rehana, Afshan Gauhar, Raheel afsa in arachi and attitudes towards labor pain and labor revealed that there was signicant association of pain relief of urban women attending a private knowledge and attitude with level of education antenatalclinicinChennai,India.IndianJournal andattendedantenatalclasses.7 ofAnesthesia.2012;56(2):195–98. 9. llman R, Smith LA, urns E, et al Parenteral opioids for maternal pain relief in labor. The Conclusion Cochrane database of systematic reviews. 2010;(9):CD00796. From this study. we are concluding that most of 10. Claahsen-vanderGrintenL,VerbruggenI,van expectantmothershadaveragelevelofknowledge den erg PP, et al Different pharmacokinetics but majority of had positive attitude. Most of of tramadol in mothers treated for labor pain the Indian parturient still suffer from the agony and in their neonates. Eur J Clin Pharmacol. of labor pains due to lack of awareness, lack 2005;61:52–29. of availability or knowledge of availability of 11. enderson , Matthews I, Adisesh A, et al labor analgesia service. The awareness levels in Occupational exposure of midwives to nitrous women needs to be improved. For this purpose, oxide on delivery suites. Occupational and evidencebasedinformationonepiduralanalgesia EnvironmentalMedicine.200;60(12):958–61. should be provided during antenatal period 12. Anim-SomuahM, SmythRM, Jones L. Epidural to improve knowledge and attitude regarding versus non-epidural or no analgesia in labor. epiduralanalgesia. CochraneDatabaseSystRev.2011;12:CD0001. 1. ruggemannOM,ParpinelliMA,OsisMJD,etal Supporttowomanbyacompanionofherchoice eferences duringchildbirth:Arandomizedcontrolledtrial. Reproductiveealth.2007;4:5. 1. Priscilla,rika,FaleirosSFAE.Validationof theratioscaleofthedifferentstypesofpain.Rev Latino-AmEnfermagem.2008;16(4):720–26.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1541-1545 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.8

Effect of Midaolam Premedication on Induction Dose of Propofol in AdultPatientsinElectieSurgery

AherPranaliYSangaleSapnilVSubhedharaeshMurugraShikumarSelaraanN

1,2Assistant Professor, Professor and ead, Department of Anaesthesia, Shri hausaheb ire Govt Medical College, Dhule, Maharashatra424001,India. 4ConsultantAnasthetic,5Professorandead,DepartmentofAnaesthesia,ovaiMedicalCenterand ospital,Coimbatore,TamilNadu641014.India.

Abstract

ntroduction: The study based on that midazolam pre-medication reduces the induction dose and cost of propofol. Aims: To study effect of midazolam pre-medication on induction dose of propofol in adult patients.Methods:Aprospectiverandomized,doubleblindcontrolstudywasconducted.Total60patients (16–45years)weredividedinto2groups.Group1received0.05mg/kgofMidazolamandGroup2received NormalSaline.Wecomparedtheinductiondoseofpropofolinbothgroups,takinglossofverbalcontactas theendpoint.Additionally,changesinhemodynamicstatuslikebloodpressureandheartrateandinduction timewerestudiedandcomparedinbothgroups.Results:ThedoseofPropofolreuiredtoinduceanesthesia inMidazolamgroupwas1.2mg/kgand2.27mg/kginthecontrolgroup.Thehemodynamicchangesin MidazolamgroupcomparedtoNSwerenon-significant.Conclusion:Werecommendmidazolamwhenused incombinationwithpropofolreducesthedoseofpropofolandthetimereuiredforinduction. eyord:Pre-medication;Midazolam;Induction;Propofol.

otocitethisarticle: AherPranjali,SangaleSwapnilV,SubhedharRajeshetalEffectofMidazolamPre-medicationonInductionDoseofPropofol inAdultPatientsinElectiveSurgery.IndianJAnesthAnalg.2019;6(5Part-1):1541-1545.

Introduction anesthesia.MckayACetaldocumentedsynergism inthestudy.5,6 Pre-medication1 refers to administration of drugs Propofol is well-established as anesthetic before induction and maintenance of anesthesia. inducing agent than thiopentone. Propofol and It allays pre-operative fear, anxiety and tension. midazolam combination is commonly used for Itfacilitaterapidandsmoothinductionofanesthesia. induction and it shows synergisticinteraction for Itproducesamnesia,sedationandanalgesia.Italso hypnosisandreexsympatheticsuppression.7–9 potentiates the anesthetic effects and hence may Some recent studies have shown that decrease the anesthetic reuirement. Srivastava administration of midazolam pre-medication etal,andAmrein R etalmentioned in their2–4 reduces the intravenous induction dose of that Co-induction is concurrent administration propofol. It reduces pain due to IV profopol of two or more drugs that facilitate induction of and hence it reduces cost of the anesthesia.10,11

Corresponding Author: Aher Pranali Y, Assistant Professor, Department of Anaesthesia, Shri hausaheb ire Govt Medical College,Dhule-424001.Maharashatra,India. Email:[email protected] eceiedon15.05.2019,Acceptedon08.06.2019

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Midazolamandpropofolco-inductionalsoleadto method by the anesthetic team not participating minimalhemodynamicchanges.Thetechniueof in the study but the researcher and the patient co-induction using two or more agents to induce wereunaware oftheir group. Either ofthe study anesthesia has been studied and synergism is drugsasprimingwereadministeredIV(Group1- reportedbetweennumberofinductionagentsand 005mggofMidazolam,Group2-normalsaline) midazolam.7,9,12 accordingtotherandomizationbytheteam,after pre-oxygenationforminutes,thestudydrugswas Objectives givenIVdilutedin10mlof normalsalineovera period of 10 seconds. After 0 seconds, anesthesia was induced by inj propofol 10 mgml in a 20 ml To study the effects of midazolam pre-treatment syringe at rate of 1 mlsecond, keeping continous oninductiondoseofpropofolanesthesiainadult verbal contact with the patient till loss of verbal patients and also to study the hemodynamic contact and the total amount of propofol given changeswithandwithoutmidazolamtopropofol. was noted. Following this regular anesthesia was givenwithoxygen,nitrousoxideandinhalational MeterialsandMethods anestheticagentwithorwithoutmusclerelaxantas pertheneedsoftheprocedure.Parametersassessed wereinductiontime,doseofpropofol,hypotension A randomized control double blind study was (Occurenceofbloodpressure0mmgsystolic), conductedattheDepartmentofAnesthesiaatour bradycardia(Incidenceofpulserate0min)and institute during theperiodof July2010–July 2012, pain on injection of propofol. Statistical Analysis after obtaining the approval of the institutional was done with SPSS and data was expressed as ethicalcommittee.Afterobtainingwritteninformed mean(standarddeviation)forcontinousvariables consent, total 60 patients belonging to both sex andproportionforualitativevariables.Students whowereundergoingelectivesurgicalprocedures undergeneralanesthesia,wereenrolled. t-test was used to test the statistical signicance foruantitativevariablesandchi-suareorsher exact test for ualitative variables. p 0.05 was InclusionCriteria consideredstatisticallysignicant. ASAGrade1and2ofagedbetween15and45years who were scheduled for various elective surgical proceduresunderGA. esults

clusionCriteria Theaverageageofthetotalpatientswere545years rangingfrom15to45years.Inthegroup1,themean Difcult intubation, patients having pharyngeal agewas5years,ingroup2itwas5years.Outof pathology,cardiovascularandpulmonarydisease, the60cases,1weremalesand29females.There on medications like benzodiazepine, clonidine or were11maleand19femalepatientsingroup1,20 betablockers. maleand10femalepatientsingroup2.Themean Pre-anestheticevaluationwasdoneinallpatients weightofpatientswas02grangingfrom40to a day prior to surgery. After detailed systemic 85g.In thegroup1,themeanweightwas07 evaluation, Patients who do not fall into our g,ingroup2itwas520g.Themajorityofthe inclusioncriteriawereexcluded.Allpatientswere patients in all the groups were ASA Gr 1 (90) explainedandafterreassurance,informedconsent however,6(10)wereinASAGr2ofbothgruop. wastaken.Allpatientswerekeptnilbymouthfor The average reuirement of Propofol varied atleasthourspriortosurgery.Nopre-medication signicantlybetween thegroups(p0.001),with wasgiven.Routineinvestigationslikehemoglobin mean80mginGroup1and14mginGroup and urine examination were done in all patients. 2 Mean Time reuired for induction in Group 1 loodsugar,SerumCreatinineandECGweredone was 15 secondsand inGroup2 was 545 seconds inpatientswithagemorethan40years.Onarrival (p 0.001). ypotension noted after induction intheoperationtheatre,IVaccesswasdonewith was 26.7 in Group 1 (midazolam propofol) 18 G canula. ECG, pulse oximeter and NIP and1.inGroup2(NSpropofol)while10 were applied for monitoring. Patients were then inGroup2ofpatientsonlyhadbradycardia.oth assignedrandomlyintotwogroupsnamely:Group ndings were non-signicant. Pain at the time of 1 (Midazolam Propofol) and Group 2 (Saline induction was . of patients in Group 1 and Propofol), according to the sealed envelope 6.7inGroup2.So96.7inGroup1and6. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectofMidazolamPre-medicationonInductionDoseofPropofolinAdultPatientsinElectiveSurgery 154 inGroup2patientsdidnthavecomplaintofpain hypoventilation. It is currently considered gold (2-10.41andp0.01)showedin(Tables. standard14,15forlaryngealmaskinsertion.Predosing withMidazolamisareliableandeffectivemethod Table:Genderdistributionofthepatients of reducing Propofol reuirement. This study was undertaken to see the effectiveness of midazolam Se roup roup pre-medication on induction dose of propofol Male 11(6.6) 20(66.7) in adult patients. In our study, induction dose, Female 19(6.7) 10(.) induction time, hypotesion, bradycardia and pain Total 0(100) 0(100) werecomparedbetweenbothgroups.Inourstudy, meaninductiondosewas80mginGroup1while Table:Ageandweightofthepatient 14mginGroup2(p0.001)whenlossofresponse Parameter roup Mean SD tValue Probability toverbalcommand,lossofeyelashreexandlossof Age 1 5.90 7.685 0.46 0.645 consciousnesswastakenasendpointofinduction.10 16 2 5 7.5 Same observed in Shahin Jamil et al study , that Weight 1 60.7 11.07 0.628 0.52 midazolam pre-medication is effective in reducing 2 59.20 7.122 theinductiondoseofpropofolandalsotheadverse effects due to higher induction dose of propofol. SD:Standarddeviation. It also decreased the incidence of apnoea, but no clearbenetsintermsofeaseofLMAinsertionand Table:Inductiondoseofpropofol cardiovascularstability.ShahinJamiletalconducted roupn MeanDose SD Value astudyon60ASA1and2patients,aged15–45years Group1(0) 80. 28.61 0.001 forvarioussurgicalprocedureswith0patientsin Group2(0) 14.66 24.0 eachgroup(n0).GroupA(studygroup)received SD–Standarddeviation. 005 mgg midazolam while Group (control) had saline as a pre-medicantion intravenously, Table:Inductiontimeofpropofol followed by Fentanyl 1 mgg after 0 seconds of pre-medication. All patients were induced with roupn Mean SD propofol(15mgg)0secondsafterfentanylbolus. Group1(0) 1.5 12.26 p-Value0.001 Our study can be compared with another study t-Value6.581 Group2(0) 54.5 14.70 conductedbyumarAetal17whoobservedthat SD–Standarddeviation there was 27.48 reduction in the induction dose of Propofol by applying priming principle. In his Table:emodynemicchanges study17 both the control group and the Propofol

Parameter roup roup priminggroupreceivedMidazolam(005mgg)as a pre-medication and Fentanyl 15 minutes prior to ypotension Present 8(26.7) 4(1.) theinduction.InstudyofOliverGWilder-Smith18 Absent 22(7.) 26(86.7) whichwasacontrolled,randomized,doubleblind radycardia Present 0(0) (10) prospectivestudyof24patients,whoreceivedeither Absent 0(100) 27(90) midazolam005mggorsalineplaceboasIVpre- Pain Present 1(.) 11(.) medication20minutespriortoinduction,concluded Absent 29(96.7) 19(66.7) midazolam pre-medication reduces the induction Sedation Present 1(.) 0(0) doseofpropofolwithoutaffectinghemodynamics. Absent 29(96.7) 0(100) AndersonLetal,ShortTGetal,McCluneSetal, used midazolam and propofol combination for Discussion inducing patients and concluded in their study that midazolam and propofol shows synergistic Propofol is a popular intravenous agent used to interactionswhenmidazolamusedinsub-anesthetic induce for general anesthesia, with a property to dosesandreducesthedoseofpropofolreuiredfor 4,5,6,7,9 suppresses the upper airway reexes adeuately induction via a synergistic action. In various 19 20 apartfromproducingarapidinduction.Whenused studieslikeDriverIetal ,JonesNaetal ,GillPS 21 22 2 as a sole agent, children reuire a larger dose of et al , Cressey DM , Martlew RA et al observed propofolforinsertionoflaryngealmaskairwaythan thatuseofmidazolamreducestheinductiondoseof adult.7,1Thislargedoseneededforinductionmay propofolandalsoactssynergistically. beassociatedwithhemodynamicalandrespiratory We also found signicant induction time of effect like hypotension, bradycardia, apnea or propofol. Mean induction time of Group 1 was

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1544 IndianJournalofAnesthesiaandAnalgesia

15secondsandthatofGroup2was545seconds. 2. Srivastava,SharmaDN,umarA,etalSmall Our ndingsarecomparablewithstudyofushi dose of propofol or ketamine as an alternative Adachi,azuhikoWatanableetal24,McayAC.5 to midazolam coinduction to propofol. Indian J Anesth.2006;50:112–14. radycardia noticed only in patients (10) . AmreinR,etzelW.Co-inductionofanesthesia: of Group 2 and none in Group 1 which was not Therational.EurJAnesthesiolsuppl.1995;12:5–11. signicant. Our ndings agrees with Goel S etal25,DjaianiGetal26 andWhitwanetal27,who 4. Anderson J, Robb . A comparison of midazolam co-induction with propofol used midazolam as co-induction agent along pre-disposing for induction of anesthesia. with propofol, noticed bradycardia which was Anesthesia1998;5:1117–129. non-signicant. Though hypotension observed 5. McayAC.SynergismamongI.V.Anesthetics.r at the time of induction was higher in Group JAnaes.1991;67:1–. 1 (26.7) than in Group 2 (1.) but it was not signicant.Thisobservationcanbecomparedwith 6. erenbaum MC. What is synergy Pharmacol Rev.1989;41:9–141. observations of Djaiani G et al26, Anderson et al4, JonesNaetal20,ShortTGetal7,ReinhartDJetal28 7. Short TG, Chui PT. Propofol and midazolam found no signicant difference in hypotension act synergistically in combination. r J Anes. 1991;67:59–45. observed in their studies when midazolam and propofolareuedasco-inductionagent. 8. McClune S, Mckay AC. Midazolam and propofolforinductionofanesthesia.rJAnesth. Pain observed at the time of induction was 1991;67:215–16. .inGroup1and6.7inGroup2whichwas 9. McClune S, Mckay AC. Synergistic interaction asignicant(p0.01).Lesspainwasobservedin betweenmidazolamandpropofolrJAnaesth patientswhoreceivedmidazolambeforepropofol, 1992;69:240–45. 21 11 in study of Gill PS et al , Edomwonyi N et al , 10. Jalota Leena, alira Vicki, Shi ung-ing. 10 LeenaJalotaetal Prevention of pain on injection of propofol: Systematic review and meta-analysis. MJ Conclusion 2001;42:d1110. 11. Edomwonyi NP, Okonofua A, Weerasinghe AS, et al A comparative study of induction This study shows that Midazolam if used as a and recovery characteristics of propofol and co-inductant, signicantly reduces the induction midazolam. Niger Postgrad Med J. 2001 dose and induction time of Propofol anesthesia. June;8(2):81–5. It also reduces the pain caused by intravenous 12. Vinik R, radley. Midazolam-alfentanyl propofol.Itdidnotproducesignifanthemodynamic synergism for anesthetic induction in patients. instabilityoranyunduedelayinrecovery.Sowe AnesthAnalg.1989;69:21–17. canrecommendmidazolamasaco-inductingagent 1. annallah RS, aker S, Casey WM, anditalsoreducesthecostofpropofolreuiredfor et al Propofol: Effective dose and induction inductionwhichisbenecialforourpatientsina characteristics in un-premedicated children. developingcountry. Anesthesiology.1991;74:217–19. 14. SJoowan,JPerksWilliam.Sevofluraneversus eyassae propofol for Anesthetic induction: A meta- analysis.AnesthAnalg.2000;91:21-19. Midazolam pre-medication reduces the induction 15. Mary E Molloy. Propofol or sevoflurane for doseandtimeforpropofol. laryngealmaskairwayinsertion.CanJAnesthesia. SourceofsuortNone. 1999;46:22–26. 16. N Jamil Shahin, Mitra Jayanta, Ahmed Md ConictininterestNonestated. Nesar,etalEffectofmidazolampre-medication CometinInterestNonestated. on induction dose reuirements of propofol in combination with fentanyl in adult patients. JAnesthclinpharmacol.2010;26():11–14. eferences 17. umarA,SanikopCS,oturPF.Effectofpriming principle on the induction dose reuirement 1. JaapV,ElskeS,MarijeR.IntravenousAnesthetics. of propofol: A RCT. Indian J Anesthesia. In: Miller RD, Eriksson LI, Fleischer LA, editor. 2006;50(4):28–87. th Millers Anesthesia, 8 edition. Philadelphia: 18. G Wilder-Smith Oliver, A Patric, Laurent A ChurchillLivingstone;2014.pp.841–42. Ravussin,etalInteractions betweenmidazolam

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pre-medication and propofol infusion induction 24. ushiAdachi,azuhikaWatanable,ideyuki of anesthesia for multiple anesthetic endpoints iguchi. A small dose of midazolam decreases including:CanadianJournalofAnesthesia.2001 time to achieve hypnosis without delaying May,48(5):49–45. emergenceduringshort-termpropofolanesthesia. 19. Driver I, Wiltshire S, Mills P, Midazolam JournalofclinicalAnesthesia.2001June;277–80. co-induction and laryngeal mask insertion. 25. Goel S, haradwaj N, Jain , et al Efficacy of Anesthesia.1996Aug;51(8):782–84. etamineandMidazolamasco-inductionagents 20. Jones NA, Elliott S, night J. A comparison with propofol for laryngeal mask insertion in between midazolam co-induction and propofol children.PediatricAnesthesia.2008;18:628–4. pre-dosingfortheinductionofanesthesiainthe 26. Djaiani G, Ribes-Pastor MP. Propofol elderly.Anesthesia.2002Jul;57(7):649–5. auto-co-inductionasanalternativetomidazolam 21. Gill PS, Shah J, Ogilvy A. Midazolam reduces co-inductionforambulatorysurgery.Anesthesia. the induction dose of propofol and laryngeal 1999Jan;54(1):6–67. mass airway insertion. Eur J Anesthesiol. 2001 27. Whitwam JG. Co-induction of anesthesia: Mar;18():166–70. day-case surgery. Eur J Anesthesiol Suppl. 1995 22. Cressy DM, Claydon P. Effect of midazolam Nov;12:25–4. pre-treatment on induction dose reuirement of 28. ReinhartDJ,GrumDR,erryJ,etalOutpatient propofolincombinationwithfentanylinyounger generalanesthesia:Acomparisonofacombination andolderpatients.Anesthesia.2001;56:108–1. ofmidazolampluspropofolandpropofolalone. 2. MartlewRA,MeakinG,WadsworthR,etalDose JClinAnesth.1997March;9(2):10–7. of propofol for laryngealmask airway insertion in children: Effect of pre-medication with midazolam.rJAnesth.1996Feb;76(2):08–09.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1547-1552 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.9

etamineasanAdunctithBupiacaineinSuidedParaertebral AnalgesiaforModifiedadicalMastectomy

aeePraapatOmPrakashSutharMTak

1Consultant Anaesthesiologist, Department of Anesthesiology, Shri Sidhivinayak ospital, Sumerpur, Pali, Rajasthan 06902, India.2AssociateProfessor,DepartmentofAnesthesiology,GovernmentMedicalCollege,Pali,Rajasthan06401,India.Professor, DepartmentofAnesthesiologyandCriticalCare,Dr.SNMedicalCollegeandAssociatedGroupofospitals,Jodhpur,Rajasthan 4200,India.

Abstract

acground:Adjuvantslikefentanylandclonidinehavefoundtoprolongthedurationofanalgesiawhen usedalongwithlocalanestheticintheparavertebralspaceforbreastsurgery.Thisstudywasplannedtostudy theeffectofadditionofketaminetobupivacaineforparavertebralblockonintra-operativeandpost-operative analgesiainpatientundergoingmodifiedradicalmastectomyundergeneralanesthesia.MaterialsandMethods: Thisprospective,randomized,controlleddoubleblindstudywasconductedin60womenofASAgradeI–III agebetween18to70yearswhounderwentmodifiedradicalmastectomy.GroupAconsistedof0patients receivingPVwith0.ml/kgof0.25bupivacaineand1mlnormalsalinepriortoGAandGroupconsisted of0patientsreceivingPVwith0.5mg/kgketaminealongwith0.ml/kgof0.25bupivacaineinnormal saline prior to GA. Intra-operative supplemental fentanyl consumption, hemodynamic parameter, pain scoreandpost-operativemorphineconsumptionwerecompared.Results:Themeanintra-operativefentanyl consumptionreuirementingroupAwas21.9521.58g,and12.819.9gingroup.(p0.828)60 ofthepatientsingroupAdidnotreuireanyanalgesicsupplementationwhichwascomparabletothatin group(6.).Firstreuirementofrescueanalgesiainpost-operativeperiodwasafter.62.55hrin groupAand.12.84hringroup,(p0.480).ThemeanVASvaluesinboththegroupswerestatistically comparableatrestandaswellasonmovement.(p0.05).Conclusion:Thepresentstudy,showedthatthe additionofketaminetobupivacainedidnotimprovetheefficacyordurationofparavertebralanalgesiainthe post-operativeandintra-operativeperiodinpatientsundergoingmodifiedradicalmastectomy. eyords:Paravertebralblock;Analgesia;etamine;upivacaine;Modifiedradicalmastectomy.

otocitethisarticle: RajeevPrajapat,OmPrakashSuthar,MLTak.etamineasanAdjunctwithupivacaineinSGGuidedParavertebralAnalgesia forModifiedRadicalMastectomy.IndianJAnesthAnalg.2019;6(5Part-1):1547-1552.

Introduction removaloftheentirebreastandaxillarydissection, in which levels I and II of axillary lymph nodes Surgeryinformofeitherlumpectomyormodied are removed. reast surgery is freuently radical mastectomy with axillary nodedissection, associated with nausea, vomiting, pain and pain incombinationwithchemotherapyorradiotherapy restrictedmovement. remainsthetreatment ofchoiceforbreast cancer. Pain, according to denition endorsed by the Modied Radical Mastectomy (MRM) includes International Association for the Study of Pain

CorrespondingAuthor:OmPrakashSuthar,AssociateProfessor,DepartmentofAnesthesiology,GovermentMedicalCollege,Pali, Rajasthan06401,India. Email:[email protected] eceiedon11.05.2019,Acceptedon08.06.2019

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(IASP), is unpleasant sensory and emotional MaterialsandMethods experienceassociatedwithactualorpotentialtissue damage, or described in term of such damage.1 This prospective, randomized, controlled double Post-operative pain managed in adeuately, is blind study was conducted in the Department of documented to have several pathophysiological Anesthesiology and Intensive Care nit at SN as well as economic implications, eg., increased MedicalCollege,Jodhpur.60womenofASAGrade morbidity, duration of hospital stay and cost of I–IIIagebetween18and70yearswhounderwent medicalcare. modied radical mastectomy were included in Awidevarietyofanalgesictechniuelikelocal studyonlyafterapprovalfrom InstitutionEthical anestheticinlteration,paravertebralandneuroxial Committeeandwritteninformedconsentfromeach analgesia, anti-convulsant, anti-neuropathic patientweretaken.Patientswithlocalsepsisatsite analgesic and NMDA (-Methyl -Aspartate) ofblock,severechestwalldeformity,coagulopathy antagonist,apartfromopioidsbasedtechniueare or patient receiving any anticoagulants (platelet employed for managing post-operative surgical 1,00,000), INR 1.5, known hypersensitivity to pain following breast surgery. It is increasingly amidetypeoflocalanesthetics,pregnancy,breast recognized that complex chronic pain syndrome feeding and severe obesity MI 5 gm2 were maydevelopmonthstoyearslater,ifthisacutepost- excludedfromthestudy.Thepatientsselectedfor operativepainisleftuntreatedorundertreated.2 thestudywereallocatedtoeithergroupAorusing computergeneratedlistofrandompermutationsin Paravertebral lock (PV) for MRM was rst doubleblindmanner: described in April 1994 by Greegrass et al e adapted the block for use in breast surgery, after Group A: Consisted of patients receiving PV surgeons asked for a way to prevent the intense withbupivacainepriorto GA.(0mlgof0.25 side effects caused by general anesthesia (GA) bupivacaineand1mlnormalsaline). precluding ambulatory surgery. The techniue Group : Consisted of patients receiving PV usedwasmodiedbyEasonandWyattstechniue, with bupivacaine with ketamine prior to GA whichwassimple to administered.4efore Eason (05mggketaminealongwith0mlgof0.25 and Wyatts described and standardized the bupivacaineinnormalsaline). techniue,variousothertechniueswereusedby The test solution was prepared by a fellow differentauthors. anesthesiologistwhowasnotinvolvedinthestudy PV givenpriorto induction of GA, for breast so as to double blind the study. All the selected surgery is known to provide improved intra- patients underwent a routine pre-anesthetic operativeandpost-operativeanalgesia,decreased assessment, including explanation to the patient incidenceofnauseaandvomiting,reducedsurgical on post-operative pain assessment scale through stressresponseandimprovedpatientsatisfaction. visual analog scale (VAS). All the patients Therefore, ThoracicParavertebrallock(TPV)is included in the study were premedicated with thetechniueofinjectinglocalanestheticadjacent oral alprazolam 025 mg two hours before the to the thoracic vertebra close to where the spinal procedure. All of them were properly explained nerve emerges from the intervertebral foramen. regarding the procedure of giving paravertebral This result in ipsilateral somatic and sympathetic blockandwerepre-loadedwith10–15mlgringer nerveblockadeinmultiplecontiguousdermatomes lactateafterI.V.lineestablishedwith18Gcannula aboveandbelowtheinjectionsite.5 on opposite hand. aseline parameters including Adjuvants like fentanyl and clonidine have pulse rate, Non-invasive lood Pressure (NIP), already been used along with local anesthetic in oxygen saturation (SpO2) and Respiratory Rate the paravertebral space for breast surgery and (RR)wererecordedbeforestartingPVandbefore havefoundtoprolongthedurationofanalgesia.6 induction.Theparavertebralblockwasperformed The addition of ketamine to a local anesthetic priortoinductionofgeneralanesthesia. or other analgesic in peripheral or neuroaxial All the patients received general anesthesia anesthesia and analgesia improve or prolong withouttestingthesensorylevelattainedbyTPV. pain relief.7,8 ence, this study was planned Allpatientspremedicatedwithondansetron4mg to study the effect of addition of ketamine to and glycopyrrolate 02 mg, then patients were bupivacaine for paravertebral block on intra- inducedwithpropofol(15–25mgg,I.V.).Muscle operativeandpost-operativeanalgesiainpatient relaxationwasprovidedwithvecuroniumbromide undergoing modied radical mastectomy under afterconrmingadeuacyofventilationafterloss generalanesthesia. of consciousness with propofol and the airway IJAA/Volume6Number5(Part-I)/Sep-Oct2019 etamineasanAdjunctwithupivacaineinSGGuided 1549 ParavertebralAnalgesiaforModifiedRadicalMastectomy was secured with appropriate sizeofendotraheal anti-emetic drugs use) were analyzed using tube.Theanesthesiawasmaintainedwithoxygen, the chi-suare test or Fischers test, whichever isouraneandvecuroniumbromide.TheEtCO2was applicable.Ap-valuelessthan0.05wasconsidered maintained between 5–40 mm g. Supplemental signicantforallparameters. analgesia was provided with fentanyl 05 gg) on thebasisofriseinheartrateorsystolicblood esults pressure by more than 20 of the base values for more than 5 minutes (inadeuate PV was suspected). No other analgesia was administered Demographic data of all the patients in both the intra-operatively. The number of doses and the groupswerefoundcomparable(p0.05).Themean totalamountofsupplementanalgesiawithfentanyl ageofthepatientsingroupAwas510181years intra operatively was recorded for comparison comparedto54.45.67ingroup.Thisdifference betweenthetwogroups.Mephenterminemgwas wasstatisticallynotsignicant(p0.757)(Table). giveninI.V.incrementaldosetotreathypotension. The fentanyl consumption was found between ContinuousmonitoringofR,NIP,SpO and 0 and 75 g in group A, 0 and 70 g in group . 2 The mean intra-operative fentanyl consumption EtCO2 were done in the intra-operative period andthesewererecordedevery15minutes.yend reuirementingroupAwas2152158g,while of surgery vecuronium effect was antagonized ingroupitwas1281g.Thisdifference by I.V. Neostigmine 50 gg (max. 5 mg) with wasstatisticallynon-signicant. glycopyrrolate 5 gg. After emergence patients (p 0.828) 60 ofthe patients in group A did were transferred to recovery room for a 2 hour not reuire any analgesic supplementation which observation period. Analgesia in recovery room wascomparabletothatingroup,where6.of was provided by morphine 1 mg I.V. as rescue thepatientsdidnotreuireanysupplementationof medication, if needed, every 10 minutes (a maxi. fentanyl(Table). limitof20mgin4hours)untilpainVASscorewas First reuirement of rescue analgesia in post- .Timetorstusingthemorphinewasrecorded operativeperiodwasafter255hrand1 and total dose of morphine was also calculated. 284hringroupAandrespectivelywhichwas R, NIP, SpO , RR and VAS score were also 2 statisticallynon-signicant.(p0.480)17(28.) recordedat0,2,6,12and24hoursafterthesurgery. out of 60 patients consumed more than 0 mg of Ondansetron (4 mg I.V.) was given 8 hourly as morphinein24hours.Amongthese8wereingroup needed. Any psychomimetic changes (dened A and 9 patients from group . The cumulative by agitation, hallucination or vivid dream) were consumption of morphine in both the group was alsoreported. comparable.(p0.05)(Table). Data was recorded in Microsoft excel 2007 ThemeanVASvaluesinboththegroupswere format and analyzed using SPSS version 15.0. statistically comparable at rest and as well as on Continuous variable (age, weight, intra-operative movement(coughing)(p0.05)(Table). supplemental fentanyl consumption, duration of surgery, hemodynamic parameter, respiratory Intra-operative and post-operative heart rate,PONVscores,painscoreandpost-operative rate, systolic blood pressure and diastolic blood morphine consumption) were compared and pressure, SpO2 and EtCO2 were recorded at 0 2 analyze using student t test. ualitative data 12and24hourspost-operatively.Therecording (presence or absence of side effects and rescue at all interval were found comparable in both

Table:Demographicandothercharacteristicsofboththegroups

roupA roupB alue MeanSD MeanSD Age(yrs) 51.01.81 49.91.67 0.757 Weight(g) 54.45.67 54.57.8 0.104 ASAgrade 1.770.49 1.80.67 0.658 Meandurationofsurgery(minutes) 10.816.15 108.14.47 0.29 Intra-operativefentanylconsumption(ug) 21.9521.58 12.819.9 0.828 Timeoffirstreuirementofrescueanalgesia-morphine(hr) .62.55 .12.84 0.480 24consumptionofrescueanalgesia-morphine(mg) 24.067.29 25.275.965 0.486

p-value(0.05)non-significantforallparameters.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1550 IndianJournalofAnesthesiaandAnalgesia

Table:Post-operativeVASscoreatrestandonmovement

Timeof VASscoreatrest VASscoreonmoement measurement MeanSD MeanSD hr roupA roupB palue roupA roupB palue 0 2.581.27 2.971.6 0.244 5.1.2 5.901.0 0.069 2 2.20.61 2.480.68 0.21 4.40.68 4.900.76 0.075 6 1.900.50 2.060.45 0.181 .470.57 .770.6 0.057 12 1.770.50 2.00.65 0.81 2.870.57 .070.67 0.227 24 1.80.40 1.90.75 0.527 2.560.6 2.80.79 0.15 p-value(0.05)non-significantatallintervalsatrestaswellasonmovement. the groups. This difference was not statistically could not be checked as general anesthesia was signicant. (p 0.05) There was no incidence of inducedimmediatelyfollowingblock. urinary retention, pruritus, pneumothorax or SingleinjectionPVatT4levelwasfoundtobe respiratorydepressioninanyofthegroup.7outof asuitablealternativetoGAinwomenundergoing the10patientwithPost-operativeNausea-vomiting breastsurgerybyPuschetal11Themultisegmental (PONV) in group A reuired anti-emetic; while spreadofsingleinjectionparavertebralblockwas 5 out of 8 patients with PONV reuired rescue conrmed by Saito et al in a voluntary study.12 anti-emeticingroup. urlacuetalalsoconrmedtheefcacyofsingle 6 injectionparavertebralblockatT4level. Discussion Oneofwaysinwhichtheefcacyofblockcanbe assessedischeckingforsensorylossforpinprick, Pain isa criticalfocusof patientcare. Substantial which could not be assessed in this study as GA improvement in knowledge of mechanisms and was immediatelyinducedafter performingblock. treatment of pain has been outcome of extensive ut as a surrogate to checking of sensory loss, research, but unfortunately, this has not been intra-operative analgesic reuirement was used. translated into appropriate patient satisfaction. ThemeanfentanylconsumptioningroupsAand Post-operative pain is still inadeuately relieved. werecomparable.Thedifferencewasstatistically This study focusing on alleviating the acute non-signicant.About60ingroupAand6. post-operativepainfollowingMRMbyperforming ingrouppatientsdidnotreuirefentanylintra- PVandprolongingthisdurationofanalgesiaby operatively.Thus,blockwasfullyeffectiveinthese additionofanadjuvantinformofetaminealong patients. In the rest ofthe patients the block was withlocalanestheticsinPV. eitherpartiallyeffectiveorfailed. The demographic parameters of the patients Moore et al described that there is a tendency includedinboththegroupswerecomparableinthis forcaudalspreadofthedrugswheninjectedinto study.Thedurationofsurgeryinthebothgroups paravertebral space.1 This explain inadeuate wasalsocomparable.Thevariationindurationof blockat T1dermatomeinthisstudy,astheblock surgery among these patients could be attributed was performed at T4 level. In this study, sitting to the varied skill and expertise of the operative posture was used for performing block, which surgeonandintra-operativending. couldnotinuencedspreadofdrugsinTPVS. In present study, paravertebral block was The VAS scores at rest in the immediate post- combined with GA. For the same reason 0.25 operative period were comparable in the both upivacaine was used instead of 0.5. urlacu groups.Thismightbebecauseofanalgesiaprovided et al too had combined single shot paravertebral by block and fentanyl supplementation provided block(0.25bupivacaine)withGA.Paravertebral intra-operatively, which continued with PCA spaceisnotasisolatedstructurebutcommunicates morphineintheimmediatepost-operativeperiods withparavertebralspaceaboveandbelow.9Thus, in the both groups. This is similar to observation inthisstudySGguidedtechniuewasperformed made in other studies which showed low pain instead of blind techniue, this was to ensure an scores in immediate post-operative period.6 The increasedprobabilityofsuccessfulblock.Theblock subseuent VAS scores on movement were also wasperformedjustpriortoinductionofanesthesia. comparableinboththegroups.Thiswasbecauseof Theonsetofblockuotedinvariousstudiesvaries theparticipantshadalreadybeeninstructedtocall from 10–20minutes.10Thesensoryblockhowever, nursetoinjectmorphineinordertomaintaintheir

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 etamineasanAdjunctwithupivacaineinSGGuided 1551 ParavertebralAnalgesiaforModifiedRadicalMastectomy pain score less than 4. VAS score greater than also comparable between both the groups. This wasconsideredthecutoffforinadeuateanalgesia couldbebecauseofmaintaininglowerpainscores basedonseveralstudiesreviewedbyDolinetal14 inboththegroups. The efcacy of block was also assessed with The PV techniue is associated with certain morphine consumption in post-operative period complicationlikepleuralpuncture,pneumothorax, in the both groups. First reuirement of rescue epiduralorsubarachnoidplacement,intravascular analgesiainpost-operativeperiodweresimilarin injection and horners syndrome.22 No incidence both the groups and difference was statistically of pneumothorax was observed in this study. insignicant. Similar result was found by Singh This might be attributed to the enhanced safety et al15 In this study, mean total consumption of associated with SG Guided techniue and less morphineingroupAandgroupwerealsosimilar. numberofcases.SeveralothersstudiesonPVfor This difference was statistically non-signicant. breastsurgeryshowsimilarresults.2,24 This could be attributed to the efcacy of block Epiduralor subarachnoid spreadhasalsobeen beingsimilarinthebothgroups. reportedwithPV.Weltzetalhavereported2cases Inthisstudy,wedidnotndanyprolongationin ofepiduralspreadoflocalanestheticsinastudyof durationofblock.Thisvariableeffectofketamine thirtypatientsusingPVasthesoleanesthesiafor probably can be explained from different site inguinalherniarepair.25leinetalalsoreportedone of injection. In human study, showing effective incidenceofepiduralspreadwithouthemodynamic analgesia, ketamine with local anesthetics was in stability out of 24 patients receiving PV for administered with incisional inltration of inguinal herniorrhaphy.26 The present study also, subcutaneously.10,16 The analgesic effect thus may didnothaveanycaseofepiduralspread. have been conseuences of a pure local effects of Incidence of failed block could not be ketamine at the level of surgical trauma where a estimated from this study as we did not assess 17,18 woundinammationoccurs. loss of sensation following PV placement and The dose of ketamine used (05 mgg), generalanesthesiawasinducedinmostpatients might have been absorbed uickly in systemic immediately after PV. Failure rate after PV circulationand any local anesthetic effectscould in adults varies from 6.1–10.7.2 This reects havebeenmaskedespeciallywiththelongacting technicallydifcultyinidentifyingparavertebral used upivacaine local anesthetic. This also space. The above uoted gures are failure rate might have happenedin Lee et alstudy as they following nerve stimulator guided techniue. injected their study solution in the interscalene SeveralothersstudiesonPVforbreastsurgery area which is vessels rich.19 The relative high uotesimilarfailurerates. incidence of ketamine related psychomimetic The mean PONV scores immediately post- adverse effects in this study may support this operative period were comparable in the both explanation.Inpresentstudy,nopsychomimetic groups. In this study, similar PONV scores and effect were seen any of the groups. This can be incidencebetweenthetwogroupscouldbebecause explainedasthegoodanalgesiaenhancingeffect ofcombiningPVwithGA.Thisobservationhas and lack of psychomimetic effect of ketamine againconrmedbyotherstudies.11,25,27 whengivenintheepiduralorcaudalroutewhere thesystemicabsorptionisslow.Thepresentstudy hypothesizedthatketamineeitheractatthenerves Conclusion as they emerges from intervertebral foramen or diffuseintoepiduralspaceandactonspinalcord. The present study showed that the addition of owever, results obtained in this study do not ketamine to bupivacaine did not improve the substantiateeitherofthesehypotheses. efcacy or duration of paravertebral analgesia in the post operative and intra-operative period in In this study, there was no episode of intra- patientsundergoingmodiedradicalmastectomy. operative hypotension in either of two groups. This could be due to intravascular absorption of ketaminefromparavertebralspace.Theabsorption eferences from paravertebral space is uite high, ranked 20 nextonlytothatfromtheintercostalnerveblock. 1. Merskey,ugdukN.Classificationofchronic etamine stimulates cardiovascular system and pain.Descriptionofchronicpainsyndromeand usuallyassociatedwithincreasesinRandP.21 definitionsofpainterms,2ndedition.Seattle,WA: Thepost-operativehemodynamicparameterswere IASPPress;1994.pp.180–96. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1552 IndianJournalofAnesthesiaandAnalgesia

2. PerkinsF,ehlet.Chronicpainasanoutcome 15. Singh A, ushwawa J, Gupta R, et al A of surgery: A review of predictor factors. comparative study between morphine, Anesthesiology.2000;9(4):112–. dexmedetomidine and ketamine as an adjunct . RoyGreengrass,RWeltzChristina,DirkIglehart to levobupivacaine in paravertebral block J.seofparavertebralblockanesthesiainSurgical duringmodifiedradicalmastectomy.IndianJof ManagementofreastCancer.AnnalsofSurgery. Research.2016;10:27–1. 1998;227:496–501. 16. De Negri P, Ivani G, Visconti C, et al ow to 4. EasonMJ,WayttR.Paravertebralthoracicblock: prolong post-operative analgesia after caudal AReappraisalAnesthesia.1979;4:68–642. anesthesia with ropivacaine in children: S-ketamine versus clonidine. Pediatr Anesth. 5. Gilbert J, untman J. Thoracic paravertebral 2001;11:679–8. block: A method of pain con. Acta Anesthesiol Scand.1989;:142–45. 17. WeberWV,JawalekarS,JawalekarSR.Theeffect ofketamineonthenerveconductioninisolated 6. urlacuCL, Frizelle P,Moriarty DC. Fentanyl sciaticnerveoftoad.NeurosciLett.1975;1:115–20. and clonidine as adjuvant analgesics with levobupivacaine in paravertebral analgesia for 18. Tverskoy M, Oren M, Vaskovich M, et al breastsurgery.Anesthesia.2006;61:92–7. etamineenhanceslocalanestheticandanalgesic effectsofbupivacainebyperipheralmechanism: 7. Abdel Ghaffar ME, Abdulatif M, Al-Gandhi A, Astudyinpost-operativepatients.NeurosciLett. et al Epidural ketamine reduces post-operative 1996;215:5–8. epidural PCA consumption of fentanyl/ bupivacaine.CanJAnesth.1998;45:10–109. 19. LeeIO,imW,ongM,etalNoenhancement of sensory and motor by ketamine added to 8. immelseher S, iegler-Pithamitsis D, ropivacaineinterscalenebrachilaplexusblockade. Argiriadou , et al Small dose S-ketamine ActaAnesthesiolScand.2002;46:821–26. reduces post-operative pain when applied with ropivacaineinepiduralanesthesiafortotalknee 20. Morgan Jr GE, Mikhail MS, Murray MJ. Local arthroplasty.AnesthAnalg.2001;92:1290–295. anesthetic. Clinical anesthesilogy, 4th edition. Nework:McGraw-ill;2008.pp.26–76. 9. lein SM, Nielsen C, Ahmed N, et al In situ images of the thoracic paravertebral space. Reg 21. Reves JG, Glass PSA, Lubarsky DA, et al AnesthPainMed.2004;29:596–99. Intravenous non-opioids anesthetics. Millers Anesthesia, 6th edition. Philadelphia: Churchill 10. MartindaleSJ,DixP,StoddartPA.Doubleblind Livingstone;2005.pp.17–78. randomized controlled trial of caudal versus intravenousS()ketamine forsupplementation 22. armakar M. Thoracic paravertebral block. of caudal analgesia in children. r J Anesth. Anesthesiology.2001;95:771–80. 2004;92:44–47. 2. Lonnvist PA, Macenzie J, Soni A, et al 11. PuschF,Freitag,WeinstablC.Singleinjection Paravertebral blockade: Failure rate and paravertebral block compared to general complication.Anesthesia.1995;50:81–15. anesthesia for breast surgery. Acta Anesthesiol 24. lein SM, Teele SM, Greengrass RA. A clinical Scand.1999;4:770–74. overviewofparavertebralblockade.TheInternet 12. Saito T, Den S, Cheema SPS. A single injection JournalofAnesthesiology.1999;:1–6. multisegmental paravertebral block extension 25. WeltzCR,GreengrassRA,Lyerly.Ambulatory of somatosensory and sympathetic block in surgical management of breast carcinoma using volunteers. Acta Anesthesiol Scand. 2001;45: paravertebralblock.AnnSurg.1995;222:19–26. 0–. 26. lein SM, Pietroban R, Nielsen C, et al 1. Moore DC. Intercostals nerve block: Spread of Paravertebral somatic nerve block compared Indianinkinjectedintothesubcostalgroove.rJ with peripheral nerve block for outpatients Anesth.1981;5:25. inguinal herniorrhaphy. Reg Anesth Pain Med. 14. Dolin SJ, Cashman JN, land JM. Effectiveness 2002;27:476–80. of acute post-operative pain management I. 27. MollerJF,Nikolajsen L,Rodt SA, etalThoracic Evidence from published data. r J Anesth. paravertebralblockforbreastcancersurgery: A 2002;89:409–2. randomized double blind study. Anesth Analg. 2007;105:1848–851.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):155-1557 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.10

An Obserational Study of Small Dose Propofol and Midaolam as CoinductionAgentstoPropofol

SandeephandelalNitinSharma

1SeniorResident,Dept.ofAnaesthesia,GovernmentMedicalCollege,RPuram,ota,Rajasthan24001,India. 2Consultant, Dept.ofAnaesthesia,ChoithramospitalandResearchCentre,Indore,MadhyaPradesh452014,India.

Abstract

ntroduction:PropofolhasbecomethemostwidelyusedI.V.hypnoticagent.Itprovidesrapidinduction butthemajordisadvantagesarecardiovascularandrespiratorydysfunctionhence,theconceptofAuto-co- inductionandCo-inductionhascomeforward.Thecurrentstudy,hasbeendesignedtoevaluatereduction ininductiondosesofpropofolandalterationinperi-intubationhemodynamicinpropofolauto-co-induction andmidazolampropofolco-inductiongroupsalongwithpropofolgroup.MaterialsandMethods:Thepresent study,isaprospective,observationalandnon-interventionalstudy,whichincludes75patientsofagebetween 20and50 years withASA gradeI. Allthe patientsweredividedinto threegroups and eachgrouphave 25patientsGroupI(PP),GroupII(MP),GroupIII(P).TwominutespriortoinductionagentGroupIreceived 0.5mg/kgpropofol,GroupIIreceived0.05mg/kgmidazolam.Inductiondoseofpropofolandhemodynamic parametersduringvariousintervalweremeasured. Results:Propofolinductiondosein GroupI,II,III,was 74.4mg,66.6mgand16.4mgrespectivelywhichwasstaticallysignificant(p0.05)whengroupIandII comparewithgroupIII.emodynamicstabilityinperi-intubationperiodwasbetteringroupIthatmean auto-co-induction. Conclusion: We conclude that midazolam co-induction and propofol auto-co-induction significantlyreducetheinductiondoseofpropofol,propofolauto-co-inductionprovidesbetterhemodynamic stabilityinperi-intubationperiod.Theprimingappearstobecosteffectivebysignificantlyreducingthetotal doseofpropofolreuiredandnosignificantadverseintra-operativeorpost-operativeeffectswereobserved inallgroups. eyords:Auto-co-induction;Co-induction;Midazolam;Propofol.

otocitethisarticle: Sandeephandelwal,NitinSharma.AnObservationalStudyofSmallDosePropofolandMidazolamasCo-inductionAgentsto Propofol.IndianJAnesthAnalg.2019;6(5Part-1):155-1557.

Introduction but the major disadvantages are cardiovascular and respiratory dysfunction hence, the concept An important landmark in the development of of Auto-co-induction and Co-induction has anesthesiahasbeenthediscoveryofanintravenous comeforward. induction agents. Propofol was introduced in the Auto-co-induction1,2 is a techniue of giving 1970s and it has become the most widely used a pre-calculated dose of induction agent prior I.V. hypnotic agent. It provides rapid induction to giving the full dose of same induction agent;

CorrespondingAuthor:Sandeephandelal,SeniorResident,Dept.ofAnaesthesia,GovernmentMedicalCollege,RPuram, ota,Rajasthan24001,India. Email:[email protected] eceiedon11.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1554 IndianJournalofAnesthesiaandAnalgesia this techniue is also known as the priming Two minutes after the co-induction agent techniue. injection, each patient received propofol at the Co-induction4,5 is dened as the concurrent rate of 0 mg every 10 seconds. Eyelash reex administrationoftwoormoredrugsthatfacilitate was checked. If there was no response, propofol inductionofanesthesiadocumentingsynergies6and injection was stopped, and face mask applied rmly. Any complication during this period, todecreasethedosereuirementoftheinduction ie., apnea, vomiting, laryngospasm, involuntary agent to make the uality of anesthesia better movements,coughing,wasnoted. withimprovementinhemodynamicstability.The commonest co-induction agent to propofol has The anesthesia continued according to the beenmidazolam.7,8 standard practice of intubation after rocuronium 1 mgg. Anesthesia was maintained on O /N O The current study, has been designed to 2 2 (5,65);inhalationalagent, ie.,isouraneand evaluatereductionininductiondosesofpropofol injection rocuronium. No stimuli were applied and alteration in peri-intubation hemodynamic duringthe10minutespost-intubationperiod. in propofol auto-co-induction and midazolam propofol co-induction groups along with Thefollowingparameterswererecorded: propofolgroup. 1. Inductiondoseofpropofol. 2. lood pressure (systolic (SP), diastolic (DP)andmeanarterialpressure(MAP) MaterialsandMethods and heart rate (R) measured at the following intervals and recorded in a customizedperforma: Thepresentstudy,wasaprospective,observational and non-interventional study, which included aseline(beforeplacementofI.V.cannula); 75 patients of age between 20 and 50 years Immediatelyafterco-inductionagent; with ASA grade I, posted for various elective Immediatelyafterinductionagent; surgeriesundergeneralanesthesiatoChoithram ospitalandResearchCenterfromMarch2015to Immediatelyafterintubation; ovember2015. Thenat5minutesand10minutes Approval from the Ethics Committee and The comparison between the three was done Scientic Review Committee and a written using one-way ANOVA. The post-hoc tukey test informed consent for participation in the study was applied to nd out the statistical difference was taken. Pre-operative clinical assessment of betweenthegroups. the patients was done and on the day of surgery patients were pre-medicated with pre-anesthetic esults agents. All the patients were divided into three groupsinaconsecutivemanner;accordinglyeach Inthepresentstudy,total75patientsagedbetween grouphas25patients: 20 and 50 years were included and as per study GroupI(n25):hadreceivedpropofol05mgg design, they were consecutively divided into propofolasinductionagent. groups. Mean age and weight were compared Group II (n 25): had received midazolam among groups. No statistically signicant 005mggpropofolasinductionagent. difference was found among three groups as the f-valueis1.9andp-valueis0.05(Table). GroupIII(n25):hadreceivedpropofolaloneas inductionagent. Table:Sociodemographicdetails aseline measurement of blood pressure, Meanage Meaneight pulse rate and arterial O2 saturation were taken before placement of IV cannula. Patients were GroupI 29.927.60 59.288.61 pre-oxygenated with 100 oxygen (8 min) GroupII 1.889.04 57.527.48 using face mask and ains circuit for three GroupIII 28.65.27 58.806.6 minutes, and then were administered fentanyl. 1 mcgg followed by co-induction agent which Mean propofol induction dose were compared was005mggmidazolam(GroupII)or05mgg amonggroups.Statisticallysignicantdifference propofol(GroupI). was found among three groups as the f value IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AnObservationalStudyofSmallDosePropofolandMidazolamasCo-inductionAgentstoPropofol 1555 is 185.28 and p - value is 0.05. As per post-hoc For post-induction systolic and diastolic blood tukeytest thepvalueforGroupI andGroupII pressurepost-hoctukeytestshowedthep-value pair was found to be0.05, whichisstatistically 0.05 for group III-I and Group III and II pair. insignicant and for Group III-II and Group III-I Thus, there was statistically signicant difference pairsp-valuewasfoundtobe0.05ie.,statistically betweenpair,butforgroupIandIIpairp-value signicant (Table ). Various hemodynamic wasfoundtobe0.05(insignicant)(Table). parametersatdifferentintervalsforallthegroups The post intubation heart rate values showed were compared (Table ). At baseline heart rate, similarvariationsamongallthreegroupsassameas systolicanddiastolicbloodpressurevaluesshow post-inductionvaluesie,statisticallyinsignicant statisticallyinsignicantdifferenceaspvaluewas (p 0.05). Whereas post- intubation systolic and 0.05(Table). diastolic blood pressure showed p - value 0.05 meansstatisticallysignicant(Table).

Table:Meanpropofolinductiondoseusedinthethreegroups In post-hock tukey test for post-intubation systolic blood pressure showed statistically roupI roupII roupIII significant difference among all the three MeanSD MeanSD MeanSD pairs of group, whereas for post-intubation Inductiondose 74.401.49 66.610.66 16.4017.29 diastolic blood pressure p - value was found to be significant for pair group I–II and group After administration of priming dose (post- III-II but not for pair group I–III. eart rate priming) of propofol and midazolam in group after 5 minutes shows no significant difference I and II respectively, the mean heart rate shows between the three groups (p 0.05), whereas statisticallyinsignicant results (p- 0.05). Same after10minutesitshowssignificantvariationin results were obtained in post-hoc tukey test for values(Table). groupIandgroupII(Table). Inpost-hoctukeytestafter5minutesheartrate We observed similar results as heart rate for shows no signicant difference among all the post-priming systolic blood pressure for group I three pairs, whereas for after 10 minutes heart and group II ie., statistically insignicant values rate statistically signicant variation was found inbothANOVAandpost-hoctukeytest(p0.05) between group I and III and group II and III. (Table). 5 minutes and 10 minutes systolic blood pressure Whereas post-priming diastolic blood pressure shows statistically signicant variation (p - value for Group I and group II shows statistically 0.05)inallthethreegroups.Post-hocktukeytest signicant results (p- value 0.05).For pair also showssignicantvalueforpairgroupIandIIand thepost-hoctukeytestwasfoundtobestatistically groupIIandIIIforsystolicbloodpressureafter5 signicant(0.05)(Table). and10minutes(Table). Againthepost-inductionheartrateandsystolic Diastolicbloodpressureafter5and10minutes blood pressure showed statistically insignicant shows statistically signicant variation (p value difference between the three groups (p 0.05). 0.05)amongallthethreegroups.Post-hocktukey Similarly values of diastolic blood pressure in all testshowssignicantvalueafter5minutesdiastolic threegroupsshowedstatisticallysignicantresults bloodpressureforpairgroupI–IIandI–III,whereas (f10.50andp0.05)(Table). after10minutessignicantvaluewasfoundforpair groupI–IIandII–III(Table).

Table:R,SPandDPvaluesforallthethreegroups

SBP DBP TimePoint I II III I II III I II III aseline 86.8411.16 86.281.2 84.8812.70 124.0010.5 12.646.78 125.7210.50 77.727.9 80.126.8 80.686.9 Post–priming 8.2010.6 80.6812.00 117.888.88 119.804.84 7.125.55 77.046.4 Post-induction 77.569.12 75.448.76 74.4811.17 108.488.97 110.27.4 98.049.44 67.485.50 70.726.46 62.566.96 Post-intubation 87.848.8 88.648.1 91.612.25 118.168.08 15.088.48 126.8012.88 74.66. 94.285.7 78.848.91 After5min 80.688.65 80.447.51 84.6018.55 112.089.2 125.248.66 108.806.7 69.646.16 78.885.29 75.884.6 After10min 76.608.59 75.966.86 82.529.99 108.408.9 115.247.85 104.086.7 66.645.88 75.484.91 64.924.28

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1556 IndianJournalofAnesthesiaandAnalgesia

Discussion theyhavereportedriseinheartrateafterintubation least in propofol-propofol group, and maximum Propofol though a wonderful I.V. anesthetic riseinpropofolgroup. induction agent with many advantages also has Afterinductionsystolicbloodpressuredecreased some side effects like hypotension, bradycardia, in all three groups which were 12.51, 10.77 apnea,etc.whicharedosedependent,soareduction and 22.01 in Group I, Group II and Group III in the induction dose would thereby reduce the respectively. Results were statistically signicant associated side-effects, the most important being on comparing Group I–III and Group II–III. Our the effect on cardiovascular system leading to resultsweresimilartoumaretal2 hemodynamicinstability. After intubation, systolic blood pressure We found that co-induction agents were increased in all three groups. Maximum rise in effective in reducing the induction dose of systolic blood pressure was observed in Group propofol considerably compared to propofol II (9.25). Results were statistically signicant alone as an induction agent. Dose reduction on comparing Group I–III and Group II–III. Our following midazolam is probably due to resultsweresimilartoAmatyaAetal10andataria synergistic interaction between the two drugs. etal(2010).9 Synergism has been reported between agents After induction, diastolic blood pressure withknownfunctionallinkinthecentralnervous decreased in all three groups which was 1.17, system vi. midazolam and propofol acting on 11.7 and 22.45 in Group I (PP), Group II a common receptor site, the GAA receptors. (MP)andGroupIII(P)respectively.Resultswere The dose reduction in the propofol auto-co- statistically signicant on comparing Group I–III induction group was probably due to priming andGroupII–III.OurresultsweresimilartoAmatya effect. The small dose of propofol prior to Aetal 10andumaretal2 induction dose caused sedation and anxiolysis, thusallowinginductionofanesthesiawithlower After intubation, diastolic blood pressure dosesofpropofol. increasedinallgroups.Maximumriseindiastolic blood pressure from baseline was observed in In our study, we have observed a signicant Group II MP (17.67). Results were statistically reduction in the induction dose reuirement of signicantoncomparingGroupII(MP)–III(P)but propofolingroupI(45.45)ascomparedtogroup oncomparingGroupI–IIIstatisticallyinsignicant III which was statistically signicant. Our results resultswereobtainedandourresultsweresimilar weresimilartoatariaetal(2010)9andAmatyaetal. to ataria et al9 they have reported that after (2014)10 they found reductionindoseof induction intubation,maximumincreaseindiastolicpressure 1.88 and 27.48 respectively. Group II shows wasobservedingroupII(MP)propofol. signicantreductionininductiondosereuirement (51.4)ascomparetogroupIII.Ourresultswere similartoatariaetal(2010)9theyfoundreduction Conclusion in dose of induction 45.7. Whereas in Djaiani et al (1999)1 signicant reduction of the total Fromabovendingsweconcludethatmidazolam inductiondoseofpropofolinbothgroup(p0.001) co-induction and propofol auto-co-induction wereobserved. signicantly reduce the induction dose of After induction with propofol heart rate propofol. Propofol auto-co-induction provides decreased in all the three groups which were better hemodynamic stability in peri-intubation 10.68ingroupI(PP),12.56ingroupII(MP)and period. The priming appears to be cost effective 12.25ingroupIII(P).Resultwerenotstatistically bysignicantlyreducingthetotaldoseofpropofol signicant between group I (PP) – group III (P) reuiredandnosignicantadverseintra-operative andgroupII(MP)–groupIII(P).Ourresultswere or post-operative effects were observed in similar to Anderson et al (1998)4 and Srivastava allgroups. et al5 they have reported fall in heart rate during inductioninallthreegroups. Abbreiation After intubation heart rate increased in all the three groups and was statistically not signicant. I.V.-Intravascular Maximumincreaseinheartratefrombaselineseen O -Oxygen ingroupIII(P)(7.6)andleastriseingroupI(PP) 2 9 (1.15).Ourresultsweresimilartoatariaretal , N2O-Nitrousoxide IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AnObservationalStudyofSmallDosePropofolandMidazolamasCo-inductionAgentstoPropofol 1557

SP-Systolicbloodpressure 4. Anderson L, Robb A. Comparison of midazolam coinduction with propofol pre- DP-Diastolicbloodpressure dosing for induction of anesthesia. Ansthesia. MAP-Meanarterialpressure 1998;5:117–20. R-eartrate 5. Srivastava,SharmaDN,umarA,etalSmall dose propofol or etamine as an alternative to PP-Propofol-propofol midazolam co-induction to propofol. Indian J MP-Midazolam-propofol Anesth.2006;50:112–14. P-Propofol 6. McayAC.SynergismamongIVAnesthetics.r JAnaes.1991;67:1–. 7. Elwood T, uchcroft S, Mac Adams C. eferences Midazolamcoinductiondoesnotdelaydischarge afterverybriefpropofolanesthesia.CanJAnesth. 1995;42:114–18. 1. Djaiani G, Ribes-Pastor MP. Propofol 8. OngL,PlummerJL,WaldowWC,etalTiming auto-induction as an alternative to midazolam of midazolam and propofol administration for co-inductionforambulatorysurgery.Anesthesia. co-induction of anesthesia. Anesth Intensive 1999;54:6–67. Care.2000;28:527–1. 2. umar AA, Sanikop CS, otur PF. Effect 9. atariaR,SinghalA.Efficacyofpropofolauto-co- of priming principle on the induction dose inductionversusmidazolampropofolco-induction. reuirement of propofol: A randomized clinical IndianJAnesthesia.2010;54(6):558–61. trial.IndianJAnesth.2006;50:28–87. 10. Amatya A, Marhatta MN, Shrestha GS, et al A . Maroof M, han RM. Priming Principle and comparison of midazolam co-induction with the induction dose of propofol. Anesth Analg. propofolpriminginpropofolinducedanesthesia. 1996;82:S1–515. JNepalealthResCounc.2014Jan;12(26):44–48.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1559-1568 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.11

EffectsofDemedetomidineInfusiononemodynamicStressesponse SedationandPostoperatieAnalgesiceuirementinPatientsndergoing aparoscopicCholecystectomy

SaradaoaMadhuriilluBhagyalakshmiMalapoluNeeraa

1SeniorResident,2,AssistantProfessor,SiddharthaMedicalCollege,Vijayawada,AndhraPradesh520008,India.

Abstract

Dexmedetomidine is a selective 2 agonist with sedative, analgesic and sympatholytic properties and hence, it can be used as an anesthetic adjuvant. Aims: We aimed primarily to evaluate the effects of low dose Dexmedetomidine infusion on hemodynamic response to critical incidences such as laryngoscopy, endotrachealintubation,creationofpneumoperitoneumandextubationinpatientsundergoinglaparoscopic cholecystectomy. The secondary aims were to observe the effects on sedation levels, post-operative analgesiareuirementsandoccurrenceofadverseeffects.Methods:NinetypatientsofAmericanSocietyof AnesthesiologistsASAphysicalgradesIandIIundergoinglaparoscopiccholecystectomywererandomly allocatedintothreegroupsof0patientseachasfollows: GroupNS:Salinegroup;n0–Received0.9normalsalineinfusion; GroupDE:0.2-PatientsreceivedDexmedetomidineinfusion0.2mcg/kg/hr; GroupDE:0.4-PatientsreceivedDexmedetomidineinfusion0.4mcg/kg/hr. Infusionswerestarted15minbeforeinductionandcontinuedtillendofsurgery.Parametersnotedwere pulse rate, mean arterial pressure, post-operative sedation and analgesia reuirements. SPSS 15.0 version softwarewasusedforstatisticalanalysisandContinuousdatawereanalyzedbyANOVAtest. Results:InGroupNS,significanthemodynamicstressresponsewasseenfollowinglaryngoscopy,tracheal intubation,creationofpneumoperitoneumandextubation.InDexmedetomidinegroups,thehemodynamic responsewassignificantlyattenuated.Theresults,however,werestatisticallybetterinDex0.4groupcompared with Dex 0.2 group. Post-operative 24 hour analgesic reuirements were much less in Dexmedetomidine groups.Nosignificantsideeffectswerenoted.Conclusion:LowdoseDexmedetomidineinfusioninthedose of 0.4 mcg/kg/h effectively attenuates hemodynamic stress response during laparoscopic surgery with reductioninpost-operativeanalgesicreuirements. eyords:Dexmedetomidine;emodynamicstressresponse;Laparoscopiccholecystectomy.

otocitethisarticle: SaradaRojaMadhuri,illihagyalakshmi,MalapoluNeeraja.EffectsofDexmedetomidineInfusiononemodynamicStress Response, Sedation and Post-operative AnalgesicReuirement inPatients ndergoingLaparoscopicCholecystectomy.Indian J AnesthAnalg.2019;6(5Part-1):1559-1568.

Introduction cholecystectomy is one of the most commonly practicedsurgeriesforgallbladderdiseasesinthe Thedevelopmentofminimallyinvasivesurgeryhas presentera. revolutionized the eld of surgery. Laparoscopic The physiological response to surgical stress

Corresponding Author: illu Bhagyalakshmi, Assistant Professor, Siddhartha Medical College, Vijayawada, Andhra Pradesh 520008,India. Email:[email protected] eceiedon14.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1560 IndianJournalofAnesthesiaandAnalgesia and anesthesia is welldocumented. Inthe earlier Group DE: 0.4-Patients received dexmede- reviewbyehlet,thestressresponsetosurgeryis tomidineinfusion04mcgghr morethananesthesiadrugsandtechniue.Awide A thorough pre-anesthetic evaluation was number of anesthetic drugs have been used in performed by taking history and clinical clinical practice to modify the stress response to examination. In all patients age, weight, Systolic anesthesia and surgery. Laparoscopic surgery bloodpressure,Diastolicbloodpressureandeart which involves insufation with carbon dioxide ratewererecorded.Allpatientswereinvestigated producesundesirableresponseslikehypertension, thoroughlytoruleoutcardiac,renal,hepaticand tachycardia,anddysrhythmias. endocrineproblems. Introduction of Dexmedetomidine which is Infusion was prepared by taking highly specic and selective 2 adrenoceptor dexmedetomidine 05 ml containing 50 mcg of agonisthasbeentriedinvariousstudiestomodify the drug withdrawn in a 50 ml syringe and was thestressresponsetosurgeryandtohaveapleasant diluted up to 50 ml with normal saline resulting anesthetic outcome with minimal cardiovascular inthenalconcentrationof1mcgml.othnormal changes. saline and dexmedetomidine was given through In present study, we have taken the schiller syringe infusion pump. According to the pharmacological advantage of Dexmedetomidine patientweight,thepumpwassetsoastodeliver to study the various cardiovascular parameters thetargetedinfusionrate. at different periods during the laparoscopic Onarrivalintheoperationtheatre,monitorswere procedure. attached,andbaselineparameterssuchasheartrate, systemic arterial pressure, and oxygen saturation MaterialsandMethods were noted down. Two intravenous lines were secured,one20guagecannulaintherighthandfor Type of study: Prospective randomized controlled the infusion and another 18 gauge cannula in left doubleblindclinicalstudy. handforintravenousuidsanddrugadministration. 500mlofcrystalloidsRingerLactatewasstarted. urationofstudy:Jan2017toJune2018. Fifteenminutesafterstartingthedruginfusion, Theinstitutionalethicalcommitteeapprovedthe pre-oxygenationwasperformedforminutes. studyandwritteninformedconsentwasobtained Patients were pre-medicated with Inj. from allthepatients beforebeing includedinthe study. ondansetron2mgI.V. Inj.Glycopyyrolate02mgI.V. SelectionCriteria Inj.Ranitidinehydrochloride50mgI.V. nclusion Inj.Fentanyl1mcggI.V. 90 ASA Grade Iand II of18 to5 yearsof age of Patients were induced with Inj. Propofol eithersexpostedforlaparoscopiccholecystectomy 2 mgg. Endotracheal intubation was facilitated wereincludedinthisstudy. by succinylcholine 15 mgg. Anesthesia was maintained with O2:N2O, sevourane 0.6 vol and vecuronium bromide 01 mgg. Intermittent clusion positivepressureventilationwascontinuedbythe Elderly, Diabetic patients, Patients with chronic mechanicalventilatortomaintainend-tidalcarbon ypertension,SevereCARDIACdisease,Pregnant dioxidebetween5–40mmofgPneumoperitoneum or Lactating women, Patients with a history of wascreatedbyinsufationofcarbondioxideatthe allergy to egg proteins and 2 agonists were rate of 2 litersmin. Intra abdominal pressure was excludedfromthestudy. maintainedat12–14mmgthroughoutthesurgical procedure.Throughouttheprocedure,anyrisein The patients were randomly allocated to three mean arterial pressure more than 20 from the groups-0Patientseach,byenvelopemethodas baselinewastreatedwithnitroglycerineinfusion. follows: Systemic arterial pressure including the GroupNS:Salinegroup;n0–Received0.9 systolic,diastolicandmeanarterialpressure,heart normalsalineinfusion; rate, Saturation, End-tidal carbon dioxide and Group DE: 0.2-Patients received dexmede- electrocardiographywererecordedatthefollowing tomidineinfusion02mcgghr. pointsoftime:

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectsofDexmedetomidineInfusiononemodynamicStressResponse,Sedationand 1561 Post-operativeAnalgesicReuirementinPatientsndergoingLaparoscopicCholecystectomy

1. efore starting of infusion 15 minutes after infusion 2. 1minuteafterinduction . 1minuteafterintubation 4. 1minuteafterPneumoperitoneum 5. 5minutesafterPneumoperitoneum 6. 12minutesafterPneumoperitoneum 7. 0minutesafterPneumoperitoneum

8. 45minutesafterPneumoperitoneum Fig:sedmaterials 9. 0minutesafterpneumoperitoneum 10. 1minafterthereleaseofPneumoperitoneum 11. 1minuteafterextubation After completion of surgery patients were reversed with Glycopyrrolate 001 mgg and Neostigmine 005 mgg. After thorough suction patients extubated and shifted to the recovery room. Patients were observed for post-operative sedation level, time for rst rescue analgesic inj. Paracetamol1gr/I.V.,adverseeffects.

StatisticalAnalysis Thesamplesizewasdecidedinconsultationwith the statistician and was based on initial pilot studyobservations,indicating thatapproximately 2 patients should be included in each group in order to ensure a power of 0.80 for detecting clinically meaningful difference by 15 in heart rate and mean arterial blood pressure. Assuming a 5 dropout rate, the nal sample was set at 0 patients in each group, which would permit a type1alpha()error0.05,withatype2errorof Fig:Inducingthedrug beta()0.2andpowerof0.8.theresultsobtained inthestudywerepresentedinatabulatedmanner esults and analysed using Microsoft excel and SPSS 20 Software.Theresultsofthepresentstudybetween thethreegroupswascomparedstatisticallyusing Allthethreegroupsunderstudywerecomparable Analysis of Variance (ANOVA) and Student t toeachotherwithrespecttoage,sex,weight,ASA test.A p-value 0.05 wastakenasstatistically grading,durationofsurgeryandanesthesia(shown signicant. inTableandraph).Therewasnosignicant Table:Agedistribution

roupNS roupDE roupDE Age Count Count Count 20 2 6.7 2 6.7 1 . 21–0 8 26.7 2 6.7 6 20.0 1–40 10 . 10 . 9 0.0 41–50 4 1. 10 . 11 6.7 51–60 5 16.7 5 16.7 10.0 60 1 . 1 . 0 0.0 Total 0 100.0 0 100.0 0 100.0 p0.5

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1562 IndianJournalofAnesthesiaandAnalgesia difference among the three groups in reference signicantly below the pre-infusion level. The to the baseline PR and the MAP, shown as in MAPdecreasedsignicantlyinDex0.2groupand Tables). highly signicantly in Dex 0.4 group. No further signicant changes were observed immediately In both the Dexmedetomidine groups, after after induction. After intubation and extubation, starting the infusion, the PR decreased highly thePRandMAPincreasedsignicantlyabovethe

raph:Agedistribution

Table:Showingaccordingtoweight roupNS roupDE roupDE Variable alue Mean SD Mean SD Mean SD Weight 58.47 9.07 58.60 8.29 58.00 9.01 0.96

raph:Showingaccordingtoweight

Table:Showingsexdistribution

roupNS roupDE roupDE Se Count Count Count Female 2 76.7 20 66.7 21 70.0 Male 7 2. 10 . 9 0.0 Total 0 100.0 0 100.0 0 100.0 p0.69

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectsofDexmedetomidineInfusiononemodynamicStressResponse,Sedationand 156 Post-operativeAnalgesicReuirementinPatientsndergoingLaparoscopicCholecystectomy

raph:Showingsexdistribution

Table:Showingdurationofsurgeryinminutes

roupNS roupDE roupDE Variable alue Mean SD Mean SD Mean SD Durationofsurgeryinmins. 57.00 1.56 58.17 11.48 64.17 1.90 .079

Durationofsurgeryinmins

raph:Showingdurationofsurgeryinminutes Table:Showingdurationofanesthesiainminutes roupNS roupDE roupDE Variable alue Mean SD Mean SD Mean SD Durationofanesthesiainmins. 78.00 16.06 80. 9.55 82.7 12.97 .49

DurationofAnesthesia inMin

raph:Showingdurationofanesthesiainminutes

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1564 IndianJournalofAnesthesiaandAnalgesia

Table:eartrate

roupNS roupDE roupDE alue Mean SD Mean SD Mean SD eforeinfusion 89.70 12.54 94.00 18.50 84.27 11.7 .08 Infusionat15min 87.6 11.96 85.60 25.52 8.60 12.49 .681 Inductionat1min 90.10 10.72 90.6 15.68 80.67 10.7 .004 Intubationat1min 95.7 10.95 90.1 20.68 97.7 11.42 .154 Pneumoperitoneumat1min 97.07 11.68 84.90 11.5 85.70 16.80 .001 Pneumoperitoneumat5min 96.97 12.70 85. 11.66 84.50 18.70 .002 Pneumoperitoneumat12min 95.9 11.66 8.50 18.5 85.4 12.86 .00 Pneumoperitoneumat0min 9.6 1.22 78.11 11.72 81.96 14.25 0.001 Pneumoperitoneumat45min 89.8 11.75 80.21 12.55 77.80 17.54 .011 Pneumoperitoneumat60min 91.65 12.99 78.64 15.07 66.92 1.69 0.001 Pneumoperitoneumreleaseat1min 84.47 8.62 74.7 11.24 76.28 1.68 .00 Extubationat1min 92.0 1.00 76.77 17.26 90.10 16.18 0.001

R

Group-NS Group-DE0.4 Group-DE0.2 110

95

80

65

50 efore at15min at1min at1min at1min at5min at12min at0min at45min at60min at1min at1min Infusion Induction Intubation Pneumoperitoneum Extubation Time raph:eartrate

Table:Showingsystolicbloodpressure

roupNS roupDE roupDE SBP alue Mean SD Mean SD Mean SD eforeinfusion 18.40 16.7 1.9 15.85 17.50 8.90 .44 Infusionat15min 14.9 15.2 128.40 11.6 11.0 7.68 .105 Inductionat1min 129.87 17.8 119.60 25.2 129.27 10.71 .067 Intubationat1min 148.57 14.42 18.60 12.68 156.0 18.72 0.001 Pneumoperitoneumat1min 150.97 16.12 127.6 10.22 15.90 12.74 0.001 Pneumoperitoneumat5min 155.9 1.68 15.27 14.42 140.40 11.28 0.001 Pneumoperitoneumat12min 154.57 10.85 17.00 14.40 1.2 10.86 0.001 Pneumoperitoneumat0min 142.47 14.70 11.00 14.04 11.4 1.92 .00 Pneumoperitoneumat45min 14.46 7.41 129.42 7.68 10.56 9.5 0.001 Pneumoperitoneumat0min 142.24 8.09 127.86 10.72 11.08 1.41 .001 Pneumoperitoneumreleaseat1min 18.77 8.24 122.0 10.65 124.90 9.1 0.001 Extubationat1min 152.47 9.04 18.87 1.57 141.80 1.9 0.001

SP

Group-NS Group-DE0.4 Group-DE0.2

160

145

10

115

100 efore at15min at1min at1min at1min at5min at12min at0min at45min at60min at1min at1min Infusion Induction Intubation Pneumoperitoneum Extubation Time raph:Showingsystolicbloodpressure

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Table:Showingdiastolicbloodpressure

roupNS roupDE roupDE DBP alue Mean SD Mean SD Mean SD eforeInfusion 86.7 9.18 84.00 10.42 88.7 6.09 .118 Infusionat15min 8.50 7.84 81.47 8.25 84.27 8.82 .407 Inductionat1min 8.60 7.9 79.0 8.10 81.6 10.18 .17 Intubationat1min 92.70 6.50 85.90 11.62 100.67 20.22 0.001 Pneumoperitoneumat1min 99.0 12.1 81.40 8.21 9.5 11.90 0.001 Pneumoperitoneumat5min 102.2 9.8 89.67 12.64 95.60 8.29 0.001 Pneumoperitoneumat12min 97.67 7.04 86.4 1.21 90.2 8.47 0.001 Pneumoperitoneumat0min 90.0 8.2 8.89 9.26 84.86 11.02 .026 Pneumoperitoneumat45min 90.2 6.69 84.17 6.0 85.56 7.7 .006 Pneumoperitoneumat0min 90.47 5.0 84.21 7.15 89.00 5.95 .022 Pneumoperitoneumreleaseat1min 89.20 6.70 77.9 6.2 82.07 7.65 0.001 Extubationat1min 97.67 8.16 90.07 12.50 98.0 1.52 .012

DP

Group-NS Group-DE0.4 Group-DE0.2

110

95

80

65

50 efore at at at at at at at at at at at 15min 1min 1min 1min 5min 12min 0min 45min 60min 1min 1min Infusion Induction Intubation Pneumoperitoneum Extubation

Time raph:Showingdiastolicbloodpressure

Table:Map

roupNS roupDE roupDE Map alue Mean SD Mean SD Mean SD eforeinfusion 101.00 12.51 102.57 14.08 104.17 9.49 .604 Infusionat15min 98.7 10.08 98.47 9.98 100.0 7.85 .742 Inductionat1min 98.20 8.79 95.60 8.94 97.97 11.10 .517 Intubationat1min 109.90 7.4 10.4 12.46 120.0 20.8 0.001 Pneumoperitoneumat1min 117. 10.9 98.0 10.2 106.7 11.50 0.001 Pneumoperitoneumat5min 118.4 12.90 10.57 17.00 108.80 10.10 0.001 Pneumoperitoneumat12min 115.90 8.96 99.1 15.99 104.00 10.61 0.001 Pneumoperitoneumat0min 104.7 10.9 97.07 1.18 100.07 11.88 .072 Pneumoperitoneumat45min 105.96 7.70 87.8 19.50 99.44 7.15 0.001 Pneumoperitoneumat0min 108.18 7.12 97.71 9.10 102.08 9.44 .005 Pneumoperitoneumreleaseat1min 104.0 7.68 88.47 9.90 95.80 8.6 0.001 Extubationat1min 114.67 9.48 106.00 1.22 112.40 1.49 .020

MAP

Group-NS Group-DE0.4 Group-DE0.2 10

115

100

85

70 efore at at at at at at at at at at at 15min 1min 1min 1min 5min 12min 0min 45min 60min 1min 1min Infusion Induction Intubation Pneumoperitoneum Extubation

Time raph:Map

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1566 IndianJournalofAnesthesiaandAnalgesia

Table:Post-operativesedationscore

roupNS roupDE roupDE Postoperatiesedatioscore alue Mean SD Mean SD Mean SD At1min 1.00 0.00 2.6 0.49 2.00 0.00 0.001 At0min 1.67 0.48 2.2 0.4 1.50 0.51 0.001 At0min 1.7 0.45 2.17 0.8 2.07 0.25 0.001 At120min 1.1 0.5 2.00 0.00 2.07 0.25 0.001

Postopsedationscore

Group-NS Group-DE0.4

2

1

0 At1min At0min At60min At120min Time raph:Post-operativesedationscore

pre-infusion level in Dex 0.2 group, though, this Discussion increase was less compared to increase in group NS p 0.05. nlike these changes in Dex 0.2 Laparoscopic procedures involve peritoneal group, PR and MAP in Dex 0.4 group remained insufations with Carbon dioxide and create below pre-infusion level after intubation and pneumoperitoneum. This induces intra- extubationp0.05whencomparedwithDex0.02. operative ventilatory and hemodynamic Pneumoperitoneum did notproduce a signicant changes that complicate anesthetic management effectinboththeDexgroups. forlaparoscopy.1 The post-operativemeanssedationscores were Thehemodynamicvariabilityduetolaparoscopy observed using Ramsay Sedation score (RSS) at isduetoreleaseofhumoralfactors,andpotential 1min,0min,0min,120minutes.Whencompared mediatorsarecatecholamines,prostaglandins,and toGroupNSpatientssedationscoresaremorein vasopressin.2 The reverse trendelenburg position dexmedetomidinegroups.GroupDE0.4patients reuired for surgery leads to diminished venous had better sedation than Group DE 0.2. The return and thereby further reduction in cardiac patients were co-operative, oriented and tranuil output. allthetime.InGroupNS,lesssedationscorewas Dexmedetomidinoffersauniuepharmacological observed initially; the later score was improved prole with sedation, sympatholysis, analgesia, due to the early reuirement of analgesia in this cardiovascular stability associated with the great group(Table). advantage to avoid respiratory depression.4,5 In particular, Dexmedetomidine can provide The mean Rescue analgesia time in Group NS dose-dependent co-operative sedation that patientswas21.50107minutes,inGroupDE allows ready interaction with the patient.6 ence, 0.4-22784minutesandinGroupDE0.2 wehavedecidedtouseDexmedetomidineinfusion -17200751minutes.Whencomparedbetween forlaparoscopiccholecystectomy2importantissues three groups p - value was 0.001 which was that are noted in this study are Pharmacological statisticallysignicant(Tables). actions of Dexmedetomidine and physiological IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectsofDexmedetomidineInfusiononemodynamicStressResponse,Sedationand 1567 Post-operativeAnalgesicReuirementinPatientsndergoingLaparoscopicCholecystectomy responsestosurgery,anesthesia,andLaparoscopy. intraandpost-operativereuirementofopioids.11–14 2-Adrenoceptoragonistsdonotaffectthesynthesis, This effect is called as an Opioid-sparing effect. storage, or metabolism of neurotransmitters and The time for rst rescue analgesic is increased in do not block the receptors, thus providing the dexmedetomidinegroups.Inourstudy,weobserved possibility of reversing the hemodynamic effects twopatientsofDE0.2groupdidnotreuireany withvasoactivedrugsorthe2-agonisteffectswitha analgesiaonthedayofsurgery. specic2-adrenoceptorantagonist.Therefore,they Providingpost-operativeanalgesiaandcomfort mayhavearoleinanesthesiaforpatientswhoareat to the patient was also anesthetist concern only. highriskofmyocardialischemiawhileundergoing Withthisconsiderationthedrugwhichwasused majorsurgery. inpresentstudyhelpedwithitsanalgesicproperty. The 2-receptors regulate the autonomic and Group NS patients in present study, had pain cardiovascular systems. 2-receptors are located post-operatively around 20–0 minutes after on blood vessels mediate vasoconstriction, and the surgery. In 2 patients of group NS were on sympathetic terminals, where they inhibit given injection Paracetamol 1 gr intravenously norepinephrinerelease.7,8 immediatelyaftersurgeryalso. Manneetalinapilotstudy,theyusedlowdose Group DE 0.2 patients have post-operatively infusionsof dexmedetomidine without any bolus. analgesia siginicantly when compared to group Initially,theyuseddexmedetomidine02mcggh DE 0.4. Surprisingly two patients who received infusion,itcontrolledtheriseinPRandMAPafter DE02mcgghrhadnopainfor24hoursanddid the creation of pneumoperitoneum, the control notreuireanyrescueanalgesic.Threepateintsof wasnotveryeffectiveatthetimeofendotracheal DE0.2hadpainimmediatelyafterextubation,so intubationandextubation. wehavegiveninjectionParacetamolI.V.forthem The Pulse Rate and Mean Arterial Pressure intherecoveryroom. both increased above pre-infusion levels. ence, GroupDE0.4patientswerepain-freeandvery they increased the dose to 04 mcgghr infusion comfortable in the post-operative period. They in our next two patients. The results were uite havereceivedrescueanalgesiaaround00minutes satisfactorywiththisdosingregime.PRandMAP 5hoursaftersurgery. were always below pre-infusion levels in Dex 0.4 group. We also studied few cases with Dex 0 mcgghr dose but the hypotension was seen Adverseeffects ina greater number of patients, and the sedation wasmore(RSS4–5).ence,theyhavetakenthree No serious adverse effects were observed in this groupsintheirstudy,whichwereGroupNS,Group study. Dex0.2andGroupDex0.4.Theirstudyconrmed In one patient endobronchial intubation the fact that critical incidences like laryngoscopy occurred. Saturations were reduced, immediately andintubation,pneumoperitoneumandextubation endotrachealtubepositionadjustedandsaturations do signicantly increase the Mean Arterial becamenormal. Pressure and Pulse Rate in patients undergoing laparoscopiccholecystectomyasseeningroupNS. Dexmedetomidineattenuatesthissympathoadrenal imitationsofthestudy response and provides hemodynamic stability. The effective attenuation dose with minimum Thelimitationsofthepresentstudyareinabilityto side effects noted in our study was 04 mcgghr assessthedepthofAnesthesia.Dexmedetomidine infusion.9 attenuates hemodynamic response, and it was Inpresentstudy,02&04mcgghrwereused verydifculttoassessthedepthofanesthesia.IS as study dose and found to be effective which monitoring and catecholamines estimation were correlateswiththeabovestudy. notpracticalincasesstudied. ThePulseRateandMeanArterialPressureboth increasedabovepre-infusionlevels15minutesafter Conclusion infusionandafterintubationingroupDE0.2group. utitcontrolledtheriseinPRhattacharjeeetal10also observedno signicant effectof Dexmedetomidine Dexmedetomidine may provide an attractive onresponsetoverbalcommandandextubationtime. alternative to anesthetic adjunctive agents now Dexmedetomidine has been found to reduce the in use because of their anesthetic-sparing and IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1568 IndianJournalofAnesthesiaandAnalgesia hemodynamic-stabilizing effects. Low dose 4. hanP,MundayIT,JonesRM,etalEffectsof Dexmedetomidine infusion given at the rate of dexmedetomidine on isoflurane reuirements 04 gramghr is uite effective for laparoscopic in healthy volunteers 1: Pharmacodynamic surgery. It provides better peri-operative and pharmacokinetic interactions. r J Anesth. 1999;8:72–80. hemodynamic stability than many agents now in use and may offer protection from ischemia due 5. all JE, hrich TD, arney JA, et al Sedative, to the attenuated neuroendocrine response. The amnestic,andanalgesicpropertiesofsmall-dose dexmedetomidine infusions. Anesth Analg. drugistobegivenininfusionratherbolustoavoid 2000;90:699–705. complications like bradycardia and hypotension. Dexmedetomidine may have a role in anesthesia 6. aselman MA. Dexmedetomidine: A useful adjuncttoconsiderinsomehigh-risksituations. for patients who are at high risk of myocardial AANAJ.2008;76:5–9. ischemia while undergoing laparoscopic surgery. Dexmedetomidine a new, more selective 7. LangerS.Presynapticregulationofthereleaseof catecholamines.PharmacolRev.1981;2:7–61. 2-adrenoceptor agonist may provide a new concept for the administration of peri-operative 8. DrewGM,WhitingS.Evidencefortwodistinct anesthesiaandanalgesia. types of postsynaptic alpha-adrenoceptor in vascularsmoothmuscleinvivo.rJPharmacol. 1979;67:207–15. Abbreiations 9. Manne GR, padhyay MR, Swadia VN. Effects of low dose dexmedetomidine infusion on ASA-AmericanSocietyofAnesthesiologists hemodynamic stress response, sedation and post-operativeanalgesiareuirementinpatients P-loodPressure undergoinglaparoscopiccholecystectomy.Indian PM-eatsperminute JAnesth.2014;58:726–1. 10. hattacharjeeDP,NayekS,DawnS,etalEffects DP-DiastolicloodPressure ofdexmedetomidineonhemodynamicsinpatients undergoing laparoscopic cholecystectomy: A EtCO2-End-tidalcarbondioxideconcentration comparativestudy.JAnesthClin.Pharmacology. G-Gauge 2010;26(1):45-48. MAP-MeanArterialPressure 11. GurbetA,asagan-MogolE,TurkerG,etalIntra- R-eartRate operative infusion of dexmedetomidine reduces peri-operative analgesic reuirements. Can J SP-SystolicloodPressure Anesth.2006;5:646–52. 12. B et al eferences .AA.200106174174. 1. Cunningham AJ. Anesthetic Implications of 1. Abdelmageed WM, Eluesny M, Shabana RI, LaparoscopicSurgery.aleJiolMed.1998Nov- etalAnalgesicpropertiesofadexmedetomidine Dec;71(6):551-78. infusion after uvulopalatopharyngoplasty in 2. Mc Iz.iughlin JG, onnell W, Seheeres DE, et patients with obstructive sleep apnea. Saudi J al The adverse hemodynamic effects related to Anesth.2011;5:150–56. laparoscopic cholecystectomy. Anesthesiology. 14. LinTF,ehC,LinFS,etalEffectofcombining 1992;77:A70. dexmedetomidineandmorphineforintravenous . WilcoxS,VandamLD.Alas,poorTrendelenburg patient-controlled analgesia. r J Anesth. and his position A critiue of its uses and 2009;102:117–22. effectiveness.AnesthAnalg.1988;67:574–78.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1569-1574 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.12

Effectieness of Demedetomidine to educe Bleeding During Tympanoplasty and Functional Endoscopic Sinus Surgery FESS: An InterentionalStudy

SumaVdayaBhaskarVSantoshNaidu

1Associate Professor, Department of Anesthesiology, JJM Medical College, Davanagere, arnataka 577004, India. 2Associate ProfessorPostGraduate,DepartmentofAnesthesiology,PESInstituteofMedicalSciencesandResearch,uppam,AndhraPradesh 517425,India.

Abstract

Contet:leedingduringthenasalandmiddleearsurgeriescanimpairthevisibilityofthesurgicalfield. Controlled hypotensionisatechniueusedtobringdowntheMeanArterialPressure (MAP)andreduce the bleeding in the surgical field. Aims: To evaluate the effectiveness of dexmedetomidine, a selective 2-adrenoceptor agonist, on reducing the intra-operative bleeding and duration of surgery. ettings and esigns:Randomized, double blind, control study. MaterialsandMethods:We includedsixtypatients who werepostedfortympanoplastyandFESSundergeneralanesthesiaanddividedrandomlytoGroupDwhere dexmedetomidine1g/kgloadingdoseplusamaintenanceof0.5to0.8g/kg/hrandGroupPinwhom normalsaline1ml/kgloadingdoseand1ml/kg/hrmaintenancewasadministered.eartrateandMAP wasmeasuredat15,0,45,60minutesandatextubation.leedingseverityscoreandthedurationofsurgery werenoted.Studentt-testandchi-suaretestwereusedfordataanalysis,p-value0.05wasconsidered statisticallysignificant.Results:Thefallinheartrate,MAPwasmoreintheGroupDthaninGroupPand was significantstatistically (p0.05). leeding severityscorewas lower intheGroup Dthanin GroupP. (noneofthepatientshadascoreofinGroupDandinGroupP10patientshadascoreof).Themean durationofsurgerywasalsolessintheGroupD(55.55min2.4)whencomparedtoGroupP(68.9min 4.8)whichwasstatisticallysignificantp0.01).Conclusion:Dexmedetomidineinfusionstartedasloading dosealongwithintra-operativemaintenanceresultsinadecreaseintheMAP,reducedbleedingandshorter surgicalduration. eyords:leedingseverityscore;Controlledhypotension;Dexmeditomidine;Placebo.

otocitethisarticle: SumaV,dayahaskar,RVRSantoshNaidu.EffectivenessofDexmedetomidinetoReduceleedingDuringTympanoplasty andFunctionalEndoscopicSinusSurgery(FESS):AnInterventionalStudy.IndianJAnesthAnalg.2019;6(5Part-1):1569-1574.

Introduction controlledhypotension.4Volatileanestheticagents, sodiumnitroprusside,nitroglycerine,betablockers A blood less eld is needed while performing and calcium channel blockers are some of the drugs used to produce controlled hypotension 5–7 Tympanoplasty and Functional endoscopic . sinus surgery FESS in order to provide a better Problemsthatcanbeseenwiththesedrugscanbe 1– a delay in recovery when volatile anesthetics are vision to the surgeon. It is a challenge to the anesthesiologisttoprovidethesame.Themethod used, drug resistance with vasodilators, cyanide 8–10 ofreducingthebloodpressureinordertoreduce toxicityandtachyphylaxiswithnitroprusside. the bleeding in the intra-opreative period and in Selective 2receptoragonistDexmedetomidine turnimprovetheoperativeeldvisibilityiscalled has anti-hypertensive effect. It also has other

CorrespondingAuthor:dayaBhaskar,AssociateProfessor,DepartmentofAnesthesiology,PESInstituteofMedicalSciences andResearch,uppam,AndhraPradesh517425,India. Email:[email protected] eceiedon2.07.2019,Acceptedon1.08.2019

RedFlowerPublicationPvt.Ltd. 1570 IndianJournalofAnesthesiaandAnalgesia properties like analgesia, sympatholysis and of anesthesia done using injection Propofol 2 sedation without causing major respiratory mgg, endotracheal intubation facilitated with depression. It has been used to suppress injection succinylcholine 15 mgg, and intubated sympathetic response also. Opioid reuirement with a appropriate sized tube. Maintenance of is also decreased in addition to a reduction in anesthesiawasdonewithnitrousoxideandoxygen stress responses to surgery and post-operative 65:5 ratio along with 0.4–1 isourane and shivering.11 Previous studies have concluded vecuronium 005 mgg used for intra-operative dexmeditomidinetobebenecialintymoanoplasty musclerelaxation.Duringintra-operativeperioda and FESS. As dexmeditomidine was not used in maintenance dose of dexmedetomidine at 05–08 ourinstitutionroutinelywedecidedtoconductthis gghrwasusedinGroupDandtheinfusionrate studytoknowifitcaneffectivelyreducebleeding wasreducediftheMAPwentbelow0mmofg intymoanoplastyandFESSsurgeries. orheartratebelow50beatsperminuteandNormal salineinfusion1mlghrwascontinuedinGroup MaterialsandMethods (P). The infusionswere stopped 20 minutesbefore theendofsurgery.eartrateandbloodpressure was noted before any intervention, at 150450 ASAclassIandIIpatientssixtyinnumberofboth minutesafterdrugadministration,andatthetimeof sex,intheagegroupof18–40years,scheduledto extubationforstatisticalanalysisbutacontinuous undergo elective FESS and tympanoplasty under monitoringofheartrateandbloodpressureevery general anesthesia were selected for the study. ve minutes was done during surgery. Atropine Institutionalethicalcommitteeapprovalandwritten 0mgwasgiveniftheheartratewas50beatsper informedconsentfromthepatientswereobtained. minute. Ephedrine 5 mg increments was used to Two groups, the dexmedetomidine group (D) correct MAPif it went below 0 mm g. Opinion andtheplacebogroup(P)weredoneandpatients of the surgeon regarding the operative eld and wereallottedrandomlyintooneofthem.Patients intra-operative bleeding was assessed using the withcomorbiddiseasescomingunderASAIIand ASAIIIphysicalstatus,pregnantfemales,patients leeding severity score obtained by the following with bleeding disorders, patients having Sinus uestionnaireandgradedaccordingly.Wemodied 2 radycardia, eart lock, Conduction defects, thescoreusedbyFrommeetal Ischemic eart Diseases (ID)/Rheumatic eart 0-virtuallybloodlesseldwithoutanybleeding. Disease, Chronic Renal Diseases with deranged 1-Amildleedingthatwasnotasurgicalnuisance. renalparametersandhypotensionpre-operatively 2-Moderate bleeding causing a surgical nuisance were not included in the study. This study was notinterferingwithaccuratedissection.-Moderate done in the Operation theatre with facilities for bleedingthatcompromisedthesurgicaldissection Induced ypotension and Resuscitation. Patients moderately. 4-A severe bleeding but controllable were examined in the pre-operative period and and interfering signicantly with surgical laboratoryinvestigations,Electrocardiogram(ECG) dissection.5-Massivebleedingwhichcouldnotbe andchest-raywereordered.Patientswerekept controlledandmadedissectionimpossible. nilbymouthforeighthours. The anesthesiologist recording the parameters On shifting to Operation theatre, an 18G/20G and the surgeon were both unaware of the drug I.V. canula secured and dextrose normal saline administered. Ondansetron 4 mg intravenous infusionwasstarted. Monitors wereconnected to was administered 0 min prior to end of surgery record non-invasive blood pressure, Pulse rate, for anti-emesis. Duration of surgery in minutes

ECG,O2saturationandend-tidalcarbondioxide. was recorded. Glycopyrrolate 002 mgg and eart rate, lood Pressure both Systolic and Neostigmine005mggwasusedforreversingthe DiastolicandMAPbeforeinductionwererecorded. residualneuromuscularblockafterthecompletion olusdoseofdexmedetomidine1ggover10mins ofsurgeryandpatientswereshiftedtotherecovery inaninfusionof100mlnormalsalinewasstarted area and were shifed from the recovery on inGroup(D),andnormalsaline100mlinfusionin achieving Aldrettescoreof9.Purposivesampling Group(P)atarateof1mlghrviaanextensionof techniue was used to calculate sample size with 25cmsconnectedtothecanulawiththemaintenance thecondenceinterval(1-)at95andpowerof uid. Injection glycopyrrolate 02 mg was given study(1-)at80.DatawasenteredinMicrosoft beforeinductionofanesthesiaandinjectionfentanyl excel, statistics were calculated using stata 14.1 15gggivenforanalgesia.Pre-oxygenationwith software.Numericaldatawascalculatedfrommean 100 oxygen was done for minutes, induction andstandarddeviation,categoricalvariablesusing

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectivenessofDexmedetomidinetoReduceleedingDuringTympanoplasty 1571 andFunctionalEndoscopicSinusSurgery(FESS):AnInterventionalStudy percentage. Student t-test was used for numerical beingmoreingroupDandsignicantstastistically. dataandchi-suaretestforcategoricaldata,p–value (p0.05).Thelowestmeanheartraterecordedin 0.05wasconsideredstatisticallysignicant. GroupDwas55.052.74whileinGroupPitwas 62.42.94thedecreasebeingsignicantinGroupD esults comparedtogroupP(p0.05)at45minutesafter thestartoftheloadingdose.

Nodifferenceintheage,sexratioandbodyweight Table:ShowingAgeweightandsexofthepatients waspresentbetweenthegroups.Shows(Table) Meanbaselineheartratewas72.51.69ingroupD Parameter roupD roupII alue and71.8.25ingroupP(p0.414).Meanarterial Meanage 2.7 7.4 0.179 pressure MAP at baseline was 91.97 4.5 for Weightin Male Female Male Female 0.184 kilograms GroupDand92.46forGroupP(p0.28)both 61.47 52.6 59.2 54.2 ofwhichwerestatisticallynotsignicant.eartrate Sexofpatients Male Female Male Female 0.46 and MAP gradually decreased following loading 15 15 12 18 dose of injection dexmedetomidine I.V. in group leedingseverityscorewas1in66.6and2in D at 15 minutes and throughout the duration of .patientsinGroupDcomparedto2in5. surgeryatallthemeasuredtimeintervalscompared andin.patientsinGroupP,morenumberof to Group P which was statistically signicant patientswithlowerscoresinGroupD,thusresulting (p0.001)displays(raphs&).Themaximum inashorterdurationofsurgeryinGroupD(5555 fall inmeanarterial pressure was seen 45 minutes min24)whencomparedtoGroupP(8min afterthestartingofthedrugandwasaround0 48)whichwasstatisticallysignicant(p0.01) from baselineingroupD (61.29.76)compared (raphs&).Thevolatileanestheticagentneeded to a fall of28 inGroup P (65.9 .18.) thefall inGroupDwaslessComparedtoGroupP.

asal 15min 0min 45min 60min Extubation raph:eartRate

asal 15min 0min 45min 60min Extubation raph:Meanarterialpressure(MAP)

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1572 IndianJournalofAnesthesiaandAnalgesia

GroupD GroupP

raph:leedingseverityscore

raph:Meandurationofsurgery

Discussion easy to titrate, have minimal or no interactions withotherdrugswiththedurationofactionbeing 15 leeding associated with impairment of visibility short. The drugs used for producing controlled hypotensionactbymainlybyreducingthevascular in the intra-operative period and resultant 5 prolongationofthesurgicaltimeisaproblemseen tone. Opioidslikeremifentanyl,volatileanesthetic inmiddleearandnasalsurgicalprocedures.1,2,,5The agents, vasodilators like sodium nitroprusside and reductionofMAPintheintra-operativeperiodby nitroglycerineareusedwithcertainadvantagesand disadvantages.8–10 agonist clonidine was used in around0ofthebasalvaluesiscalledcontrolled 2 hypotension.1Thistechniueisemployedinmiddle manystudiestoreducethebleedingduringmiddle ear and nasal surgery.15 A selective receptor ear and nasal surgeries, operation of spine, head 2 andnecksurgicalprocedures, agonistdexmeditomidinewasapprovedforhuman usebytheFDAin1999.Clonidinethe adrenergic In neurosurgery and orthopedic surgeries that 2 receptor agonist has 2:1 binding ratio of 220:1 are associated with major bleeding. Controlled partial2withaeliminationhalflifeofeighthours hypotension in addition to improving the surgical while dexmeditomidine has 2:1 of 1620:1 full visibilityalsoreducestheneedforbloodtransfusions agonistof witheliminationhalflifebeing2–2.5 1,14 2 by reducing the blood loss during surgery. The hours.ence,dexmedetomidineisapreferreddrug drugsusedto reduce the MAP should be specic, over clonidine.11 Dexmedetomidine reduces the

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EffectivenessofDexmedetomidinetoReduceleedingDuringTympanoplasty 157 andFunctionalEndoscopicSinusSurgery(FESS):AnInterventionalStudy

bloodpressureandbleedingby2receptormediated whichreducedto55.052.74from72.51.69at decreaseinthenorepinephrinereleasewithresultant 45minutesafterthestartofdexmedetomidine.The symphatholysis.4 We selected the loading dose of meanheartrateinGroupPwas71.8.25beforethe 1ggalongwithamaintenancedoseof05–08g startoftheinfusionandreachedthelowestof62.4 ghourbasedontheresultsofthepreviousstudies.1,4,5 2.94at45minutesaftertheplaceboadministration. The basal MAP was not different signicantly ThefallwasmoreinGroupDwhichagainisdue amongstthegroups.AreductionintheMAPwas to symphatholysis caused by dexmeditomidine. 1 5 16 observed in the Group D, from ameanof 91.97 Ayoglu et al , Durmus et al , Vora S et al and 17 4.5to61.29.76withmaximumreductionseenat Panchgar V et al alsoobserved adecrease inthe 45minutesafterthestartingofthedexmeditomidine heartratewhenDexmedetomidinewasadministerd. andintheGroupPalsoafallofMAPwaspresent The reuirement of isourane to decrease the fromabasalmeanof92.46to65.9.18,with intra-operativeMAPandbleedingwashigherinthe a maximum fall at 45 minutes after the infusion. GroupPcomparedtoGroupD. owever,thefallintheGroupDwassignicantly lower when compared with group P at all the Conclusion timeintervals.Ayogluetalintheirstudydoneto know the effectiveness of dexmedetomidine on Dexmedetomidineusedasanintravenousloading bloodlossinseptoplastyandtympanoplastyfound dose pre-operatively along with maintenance dexmedetomidinetocauseafallinbloodpressure during tympanoplasty and FESS surgery reduces fromthebasalvalues.1Instudiesdonetoassessthe the MAP, intra-operative bleeding, surgical time, effectsofdexmedetomidineinpatientssubjectedto heartrateandreuirementofvolatileanesthetic. laparoscopicsurgeriesVoraS16etalandPanchgar V et al17 noted a signicant fall in the MAP in SourceofsuortNil patients who received dexmedetomidine when ConictsofinterestNil compared to placebo. Durmus et al5 in the study of dexmedetomedine versus placebo in patients eferences undergoingtympanoplastyreportedafallinblood pressure in both the groups without a signicant differencewhichisincontrasttoourndings.The 1. ilalA,Osman,Mehmet,etalEffectiveness higherfallinMAPinGroupDcanbeattributedto ofdexmedetomidineinreducingbleedingduring dexmedetomidine mediated symphatolysis with a septoplasty and tympanoplasty operations. decrease in the vascular tone. Durmus et al5 used Journalofclinicalanesthesia.2008;20:47–44. nitroglycerine infusion along with isourane to 2. oezaart AP, van der Merwe J, Coetzee A. maintain lower levels of MAP in both the groups. Comparisonofsodiumnitroprussideandesmolol ence,therewasafallinMAPinboththegroups. induced controlled hypotension for functional endoscopic sinus surgery. Can J Anesth. Thebleedingseverityscoreobtainedbyuestioning 1995;42(5):7–76. the surgeons was lower in patients in the Group D. 66.6 (20 patients) had a score of 1 and . . Simpson P. Per-operative blood loss and its reduction: The role of anesthetist. r J Anesth. (10patients)hadascoreof2.Intheplacebogroupthe 1992;69:498–507. scorewashigher1(4patients)hadascoreof1,5 (16patients)hadascoreof2,(10patients)had 4. Shams T, El ahnasawe NS, Abu-Samra M, et al Induced hypotension for functional ascoreof.Signicantlyhighernumberofpatients endoscopic sinus surgery: A comparative study hadascoreof1inthegroupD.(p0.05).Ayoglu of dexmedetomidine versus esmolol. Saudi J 5 etal,Durmusetal alsoreportedalowersurgical Anesth.201;7:175–80. bleedingscoresindexmedetomidinegroups.Shams 5. Durmus M, ut A, Dogan , et al Effect etalinthestudycomparingdexmedetomidineand of dexmedetomidine on bleeding during esmolol administration in FESS noticed a lower tympanoplasty or septorhinoplasty. Eur J surgical bleeding scores when dexmedetomidine Anesthesiol.2007May;24(5):447–5. 4 was used. Lower scores for severity surgical 6. Degoutes CS, Ray MJ, Manchon. Remifentanyl bleedingcanbeduetoadecreaseintheMAPand and controlled hypotension: Comparison with bleedingintheintra-opertiveperiod.Wealsonoted nitroprusside oresmololduringtympanoplasty. asignicantreductioninthesurgicaltimeinGroup CanJAnesth.2001;48:20–27. D which could be due to decreased bleeding and 7. Akken V, Miller ED. Deliberate hypotension. better visibility of the operating eld. There was MillerRD,Anesthesia,5thedition,vol.1,Newyork. alsoareductioninthemeanheartrateinGroupD SA:ChurchillLivingstoneInc;2000. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1574 IndianJournalofAnesthesiaandAnalgesia

8. Orien E, oung WL, Ostapkovich N, et al 14. Newton MC, Chadd GD, O Donoughe , et al Deliberate hypotension in patients with Metabolic and hormonal responses to induced intracranial arteriovenous malformations: hypotensionformiddleearsurgery.rJAnesth. Esmolol compared with isoflurane and sodium 1996;76:52–57. nitroprusside.AnesthAnalg.1991;72:69–44. 15. Lee J, Lovell AT, Parry MG, et alI.V. clonidine 9. loweyDL.Antihypertensiveagents:Mechanism does it work as hypotensive agent with in of action, safety profiles and current uses in halationalanesthesiarJAnesth.199;82:69–40. children.CurrTherResClinExp.2001;62:298–1. 16. VoraS,aranda,ShahVR,etalTheeffectsof 10. RichaF1,azigiA,SleilatyG,etalComparison dexmedetomidineonattenuationofhemodynamic between dexmedetomidine and remifentanil for changesandthereeffectsasadjuvantinanesthesia controlled hypotension during tympanoplasty, during laparoscopic surgeries. Saudi Journal of EurJAnesthesiol.2008May;25(5):69–74. Anesthesia.2015;9(4):86–92. 11. aur M, Singh PM. Current role of 17. Panchgar V, Shetti AN, Sunitha , et al The dexmedetomidine in clinical anesthesia and Effectiveness of Intravenous Dexmedetomidine intensivecare.Anesthesia,EssaysandResearches. on Peri-operative emodynamics, Analgesic 2011;5(2):128–. Reuirement,andSideEffectsProfileinPatients 12. Fromme GA, Macenzie RA, Gould A, et al ndergoingLaparoscopicSurgerynderGeneral Controlledhypotensionfororthognathicsurgery. Anesthesia. Anesthesia, Essays and Researches. AnesthAnalg.1986;65:68–86. 2017;11(1):72–77. 1. WardCF,AlferyDD,SaidmanLJ,etalDeliberate hypotension in head and neck surgery. ead NeckSurg.1980;2:185–95.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1575-1582 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.1

Perioperatie igh Sensitie Creactie Protein for Prediction of CardioascularEentsafterCoronaryArteryBypassraftingSurgeryin eftVentricularDysfunctionPatients:AProspectieObserationalStudy

arshiloshiViayaumarauruprasadaiakamalVishnu

1,2Assistant Professor,Dept. ofAnesthesia, Assistant Professor 4Senior resident,Deptof Cardiac Surgery,ManipalAcademy of igherEducation,asturbaMedicalCollege,Manipal,arnataka576104,India

Abstract

igh sensitivity C-reactive protein is inflammatory marker having predictive value in both stable and unstable angina as well as in the acute phase after coronary artery bypass grafting. Many studies haveevaluatedtheprognosticvalueofCRPforpredictingpost-operativeoutcome,mosthavefocusedon pre-operativeCRPlevels,whichcannotreflecttheinflammatoryreactionsinducedbysurgeryitself.ere authorhypothesizedthatpost-operativeCRPelevation,reflectingsurgery-inducedinflammatoryreactions, is related to the occurrenceof post-operativemajor adverse cardiovascularand cerebral events(MACCE) inpatientsundergoingoff-pumpcoronaryarterybypasssurgery(OPCA).Objective:Tobetterunderstand the current state and application of high sensitivity C-reactive protein (hs-CRP) in clinical practice. To establish excellence of hs-CRP level as a prognostic marker in low EF heart patients. We have done prospectiveobservationalstudyinperi-operativeperiodof100patientswithstableischemicheartdiseaseand leftventriculardysfunction(EF5)whounderwentoffpumpCAGtoascertainwhetheranactivation oftheinflammatorysystemduringsurgery,detectedbyelevatedserumhs-CRP,hasanyassociationwith prognosis.Result:Inpatientswithpre-operativehs-CRP1.0mg/dl,thecumulativeeventincidencewas8 comparedto15inpatientswithlevelspre-operativelyofhs-CRPlessthan1.0mg/dl.Post-operativehs-CRP hasnosignificantdifference.Conclusion:Authorconcludethatincreasedpre-operativehs-CRP1.0mg/dl predictinhospitalcardiacandcerebrovascularmorbidityandmortality.Thereisincreaseinpost-operative hs-CRPbutitisnotstatisticallysignificanttoconcludeitasprognosticmarkerforpredictingpost-operative morbidity. eyord:C-reactiveProtein;CAG;Prognosis;Inflammation.

otocitethisarticle: arshil Joshi, Vijaya umara, Guruprasad Rai et al Peri-operative igh Sensitive C-reactive Protein for Prediction of Cardiovascular Events after Coronary Artery ypass Grafting Surgery in Left Ventricular Dysfunction Patients: A Prospective ObservationalStudy.IndianJAnesthAnalg.2019;6(5Part-1):1575-1582.

Introduction Early complications include stroke, myocardial infarction,hemodynamicinstabilityandlongIC Coronary Artery ypass Graft (CAG) is the stay.2 Atherosclerosis, underlying cause of most most common cardiac surgery which has both Coronary eart Disease, is basically Systemic early and late post-operative complications.1 as well local inammation in arterial wall and

CorrespondingAuthor:Viayaumara,AssistantProfessor,ManipalAcademyofigherEducation,asturbaMedicalCollege, Manipal,arnataka576104,India. Email:harshil[email protected] eceiedon11.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1576 IndianJournalofAnesthesiaandAnalgesia shoulder region of plaue is heavily inltrated (totalbilirubinmgdl),treatmentwithintravenous with inammatory cells.,4 As it is inammation, nitrates or inotropes before surgery, redo cardiac inammatory markers must be elevated across surgery, treatment with steroids in the previous the clinical spectrum of atherosclerotic coronary six months, previous percutaneous coronary arterydisease.5,6 intervention, cerebrovascular accident during ighsensitiveC-reativeProtein(hs-CRP)isused the year prior to the study,current inammatory todetectthelowlevelinammationwhenCRPis conditionorhistoryofaneoplasticcondition. within the normal range. Elevation of hs-CRP is The number, type and severity of diseased associatedwithapoorprognosis inpatientswith coronary arteries were determined based on acutemyocardialinfarction(AMI).7Therecognition angiographyofthepatient.Arterywasconsidered thatactiveinammatoryprocessesmaydestabilize tobediseasedifthestenosiswaseualorgreater thebrouscaptissue,thustriggeringplauerupture than60oftheluminaldiameter. and enhancing the risk of coronary thrombosis.8,9 Manystudieshaveevaluatedtheprognosticvalue AnesthesiaandSurery ofCRPforpredictingpost-operativeoutcome,most have focused on pre-operative CRP levels, which A single surgical and anesthesia team involved cannotreecttheinammatoryreactionsinduced incurrent study. All patients underwent general bysurgeryitself.10,11 anesthesia according to standardized protocol. After endotracheal intubation, 50 O , 50 air, In current study, author hypothesized that 2 peri-operative hs-CRP elevation is related to and1to2sevouranewasusedforallpatients. the occurrence of post-operative major adverse Antibrinolytic agents were not used. Intra- cardiovascular and cerebral events (MACCE) in operative TEE was done to document regional patients undergoing Off-pump Coronary Artery wallmotionabnormality.Patientsweretransferred ypass (OPCA) surgery with left ventricular to the surgical Intensive Care nit (IC) after dysfunction. Author investigated the predictive CAG and extubated there only after achieving value of a peri-operative high sensitivity CRP on extubationcriteria.Patientsolderthan0yearswith 0daysmortalityafterelectiveOPCAsurgery. a hemoglobin value less than gdl and patients aged 0 years or less with a hemoglobin value They studied 100 patients with stable ischemic less than 8 gdl received packed red blood cells. heart disease and left ventricular dysfunction Patientswithatendencytobleedweretreatedby (EF 5) who underwent off pump CAG to transfusion of fresh frozen plasma and platelet ascertainwhetheranactivationoftheinammatory concentrate. Inotropes were used only when systemduringsurgery,detectedbyelevatedserum hemodynamic stabilizationcouldnot beachieved hs-CRPhasanyassociationwithprognosis. by uid administration or when there was other evidence of impaired contractility. In case of an MaterialsandMethods insufcient response to inotropes, intra-aortic balloon counter pulsation was initiated at the This study was done at tertiary care hospital. discretionofintensivist. Studypopulationof100patientswereenrolledin followingapprovalbythelocalethicalcommittee atacollection approvalandgettinginformed,writtenconsentof patients.Thisisprospectiveobservationalstudy. Fasting blood samples were collected from a peripheralveinbeforetheoperation.Post-operative blood samples were taken from indwelling CVP InclusionCcriteria line. Peri-operative White lood Cells (WC), Patientsscheduledforoff-pump Coronary Artery Platelets (PLT), emoglobin (b), S. creatinine, ypass Grafting (CAG) surgery, less than S. total bilirubin, SGOT and SGPT levels were 75yearsandwithleftventricleejectionfractionless measured by certied technician in the central than5. biochemical and clinical laboratory. Pre-operative hs-CRP was taken within days prior to surgery and Post-operative Troponin I and hs-CRP level clusionCriteria was measured at 12 and 24 hours post-operative Chronic obstructive pulmonary disease, recent from central vein sample. A highly sensitive myocardialinfarction,acuteorchronicrenaldisease CRP (hs-CRP) analysis was performed using the (serumcreatinine2mgdl),chronicliverdisease commercially available kit of abbott CRP vivoan

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 Peri-operativeighSensitiveC-reactiveProteinforPredictionofCardiovascularEventsafterCoronary 1577 ArteryypassGraftingSurgeryinLeftVentricularDysfunctionPatients:AProspectiveObservationalStudy automated blood test that uses particle-enhanced esults immunoturbidimetric method to uantify CRP in serumsamples. Categorical variables are presented as numbers

Denition of post-operative MACCE (Major and percentages and analysed using the 2test. adversecardiovascularandcerebralevents). Continuous variables are assessed for normal The primary endpoint was post-operative distributionandpresentedasmeansandstandard MACCE, which was dened as a composite of deviation. Continuous variables are compared death from cardiac causes and stroke. Cardiac using students t-test for normally distributed cause include MI, cardiac arrhythmia, or heart variables and the mann-whitney test for failure caused primarily by a cardiac problem. non-normally distributed variables. The level of Stroke was dened as a new ischaemic or signicance was accepted at p 0.05. Statistical hemorrhagic cerebrovascular accident with a analysis was performed using SPSS, version 20.0 neurological decit lasting more than 24h. The (Chicago,IL,SA). diagnosisofMIwasbasedontheassociatedwith In current study, both the groups were cardiacbiomarkerlevelsmorethanvetimesthe comparablewithregardstoage,sex,weight,height, upperreferencelimit. bodysurfacearea,leftventricularejectionfraction, Recentmyocardialinfarction(MI)wasdenedas comorbidities, coronary artery involvement and myocardialinfarctionlessthan0daysatthetime medical management (p 0.05), below shows ofsurgery.12Patientswerefollowedupto 0days (Table ). During the rst 0 days after surgery, aftersurgeryandeventsrecordedinclude: 78 patients were free from observed events and 22 patients developed following cardiovascular 1 (1)Deathfromcardiovascularcauses. events: 8 (6.6) had myocardial damage or (2) Ischemic stroke1 (dened as new ischemic infarction,8(6.6)hadlowoutputheartfailure, or hemorrhagic cerebrovascular accident with 4(18.18)sufferedcerebrovascularaccidentand a neurological decit lasting more than 24h 2(9.09)patientsweredead. with denite image evidence by head computer tomography). Table:DemographicandmedicationdataaccordingtoMajor ()emodynamicinstabilityduetoLowOutput AdverseCardiovscularandCerebralEvents(MACCE). 14 Withouteents Witheents Systemicheartfailure (LOF)(denedasneeding Data alue one of the following: Intra-operative Intra-aortic n n alloonPump(IAP),returntograftrevision,or emographics twoinotropesat48hourspost-operatively). Age,years 57.548 54.647.47 0.11 Gender, (4)Myocardialinfarctionordamage15,16(dened M 65 19 0.98 aselevatedtroponinI(TnI)greaterthan100glat F 1 12hoursaftersurgeryassociatedwithcharacteristic SA,m2 1.670.17 1.670.15 0.954 Electrocardiographic(ECG)changes(development Comorbidities of new waves or new persistent ST-T change) DM 15 4 0.849 or echocardiographically documented new dyskinetic-akineticsegment). TN 6 1 0.9698 DMTN 6 1 0.9698 seofinotropicagentsandIntra-aorticalloon Angiography Pump (IAP), Mechanical ventilation (MV) SVD 5 2 0.9698 duration, lengths of Intensive Care nit (IC), DVD 0 9 0.9684 hospitalstay,numberofgraftsandperi-operative TVD 4 11 0.854 redbloodcelltransfusionwererecorded.Alldata chocardiography werecollectedprospectively. LVEF 0.265.22 29.785.46 0.704 Deaths were classified as either cardiac or Medications non-cardiac.Deathsthatcouldnotbeclassified etablockers 59 19 0.449 were considered cardiac. ospital mortality is ACEinhibitors 0 8 0.9445 definedasalldeathswithin 0daysof surgery, Nitrates 19 6 1 irrespective of where the death occurred, and Statins 55 1 0.4499 all deaths in the hospital after 0 days among Diuretics 28 7 0.9194 patients who had not been discharged after Aspirin 50 12 0.5707 undergoingsurgery. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1578 IndianJournalofAnesthesiaandAnalgesia

The impact of pre- and intra-operative clinical in belo shows (Table & ). There is signicant variables,accordingtochi-suaretest,oncombined correlation of pre-operative hs-CRP with blood post-operative cardio-vascular event is shown transfusion, ventilation duration, IC stay and

Table:ClinicaldataaccordingtoMajorAdverseCardiovscularandCerebralEvents(MACCE).

Withouteents Witheents Data alue n n ematology WC/cmm 9676.542654.74 908.19251.67 0.558 Post-opWCcmm 14674.62496.7 1468.645296.97 0.994 emoglobin,gmdl 12.661.6 12.862 0.66 Post-opemoglobin,gmdl 10.91.29 10.541.41 0.258 Platelet/cmm 29826.998296.9 269609.16479.7 0.279 Post-opPlatelet/cmm 15990.8585962.2 15018.195090.82 0.62 Pre-creatinine,mgdl 0.990.29 1.020.26 0.615 Creatinine,mgdl 1.090.07 1.1640.44 0.92 Pre-illirubin,mgdl 0.850.44 0.770.56 0.482 Post-opillirubin,mgdl 1.40.97 1.251.11 0.47 Pre-hs-CRP,mgdl 0.70.69 1.62.5 0.0 Post-ophs-CRP12hrmgdl 5.814.2 4.58.8 0.21 Post-ophs-CRP24hrmgdl 12.077.9 12.766.68 0.69 TroponinI,g/l 1.452.15 7.477.52 0.0001 RS,mgdl 175.22157.06 16.729.82 0.25 RS12hrmgdl 165.158.65 161.696.75 0.709 RS24hrmgdl 16.4228.71 171.8744.5 0.287 Pre-Lactate,mmoll 1.410.52 1.440.86 0.849 Post-opLactate12hr,mmoll .01.74 4.22.64 0.15 Post-opLactate24hrmmoll 2.220.78 2.60.89 0.2 Pre-Ph 7.90.04 7.90.04 0.888 Post-opPh12hr 7.70.05 7.90.06 0.29 Post-opPh24hr 7.80.04 7.60.05 0.067 SVO2 70.158.44 69.27.27 0.64

Post-opSVO212hr, 67.977.44 69.216.46 0.478

Post-opSVO224hr, 67.626.66 66.67.18 0.58 Surgery Numberofgrafts 2.720.8 2.50.68 0.256 RCtransfusion,unit 1.261.47 2.71.82 0.004 Ventilationtime,hours 5.994.22 16.9618.85 0.0001 ICStay,days .1.04 6.467.8 0.0001 ospitalstay,days 6.812.56 9.556.62 0.004

Table:Demographicandmedicationvariableaccordingtopre-ophs-CRP10mgdlor10mgdl

PreophsCPmdl PreophsCPmdl Data alue (n) (n2) emographics Age,years 57.177.1 56.259.8 0.599 Gender, F 14 2 0.198 M 57 27 SA,m2 1.670.16 1.670.17 0.85 Comorbidities DM 15 4 0.5705 TN 5 2 0.671 DMTN 4 0.6848

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 Peri-operativeighSensitiveC-reactiveProteinforPredictionofCardiovascularEventsafterCoronary 1579 ArteryypassGraftingSurgeryinLeftVentricularDysfunctionPatients:AProspectiveObservationalStudy

PreophsCPmdl PreophsCPmdl Data alue (n) (n2) Angiography SVD 4 0.6848 DVD 29 10 0.7144 TVD 8 16 0.946 chocardiography LVEF 29.95.11 0.695.6 0.514 Medications etablockers 55 2 0.9491 ACEinhibitors 26 12 0.8275 Nitrates 19 6 0.7027 Statins 48 20 0.9172 Diuretics 28 7 0.2208 Aspirin 47 15 0.2602

Table:ClinicaldataaccordingtoPre-ophs-CRP10mgdlOR10mgdl

PreophsCPml PreophsCPml Data alue (n) (n2) ematology WC/cmm 9626.622442.87 9519.22946.92 0.852 Post-opWC/cmm 14914.09509.57 14095.184981. 0.461 emoglobin,mgdl 12.751.75 12.581.6 0.655 Post-opemoglobin,mgdl 10.81.7 10.781.19 0.841 Platelet/cmm 296161.9898910.89 26977.947140. 0.195 Post-opPlatelet/cmm 157759.1685470.4 157882.766717.8 0.994 Pre-Creatinine,mgdl 10. 0.980.24 0.8 Creatinine,mgdl 1.1220.6 1.0740.271 0.524 Pre-illirubin,mgdl 0.840.49 0.80.4 0.695 Post-opillirubin,mgdl 1.441.0 1.270.9 0.457 Post-ophs-CRP12hrmgdl 5.44.02 6.024.76 0.47 Post-ophs-CRP24hrmgdl 11.97.27 12.957.1 0.525 TroponinI,g/l 2.454.56 .584.9 0.275 RS,mgdl 174.17164.79 148.22.7 0.405 RS12hr,mg/dl 164.678.49 16.697.7 0.908 RS24hrmgdl 67.46.78 67.296.8 0.926 Pre-Lactatemmoll 1.40.56 1.460.72 0.65 Post-opLactate12hrmmoll .01.7 .92.55 0.041 Post-opLactate24hrmmoll 2.40.87 2.220.89 0.56 Pre-Ph 7.90.04 7.80.04 0.09 Post-opPh12hr 7.70.05 7.80.05 0.69 Post-opPh24hr 7.80.04 7.70.05 0.02 urgery Numberofgrafts 2.680.76 2.660.9 0.905 RCtransfusion,nits 1.11.51 1.971.77 0.06 Ventilationtime,hrs 7.179.09 11.421.02 0.066 ICStay,days .692.4 4.85.87 0.167 ospitalStay,days 7.41.22 7.425.45 0.995 MACCE 11 11 0.0284 hospital stay. Twenty nine patients had elevated to 15 in patients with levels pre-operatively of serum concentration pre-operatively of hs-CRP hs-CRPlessthan10mgdl.Serumconcentrationof 10mgdl(p0.028).(Tableshowsthedistribution pre-operativehs-CRP10mgdlwasindependent of other pre-operative variables according to predictorsofcombinedcardiovasculareventafter high sensitivity CRP less than 1.0 mg/dl or CAG surgery. Post-operative lactate at 12 hour 1.0mg/dl.Withpreoperativehs-CRP1.0mg/dl, and ventilation time is signicantly affected by thecumulativeeventincidencewas8compared pre-operativehs-CRP10mgdl.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1580 IndianJournalofAnesthesiaandAnalgesia

Discussion alimitationwhenrelativelyrarecomplicationsare analysed. s-CRP may be adversely affected by Asfarasauthorknowsnostudyhasbeendonefor local or systemic infection which limits its utility 2 predictionofcardiovasculareventsinpatientswith for prognostic marker. It is recommended that dysfunctional heart undergoing CAG surgery patientswitha CRPof 1mgd1in thepresence basedonpreandpost-operativehs-CRP.Incurrent of active infection, should have the test repeated in2wees,astheclinicalsignicanceofthetestis study,authorconcludedthatpre-operativeserum 2 concentrationsofhs-CRP10mgdlisassociated uestionable. Infections would be expected to withasignicantlyincreasedriskofoverallpost- increase false negative test results and decrease the utility of the test.Inour study, pre andpost- operative cardiac death, myocardial infarction, operative total WC count and platelet count is lowcardiacoutputsyndromeandcerebrovascular comparable so there is less chance of infection accidents. Immediate post-operative hs-CRP does associated inammatory response. Though pre- notappeartobeausefulbiomarkerintheoutcome operativehs-CRPisrelatedwithMACCE,ithasno aftercardiacsurgeryaspre-operativehs-CRP. correlation with post-operative renal dysfunction CRPhasbeenshowntobeastrongpredictorof oracutekidneyinjury. early and long-term outcome after percutaneous A number of studies implicate CRP as coronary intervention and peripheral vascular an important mediator in the generation of surgery.17,18 A pre-operative CRP 0 mgdl is atheromatouscoronaryplaue,includinguptakeof associatedwithasignicantlyincreasedriskoflate low-densitylipoproteinbymacrophages,triggering all-cause mortality, cardiac death. As vulnerable increased expression of endothelial cell surface plaue is probably responsible for approximately adhesion molecules, and activating complement halfofperi-operativeMI.19,20 system proteins.24,25 Moreover, although there is There are very few authors who used hs-CRP strong evidence that putative CRP gene single which is used in our study. Serum concentration nucleotide polymorphisms inuence systemic of hs-CRP mgl was an independent risk CRP levels, an independent association between factor of post-operative combined cardiovascular these CRP single nucleotide polymorphisms eventinpatientsundergoingCAGsurgery.21 ut and adverse cardiovascular events has not been average ejection fraction was 50 in this study. denitivelyestablished26.Conrmationofadirect Cardiovascular events happen more often in causalrelationshipbetweenpost-operativehs-CRP dysfunctionalheart.So,authorstudiedpredictive and cardiovascular outcomes will reuire further value of hs-CRP in dysfunctional heart patient investigation. undergoingCAGinIndiancontinent.Andauthor Another intra-operative factor that is ndoutthatcutofflimitofhs-CRPasindependent signicantly associated with MACCE is peri- riskfactorforcardiovasculareventisonlowerside operative RC transfusion. Transfusion of red inlowEFpatients.Thismightbeusedtorenethe blood cells remained an independent risk factor predictivevalueofscoressuchastheEuroscore.12 of combined cardiovascular event after CAG Furtherstudieswithlargernumberofpatientsare surgery.27TransfusionofstoredRCcanaugment neededtoallowgeneralizationofourndings. inammation by various mechanisms and that Thereisstudyshowingnocorrelationofpostof might have been reected in post-operative CRP hs-CRPand post-operative outcome,22in valvular levelsinourstudy.Anotherpossibleexplanationis andcoronarysurgery.uthereauthorhavestudied thatsignicantbleedingreuiringRCtransfusion onlyincoronarysurgeryasthispatientsaremore might have caused hypoperfusion which can vulnerable for atherosclerosis plaue. In current lead to MACCE. Additionally, intra-operative study,post-operativehs-CRPat24hrishigherin hypoperfusion triggers inammatory reactions patienthavingcardiovasculareventbutstatistically and conseuently increases post-operative serum notsignicant.SoifwefollowitPost-erativeday2 CRPlevels. ,wemightgetstatisticallysignicantresult.ut Lowejectionfractionpatientsmaybelimitation thatislimitationofourstudy. andonemayarguethatthecurrentndingsmay Factors that can affect peri-operative hs-CRP be not generalized to the contemporary surgical likepre-operativestatinandotherdrugtreatment, population. Anyway, the pre-operative high peri-operativetotal count,leftventricularejection sensitivity CRP to 10 mgdl is associated with fraction and other demographic and clinical data poor outcome after elective OPCAG surgery in aresimilarinbothgroupofpatients.Thereisalways dysfunctionalheart.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 Peri-operativeighSensitiveC-reactiveProteinforPredictionofCardiovascularEventsafterCoronary 1581 ArteryypassGraftingSurgeryinLeftVentricularDysfunctionPatients:AProspectiveObservationalStudy

Conclusion 10. Perry TE, Muehlschlegel JD, Liu , et al Pre- operative C-reactive protein predicts long- term mortality and hospital length of stay after In this study, author conclude that increased primary, non-emergent coronary artery bypass pre-operative hs-CRP 10 mgdl predict in grafting. Anesthesiology. 2010;112:607–1. doi: hospital cardiac and cerebrovascular mortality 10.1097/ALN.0b01e181ceab5. and morbidity in low EF patients undergoing 11. Padayachee L, Rodseth RN, iccard M. CAG. Post-operative increase in hs-CRP may A meta-analysis of the utility of C-reactive be due to inammatory response of surgery. ut protein in predicting early, intermediate-term its prognostic value for predicting post-operative and long-term mortality and major adverse morbidityneedsfurtherrandomisedcontrolstudy. cardiac events in vascular surgical patients. These ndings may allow for more objective risk Anesthesia. 2009;64:416–24. doi: 10.1111/j.165- stratication of patients who present for elective 2044.2008.05786.x. surgicalcoronaryrevascularization. 12. Aetal C. C . 19996913 https://doi. eferences org/10.1016/S1010-7940(99)0014-7. 1. Gokce N, eaney JF Jr, unter LM, et al Risk 1. Serruys PW, Morice MC, appetein P, et stratification for post-operative cardiovascular al Percutaneous coronary intervention eventsvianon-invasiveassessmentofendothelial versus coronary-artery bypass grafting function: A prospective study. Circulation. for severe coronary artery disease. N Engl 2002;105:1567-72. https://doi.org/10.1161/01. J Med. 2009;60:961–972. doi: 10.1056/ CIR.000001254.55874.47. NEJMoa0804626. 14. Surgenor SD, DeFoe GR, Fillinger MP, et al 2. anach M, ourliouros A, Reinhart M, et al Intra-operativeredbloodcelltransfusionduring Post-operative atrial fibrillation-what do we coronary artery bypass graft surgery increases reallyknowCurrVascPharmacol.2010;8:55–72. the risk of post-operative low-output heart DOI:10.2174/1570161107910807. failure.Circulation.2006;114:I4–48.https://doi. . Fuster V, adimon L, adimon JJ, et al The org/10.1161/CIRCLATIONAA.105.001271. pathogenesis of coronary artery disease 15. CroalL,illisGS,GibsonP,etalRelationship and the acute coronary syndromes. N Engl betweenpost-operativecardiactroponinIlevels J Med. 1992;26:242–250. DOI: 10.1056/ and outcome of cardiac surgery. Circulation. NEJM1992010260506. 2006;114:1468–475. https://doi.org/10.1161/ 4. MorenoPR,FalkE,PalaciosIF,etalMacrophage Circulationaha.105.60270. infiltration in acute coronary syndromes. 16. Thygesen , Alpert JS, White D. niversal Implications for plaue rupture. Circulation. definition of myocardial infarction. Eur eart 1994;90:775–758.Doi:10.1161/01.CIR.92..657. J. 2007;28:2525–58. https://doi.org/10.109/ 5. erkC,WeintraubWS,AlexanderRW.Elevation eurheartj/ehm55. ofC-reactiveproteininactivecoronaryartery 17. uffon A, Liuzzo G, iasucci LM, et al Pre- disease. Am J Cardiol. 1990;65:168–72. https:// procedural serum levels of C-reactive protein doi.org/10.1016/0002-9149(90)90079-G. predict early complications and late restenosis 6. MendallMA,PatelP,allamL,etalCreactive after coronary angioplasty. J Am CollCardiol. protein and its relation to cardiovascular risk 1999;4:1512–521. https://doi.org/10.1016/ factors: A population based cross sectional S075-1097(99)0048-4. study. MJ. 1996;12:1061–65. doi: https://doi. 18. iancari F, antonen I, Alback A, et al Limits org/10.116/bmj.12.708.1061. of infrapopliteal bypass surgery for critical 7. Walter D, Fichtlscherer S, Sellwig M, et al leg ischemia: when not to reconstruct. World J Preprocedural C-reactive protein levels and Surg. 2000;24:727–. https://doi.org/10.1007/ cardiovascular events after coronary stent s002689910117. implantation.JAmCollCardiol.2001;7:89–46. 19. Cohen MC, Aretz T. istological analysis of DOI:10.1016/S075-1097(00)0119-1. coronary artery lesions in fatal post-operative 8. Libby P. Molecular bases of the acute coronary myocardialinfarction.CardiovascularPathology. syndromes. Circulation. 1995;91:2844–50. 1999;8:1–9. doi/10.1161/circ.91.11.2844. 20. Dawood MM, Gutpa D, Southern J, 9. Maseri A. Inflammation, atherosclerosis, and et al Pathology of fatal peri-operative ischemic events: exploring the hidden side of myocardial infarction: Implications regarding themoon.NEnglJMed.1997;6:1014–16.DOI: pathophysiology and prevention. International 10.1056/NEJM199704061409. JournalofCardiology.1996;57:7–44. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1582 IndianJournalofAnesthesiaandAnalgesia

21. Ranucci M, allotta A, Castelvecchio S, et al 24. wakaTP,ombachV, Torzewski J.C-reactive Intensive Care nit admission parameters proteinmediated low densitylipoproteinuptake improve the accuracy of operative mortality bymacrophages:Implicationsforatherosclerosis. predictivemodelsinCardiacSurgery.PLoSONE. Circulation.2001;10:1194–197. 5(10):e1551. doi:10.171/journal.pone.001551. 25. Pasceri V, Willerson JT, eh ET. Direct https://doi.org/10.171/journal.pone.001551. proinflammatory effect of C-reactive protein 22. Aouifi A, Piriou V, lanc P, et al Effect of on human endothelial cells. Circulation. cardiopulmonarybypassonserumprocalcitonin 2000;102:2165–168. and C-reactive protein concentrations. r J 26. ardys I, De Maat MP, itterlinden AG, et al Anesth.1999;8:602–607. C-reactive protein gene haplotypes and risk of 2. Pearson TA, Mensah GA, Alexander RW, et al coronary heart disease: The Rotterdam Study. Markers of inflammation and cardiovascular Eur eart J. 2006;27:11–7. https://doi. disease:Applicationtoclinicalandpublichealth org/10.109/eurheartj/ehl018. practice;Astatementforhealthcareprofessionals 27. Miyaji , Miyamoto T, ohira S, et al The from the Centers for Disease Control and influences of red blood cell transfusion on PreventionandtheAmericaneartAssociation. peri-operative inflammatory responses using Circulation. 200;107:499–511. https://doi. a miniaturized biocompatible bypass with an org/10.1161/01.CIR.000005299.5909.45. asanguineousprime.InteartJ.2009;50:581–9.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):158-1589 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.14

AComparatieStudyofeobupiacaineithFentanylVersus opiacaineithFentanylforContinuousEpiduralaborAnalgesia

MahalakshmiAnnaduraiSaraananaiayathriamanathanarthikMani

1Resident,2AssociateProfessor,Professor,4AssistantProfessor,DepartmentofAnesthesiology,SRMMedicalCollegeospitaland ResearchCentre,Potheri,Chengalpattu,TamilNadu60211,India.

Abstract

acground: Ropivacaine and Levobupivacaine are newer local anesthetic agents in obstetric practice for labor epidural analgesia which have got advantages of less motor blockade and systemic toxicity comparedtoupivacaine.Objective:TocomparetheefficacyofeuipotentdosesofRopivacaine0.1and Levobupivacaine0.0625withfentanylascontinuousinfusionforlaborepiduralanalgesia.tudyesign:A Prospectiverandomizedcontroltrial.Methods:Afterobtainingtheinstitutionalethicscommitteeapproval, PatientswhomettheinclusioncriteriawererandomlyallocatedtogroupandgroupR(20patientsineach group)bycomputergeneratedrandomnumbers.Patientswererandomlyassignedtoreceiveeither10mlof 0.2ropivacaineor10mlof0.125levobupivacainefollowedbyinfusionof0.1ropivacainewithfentanyl 2mcg/ml or 0.0625 levobupivacaine with fentanyl 2 mcg/ml at 8 ml/hr continuous epidural infusion. Visualanaloguescale(VAS)beforeepiduralbolusdoseandthroughoutthelaborwererecorded.Maternal heartrate,bloodpressure,oxygensaturation,fetalheartrate,maximumsensorylevelachievedanddegree ofmotorblockadewererecordedeveryfifteenminutes.Results:Thedemographicvariableswerecomparable betweenthetwogroups.Therewasnosignificantdifferenceintheonsetofpainrelief,VASscoresduringthe infusionandlevelofSensoryblock.Therewasnodifferencefoundinthehemodynamicparameters,delivery outcome,patientsatisfactionandneonataloutcome.Conclusion:EpiduralLevobupivacaineprovidesgoodand effectiveanalgesiaasRopivacaineforlaborpainandhence,agoodalternatelocalanestheticinlaborepidural analgesiawithcostlimitations. eyords:Epidural;Laboranalgesia;Levobupivacaine;Ropivacaine.

otocitethisarticle: MahalakshmiAnnadurai,SaravananRavi,GayathriRamanathanetalAComparativeStudyof0.0625Levobupivacainewith FentanylVersus0.1RopivacainewithFentanylforContinuousEpiduralLaborAnalgesia.IndianJAnesthAnalg.2019;6(5Part-1): 158-1589.

Introduction inthepresenceofcardiaccomorbiditiesinapatient. Labor analgesia is an age-old practice started in Laborpainisoneofthemostseverepainwhichmay 1847withetherbyJSimpsonandhistoricincident leadtounpleasantexperienceswhennotadeuately inlaboranalgesiabychloroformadministrationto treatedanditmayleadtodevastatingconseuences ueenVictoriabyJohnSnowin185.1Eventhough

CorrespondingAuthor:aiSaraanan,AssociateProfessor,DepartmentofAnesthesiology,SRMMedicalCollegeospitaland ResearchCentre,Potheri,Chengalpattu,TamilNadu60211,India. Email:[email protected] eceiedon10.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1584 IndianJournalofAnesthesiaandAnalgesia variousnon-pharmacologicalandpharmacological LORsyringe.Epiduralcatheterthreaded5cminto methodsareavailableforlaboranalgesia,epidural thespaceandsecuredinposition.Epiduraltestdose analgesia remain the gold standard and most given after negative aspiration for blood or CSF. practicedtechniue.Theadvantagesarecontinuous Initial bolusof 10 ml of 0.2 Ropivacaine (group and effective analgesia with minimal systemic R)or0.125Levobupivacaine(group)wasgiven. side effects to mother and foetus compared to Additional 5 ml boluses were given if VAS score inhalational agents and systemic opioids. Also, it wasmorethanevenafter15minsofinitialbolus hasgottheadvantageofconversiontoanesthesia dose. Analgesia was maintained with continuous forcesareansection. infusionof0.1Ropivacainewith2mcgmlfentanyl Lowerconcentrationsoflocalanestheticsreduce (groupR)or0.0625Levobupivacainewith2mcg themotorblockadeandwhencombinedwithopioids ml fentanyl (group ) at 8 mlhr using a syringe likefentanylimprovestheualityofanalgesia.2,,4 pump. Further boluses of 5 ml of Ropivacaine upivacaineisthecommonlyusedlocalanesthetic 0.2 or Levobupivacaine 0.125 were given for breakthrough pain. The total number of boluses whichprovidesgoodanalgesiabutwithhighmotor reuiredwererecorded.Thestudywasconcluded blockadepotential and cardiotoxicity on systemic atthetimeofnormalorassistedvaginaldelivery absorption. Ropivacaine produces more sensory or when decided for cesarean section. Epidural and less motor blockade than bupivacaine with anesthesia was provided through the catheter in less systemic toxicity.5,6,7 Levobupivacaine is one casesconvertedtocesareansection. of the newest local anesthetic with good sensory andminimal motorblockade effectsandminimal oth the patient and anesthesiologist in labor cardiotoxicity.8Thisstudyisdonetocomparethe roomwereblindedtothestudysolutions.Various efcacy of Ropivacaine and Levobupivacaine in maternal parameters like pulse rate, systolic and providingepiduralanalgesiaforlabor. diastolic blood pressure, oxygen saturation, level of sensory blockade, VAS score displays in (Fig )andmodiedromagescaleformotorblockade MaterialsandMethods showsin(Table),Foetalheartratewasmonitored continuously. Thisstudywas aprospectiverandomized double blinded control trial involving 40 parturients (20ineachgroup)inatertiarycarehospitalafter obtaininginstitutionalethicscommitteeapproval. NoPain Nagging, Distressing, Intense, Worst Primigravida as well as multigravida patients uncomfortable, miserable dreadful, possible, withpreviousnormaldeliveryofagegroupbetween troublesome pain horrible unbearable, pain pain excrutiating 18and5belongingtoASAphysicalstatusIandII pain whowereinactivelaborwithcervicaldilatationof Fig:Visualanalogscale to 4 cmwereincluded in the study. Those who have contraindications to epidural block, failed Table:Assessmentofmotorblockbymodifiedromagescale epidural block and complications associated with Grade0 Nomotorblock pregnancy like preterm labor, multiple gestation Grade1 Inabilitytoraiseextendedleg,abletomoveknees andpreviouscesareansectionswereexcluded. andfeet All the patients meeting the inclusion criteria Grade2 Inabilitytoraiseextendedlegandmoveknee,able tomovefeet werecounselledforlaboranalgesiaandinformed Grade Completemotorblockofthelowerlimbs consent obtained after explaining the procedure. istory of the patient was collected and routine The clinical outcomes like time to achieve basicbloodinvestigationsdoneasperourhospital adeuatepainrelief(VAS),maximumsensory protocol. Patients were then randomly allocated level attained, degree of motor block, duration into two groups (R and ) by computerized of labor, mode of delivery, patient satisfaction, randomizedlist. neonatal outcome (APGAR score) were studied efore epidural placement 18G intravenous andcomparedinboththegroups. cannulawasestablishedinallpatientsandmonitors like pulse oximeter and non-invasive P were esults applied. nder strict aseptic precautions, lumbar epidural space identied by loss of resistance 20patientswerestudiedineachgroupwhowere techniuetoairwith18GTuohyneedleand10ml comparableintermsofdemographicdatalikeage,

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudyof0.0625LevobupivacainewithFentanylVersus0.1 1585 RopivacainewithFentanylforContinuousEpiduralLaborAnalgesia weight, height and ASA physical status. Parity Chi–suaretestanditwasfoundtobestatistically andcervicaldilationattheonsetoflaborwerealso insignicantdisplaysin(Fig).Oncomparingthe comparablebetweenthegroups. VASscore,therewasanoticeabledecreaseinthe Themeanonsetofpainreliefingroup(115 pain levels after administration of epidural local 10 mins) though slightly less than in group R anesthetic.Thepainlevelsdidnotgoabovevisual (1251mins)displaysin(FigandTable). analogscoreofduringinfusioninboththegroups This variable does not have any statistical displaysin(Fig).Thevariationinpainscoresdid signicancedifference(p0.08).Statisticalanalysis not have any statistical signicance. The motor was calculated using student independent t-test. blockadewasnotpresentinboththegroupsandall Ingroup45hadasensorylevelofT6and60 patientshadgrade0inmodiedbromagescaleand hadT8level,whereasingroupR50hadT8and hencestatisticallyinsignicant. 45 had T6. The statistical analysis was done by

Onsetofpainrelife

Fig :Comparison ofonsetof pain reliefbetweenthe two groups. oth groups were comparable with no statisticalsignificance. SensoryLevel

Fig:Comparisonofsensorylevelbetweenthetwogroups.othgroupswerecomparablewithnostatistical significance.

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Table:Comparisonofvariousparametersbetweenthegroups Themeandurationoflaborin1ststageingroup Parameters roupB roup alue (182.6521.99)thoughslightlylessthaningroup Onsetofanalgesia(min) 11.651.6 12.51.9 p0.08 R (18.50 25.06) which carries no statistically Durationoflabor(min) signicantdifference(p0.11).Themeanduration nd Istage 182.6521.99 18.5025.06 p0.91 of2 stageoflaboringroup(29.712.22)though IIstage 29.712.22 0.92.0 p0.8 slightlylessthaningroupR(0.92.0)without Natureofdelivery any statistically signicant difference (p 0.89). (normal/assisted/ 15/2/ 15//2 p0.81 Statistical analysis was calculated using student LSCS) independentt-test. Patientsatisfacation (Good/Fair/Poor) 14/6/0 14/6/0 p1.00 The hemodynamic variables like pulse rate, APGARScore(outof10) systolicanddiastolicbloodpressureofthemother 1min 7.85 7.80 p0.68 and fatal heart rate recorded at regular intervals 5min 8.90 8.85 p0.64 wereanalysedbetweenthegroupsatvarioustime Allarestatisticallyinsignificant pointsandfoundtobecomparable.

VASScore

Fig:ComparisonofVASscorebetweenthegroups. Patients inboth thegroupshad drastic reductionin VAS score after bolus dose and score of less than was maintained throughout the labor and statistically insignificantwhencompared.

TypeofDelivery

Fig:Comparisonoftypeofdeliverybetweenthetwogroups.othgroupswerecomparablewithnostatistical significance.

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PatientsSatisfaction

Fig:Comparisonofpatientsatisfacationbetweenthetwogroups.othgroupswerecomparablewithno statisticalsignificance.

GroupRhad75ofnormaldelivery,10had wasaround5.2inLevobupivacainegroupand5.01 LSCSand15hadvacuumwhereasinGroup, inropivacainegroup.Thishasbeenreducedto2.01 75 of normal delivery, 15 had LSCS and 10 inLevobupivacainegroupand2.05inropivacaine hadvacuumdisplaysin(Fig).Theirdistribution group15minsafterepiduraladministrationoflocal among groups was not signicant (p 0.81) in anesthetic.TheVASscorewasfurtherreducedto statistical analysis calculated using chi-suare aminimum.Therewasnoclinicallydemonstrable test.Theoverallpatientsatisfactionwasgradedas difference in the onset of pain relief. The patient good,fair and unsatisfactory.GroupRaswellas satisfaction was also comparable between the Group , both groups had 70 good satisfaction twogroups. and0fairsatisfactiondisplaysin(Fig).Their This was consistent with the results obtained distribution among groups was not statistically by Supandji M9 et al when they compared 0.2 signicant (p 1.00) with chi-suare test. The ropivacaine and 0.2 levobupivacaine. The neonatal outcome was rated with APGAR score Preblockvisualanalogscale(VAS)scoreandVAS at1and5mins.Thechi-suaretestrevealsthatthe score after ve, ten, 15 20 25 and 0 min from values were not statistically signicant at 1 and time(0)andVASattimeofreuestforadditional 5mins.TwopatientsingroupRandonepatientin analgesia(time)wererecordedanditwasfoundto grouphadnausea.ypotensionwaspresentin becomparableinboththegroups. 2patientsingroupRandpatientsingroup.We 10 observedthatthecomplicationsinboththegroup PurdieandMcCradyin2004 demonstratedthat werestatisticallyinsignicantinANOVAtwo-way 0.1 ropivacaine and 0.1 levobupivacaine with test. 0.00002fentanylprovidedcomparablepainrelief labor epidural analgesia and also insignicant differencesintermsoflocalanestheticconsumption, Discussion onsetanddurationofanalgesia,sensoryandmotor blockade,modeofdelivery,neonataloutcomeand Inourstudy,weusedinitialbolusof10ml0.125 patientsatisfaction.Similarresultsareencountered Levobupivacaine and 0.2 ropivacaine and in other studies11,12 comparing ropivacaine and maintained with low concentration of euipotent levobupivacaineforlaboranalgesia. doses of 0.0625 Levobupivacaine with fentanyl 2 mcgml and 0.1 ropivacaine with fentanyl otorlocade 2gmlatarateof8mlhrascontinuousinfusion theparturientswerecomparableinregardstoage, oth Ropivacaine and Levobupivacaine did comorbid conditions, ASA grading, parity and not cause motor blockade in our study as Cervicaldilatationinboththegroups. the concentrations used were low which was demonstratedinsimilarotherstudies.9,10,11Finegold et al1 and alpern et al14 demonstrated the ainRelief superiorityofropivacainetobupivacaineregarding Inour study. wefound thatthe meanVAS score motor blockade in labor epidural analgesia but

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eilinetal15foundlevobupivacaineproducedless 2. Polley LS, Columb MO, Wagner DS, et al motorblockadethanropivacaineandbupivacaine. Dose dependent reduction of the minimum owever,Wangetal16 observednodifferencesin local analgesic concentration of bupivacaine motor blockade among bupivacaine, ropivacaine by sufentanil for epidural analgesia in labor. Anesthesiology.1998;89():626–2. andlevobupivacaineinlowconcentrations. . Lyons G, Columb M, awthorne L, et al odeofelivery Extradural pain relief in labor: upivacaine sparingbyextraduralfentanylisdosedependent. Inourstudy.wehadcomparablenumbersinmode rJAnesth.1997;78(5):49–97. of delivery between Levobupivacaine group and 4. Justins DM, Francis D, oulton PG, et al A Ropivacainegroupwithnostatisticalsignicance. controlledtrialofextraduralfentanylinlabor.r Ourstudyresultscoincidewiththestudydoneby JAnesth.1982;54(4):409–14. 12 ui-Ling Lee et al comparing Levobupivacaine 5. Polley LS, Columb MO, Naughton NN, et al 0.06 and Ropivacaine 0.08 with fentanyl Relative analgesic potencies of ropivacaine and found that there was no difference in mode and upivacaine for epidural analgesia in of delivery in both the groups. Finegold et al1 labor: Implications for therapeutic indexes. observedaninstrumentalvaginaldelivery rateof Anesthesiology.1999;90:944–50. 18inropivacainegroupand28inbupivacaine. 6. Capogna G, Celleno D, Fusco P, et al Relative potencies of upivacaine and ropivacaine for Fetalandneonataloutcome analgesiainlabor.rJAnesth.1999;82:71–7. In our study. the foetal heart rate during the 7. Owen MD, D Angelo R, Gerancher JC. 0.125 process of labor analgesia was within normal ropivacaineissimilarto 0.125upivacainefor laboranalgesiausingpatientcontrolledepidural limits. There was no incidence of post epidural infusion.AnesthAnalg.1998;86:527–1. foetalbradycardia.TheAPGARscorewasalsonot statistically signicant. This was consistent with 8. Foster R, Markham A. Levobupivacaine: A thestudiesdonebyuiLingLeeetal12andeilein review of pharmacology and use as a local etal.15comparingropivacaineandlevobupivacaine. anesthetic.Drugs.2000Mar;59()551–79. 9. SupandjiM,SiaAT,OcampoCE.0.2Ropivacaine Comlications and levobupivacaine provide eually effective epidural labor analgesia. Canadian journal of The complications like nausea, vomiting and anesthesia.2004Nov;51(9):918–22. hypotensionwereobservedinboththegroupsand 10. PurdieNL,McGradyEM.Comparisonofpatient- itwasfoundtobestatisticallyinsignicant. controlledepiduralbolusadministrationof0.1 ropivacaineand0.1levobupivacaine,bothwith Conclusion 0.0002 fentanyl, for analgesia during labor. Anethesia.2004;59(2):1–7. 11. Paraskevi M, Chrysanthi , Stylliani A, et al Our study concludes that pain relief offered by Patient-controlled epidural analgesia after epiduralLevobupivacaineisasgoodandeffective Cesareansection:Levobupivacaine0.15versus asepiduralRopivacaine.Itiscomparableintermsof ropivacaine 0.15 alone or combined with painrelief,motorblockade,sensorylevelachieved, fentanyl2gml;Acomparativestudy.ArchMed patientsatisfactionandneonataloutcome.ence, Sci.2011Aug;7(4):685–9. Levobupivacaine is an effective alternative to 12. LLoLee,ChouC,ChuahE.Comparisonbetween Ropivacaine in laborepidural analgesia withcost 0.08 Ropivacaine and 0.06 Levobupivacaine limitations. forEpiduralAnalgesiaduringNulliparousLabor: Source(s) of suort SRM Medical College ARetrospectiveStudyinASingleCenter.Chang GungMedJ.2011;4:286–92. ospital,SRMIST 1. Finegold , Mandell G, Ramanathan S. resentationatameetinNil Comparison of ropivacaine 0.1-fentanyl and ConictinInterestNil bupivacaine0.125-fentanylinfusionsforepidural laboranalgesia.CanJAnesth.2000;47(8):740–45.

eferences 14. alpern S, reen TW, Campbell DC, et al A multicenter, randomized, controlled trial comparing bupivacaine with ropivacaine 1. awkins JL. Epidural analgesia for Labor and for labor analgesia. Anesthesiology. 200 delivery.NEnglJMed.2010;62:150–510. Jun;98(6):141–45. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudyof0.0625LevobupivacainewithFentanylVersus0.1 1589 RopivacainewithFentanylforContinuousEpiduralLaborAnalgesia

15. eilin , Guinn NR, ernstein , et al Local 16. Li-zhong W, iang-yang C, ia L. Comparison Anesthetics and Mode of Delivery: upivacaine ofbupivacaine,ropivacaineandlevobupivacaine Versus Ropivacaine Versus Levobupivacaine, with sufentanil for patient-controlled epidural AnesthesiaandAnalgesia.2007;105():756–6. analgesia during labor: A randomized clinical trial.ChinMedJ.2010;12(2):178–8.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia1591 OriginalResearchArticle 2019;6(5)(Part-I):1591-1597 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.15

Efficacy of Intraenous Paracetamol for Attenuating emodynamic esponse to aryngoscopy and Intubation: A Prospectie andomied Study

MonmyDekaTridipyotiBorahNilotpalDas

1SeniorResident,2AssistantProfessor,Dept.AnesthesiologyandCriticalCare,hubaneshwarorooahCancerInstitute,Guwahati, Assam781016,India.Professorandead,Dept.AnesthesiologyandCriticalCare,FakhruddinAliAhmedMedicalCollegeand ospital,arpeta,Assam78101,India.

Abstract

acgroundandAims:Laryngoscopyandendotrachealintubationviolatethepatientsairwayreflexesand causeintensesympatheticactivity.Literaturesuggeststhatthisdeleteriousresponsemaybebluntedbydrugs. Opioidsaremostcommonlyusedforthispurpose.owever,thereisnoconsensusregardingthebestdrugand bestrouteofadministration.Therefore,therehasbeenagrowingtrendtofindaneffectivesubstitutetolower thesesideeffectsasmuchaspossible.Paracetamolisanon-opioidanalgesicwithCO-2selectiveinhibiting property.Themainpurposeofourstudywastoevaluatetheeffectofpre-operativeintravenousparacetamol onhemodynamicresponsetolaryngoscopyandendotrachealintubation.Methods:AfterInstitutionalEthical Committee clearance, 160 patients of American Society of Anesthesiologists (ASA) Physical Status I and IIwereenrolledinthe studyanddividedinto twogroups.GroupAreceived1 gmparacetamolinfusion (LabelledA1)in100mlvolumewhereasGroupreceived0.9normalsalineinfusion(1)in100mlvolume Intravenously (I.V.) thirty minutes prior to induction over fifteen minutes. Standard general anesthesia techniueswereusedforbothgroups.Thehemodynamicswererecordedatbaseline,beforeinduction,after induction,beforelaryngoscopy,immediatelyafterintubationandthereafter1,,5,7and10inutesfollowing intubation.After10minutesofintubation,GroupAreceivedtheinfusionlabeledA2(0.9Normalsaline in100mlvolume)whereasGroupreceivedtheinfusionlabeled2(paracetamol1gmin100mlvolume) over15minutes.Results:othgroupsweresimilarintermsofage,sex,height,weight,Mallampatiscoresand AmericanSocietyofAnesthesiologists(ASA)physicalstatus.After1minuteoflaryngoscopyandintubation, significantincreaseintheheartratewasseeninboththegroups.(p0.05)inGroupA,theincreaseinmean heartrateproducedbylaryngoscopyandintubationwasnotstatisticallysignificantatmins(p0.05)and remainedinsignificantat5,7and10minutesafterintubation.owever,inGrouptheincreaseinmean heartrateproducedbylaryngoscopyandintubationwassignificantlyhighatmin(p0.0001)andremained significantat5,7and10minutesafterintubation.TherewassignificantfallinSP,DPandMAP(p0.05) frombaselineafterinduction,laryngoscopyandafter1minuteofintubationinbothGroupAandGroup but inter group comparisons at these time points were statistically insignificant (p 0.05). Conclusion: Administration of paracetamol (1 gram), thirty minutesprior to induction of anesthesia could not totally bluntallthecardiovascularresponsestolaryngoscopyandintubation,butitdidshowbettercontrolofheart rateafterintubation. eyords:Anesthesia;Laryngoscopy;Intubation;Paracetamol.

otocitethisarticle: MonmyDeka,TridipJyotiorah,NilotpalDas.EfficacyofIntravenousParacetamolforAttenuatingemodynamicResponseto LaryngoscopyandIntubation:AProspectiveRandomizedStudy.IndianJAnesthAnalg.2019;6(5Part-1):1591-1597.

CorrespondingAuthor:TridipyotiBorah,AssistantProfessor,AnesthesiologyandCriticalCare,hubaneshwarorooahCancer Institute,Guwahati,Assam781016,India. Email:[email protected] eceiedon14.06.2019,Acceptedon24.07.2019

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Introduction MaterialsandMethods

Laryngoscopyandendotrachealintubationviolate This study was conducted in our hospital after the patients airway reexes and cause intense approval from institutional ethics committee sympathetic activity which lead to tachycardia, and informed consent. We included 160 patients hypertension and dysrhythmias.1 These effects between 18 and 0 years of age belonging to have been reported since 1950, during intubation American Society of Anesthesiologists class I under lighter plane of anesthesia, which may be and II having Mallampati grade of either I or II further complicated by hypoxia, hypercapnia or who underwent elective non-cardiac surgeries cough.2,Thisresponsemayalso have deleterious reuiring general anesthesia with endotracheal effect on patients with raised intracranial and intubation. Patients with known hypertension, intraoculartensions. autonomicneuropathy, diabetes mellitus or other endocrinopthy,patientstakingcardioactivedrugs, emodynamic stability is an integral and antiepileptic drugs or antipsychotic drugs and essentialgoalofanyanestheticmanagementplan. patientswithanticipateddifcultmaskventilation Increase in blood pressure and heart rate occurs orlaryngoscopyandallemergencysurgical cases most commonly from reex sympathetic activity wereexcludedfromthestudy. inresponsetolaryngotracheal stimulation, which in turn leads to increase plasma norepinephrine All patients were provided with patient concentration.4 Literature suggests that this information sheet and written informed consent deleteriousresponsemaybebluntedbydrugswith was obtained. Pre-anesthetic check up and different mechanisms of action like lignocaine, investigations were done. The patients were kept glossopharyngeal and superior laryngeal nerve fastingovernightafter10:00pmandreceivedtablet blocks, calcium channel blockers, beta blockers, ranitidine 150 mg orally and tablet alprazolam combined alpha-beta blockers, alpha blockers, 025 mg orally as premedication the night before peripheralvasodilators,narcotics,oralgabapentine surgery. All patients were monitored using andmagnesiumsulphate.5 standard American Society of Anesthesiologists (ASA) monitors like non-invasive blood pressure owever, there is no consensus regarding (NIP), pulse oximetry, and electrocardiography the best drug and best route of administration. (ECG).Intravenousaccesswassecuredusingan18 Althoughopioidsaremostcommonlyuseddrugs Gcannulaintheforearmofthenon-dominanthand. for prevention of hemodynamic responses to intubation, these drugs are not cost effective and Patients were randomized into two groups, have unfavorable effects like nausea, vomiting, eitherGroupAorGroup,consistingof80patients sedation and respiratory depression.6 Therefore, each using computer generated random number therehasbeenagrowingtrendtondaneffective table. Double blind techniue was used in which substitute to lower these side effects as much as both the anesthesiologist administering the drug aswellasthepatientswereunawareasto which possible.7,8 groupthepatientbelongedto.Oneanesthesiologist Paracetamolisanon-opioidanalgesicandisin labeled the intravenous (I.V.) infusions which clinical use for last hundred years.9 Paracetamol werethenadministeredtothepatientsbyanother is,onaverage,aweakeranalgesicthanNSAIDsor anesthesiologistwhodidnotknowthecontentsof CO-2 selective inhibitors but is often preferred theinfusion.Theparameterswererecordedbythe because of its better tolerance.10 Intravenous secondanesthesiologist. paracetamol has an onset and peak effect of Group A received 1 gm paracetamol infusion 15minutesorlessandadurationofanalgesiceffect (Labeled A1) in 100 ml volume whereas Group between 4 and hours.11,12 Recently the prodrug received0.9normalsalineinfusion(1)in100ml of paracetamol has been shown to have blunting volumeintravenously(I.V.)thirtyminutespriorto effect on hemodynamicresponseto laryngoscopy inductionoverfteenminutes.Afterpre-oxygenation andintubation.1 with100O2forthreeminutesandpremedication owever,thereislimiteddataabouttheeffects withinjectionFentanyl1mcggintravenously(I.V.), of I.V. paracetamol on hemodynamics.Therefore, the patients were induced with injection Propofol themainpurposeofourstudywastoevaluatethe 2 mgg I.V. and intubated with appropriate sized effect of pre-operative intravenous paracetamol cuffedendotrachealtubewithinjectionVecuronium on hemodynamic response to laryngoscopy and 01mggI.V.afterestablishmentofneuromuscular endotrachealintubation. blockade conrmed with disappearance of single

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EfficacyofIntravenousParacetamolforAttenuatingemodynamicResponse 159 toLaryngoscopyandIntubation:AProspectiveRandomizedStudy twitch response with a nerve stimulator. The in terms of age, sex, height, weight, Mallampati hemodynamics were recorded at baseline, before scores and American Society of Anesthesiologists induction, after induction, before laryngoscopy, (ASA)physicalstatusshowsin(Table). immediatelyafterintubationandthereafter,157 and10minutesfollowingintubation.After10minutes Table : aseline characteristics between the groups of intubation, Group A received the infusion (meanSD) labeledA2(0.9Normalsalinein100mlvolume) roupA roupB Characteristics alue whereas Group received theinfusionlabeled 2 n n (paracetamol1gmin100mlvolume)over15minutes. Age(Inyears) 5.980.22 5.5010.9 0.95 Anesthesia was maintained with isourane Sex(M/F) /4 1/44 0.87 2 Weight(g) 55.068.61 54.49.28 0.2 (0.6 to 1) in a mixture of O2 and N O (1:2) and injection vecuronium bromide. Total intubation eight(Incms) 157.769.62 158.41.56 0.5 time (in seconds) was dened as the time from MPS(I/II) 19/57 17/58 0.85 insertionofthetipoftheendotrachealtubeintothe ASA(1/2) 54/22 50/25 0.56 trachea,uptothetimeoftubeconrmation. SD Standard deviation; n number of patients; ASA AmericanSocietyofAnesthesiologists;MPSMallampatiscore. StatisticalAnalysis The baseline heart rates (R), systolic blood AllstatisticalanalysiswasperformedusingStatistical pressure(SP),diastolicbloodpressure(DP)and Packages for Social Science version 19 (SPSS Inc., meanarterialpressures(MAP)werecomparablein Chicago, IL, SA). Data were expressed as mean boththegroups.Thedecreaseinthemeanheartrates (standarddeviation)foruantitativevariableslike after induction was also statistically insignicant in both the groups. (p 0.001) after 1 minute of age, weight, SP, DP, R. Independent sample t-test and Mann-Whitney tests were applied to laryngoscopy and intubation, signicant increase compare the mean/median difference between in the heart rate was seen in both the groups. groupsforage,weight.Thepairedt-testwasused (p0.05)InGroupA,theincreaseinmeanheart rateproducedbylaryngoscopyandintubationwas to compare within-subject effect for R and P. p0.05wasconsideredassignicant. notstatisticallysignicantatmins(p0.05)and remainedinsignicantat5,7and10minutesafter intubation. esults owever,inGrouptheincreaseinmeanheart rate produced by laryngoscopy and intubation Atotalof160patientswereincludedinthestudy was signicantly high at min (p 0.0001) and with 80 patients each in Group A (Paracetamol remained signicantat 5 7 and 10 minutes after group) and Group (Normal saline). owever, intubation. Shows (Table ) the mean baseline fourpatientsfromGroupAandvepatientsfrom values of systolic blood pressure (SP), diastolic Group were excluded from the study as they blood pressure (DP) and mean arterial pressure neededmorethanoneattemptforintubation.There (MAP) were similar and statistically insignicant wasnostatisticaldifferencebetweenthetwogroups (p 0.05) between Group A and Group . There

Table:MeaneartRateatdifferentpre-definedpointsoftime

Intraroupcompared eartatebeatsperminute tothebaseline Interroup comparedbeteen roupA roupB roupA roupB similarpointsoftime MeanSD MeanSD Value Value Value aseline 78.441.9 80.2411.97 0.19 eforeinduction 78.41.59 80.611.60 0.48 0.47 0.16 Afterinduction 77.211.61 79.9012.28 0.29 0.4 0.20 eforelaryngoscopy 78.2211.78 79.2212.46 0.45 0.0 0.1 1minafterintubation 84.2811.50 98.4412.74 0.04 0.0001 0.0001 minafterintubation 84.0511.15 94.161.56 0.07 0.0001 0.0001 5minafterintubation 81.6010.0 87.12.22 0.06 0.0002 0.001 7minafterintubation 80.468.25 86.9111.64 0.052 0.000 0.000 10minafterintubation 78.5710.85 82.8811.75 0.69 0.007 0.012 SDStandarddeviation.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1594 IndianJournalofAnesthesiaandAnalgesia wassignicantfallinSP,DPandMAP(p0.05) The mean SP, DP and MAP at 5 7 and from baseline after induction, laryngoscopy and 10minutesshowednodifferencebetweenGroupA after 1minuteof intubation inboth Group A and and Group (p 0.05) shows in (Tables ), Groupbutintergroupcomparisonsatthesetime alongwithdisplays(raphs). points were statistically insignicant (p 0.05).

Table:MeanSPatdifferentpre-definedpointsoftime

SBP Withinroup Interroup roupA roupB roupA roupB MeanSD MeanSD Value Value Value aseline 122.5711.82 124.4911.96 0.11 eforeinduction 122.7611.99 12.8810.91 1.0 1.0 0.59 Afterinduction 115.9711.0 116.2511.66 0.012 0.001 0.25 eforelaryngoscopy 11.710.8 116.5611.6 0.001 0.002 0.85 1minafterintubation 11.541.2 14.9615.22 0.001 0.0001 0.2 minafterintubation 126.1611.86 126.812.1 0.59 0.96 0.49 5minafterintubation 120.4512.07 119.4712.66 0.97 0.22 0.72 7minafterintubation 119.789.99 121.6112.81 0.86 0.16 0.51 Afterintubation 119.7210. 119.4511.66 0.84 0.21 0.40

Table:MeanDPatdifferentpre-definedpointsoftime

DBP Withinroup Interroup roupA roupB roupA roupB MeanSD MeanSD Value Value Value aseline 76.019.82 76.9711.12 0.1 eforeinduction 76.411.41 77.8510.02 1.0 1.0 0.14 Afterinduction 71.579.2 7.218.89 0.00 0.001 0.8 eforelaryngoscopy 72.0010.84 72.929.5 0.02 0.005 0.41 1minafterintubation 82.910.95 86.2715.06 0.005 0.0001 0.8 minafterintubation 77.7410.98 79.6812.72 0.98 0.86 0.42 5minafterintubation 74.4710.29 74.979.8 0.99 0.97 0.10 7minafterintubation 74.79.74 77.110.87 0.99 1.0 0.1 10minafterintubation 7.2610.1 75.0810.8 0.79 0.98 0.24 DPDiastolicloodPressure;SDStandarddeviation.

Table:MeanofMAPatdifferentpre-definedpointsoftime

MAP Withinroup Interroup roupA roupB roupA roupB MeanSD MeanSD Value Value Value aseline 91.2911.0 92.7711.24 0.06 eforeinduction 91.4911.99 94.0710.65 1.0 0.9 0.11 Afterinduction 86.249.10 87.78.5 0.002 0.001 0.7 eforelaryngoscopy 86.0110. 87.499.5 0.002 0.007 0.19 1minafterintubation 99.2611.94 10.415.5 0.0001 0.0001 0.55 minafterIntubation 95.0711.1 96.5711.86 0.9 0.47 0.06 5minafterintubation 90.4710.24 90.8510.08 1.0 0.98 0.6 7minafterintubation 90.548.25 91.7610.52 1.0 1.0 0.2 10minafterintubation 89.49.49 91.0510.60 0.98 0.99 0.54 MAPMeanArterialPressure;SDStandarddeviation.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EfficacyofIntravenousParacetamolforAttenuatingemodynamicResponse 1595 toLaryngoscopyandIntubation:AProspectiveRandomizedStudy

raph:MeanSPofboththegroupsatdifferenttimes

raph:GraphshowingthemeanDPofboththegroupsatdifferenttimes

raph:ShowingintergroupMAPatdifferenttimes

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Discussion of paracetamol did help attenuate the heart rate response to laryngoscopy and endotracheal Laryngoscopyandendotrachealintubationarethe intubationascomparedtonormalsaline.owever, basisofprotectingtheairwayinpatientsreceiving paracetamol did not have any benecial effect general anesthesia. In addition to securing the on attenuation of blood pressure responses to airway,preventingaspirationandaidingdeliveryof laryngoscopy and intubation. Acute increase in anestheticgases,theyarealsoresponsibleforvarious heartrateintheirstudywasbetterattenuatedthan stressresponsessuchastachycardia,hypertension, ours,whichcouldbeattributedtoahigherdoseof laryngospasm, bronchospasm, raised intracranial fentanyl(2mcgg)usedbythem. pressure and intraocular pressure.1 Several drugs Ayatollahi V et al, studied the effect of havebeenusedpreviouslytoattenuatethesestress pre-operative administration of intravenous responses to the manipulationand stimulation of paracetamol during cesarean section on the airway during laryngoscopy and intubation. hemodynamic variables relative to intubation Fentanyl, beta-adrenergic receptors blockers, and in 60 patients and observed that paracetamol lignocaine have all been used previously with prevented signicant increase in SP, DP, varyingresults.14 MAP and R at all times after laryngoscopy 18 In our study, we compared the efcacy of and intubation. ossam et al, too evaluated preoperative administration of intravenous the effect of 1 gram of pre-operative intravenous paracetamol1gramin100mlvolumeonattenuation paracetamol on hemodynamic variables after ofhemodynamicresponsesafterlaryngoscopyand intubation in 60 obstetric patients planned for tracheal intubation. Patients of both the groups cesarean section and concluded that preoperative werepremedicatedwithI.V.Fentanyl1mcgg,as administration of intravenous paracetamol was effective in preventing hemodynamic responses othernopharmacologicalagentwasusedtoprevent 19 hemodynamic response in any single patient to intubation. In both the studies by Ayatollahi undergoing laryngoscopy and intubation. The V et alandossam et al, opioids were not used study was designed to evaluate the efcacy of beforeintubationasthepatientswereallobstetric paracetamol to attenuate the hemodynamic cases. So, in the absence of opioids, probably the responsescausedbythepainoflaryngoscopyand antinociceptive activities of paracetamol might endotrachealintubation. have been augmented. owever, another study by Ozmete et al on the effect of pre-operative Paracetamol has a well-established safety and paracetamol on hemodynamic responses after analgesicprole.Themainmechanismofactionis intubation and its role on post cesarean delivery inhibitionoftheenzymecyclo-oxygenase,whichis pain did not nd any favorable effect on the responsiblefortheproductionofprostaglandins,an hemodynamic variables following laryngoscopy 15 importantmediatorofinammationandpain. The andintubation.20 exactmechanismofparacetamolonhemodynamic responsesisunclearbutmaybeattributabletoits Thus,differentstudieshavedifferentopinionson analgesiceffectmediatedbyitsantiprostaglandin theroleofpre-operativeparacetamolonattenuation action.16 ofhemodynamicresponsetointubation.owever, the context of these studies were not similar; in Althoughtheperi-operativeanalgesiceffectsof somestudiesopioidswereusedaspremedication intravenousparacetamolarewell-known,literature and in some they were not used. ence, it may documenting the attenuation of hemodynamic berecommendedthatfurtherstudieswithsimilar responses to laryngoscopy and intubation are contextandlargersamplesizesarecarriedoutto veryrare.AliordValeshabadetalcomparedthe nd out the exact roleof paracetamol among the prodrug of paracetamoli in 2 gram intravenous pharmacological armamentarium available for propacetamolwithintravenouslidocaine15mgg bluntingofhemodynamicresponses. andfoundthatpropacetamolattenuatedtheheart rate responses to laryngoscopy but not the blood pressure responses to intubation.1 Propacetamol Conclusion 4-(acetamido) phenyl N, N-diethylglycinate is a prodrug, which is uickly hydrolyzed by Administration of paracetamol (1 gram), thirty plasma esterase to vigorous paracetamol; 1 gr minutespriortoinductionofanesthesiacouldnot propacetamolmetabolizedto500mgparacetamol.17 totally blunt all the cardiovascular responses to Thesendingswereuitesimilartoourstudy.Our laryngoscopyandintubation,butitdidshowbetter ndings showedthat preoperativeadministration controlofheartrateafterintubation.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EfficacyofIntravenousParacetamolforAttenuatingemodynamicResponse 1597 toLaryngoscopyandIntubation:AProspectiveRandomizedStudy

eferences proparacetamol for prevention or treatment of post-operative pain: A systematic review and meta-analysis.rJAnesth.2011Jun;106(6):764–75. 1. ShribmanAJ,SmithG,AcholaJ.Cardiovascular and catecholamine responses to laryngoscopy 1. ord Valeshabad A, Nabavian O, Nourijelyani withandwithouttrachealintubation.rJAnesth. , et al Attenuation of emodynamic 1987;59:295–99. Responses to Laryngoscopy and Tracheal Intubation: Propacetamol versus Lidocaine; A 2. urstein CI, Newman W. Electrocardiographic RandomizedClinicalTrial.AnesthesiolResPract. studies during endotracheal intubation. 2014;2014:170247. Anesthesiology.1950;11(2):224–7. 14. umar A, Seth A, Prakash S, et al Attenuation . ForbesAM,DailyFG.Acutehypertensionduring of the hemodynamic response to laryngoscopy induction in normotensive man. r J Anesth. andtrachealintubationwithfentanyl,lignocaine 1970;42:618. nebulization, and a combination of both: A 4. SheppardS,EagleCJ,StruninL.Abolusdoseof randomizedcontrolled trial. Anesth Essays Res. esmolol attenuate tachycardia and hypertension 2016;10():661–66. after tracheal intubation. Can J Anesth. 15. Elbohoty AE, Abd-Elrazek , Abd-El-Gawad 1990;7:202–205. M, et al Intravenous infusion of paracetamol 5. han FA, llah . Pharmacological agents versus intravenous pethidine as an intrapartum for preventing morbidity associated with the analgesicinthefirststageoflabor.IntJGynecol hemodynamic response to tracheal intubation. Obstet.2012;118:7–10. Cochrane Database Syst Rev. 201 rd Jul; 7:CD004087. 16. AronoffDM,OatesJA,outaudO.Newinsights intothemechanismofactionofacetaminophen: 6. Freye E and Levy JV. Reflex activity caused Itsclinicalpharmacologiccharacteristicsreflectits by laryngoscopy and intubation is obtunded inhibitionofthetwoprostaglandin2synthases. differently by meptazinol, nalbuphine and Clinical Pharmacology Therapeutics. fentanyl. European Journal of Anesthesiology. 2006;79(1):9–19. 2007;24(1):5–58. 17. Flouvat , Leneveu A, Fitoussi S, et al th 7. Miller RD. Anesthesia, 6 edition. Philadelphia, ioeuivalence study comparing a new Pa,SA:ChurchillLivingstone;2005. paracetamol solution for injection and 8. Mackanes S and Spendlove JL. Acetaminophen propacetamol after single intravenous infusion asan adjuncttomorphine bypatientcontrolled in healthy subjects. International Journal of analgesia in the management of acute post- Clinical Pharmacology and Therapeutics. operative pain. Anesthesia Analgesia. 2004;42(1):50–57. 1998;87(2):68–71. 18. Ayatollahi V, Faghihi S. Effect of pre-operative 9. aley , Michalov , ossick MA, et al administration of Intravenous paracetamol Intravenous acetaminophen and intravenous during cesarean surgery on hemodynamic ketorolac for management of pediatric surgical variables relative to intubation, post-operative pain: A literature review. AANA J. 2014 pain and neonatalapgar.ActaClin Croat. 2014; Feb;82(1):5–64. 5:272–278. 10. Graham GG, Davies MJ. The modern 19. assan Ibrahim E A ossam. Peri-operative pharmacology of paracetamol: Therapeutic analgesic effects of intravenous paracetamol: actions, mechanism of action, metabolism, Preemptive versus preventive analgesia in toxicity and recent pharmacological findings. elective caesarean section. Anesth Essays Res. 201June;21():201–22. 2014;8():9–44. 11. ONeal J. The utility of intravenous 20. Ozmete O, ali C. Pre-operative paracetamol acetaminophen in the peri-operative period. improves post cesarean delivery pain FrontPublicealth.201Aug6;1:25. management: A prospective, randomized, 12. McNicol ED, Tzortzopoulou A, Cepeda MS, double-blind,placebo-controlledtrial.Journalof et al Single dose intravenous paracetamol or ClinicalAnesthesia.2016;,55–56.

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1599-160 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.16

A Comparatie Study on the Endotracheal Tube Cuff Pressure Changes beteenSupineandProneinPatientsndergoingPronePositionSurgeries

AMurshidAhamedSureshumarSBalasubramanianSuneethPaarusVidaiVikram Saprasathaprasath

1,5AssistantProfessor, 2AssociateProfessor, Professor, 4Professorandead,DepartmentofAnesthesiology, 6ResearchAssistant, CentralResearchLab,SriManakulaVinayagarMedicalCollegeandospital,Puducherry605107,India.

Abstract

acground:Theobjectiveofthestudywastocomparethestudyontheendotrachealtubecuffpressure changes between supine and prone in patients undergoing prone position surgeries. Materials and Methods: After obtaining approval from institutional ethicscommittee, this study wasconductedin Department of AnesthesiologyatSriManakulaVinayagarMedicalCollegeandospital,Puducherrybetweenovember2015 andAugust2017.Atotalof60patientswhomettheinclusioncriteriawereenrolledintostudyandprepared forGeneralAnesthesiainproneposition.Afterinduction,thecuffpressurewasrecordedwithheadinneutral, flexedandextendedposition;theseparameterswerenotedwithpatientinsupinepositionandtheninprone position.Results:Therewasnosignificantdifferenceinmeancuffpressureatneutralposturebetweensupine andproneposition. Mean cuff pressure wasincreased afterflexion and extension fromneutral posture in bothsupineandproneposition.Atflexedposturemeancuffpressurewashigherinsupinepositionandat extendedposturemeancuffpressurewashigherinproneposition.Conclusion:Withthisstudyweconcluded thatthesupineorpronepositionhasnoinfluenceonthecuffpressurewhentheheadisinneutralposition. Inthesupinepositionflexionoftheheadshouldbeavoidedbecauseitleadstohighercuffpressurethanwith theheadflexedinproneposition.Similarlyextensionoftheheadshouldbeavoidedintheproneposition. eyords:Cuffpressure;Supineposition;Proneposition.

otocitethisarticle: AMurshidAhamed,Sureshumar,Salasubramanian.AComparativeStudyontheEndotrachealTubeCuffPressureChanges betweenSupineandProneinPatientsndergoingPronePositionSurgeries.IndianJAnesthAnalg.2019;6(5Part-1):1599-160.

Introduction ofsurgeryandanesthesiaand,morerecently,with critical care medicine. General anesthesia is one AndreasVesalius(154)rstexperimentedtheidea of the most common type of anesthesia practiced of tracheal intubation by placing a reed into the allovertheworld.Airwaymanagementbyusing tracheaofapigtotreatapneumothorax.1,2enjamin a endotracheal tube (ETT) is the most important Pugh (1754) performed the rst endotracheal skillforaclinicalanesthesiologistasitisanintegral intubation to resuscitate a neonate with a leather part of general anesthesia. The endotracheal tube covered coiled wire.1 The main evolution of the cuff pressure is normally kept between 20 and endotracheal tube (ETT) is intertwined with that 0cmof2O.nderinationcancauseairleakage

CorrespondingAuthor:Sureshumar,AssociateProfessor,DepartmentofAnaesthesiology,SriManakulaVinayagarMedical Collegeandospital,Puducherry605107,India. Email:[email protected] eceiedon29.05.2019,Acceptedon11.07.2019

RedFlowerPublicationPvt.Ltd. 1600 IndianJournalofAnesthesiaandAnalgesia because the glottis seal is inadeuate and which night and at 7 AM on the day of surgery along lessens the effect of mechanical ventilation and with T. Metoclopramide 10 mg. The patients produces a leakage of inhalation anesthetics, it were shifted to waiting room and again re- mayleadtomicroaspirationanditsanriskfactor assesed. An intravenous line was secured using for ventilator associated pneumonia. owever, a 18 G venon. aseline monitors were attached over-ination of the endotracheal tube cuff can and recorded (ECG, NIP, SpO2, ETCO2 causeaseriousinjuryandaffectbloodowtothe Temperature). Anesthesia was induced by Inj. tracheal mucosa, resulting in tracheal stenosis, Glycopyrolate 001 mgg I.V., Inj. Midazolam tracheoesophageal stula, or tracheal rupture. It 005 mgg I.V. followed by Inj. Fentanyl 2 mcg is commonly associated with long procedures, g I.V., Inj. Propofol 2mgg I.V., then followed thesecomplications mayoccurevenaftera short byInj.Succinylcholine2mggI.V.andpatients durationofanesthesia.ThetrachealintubatedETT wereintubatedwithappropriatesizeexometallic can be displaced by movement of the patients endotracheal tube and cuff were inated by head and neck. Movement of the head and neck using air. Anesthesia was maintained with Inj. (rotation, exion, and extension in the supine Vecuronium 008 mgg I.V. and Sevourane position) can cause displacementof endotracheal followingwhichthecuffpressurewasmonitored tube and change in endotracheal tube cuff with patient in supine position with head in pressure.Flexionmaycausecarinastimulationor neutralposition,exionandextension. Afterthe endobronchial intubation by advancing the ETT, patient position changed from supine to prone whereas extension can cause balloon-induced onceagainthecuffpressurewasmonitoredwith vocalcorddamageorunintentionalextubationby patient in prone position with head in neutral withdrawing the tube. Although cuff pressures position,exionandextension. arecheckedinitiallyafterintubation,seldomitis done intermittently or continuously throughout Results operation. There are multiple peri-operative factorswhichmayaltertheETTcuffpressurelike usageofNitrousoxide inanesthesia,inadeuacy Sixtypatientsincludingmenand27womenwere ofmusclerelaxation,surgicalstimulationincases assessed for endotracheal cuff pressure between ofheadandnecksurgeriesandchangeinpatient supineandproneposition.Demographicdataare position. This puts the patients for either micro shownin(Table). aspirationortotheotherextremetrachealischemic necrosisleadingtotrachealstenosis.Thepurpose Table:Demographicdataofthestudiedpatients of the study is to compare the endotracheal enderMale/Female / tube cuff pressure changes between supine and Patientsageinyears(MeanSD) 42.19.8 prone positions in patients undergoing prone MI(MeanSD) 22.2.6 positionsurgeries. Mean cuff pressure was increased after exion andextensionfromneutralpostureinbothsupine MaterialsandMethods and prone position. At exed posture mean cuff pressure were higher in supine position and at Aftergettingclearancefromtheinstitutionalethical extendedposturemeancuffpressurewerehigherin committeeandinformedwrittenconsentfromthe proneposition.Therewerenodifferencesbetween study participants, a prospective observational supineandproneinneutral,exedandextended studywasconductedon60patientsbetweentheage postureshowsin(Table). groupof20and0yearswithASAI,ASAIIphysical statusundergoingelectivesurgeriesundergeneral Table:CuffpressureinSupineandPronepositions anesthesia. Patients with ASA III and ASA IV Supine Prone physicalstatus,Neckpain,previoushistoryofneck Cuffpressure surgery, limitation of neck movements, Morbid MeanSD MeanSD obesity(bodymassindex5)wereexcludedfrom NeutralPosture 25.22. 24.81.9 thestudy. FlexedPosture 8.6.2 7.5.1 ExtendedPosture 41.14.4 42.64.0 Pre-anesthetic checkup was done a day prior to the surgery and the patient were kept fasting Therewerenosignicantdifferenceinmeancuff for to 8 hours. On the day before surgery the pressurebetweenmalesandfemalesinbothsupine patients received T Ranitidine 150 mg in the andpronepositionshowsin(Table).

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudyontheEndotrachealTubeCuffPressureChanges 1601 betweenSupineandProneinPatientsndergoingPronePositionSurgeries

Table:DifferenceincuffpressureinSupineandProneposition designedcuffsfromrubberdentaldamsthatwere betweenmalesandfemales shorter,1.5incheslong,anddesignedtositbelow SupineMeanSD ProneMeanSD thevocalcords.7 Male Female Male Female Two modications of the standard ETT were NeutralPosture 24.82. 25.62. 25.11.7 24.42.0 introduced commercially in the 1970s. One FlexedPosture 9.0. 8.12.9 7.1.4 8.12.8 modication was to replace the standard pilot ExtendedPosture 41.8.8 40.25.0 4..2 41.64.7 balloonwith a larger ballooncontainingan inner SupineNeutral 6.06.2 2.77.5 1.97.2 5.57. pressure-regulatingvalvethatmaintainsintracuff toFlexion 8 pressureat0cm2O. Anothermodicationwasto SupineNeutral 40.07.6 4.717. 41.85.4 40.76.7 replacetheair-lledcuffwithaself-inatingfoam toExtension cuffin1971byamenandWilkinson,itisknownas Mean cuff pressure were lowest in neutral theivonaFome-CuffTube.9,10Eisenmenger(189) position and highest in extended posture in all was the rst to describe the use of a cuffed ETT, the MI groups. Mean cuff pressures in supine aswellastheconceptofapilotballoontomonitor positionswerehighestinnormalMIsubjectsand intracuffpressure.11 lowestinunderweightsubjectsshowsin(Table). Endotracheal tube cuff pressure monitoring is important to prevent serious complications like Table : Mean cuff pressure comparison with respect to MI tracheal micro aspirations, inadeuate delivery in neutral, flexed and extended posture in supine and prone of inhaled anesthetics, aspiration pneumonia, positions. bronchospasm, laryngospasm, tracheal stenosis, BMI tracheoesophagealstula,ortrachealrupture. to Normalendotrachealtubecuffpressureshould ndereight Normal Oereight be maintained between 20 and 0 cm of O to MeanSD MeanSD MeanSD 2 preventabovesaidcomplications.Itisnotedthat Supine Neutral 26.02.8 25.11.9 25.14.5 Posture endotrachealtubecuffpressurevarieswithvarying Flexed 6.05.7 8.92.4 7.16. headposturelikeneutral,exionandextensionin Posture both supine and prone position. This study was Extended 7.09.9 41.4.7 9.77.4 conductedtoknowthechangesintheendotracheal Posture tube cuff pressure in different head postures and Prone Neutral 26.02.8 24.91.6 2.7.1 resultsareobtained. Posture In similar to our study, Christelle Lizy et al, Flexed 9.04.2 8.02.9 .72.4 showed that there was a signicant rise in Posture endotracheal tube cuff pressure with change of Extended 4.04.2 42.9.5 9.76.5 Posture position from supine neutral to supine extension andsupineexion.12 InsimilartoourstudyDeokkyuetal,observed Discussion there were differences between supine and prone position for neutral, exed, and extended angles. Trendelenburg (1869) is credited with designing The initial neutral pressure increased after the rst inatable cuff, which was a thin rubber changingpositionfromsupinetoprone.Flexedand bag tted over the end of a tracheostomy tube, extendedpressureinsupinewasincreasedthanthe creating a tight seal to prevent aspiration during adjusted neutral pressure. Flexed and extended 4 anesthesia. Although the detachable inatable pressureinpronewereincreasedthantheadjusted cuff had been introduced by Trendelenburg, it neutral pressure. In our study. we observed that hadfallenoutoffavorduetotechnicalissues,and endotrachealtubecuffpressureincreaseswhenthe clinicianspreferredtousepharyngealpackingwith patients positionchangedfrom supineneutralto spongestosealtheupperairway. supineexionandsupineextension. Guedel (1928) and Waters (191) reintroduced Inastudy,donebymeshkumarAthiramanet theinatablecufftoMagillsrubbertubeandare al,showedthatsignicantdeclineinendotracheal creditedwithstartingaperiodofETTdesign.5Their tubecuffpressurewerefoundinthepronegroup rst cuffs were made from the ngers of rubber frominitialintubatedsupineposition.Theseresults gloves and from rubber condoms. These cuffs, werenon-concurrentwithourstudy,weobserved rangingfromto4incheslong,weredesignedtosit thatthereisriseinendotrachealtubecuffpressure halfaboveandhalfbelowtheglottis.6Later, they werenotedinproneexionandproneextension.1 IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1602 IndianJournalofAnesthesiaandAnalgesia

Insimilartoourstudy,ArmandoCariosFranco In supine position, exion of the head should deGodoyetal,showedthatchangeinbodyposition beavoidedbecauseitleadstohighercuffpressure cancausesignicantchange in endotrachealtube than with the head exed in prone position. cuff pressure. These results are comparable with Similarlyextensionoftheheadshouldbeavoided our study where endotracheal tube cuff pressure inthepronepositionbecauseitleadstohighercuff were increased in both exion and extension in pressure. 14 supineandproneposition. Endotracheal tube cuff pressure have to be In similar to our study, iromi ako et al, monitoredandoptimizedduringchangeofpatients concludedthatthesignicantchangesintheintra positionfromsupinetopronepositiontoprevent cuffpressureoccurwithchangesinheadandneck microaspirationandmucosaldamageofairway. position.15 Source(s)ofsuortNil Incontrasttoourstudy,ToshiyukiMinonishietal., concluded that after the supine-to-prone position resentationatameetinNil change,patientshadETTtubedisplacement.Such ETTmovementmaybeaccompaniedbyadecrease ConictinInterestNil in cuff pressure. ut in our study, we observed that there was no ETT displacement in supine to proneposition.utendotrachealtubecuffpressure eferences increases when the patients position changed from prone neutral to prone exion and prone 16 1. White GM. Evolution of endotracheal and extension. endobronchial intubation. rit J Anesth. Insimilartoourstudy,Nobuyasuomasawaet 1960;2(5):25–46. al,concludedthattherewerecuffpressureincreases 2. Dunn PF, Goulet RL. Endotracheal tubes with positional changes in head and neck exion and airway appliances. Int Anesthesiol Clin. andextension.utinourstudy,weobservedthat 2000;8():65–94. atFlexedposturemeancuffpressurewashigherin . im D, Jeon , Son JS, et al The changes of supinepositionandatextendedposturemeancuff endotracheal tube cuff pressure by the position pressurewashigherinproneposition.17 changes from supine to prone and the flexion and extension of head. orean Journal of In our study, we compared the changes in Anesthesiology.2015Feb1;68(1):27–1. endotracheal tube cuff pressure by change in positionbyclassifyingthestudyobjectsbasedon 4. aasCF,EakinRM,onkleMA,etalEndotracheal Tubes:Oldandnewdiscussion.respiratorycare. their ody Mass Index (MI). Our observation 2014Jun1;59(6):9–55. showed that there were no signicant change in endotracheal tube cuff pressure in obese 5. WatsonWF.DevelopmentofthePVCendotracheal tube.iomaterials.1980Jan1;1(1):41–46. patient compared to normal and underweight patients.Thechangesweresimilarinbothgroup, 6. Morris LG, oumalan RA, Roccaforte JD, et al so we conclude that the change in ody Mass Monitoring tracheal tube cuff pressures in the intensive care unit: A comparison of digital Index (MI) has no impact in endotracheal tube palpation and manometry. Annals of Otology, cuffpressure. RhinologyLaryngology.2007Sep;116(9):69–42. ased on our observation we recommend that 7. Efrati S, Deutsch I, Gurman GM. Endotracheal eitherinsupineorpronepositiontheheadshould tube cuff-small important part of a big issue. be preferably placed in neutral position to avoid Journal of Clinical Monitoring and Computing. unwantedincidentsliketrachealischemicnecrosis, 2012Feb1;26(1):5–60. stenosis due to pressure changesin cuff. Wealso 8. Lanz E, immerschitt W. Volume and pressure advocate intermittent endotracheal tube cuff changes due to nitrousoxide diffusion in pressuremonitoringismandatoryintra-operatively costumary and in low-pressure cuffs of forthesafetyoutcomeofthepatients. endotracheal tubes (authors transl). Der Anesthesist.1976Oct;25(10):491–98. 9. amen JM, Wilkinson CJ. A new low-pressure Conclusion cuff for endotracheal tubes. Anesthesiology. 1971;4(5):482–85. Thesupineorpronepositionhavenoinuenceon 10. McCormack J, Purdy R. Airway complication theendotrachealtubecuffpressurewhenthehead related to an electromyography tracheal tube. isinneutralposition. PediatrAnesth.2008;18(6):572–7. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 AComparativeStudyontheEndotrachealTubeCuffPressureChanges 160 betweenSupineandProneinPatientsndergoingPronePositionSurgeries

11. aasCF,EakinRM,onkleMA,etalEndotracheal 15. ako , rishna SG, Ramesh AS, et al The Tubes:OldandnewDiscussion.RespirCare.2014 relationship between head and neck position Jun1;59(6):9–55. and endotracheal tube intracuff pressure in the 12. LizyC,SwinnenW,LabeauS,etalCuffpressure pediatric population. Pediatric Anesthesia. 2014 of endotracheal tubes after changes in body Mar1;24():16–21. position in critically ill patients treated with 16. Minonishi T, inoshita , irayama M, et al mechanical ventilation. American Journal of The supine-to-prone position change induces CriticalCare.2014Jan1;2(1):e1–8. modification of endotracheal tube cuff pressure 1. Athiraman , Gupta R, Singh G. Endotracheal accompanied by tube displacement. Journal of cuff pressure changes with change in position ClinicalAnesthesia.201Feb28;25(1):28–1. in neurosurgical patients. International Journal 17. omasawa N, Mihara R, Imagawa , et al of Critical Illness and Injury Science. 2015 Comparison of pressure changes by head and Oct;5(4):27. neckpositionbetweenhigh-volumelow-pressure 14. GodoyAC,VieiraRJ,CapitaniEM.Endotracheal andtaper-shapedcuffs:Arandomizedcontrolled tube cuff pressure alteration after changes in trial. io Med Research International. 2015 positioninpatientsundermechanicalventilation. Oct5;2015. Jornal rasileiro de Pneumologia. 2008 May;4(5):294–97.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1604-1608 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.17

Comparison of Bolus Doses of Bronchodilator and Adrenergic on Intraoperatie ypotensie Episodes throughout Caesarean beneath SpinalAnesthesia

NeelamuptaAkhileshMishra

1Associate Professor, 2Assistant Professor, Department of Anesthesiology, Saraswathi Institute of Medical Sciences, Anwarpur, apur,ttarPradesh24504,India.

Abstract

acground:Thepresentstudywasdesignedtocheckthevasoconstrictiveeffectsofbronchodilatorand adrenergicinbetteringcardiovasculardiseaseinelectivecesareanreceivingcrystalloidcoloadingthroughout intrathecal bupivacaine injection. Material and Methods: 0 patients were selected in present study. Once pre-anesthetic analysis and investigations, the patients were explained regarding the procedure. Cluster E were received blood vessel (IV) bronchodilator five mg and cluster P were received blood vessel (IV) adrenergicahundredweightunitoncetherellbefallinmaternalpulseforceperunitarea(SP)20from thebottomline.Results:Thetwoteams,i.e.,clusteroneandclusterapairofmatchedwithrelationtotheirage, weightandheight.Overall,7/15(46.66)patientswithintheadrenergicclusterand7/15(46.66)patients withinthebronchodilatorclusterhadoneoradditionalepisodeofcardiovasculardiseaseandneededoneor additionalbolusofvasoconstrictive.Comparedwiththebaselinevalues,theamendmentinmeanrateamong completelydifferentintervalswerefoundtobenon-vitalatanygiventimeinterval(p0.05).Conclusion:We concludefromthecurrentstudythatbronchodilatorfivemgandadrenergicahundredgsuaremeasure euallyeconomicalinmanagingcardiovasculardiseasethroughoutspinalforcesarean. eyords:ronchodilator;Adrenergic;SpinalAnesthesia;CesareanSection.

otocitethisarticle: NeelamGupta,AkhileshMishra.ComparisonofolusDosesofronchodilatorandAdrenergiconIntra-operativeypotensive EpisodesthroughoutCaesareanbeneathSpinalAnesthesia.IndianJAnesthAnalg.2019;6(5Part-1):1604-1608.

Introduction Spinalcardiovasculardisease willoccur sharply and,ifsevere,mayendupinvitalperinataladverse Spinal anesthesia (SA) is today thought-about outcomes,likematernalnauseaandejection,vertigo the uality anesthetic techniue for elective craniate pathology and should be a vital tributary cesarean.1owever,cardiovasculardiseaseisthat issueformaternaldeathassociatedwithanesthesia. the commonest aspect result of neuroaxialblocks Mothers with pre-delivery hypovolemia is within the medicine patient. Spinalforcesarean is alsoindangerofvesselcollapseasaresultofthe relatedtoeightiethofcardiovasculardiseasecases sympathetic blockade could severely decrease whilenotprophylacticmeasures.2 blood vessel come back. Profound cardiovascular

Corresponding Author: Akhilesh Mishra, Assistant Professor, Department of Anesthesiology, Saraswathi Institute of Medical Sciences,.Anwarpur,apur,24504,ttarPradesh,India. Email:[email protected] eceiedon07.05.2019,Acceptedon05.06.2019

RedFlowerPublicationPvt.Ltd. ComparisonofolusDosesofronchodilatorandAdrenergiconIntra-operative 1605 ypotensiveEpisodesthroughoutCaesareanbeneathSpinalAnesthesia disease will probably result in serious drive and cardiovasculardiseaseinelectivecesareanreceiving hypovolemia within the mother and therefore crystalloid co-loading throughout intrathecal thevertebrate.Asplacentalbloodowisdirectly bupivacaineinjection. proportionaltothematernalforceperunitarea,the cardiovascular disease will result in to placental MaterialsandMethods hypoperfusion and craniate physiological state leading to explained less craniate activity and cranialpathology. The analysis of Comparison of bolus doses of bronchodilator and adrenergic on intra-operative So, hindrance of spinal cardiovascular disease hypotentive episodes throughout cesarean has been a key analysis space at intervals the beneath spinal anesthesia were allotted within sphere of medicineanesthesia. To prevent spinal the Department of Anesthesiology, Saraswathi cardiovascular disease, variety of approaches Institute of Medical Sciences, Anwarpur, apur, is investigated like girdle tilt, leg elevation ttarPradesh,India. and wrapping, and therefore the prophylactic administration of uids or vasopressors that suaremeasureaccustomedcutbacktheincidence InclusionCriteria ofmaternalcardiovasculardisease.Theutilization ASAIandIIdenoteforelectivecaesarean. ofvasopressorshasgainedincreasingprominence All the patients WO suare measure because the primary techniue for the hindrance willingtograntconsent. and treatment of spinal cardiovascular disease throughoutcesarean. Ageclustereighteentothirtyveyears. There is a trend to bank additional on Weight40–70g. vasopressors than either crystalloid or mixture eightonehundredfty–10cm. alone. Crystalloid pre-hydration has poor effectivity for preventing cardiovascular disease, in all probability as a result of it undergoes clusionCriteria speedy distribution. As an alternate, speedily 1. Patientsnotwillingtograntconsent. administering crystalloid at the time of initiation 2. Patients WO have a past history of of physiological condition (called coloading) is reactiontoreviewmedicine,majorviscus, alsoadditionalphysiologicallyapplicablebecause excretoryorganorvesseldysfunctionand the most result may be achieved throughout the anyreasontocentralneuraxialblockade. time of block and resulting dilation evolution. . Patients having allergic to native Completelydifferentvasopressorssuaremeasure anesthetics. unremarkably used now-a-days with varied 4. Patientshavingtraumacoagulopathy. degrees of success. Despite the utilization of prophylactic blood vessel (I.V. infusion or bolus 5. Patients WO were taking anti-emetic bronchodilatorforthelastdecades,agoodrange medication. offailureshaveadditionallybeenreportable.4 6. Fatpatient. Ephedrine has beenthe vasoconstrictive of 7. Patients with physiological condition selectionsinceitsbeenshowntoownaadditional connected complications like vertebrate protecting result on female internal reproductive malpresentation, pregnancyinduced high organ blood ow and introduction pressure than bloodpressure,physiologicalstatediabetes -adrenergicagonists.5owever,bronchodilatoris andptswithpre-toxemiaofpregnancyand notanylongertheoldnormalforpreventionand toxemiaofpregnancy. treatmentofcardiovasculardiseaseoncespinalfor cesarean.Moreover,higherdoseofbronchodilator ethods causes vital maternal cardiac arrhythmia and 6 cranialpathology. 0 patientswere selected in present study. Once Newer proof has supported the utilization of pre-anesthetic analysis and investigations, the alphagonistslikeadrenergicdemonstratinghigher patientswereexplainedregardingtheprocedure, acid basestanding andsimilareffectivity inforce sophisticated written consent was obtained. per unit area management. ence, the current normal pre-operative procedure was followed study was designed to check the vasoconstrictive and nal analysis important parameters were effectsofbronchodilatorandadrenergicinbettering recorded.18GIVtubeweresecuredandallotted IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1606 IndianJournalofAnesthesiaandAnalgesia into 2 teams of fteen every with pc generated also will assessed for side-effects like nausea, information.clusterEwerereceivedbloodvessel vomiting, cardiovascular disease, arrhythmia, (IV) bronchodilator ve mg and cluster P were itching,abnormality. received blood vessel (IV) adrenergic a hundred weightunitoncetherellbefallinmaternalpulse StatisticalAnalysis forceperunitarea(SP)20fromthebottom line. In the operation theatre, routine monitors All the information were expressed as mean (electrocardiogram, non-invasive force per unit Americanstate,appliedmathematicsanalysiswere area, pulse oximeter), blood vessel access was performed with SPSS version 17.0 for analysis of secured. All the patients were co-loaded with demographiccomparisonofteams,x2,unmatched Ringerwet-nurse20mlg. students t-test and paired-t-test were applied. p0.05werethought-aboutasstatisticallyvital. SpinalwasgiventwentythreeGuinckeneedle insittingpositionattheL-L4interspace.Oncethe freeowofhumour(CSF)isobtained,2ml(10mg) esults ofzero.5upivacaine(heavy)wereadministered over zero. 2mlsec Co-loading with speedy The two teams, ie., clusteroneandcluster a pair administration of 20mlg of Ringer wet-nurse ofmatchedwithrelationtotheirage,weightand were started. Patients can then be placed within height shows in Table . Overall, 7/15 (46.66) thesupineposition,activitygotviaaudsonmask patients within the adrenergic cluster and 7/15 atthespeedofthreelmin. (46.66)patientswithinthebronchodilatorcluster Sensoryblockwereassessedbyapinpricktake had one or additional episode of cardiovascular alook at. The onset ofsensory blockade (dened disease and needed one or additional bolus of because the time from the injection of intrathecal vasoconstrictive. the amount of rescue doses medicinetotheabsenceofpainattheT8surgical needed in cluster one and cluster a pair of was instrument were recorded each minute until the statisticallyinsignicantshowsinTablesand. T8levelisachieved.Onsetofmotorblockadewere There was the next incidence of arrhythmia in assessedat5minintervalsuntilfteenmin(ie5, patientsreceivingadrenergicthanthosereceiving 10and15)perthechanged. bronchodilatorshowsinTable. romagescale0-nomotorblock,one-inability The comparison of mean of rate in numerous to ex the hip hip blocked, a pair of - inability interval in between teams. Compared with the to ex the knee hip and knee blocked, three - baseline values, the amendment in mean rate inability to ex the articulation talocrural is hip, amongcompletelydifferentintervalswerefoundto kneeandarticulationtalocruralisblocked),shows benon-vitalatanygiventimeinterval(pzero.05) in(Table). asshownintableontopofandshowsthesimilar trends in between teams. Intra-operatively there Table : Sedation Scale: Sedation will be assessed by Ramsey wasnoarrhythmiarecordedineachteamsatany SedationScoring given interval. ut the distinctionin SpO2wasnt Level1 Patientanxiousandagitatedorrestless,orboth found be statistically vital among completely different study teams at any given time intervals Level2 Patientco-operative,oriented,andtranuil (p 0.05) shows in Table . The distinction in Level Patientrespondstocommandsonly birthweightofneonatesbetweenthe2teamswas Level4 riskresponsetoalightglabellartaporauditory statistically insignicant. No neonatal had Apgar stimulus scoreshowsinTable. Level5 Sluggishresponsetoalightglabellartapor auditorystimulus Level6 Noresponsetostimulimentionedinitems4and5 Table:DemographicdataofGroupsEandP

lood pressure (systolic, beat and mean), roupEn roupn alue heart rate, rate of respiration and peripheral gas Age(years) 0.170.49 1.10.51 0.58 saturation(SpO2)aregoingtoberecordedvemin ASAi:ii(n) 14:1 1:2 0.42 before theintrathecal injection (0)andat ve, 10, Weight(g) 60.25.80 68.268.61 0.06 15,20,twentyveandthirtyminoncetheinjection, andaftereachfteenmin.Arrhythmia(denedas eight(cm) 15.294.77 152.95.2 0.51 rateofbut50)aregoing tobetreatedwithblood nNumberofpatients vessel zero. mg spasmolytic sulphate. Patients

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparisonofolusDosesofronchodilatorandAdrenergiconIntra-operative 1607 ypotensiveEpisodesthroughoutCaesareanbeneathSpinalAnesthesia

Table : eart rate recordings during various stages of of cardiovascular disease within the study anesthesia populationwasfortyeighththatwasconsiderably eartate roupE roupP less compared to the incidence (more than 80) 2 0Minutes 79.2016.01 77.5714.40 discoveredinalternativestudies. 5Minutes 79.8011.47 75.578.472 In this study, there was the next incidence 10Minutes 81.979.750 76.6011.8 of arrhythmia in patients receiving adrenergic 15Minutes 87.76.990 84.207.599 than those receiving bronchodilator, this can be 20Minutes 86.77.299 81.810.95 expectedtoensuetoextendinforceperunitarea 25Minutes 86.0010.00 80.5011.40 withassociatedegree -agonistwhichmayresult 0Minutes 86.608.261 82.78.081 in reactive arrhythmia (baroreceptor reex). 45Minutes 81.010.6 77.212.5 owever,thiswastunedintoglycopyrollatewhile 0Minutes 85.077.565 85.9711.4 notadverseconseuences.Theresultsofthisstudy 75Minutes 86.976.990 8.66.744 is in accordance with the studies of Nazir et al.7 0Minutes 86.77.850 84.1020.50 (5/50 vs 17/50 within the adrenergic group) and Leeetal8relativerisk(RR)offour79;ninetyfth

Table:SpO2recordingsduringvariousstagesofanesthesia condenceinterval(CI),1.47–15.60withp0.05. On the opposite hand, the incidence of nausea SpO roupE roupP andejectionwasadditionalwithintheadrenergic 0Minutes 98.1.241 98.01.512 cluster than the bronchodilator cluster 14/40 5Minutes 97.901.22 98.21.15 (5)versus9/40(22.5)inourstudythatwasnt 10Minutes 98.001.486 98.271.285 statisticallyvital(p0.16). 15Minutes 97.071.69 97.771.278 20Minutes 97.571.524 97.771.775 In our study, the common vasoconstrictive 25Minutes 97.61.691 98.01.629 consumption was reduced within the 0Minutes 97.671.58 98.170.9129 bronchodilatorclustercomparedtotheadrenergic 45Minutes 97.601.74 98.101.7 cluster, assumptive that the euivalent doses of 0Minutes 98.21.524 98.171.05 bronchodilatorandadrenergicwerevemganda 9 75Minutes 97.571.675 97.81.487 hundredg,severally. Theincidenceoffallinforce 0Minutes 97.471.655 98.101.494 per unit area was most throughout the primary ten min following the sub-arachnoid block and Table:Comparisonofparametersinbetweengroups that we discovered that vasoconstrictive use was mostthroughoutthisera.Thiscorrespondstothe roupE roupP Parameters alue immediate sympathetic block once intrathecal n n injection.Wetendto additionallydiscoveredthat ypotension(yes) 7(46.66) 7(46.66) 1.00 adrenergicwasusedadditionaloftimesintenmin ypotension(no) 8(5.) 8(5.) compared to bronchodilator. Its clearly apparent radycardia 0 2(1.) 0.01 bythebroaderSDsofmeanSPvalueswithinthe Nausea/Vomiting 4(26.66) 6(40) 0.15 adrenergicclusterhowevernoappliedmathematics Tachycardia (20) 4(26.66) 0.75 vital distinctionwas discovered (p 0.05). On the oppositehand,Nganeeetal10andSkilledworker Table:Apgarscoreofthetwogroupsatdifferenttimeintervals et al11 opined that vasoconstrictive needs was roupE roupP reduceduntilthetimeofdeliveryintheirstudies. Parameters Value n n The common median dose was zeromg versus APGAR(0min) 7.70.9 7.690.41 0.767 ten mg of bronchodilator (p 0.001) within the APGAR(1min) 9.110.41 8.970.49 0.252 studybyNganeeetal10 APGAR(5min) 9.080.2 8.950.1 0.249 Gunda et al12comparedtheeffectivenessand abyweight(g) .0680.22 .160.4 0.781 aspect effects of vasopressors bronchodilator and adrenergic administered for cardiovascular Discussion disease throughout cesarean beneath spinal. owever, their studyadvised that adrenergic is In the gift study, there was no statistically vital also the additional applicable vasoconstrictive distinctionwithin the incidence of cardiovascular onceconsideringmaternalwell-being.Thiscould diseasewithspeedyadministrationofcrystalloidat arebecauseoflessdoseofbronchodilator(mg) thetimeofinductionofspinal(coload)ineachthe thatwasutilizedintheirstudyascomparedwith teams(p 0.05). Moreover, the general incidence thisstudy.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1608 IndianJournalofAnesthesiaandAnalgesia

Conclusion 6. Cooper DW, Carpenter M, Mowbray P, et al Fetalandmaternaleffectsofphenylephrineand ephedrine during spinal anesthesia for cesarean We conclude from the current study that delivery.Anesthesiology.2002;97:1582–590. bronchodilatorvemgandadrenergicahundredg 7. Nazir I, hat MA, azi S, et al Comparison suare measure eually economical in managing between phenylephrine and ephedrine in cardiovascular disease throughout spinal for preventinghypotensionduringspinalanesthesia cesarean. Maternal arrhythmia was additional for cesarean section. J Obstet Anesth Crit Care. within the adrenergic cluster and there was no 2012;2:92–97. distinctionwithintheincidenceofcranialpathology 8. Lee A, Ngan ee WD, Gin T. A uantitative, within the 2 groups. Neonatal outcome remains systematic review of randomized controlled euallysmartineachtheteams. trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. AnesthAnalg. eferences 2002;94:920–26. 9. NganeeWD,LeeA,hawS,etalArandomized 1. irnbach DJ, rowne IM. Anesthesia for double-blinded comparison of phenylephrine obstetrics.In:MillerRD,ErikssonLI,FleisherL, andephedrineinfusioncombinationstomaintain Wiener-ronish JP, oung WL, editors. Millers blood pressure during spinal anesthesia for Anesthesia,Vol.2.7thedition.Philadelphia,SA: cesarean delivery: The effects on fetal acid-base ChurchillLivingstone;2010.pp.220–240. statusandhemodynamiccontrol.AnesthAnalg. 2. NganeeWD,hawS,Lee,etalA dose- 2008;107:1295–02. response study of prophylactic intravenous 10. Ngan ee WD, haw S, Ng FF. Prevention ephedrine for the prevention of hypotension of hypotension during spinal anesthesia for during spinal anesthesia for cesarean delivery. cesarean delivery: An effective techniue AnesthAnalg.2000;90:190–95. using combination phenylephrine infusion . RehmanA,aig,RajputM,etalComparison and crystalloid cohydration. Anesthesiology. ofprophylacticephedrineagainstprnephedrine 2005;10:744–50. during spinal anesthesia for cesarian sections. 11. Dyer RA,Farina,JoubertIA, etalCrystalloid AnesthPainandIntensiveCare.2011;15(1):21–24. pre-load versus rapid crystalloid administration 4. Rout CC, Akoojee SS, Rocke DA, et al Rapid afterinductionofspinal anesthesia(co-load)for administration of crystalloid preload does not electivecesareansection.AnesthIntensiveCare. decreasetheincidenceofhypotensionafterspinal 2004;2:51-57. anesthesia for elective cesarean section. r J 12. Gunda CP, Malinowski J, Tegginmath A, et al Anesth.1992;68:94–97. Vasopressor choice for hypotension in elective 5. Ralston D, Shnider SM, DeLorimier AA. Cesarean section: Ephedrine or phenylephrine Effects of euipotent ephedrine, metaraminol, ArchMedSci.2010;6:257–6. mephentermine, and methoxamine on uterine bloodflowinthepregnantewe.Anesthesiology. 1974;40:54–70.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1609-1614 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.18

Preention of Postoperatie Nausea and Vomiting in aparoscopic Cholecystectomy:AComparisonofMetoclopramideandOndansetron

PreeteenaurIbalSingheetanaliPushkarnaSaruSinghaganotaurasleenaur

1Consultant,Dept.ofAnesthesia,Civilospital,Amritsar(formerlyAssistantProfessor,Dept.ofAnesthesia,SGRDInstituteof MedicalSciencesandResearch,Amritsar,Punjab14501,India).AssociateProfessor,5AssistantProfessor,6JuniorResident,Dept. ofAnesthesia,SGRDInstituteofMedicalSciencesandResearch,Amritsar,Punjab14501,India.2Retd.Professorandead,Deptt ofAnesthesia,GMCAmritsar,Punjab14001,India. 4AssociateProfessor,Dept.ofAnesthesia,hagatPhoolSinghGovtMedical College(Women),hanpuralan,Sonepat,aryana1105,India.

Abstract

acground: Post-operative nausea and vomiting (PONV) is a freuent complication associated with laparoscopic cholecystectomy. In this randomized double-blind placebo controlled prospective study, we comparedtheefficacyofintravenousmetoclopramideandondansetronforpreventionofPONVfollowing laparoscopic cholecystectomy in patients. Materials and Methods: A total of 75 patients (20–0 years of age) undergoingelectivelaparascopiccholecysetectomywererandomlyallocatedtooneofthethreegroupsof 25 patients each. Group A received metoclopramide 10 mg Group received ondansetron and group C receivednormalsaline10mlafterinduction.AllepisodesofPONVwithin24hrs.afterinductionofanesthesia were recorded. Results: The overall incidence of post-operative emesis was 44 in control group, 16 in Metoclopramidegroupand12inOndansetrongroup.ThedecreaseinincidenceofemesisinMetoclopramide and Ondansetron group was significant as compared to control group whereas there was no statistical difference between Metoclopramide and Ondansetron groups. Conclusion: For prevention of PONV after laparoscopiccholecystectomy,bothmetoclopramideandondansetronareeuallyeffectiveincomparisonto placebogroup. eyords: Laparoscopic cholecystectomy; Ondansetron; Metoclopramide; Post-operative nausea and vomiting.

otocitethisarticle: Preetveen aur, Ibal Singh, Geetanjali Pushkarna et al Prevention of Post-operative Nausea and Vomiting in Laparoscopic Cholecystectomy:AComparisonofMetoclopramideandOndansetron.IndianJAnesthAnalg.2019;6(5Part-1):1609-1614.

Introduction the stomach and gut due to pneumoperitoneum as well as chemical factors like inuence of Post-operative nausea and vomiting (PONV) has carbon dioxide. Although nausea and vomiting beenoneofthemostdistressingaccompaniments can result in dehydration, electrolyte imbalances of surgery and anesthesia, with an incidence of and delay in discharge from hospital but for the approximately0.1owever,ahigherincidence anesthesiologists, the most dreaded complication rate of 46 to 75 has been reported in patients isthepulmonaryaspirationofvomitusespecially afterlaparoscopiccholecystectomy.2–4Thishasbeen when airway reexes are depressed due to the attributed tomechanical factors like pressure on residualeffectsofanestheticdrugs.

CorrespondingAuthor:Preeteenaur,Consultant,Civilospital,Amritsar.(formerlyAssistantProf,DepttofAnaesthesia,SGRD InstituteofMedicalSciencesandResearch,Amritsar,14501,Punjab,India.) Email:[email protected] eceiedon28.05.2019,Acceptedon11.07.2019

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Various drugs and techniues have been Group(n25)receivedinjectionondansetron employedinthepastforthepreventionofPONV 4 mg I.V. diluted upto 4 ml. Group C (n 25) butthesearchforbetteranti-emeticsisstillgoing received4mlnormalsaline. 5,6 on. Metoclopramideistheroutinedrugbeingused All the patients were subjected to a thorough forpreventionofPONVforthelast0yearsdueto pre-anestheticcheckupadaypriortosurgeryand 7 its various favorable properties. The anti-emetic relevant investigations were done. The patients actionofmetoclopramideisduetotheantagonism were given tablet Diazepam 10 mg on the night of D receptors centrally and peripherally. The 2 beforesurgery.AfterbringingpatienttotheO.T,I.V. inhibitionofchemoreceptortriggerzone(CT)in cannula was placed and monitors were attached. the central nervous system prevents nausea and Inj. utorphanol 1 mg and inj. Atropine 0 mg vomitingtriggeredbymanystimuli.Italsoexhibits wereused forintravenous(I.V.)pre-medicantion. a gastrokinetic effect by increasing selective All patients were induced with inj. Thiopentone cholinergic response of gastrointestinal tract 5mggandsuxamethnoium2mggI.V.Thestudy by inhibiting gastric smooth muscle relaxation. drug was given soon after intubation. During The tone of lower oesophageal sphincter is also IPPVusingbagandmaskventilation,lowairway increased thus decreasing the risk of aspiration. pressuresweremaintained. owever,higherdosescanleadtoextrapyramidal side effects. In the recent years, interest has been Anesthesiatechniueemployedwassameinall focusedonanew5Treceptorspecicantagonist, patientsusinghalothane,nitrousoxide,oxygenand vecuronium. efore extubation, patients received Ondansetronwhichdoesnotactonotherreceptors Inj.Diclofenac75mgintra-muscularly. likedopaminergic,histaminic,cholinergicetc.and sohasfewsideeffects.8 Intra-operatively, continuous monitoring of patientsheartrateandbloodpressureweredone. Therefore,thisstudywasplannedtoevaluatethe Post-operatively, patients were monitored every effectiveness ofondansetronandmetoclopramide hourfortherst4hoursandthenat24hours.All in preventing PONV in patients undergoing episodes of nausea and vomiting were recorded laproscopiccholecystectomy. during rst 24 hours after general anesthesia. Nauseawasdenedasthesubjectivelyunpleasant MaterialsandMethods sensationassociatedwithawarenessoftheurgeto vomit,whereasvomitingwasdenedastheforceful This study was carried at Government Medical expulsionofgastriccontentsfromthemouth.Any College in Punjab after obtaining approval from sideeffectsofthedrugswerealsorecorded. ethical committee. The study was conducted on Nausea was measured by 11 points numerical 75 adult patients of both sexes in age group of visual analog scale with 0 no nausea and 20–0 years of ASA grade I and II undergoing 10nauseaasbadcanbe.Ascoreofmorethan5 elective laparoscopic cholecystectomy. efore wasconsideredsevere,5moderateand4orless enrolmenttothestudy,awritteninformedconsent wasconsideredminimal.Moderateorseverenausea wasobtainedfrompatients.Criteriaforexclusion was considered asmajornausea.The numbers of wereobesepatients(20expectedbodyweight vomiting episodes were counted and more than for their age), patients with history of motion 2 episodes were counted severe, 2 episodes as sickness,chronicsteroidtherapyorhavinghadanti- moderateandlessthan2consideredmildvomiting. emeticswithinlast24hoursbeforesurgery.Patients Patientswhohadmorethan2episodesofvomiting withchronicexposuretonicotineandhavingany were given inj. Metoclopramide 10 mg I.V. as a disease that could prolong gastric emptying or rescueanti-emetic. makethempronetovomitingeg.,diabetes,hiatus herniawerenotincludedinthestudy. esults Randomallocationwasdecidedonthebasisof computer generated random number table. The Allthe75patients,25ineachgroupwereincluded codedslipswerepreparedandputinenvelopand inthestudy.Therewerenosignicantdifferences according to the slip, solution was prepared by betweenthethreegroupswithregardtoage,weight independentobservernottakingpartinstudy. anddurationofsurgeryasshownin(Table).Intra- Group A (n 25) received injection operativevitalscorewas1.880.,1.920.28and metoclopramide10mgI.V.dilutedtomakevolume 1.840.7ingroupA,andCrespectively.This of4ml. was statistically in-signicant. The post-operative

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 PreventionofPost-operativeNauseaandVomitinginLaparoscopicCholecystectomy: 1611 AComparisonofMetoclopramideandOndansetron vitalscoreswerealmostsimilarinallgroups.Atno time,differenceinthepost-operativevitalscorewas signicantbetweenthegroupsasshownin(Table). Nauseawas experienced by17 patientsofcontrol group (68) while it was reported in 8 patients of Metoclopramide group (2) and 9 patients of Ondansetron group (6) respectively displays (Fig).Themeanmaximumnauseaseverityscore was1.682.97inthemetoclopramidegroup,1.68 2.98intheondansetrongroupand4.28.92in thecontrolgroupshows(Table).Thisdifference wasstatisticallysignicantbetweencontrolversus Fig:Incidenceofnauseaindifferentgroups (vs)metoclopramidegroup(p0.05)andcontrol vs ondansetron group (p 0.05) but statistically Table:Post-operativenauseascoreatdifferenttimeintervals in-signicant on comparison of metoclopramide Time(ours) Group vs ondansetron groups (p 0.05). In our study, Metoclopramide Ondansetron Control metoclopramide was found to be more effective 0 0.120.44 0.080.28 0.240.52 in decreasing severity of early nausea (0–2 hours) 1 0.561.19 0.721.24 1.041.21 whileondansetronprovedbetterasfarascontrolof 2 1.22.46 1.042.17 2.682.69 latenausea(2–24hours)wasconcernedasshownin 1.482.90 1.082.6 2.96.5 (Tables&). 4 0.440.92 0.722.21 1.76.28 4–24 0.000.00 0.000.00 0.000.00 Table:Patientcharacteristics Max.Mean 1.682.97 1.682.98 4.28.92 SeverityScore Variables roupA roupB roupC MeanSD n n n The overall incidence of post-operative Age(y)SD 9.9610.69 40.67.78 9.089.42 emesis was 44 in control group (11/25), 20 Weight(kg)SD 6.169.47 64.2611.20 6.4810.61 in Metoclopramide group (5/25) and 12 in Durationof 56.001.69 57.4014.44 5.6012.71 Ondansetron group (/25) (Fig ). The decrease surgery(min) in incidence of emesis in Metoclopramide and Ondansetron group was signicant as compared Table:Meanvitalscores to control group whereas there was no statistical roupA roupB roupC difference between Metoclopramide and IVS 1.880. 1.920.28 1.840.7 Ondansetrongroups.owever,duringearlyperiod PVS-0R 1.840.7 1.920.28 1.920.28 (0–2 hours) the incidence of vomiting was 4 in PVS-1R 2.000.00 2.000.00 2.000.00 metoclopramidegroupascomparedto12inboth PVS-2R 2.000.00 2.000.00 2.000.00 ondansetronandcontrolgroupwhileitincreasedto PVS-R 2.000.00 1.960.20 2.000.00 PVS-4R 2.000.00 2.000.00 2.000.00 20inmetoclopramideand40incontrolgroup PVS-4-24R 2.000.00 2.000.00 2.000.00 as compared to 8 in ondansetron group during IVS-Intra-operative vital score; PVS-Post-opeartive vital score; lateperiod(2–24hours).Nosignicantuntoward R-our. sideeffectswereseeninanyofthethreegroupsas

Table:Post-operativeemesisatdifferenttimeintervals

Timeours roup Metoclopramide Ondansetron Control No Mean No Mean No Mean 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 2 1 4 0.040.20 12 0.120. 12 0.120. 4 16 0.160.47 2 8 0.080.28 8 2 0.20.48 4 4 16 0.160.7 2 8 0.080.28 10 40 0.400.71 4–24 1 4 0.040.20 1 4 0.040.20 5 20 0.200.50 Metoclopramidevsondansetron-notsignificant; Controlvsmetoclopramide-notsignificant; Controlvsondansetron-highlysignificantathoursand4hours

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1612 IndianJournalofAnesthesiaandAnalgesia shownin(Table).seofrescuetreatmentshown cholecystectomy is multifactorial. Anesthetic in (Fig ) was similar in metoclopramide and factorslikethetypeofpre-medication,amountof ondansetrongroup(8)whileitwaswashigherin gastric distension, suctioning, anesthetic drugs, controlgroup(24). anesthetic techniue and post-operative pain increase the incidence of PONV. Various non- Table:Incidenceofsideeffects anesthesticfactorslikeage,gender,weight,history of motion sickness, anxiety, gastroparesis etc. eadache Drynessofmouth Sedation Anyother alsopre-disposepatientstoPONV.9Inourstudy, GroupA 1 1 1 1 patients were similar in terms of demographic Group 2 2 0 1 variables,durationofsurgeryandbasicvitalsigns. GroupC 1 2 0 1 Patients with low threshold for vomiting like gastroparesis, motion sickness etc. were excluded Discussion fromourstudy.Anestheticdrugsandthetechniue usedwerekeptsimilarinallgroups. Despite scientic advances in anesthesia and In the present study, the overall incidence of surgery,nauseaandvomitingareamongthemost nauseawas68incontrolgroupwhileitwas2 commondistressingpost-operativecomplications. inmetoclopramidegroupand6inondansetron The etiology of PONV after laparoscopic group which was statistically in-signicant

Fig:Incidenceofpost-operativeemesisindifferentgroups

Proportionofpatients

Fig:Incidenceofuseofrescuetreatmentindifferentgroups

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 PreventionofPost-operativeNauseaandVomitinginLaparoscopicCholecystectomy: 161 AComparisonofMetoclopramideandOndansetron amongstmetoclopramideandondansetron group et al16 in their study concluded that Ondansetron but signifant for both groups in comparison was more effective than dexamethasone and with control group. Incidence of post-operative metoclopramide in preventing vomiting after emesis was 44 in control group (11/25) which laparoscopic cholecystectomy at intervals of 0–1 was signicant (p 0.001) when compared to and1–hoursandalsodelayedtheonsetofnausea 20inMetoclopramidegroup (5/25)and12in andvomiting. Ondansetron group (/25) thus showing that the Many studies reported that ondansetron is incidenceofpostoperativevomitingwasmaximum statistically superior to metoclopramide for incontrolgroup.Asperourresults,thefreuency prevention of PONV.17–19 In our study too, of emesis was less in the ondansetron group but ondansetron group has low freuency of emesis itwasnot statisticallysignicantwhencompared although it was statistically insignicant. Other tothemetoclopramidegroup.Theseresultsarein published studies that evaluated the efcacy of concordancewiththestudiesbyWilsonetaland ondansetron and metoclopramide administered ilgin TE etalwhoprovedasignicant decrease intravenouslyhaveshownsimilarreductionsinthe in the incidence of vomiting in the ondansetron incidenceofPONVduringthe24hrs.postrecovery and metoclopramide groups as compared to the period.20,21 Though we encountered very few and control group without any statistical difference mild side effectswith regard to all groups, Daria 10,11 12 amongstthemselves. Isazadehfar concluded and umar stated that metoclopramide not only that both metoclopramide and ondansetron are hasalow(6.7)successrateinthepreventionof euallyeffectiveforpreventionofvomitingbutfor PONV,butalsoahigherincidenceofsideeffects. preventionofnausea,ondansetronismoreeffective owever, they also discredited the efcacy of thanmetoclopramide. ondansetronforthepreventionofPONV.22 Inasimilarresearch,uanyorandRaedarshowed theoverallincidenceofpost-operativenauseaand Conclusion vomiting to be almost similar in metoclopramide and ondansetron groups. Incidentally, they also observed a greater incidence of moderate Ondansetron4mgandmetoclopramide10mgare bothalmosteuallyeffectiveasprophylacticanti- to strong pain during the post-operative period emeticsforthepreventionofpost-operativenausea in the ondansetron group as compared to the metoclopramidegroup.1 and vomiting in laparoscopic cholecystectomy proceduresundergeneralanesthesiaascompared Farhatetalontheotherhand,statedthatthe toplacebowithminimalsideeffects. freuency of nausea and vomiting was clinically and statistically lower in ondansetron group as comparedtothemetoclopramidegroup(p0.05) eferences whiletheuseofrescueanti-emeticwassignicantly higherinthelatter(p0.022).14Thesendingswere 1. AcalovschiI.Post-operativenauseaandvomiting. alsoreinforcedinametaanalysisbyWuSJ etal, CurrAnesthCritCare.2002;1:7–4. wherethetotalincidenceofpost-operativenausea 2. elmy SA. Prophylactic anti-emetic efficacy of and vomiting within 24 hours after laparoscopic ondansetron in laparoscopic cholecystectomy cholecystectomy was 1 in the ondansetron under total intravenous anesthesia. Anesthesia. groupand56inthemetoclopramidegroupthus 1999;54:266–71. indicatingondansetrontobeabetteranti-emetic.15 . NaguibM,akryA,hoshimM.Prophylactic anti-emetictherapywithondansetron,tropisetron, Inthepresentstudy,wefoundtheincidenceof granisetron and metoclopramide in patients earlynauseatobe28and6inmetoclopramide undergoing laparoscopic cholecystectomy: A andondansetrongrouprespectivelyas compared randomized, double-blind comparison with to 64 in control group. The incidence of late placebo.CanJAnesth.1996;4:226–1. nauseawas2 formetoclopramide group,24 4. CekmenN,AkcabayM,MahliA.Comparisonof forondansetrongroupand60forcontrolgroup. theeffectsofdexamethasoneandmetoclopramide Thus it shows that ondansetron is more effective on post-operative nausea and vomiting. Erciyes for late nausea than metoclopramide. It also MedJ.200;25:17–4. decreases severity of late nausea as compared . et al Post- to Metoclopramide. The decreased effect of operative nausea and vomiting: A simple metoclopramide on late nausea may be due to yet complex problem. Anesth Essays Res. its shorter duration of action. Masoomeh Tabari 2016;10:88–96.

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6. GanTJ,DiemunschP,abibAS,etalConsensus vomiting after laparoscopic cholecystectomy: A guidelines for the management of post- systematic review and meta-analysis. epato operative nausea and vomiting. Anesth Analg. Gastroenterology.2012;59(119):2064–074. 2014;118:85–11. 16. Tabari M, Shabahang , Tavasoli A, et al 7. De Oliveira GS, Castro-Alves LJ, Chang R, Comparative study of the effectiveness of et al Systemic metoclopramide to prevent ondansetron, metoclopramide and low dose post-operative nausea and vomiting: A meta- dexamethasone to prevent post-operative analysis without Fujiis studies. r Jour Anesth nausea and vomitting in females who undergo 2012109697. laparoscopic cholecystectomy.Women ealth 8. abibAS,GanTJ.Evidence-basedmanagement ull.2014. ofpost-operativenauseaandvomiting:Areview. 17. GuptaV,WakhlooR,MahtaM,etalProphylactic CanJAnesth.2004;51:26–41. Anti-emetic Therapy with Ondansetron, Granisetron and Metoclopramide in Patients 9. Ahmed N, Muslim M, Aurangzeb M, et al ndergoing Laparoscopic Cholecystectomy Prevention of post-operative nausea and nder General Anesthesia. J Med Edu Res. vomitinginlaparoscopiccholecystectomy.JMed 2008;10:74–77. Sci.2012;20:–6. 18. aki MA, EL-akeem EE. Prophylaxis of post- 10. Wilson E, ass CS, Abrameit W et al operativenauseaandvomitingwithondansetron, Metoclopramide versus ondansetron in metoclopramide or placebo in total intravenous prophylaxis of nausea and vomiting for anesthesia patients undergoing laparoscopic laparoscopic cholecystectomy. Am J Surg. cholecystectomy.SaudiMedJ.2008;29:1408–41. 2001;181:18–41. 19. SandhuT,TanvatcharaphanP,Cheunjongkolkul 11. ilginTE,irbicer,Ozer,etalAcomparative V. Ondansetron versus metoclopramide studyoftheanti-emeticefficacyofdexamethasone, in prophylaxis of nausea and vomiting for ondansetron, and metoclopramide in patients laparoscopic cholecystectomy: A prospective undergoing gynecological surgery. Med Sci double-blind randomized study. Asian J Surg. Monit.2010Jul;16(7):CR6–41. 2008;1:50–54. 12. Isazadehfar , Entezariasi M, Shahbazzadegan 20. easmeen S, asmin R, Akhtaruzzaman A, et , et al The comparative study of ondansetron al Intravenous Granisetron, Ondansetron and and metoclopramide effects in reducing nausea MetoclopramideinthePreventionandTreatment andvomitingafterlaparoscopiccholecystectomy. of Post-operative Nausea and Vomiting after ActaMedIran.2017;55(4):254–258. Laparoscopic Cholecystectomy: A Comparative 1. uaynor,RaederJC.Incidenceandseverityof Study.JSA.2006;19:20–27. post-operative nausea and vomiting are similar 21. Monagle J, arnes R, Goodchild C, et al after metoclopramide 20 mg and ondansetron Ondansetron is not superior to moderate 8 mg given by the end of laparoscopic dose metoclopramide in the prevention of cholecystectomies. ActaAnesthesiolScand.2002 post-operative nausea and vomiting after Jan;109:(1)46–1. minor gynecological surgery. Eur J Anesthesiol. 14. Farhat , Pasha A, azi WA. Comparison of 1997;14:604–09. Ondansetron and Metoclopramide for PONV 22. Daria , umar V. ualitative comaparison of Prophylaxis in Laparoscopic Cholecystectomy. J metoclopramide, ordansetron and granisetron AnestheClinicRes.201;4:297.doi:10.4172/2155- alone and in combination with dexamethasone 6148.1000297. in the prevention of post-operative nausea and 15. Wu SJ, iong , Cheng T, et al Efficacy vomitingindaycarelaparoscopicsurgeryunder of ondansetron vs. metoclopramide in general anesthesia. Asian J Pharm Clin Res. prophylaxis of post-operative nausea and 2012;5:165–67.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1615-1622 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.19

Study of Clonidine s Fentanyl Intrathecally ith Bupiacaine in Vaginalysterectomy:AComparatieStudy

aneshamanhandarkarPradnyaMilindBhaleraoaashekarS

1,Assistant Professor, Department of Anesthesia, SRTR Medical College, Ambajogai, Maharashtra 41517, India. 2Associate Professor,DepartmentofAnesthesia,.J.MedicalCollege(JMC),Pune,Maharashtra411001,India.

Abstract

upivacaine is the most common drug used in spinal anesthesia in vaginal hysterectomy which gives adeuateanesthesiafortheprocedure.Clonidineis2agonistusedtoprolongthedurationofintrathecally administeredlocalanestheticandhaspotentantinociceptiveproperties.Fentanylnotonlyimprovestheuality ofintra-operativeanalgesiabutalsoreducestheneedofsupplementalsedation.Inthepresentstudy,wetried tofindoutwhetherualityofofanesthesiaisbetterwithlowdosebupivacaineandclonidineorwithlowdose bupivacaineandfentanyl.Methods:Prospective,randomiseddouble-blind,controlledstudywasconductedin atertiarycareinstitution.80patientsASAGradeIandIIscheduledforvaginalhysterectomywererandomly allocatedintotwogroupsbyusingcomputergeneratedrandomnumbers.GroupC(n40)received0.5 yperbaricbupivacaine2.8ml(14mg)25mcgClonidineandGroupF(n40)received0.5hyperbaric bupivacaine2.8ml(14mg)0mcgFentanylintrathecally.Timeforonsetofsensoryandmotorblockade, timetoachievemaximumsensoryandmotorblockade,timeforsegmentregressionuptoL1,sideeffects,peri- operativeandpost-operativeanalgesicreuirementswereassessed.Results:Meandurationofonsettopeak sensoryblock(5.450.50min),onsettopeakmotorblock(7.050.22min)wassignificantlyhigheringroup CascomparedtogroupF(6.900.8min)and(8.670.47min)respectively.Significantdifferenceinmean durationofsensoryblockandmotorblock(189.806.49min,247.288.42min)ingroupCandgroupF (150.24.2,197.086.25min)werenoted.Durationofpost-operativeanalgesiawassignificantlyhigherin groupC(495.922.4min)ascomparedtogroupF(269.17.98min).Therewassignificantdifference betweenVASscoreingroupCandgroupFexcept4thhrand18thhr.Allpatientswerehemodynamically stableandnosignificantdifferenceinpost-operativesedationandadverseeffectswasobserved.Conclusion: Clonidineandfentanylaregoodadjuvantdrugsandtheiruseintrathecallyasanadditiveto bupivacaine extendsthedurationofspinalanesthesiasignificantly,loweringtheneedtoadministergeneralanesthesia ifdurationofsurgeryisprolonged.Furthertheyalsoprovidesexcellentpost-operativeanalgesia.Clonidine isbetteradjuvantwithbupivacaineinviewofbettersensoryandmotorblockade,prolongedpost-operative analgesia. eyords:Clonidine;Fentanyl;Analgesia;Vaginalhysterectomy.

otocitethisarticle: GaneshLaxmanhandarkar,PradnyaMilindhalerao,RajashekarSetalStudyofClonidinevsFentanylIntrathecallywith0.5 upivacaineinVaginalysterectomy:AComparativeStudy.IndianJAnesthAnalg.2019;6(5Part-1):1615-1622.

CorrespondingAuthor:PradnyaMilindBhalerao,AssociateProfessor,DepartmentofAnesthesia,.J.MedicalCollege(JMC), Pune,Maharashtra411001,India. Email:[email protected] eceiedon29.05.2019,Acceptedon11.07.2019

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Introduction and clonidine or with low dose bupivcaine andfentanyl. Pain, one of the most dramatic, complex and universal phenomenon is dened as unpleasant AimsandObjectives sensoryandemotionalexperienceassociatedwith actual or potential tissue damage or described Aimofourstudywastoevaluatetheeffectiveness in terms of such damage. Post-operative pain is of 0.5 bupivacaine with clonidine and 0.5 associatedwithvarioussystemicadverseresponses bupivacainewithfentanylforspinalaneshthesiain all contributing to increase post-operative morbidityandmortality.ence,aneffectivepain termsof reliefaftersurgeryisessentialforoptimalcareof Onsetanddurationofsensoryblockade; surgical patients. Effective post-operative pain is Onsetanddurationofmotorblockade; anessentialcomponentofthecareofthepatient. Inadeuatepaincontrol,apartfrombeinginhuman Durationofpost-operativesedation; mayresultinincreased morbidityandmortality.1 Durationofpost-operativeanalgesia; Good analgesia can reduce deleterious effects. Complications,ifany. Afferent neural blockade with local anesthetics is the most effective analgesic techniue. Next in orderofeffectivenessarehighdoseopioidtherapy MaterialsandMethods andNSAIDS. Regional anesthesia avoids the complications Studyesin of general anesthesia and also intubation while Afterobtaininginstitutionalandethicalcommittee providing adeuate analgesia and muscle approval,writteninformedconsentwastakenfrom relaxation in the operative area. It thus is a good allpatientspriortojoiningthestudy.Studywasa alternative to general anesthesia. It also provides prospective,randomiseddouble-blind,controlled, post-operative pain relief. Spinal anesthesia is a single centre study. 80 patients ASA grade I and simple techniue with rapid onset of action most ASAgradeIIscheduledforvaginal hysterectomy commonly used in vaginal hysterectomy.2 Most wererandomlyallocatedintotwogroupsbyusing commonLocalanestheticusedforspinalanesthesia computergeneratedrandomnumbers. isbupivacaine,butduetoshortdurationofaction early analgesic intervention in the post-operative periodisreuired.Anumberofadjuvantstolocal InclusionCriteria anestheticshavebeenusedintrathecallytoprolong ASA Grade I and II patients posted for vaginal the intra-operative and post-operative analgesia. hysterectomy, aged between 45 and 5 years, Theadditionoflowdosesoffentanylandclonidine normotensivepatients. to local anesthetics during spinal anesthesia decreasestheincidence of localanesthetic related sideeffects,reducesthetimeofonsetofthesensory clusionCriteria and motor blockade, and increases the uality of ASA Grade III and IV patients, patients with intraandpost-operativeanalgesiabyreducingthe signicant cardiovascular, renal, hepatic 4 dose of local anesthetics. Clonidine is a selective dysfunction, having contraindication for spinal partial agonist for 2-adrenoreceptor, with ratio anesthesiaandmorbidlyobesepatients. 5 of approximately 200:1 ( 2: 1), it has potent anti- nociceptiveproperties6 andincreasestheduration of analgesia. Fentanyl is a synthetic opioid lindin and receptor agonist, about 100 times more Thedrugsolutiontobeusedforspinalanesthesia potent than morphine as an analgesic.7 It is most was preparedbyanother anesthetist according to commonly administered intravenously, although therandomizationchart.Therandomizationcode it is also commonly administered epidurally and was sealed in an envelope. The code number of intrathecally for acute post-operative and chronic eachindividualwasalsosealedintheenvelope. pain management. Fentanyl not only improves the uality of intra-operative analgesia but also Samlesie reducestheneedofsupplementalsedation.8Inthe presentstudy,wetriedtondoutwhetheruality Samplesizeiscalculatedbyusingthepilotstudyof of anesthesiais betterwith low dose bupivacaine 25patientswithparameterdurationofmotorblock IJAA/Volume6Number5(Part-I)/Sep-Oct2019 StudyofClonidinevsFentanylIntrathecallywith0.5 1617 upivacaineinVaginalysterectomy:AComparativeStudy inminutes.GroupCMeanSDis184 byusingromagescore: minandGroupFMeanSDis174158miny usingformula: romage0 Patientisabletomovehip,kneeandankle romage1 Patientunabletomovehipbutabletomove SD combined kneeandankle d romage2 Patientunabletomovehipandkneebutableto moveankle 1.96,1-0.84; romage Patientunabletomovehip,kneeandankle CombinedSD8.9; Afterintrathecaldruginjection,intra-operatively Differenceofmeans(d)24.; datawasrecordedduring1st2hoursat515045 Minimumreuiredsamplesize(n)9.140per 00120minutes.Duringsurgery,patientdidnot group.roupBCn:Patientsreceived0.5 receiveanysedation. yperbaric bupivacaine 28 ml (14 mg) 25 mcg Clonidine; roup BF n : Patients received ostoerativemonitorin 0.5 hyperbaric bupivacaine 28 ml (14 mg) 0mcgFentanyl. Assesment of post-operative sedation done by usingRamsaysedationscale.

Studylan Score eelofsedation 1 Anxiousoragitatedorrestlessorboth Pre-anestheticevaluationwascarriedoutindetail 2 Co-opreative,orientedandtranuil which included general examination, systemic Respondingtocommandsonly examination, airway assessment, spine and neck 4 riskresponsetolightglabellartap examination.Allbaselineinvestigationsweredone including hemoglobin, platelet count, bleeding 5 Sluggishresponsetolightglabellartap time,clottingtime,bloodsugarlevel,liverfunction 6 Noresponsetolightglabellartap tests, renal functions tests, serum electrolytes, Assesmentof post-operative analgesia done by ECGandchest-rayPAview.GroupC(n40) using Visual Analogue Scale between 0 and 10. received 0.5 yperbaric upivacaine 28 ml (14 0-Nopain:10-mostseverepainPost-opearatively mg) 25 mcg Clonidine and group F (n 40) data was recorded for rst 4 hour every hourly, received 0.5 yperbaric upivacaine 28 ml (14 for next 8 hours every 2 hourly, for next 12 hours mg)0mcgFentanylintrathecally.Pre-operatively everyhourlyintervalupto 24hours.Durationof pulserate,bloodpressure,oxygensaturationwere Anesthesia was measured as time interval from noted.Aftershiftingthepatientonoperatingtable intrathecalinjectiontoregressionofsensoryblock monitors like ECG, NIP, pulse oxymeter were belowL1. attached.Intravenouscanulaof18Gwassecured andpre-loadingdonewith10mlgofRingerlactate onitorinandtreatmentofsideeffects solutionandpre-medicatedwithinj.Ondensetron 008mggI.V.andinj.Ranitidine1mggI.V.before Intra-operativeandpost-operativesideeffectssuch givingspinalanesthesia.Paintinganddrapingdone as nausea, vomiting, hypotension, bradycardia, insittingpositionunderallasepticconditions.After shivering and sedation were noted till complete palpating L-L4 space subarachanoid block was recovery.ypotensionwasdenedasadecreasein giveninGroupCpatientswith0.5yperbaric systolicbloodpressuremorethan0ofbaseline upivacaine 28 ml (14 mg) 25 mcg Clonidine value. ypotension was treated with oxygen and in Group F patients with 0.5 yperbaric supplementation, I.V. uids or Mephenterine. upivacaine28ml(14mg)0mcgFentanylwith radycardia (Pulse rate 60) treated with inj. 25 G spinal needle. Supine position was given Atropine. Inj Ondensetron 008 mgg used for immediately.Allpatientsweregivensupplemental nauseaandvomiting.Inj.Naloxonewaskeptready oxygenbyventimask@4–6lit/min. forrespiratorydepression.

Intraoerativemonitorin Statisticalanalysis

Intra-opratively pulse rate, blood pressure, O2 Statistical evaluation was done by using 2 saturation,ECGwasmonitored,Sensoryblockwas independent sample t-test and Mann-Whitney assessedbya pinpricktestperformedwith22G -test. The detailed data was entered into well shortboreneedle.Motorblockwasassessedusing tabulated Microsoft Excel sheet and subseuently

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1618 IndianJournalofAnesthesiaandAnalgesia analyzedstatistically.Graphicaldisplaywasdone y using 2independentsample t-testp - value forvisualinspection, pvalueless than 0.05was 0.05 therefore, there is signicant difference consideredtobesignicant. betweenmeanonsetofsensoryblockandonsetof motorblockinGroupCandGroupF. esults Table:Meandurationofsensoryandmotorblock

Therewasnostatisticaldifferenceamonggroupsas roupBC roupBF farasage,weight,height,anddurationofsurgery n n palue concerned.Meandurationofonsettopeaksensory Mean SD Mean SD block(545050min),onsettopeakmotorblock Durationof 189.80 6.49 150.2 4.2 0.001 (705022min)wassignicantlyhigherinGroup sensoryblock CascomparedtoGroupF(008min)and Durationof 247.28 8.42 197.08 6.25 0.001 (87047min)respectively.Signicantdifference motorblock inmeandurationofsensoryblockandmotorblock Significant (18804min,24728842min)inGroupC y using 2independentsample t-testp - value and Group F (1502 42 1708 25 min) 0.05 therefore, there is signicant difference were noted. Duration of post-operative analgesia betweenmeandurationofsensoryblockandmotor wassignicantlyhigheringroupC(45224 blockinGroupCandGroupF. min)ascomparedtogroupF(2178min). TherewassignicantdifferencebetweenVASscore ingroupCandgroupFexcept4thhrand18thhr. Table:Meandurationofanalgesia Allpatientswerehemodynamicallystableandno Durationof Numberof signicant difference in post-operative sedation roup Analgesiamin palue patients andadverseeffectswasobserved,(Tablesare Mean SD showedFigsaredisplayed). GroupC 40 495.9 22.4 0.001 GroupF 40 269. 17.98 Table : Onset to peak sensory and complete motor block duration Significant roupBC roupBF y using 2independentsample t-testp-value n n palue 0.05 therefore, there is signicant difference Mean SD Mean SD betweenmeandurationofanalgesia(min)inGroup Onsettopeak 5.45 0.50 6.90 0.8 0.001 CandGroupF. sensoryblock Onsettomotor 7.05 0.22 8.68 0.47 0.001 block(GradeIV) Significant

Fig:Onsettopeaksensoryandcompletemotorblockduration

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 StudyofClonidinevsFentanylIntrathecallywith0.5 1619 upivacaineinVaginalysterectomy:AComparativeStudy

Fig:Meandurationofsensoryandmotorblock

Fig:Meandurationofanalgesia

Table:Meanvisualanaloguescale

VAS VASat roupBC roupBF alue Min Ma Median Min Ma Median 1hr 0 0 0 0 2 0 0.04 2hr 0 0 0 1 5 2 0.001 hr 0 0 0 0 6 5 0.001 4hr 0 0 0 0 5 0 0.079 hr 1 5 2 0 1 0.001 8hr 0 6 5 2 6 0.001 10hr 1 2 1 0 6 5 0.001 12hr 2 5 2 0 4 0 0.001 18hr 2 6 5 5 6 5 0.876 24hr 2 6 2 2 5 0.001 Significant

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yusingMann-Whitney-testp-value0.05 resultswherethedurationofanalgesiainclonidine therefore there is signicant difference between (0mcg)Groupwas451484min. th VASscoreinGroupCandGroupFexcept4 hr Inourstudy,weobservedthatthetimetoreach th and18 hr. peaksensorylevelwas008min,durationof sensoryblockwas150242minandtheduration Discussion post-operativeanalgesiawas2178minin GroupF.Ourndingsweresimilartothestudy conducted by Dhumal PR14 et al where the time Local anesthetics are commonest agents used for to reach peak sensory level was 50 145 min, spinalanesthesia,butduetotheirrelativelyshort durationofsensoryblockwas121114minand duration of action, post-operative period needs thedurationofpost-operativeanalgesiawas225 the early analgesic intervention.9 Clonidine is 22mininpatientsreceivingfentanyl(25mcg)with selective partial agonist for adrenoreceptors.10 2 bupivacaine.AnotherstudyconductedbyGauchan The analgesic effect following its intrathecal S15etalhasalsorevealedthecomparableresultfor administration is mediated spinally through peaksensorylevelwherethetimetoachievepeak activationofpostsynaptic receptorsinsubstantia 2 sensorylevelwas25minwith20mcgfentanyl. gelatinosaofspinalcord.Itworksbyblockingthe conduction of C and A bers.11 It also increases The time to reach peak sensory level was 545 potassium conductance in isolated neurons in 050 min and the duration of motor block was vitro and intensies conduction block of local 1707 24 min in Group F. Our results were anesthetics. Fentanyl is a potent synthetic opioid comparablewiththestudyconductedbySanchan 16 analgesic with rapid onset of action.12 It binds to P etalinwhichtheyfoundthatthetimetoreach -opioidG-proteincoupledreceptor,whichinhibit peaksensoryblockadewas4402minandthe painneurotransmitterreleasebydecreasingintra- durationofmotorblockwas185011minwith cellularcalciumlevels. 75mcgofclonidine. Additionoffentanylorclonidinetobupivacaine esides,thedurationofsensoryblockwas1880 may help in increasing the duration of sensory 4minandtimeforrstanalgesicreuestwas 12 andmotorblockade,post-operativeanalgesiaand 45224mininGroupC.hezriM etal decreasethedoseoflocalanesthetic.Inthispresent found similar results where the mean duration of study there was no statistical difference among sensoryblockwas125minandtimeforrst groups in age, height, weight and duration of rescueanalgesicwas5144825mininpatients surgery. receivingclonidine(75mcg)withbupivacaine. In our study, we observed the signicant In our study, the mean duration of motor difference between mean Systolic lood Pressure block was 24728 842 min and the duration of (SP)inGroupCandGroupFat15minto45min. post-operativeanalgesiawas45224minin 17 (p0.05)andsignicantdifferencebetweenmean Group C. Singh R et al found that the mean Diastolic lood Pressure (DP) in Group C and durationofmotorblockwas2808088minand GroupFat15min,0minandat0min(p0.05). thedurationofpost-operativeanalgesiawas510 Ourresultswerecomparablewithstudyconducted 14mininpatientsreceivingclonidine(50mcg) byAgarwalDetal1forSP.Thereisnosignicant withbupivacaine. difference between mean pulse rate in Group C Thedurationofsensoryblockwas1884min andGroupFatpre-operativeto120min,(p0.05). and 150.22 4.22 minand the duration of motor blockwas24727842min170724mininC Wefoundthatthedurationofsensoryblockade andFGrouprespectively.Numberofdiclofenac was 1880 4 min and the duration of motor injectionsusedinCGroupwas2(median2) blockadewas24728842mininpatientreceiving anditwas4(median)inFGroup.Chopra clonidinewithbupivacaine.SethiS11etalhasalso P5 et al found the comparable results where the shownthecomparableresultsinwhichtheduration durationofsensoryblockwas177848minandit ofsensoryblockadewas218min(150–240min)and was1422147mininpatientsreceivingclonidine duration of motorblockadewas 205(0–00min) (0 mcg) and fentanyl (15 mcg) respectively. The in patient receiving clonidine (1 mcgg) with duration of motor block in clonidine Group was bupivacaine. 20 4 min and it was 12 158 min in Similarly the duration of analgesia was 45 fentanyl Group. Number of diclofenac injections 224 min in patients receiving clonidine with usedinclonidineGroupwas1.16(12)anditwas bupivacaine. Shah 4 et al found the similar 2.66G(2)infentanylgroup. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 StudyofClonidinevsFentanylIntrathecallywith0.5 1621 upivacaineinVaginalysterectomy:AComparativeStudy

We found that the mean time to reach peak inpatientsundergoinginguinalherniorrhaphy:A sensorylevelwas545050mininGroupCand randomizeddouble-blindedstudy.JAnesthesiol itwas 705022 mininGroup F. hattacharjee ClinPharmacol.201;29(1):66–70. A7 et al. found that the mean time to reach peak 4. Shah,JoshiSS,ShidhayeRV,etalComparison sensory level in clonidine (75 mcg) Group was ofdifferentdosesofclonidineasanadjuvantto 2521minanditwas42minfentanyl intrathecalbupivacaineforspinalanesthesiaand (25mcg)group. post-operative analgesia in patients undergoing cesareansection.Anesthpainandintensivecare. esides, the time to reach peak sensory level 2012;16():266–272. was 02 08 min,timeofregressionofmotor 5. ChopraP,TalwarV.Lowdoseintrathecalclonidine block to romage scale 0 was 1707 24 min and fentanyl added to hyperbaric bupivacaine and mean duration of analgesia was 22 prolongs analgesia in gynecological surgery. J 178mininGroupF. acha 18etalhas also AnesthesiolclinPharmacol.2014;0:2–7. shownthesimilarresultsinwhichthetimetoreach 6. limschaW,ChiariA,rafftP,etalemodynamic peaksensorylevelwas74075minandtimeof andanalgesiceffectsofclonidineblocks.Anesth regressionofmotorblocktoromagescale0was Analg1995;80:22–27. 1881 22 min and mean duration of analgesia 7. hattacharjee A, Singh NR, Singh SS, et al A was 251 2128 min with 25 ml bupivacaine comparative study of intrathecal clonidine 25mcgoffentanyl. and fentanyl along with bupivacaine in spinal anesthesia for cesarean section. J Med Soc. InOurstudy,themeandurationofsensoryblock 2015;29:145–149. was1884minandmeansedationscorewas2 inGroupC.Weobservedhypotensionin1patient 8. enhamou D, Thorin D, richant JF, et al Intrathecalclonidineandfentanylwithhyperbaric and bradycardia in 2 patients. aj 9 et al found bupivacaineimprovesanalgesiaduringcesarean similarresultswherethemeandurationofsensory section.AnesthAnalg.1998;87:609–1. blockwas12501minandmeansedationscore 9. aj,SinghS,NagPS,etalIntrathecalclonidine byusingRamsaysedationscorewas200414min as an adujuvant to hyperbaric bupivacaine in with25mcgofclonidine.Theyalsonotedhypotension patients undergoing surgeries under spinal in2patientsandbradycardiainpatients. anesthesia: A randomized double blinded study. Journal of Dental and Medical Sciences. Conclusion 2015;14:69–7. 10. SinghR,GuptaD,JainA.Theeffectofaddition ofintrathecalclonidinetohyperbaricbupivacaine Toconclude,0mcgclonidineand25mcgfentanyl on post-operative pain after lower segment isanattractivealternativeasanadjuvanttospinal cesarean section: A randomized control trial. bupivacaine in surgical procedures of prolonged SaudiJAnesthe.201;7:28–290. duration with minimal side effects and excellent 11. Sethi S, Samuel , Sreevastava D. Efficacy of uality of spinal analgesia. Clonidine when analgesiceffectsoflowdoseintrathecalclonidine comparedwithFentanyl,offersabettereffectowing as adjuvant to bupivacaine. Indian J Anesthe. toearlieronsetandprolongeddurationofsensory 2007;51:415–19. andmotorblockadeaswellaslongerdurationof 12. hezri M, Rezaei M, Reihany MD, et al post-operativeanalges. Comparison of post-operative analgesic effect of intrathecal clonidine and fentanyl added to bupivacaine in patients undergoing cesarean eferences section: A randomizeddouble-blindstudy.Pain ResTreat.2014:51–628. 1. atzJ,JacksonM,avanaghP,etalAcutepain 1. AgrawalD,ChopraM,MohtaM,etalClonidine after thoracic surgery predicts long-term post- as an adjuvant to hyperbaric bupivacaine for thoracotomypain.ClinJPain.1996;12:50–55. spinalanesthesia inelderlypatients undergoing 2. NayagamA,SinghNRatan,SinghShanti.A lowerlimborthopedicsurgeries.SaudiJAnesth. prospective randomized double blind study of 2014;8:209–14. intrathecalfentanylanddexmedetomedineadded 14. DhumalPR,olheEP,GunjalV,etalSynergistic to low dose bupivacaine for spinal anesthesia effects of intrathecal fentanyl and bupivacaine for lower abdominal surgeries. IndianJ Anesth. combination for cesarean section. Int J Pharm 2014;58(4):40–45. iomedRes.201;4(1):50–56. . Thakur A, hardwaj M, ooda S. Intrathecal 15. Gauchan S, Thapa C, Prasai A, et al Effects clonidineasanadjuvanttohyperbaricbupivacaine of intrathecal fentanyl as an adjuvant to

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hyperbaric bupivacaine in spinal anesthesia 17. Singh R, Chopra N, Choubey S, et al Role of for elective cesarean section. Nepal Med Coll J. clonidine as adjuvant to intrathecal bupivacaine 201;15():156–59. inpatientsundergoinglowerabdominalsurgery: 16. Sanchan P, umar N, Sharma JP. Intrathecal Arandomizedcontrolstudy.2014;8:07–12. clonidine with hyperbaric bupivacaine 18. acha,ashir,RatherAJ,etalAcomparative administered as a mixture and seuentially in studybetweenlowdosebupivacaine-fentanyland cesareansection:Arandomizedcontrolledstudy. bupivacaine-clonidinewithplainbupivacainein IndianJAnesth.2014;58:287–92. spinalanesthesiainorthopedicpatients.rJMed ealthRes.2015;2(9).

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):162-1626 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.20

oleofPerfusionIndeasaToolforAcutePostoperatiePainAssessment: AnObserationalStudy

SaneeumarMumtaussainayPrakashPremPrakashaghendra

1,5Professor,2AssociateProfessor,Dept.ofAnesthesiologyandCriticalCare,4AssociateProfessor,Dept.ofGeneralSurgery,Indira GandhiInstituteofMedicalSciences,Patna,ihar800014,India. AssistantProfessor,Dept.ofAnesthesiologyandCriticalCare, VydehiInstituteofMedicalSciencesAndResearchCentre,engaluru,arnataka560066,India.

Abstract

acground:Apainfulstimuluscanproducevasoconstrictionandadecreaseinperfusionindex(PI).The visualanalogscale(VAS)isthemostcommonpainassessmentscale.owever,itisaffectedbypsychometric instability. This study was designed to evaluate the correlation between VAS as a subjective indicator of pain and PI as an objective indicator of pain. Materials and Methods: At the post-anesthesia care unit, the perfusion index was checked to 50 adult patients of ASA-I who underwent laparoscopic surgery. At the time ofthefirstreuestforanalgesia (T1) VASwasrecordedtogetherwiththe PI, heartrate (R),Mean ArterialloodPressure(MAP),peripheraloxygensaturationandfollowingwhichanalgesiawasgiven.Thirty minutesthereafter,(T2)secondmeasurementsforthementionedparametersweretaken.Results:ThePIwas significantlyhigheratT2thanatT1(meanincrease90vs81.4).Thisincreasewasassociatedwitha statisticallysignificantdecreaseinVAS,R,andMAP.ThismeansthatthePIincreaseswithadeuaterelief from pain,as indicatedbya decreasein VAS,R,and MAP.A decrease in VASwas associatedwithan increaseinPI,butthecorrelationwasnotstatisticallysignificantasthedegreeoftheincreaseinPIinrelation tothedecreaseinVASwasvariableamongpatients.Conclusion:PIcanbeaddedtootherindicatorsofpain assessmentinthepost-anesthesiacareunit. eyords:Pain;Perfusionindex;Post-anesthesiacareunit;Visualanalogpainscore.

otocitethisarticle: Sanjeevumar,Mumtazussain,JayPrakashetalRoleofPerfusionIndexasaToolforAcutePost-operativePainAssessment:An ObservationalStudy.IndianJAnesthAnalg.2019;6(5Part-1):162-1626.

Introduction (decreased bowel movement, nausea, vomiting) andtheendocrinalsystem(increasedcatecholamine secretion). It also promotes thromboembolism by n-relieved post-operative pain can result in 1 serioussideeffectsthataffecttherespiratorysystem delayingmobilization. (atelectasis,retentionofsecretions,pneumonia),the The International Association for the Study of cardiovascularsystem(hypertension,arrhythmias, Pain(IASP)denespainasAnunpleasantsensory coronary ischemia), the gastrointestinal system andemotionalexperienceassociatedwithactualor

CorrespondingAuthor:Saneeumar,Professor,Dept.ofAnesthesiologyandCriticalCare,IndiraGandhiInstituteofMedical Sciences,Patna,ihar800014,India. Email:sanjeev[email protected] eceiedon01.06.2019,Acceptedon11.07.2019

RedFlowerPublicationPvt.Ltd. 1624 IndianJournalofAnesthesiaandAnalgesia potential tissue damage, or described in terms of Asfarasweknow,nostudyhasinvestigatedthe suchdamage.2Effectivepainmanagementreuires correlationbetweenVASasasubjectiveindicator carefulassessmentandcontinuousreviewofpain. of pain and PI as an objective indicator of pain. The objectives of pain assessment are to measure This correlation can be of great help in analgesic theseverityofpain,selecttheappropriateanalgesic, guidanceinPost-anesthesiaCarenit(PAC)and and estimate the response to treatment. Pain is a unconsciouspatientsinICs. subjectivesymptomastheindividualcandescribe hisownfeelings.Thus,emotionalandpsychological Aimofor factors may interfere with the assessment of the physicalcomponentofpain.Self-reportpainscales The aim of the study was to correlate pulse havebeenthemostcommonpainassessmenttools co-oximetry PI with VAS and evaluate the overtheyears.Thevisualanaloguescale(VAS)is possibility of its useas an objective toolforpost- the most common pain assessment scale.–5 oth operativepainassessment. VASandnumericratingscalehavebeenprovento besuperiortoafour-pointverbalcategoricalrating MaterialsandMethods scale.6owever,theirvaliditycannotbeestablished ineveryenvironmentbecauseofthedifferencein psychometricstability.7 Aprospective,observationalstudywasperformed in Indira Gandhi Institute of Medical sciences, The pulse oximetry system can measure the Patna after obtaining the approval of the Ethical perfusion index (PI) at the monitored site by Committee and informed written consent from calculatingtherelationbetweenpulsatileandstatic patientsundergoingelectiveLaparoscopicsurgery. blood in peripheral tissues. The PI is an indirect, non-invasive,andcontinuousmeasureofperipheral perfusion.It ranges from 0.02(veryweakpulse InclusionCriteria strength) to 20 (very strong pulse strength). It Patients of ASA-I, aged 18–50 years, who were can also measure PI in conjunction with oxygen consciousenoughtoco-operateandwhosemental saturationandpulseratebysimpleapplicationof statuswasnormalintheimmediatepost-operative thepulseOximeterprobetothenger.yknowing, periodwereenrolledinthestudy. the highest recorded PI, the best monitoring site forpulseoximetrycanbeidentied.Thechanges insympatheticnervoustoneaffectsmoothmuscle clusionCriteria toneandcanalterthelevelofperfusion. Patients with pre-existing cardiovascular, Temperature, volume, and anesthetics can pulmonary or metabolic diseases or history of a affect the perfusion at the extremities by causing neurological,psychiatricorchronicpaindisorder, vasoconstrictionandvasodilatation,whichcancause whoweretakingpsychotropicdrugs,patientswith a decrease in PI or an increase in PI, respectively. allergyto any drugusedinthestudy,thosewith ThemeasurementofPIisnotaffectedbyeartRate unstable hemodynamic status, and unconscious 8,9 wereexcluded. (R)variability,SpO2,oroxygenconsumption. Most anesthetics produce a vasodilator effect Pre-operatively,patientsweretrainedonhowto while pain induces vasoconstriction. A study expresstheirpainlevelusingVAStoincreasetheir had investigated whether a painful stimulus familiaritywiththescale.VASisasubjectivetool can produce vasoconstriction and a decrease in thatdependsonthepatientsself-expression.The PI in normothermic anesthetized patients.8 The scale consists of a 10 cm horizontal line. Patients researchers found that the PI decreased during canmakeamarkonthelineaccordingtotheirpain painful stimuli in anesthetized volunteers at intensitythatcanrangefrom0to10. different concentrations of sevourane. They Thepatientswerepremedicatedwithintravenous hypothesizedthatanincreasedPIafteranesthetic (I.V.)1mgmidazolam,40mgpantoprazole,75g administration can be an early indicator of palonosetron and 8 mg dexamethasone. In the successful anesthesia, whereas absence of this operating room, standard monitors were applied increase may be an early warning of anesthetic likeECG,pulseoximeterandnon-invasivearterial failure.ence,itcouldbeavaluabletoolforpain blood pressure monitor. Pre-oxygenation was assessmentunderanesthesia. carriedoutforminbymeansofafacemaskwith Laparoscopic surgery is associated with severe 100 oxygen. Anesthesia was induced by I.V. acutepost-operativepainunlessitiswellmanaged. fentanyl2gg,propofol25mggandatracurium

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 RoleofPerfusionIndexasaToolforAcutePost-operativePainAssessment:AnObservationalStudy 1625

05 mgg. After endotracheal intubation, parameters were taken simultaneously like VAS capnography and a temperature nasopharyngeal forpainintensity,PI,R,MAP,peripheraloxygen probe were applied. The lungs were ventilated saturation,andaxillarytemperature. withatidalvolumeof–8mlgandtheventilatory rate was adjusted to maintain EtCO between 5 2 Statisticalanalysis and 40 mm g. Maintenance was done with 1.5 MAC isourane and top-up doses of atracurium. Datawerestatisticallydescribedintermsofmean Analgesia was maintained with I.V. fentanyl at SD.Comparisonofthetimepointvalueswasdone 05 ggh. The intra-operative Mean Arterial usingthepairedt-test.valueslessthan0.05were lood Pressure (MAP) was kept around 0 mm considered statistically signicant. All statistical g. Patients who reuired I.V. nitroglycerine or calculations were performed using the computer ephedrine were excluded from the study. Warm program SPSS (Statistical Package for the Social I.V.Ringersacetatesolutionwasinfusedtoreplace Science; SPSS Inc., Chicago, Illinois, SA) release uid decit and basal uid reuirements. The 15forMicrosoftWindows(2006). patient was kept warm by maintaining the room temperature at 25C. At the end of the operation oeranalysis themusclerelaxantwasreversedandallpatients tracheawereextubatedandsenttothePAC. Power analysis was carried out by comparing all variablesbetweenthetwostudytimepoints.The paired t-test was chosen to perform the analysis. Attheostanesthesiacareunit -Error level was xed at 0.05 and the sample The following monitors were attached to the size at 50 participants. The statistical power of patient:ECG,non-invasivearterialbloodpressure ourcomparisonsisshowninthe(Tablebelow. monitorandngertipPulseOximeter(Romsonss CalculationswereperformedusingPSPowerand OxeeCheck).TheOximeterprobeusedtomonitor SampleSizeCalculationsSoftware,version.0.11, thePIwasattachedtothemiddlengertipofthe forMSWindows(WilliamD.DupontandWalton hand contralateral to the site of blood pressure D.Vanderbilt,SA). monitoringandwaswrappedinatoweltodecrease heat loss and interference by ambient light. An esults oxygenmaskwasappliedifSpO2wasbelow90. Thepatientswerekeptwarmwithwoolblankets, warmI.V.uids,andawarmair-forceddevice. The study initially comprised 62 patients who underwentlaparoscopicsurgery.Allpatientswho mettheinclusioncriteriawereenrolledinthestudy. Observation Twelve patients were excluded as they reuired All patients were observed until they asked for I.V. nitroglycerine or ephedrine intra-operatively. analgesia like at the time of the rst reuest for Finally, 50 patients completed the study. The analgesia(T1)VASforpainintensitywasrecorded, demographiccharacteristicsofthepatientswereas together with the PI. Simultaneously, R, MAP follows: Sex, 24 womenand 26 men; age, 424 2 andperipheraloxygensaturationwerealsonoted. 125years;andMI,247427gm .Therewas For all patients analgesia was achieved with I.V. a statistically signicant increasein PIat T2 than morphineat005mggandI.V.1gparacetamolvial. atT1.Themeanincreaseeualled90.081.4 (Table). Thirty minutes after post-operative analgesia (T2),secondmeasurementsoftheabove-mentioned

Table:Theperfusionindex,visualanalogscale,meanarterialpressure,andheartrateatT1andT2,their differencebetweenT2andT1.

VisualAnalogue PerfusionIndePI MAPmm beatsmin ScaleVAS T1(atfirstreuestofanalgesia) 1.081.04 6.751.4 84.5811.24 81.681.76 T2(0minafteranalgesia) 1.761.71 1.861.24 81.4810.14 78.4912.64 DifferencebetweenT2andT1 0.810.94 -4.61.44 -.4.64 -11.085.94 ValueswerepresentedbymeanSD,umberofpatients. ihlySinificancep0.001

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1626 IndianJournalofAnesthesiaandAnalgesia

Discussion Conclusion

Pain is a subjective and personal experience Perfusionindexcanbeaddedtootherindicatorsof that makes objective measurements impossible.6 painassessmentinPAC.Itiseasy,noninvasive, owever,theincreaseinsympatheticnervoustone free of subjective interpretation and low time caused by pain can affect the PI, which can be a consuming. guideforthegivenanalgesicsinPAC.Thistool Source(s)ofsuortNil for pain assessment can eliminate the variations inpersonality, age,sex,andculturalbackground. resentationatameetinNil Itcanalsoeliminatepsychologicalfactorssuchas ConictinInterest:Nil fear,anxiety,depression,andanger. AcnoledementNil Inthisstudy, thePIwassignicantlyhigherat T2 than at T1 (mean increase 94. 82.7). This increase was associated with a statistically eferences signicant decrease in VAS, R, and MAP. The meandecreasewas70.519.88,11.17.2,and 1. VadiveluN,MitraS,NarayanD.Recentadvances .965.01inVAS,R,andMAP,respectively. in post-operative pain management. ale J iol This means that the PI increases with adeuate Med.2010;8:11–25. relieffrompainasindicatedbyadecreaseinVAS, 2. lufer Sivrikaya G. Multimodal analgesia for R,andMAP.AdecreaseinVASwasassociated post-operative pain management. Rac Gabor, withanincreaseinPIbutthecorrelationwasnot editor. Pain management: Current issues and statisticallysignicantasthedegreeoftheincrease opinions,2012.pp.178–210. inPIinrelationtothedecreaseinVASwasvariable . GouldDJ,ellyD,GoldstoneL,etalExamining amongpatients. the validity of pressure ulcer risk assessment Thisstudywassimilartoastudyconductedby scales: Developing and using illustrated patient agaretalinwhichanelectricalcurrentwasapplied simulations to collect the data. J Clin Nurs. to the anterior thigh in two healthy volunteers 2002;10:697–706. anesthetized with propofol and maintained with 4. odian CA, Freedman G, ossain S, et al The sevourane at different concentrations (1, 1.5, 2, visualanalogscaleforpain:Clinicalsignificance 2.5).8Thispainfulstimulusproducedasignicant in post-operative patients. Anesthesiology. increaseinRandMAPwithasignicantdecrease 2001;95:156–61. inPI.TheyconcludedthatthePImaybeofclinical 5. LiL,Liu,err.Post-operativepainintensity valueinassessingpainintheanesthetizedstate. assessment: A comparison of four scales in Chineseadults.PainMedicine.2007;8:22–4. A new-generation nger tip pulse oximeter (Romsonss Oxee Check) is easily available and 6. reivik , orchgrevink PC, Allen SM, et al Assessmentofpain.rJAnesth.2008;101:17–24. the easiest of all peripheral perfusion assessment modalities.Itenablesphysicianstoobtainreliable 7. irdJ.Selectionofpainmeasurementtools.Nurs measurements even under difcult clinical Stand.200;18:–9. conditions: Patients movements, hypotension, 8. agar , Church S, Mandadi G, et al The hypothermia, or electromagnetic eld of other perfusionindexasmeasuredbyapulseoximeter devicesbecauseofthepresenceofreferencesignal indicatespainstimuliinanesthetizedvolunteers. calculations,theadaptivelter,andtransformation Anesthesiology.2004;101:A514. ofasinglesaturationsignal. 9. ager, Reddy D, urz A.Perfusion index: A valuable tool to assess changes in peripheral Pain can alter the endocrine system leading perfusioncausedbysevoflurane.Anesthesiology. to increased catecholamine secretion causing 200;99:A59. vasoconstriction.1ItwasreectedasdecreasedPI 10. emura A, agihara M, Miyabe M. Pulse withhighVAS,butafterreceivinganalgesiathePI oxymeter perfusion index as a predictor for the increasedsignicantly. effectofpediatricepiduralblock.Anesthesiology. PI was used before for prediction of the onset 2006;105:A154. of successful regional sympathetic blocks, by 11. akazu C, Chen J, wan WF. Masimo set measuringPIbeforeandafterblock,liketheonset technology using perfusion index is a sensitive of the epidural anesthesia, which was associated indicator for epidural onset. Anesthesiology. withanincreaseinPI10–11 2005;10:A576.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1627-164 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.21

Comparison beteen opiacaine and opiacaine Plus Tramodol in WoundInfiltrationasanAnalgesicafterOpenCholecystectomySurgeries forPostoperatieAnalgesia

SaurinBPanchalVatsalCPatelTarakModi

1AssistantProfessor,ResidentDoctor,DepartmentofAnesthesia,SmtSCLospital,NLMedicalCollege,Ahmedabad,Gujarat 80006,India. 2AssistantProfessor,DepartmentofAnesthesia,VSospital,NLMedicalCollege,Ahmedabad,Gujarat80006, India.

Abstract

Post-operative pain is common after abdominal surgery and is a major cause of patient dissatisfaction inpost-operativeperiod.Variousdrugslikeopioids,nonsteroidalanti-inflammatorydrugs,dexamethasone hasbeenusedtocontrolpost-operativepainbutefficacyisvariable.Woundinfiltrationisbeingusednow- a-daysto provide analgesiain immediate post-operativeperiod. Ropivacaine,a newerlongeractinglocal anesthetic,isusedduetoitslesssideeffects.Tramadolcanbeusedtoasanadjuvanttoropivacaineinwound infiltration.Atotalof75patients,postedforopencholecystectomy,wererandomlydividedintothreegroups. GroupC–inj.normalsaline22ml,GroupR-0.75ropivacaine20mlinj.normalsaline2ml.GroupRT- 0.75ropivacaine20mlinj.tramadol2mggin2ml.Atotalvolumeof22mlwasinfiltrated.Localwound infiltrationwasdoneattimeofclosureaccordingtostudygroups.VASscoreinpost-operativeperiod,timefor firstrescueanalgesic,numberofrescuedosesinfirst24hrs,PONVandpatientsatisfactionwerenoted.There washigherVASscoreandearlyreuirementofrescuedoseincontrolgroupcomparedtogroupRandRT (p0.001).TherewasalsolongerdurationofanalgesiaingroupRTcomparedtogroupR(p0.05).Incidences of PONV were comparable in all three groups. Ropivacaine and ropivacaine-tramodol were effective in woundinfiltrationforpost-operativeanalgesiabutlaterwaspreferredduetolongerdurationofactionand betterpatientsatisfactionwithoutincreasedincidenceofPONV. eyords:Infiltration;Ropivacaine;Tramadol.

otocitethisarticle: SaurinPanchal,VatsalCPatel,TarakModietalComparisonbetweenRopivacaineandRopivacainePlusTramodolinWound InfiltrationasanAnalgesicafterOpenCholecystectomySurgeriesforPost-operativeAnalgesia.IndianJAnesthAnalg.2019;6(5Part-1): 1627-164.

Introduction Post-operative analgesia is important part of optimal peri-operative management. Currently Post-operativepainisinevitableaftermajorupper various methods are available for post-operative abdominal surgeries like open cholecystectomy. pain control like epidural analgesia, intravenous Post-operative pain may cause stress response to analgesiaandpatientcontrolledanalgesiapump.4 body and respiratory or cardiac complications.1– Opioids are mainstay of post-operative pain So, post-operative pain should be controlled as controlbutareassociatedwithsomeadverseside earlyaspossible. effectslikerespiratorydepression,sedation,nausea

CorrespondingAuthor:SaurinBPanchal,AssistantProfessor,DepartmentofAnesthesia,SmtSCLospital,NLMedicalCollege, Ahmedabad,Gujarat,India. Email:[email protected] eceiedon11.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1628 IndianJournalofAnesthesiaandAnalgesia and vomiting.5–7 Nonsteroidal anti-inammatory clusionCriteria drugsarelesseffectiveassoleanalgesicafterupper Patientrefusal abdominalsurgeries.Localanestheticmethodsare more useful than intravenous analgesia with less Allergytolocalanestheticdrugs 8 sideeffectsirrespectiveofsurgicalprocedure. Liverdysfunction Now-a-days, wound inltration with local Renaldysfunction anestheticdrugsiswidelyusedinvarioussurgeries istoryoftreatmentonpainmedicationsor asapartofoptimalpost-operativepaincontrol.9,10 opioidsuse Woundinltrationissafe,effectiveandinexpensive methodofpost-operativepaincontrol.Itprovides Severe un-controlled comorbities like immediateanalgesialastingforfewhourswithout diabetes,hypertension 11,12 majorsideeffects. leedingdisorders upivacaineandropivacainearecommonlyused Meticulouspre-operativeevaluationwascarried localanestheticsinwoundinltrationduetolonger out on day before surgery. Visual Analogue 1 duration of action. Ropivacine has wider safety Score (VAS) was used to grade intensity of pain prole and associated with less adverse events. in post-operative period. Patients were given 0.75and0.5concentrationsofropivacaineare information about VAS score grading pre- commonly used for wound inltration for post- operatively.VASispainmeasurementtoolranging 14,15 operativeanalgesia. Variousadjuvantsareused from 0 to 10, 0-no pain, 10-most severe pain. All inadditiontolocalanestheticstopotentiateeffects patientswerepremedicatedwithinj.gycopyrrolate of local anesthetics and reduce rescue analgesic 4 mcgg and inj. midazolam 1 mg intravenous 5,16,17 reuirement. 0minutesbeforesurgery.Allpatientswereinduced Tramadoliscommonlyusedinwoundinltration withgeneralanesthesia.Allpatientsofthreegroups due to its safety and efcacy. Tramadol is weak wereinduced with inj. sodium pentothal mgg opioid and its local anesthetic effects have been andinj.succinylcholine15mgg.Allpatientswere demonstratedinvariousstudies.18Asanadjuvant given inj. fentanyl 15 mcgg. Anesthesia was in wound inltration, tramadol can potentiate maintainedwithoxygen,sevouarne1MACand effects of local anesthetics without systemic side inj.atracurium.Attimeofwoundclosure,muscle, effects.1Tramadolhaslesspotentialforrespiratory subcutaneous tissue and skin inltration were depressionandabuseunlikeothercommonlyused carriedoutbyoperatingsurgeonwithtotalvolume opioids.19 of22mlaccordingtostudygroup.Randomization wasdonewithsealedenvelopetechniue. Aims roup C – Inj. Normal saline (0.9) - Total volume22ml; Aim of our study was to compare effectiveness roup–Inj.Ropivacaine(0.75)20mlInj. of wound inltration with ropivacaine alone Normalsaline2ml-Totalvolume22ml; and ropivacaine plus tramodol after open roupT–Inj.Ropivacaine(0.75)20mlInj. cholecystectomysurgeriesintermofpost-operative Tramadol(2mgg)in2ml-Totalvolume22ml analgesia. Secondary outcomes measured were time for rst rescue analgesic, number of rescue Attheendofsurgery,patientswerereversedfrom doses in rst 24 hrs, patient satisfaction and side neuromuscular blockade with inj. glycopyrrolate effectsifany. 8 mcgg and inj. neostigmine 005 mgg. emodynamic parameters were recorded intra- operatively and immediate post-operative period MaterialsandMethods upto 24 hrs. Post-operative pain was measured using VAS score in immediate post-operative This prospective randomized double blind study period,0min,1hr,2hr,4hr,hr,8hr,12hr,18 wascarriedout inour institutefromNov2018to hrand24hr.VASscoreatanytimewasnoted March 2019. A total of 75 patients of age group andrescuedruginformofinj.diclofenac15mgg 20–50 years, either gender, belonging to ASA I/II I.V.slowlywasgiven.VASscoreatdifferenttime postedforelectiveopencholecystectomysurgeries interval and time for rst rescue analgesic were were selected in our study. Written informed recorded. Number of rescue doses in rst 24 hrs consentwastakenfromeachpatient.Patientswere in post-operative period and incidences of post- dividedintothreegroups,25patientsineachgroup. operative nausea/vomiting were also recorded. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparisonbetweenRopivacaineandRopivacainePlusTramodolinWoundInfiltration 1629 asanAnalgesicafterOpenCholecystectomySurgeriesforPost-operativeAnalgesia

Patientsatisfactionscoreat24hrwasalsorecorded operative period 1 hr for all three groups. There using patient satisfaction scale (0–4), 0-poor to wassignicantincreaseinVASscorearound1hr 4-excellent. Operating surgeons whose had done in Group C, difference is statistically signicant inltrationandanesthesiologiststakingfollowup (p0.05).VASscorewerecomparableinGroupR inpost-operativeperiodwerekeptblindtostudy andGroupRTduringalltimesexcept4hr,hrand drugadministered. 8hr,(p0.05)(Table2). Time for rst rescue analgesic was signicant StatisticalAnalysis shorterinGroupCcomparedtoothertwogroups (p 0.05). There was also signicant difference AlldatawerecollectedandanalysedwithSPSS17 intimeforrst rescueanalgesicforGroupRand software. Statistical methods such as Anova test, GroupRT,shorteringroupR(p0.05).Numberof studentst-testandchi-suaretestwereperformed rescuedosesreuirementinrst24hrswashighest tondlevelofsignicanceofourdatavaluesfor forGroupCandleastforGroupRT,differenceis all three groups. Level of signicance was set to statisticallysignicant,(p0.05)(Table). p0.05.

Table:PONVincidence esults roupC roup roupT alue Nausea/vomiting 5(20) 4(16) 5(20) 0.05 All75patientsofthreegroupswereassessedand (First24hrs) resultswereshownin(Tables). Therewasnosignicantdifferenceinincidences Table:Demographiccharacteristics ofPONVinrst24hrsforallthreegroups(p0.05) (Table4). roupC roup roupT alue Age 4.5612.5 .810.79 6.7812.88 0.05 Table:Patientsatisfactionscale Sex(M/F) 20:5 18:7 21:4 0.05 ASAI/II 24/1 2/2 24/1 0.05 roupC roup roupT alue Weight 62.1011.67 66.451.01 6.7815.89 0.05 Patient satisfactionscale 1.560.56 2.050.57 2.890.67 0.05 Durationof 81.7816.68 85.981.85 84.8714.7 0.05 (At24hrs) surgery Allpatientsofthreegroupswerecomparablein Patient satisfaction at 24 hrs was higher with demographicproles,ASAstatusanddurationof groupRandRTcomparedtoGroupC.Therewas surgery(p0.05)(Table1). signicantdifferenceforlevelofpatientsatisfaction forGroupRandRT,highersatisfactionwithGroup Therewasnodifferencein VAS score till post- RT(p0.05)(Table5).

Table:VASscoreinpost-operativeperiod

min min r r r r r r r r GroupC 2.060.4 2.170.4 2.670.98 2.000.7 2.100.4 2.640.8 2.200.54 2.50.46 2.40.77 2.90.

GroupR 1.780.4 2.100.67 2.140.56 2.00.45 2.891.2 2.110.87 2.080.65 2.40.54 2.50.56 2.260.4

GroupRT 1.890.56 2.00.45 2.270.56 2.100.66 2.760.97 2.20.65 2.60.64 2.20.54 2.500.87 2.10.1

Table:Post-operativerescuedosereuirement

roupC roup roupT alue Timeforfirstrescuedose 56.216.67 280.7840.67 400.6550.4 0.001(CR) 0.001(CRT) 0.01(RRT)

Numberofrescuedoses 2.450.78 1.460.75 1.00.65 0.001(CR) in24hrs 0.001(CRT) 0.0(RRT)

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Discussion Wound inltration is important part of a multimodal approach for post-operative Pain is a protective body mechanism to injurious analgesia. Local wound inltration is attractive 20 method as it is simple, effective and side effects stimulus with or without actual tissue damage. ,0 Individual variations in response to pain may be are minimal. Various studies have shown that inuenced by age, gender, genetic makeup and incisional inltration of local anesthetics was siteofsurgery.21,22Approximately80–90surgical safe and effective techniue for post-operative pain relief in orthopedic surgeries, abdominal patientsexperiencemoderateto severepainpost- 18,1–5 operatively.2,24Post-operativepainduetosurgical surgeries and cesarean sections. So we had chosen local anesthetics wound inltration incision is nociceptive acute pain which is major method for post-operative analgesia in open causeofpost-operativemorbidity. cholecystectomysurgeries. In-adeuate control of post-operative pain has Various local anesthetics, like bupivacaine certainadversehealthimpactsoncardiovascularand and ropivacaine, are used in wound inltration respiratorysystem,likehypertension,tachycardia, in various surgeries like open cholecystectomy. in-adeuatecoughing,basalatelectasis,deepvein Localanestheticsusedinwoundinltrationblock thrombosis,insomnia.esidesthis,itdelaysearly afferentpainsignalsfromincisionsiteandreduce ambulation and prolong hospital stay.25,26 Post- sensitizationofspinaldorsalhornneurons.6,7Local operative pain may be major cause of patient anestheticscaninhibitsensitizationofnociceptive dissatisfaction after surgery. So, efforts should be receptors that can cause in-ammatory response. alwaystowardsearlyandeffectivecontrolofpost- Various studies have shown that inltrationwith operativepain. localanestheticsmayreduceinterleukinlevelsand Managementofpost-operativepainischallenging increasesubstanceinthewound.19 afterabdominalsurgeries.Effectivepost-operative Ropivacaine, longer acting anesthetic, has been pain control can provide faster recovery, early widelyusedinlocalwoundinltrationbesidesits hospitaldischargeandbetterpatientsatisfaction.27 useperipheralnerveblocksandepiduralanesthesia. Appropiatemethodsshouldbeappliedasearly Ropivacaineisnearlycomparabaletobupivacaine as possible to control pain in immediate post- in terms of potency and duration of action with operative period. Various drugslike, opioidsand bettersafetyprole.5,8Ropivacaineislesslipophilic nonopioids drugs has been used to effectively hence less chancesof centralnervous systemand controlpost-operativepain.Opioidsarecornerstone cardiovascular toxicity.14,15,17 Various studies have forpost-operativepaincontrol.Morphine,fentanyl, shownthat0.75and0.5ropivacainecouldbe sufentanyl are effective for moderate to severe used for local wound inltration, with maximum post-operative pain. These drugs are associated dosebeingmgg.1,14,17,9So,wehadused0.75 withsomesideeffectslikerespiratorydepression, ropivacaineinwoundinltrationforpost-operative pruritus, urinary retention, nausea and vomiting analgesia. whichmaycausepatientdiscomfort.5–7,28 Wound inltration with local anesthetics has Nonsteroidal anti-inammatory drugs like shortdurationofaction(0mintohr)evenwith paracetamol, diclofenac, ketorolac are commonly longeractinganestheticropivacaine.14Despiteuse used as second line drugs for post-operative oflongeractingropivacaine,thereisalwaysneed pain control. These drugs are in-effective as sole foradjuvantstoprolongdurationofanalgesia.With analgesicafterabdominalsurgeries.Asthesedrugs singleshotwoundinltration,durationofanalgesia arelesseffectiveformoderatetoseverepainwhich is more limited as catheter may have certain iscommoninimmediatepost-operativeperiod.8,28 disadvantages like dislodgement and infection.1 Theycanbeusedaspartofmultimodalapproach. Variousadditiveshadbeenusedtolocalanesthetic owever, post-operative pain control is still inltrationtoimproveualityanddurationofpost- demandinginrst24hrs.Nosingleavailablemethod operativeanalgesia.Tramadol,fentanyl,morphine, iseffectiveforoptimalpost-operativepaincontrol. sodium bicarbonate and dexmedetomidine are Post-operativepainshouldbecontrolledeffectively commonlyusedasadditivetolocalanestheticsin 40–42 atearliestbymultimodalapproachsosideeffects woundinltration. ofindividualdrugscouldbeminimized.5American Various studies has shown that inltration society of anesthesiologists also stated that acute with opioids could potentiate analgesic action of pain might be better controlled with multimodal local anesthetics in wound inltration.40,41 As an analgesia.29 adjuvant,tramadolisgainingpopularityinwound

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparisonbetweenRopivacaineandRopivacainePlusTramodolinWoundInfiltration 161 asanAnalgesicafterOpenCholecystectomySurgeriesforPost-operativeAnalgesia inltration besides systemic use for pain control. Duration of analgesia as dened by time for Tramadolisasyntheticopioidusedasanadjuvant rst rescue analgesic was signicantly shorter in to local anesthetic in wound inltration. It may controlgroupcomparedtoothergroups.Timefor exertsitsanalgesiceffectsthroughreceptorsand rstrescueanalgesicwaslongestforropivacaine- inhibitionofmonoaminergictransmitters.Various tramodol group among all three groups. Our studieshasdemonstratedthattramadolmighthad study revealed that duration of post-operative anti-inammatory and local anesthetic action on analgesia was higher in ropivacaine-tramodol peripheral nerves.4–46 Various studies has shown group compared to ropivacaine group and saline that tramadol in dose of 15–2 mgg could be group.Ozyilmazetalrevealedthatinlumbardisk effective in wound inltration for post-operative surgeries,timeforrstrecsueanalgesicwasealiest analgesia.19,9,47,48 So, in our study, we had used insalinegroupfollowedbylevobupivacainegroup tramadolindoseof2mggforinltrationinopen andthentramodolgroup.47Incontrasttoourstudy, cholecystectomysurgeries. Anders et al found that wound inltration with Wound inltration volume may depend on ropivacainewithorwithoutfentanylhadnoeffects 2 length of surgical incision. Various studies have onpost-operativepainreliefafterbreastsurgery. shown that volume used for wound inltration Mitra et al demonstrated that wound inltration for post-operative analgesia could range from 20 with tramadol as adjuvant to ropivacaine for ml–40mldependingonnatureofsurgery.5,12,1,17,2,9 lumber discectomies had longer time for rst So. we had used total volume of 22 ml in open rescueanalgesicreuirement.Thesendingswere 9 cholecystecomy wound inltration for post- inaccordancetoourstudy. So,localanestheticsin operativepaincontrol. woundinltrationcouldprolongdurationofpost- operativeanalgesia.Whenadjuvants(tramodolin In our study, we found that VAS scores were ourstudy)wereaddedtolocalanesthetics,duration signicantly higher in control group (Group C) ofanalgesiawassignicantlyprolonged. compared to other groups. These ndings were indicating that wound inltration with local Numberofrescuedosesinrst24hrswashigher anesthetic drugs might reduced pain score by in saline group compared to other two groups. providing post-operative analgesia. Duration of These ndings were indicating that patients with pain relief of wound inltration with ropivacaine woundinltrationwithlocalanestheticsreuired wascomparabletothatreportedbystudyofaudry lessrescueanalgesicandbetterpaincontrol.Mohta etal49AxelleVetalalsodemonstratedthatwound etalfoundthattherewaslessreuirementofrescue inltration with ropivacaine after breast cancer doses in local anesthetic inltration compared 17 surgeryhadlowerpainscorecomparedtocontrol to control group for tubercular spine surgery. group during immediate post-operative period.12 Lee et alalso revealed similarndings for single 10 Jingianetalalsorevealedthatwoundinltration incisionlaproscopiccolectomy. Incontrasttoour withropivacaineafteropenhepatectomydecresed study,Muratetalrevealedintheirstudyofwound VASscorecomparedtosalinegroup.Thesendings inltration for cesarean delivery that there was correlatedwithourstudy. no differencebetweensalinegroupandtramadol groupintermsofrescuedosereuirement.4 VAS scores were also higher in ropivacaine group compared to ropivacaine-tramodol Rescue dose reuirement were also higher group.Thesendingswereindicativeofefcacy for ropivacaine group compared to ropivacaine- of tramodol as an adjuvant to ropivacaine to tramodol group. These was might be due to reduce pain score in post-operative period. additionofopioids(tramodolinourstudy)tolocal When adjuvants were added to ropivacaine in anesthetic in wound inltration could prolong wound inltartion, pain scores were decresed durationofanalgesia.Mitraetalrevealedthatlocal signicantly. Shaman et al also stated that woundinltrationwithropivacaine-tramadolhad ropivacaine plus dexmedetomidine in local nodifferenceinrescuedosereuirementcompared 9 wound inltration had signicantly low pain to ropivacaine group. hajavi et al found that scorecomparedtoropivacainealoneforcesarean subcutaneous wound inltration with tramodol section.5Demiraranetalrevealedintheirstudy after renal surgery had lower rescue analgesic 14 thatwoundinltrationwithtramodolatcesarean reuirement. sectionhadlowerVASscorecomparedtosaline Inourstudy,incidencesofPONVinrst24hrs group.48Muratetalalsofoundthattramodolin werenearlysimilarinallthreegroups.Therewas wound inltration had lower pain scores. These no increase incidence of PONV in ropivacaine- ndingswereincorrelationwithourstudy.4 tramodol group. hajavi et al revealed that

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 162 IndianJournalofAnesthesiaandAnalgesia subcutaneous tramodol inltration after renal 2. LatimerRG,DickmanM,DayWC,etalVentilatory surgeryhadnoincreaseriskforPONV.14ongetal. patterns and pulmonary complications after also revealed that ropivacaine wound inltration upper abdominal surgery determined by pre- reduced incidence of PONV.50 These ndings operative and post-operative computerized spirometry and blood gas analysis. Am J Surg. were in correlation with our study. There was 1971;122:622–2. no increased incidence of PONV in ropivacaine- tramodol group indicating better safety prole . SunJ,ai,LiuF,etalEffectsoflocalwound infiltration with ropivacaine on post-operative oftramodol. pain relief and stress response reduction after Inourstudy,highestpatientsatisfactionat24hrs open hepatectomy. World J Gastroenterol. was seen with ropivacaine-tramodol group and 2017;2(6):67–740. lowest with control group. These might be due 4. hu,WangC,uC,etalInfluenceofpatient- to better uality of pain control with prolonged controlled epidural analgesia versus patient- analgesia in ropivacaine-tramodol group. These controlledintravenousanalgesiaonpost-operative ndings also suggested that wound inltration pain control and recovery after gastrectomy for could provided better post-operative analgesia gastric cancer: A prospective randomized trial. as part of multimodal approach hence better GastricCancer.201;16:19–200. patientsatisfaction.Mohtaetalfoundthatpatient 5. hardwajS,DevganS,SoodD,etalComparison satisfactionwashigherforwoundinltrationwith oflocalwoundinfiltrationwithropivacainealone local anesthetics compared to control group for or ropivacaine plus dexmedetomidine for post– 17 operativepainreliefafterlowersegmentcesarean tubercularspinesurgery. section.AnesthEssaysRes.2017;11(4):940–45. 6. Dahl J, Jeppesen IS, Jorgensen , et al Intra- imitations operative and post-operative analgesic efficacy and adverse effects of intrathecal opioids in Woundinltrationasapartofmultimodalapproach patients undergoing cesarean section with should be considered in term of opioid sparing spinalanesthesia:Aualitativeanduantitative analgesic method. There are certain limitations systematicreviewofrandomizedcontrolledtrial. to our study. Firts of all, sample size selected in Anesthesiology.1999;91:1919–927. our study was small and results obtained could 7. Gehlin M, Tryba M. Risks and side effects of not be applied to general populations. Second, intrathecal morphine combined with spinal surgeries were done by different surgeons hence anesthesia: A meta-analysis. Anesthesia. tissue handling and wound inltration done by 2009;64:64–51. them might affect results of our study. Third, it 8. WuCL,CohenSR,RichmanJM,etalEfficacyof wouldbebettertotakefollowupforatleast48hrs post-operativepatient-controlledandcontinuous post-operatively for more accurate results. So, infusion epidural analgesia versus intravenous we could access post,operative pain in late post, patient-controlledanalgesiawithopioids:Ameta- operativeperiod,durationofhospitalstayandany analysis.Anesthesiology.2005;10:1079–088. complicationsifany. 9. Scott N. Wound infiltration for surgery. Anesthesia.2010.65S:67–75. Conclusion 10. Lee C, Lu CC, Lin SE et al Infiltration of local anesthesia at wound site after single- incision laproscopic colectomy reduces post- oth,ropivacaine and ropivacaine plus tramodol, operative pain and analgesic usage. epato in wound inltration were highly effective for Gastroenterology.2015;62:811–16. post-operative analgesia in open cholycystectomy 11. Moiniche S, Mikkelsen S, Wetterslev J, et al A surgeries. Ropivacaine-tramodol combination systematicreviewofincisionallocalanesthesiafor mightbepreferredinwoundinltrationbecauseof post-operative pain after abdominal operations. prolongdurationofanalgesia,leastrescueanalgesic ritAnesth.1998;81:77–8. reuirementandbetterpatientsatisfactionwithout 12. VigneauA,SalengroA,ergerJ,etalAdouble increaseincidencesofPONV. blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery withaxillarynodesdissection.MCAnesthesiol. eferences 2001;24:11–2. 1. ditaNaithani,Indiraumari,RekhaRoat,etal 1. Wightman JA. A prospective survey of the Efficacyofwoundinfiltrationusingbupivacaine incidences of post-operative pulmonary versus ropivacaine along with fentanyl for complications.rJSurg.1968;55:85–91. post-operative analgesia following abdominal

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hysterectomy under spinal anesthesia. Journal 26. Shoar S, Esmaeili S, Safari S. Pain management of Evolution of Medical and Dental Sciences. after surgery: A brief review. Anesth Pain 201;2(4):6478–489. 2012;1():184–86. 14. uthialaG,ChaudharyG.Ropivacaine:Areview 27. LeeRM,TeyJL,ChuaNL.Post-operativepain of its pharmacology and clinical use. Indian J control for total knee arthroplasty: Continuous Anesth.2011;55:104–110. femoral nerve block versus intravenous patient 15. LeoneS,DiCianniS,CsatiA,etalPharmacology, controlledanalgesia.AnesthPain.2012;2():184– toxicologyandclinicaluseofnewlongactinglocal 86. anesthetics, ropivacaine and levobupivacaine. 28. Sujata N, anjoora VM. Pain control after Actaiomed.008;79:92–105. cesareanbirth-whataretheoptionsJGenPract. 16. SwainA,NagDS,SahuS,etalAdjuvantstolocal 2014;2:164. anesthetics: Current understanding and future 29. Ashburn MA, Caplan RA, Carr D. Practice trends.WorldJClinCases.2017;5:07–2. guidelines for acute pain management in the 17. MohtaM,RaniA,SethiA,etalEfficacyoflocal peri-operativesetting.Anupdatedreportbythe AmericanSocietyofAnesthesiologiststaskforce woundinfiltrationanalgesiawithropivacaineand dexmedetomidineintubercularspinesurgery:A on acute pain management. Anesthesiology. 2004;100:157–81. pilot randomized double-blind controlled trial. IndianJAnesth.2019;6:182–87. 0. Rawal N, Axelsson , ylander J, et al Post- operative patient-controlled local anesthetic 18. hajavi MR, Navardi M, Shariat Moharari R, et administration at home. Anesth Analg. al Combined ketamine-tramadol subcutaneous 1998;86:86–89. woundinfiltrationformultimodalpost-operative analgesia:Adoubleblindrandomizedcontrolled 1. Marues EM, Jones E, Elvers T, et al Local trial after renal surgery. Anesth Pain Med. anesthetic infiltration for peri-operative pain 2016;6(5):e7778. control in total hip and knee replacement: Systematic review and meta-analyses of short 19. Sachidananda R, Joshi V, Shaikh SI, et al andlong-termeffectiveness.MCMusculoskelet Comparison of analgesic efficacy of wound Disord.2014;15:220. infiltration with bupivacaine versus mixture of bupivacaineandtramadolforpost-operativepain 2. AndersonL,ehlet.Analgesicefficacyoflocal reliefincesareansectionunderspinalanesthesia: infiltrationanalgesiainhipandkneearthroplasty: Adoubleblindrandomizedtrial.JObstetAnesth Asystemicreview.rJAnesth.2014;11:60–74. CritCare.2017;7:85–89. . Gottschalk A, urmeister MA, Radtke P, et al 20. Merskey , ogdukN.Classificationof chronic Continuouswoundinfiltrationwithropivacaine painsecondedition.Seatttle:IASPTaskForceon reduces pain and analgesic reuirement after Taxonomy,IASPPress;1994. shouldersurgery.AnesthAnalg.200;97:1086–91. 21. osseini Jahromi SA, Sadeghi Poor S, osseini 4. alilogluM,ilgenS,MendaF,etalAnalgesic Valami SM, et al Effects of suppository efficacy of wound infiltration with tramadol acetaminophen, bupivacaine wound infiltration aftercesareandeliveryundergeneralanesthesia: and caudal block with bupivacaine on Randomized trial. J Obstet Gynecol Res. post-operative pain in pediatric inguinal 2016;42(7):816–21. herniorrhaphy.AnesthPain.2012;1(4):24–47. 5. Singh S, Prasad C. Post-operative analgesic 22. GoushehSM,NesioonpourS,JavaherForooshF, effect of dexmedetomidine administration in etalIntravenousparacetamolforpost-operative wound infiltration for abdominal hysterectomy: analgesiainlaproscopiccholecystectomy.Anesth A randomized control study. Indian J Anesth. PainMed.201;(1):214–18. 2017;61:494–98. 2. Wils VL, unt DR. Pain after laproscopic 6. rennan TJ, ahn P, Pogatzki-ahn EM. cholecystectomy.rJSurg.2000;87:27. Mechanismsof incisionalpain. Anesthesiol Clin NorthAmerica.2005;2:1–20. 24. Ahmadkhan,ShabirAhmadSofi,Farhanaashir, et al A comparative study showing efficacy of 7. awamata M, Takahashi T, ozuka , et al preemptiveintravenousparacetamolinreducing Experimental incision-induced pain in human post-operative pain and analgesic reuirement skin: Effects of systemic lidocaine on flare inlaproscopiccholecystectomy.JofEvolofMed formationandhyperalgesia.Pain.2002;100:77–89. andDentSci.2015;4(62):10771–77. 8. Whiteside J, Wildsmith JA. Developments in 25. ImaniF,RahimzadehP,FaizSR.Comparisonof local anesthetics drugs. r J Anesth. 2001;87:27– theefficacyofaddingclonidine,chlorpromazine, 5. promethazine and midazolam to morphine 9. Mitra S, Purohit S, Sharma M. Post-operative pumpsinpost-operativepaincontrolofaddicted analgesia after wound infiltration with patients.AnesthPain.2011;1(1):10–14. tramadol and dexmedetomidine as an adjuvant

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IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):165-1640 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.22

Comparison of ocal Infiltration ith Modified Pectoralis Block for Postoperatie Analgesia after Modified adical Mastectomy: An Open abelandomiedTrial

ShetaMahaanSonaliaushal

1AssociateProfessor,Dept.ofAnaesthesiaandCriticalCare,2AssistantProfessor,Dept.ofAnaesthesia,IndiraGandhiMedical College(IGMC),Shimla,imachalPardesh171001,India.

Abstract

Objectives:OwingtosafetyofModifiedPectoralisblockandlimitedstudiesavailableourstudywillcompare theanalgesicefficacyofModifiedPectoralisblockwiththecombinationoflocalandpocketinfiltrationafter MRM. Design Open label randomized trial. etting: Indira Gandhi Medical College, Shimla, P, India. Participants60ASAphysicalstatusI-IIpatients(aged25-65years),scheduledforelectiveMRMprocedures wererecruitedforthestudy.InterventionGroupI(PEC0patients)receivedultrasoundguidedPECblock preoperativelyandGroupII(localinfiltration0patients)receivedlocalanaestheticinfiltrationatsurgical incisionandpocketinfiltrationpostoperatively.Patientswereinducedwithstandardgeneralanaesthesiaand thenafterreversalandshiftedtorecoveryroom.MainOutcomeandMeasurePost-operativepainassessment wasdoneusingVisualAnalogueScoreatOhour(TimetakenaspatientisshiftedtoPAC),0min,1,2,4, 6,12and24hours.Results:InthePAC,themeanforrescueanalgesiareuiredingroup1was0.07(SD .47)andingroup2was8.1(SD1.196)andthiswasstatisticallysignificant.Thedifferenceinmeanof VASscoreingroup2at6hrswas(.00)andingroup1was(1.7)andthisscoreincreasedsignificantlyinnext hours.Themeanoftotalanalgesicreuiredinfirst24hrsingroup1was0.00(SD0.000)andingroup2was 2.6(SD556).Conclusion:ltrasoundguidedPECblockhadprolongpost-operativeanalgesiaascompareto localanaesthesiainfilterationatsurgicalincisionwithpocketinfilterationpost-operatively. eyords:Anaesthesia;Analgesia;Pain;Post-operative;Mastectomy;PEC,Localanaesthesiainfilteration.

otocitethisarticle: ShwetaMahajan,SonaliaushaletalComparisonofLocalInfiltrationwithModifiedPectoralislockforPost-operativeAnalgesia afterModifiedRadicalMastectomy:AnOpenLabelRandomizedTrial.IndianJAnesthAnalg.2019;6(5Part-1):165-1640.

Introduction rateofbreastcancervariesfrom9to2per100,000 women.1 Patients after mastectomy and breast reconstruction suffer from acute nociceptive pain reastcanceristhemostcommoncanceramongst (6) and chronic neuropathic pain syndromes womenworldwidewithanincidenceratethatvary (20–68).2Itisveryimportanttomanagethepost- greatlyworldwidefrom19.per100,000womenin operative pain in patients undergoing modied EasternAfricato89.7per100,000womeninWestern radical mastectomy. Appropriate post-operative Europe. In India, the age standardized incidence analgesic techniueafterbreastsurgeryisalways

Corresponding Author: Sheta Mahaan, Associate Professor, Dept. of Anaesthesia and Critical Care, Indira Gandhi Medical College(IGMC),Shimla,imachalPardesh171001,India. Email:shwetamahajan4[email protected] eceiedon12.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 166 IndianJournalofAnesthesiaandAnalgesia dubious.Variouspracticeslikecombinationofboth Group I (PEC 0 patients) received ultrasound localandpocketinltration,regionalanestheticand guided PEC block pre-operatively and Group intravenous analgesic techniues have been used II (local inltration 0 patients) received local forthepainrelief.Amongsttheregionaltechniues anesthetic inltration at surgical incision and thoracic epidural is considered as gold standard pocketinltrationpost-operatively.PECblockwas butisassociatedwiththeriskofneuraxialdamage performed with the patients in supine position, andpersistentneurologicaldecitsandalsoresult placing the ipsilateral upper limb in abduction in serious complications like intrathecal spread, positionusingalinearSGprobeofhighfreuency epiduralhematoma,andinadvertentintravascular (–1M,sonosite)withimagingdepthof4–cm injection.4,5 Owing to the safety and greater pain after sheathing. The SG probe was rst placed reliefbymodiedPECblock,ithasbecomemore at infraclavicular region after skin sterilization familiarnow-a-daysamonganesthetistscompared usingchlorhexidineandmovedlaterallytolocate to paravertebral and thoracic epidural nerve the axillary artery and vein directly above rst blocksforpain relief following breast surgeries.6,7 rib where pectoralis major and pectoralis minor owever,sofar,nodataisavailablethatcompares muscles were identied with the help of SG modiedPECblockwiththecombinationoflocal probe.Afterinltrationoftheskinatthepuncture andpocketinltration.Therefore,wehypothesized sitewithmloflignocaine2,the2Gneedlewas that the PEC 2 block may effectively alleviate insertedinplanewithSGprobetothefacialplane acute post-operative pain in patients undergoing between pectoralis major and pectoralis minor MRM. The present study evaluated the analgesic muscle and 10 ml of levobupivaciane 0.25 was efcacy of PEC 2 block in patients undergoing injected.ThenSGprobewasmovedtowardaxilla MRM. In addition, this study also compared the till serratus anterior muscle was identied above analgesic efcacy of Modied Pectoralis block 2nd, rd and 4th ribs and the needle was reinserted with the combination of local anesthetic and into the facial plane between pectoralis minor pocketinltration. muscleandserratusanteriormuscleand20mlof 0.25levobupicainewasinjectedinincrementsof 5mlafteraspiration. MaterialsandMethods In Group II patients 10 ml of 0.25 levobupivacaine was given as pocket inltration This study enrolled patients with breast cancer and20mlof0.25levobupivacainewasinltrated posted for modied radical mastectomy between attheincisionalsitebythesurgeonbeforeclosure. July201andMay 2017.Afterobtainingapproval from our institutional scientic and research All patientsreceived midazolam 1–2mgbefore committee with registration number ECR/5/ induction of anesthesia and monitored with ve INST/P/2014 with ethical number G-5 leads ECG, pulse oximetry, non-invasive blood (Ethic)/2015-1064,writteninformedconsentwas pressureandcapnography.Generalanesthesiawas taken from 60 ASA physical status I-II patients inducedwithfentanyl2mgg,propofol15–2mgg (aged 25–5 years), scheduled for elective MRM and endotracheal intubation was facilitated with procedures. Exclusion criteria included history of atracurium 05 mgg. Anesthesia was maintained any allergy to local anesthetic, bleeding disorder withisouraneandO2/NO2mixturewithafraction or receiving anticoagulant, MI 5 gm2, spine ofinspiredoxygen.Fentanyl1mgginbolus or chest wall deformity, pregnancy, prior breast doses was given intravenously if mean blood surgery and patient declining to give consent. pressure or heart rate exceeded 20 of the pre- During preoperative visit, demographic data operative value. After recovery from anesthesia, was recorded and visual analog scale score (VAS patientsshiftedtopost-anesthesiacareunitforthe score:0–10,(0)Nopain,(4–8)mildpain,(8–10)Worst rst 2 hours. Post-operative pain assessment was pain) was explained to patients. efore surgery done using Visual Analog Score at rest at 0 hour patientswererandomlyallocatedaccordingtothe (Time taken as patient was shifted to PAC), computer-generated seuence into two groups 0min,12412and24hours.Post-operativerescue of 0 each. The group allocation numbers were analgesiawasgivenwhenevertheVASscore4in concealed in sealed opaue envelopes that were theformofI.V.Diclofenac75mgorI.V.Tramadol openedafterenrolmentofthepatients.Allbaseline 100mgI.V.stat. andpost-operativemeasurementswereevaluated Nauseaorvomitinglastingmorethan10minutes byanindependentphysicianwhowasblindedto was treated with ondansetron 01 mgg. Patient treatmentallocation. satisfaction for post-operative analgesia was

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparisonofLocalInfiltrationwithModifiedPectoralislockforPost-operative 167 AnalgesiaafterModifiedRadicalMastectomy:AnOpenLabelRandomizedTrial recordedaccordingtosatisfactionscore:Poor0; wascomparablebetweenthetwogroups. Fair 1; Good 2; Excellent . Any untoward side effects or complications related to procedure Table:PatientCharacteristics andlocalanestheticwererecorded. Parameters roupn roupn Age(yrs) 28.42(mean) 2.58(mean) .54 StatisticalAnalysis Weight(gs) 4.05(mean) 26.95(mean) .114 All analysis was performed using IM SPSS n-Numberofpatients; software version 22.0 (Statistical Packages for the p-Statisticallysignificance(p.05). SocialSciences,Chicago).Thenormallydistributed In the PAC, the patients of Group 1 had datawerecomparedbyusing Studentsunpaired signicantly lower consumption of intravenous t-test,whereasnon-parametricdatawerecompared fentanyl as compare to Group 2 (Table ). The bychi-suaretestforintergroupdifferences.Intra- mean time for rst rescue analgesia in Group 1 operativehemodynamicdatawerecomparedwith washigherandstatisticallysignicantinGroup2. baseline by repeated measures ANOVA followed The mean forrescue analgesia reuired inGroup by students paired t–test. The pain scores, time 1was007hrs(SD.47)andmeanofrstdose to rstrescue analgesia, and total 24 hranalgesic ofrescueanalgesiainGroup2was81hrs(SD consumption were compared by using Wilcoson 1.196)andthiswasstatisticallysignicant(Table). W and Mann-Whitney -test for pairwise VASscorewassameforrst4hrspost-operatively comparisons.Condenceintervalswerecalculated in both the groups. The difference in VAS score forstatisticallysignicantdifferences.Thesample became statistically signicant between both the sizewascalculatedonthebasisofapilotstudy. groupsafterhrswithmeanofVASscoreinGroup 2 at hrs was (.00) and mean of VAS score in esults Group1was(1.7)athrsandthisscoreincreased signicantlyinnexthours.VASscorewasfoundto This study enrolled patients with breast cancer bestatisticallysignicantat12,18,24,0and0hrs. posted for modied radical mastectomy between Themeanoftotalanalgesicreuiredinrst24hrs July 201 and May 2017. efore surgery patients inGroup1was.00(SD000)andinGroup2was wererandomlyallocatedaccordingtothecomputer- 2.6(SD556),(Table). generatedseuenceintotwogroupsof0each.The There was no signicant difference between groupallocationnumberswereconcealedinsealed the groups with respect to R, SpO2, and mean opaueenvelopesthatwereopenedafterenrolment arterialpressureduringtheperi-operativeperiod. ofthepatients.GroupI(PEC0patients)received owever, the intra-operative consumption of ultrasoundguidedPECblockpre-operativelyand fentanyl was less in the PEC block group during Group II (local inltration 0 patients) received MRMbutnotstatisticallysignicant. localanestheticinltrationatsurgicalincisionand No untoward effects like vascular injury, pocketinltrationpost-operatively. hemodynamic instability, pleural puncture or Thepatientcharacteristic(age,bodymassindex pneumothoraxwasseenandnocaseofallergicto andASA)werecomparablebetweenthetwogroups localanestheticwasseen.Nopatientsufferedwith (Table).Thedurationofsurgeryandanesthesia PONVinanyofthegroup.

Table2:Intra-operativeandPost-operativedata

MannWhitney Parameters roupPEC roupA Totalfentanylatinduction(mg) 109 112 4.5 -1.58 .114 (S.D.-7.48) (S.D.-6.518) Totalfentanylconsumptionintra- 160.17 168.00 7.5 -1.672 .095 operatively(mg) (S.D.-22.042) (S.D.-9.777) Timefor1strescueanalgesia(hrs) 0.07 8.1 .000 -6.696 .000 (S.D.-.47) (S.D.-1.196) Totaldosesofrescueanalgesia .00 2.6 .000 -7.282 .000 (S.D.-.000) (S.D.-.556) pstatisticallysignificance(p.05).

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Table:ComparisonofVASbetweentwogroups

roup N Mean StdDeiation StdErrorMean Sigtailed VAS0 LAinfiltration 0 .07 .254 .046 .155 PECblock 0 .00 .000 .000 .161 VAS0 LAinfiltration 0 .60 .498 .091 .00 PECblock 0 .2 .40 .079 .00 VAS60 LAinfiltration 0 .87 .507 .09 .075 PECblock 0 .6 .490 .089 .075 VAS2 LAinfiltration 0 1.4 .568 .104 .000 PECblock 0 .97 .18 .0 .000 VAS4 LAinfiltration 0 2.07 .450 .082 .000 PECblock 0 1.27 .521 .095 .000 VAS6 LAinfiltration 0 .00 1.287 .25 .000 PECblock 0 1.7 .450 .082 .000 VAS8 LAinfiltration 0 5.50 1.676 .06 .000 PECblock 0 2.2 .971 .177 .000 VAS12 LAinfiltration 0 6.07 1.574 .287 .000 PECblock 0 2.7 .850 .155 .000 VAS18 LAinfiltration 0 6.4 1.1 .24 .000 PECblock 0 .07 .740 .15 .000

Discussion PECblock1wasrstperformedin2011,on50 patientswhohadbreastexpandersplacedaspart 12 Inthisstudy,wehavedemonstratedthatpatients ofbreastreconstructivesurgery. In2012,another study comparedPECblock2 withthePECblock in Group 1 who received PEC block had better 14 post-operative analgesia than patients who had I introduced Pectoral nerve block 1 (PEC 1) is receivedlocalanesthesiainltration.Theduration givenbetweenpectoralismajorandminormuscle, ofanalgesiawasprolongedinGroup1asassessed andmodiedpectoralisnerveblock2(mPEC2)is performed betweenpectoralisminor andserratus by the demand of rst rescue analgesia by the 17 patient. Also, the consumption of fentanyl in anterior muscle along with PEC 1 block. The post-operativeperiodwas more in groupoflocal advantageofthisnewmodiedtechniueofPEC anesthesia inltration as compare to that of PEC block2wasthatitcoveredtheaxillaryclearancein breastsurgeries,maintaining good post-operative blockwhichwasfoundtobestatisticallysignicant. 14 Regionalanesthetictechniuesappearsuperiorto analgesia. This is because PECs 2 block the intravenousanalgesicswithreducedpost-operative pectoral,intercostobrachial,theintercostalisand pain, decreased post-operative nausea vomiting, 6andthethoracicnerves.Theblockageoftheseall 7 respiratorydepressionandalsocostsaving.9 nerves help to provide complete analgesia. Also, the spread of local anesthetic into the axilla has Various anesthetic techniues such as local been demonstratedbydissection of cadaversand wound inltration, thoracic epidural, thoracic contrast distribution.14,15 The pectoral nerve block paravertebralandveryrecentfascialplaneblocks wasalsofoundtobebenecialforaxillarysurgery.16 havebeenusedtoprovideanalgesiaaftermodied MRM.10 Amongst the regionaltechniuesthoracic Furthermore, this techniue was compared epiduralwasconsideredasgoldstandardbutwas withparavertebralandthoracicepiduralinbreast associated with the risk of neuraxialdamageand surgeriesandconcludedthatitwasuitesafe,with persistent neurological decits.4 Previously many lessincidenceofpneumothoraxthanparavertebral studies have supported the use of paravertebral block and lacking sympathetic nerve block as 12 blockinbreastsurgeries,butithasincreasedrisk thoracicepidural. of intravascular injection, bleeding, infection, In2014,thestudywasconductedon60patients; nerve injury, short segment contralateral block PEC block was compared with thoracic andhighfailurerateaswell.So,itmightcauseless paravertebral block (second group) for post- complicationsthanthoracicepiduralbutstillmore operative analgesia. Patients receiving PEC block riskythanultrasoundguidedPEC2block.11,12 reuired decreased intra-operative fentanyl or

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 ComparisonofLocalInfiltrationwithModifiedPectoralislockforPost-operative 169 AnalgesiaafterModifiedRadicalMastectomy:AnOpenLabelRandomizedTrial morphine consumption as well as had decreased blocks. It is simple to perform via ultrasound incidenceofpost-operativenauseaandvomiting.6 guided andshould potentially beassociatedwith Accordingtopreviousstudies,nocomplications fewsideeffects.Pendingcomparativerandomized were associated with PEC 2 block. Owing to controlledclinicaltrials,thePECblockmightprove safetyofPEC2block,ithasbecomemorefamiliar tobeanimportantclinicaltoolforthetreatmentof among anesthetists now-a-days as compared to painafterthoracicandchestwallsurgery. paravertebral and thoracic epidural nerve blocks with breast surgeries. A PEC 2 block is given Conclusion whenpatientisinsupinepositionandtheneedle ismanipulatedeasilyunderultrasoundguidance. ltrasound-guided PEC block reduces post- Also, the target areas of needle in PEC 2 block operative pain scores, prolongs the duration is distant from the pleura and epidural space. of analgesia and decreases demands for rescue Directintravascularinjectionoflocalanestheticsis analgesics in the rst 24 hours of post-operative performedveryrarelyduetothelackofvaculature 18,19 period compared to local anesthetic inltration at the interfascial plane. The more invasive aftermodiedradicalmastectomy. techniuessuchasselectiveintercostalnerveblocks and thoracic paravertebral blockade may lead to FinancialSuortandSonsorshiNil pneumothorax or transient orners syndrome Conicts of Interest There are no conicts of because of techniue difculty and dosage of interest. drugused.1 In our study, the duration of post-operative eferences analgesia was more in patients with PEC block thanthepatientswhoweregivenlocalanesthesia 1. amath R, Mahajan S, Ashok L, et al A inltration with pocket inltration of local study on risk factors of breast cancer among anesthetic.Thetotalanalgesicdoseintheformof patients attending the tertiary care hospital, rescueanalgesiareuiredafterPECblockwasless in udupi district. Indian J Community Med. thanthetotaldosereuiredbythelocalinltration 201;8(2):95–99. oflocalanesthetic.Ingeneral,localinltrationwith 2. VilholmOJ,ColdS,RasmussenL,etalThepost- pocket inltration of wound is easy and safe but mastectomy pain syndrome: an epidemiological the limitation was the duration of post-operative study on the prevalence of chronic pain analgesiaandlimitedbythepharmacodynamicsof after surgery for breast cancer. r J Cancer. thelocalanesthetic. 2008;99(4):604–10. . Doo-wanim,Sooyoungim,ChanSikim,et This study had several limitations. First, the alEfficacyofPectoralnerveblocktype2forbreast PECS block was performed before the induction -conservativesurgeryandsentinellymph node of general anesthesia which may have affected biopsy: A prospective randomized controoled post-operative pain. Also, the wound dressing study. Pain Research and Management. and a surgical crepe bandage dressing may have 2018;ArticleID41591:8pages. interfered with the response to sensory level 4. DaviesRG,MylesPS,GrahamJM.Acomparison test including post-operative pain. owever, we of the analgesic efficacy and side-effects speculated that the PEC 2 block was successfully of paravertebral vs epidural blockade for performed based on the changes in mean blood thoracotomy: A systematic review and meta- pressure and heart rate during the incision. analysis of randomized trials. r J Anesth. Conseuently, this study did not present sensory 2006;96(4):418–26. testdata.Asecondlimitationwasourinabilityto 5. FreiseandVanAken.Risksandbenefitsof performadoubleblind,placebocontrolledstudy. thoracic epidural anesthesia. ritish Journal of owever, the patients and investigators were Anesthesia.2011;107(6):859–68. blinded to group assignment, suggesting that the 6. SherifSamirWahba,SaharMohammed.Thoracic lackofabilitytoperformaplacebocontrolledstudy paravertebral block versus pectoral nerve block hadlittleinuenceonstudyoutcomes.Oneshould for analgesia after breast surgery. Egyptian alsobeawarethatlocalanestheticcanspreadalong JournalofAnesthesia.2014;0(2):129–5. thefascialplanefollowingPECSblockcanlimitthe 7. ulhari S, harti N, ala I, et al Efficacy of useofelectrocauterybythesurgeon.20 pectoralnerveblockversusthoracicparavertebral block for post-operative analgesia after radical This new PEC block is another step towards mastectomy: A randomized controlled trial. a new generation of ultrasound-guided nerve ritishJournalofAnesthesia.2016;117():82–86.

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8. huvaneswari V, Wig J, Mathew PJ, et al Post- ultrasound block: A cadaveric and radiological operative pain and analgesic reuirements evaluation.RevistarasileiraDeAnestesiologia. after paravertebral block for mastectomy: 2017;67(6):555–64. A randomized controlled trial of different 16. okota,MatsumotoT,MurakamietalPectoral concentrations of bupivacaine and fentanyl. nerveblocksareusefulforaxillarysentinellymph IndianJAnesth.2012;56(1):4–9. nodebiopsyinmalignanttumoursontheupper 9. The 1978AnnualScientificMeeting.Anesthesia. extremities.InternationalJournalofDermatology. 1979;4(4):90–402. 2017;56():64–65. 10. Garg R, han S and Vig S. Newer regional 17. GoswamiS,undraP,hattacharyyaJ.Pectoral analgesia interventions(fascial plane blocks)for nerve block 1 versus modified pectoral nerve breast surgeries: Review of Literature. Indian block2 for post-operativepainrelief inpatients JournalofAnesthesia.2018;62(4):254–62. undergoing modified radical mastectomy: A 11. armakar M. Thoracic paravertebral block. randomized clinical trial. ritish Journal of Anesthesiology.2001;95():771–80. Anesthesia.2017;119(4):80–5. 12. lanco R. The pecs block: A novel techniue 18. oung MJ, Gorlin W, Modest VE, et al Clinical for providing analgesia after breast surgery. implicationsofthetransversusabdominis plane Anesthesia.2011;66(9):847–48. block in adults. Anesthesiology Research and Practice.2012.ArticleID71645:11pages. 1. lanco R, Parras T, McDonnell JG. Serratus planeblock:Anovelultrasound-guidedthoracic 19. Okmen , Okmen M and ysal S. Serratus wall nerve block. A Prats-Galino, Anesthesia. anterior plane block used for thoracotomy 201;68(11):1–12. analgesia:Acasereport.oreanJournalofPain. 2016;29():189–92. 14. lanco R, Fajardo M, and Maldonado TP. ltrasounddescriptionofPECS2block(modified 20. G akshi Sumitra, aran Nupur, Parmar PEC 1): A novel approach to brastsurgery.Rev Vani. Pectoralis block for breast surgery: A EspAnestesiolReanim.2012Nov;59(9):470-5. surgical concern Indian Journal of Anesthesia. 2017;61(10):851–52. 15. TorrePA,JonesJrJW,SLAlvarez.Axillarylocal anesthetic spread after the thoracic interfascial

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1641-1646 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.2

Outcome of Oral abapentin in Total Abdominal ysterectomies on PostoperatieEpiduralAnalgesia

ThomasPeorgeironoeoseph

1AssociateProfessor,AssistantProfessor,PushpagiriInstituteofMedicalSciencesandResearchCentre,Thiruvalla,erala689101, India.2Consultant,StThomasospital,Chethpuzha,Changanassery,erala686104,India.

Abstract

acground:Pre-emptiveanalgesiaisdefinedasananti-nociceptivetreatmentthatpreventstheestablishment of altered central processing ofafferentinput, which amplifies post-operative pain. Objective:To evaluate the role of gabapentin as pre-emptive analgesic in patients undergoing total abdominal hysterectomy. Methods:Aprospective,randomizedclinicalstudywasconductedandthepatientswererandomlyallocated totwogroupsof15eachwithASAGradeIandII.PatientsinGroupAweregivenoralgabapentin1200mg 1hourbeforesurgerywhereasplacebowasgiventopatientsbelongingtoGroup.Epiduralblockisachieved inbothgroupswithabolusdoseof0.5bupivacaine(maximumallowabledose–2mgg)priortosurgery. Afterskinclosure,theinfusiondoseisreducedtoalowerconcentrationofupivacaine(0.0625)attherate of2mlhrandthepatientwillbeshiftedtoD(highdependencyunit).Datacollectedincludespatients age,bodyweight,post-operativeVASscores,andtramadol50mgI.V.dosesgivenat1481212024 hours. Results: Study revealed that the mean VAS score in the post-operative period is lower in group A (Gabapentin)ascomparedtogroup(placebo).Meannumberoftotaltopupswithtramadolislowerin GroupA(Gabapentin)ascomparedtoGroup(Placebo).Conclusion:Pre-emptiveuseofgabapentin1200 mgorallysignificantlyreducesthenumberofpost-operativeanalgesicdosereuirementsandpost-operative paininpatientsundergoingtotalabdominalhysterectomyunderepiduralanesthesia. eyords:Gabapentin;Totalabdominalhysterectomy;Pre-emptiveanalgesia.

otocitethisarticle: ThomasPGeorge,ironG,JoeJoseph.OutcomeofOralGabapentininTotalAbdominalysterectomiesonPost-operativeEpidural Analgesia.IndianJAnesthAnalg.2019;6(5Part-1):1641-1646.

Introduction Gabapentin 1-(aminomethyl) cyclohexane acetic acid is a structural analogue of gamma amino butyricacid(GAA),whichwasinitiallyintroduced Post-operative pain is typically regarded as a in 1994 as an antiepileptic drug, particularly for type of nociceptive pain involving peripheral partialseizures.Itwassoonfoundtobepromising mechanoreceptor stimulation, inammatory, in treatingneuropathic pain associated with post- and neurogenic and visceral mechanisms, with herpetic neuralgia (PN)2,, post-poliomyelitis a transient, reversible type of neuropathic pain1 neuropathy4, and reex sympathetic dystrophy5.

CorrespondingAuthor:iron,Consultant,St.Thomasospital,Chethipuzha,Changanassery,erala686104,India. Email:[email protected] eceiedon08.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1642 IndianJournalofAnesthesiaandAnalgesia

Placebo-controlled clinical trials also have clusioncriteria indicated a role of gabapentin in treating pain (1) Patients with cerebrovascular disease, related to diabetic neuropathy (DNP)6 and PN7. cardiovasculardisease. The concept of pre-emptive analgesia to reduce post-operative pain was founded on a series of (2) Poorlycontrolledarterialhypertension. successfulanimalexperimentalstudiesthatshowed () Coagulationdefects. centralnervoussystemplasticityandsensitization afternociception.8Pre-emptiveanalgesiaisdened (4) istoryofrenalin-sufciency. as an anti-nociceptive treatment that prevents (5) istoryofhepaticinsufciency. the establishment of alteredcentral processing of (6) ypersensitivitytothedruginstudy. afferentinput,whichampliespost-operativepain.9 Gabapentin has demonstrated analgesic effects in (7) Patients with baseline pulse 0 bpm and clinicaltrialsasapre-emptiveanalgesicandinacute systolicP100mmg. post-operativepainmanagement.So,therationale (8) istoryofpepticulcer. behindthestudytoinvestigatewhetherpre-emptive useofgabapentin1200mgorallycouldreducepost- thicalConsiderations operativepainandnumberofadditionalanalgesics in theinitial 24 hours in patients undergoing total Thestudywasconductedafterattainingapproval abdominalhysterectomy. fromresearchandethicalcommittee.

MaterialsandMethods InformedConsent

Studyesin Written informed consent was taken from all patients. Arandomizedcontrolstudyinvolving0patients belonging to ASA 1 2, who were posted for ethodoloy electivetotalabdominalhysterectomies. Patientwillbeassignedtotwogroupsof15each. StudySettin PatientsinGroupAwillbegivenoralgabapentin 1200 mg 1 hour before surgery whereas placebo Tertiary care teaching hospital–major operation willbegiventopatientsbelongingtoGroup. theatre,DepartmentofAnesthesiology,Pushpagiri InstituteofMedicalSciences,Thiruvalla,erala. reoerativevaluation

SamleSie A thorough pre-anesthetic check-up was carried out.Detailedhistorywastaken,airwayandsystems Forasignicantlevelof5andapowerof90,and were examined. Pulse rate, blood pressure and eualnumberinbothgroups,apooledvarianceof16; bodyweight were noted. Routine investigations tondadifferenceofhourbetweenthe2Groups, like hemogram, blood sugar, renal function test, the sample size reuired is 11. For accounting liver function test, bleeding and clotting time, dropouts,thesamplesizeisroundedto15. prothrombin time, international normalized ratio (INR),chest-ray(PA)viewandelectocardiogram Studyoulation weredoneandreviewedinallthesubjects. 0 female patients with American Society of Anesthesiologists (ASA) physical status 1 or reoerativerearation 2 aged 5–0 years scheduled for total abdominal Allpatients were keptfasting forsihoursbefore hysterectomy. surgery.Allthesubjectswerepre-medicatedwith Selectionwasbasedoninclusionandexclusion Tab.Ranitidine150mgTab.Alprazolam025mgon criteria: previousnightandtwohourspriortosurgery.

Inclusioncriteria rocedure 1. Agebetween5–0years Epiduralblockwasachievedinbothgrouppatients 2. Physical status: American Society of withabolusdoseof0.5bupivacaine(maximum Anesthesiologists(ASA)1or2. allowable dose–2 mgg) prior to surgery. Intra- IJAA/Volume6Number5(Part-I)/Sep-Oct2019 OutcomeofOralGabapentininTotalAbdominalysterectomiesonPost-operativeEpiduralAnalgesia 164 operatively analgesia was maintained with 0.5 esults bupivacaine infusion at the rate of 4 mlhr. After skin closure, the infusion dose was reduced to a Table:Agewisedistributionofthestudyparticipants lowerconcentrationofbupivacaine(0.0625)atthe roup Sample Mean Standarddeiation alue rateof2mlhrandthepatientwasshiftedtoD Gabapentin 15 45.47 5.475 0.645 (highdependencyunit).VASscoreswereassessed Control 15 46.40 5.501 byanindependentphysicianwhowasnotawareof thegroupallocationonascaleof0–10cm(0mean MeanageinGroupA(Gabapentin)andGroup nopain,10eualstoworstimaginablepain)after1 (Control) were 4547 5475 years and 440 4812120and24hrsafterthesurgeryandatthe 5501 years respectively. This difference in the sametimepatientswereaskedforanycomplication agesbetweenthetwogroupswasstatisticallynot suffered by them. Whenever the VAS score was signicant(pvalue0.6450.05)(Table1). above4additionalanalgesiawith50mgtramadol I.V.wasgiven.Totalnumbersoftramadoltopups Table:Weightwisedistributionofthestudyparticipants receivedbyeachpatientwerealsonoted. roup Sample Mean Standarddeiation palue Gabapentin 15 6.9 8.447 0.150.05 atacollection Control 15 66.9 7.58 Post-operativeassessmentofpainwasdoneusing Mean weight in Group A (Gabapentin) and VAS(visualanaloguescale).Otherparameterslike, Group (Control) were 8447 years and additional analgesic reuirements, hemodynamic 758yearsrespectively. Thisdifferencein variables(R)werealsomonitoredatspecictime theagesbetweenthetwogroupswasstatistically intervals. All collected data were recorded in a notsignicant(p–value0.150.05)(Table2). tabular fashion on a printed study proforma that The mean VAS score is lower in Group A waspreparedearlier. (Gabapentin)ascomparedtoGroup(Control)at 1hour4hours12hours1hours20hours24hours Statisticalmethods aftersurgery.Statisticalanalysisprovedthatthere is signicant difference in mean heart rate of the Data was analysed using computer software, twogroupsat1hour4hours1hours12hoursafter statistical package for social sciences (SPSS). The surgery(Table). categorical variableswere presented as percentages Comparison of baseline heart rate in the two andfreuencies.Continuousvariableswereexpressed groups indicates that there is no signicant as means and standard deviations. Changes in differencebetweenthetwogroups.Themeanheart variables were analyzedusing repeated measures rateislowerinGroupA(Gabapentin)ascompared ANOVA. Other outcome variables were tabulated toGroup(Control)at141212024hoursafter andsubjectedtochi-suaretest.Ap -valueofless surgery. Statistical analysis proved that there is than0.05wasconsideredstatisticallysignicant.

Table:DistributionofVASscoreintermsofhoursaftersurgery

VASScore roup Mean Standarddeiation falue alue oursaftersurgery 1hr Gabapentin 0.67 0.724 147.875 0.0000.05 Control 4.1 0.84 4hr Gabapentin 2.47 1.246 41.600 0.0000.05 Control 5.9 1.668 8hr Gabapentin 4.80 1.568 0.257 0.6160.05 Control 4.5 1.02 12hr Gabapentin 4.07 2.219 2.949 0.970.05 Control 5. 1.799 1hr Gabapentin .47 0.15 4.9000 0.050.05 Control 4.40 1.52 20hr Gabapentin 4.1 0.915 12.785 0.0010.05 Control 5.60 1.298 24hr Gabapentin 4.07 1.22 0.980 0.10.05

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1644 IndianJournalofAnesthesiaandAnalgesia signicantdifferenceinmeanheartrateofthetwo ComparisonofbaselineSp02inthetwogroups groupsat4hours12hoursand20hoursaftersurgery indicates that there is no signicant difference (Table4). betweenthetwogroups.ThemeanSpo2islower ThemeanMAPislowerinGroupA(Gabapentin) inGroupAascomparedtoGroupat14812 as compared to Group (Control) at 1 hour, 1 20 24 hours after surgery. Statistical analysis 4hours,12hours,16hours,20hours,24hoursafter proved that there is no signicant difference in surgery. Statistical analysis proved that there is meansaturationofthetwogroupsatvarioustime nosignicantdifferenceinmeanMAPofthetwo periods(p–value0.05)(Table6). groupsatvarioustimeperiods(Table5).

Table:ComparisonintheeartRateamongthestudygroups

eartrate roup Mean Standarddeiation falue alue aseline Gabapentin 67.27 6.497 0.116 0.760.05 Control 68.1 7.96 1hraftersurgery Gabapentin 72.9 11.548 0.085 0.770.05 Control 74.20 12.07 4hrsaftersurgery Gabapentin 75. 9.926 8.970 0.0060.05 Control 84.1 5.566 8hrsaftersurgery Gabapentin 8.20 1.007 .181 0.0850.05 Control 74. 14.196 12hrsaftersurgery Gabapentin 77.00 9.554 4.24 0.0490.05 Control 84.07 9.254 1hrsaftersurgery Gabapentin 74.47 8.766 0.005 0.9460.05 Control 74.7 12.72 20hrsaftersurgery Gabapentin 75.67 12.760 7.766 0.0090.05 Control 87.07 9.92 24hrsaftersurgery Gabapentin 75.5 8.90 0.489 0.4900.05 Control 78.5 14.00

Table:ComparisonintheMeanArterialPressureamongthestudygroups

MAP roup Mean Standarddeiation falue alue aseline Gabapentin 75.60 9.804 5.10 0.020.05 Control 69.97 4.667 1hraftersurgery Gabapentin 76.87 10.49 0.020 0.880.05 Control 77.5 14.952 4hrsaftersurgery Gabapentin 78.1 14.50 8.104 0.0080.05 Control 92.67 1.409 8hrsaftersurgery Gabapentin 87.07 15.691 1.461 0.270.05 Control 81.07 11.11 12hrsaftersurgery Gabapentin 80.1 10.862 .840 0.0600.05 Control 87.80 10.564 1hrsaftersurgery Gabapentin 79.47 12.682 0.005 0.940.05 Control 79.80 12.497 20hrsaftersurgery Gabapentin 82. 16.800 1.952 0.170.05 Control 89.47 10.426 24hrsaftersurgery Gabapentin 78.20 12.214 1.25 0.2760.05

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 OutcomeofOralGabapentininTotalAbdominalysterectomiesonPost-operativeEpiduralAnalgesia 1645

Table:ComparisonintheSpo2amongthestudygroups

Pulseoimeter roup Mean Standarddeiation falue alue aseline Gabapentin 99.00 0.78 1.909 0.178 Control 99.20 0.414 0.05 1hraftersurgery Gabapentin 99.00 0.655 0.085 0.7720.05 Control 99.07 0.594 4hrsaftersurgery Gabapentin 98.9 0.258 0.000 1.0000.05 Control 98.9 0.258 8hrsaftersurgery Gabapentin 98.80 0.414 1.909 0.1780.05 Control 99.00 0.78 12hrsaftersurgery Gabapentin 98.87 0.52 2.154 0.150.05 Control 99.00 0.000 1hrsaftersurgery Gabapentin 98.9 0.458 0.18 0.5770.05 Control 99.00 0.000 20hrsaftersurgery Gabapentin 99.00 0.000 0.18 0.5770.05 Control 99.07 0.458 24hrsaftersurgery Gabapentin 98.9 0.258 0.00 1.0000.05 Control 98.9 0.258

Discussion inthegabapentin-treatedpatientscomparedwith thecontrolgroup.Vermaetal11foundoutintheir Gabapentin is a structural analogue of gamma- study that single oral dose of gabapentin given amino butyric acid. It has been rst reported to 2hrsbeforesurgeryprovidesbetterpaincontrol beeffectivefor thetreatment ofneuropathicpain as compared to the placebo and also reduces and diabetic retinopathy. It has also been used the reuirement of epidural boluses in patients successfullyasanon-opoidanalgesicadjuvantfor undergoingtotalabdominalhysterectomywithout post-operativepainmanagement.Itiseffectivein increase in freuency of side effects. Patients in reducing narcotic usage post- operatively and is theGroupG(gabapentin)hadsignicantlylower helpfulinneuropathicpainduetocancer. VASscoresatalltimes24812and24hrsthan The mean VAS score is lower in Group A thoseintheGroupP(placebo).Thetotalnumber (Gabapentin)ascomparedtogroup(Control)at epidural boluses demanded after surgery in the 1hour4hours12hours1hours20hours24hours rst24hrintheGroupG(gabapentin)(.41.6, aftersurgery.Thiswassimilartothestudiesdone mean SD) was signicantly less than in the by Turan et al10 and Anil verma et al11 owever, GroupP(placebo)(5.62.1,p0.05).12,1 VAS score in gabapentin group was higher than controlgroupatthe8hour. Conclusion The mean heart rate is lower in Group A (Gabapentin)ascomparedtoGroup(Control)at Pre-emptive analgesia is dened as an anti- 1hour4hour12hours1hours20hours24hours nociceptive treatment that prevents the aftersurgery.Statisticalanalysisprovedthatthere establishment of altered central processing of is signicant difference inmean heart rate of the afferentinput,which ampliesthepostoperative two groups at 4 hour,12 hour, and 20 hours after pain.9 Many drugs have been proposed to attain surgery(p-value0.05).Turan,Getal10,found outintheirstudythatoralgabapentin(12gday) the same. Our study found out that the mean asanadjuncttoepiduralanalgesiadecreasedpain VAS score in the post-operative period is lower andanalgesicconsumption.TheVASpainscores in Group A (gabapentin) as compared to Group weresignicantlygreaterat14812and1hr (placebo). ence, we conclude that a single afteroperationinpatientsreceivingplacebothanin oraldoseofgabapentingiven1hrbeforesurgery thosereceivinggabapentin(p0.001).Compared provides better pain control as compared to the with the placebo group, PCA reuirements placebo and also reduces the reuirement of were signicantly reduced in the gabapentin- additional analgesics inpatients undergoing total treatmentgroupat2448,and72hraftersurgery. abdominal hysterectomies receiving epidural Inaddition,oralanalgesicconsumptionwasless bupivacaineinfusion.

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eferences neuralgia:Arandomizedcontrolledtrial.JAMA. 1998;280:187–842.

1. Dahl J, Mathiesen O, Moiniche S. Protective 8. Woolf CJ, Wall PD. Morphine-sensitive and pre-medication: An option with gabapentina morphineinsensitiveactionsofC-fiberinputon andrelated drugsA reviewofgabapentinand theratspinalcord.NeurosciLett.1986;64:221–25. pregabalin in the treatment of post-operative 9. issin I. Pre-emptive analgesia. Anesthesiology. pain.ActaAnesthesiolScand.2004;48:110–16. 2000;9:118–14. 2. Segal A, Rordorf G. Gabapentin as a novel 10. Turan A, aya G, aramanliolu , et al treatmentforpostherpeticneuralgia.Neurology. Apfel: Effects of oral gabapentin on post- 1996;46:1175–76. operative epidural analgesia. r J Anesth. 2006 . Rosner,RubinL,estenbaumA.Gabapentina February;96(2):242–46. adjunctive therapy in neuropathic pain states. 11. VermaA,AryaS,SahuS,etalToevaluatetherole ClinJPain.1996;12:56–58. ofgabapentinaspre-emptiveanalgesicinpatients 4. app JJ. Post-poliomyelitis pain treated undergoing total abdominal hysterectomy in with gabapentin letter. Am Fam Physician. epiduralanesthesia.IndianJAnesth.2008;52:428. 1996;5:2442. 12. Groen GJ, aljet , Drukker J. The innervation 5. Mellick GA, Mellick L. Reflex sympathetic of the spinal duramater. Anatomy and dystrophy treated with gabapentin. Arch Phys clinical implications. Acta Neurochir (Wien). MedRehabil.1997;78:98–105. 1988;92:9–46. 6. ackonja M, eydoun A, Edwards R, et al 1. Renfrew DL, Moore TE, athol M, et Gabapentin for the symptomatic treatment of al Correct placement of epidural steroid painful neuropathy in patients with diabetes injections: Fluoroscopic guidance and mellitus: A randomized controlled trial. JAMA. contrast administration. Am J Neuroradiol. 1998;280:181–86. 1991;12:100–007. 7. Rowbotham M, arden N, Stacey , et al Gabapentina for the treatment of post-herpetic

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1647-1650 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.24

SafetyandSuccessofltrasounduidedInterscaleneandCericalPleus BlockasaSoleAnesthesiaMethodforAcromioclaicularointFiation:A etrospectieObserationalStudy

SureshakumarVariBabu

1,2Associate Professor,Department ofAnesthesiology, Aarupadaiveedu MedicalCollege, irumampakkam, Puducherry 607402, India.

Abstract

urpose:Thepurposeofthisstudyistoanalysethesafetyandsuccessofcombinedinterscalene-cervical plexusblockasasoleanesthesiamethodforAcromioclavicularjointfixationretrospectively.Methodology:We retrospectively analysed and present a case series of acromioclavicular joint fixation surgery that were operatedundercombinedinterscalene-cervicalplexusblockbetweenJan2017andec2018inourinstitute. locksuccess,anycomplicationsasinadvertentarterialpuncture,hematomaformation,respiratorydistress, ornerssyndrome,pneumothorax,andsignsoflocalanesthetictoxicityfromtherecordswereevaluated. Anyconversiontogeneralanesthesia,intra-operativeanestheticsupplementationandtimetoreceivefirst dose of analgesicsalso analysed fromthe records. Results:After exclusion 2patients were analysed and found100blocksuccessrate.Noneofthemreuiredconversiontogeneralanesthesia.Inourstudy,four patients developed hoarseness of voice (12.50), and three patients complained of breathing difficulty (9.8).Noothermajorcomplications.Conclusion:Theultrasoundguidedcombinedinterscaleneandcervical plexusblockabletoprovideasuccessful,safeandeffectivesoleanesthesiatechniueforacromioclavicular reconstructionsurgerieswithoutmajorcomplications.Prospectivecomparativestudywouldprovethatitcan beanalternatemethodovergeneralanesthesia. eyords: Interscalene and cervical plexus block; ltrasonographic guidance; Acromioclavicular joint fixation.

otocitethisarticle: SureshRajkumar,V.ariabu.SafetyandSuccessofltrasoundGuidedInterscaleneandCervicalPlexuslockasaSoleAnesthesia MethodforAcromioclavicularJointFixation:ARetrospectiveObservationalStudy.IndianJAnesthAnalg.2019;6(5Part-1):1647-1650.

Introduction management is typically indicated for patients with Grades IV to VI Acromioclavicular joint injuries.1 A large variety of stabilization methods Acromioclavicular(AC)jointinjuriesaregrouped have been introduced for the Acromioclavicular according to the Rockwood classication system. joint,including-wiretransxation,hookplates, GradesIandIIinjuriesrepresentstrainandpartial arthroscopic tight rope, and suture anchors. One tearing of supporting ligaments and are treated of the treatment modalities is Acromioclavicular conservatively with excellent results. Surgical joint reconstruction by open reduction and

Corresponding Author: V ari Babu, Associate Professor, Department of Anesthesiology, Aarupadaiveedu Medical College, irumampakkam,Puducherry607402,India. Email:[email protected] eceiedon11.06.2019,Acceptedon22.07.2019

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xation using endo button tight rope. Surgical fractures and hypersensitivity to local anesthetics reconstructionofthedislocatedAcromioclavicular (bupivacaine). jointreuiresexposureandinstrumentationofthe Thetechniueusedwasultrasound-guidedin- coracoid. A transverse incision is made over the planelateraltomedialapproachdouble-injection Acromioclavicularjointforthissurgery.suallythis (rstcervicalplexusblockfollowedbyinterscalene surgeryisdoneundergeneralanesthesia,butafter block)method.Thepatientwasplacedinasupine establishment of ultrasound guided interscalene position with the head turned away from the andcervicalplexusblock,wecanprovidecomplete sidetobeblocked. Theskinwaspreparedusing 2 regionalblockwithlessfailurerate. an antiseptic solution, and the transducer was dressed with a sterile cover. A –11 megahert Aims linear transducer was used for performing the blocks.Therelatedsideofthepatientwasscanned Thepurposeofthisstudy isto analysethesafety byultrasoundinatransverseorientationacrossthe and success of combined interscalene-cervical neckwiththeprobemarkerfacingmedially.The plexus block as a sole anesthesia method for blockswereperformedusinga 2gauge(8mm Acromioclavicular joint xation retrospectively. Dispovan) hypodermic needle. First supercial Theprimaryobjectivesaretondthenumbercases cervical plexus block was performed by placing converted to general anesthesia and number of the needle tip deep to the Sternocleidomastoid casesreuiredanestheticsupplementation during muscle along its tapering posterolateral border intra-operative period. The secondary objective is but supercial to the prevertebral fascia and toanalysetheoccurrenceofcomplications. 10 ml of 0.75 bupivacaine injected. Followed byprobemovedcaudallytondoutthecervical nerve roots at interscalene groove in short- MaterialsandMethods axis view and 20 ml of 0.75 bupivacaine was given. Distribution of the local anesthetic drug Following approval by our Institutional Research was visualized during the procedure. Standard and ethical committee, the medical records of monitorswereappliedandpatientsweresedated patients who underwent Acromioclavicular joint withinj.Midazolam(00mgg),inj.Ondansetron xationsurgeryovertwoyears(betweenJan2017 (4 mg) and inj. Fentanyl (1 mgg). To know the and ec 2018) were reviewed. Acromioclavicular desiredeffect,motorblockadewasdeterminedby joint xationthat were operated under combined lossofshoulderabductionandsensoryblockade interscalene and cervical plexus block using was assessed using the spirit cotton for cold endobutton tight rope were included for study. sensationandpinpricktestforpainatthesurgery Surgeries done under general anesthesia and site compared with normal side before proceed Acromioclavicularjointstabilizationdonebyother to surgery. locks were performed by same methods like hook plate, -wire trans xation anesthesia team experienced with ultrasound and also by arthroscopic method were excluded guided regional techniues and also procedure resultinginatotalof2patients. wasdonebythesamesurgeryteam. Patientsanestheticrecordsanddrugchartswere A successful block was dened as one which retrospectivelyreviewedstartingfromJan2017to did not necessitate the conversion to general ec 2018. Also, available stored scanned images anesthesia. Duration of surgery reviewed from of the cases reviewed from the SG machine anesthesiarecordandtimetoreceiverstdoseof local storage system (EsaotemylabGamma, analgesiccalculatedbythedifferenceinthetimeof Italy).Demographic data ofthe patients age, sex, administrationofblockandthetimeofrstdose height,weight,ASAphysicalstatus,timeofdrug of analgesic received by the patient from patient administration, type and volume of the local post-operative nurse chart. Anesthetic records anestheticusedwasnoted.Astandardinstitutional wereanalysedforratesofsuccessfulblocks,failed protocolfollowedinallpatientsplannedforsurgery blocks necessitating conversion to GA and local underregionalblock.Ifpatientsplannedforsurgery or intravenous anesthetic supplementation. And under regional block, they were informed about also,complicationssuchasseizures,hypotension, techniue of regional block. Routine informed breathing difculty, orners syndrome, consent was obtained and documented properly. pneumothorax and drug toxicity accompanying Standard contraindications to interscalene nerve diseases of the patients were reviewed. Data block included coagulopathy, local site infection, were presented as mean standard deviation phrenicnerveparalysis,polytraumawithmultiple orpercentages.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 SafetyandSuccessofltrasoundGuidedInterscaleneandCervicalPlexuslockasaSole 1649 AnesthesiaMethodforAcromioclavicularJointFixation:ARetrospectiveObservationalStudy

esults Discussion

We analysed medical records of 2 patients who In our study, we aim to report our clinical underwent Acromioclavicular joint xation experiences of the ultrasound-guided combined surgeryunderultrasound-guidedinterscaleneand interscalenecervicalplexusblocktechniueasasole cervicalplexusblockovertwoyears.Demographic anesthesiamethodforopenreductionandxation data,clinicalparametersandotherparameterslike of Acromioclavicular joint dislocation. Surgeries ASA physical status and duration of surgery are onclavicleandshoulderunderultrasoundguided shownin (Tables &. Allpatients were male, interscalene and cervical plexus block have been and most of them underwent surgery for right increasing now-a-days. Regional anesthesia is Acromioclavicular joint. In our study, we found always better than general anesthesia but it has 100 success rate and none of them reuired issuesonsafetyandsuccessrate. conversiontogeneralanesthesia.Inthisstudy,no With the advent of ultrasound-guidance, additionalanalgesicswereusedandnointravenous interscalenebrachialplexusblockwithsupercial rescue analgesics was reuired intra-operatively cervical plexus block has become ease and high exceptforonepatientwhoreceivedlocalanesthetic success rate with less complications in view (8mlof1lignocainewithadrenaline)inltration of phrenic nerve paralysis and intravascular due to extension of surgical incision involved T2 injectionleadstolocalanesthetictoxicityorother dermatomalarea. complications.2–4 The possibility of phrenic nerve Inourstudy,fourpatientsdevelopedhoarseness paralysis can be avoided by the local anesthetic ofvoice(12.50),andthreepatientscomplainedof drug spread limited to supercial cervical plexus breathingdifculty(9.8).Theyweremonitored areapossiblewithdirectimagingofneedlelocation closely and their vital parameters and oxygen usingultrasoundguidance.5 saturationwerenormal.Sevenpatientsdeveloped Although the incision for Acromioclavicular orners syndrome (21.88), which is clinically surgery is different from surgical incision for insignicant.Notreatmentwasreuiredforthose fracture clavicle, the incision is conned to the complications and subsides with recovery from block area of interscalene and supercial cervical block effect. In our study, intra-operative vitals pexus,displaysin(Fig). werestableinallpatientsandtherewerenoother major acute or chronic complications noted. The mean time to receive the rst dose of analgesic observedinourstudywas15052hours.

Table:Demograhicandintraoperativevitalsdata

Numberofpatients ASA(I/II/III) (21/8/) Parameter MeanSD Age(year) 8.7811.09 Weight(kg) 71.656.72 eight(cm) 159.757.22 Fig:Showingsurgicalincisionareaandprocedures PulseRate(Intra-operative) 81.228.02 Inourstudy,wefound100blocksuccessandno SystolicP(Intra-operative) 128.1214.86 DiastolicP(Intra-operative) 79.068.9 patients reuired conversion to general anesthesia. One patient received local anesthetic inltration Meanstandarddeviation. during intra-operative period. From the anesthesia Table:Surgicalandanesthesiaoutcomes record we found that, the patient was obese and reuiredfurthersurgicalincisionforbetterexposure Durationofsurgery(minutes) 61.09.09 belowthelateralendoftheclavicleanteriorlyinvolves Timedurationtoreceivefirstdoseof 6.150.52 analgesia(hour) T2dermatome.Around8mlof1lignocainewith locksuccessrate 100 adrenaline was inltrated from subcutaneous to Additionalanestheticsupplementation surgicaldepthbeforeextendingincisionbelow. nil reuired In our study, complications were minimal and Complications didnotreceiveanyspecictreatment.Fourpatients ornerssyndrome 21.88(7/2) oarsenessofvoice 12.50(4/2) developed hoarseness of voice probably due to blockade of recurrent laryngeal nerve. And three reathingdifficulty 9.8(/2)

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1650 IndianJournalofAnesthesiaandAnalgesia patients were presented with breathing difculty andgoodalternativetogeneralanesthesia. whichwasmildsubjectivedyspnoeaduetophrenic nervedysfunction.Reassurancewasgiventothese AcnoledementNil patientsandtheywereexplainedthatshortnessof riorublicationNil breathismildsubjectivefeelingandhoarsenessof voicewillresolvewithrecoveryfromblockeffect. SuortNil All these complications were mild and managed withreassurance. ConictsofinterestNil Thecombinedinterscalene-cervicalplexusblock ermissionsNIL for clavicular surgeries was used as a primary method of anesthesia by alaban et al6, shown highsuccessrate.Theyfoundthismethodeffective eferences forachieving surgicalanesthesiaandcanbeused as an alternate method to general anesthesia. 1. Collins DN. Disorders of the acromioclavicular Recentstudybyanerjeeetal7,comparedgeneral joint.In:RockwoodCAJr,editor.Theshoulder.4th anesthesia with ultrasound-guided dual block edition. Philadelphia: Elsevier ealth Sciences; (supercial cervical plexus block and interscalene 2009.pp.45–526. brachial plexus block) for clavicular surgeries 2. apral S, Greher M, uber G, et al regarding various parameters such as intra- ltrasonographicguidanceimprovesthesuccess operative anesthesia, post-operative analgesia, rateofinterscalenebrachialplexusblockade.Reg AnesthPainMed.2008;():25–58. anddischargetimefrompost-operativecareunit. The time interval for the rst complaint of pain . adzic A, Williams A, araca PE, et al For in interscalene brachial plexus block group is outpatient rotator cuff surgery, nerve block anesthesiaprovidessuperiorsame dayrecovery comparablewiththetimetoreceivetherstdose over general anesthesia. Anesthesiology. 2005 ofanalgesic(15052hours)inourstudy.When May;102(5):10011007. compare to Contractor et al8, our study shows, 4. NealJM.ltrasound-GuidedRegionalAnesthesia lessincidencesofsideeffectsornerssyndrome and Patient Safety: pdate of an Evidence-ased (21.8)andhoarsenessofvoice(12.5).Noother Analysis.RegAnesthPainMed.2016;41(2):195–204. signicantsideeffectswerenoted. 5. Masters RD, Castresana EJ, Castresana MR. Superficial and deep cervical plexus block: imitations Technicalconsiderations.AANAJ.1995;6:25–4. Limitationsofthisstudystartsfromitsretrospective 6. alabanO,DlgeroluTC,AydnT.ltrasound- guided combined interscalene-cervical plexus nature, and also several measurements like block block for surgical anesthesia in clavicular performance, onset time, post-operative VAS score fractures: A retrospective observational study. and analgesic reuirement were not evaluated. AnesthesiolResPract.2018;2018:7842128. Acromioclavicular joint reconstruction is a rarely 7. anerjee S, Acharya R, Sriramka . ltrasound- performed intervention, a smaller number of cases guided inter-scalene brachial plexus block with was also a limitation. This should be a prospective superficial cervical plexus block compared studytoanalysesurgeonandpatientsatisfaction,post- with general anesthesia in patients undergoing operative pain score, analgesic duration, analgesic clavicular surgery: A comparative analysis. reuirementandhospitalstayinnearfuture. AnesthEssaysRes.2019;1:149–54. 8. Contractor,ShahVA,GajjarVA.ltrasound Conclusion guidedsuperficialcervicalplexusandinterscalene brachial plexus block for clavicular surgery. AnesthPainIntensiveCare.2016;20:447–50. This retrospective analysis shows that ultrasound 9. im JS, o JS, ang S, et al Cervical plexus guided interscalene and cervical plexus block block.oreanJAnesthesiol.2018;71(4):274–288. was safe with minimal complications and able to 10. Shanthanna . ltrasound guided selective provideadeuatesurgicalanesthesia.Inconclusion, cervicalnerverootblockandsuperficialcervical ultrasound guided combined interscalene and plexusblockforsurgeriesontheclavicle.IndianJ supercial cervical plexus block can be a sole Anesth.2014;58:27–79. anesthesiamethodofchoiceforAcromioclavicular 11. Singh S. The cervical plexus: Anatomy and reconstruction surgeries. Further prospective and ultrasoundguidedblocks.AnesthPainIntensive comparativestudywouldprovethatitcanbeasafe Care.2015;19:2–2.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1651-1658 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.25

EaluationofTransdermalFentanylforPostoperatiePainelief

VipinumarVarshneyarshaslialMMNeema

1AssistantProfessor,DepartmentofAnesthesiology,TeerthankerMahaveerMedicalCollegeResearchCentre,Pakwara,ttar Pradesh244001,India.2AssistantProfessor,Professorandead,DepartmentofAnesthesiology,RDGardiMedicalCollege,jjain, MadhyaPradesh456001,India.

Abstract

acground: Overview of post-operative pain control strategies lacks high uality effectiveness of the commonlyusedanalgesics.Restricteduseofstrongsystemicanalgesicsborneoutofthefearofrespiratory depressionandotheropoidsrelatedcomplicationslikenausea,vomiting,constipation,urinaryretentionetc. thatresultsinfailuretoprovidecontinuousanalgesiaofgoodualityinpost-operativeperiod.Therapeutic transdermal fentanyl (TTF) is a uniue innovative way of administering strong analgesic fentanyl transcutenously. Pharmacokinetic studies provides sufficient evidences that with TTF plateau analgesic concentrationoffentanylareattainedafter8–12hoursandaremaintainedoverprolongedperiodof72hours ormoreasthedrugremainsincirculationevenafterremovalofpatch.Therefore,TTFisexpectedtoprovide continuousanalgesiaofsuperiorualityinpost,operativeperiod.MaterialsandMethods:25patientsincluded in the study underwent major surgeries under uniform method of general anesthesia with gas, oxygen, relaxant and analgesic techniue with controlled ventilation on ain circuit. On these patients fentanyl transdermalpatchreleasing50mcghourfentanylwasappliedtothehairfreeskinonlateralchestwalland securedinplacejustbeforeinductionofanesthesia.Weassessedtheuality,durationandintensityofpain; patientscomfortscore,reuirementsofrescueanalgesics,efficacysafetyinitsuse,patientssatisfaction. Wevigilantlyobservedthemforanyadversecardiovascular,respiratoryandlocalcomplications.Results:68 (17/25)patientsdidnotdemandrescueanalgesicdoseduringentirepost-operativeperiodandmeanVAS scorewaslessthan1after12hourspost-operativelytilltheobservationperiodof72hours.Only2(8/25)of thepatientsreuiredsupplementanalgesicwithone/twodoseof75mgdiclofenacsodiumbyintramuscular route. All patients expressed satisfaction with the analgesia provided; some had local complications like erythemaatpatchapplicationsite.Thepatientsunderstudyneithershowedincidencesofsevererespiratory depressionnoracutechangesincardiovascularparameter(R,ECGandSP,DP)measurementthroughout studyperiod.Thechangesobservedincardiovascularandrespiratoryparameterwerein-significantanddid notreuirespecifictreatment.Conclusion:TherapeuticTransdermalFentanylreleasing50mcghrfentanylcan besafelyusedtocontrolpost-operativepainandiseffectiveafter8–12hoursofapplicationwithfewerside effectsatpatchapplicationsite. eyords:PostopPain;Transdermal;Cardiovascular.

otocitethisarticle: VipinumarVarshney,arshasliwal,MMNeema.EvaluationofTransdermalFentanylforPost-operativePainRelief.Indian JAnesthAnalg.2019;6(5Part-1):1651-1658.

CorrespondingAuthor: arshaslial,AssistantProfessor,DepartmentofAnesthesiology,RDGardiMedicalCollege,jjain, MadhyaPradesh456001,India. Email:[email protected] eceiedon10.05.2019,Acceptedon05.06.2019

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Introduction fentanyl administration in management of post- operative pain following surgeries of moderate Traditionally systemic administration of narcotic toseverecategory.Studywasaimedtoassessthe analgesics (morphine/pethidine) remained safety, efcacy and uality of analgesia provided cornerstone for management of post-operative byTTF. pain for decades. This practice exposed patients Aimofthepresentstudytodetermineualityand toopioidrelatedcomplicationslikedisorientation, duration of Post-operative pain control offered depressionofrespiration,urinaryretention,bladder by transdermal administration of fentanyl and andboweldisturbances,nausea,vomiting,pruritus associationofsideeffectswithtransdermalrouteas etc. Reluctance in their prescription is because seenwithsystemicadministrationfentanyl. of fear of addiction, caused incidences of break through pain in post-operative period. Freuent MaterialsandMethods administration of analgesics on demand poses work load on nursing/paramedical staff.1,2 Series ofsyntheticanalogueofmorphinewereresearched The present study was conducted between June and several narcotic analgesics were marketed as 201toebruary2015inRDGardiMedicalCollege saferalternatives.Fentanylcitrateisonesuchpotent jjain. We calculated the sample size assuming narcotic analgesic synthesized in 1960 by Paul thatwithTTF,0patientswouldneedadditional Johnson and is favored in clinical anesthesiology analgesic and an alpha error of 0.05 and 80 because of its excellent pharmacological and power of study. We needed 21 patients for the pharmacokinetic prole and intra-operative studyandtherefore,theClinicalobservationswere cardiovascular stability. 1975 onwards fentanyl madeon25adultpatientsofbothgendersofASA waswidelyacceptedasintravenoussupplementto physical status I/II undergoing various surgeries produce balanced anesthesia. Although, fentanyl under general anesthesia. Pre-operatively all the can be used by traditional systemic route of patients were screened to rule out presence of administrationbut,itspharmacokineticproperties pre-existing cardiovascular, respiratory, renal or prompted investigators to explore alternative hepatic diseases besides routine biochemical and methods of its administration in an attempt to hematological tests. Patients were assured for enhancetheualityofanalgesia.Fentanylwasused providingadditionalanalgesiaondemand. as continuous intravenous infusion, by intra and extra thecal route and also with peripheral nerve atchAlication blocks.Newermodalitiesofitsadministrationlike patientcontrolledanalgesiasystem(PCA)cameinto Fentanyl patch was applied immediately before existence. Fentanyl proved its effectiveness in all inductionofgeneralanesthesiaonrightsideofchest theroutesofitsadministration.utallthesereuire wallonnon-hairyskinwithoutusingantisepticor technical expertise and are costly methods.2,4,5 spiritandsecuredinplace.Timeofpatchapplication Patchisamedicatedtape,typicallyconsistsofone was counted as zero hour. Anesthesia techniue: or multiple layers of medicated membrane, or a niform techniue of balanced anesthesia was drug reservoir or a semisolid matrix of drug; for adoptedforallthepatients.Inductionofanesthesia applicationtotheskin.Patchapplicationprovides was done with injection propofol 2– mgg, constantrateofdrugdeliverynon-invasivelyand followedbysuccinylcholinechloride2mgg(max. maintainsuniformconcentrationofdruginbloodfor dose100mg)tofacilitateendotrachealintubation. severalhours.Novelmethodstoimprovediffusion Maintenance of anesthesia was achieved with ofdrugthroughintactskinincorporateschemical injection pentazocine 0 mg and atracurium. enhancers,ionophorasis,microneedle,ultrasound PatientswereventilatedwithGas,Oxygen(50:50) etc.withpatch.,5Therapeutictransdermalfentanyl andIsourane0.6to1.2.ThedoseofIsourane patch(TTF)wasinitiallyavailableformanagement wasadjustedtokeeppulserateandbloodpressure of chronic pain. Since 1999, TTF have also been within20ofpre-operativevalues.Continuous usedformanagementofacutemoderatetosevere monitoring of vital signs was done using multi- post-operative pain. SFDA has approved use of parameter. eart Rate, Electrocardiogram, SpO2, iontophoresispatchafterPhaseIIIclinicaltrialsfor non-invasivebloodpressurerecordedat0minutes post-operative pain control. TTF is an advanced tillrecoveryfromanesthesia. Durationofsurgery pain management system that addresses many wasrecordedinminutes.Residualneuromuscular concernofsafetyandconvenienceofuse.4Weare blockwasreversedwithneostigmine25mgwith presenting our experiences of using transdermal glycopyrrolate 04 mg. Post-operative monitoring: IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EvaluationofTransdermalFentanylforPost-operativePainRelief 165

pon arrival in recovery room vital parameters tocommentonualityofpainreliefas-satisfactory were recorded and initial pain assessment was ornotsatisfactory. doneusingVAS(VisualAnalogueScale).Patients having initial pain score more than 5 were given esults injectiondiclofenacsodium75mgbyintramuscular route.Afterrecoveryfromgeneralanesthesiaand in no discomfort condition, patients were shifted Thedemographicdataofthepatients,sexratioand to post-operative surgery ward and monitored meandurationofsurgeryofpatientsunderstudy for pain intensity, changes in vital parameters, showsin(Table). respiratory rate, SpO , comfort score every two 2 The changes observed in mean eart rate, hours for 24 hours and every si hours for next systolic and diastolic pressure, ECG changes 24 hours and every 12 hours till 72 hours. Patients observed are displayed in (raphs ). After havingpainscoremorethan5wereadministereda inductionanesthesiaandintubationanincreaseof doseofdiclofenacsodium75mgbyintramuscular 77 bpm in R, 541 and 50 mm of g in systolic route. Although the patch was removed after anddiastolicpressurewasobserved.Inremaining 48hoursafterapplication;Patientswerekeptunder intra-operative period cardiovascular parameters observationfor72hoursforoccurrenceofdelayed remainedwithin20ofbaselinevalueanddidnot respiratory depression. Application site was neededtreatment. inspectedforlocaltissuereaction.Patientsreceived oxygenthroughfacemask@ 4litmt.till 12hours Table is showing the changes observed in post-operatively.After48hourspatientswereasked mean heart rate, systolic and diastolic pressure

Table:DemographicdetailsofStudyPopulation

Parameter Meanalue angeofobseration Age 81111years 20–0years eight 1558cms 14–175cms Weight 052g 50–70g odyMassIndex 24.00 Male/Female 11:24 Meandurationofsurgery 1407274minutes 100–200minutes

98

96

94

92

90

88

86

84

82

80

raph:MeanPulserateinbeatsperminute

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1654 IndianJournalofAnesthesiaandAnalgesia

Table:Meaneartrate,systolicanddiastolicpressureduringthefirst12hoursofTTFapplication

Meanalueinbm Meanalueinmm Meanalueinmm Timeinterals MeanSD SBPMeanSD DBPMeanSD Post-operativeonarrivalinRR 96.08.26 11.111.28 86.079.81 After0mininRR 95.117.18 1.8.66 87.97.57 2hours 92.155.14 129.488.22 81.567.81 4hours 89.047.61 129.488.69 82.897.4 hours 87.856.81 128.5210.12 82.967.77 8hours 87.267.7 128.229.0 81.567.9 10hours 87.68.67 127.10.05 80.817.91 12hours 84.0710.10 12.4811.8 77.9.20

Table:MeanVASscoreatdifferenttimeintervals

Timeinterals VASscoremeanalueMeanSD 2hours 2.70.9 4hours 1.890.9 hours 1.961.7 8hours 2.001.47 10hours 1.61.01 12hours 1.671.47 24hours 0.000.00 hours 0.241.01 48hours 0.241.01 0hours 0.601.50 72hours 0.881.59

raph:Meancomfortscale(post-operativeto72hours)

Table:MeanPulserate,systolicanddiastolicbloodpressureatpost-optimeintervals

Pulseratein Systolicblood DiastolicBlood Timeinterals bm pressureinmm Pressureinmm MeanSD MeanSD MeanSD Post-operative(at0minutesinRR) 96.728.44 10.21.42 85.529.95 12hour 84.1610.41 12.2811.76 77.049.51 24hours 70.25.91 109.0410.6 68.407.02 hours 71.447.67 115.9211.28 74.007.2 48hours 72.28.6 115.209.95 7.128.41 0hours 77.607.21 12.7610.45 78.248.29 72hours 77.688.16 12.209.5 78.568.42

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Table:MeanValueofcomfortscoreatdifferenttimeintervals (14 doses) rescue dose of analgesic in majorityin Meanalueofcomfort earlypost-operativeperiod.Inlaterperioddemand Timeinterals scoreMeanSD wasreducedgreatly. 2hours 2.260.5 4hours 2.040.44 Table:Reuirementofrescueanalgesia hours 2.260.71 escue Numberof ofpatients 8hours 2.260.66 analgesia patientsanddose 10hours 2.040.44 Reuired 8(14) 2.0 12hours 1.960.71 Notreuired 17(ero) 68.0 24hours 1.000.00 Total 25 100.0 hours 1.560.65 48hours 1.680.6 0hours 2.080.40 72hours 2.120. during the rst 12 hours of TTF application. We observed statistically and clinically insignicant fall in eart rate, systolic and diastolic pressure. Reuired Patientswerecloselyobservedinremainingpost- NotReuired operative period upto 72 hours and we observed insignicantchangesincardiovascularparameters didnotfoundclinicallysignicantchanges.Mean value of oxygen saturation and respiratory rate were clinically and statistically insignicant. Patientswerecloselyobservedinremainingpost- raph:Reuirementofrescueanalgesia operative periodupto 72 hoursand we observed Tableshowsthepatientsnarrationonuality in-signicant changes in respiratory parameters of analgesia provided to them in post-operative didnotfoundclinicallysignicantchanges.Patient period.Allpatientsincludedinthestudyexpressed was considered to have respiratory depression satisfaction with the analgesia provided with or if RR was less than 10 and SpO less than 90. 2 withoutneedofrescueanalgesia. At2hoursofobservationthemeanVASscorewas 2.7 0.9. It decreased to 17 at 12 hours post- Table:Patientssatisfaction operatively,indicatingthatsomepatientshadmild post-operativepainafterrecoveryfromanesthesia. Satisfied 25 PatientswhohadVASscoreeualtoormorethan5 Non-satisfied 00 weregivenrescueanalgesicdosebyintramuscular Tableshowsthecomplicationrateofoccurrence route(injectiondiclofenacsodium75mg).Patients ofsideeffectpeculiartosystemicnarcoticanalgesic. werepracticallypainfreebetween12and72hours. Nopatientincludedinthestudyshownclinically Table shows the pain intensity measured on signicant fall in respiratory rate or oxygen Visual Analogue Scale in early post-operative saturation of hemoglobin reuiring supplemental period(PainScale)(N25) oxygen therapy after 12 hours till the removal of Table shows that mean pulse rate, systolic patch at 48 hours and thereafter till 72 hours. No and diastolic blood pressure remained close to incidenceofpruritusatthesiteofpatchapplication pre and immediate post-operative mean and did orgeneralized itching wasnoted. 08patientshad not need corrective treatment. Table shows the erythemaofsurroundingskinofpatchapplication mean comfort score majority of patients had a site. comfortscoreof2–indicatingthateitherpatient hadnopainormilddiscomfort.Patientscomfort Table:AdversedrugreactionandlocalreactiontoPatch wasmonitoredon6pointscaleusedbyRafaeland Migueletal(1995). Parameter Numberofpatients Fallinrespiratoryrate 00 Tableshowsthereuirementofrescueanalgesia Lowoxygensaturation(Lessthan95) 00 75 mgdiclofenac. Pain and analgesic reuirement rinaryretention 00 werelowestafter18–24hours.68(17/25)didnot Pruritus 00 reuired where as only 2 patients demanded Localerythema 08/25

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1656 IndianJournalofAnesthesiaandAnalgesia

Discussion imeofatchAlication Weappliedthefentanylpatchjustbeforeinduction Painmanagementisanessentialelementofpatient ofanesthesiawhichdidnottakepharmacokinetic care and rehabilitation following surgery, as the consideration of transdermal administration. resultsofclinicalstudieshasshownthateffective Patients therefore, were expected to have plasma pain control can reduce patients morbidity concentration lower than analgesic concentration and associated healthcare cost in addition to in the window period and may demand rescue minimization of patients anxiety and physical analgesic. For the above reasons in present discomfort.6 Currently used Patient Controlled study, we did not nd adeuate analgesia in all Analgesia (PCA) to treat post-operative pain patientsinrst12hoursofpatchapplication;2 introduces some potentially dangerous risk from patients reuired rescue analgesia in immediate invasivemethod,errorsinmanualprogrammingof post-operative period. Similar to our ndings pump,needlerelatedinjuries,infection,limitationof Rawbotham et al (1989),11 Sevarino et al (1997),12 mobilityandhighmaintenancecostandavailability Caplan et al (1989),1 Gourlay et al (1990),14 6 for all patients. Transdermal fentanyl is an Alan N sandler et al (1994),15 did not consider advancedpainmanagementsystemandaddresses pharmacokinetics and administered transdermal manyconcerns(issues)ofsafetyandconvenience fentanyl before induction of anesthesia and ofuse.TransdermalDrugDeliverySystem(TDDS) reported in their studies that analgesiceffectwas needs more clinical evaluation across population commonlylessapparentduringrst12hoursafter dividedaccordingtobodyweight,ageandtimeof application. surgerytoevaluatepotentialimpactoftransdermal fentanyl16inclinicalpractice. Pharmacokinetic prole suggests (IJ roome etal.1995)8thatpatchshouldbeapplied8–12hours beforeanesthesiatoachieveanalgesiainearlypost- oseSelection operativeperiod.Thosestudiesinwhichfentanyl Choiceoftransdermaldeliverysystemoffentanyl patchapplied8–12hoursbeforeanesthesiaprovided withpredicteddeliveryrateof50mcghrwasbased adeuateanalgesiainearlypost-operativeperiod. onpreviousstudiescharacterizingtherelationship betweenserum concentration andanalgesic effect RescueAnalesia inpost-operativepatients.Weusedmatrixtypeof patchinthestudy. Inpresentstudy,75mgofdiclofenacsodiumwas administered by intramuscular route as rescue 7 ug CC et al (1984) found that use of lower analgesic.Weconsideredthatpost-operativepain dose releasing fentanyl patch 25 mcghr resulted in is a complex phenomenon and involves multiple in-signicant reduction in morphine consumption. factors.Presenceofinammationinpost-operative igherdosesof75mcghrplacedthepatientsatrisk patients at the operative site is an important 8 of respiratory depression. IJ roome et al (1995) accompanying factor and hence, diclofenac have shown that peak analgesic concentration wasused. of 1425 ngml much below the dose (–4 ngml) causing severe respiratory depression is achieved In none of study, available anti-inammatory at hours. igher rates of fentanyl delivery were drug was used as rescue analgesic. All reported associated lower VAS score and reduced morphine studies employed morphine as supplemental consumption as rescue analgesic. Concentration of analgesiceitherasbolosorPCApumpdelivering fentanylinplasmacanbeincreasedbyadministering pre-xeddoseoffentanylintravenously. intravenous loading dose at the start of surgery. Analgesic concentrations are maintained from fficacyofransdermalFentanyl 12hoursto48hours.SamyAetal(2012)9foundthat reservoirandmatrixtypeofpatcharebioeuivalent Sixty-eight percent of the patients did not and delivered fentanyl at constant rate and shown reuire additional rescue analgesic dose. Only 8 linerkinetics.AuthorsfoundthatusingTDDSwith patients needed 14 doses of additional analgesia predictednominalrate50mcghrachieveeffectiveand in majority in early post-operative period. ug safeanalgesiainpatientsundergoingpelvi-abdominal CC (1984)7 reported that there is a interpersonal cancersurgery.Sevarinoetal(1997)10uestionedthe variability in serum concentration resulting utility of transdermal fentanyl in combination with from pharmacokinetic, pharmacodynamic and intravenousmorphinesupplementconsideringmulti psychologicalfactors.Sandleretal(1994)15compared factorialgenesisofpost-operativepain. transdermalfentanylintwodifferentdeliveryrate IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EvaluationofTransdermalFentanylforPost-operativePainRelief 1657

50 mcghr and 75 mcghr with placebo for post- in comparison to placebo. Difference between operativeanalgesiaafterabdominalhysterectomy. the two fentanyl group was not signicant. Also Thepatchwasappliedtwohoursbeforesurgeryand reported that patients comfort score signicantly removedafter72hours.Theyfoundthattherewere bettercomparedwithplacebogrouppatients.We signicant reduction in pain intensity and rescue did not nd signicant lowering of pulse rate, analgesic with delivery rate of 75 mcghr when blood pressure and ECG abnormality during compared with placebo and there was signicant post-operative observation period of 48 hours. reduction in rescue analgesic consumption with Cardiovascularparametersremainedwithin20 50 mcghrdose. ilbride M etal(1994)16reported oftheirbaselinevalues.Similartondingsofour asignicantreductioninpost-operativeanalgesic study Lauretti GR et al (2009),18 reported that all reuirements after hemorroidectomy using physiologicalparametersuctuatedwithinnormal 50 mcghr fentanyl releasing patch. Severino et al range.PhilipWetal(1999)19inareviewarticle (1992)10comparedtwodifferentdeliveryrate25and shown that fentanyl at a plasma concentration of 50mcghrwithplaceboforpost-operativeanalgesia –4ngmlalterscarbondioxideresponseofcentral afterabdominalgynecologicalsurgery.Therewere respiratory control by 50. These concentrations no differences in the pain intensity in both TDF arenotachievedwith50mcgmlpatchbutcautions group and no difference in rescue analgesia in for continuous measurement of ventilation is TDF group with delivery rate of 25 mcghr when preferable. Factors responsible for respiratory compared with placebo group. There was only a depressionaretypeofsurgicalprocedure,elderly signicantreductionintherescueanalgesiainthe patients, interaction withothercentraldepressive TDFgroupwithadeliveryrateof50mcghr. drugsandindividualvariationinpharmacokinetics andpharmacodynamics. ualityofanalesia Adversedrureactions During entire observation period68 patient felt nopainduringentireobservationperiod;Onlyin The patients were observed for opioids like side 8/25 patients experienced pain of intensity more effects after patch application. We did not notice than5onVASinmajorityinearlypost-operative signicant fall in respiratory rate, fall in oxygen periodforthat14dosesifrescueanalgesicdiclofenac saturation below 95 reuiring oxygen therapy, sodiumbyintramuscularroutewereadministered. urinaryretentionandpruritus.Localcomplication AdditionaldoseofdiclofenacsodiumreducedVAS likeerythemaoccuredatthepatchapplicationsite atnextobservation. in 2 cases which did notreuired any kind of ug CC (1984)7 reported that there is a treatmentandresolvedin72hours.Incontradiction 17 interpersonal variability in serum concentration to our ndings Rafael M (1995) reported that resulting from phramcokinetic and pruritus occurred in 10 patients who received pharmacodinamic and psychological factors. 0–100 mcghr than in patients and in 6 with And we decided to usediclofenac as multimodal 70–80mcghrgroup.Erythemawasmorecommon approach.VASscorewas0–2inallpatients,after in 0–100 mcg group. Possible reason for not 12hoursofpatchapplicationandwasmaintained conrmingtoourndingsisemploymentofhigher till 48 hours and started rising after wards. All doseoftransdermalfentanyl. patients expressed satisfaction with the analgesia providedwitheithertransdermalfentanylaloneor Conclusion with intramusculardiclofenac asrescue analgesia when they rated their pain intensity eual to or Transdermalfentanylissuperior,safeandeffective more than 5 and remained pain free throughout methodofmanagingpost-operativepainoverthe observation period. The safety and efcacy of traditional systemic opioid and can be a part of transdermalfentanylusedasmainpost-operative multimodal approach. It is free from side effects analgesicinpatientsundergoingdorsalorlumbar of intravenous administration. 50 mcghr fentanyl spinefusionVASscoreandrescueanalgesicwere releasing patch proved as safe and effective in lowerintransdermalfentanylgroup. patientsofnormalbuilt. I power (2007)6 reported that patients rated pain relief as good to excellent analgesia in post- Caution operativeperiodinITFgroupinIIandIII24hour period.RafaelMetal(1995)17reportedonpatients It is important to observe patients for respiratory global satisfaction of analgesia in TDF groups parameters closely for occurrence of respiratory IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1658 IndianJournalofAnesthesiaandAnalgesia depression and oxygen supplement should be after major abdominal surgery. J Am Sci. doneasandwhenreuired.Medication(Injection 2012;8(6):417–24. Nalaxone) readily reverses the respiratory 10. Betal depression. .A.199277346366. eferences 11. Rowbotham DJ, Wyld R, Peacock JE, et al Transdermal fentanyl for the relief of pain 1. Allen LV, Popovich NG, Ansel C Ansels after upper abdominal surgery. r J Anesth. PharmaceuticalDosageFormsandDrugDelivery 1989;6:56–59. th Systems, 8 Edition. Lippincott Williams 12. Sevarino F, Paige D, Sinatra RS, et al Post- Wilkins;2005.pp.298–15. operative analgesia with parenteral opioids: 2. Anna M Wokovich, Suneela Prodduturi, William Doescontinuousdeliveryutilizingatransdermal Doub, etalTransdermaldrugdeliverysystem opioid preparation affect analgesic efficacy or (TDDS) adhesion as a critical safety, efficacy and patientsafety.JClinAnesth.1997;9():17–78. ualityattribute.EuropeanJournalofPharmaceutics 1. Caplan RA, Ready L, Oden RV, et al andiopharmaceutics.2006Aug;64(1):1–8.https:// Transdermal fentanyl for post-operative pain doi.org/10.1016/j.ejpb.2006.0.009. management. A double-blind placebo study. . ArchanaGaikwad.Transdermaldrugdelivery JAMA.1989;261:106–069. system: Formulation aspects and evaluation. 14. GourlayG,owalskiSR,PlummerJL,etalThe Comprehensive Journal of Pharmaceutical efficacyoftransdermalfentanylinthetreatmentof Sciences.201Feb;1(1):1–10. post-operativepain: A double-blindcomparison 4. arry.TransdermalDrugDelivery,Inedition. offentanylandplacebosystems.Pain.1990;40:21. AultonME,Pharmaceutics.ChurchillLivingston: 15. Sandler AN, axter AD, atz J, et al A double The Science of Dosage Form Design; 2002. pp. blind placebo-controlled trial of transdermal 499–5. fentanyl after abdominal hysterectomy. 5. erner and John VA. Pharmacokinetic Analgesic, respiratory, and pharmacokinetic characterisationoftransdermaldeliverysystems. effects.Anesthesiology.1994;81:1169–180. ClinPharmacokinet.1994;26:121–4. 16. ilbride M, Morse M and Senagore A. 6. PowerI.FentanylCIiontophoretictransdermal Transdermal fentanyl improves management system(ITS):Clinicalapplicationofiontophoretic of post-operative hemorrhoidectomy pain. Dis technology in the management of acute post- ColonRectum.1994;7:1070–072. operativepain.ritishJournalofAnesthesia.2007 17. Miguel R, reitzer JM, Reinhart D, et al Post- Jan;98(1):4–11.doi:10.109/bja/ael14. operative pain control with a new transdermal 7. ug CC. Pharmacokinetics and dynamics of fentanyl delivery system. A multicenter trial. narcoticanalgesics.In:Prys-RobertsC,ugCC, Anesthesiology.1995;8:470–77. edition.PharmacokineticsofAnesthesia.Oxford: 18. LaurettiGR,MattosAL,AlmeidaR,etalEfficacy lackwellScientificPublications;1984.p.187–24. offentanyltransdermaldeliverysystemforacute 8. roome IJ, Wright M, ower S et al Post- post-operativepainafterposteriorlaminectomy. operative analgesia with transdermal fentanyl Poster Sessions European Journal of Pain. following lowerabdominal surgery. Anesthesia. 2009;1:S55–S85. 1995;50:00–0. 19. Peng PW, Sandler AN. A Review of the use 9. SamyAAmr,MostafaGMostafa,andMohamed of fentanyl analgesia in the management of AMMostafa.Efficacyandsafetyoftransdermal acute pain in adults. Anesthesiology. 1999 fentanyl patches on post-operative pain relief Feb;90(2):576-99.

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 IndianJournalofAnesthesiaandAnalgesia OriginalResearchArticle 2019;6(5)(Part-I):1659-1664 DOI:http://dx.doi.org/10.21088/ijaa.249.8471.6519.26

Ealuation in Supraclaicular Brachial Pleus Block beteen DemedetomidineanddeamethasoneasanAduanttoocalAnesthetic: ADoubleBlindProspectieStudy

ThomasPeorgeiranumarToeoseph

1AssociateProfessor,AssistantProfessor,PushpagiriInstituteofMedicalSciencesandResearchCentre,Thiruvalla,erala689101, India.2Consultant,NSMemorialInstituteofMedicalScience,NypassRoad,Palathara,ollam,erala691020,India.

Abstract

acground:Supraclavicularbrachialplexusblockisacommonlyemployedregionalnerveblocktechniue for upper extremity surgery. Various adjuvants were added tolocal anesthetics in brachial plexus block to achieverapidonsetandprolongedblock.Objective:Tocomparedexamethasoneanddexmedetomidineasan adjuvanttolocalanestheticagentinsupraclavicularbrachialplexusblockwithrespecttoonsetanddurationof sensoryandmotorblock.Methods:FortyASAIandIIpatientsscheduledforelectiveupperlimbsurgeriesunder supraclavicularbrachialplexusblockweredividedintotwoeualgroupsinadouble-blindedfashion.Group onewasgiven0.25upivacaine2milligram/kgaslocalanestheticandDexmedetomidine1microgram/kg asadjuvant.Grouptwowasgiven0.25upivacaine2milligram/kgandDexamethasone100microgram/kg asadjuvant.Onsetanddurationofsensoryandmotorblockadeandhemodynamicstabilitywererecorded. Allpatients were observed for any side effects and complications. All data were recorded, and statistical analysiswasdone.Results:Sensoryblockandmotorblockonsetwasearlierindexmedetomidinegroup.The duration ofblockadewasalso prolonged in dexmedetomidine group when compared with dexamethasone groupandisnotassociatedwithanymajorside-effect.Conclusion:Dexmedetomidineisabetteradjuvantthan dexamethasoneinsupraclavicularbrachialplexusblock.

eyords:Dexmedetomidine;Dexamethasone;upivacaine;Supraclavicularbrachialplexusblock.

otocitethisarticle: ThomasPGeorge,iranumarT,JoeJoseph.EvaluationinSupraclavicularrachialPlexuslockbetweenDexmedetomidine and dexamethasone as an Adjuvant to Local Anesthetic: A Double-lind Prospective Study. Indian J Anesth Analg. 2019;6(5Part-1):1659-1664.

Introduction interscalene, transscalene, infraclavicular and axillary. Supraclavicular approach is the easiest andmostconsistentmethodforsurgerybelowthe rachial plexus block is a popular and widely shoulderjoint.Regionalnerveblockminimizesthe employed regional nerve blocktechniue for stressresponseandusingminimalanestheticdrugs perioperativeanesthesiaandanalgesiaforsurgery is always benecial for the patients with various of the upper extremity. Various approaches cardio-respiratorycomorbidities.1Localanesthetics have been described such as supraclavicular, alone for Supraclavicular brachial plexus block

CorrespondingAuthor:iranumarT,Consultant,NSMemorialInstituteofMedicalScience,NypassRoad,Palathara,ollam, erala691020,India. Email:[email protected] eceiedon08.06.2019,Acceptedon24.07.2019

RedFlowerPublicationPvt.Ltd. 1660 IndianJournalofAnesthesiaandAnalgesia providegoodoperativeconditionsbuthaveshorter of four hours of sensory and motor blockade duration of post-operative analgesia. upivacaine between dexmedetomidine and dexamethasone is used freuently for supraclavicular nerve withpooledvariantsof16,asamplesizeof17per block as it has long duration of action from to groupwasestimated.Foraccountingdropoutsthe hr. So, various adjuvant like opioids, clonidine, samplesizeisroundedto20. neostigmine,midazolam,dexamethasoneetc.were addedtolocalanestheticsinbrachialplexusblockto Inclusioncriteria achieveuick,denseandprolongedblock,butthe results are either in conclusive orassociatedwith 1. Agebetween18–0years side effects.2 Dexmedetomidine is highly specic 2. Physical status American Society of to-2adrenoceptors,yieldingan-2/-1ratioof Anesthesiologist(ASA)IandII. 16206.Inhumans,dexmedetomidinehasshownto prolong the duration of block and post-operative clusioncriteria analgesia when added to local anesthetic in variousregionalblocks.–6Dexmedetomidinewhen 1. ASAgrademorethantwo. addedtobupivacaineforsupraclavicularbrachial 2. nownhypersensitivitytolocalanesthetic plexus block shortenstheonset timesfor sensory drugs. and motor blocks and prolongs their duration. . leedingdisorders. The signicantly prolonged duration of analgesia 4. Pregnantwomen. obviates the need for any additional analgesics.7 5. Pre-existingperipheralneuropathy. Addition of 8 mg dexamethasone to bupivacaine 0.25 solution in supraclavicular brachial plexus 6. Patientsalreadyondexamethasoneorany blockprolongsthedurationofsensoryandmotor adrenoceptoragonist/antagonist. blockade, reduces the reuirement of rescue analgesicinpost-operativeperiod.8So,therationale thicalConsiderations behind the study was to test the hypothesis that Thestudywasconductedafterattainingapproval dexmedetomidine when added as an adjuvant to fromresearchandethicalcommitteeofPushpagiri localanesthetic insupraclavicularbrachialplexus InstituteofMedicalsciences,Tiruvalla. blockenhancedthedurationofsensoryandmotor block,durationofanalgesiaandualityofblockas comparedwithdexamethasone. Informedconsen Written informed consent was taken from all MaterialsandMethods patients.

Studydesin ethodoloy Adouble-blindprospectivestudy. Patientswereassignedtotwogroupsof20each asfollows: Studysettin oup : Dexmedetomidine group. Injection Tertiary care teaching hospital-major operation 0.25upivacaine2milligramgaslocalanesthetic theatre, Dept of Anesthesiology, Pushpagiri anDexmedetomidine1microgramgasadjuvant. InstituteofMedicalSciences,Tiruvalla,erala. roup:Dexamethasonegroup.Injection0.25 upivacaine 2 milligramg and Dexamethasone Studyoulation 100microgramgasadjuvant. 40patientsoftheagegroup18–0yearsbelonging reoerativeevaluation toASAGradeIandIIwhowerepostedforupper limb orthopedic surgeries under supraclavicular A thorough pre-anesthetic check-up was carried brachial plexus block. Selection was based on out. Detailed history was taken, airway and inclusionandexclusioncriteria. systemswereexamined.Pulserate,bloodpressure andbodyweightwerenoted. Samlesie reoerativerearation With 80 power and 95 condence, assuming eualnumberinbothgroups,toestimateadifference Allpatientswerekeptfastingforeighthoursbefore IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EvaluationinSupraclavicularrachialPlexuslockbetweenDexmedetomidineand 1661 dexamethasoneasanAdjuvanttoLocalAnesthetic:ADouble-lindProspectiveStudy surgery. All the subjects were premedicated with rade:Normalmotorfunctionwithfullexion Tab.Ranitidine150mgTab.Alprazolam025mgon andextensionofelbow,wristandngers. previousnightandtwohourspriortosurgery. rade:Decreasedmotorstrengthwithability tomovethengersonly. rocedure rade:Completemotorblockwithinabilityto After allowing the patients to settle down in movethengers. the operative room for a period of ve minutes, Thedurationofsensoryblockwasdenedasthe baseline parameters like heart rate, blood time interval between complete injection of local pressure,andoxygensaturationweremeasured anesthetic and when the patient rst experienced andrecorded.Allthepatientsweregivenbrachial pain in the post-operative period. The duration plexus through supraclavicular approach by an of motor block was dened as the time interval experienced anesthesiologist different from one betweencompleteadministrationoflocalanesthetic assessingthepatientintra andpost-operatively. and complete recovery of motor function. All Eachpatientwasmadetoliesupine,armsatthe patients were observed for any side effects and side,headturnedslightlytotheoppositeside.The complications. supraclavicularareawasasepticallypreparedand draped.Thetipoftheindexngerplacedinthe supraclavicularfossadirectlyoverthesubclavian StatisticalAnalysis arterypulsationwhichisusedasthelandmark. Collected data were compiled, entered and Thepulsationcanbefeltinaplanejustmedialto subjected to statistical analysis using Statistical the midpoint of the clavicle. After a skin wheal PackageforSocialSciences(SPSS)Version20.For with local anesthetic approximately 1 cm above all statistical evaluation, an independent sample themidclavicularpoint,thestimuplexneedleis t-testwasappliedwithprobabilityvalueof0.05 introduced through the skin and directed just wasconsideredsignicant. aboveandposteriortothesubclavianpulseand advancedslowlyincaudal,medialandposterior directions.Thenervestimulatorisinitiallysetat esults 1.0to1.2Ma.Theneedleisadvanceduntilexion ofngersisnoted.Ifcontractionisstillobserved Table:Agewisedistributionofstudyparticipants withthenervestimulatorvoltagedecreasedto05 Standard roup Sample Mean Palue mA,thelocalanestheticsolutionisinjectedafter Deiation conrming negative aspiration of blood. Onset Dexmedetomidine 20 41.20 14.44 0.220.05 and duration of sensory and motor blockade Dexamethasone 20 6.00 11.98 and hemodynamic stability were measured and recorded at specied time intervals. Sensory Aspershowsin(Table)MeanageinGroup1 block was assessed by the pin prick method. (Dexmedetomidine)andGroup2(Dexamethasone) Assessment of sensory block was done in the were41201444yearsand00118years dermatomal areas at specied time intervals respectively. This difference in the ages between aftercompletionofdruginjection.Sensoryonset thetwoGroupswasstatisticindicatesthatthetwo wasconsideredwhentherewasadullsensation Groupsaremoreorlesshomogenouswithrespect topinprick. toageandarehencecomparable. SensoryblockwasGradedas: Table:Genderwisedistributionofthestudyparticipants rade:Sharppinfelt. roup Percentage rade:Analgesia,dullsensationfelt. Male Female rade:Anesthesia,nosensationfelt. Dexmedetomidine 65 5 Assessment of motor block was carried out Dexamethasone 50 50 by the same anesthesiologist at specied time intervalstillcompletemotorblockadeafterdrug Thereisnosignicantdifference(p–value0.7 injection.Onsetofmotorblockadewasconsidered 0.05)betweenGroup1(Dexmedetomidine)and when there was Grade 1 motor blockade. Motor Group2(Dexamethasone)withrespecttogender blockadewasdeterminedaccordingtoamodied ofthepatientsincludedinthestudy.Thisindicates romage scale for upper extremities on a thatthetwoGroupsaremoreorlesshomogenous -pointscale: withrespecttogenderandarehencecomparable. IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1662 IndianJournalofAnesthesiaandAnalgesia

Onsetofsensoryblockwasearliestin Group1 Mean duration of motor block was higher (Dexmedetomidine) and this was statistically in group 1 (Dexmedetomidine) and this was signicant when compared to Group 2 statisticallysignicantwhencomparedtoGroup2 (Dexamethasone)(p–value0.0240.05).though (Dexamethasone(p–value0.0180.05). themeanvaluesofGroup1ishigherthanGroup2. Comparison of baseline eart rate in the Onset of motor block was earliest in Group 1 two groups indicates that there is no signicant (Dexmedetomidine) and this was statistically difference between the two Groups. The mean signicant when compared to Group 2 heartrateislowerinGroup1(Dexmedetomidine) (Dexamethasone)(p-value0.0060.01). as compared to Group2 (Dexamethasone) at ero Mean duration of sensory block was higher minute, ve minutes, ten minutes, twenty minutes, in Group 1 (Dexmedetomidine) and this was fortyminutes,sityminutes,eightyminutes,hundred statisticallysignicantwhencomparedtoGroup2 minutes and one hundred and. Statistical analysis (Dexamethasone)(p–value0.000.01).Mean provedthatthereissignicantdifferenceinmean values are higher in Group 1 as compared to heartrateofthetwoGroupsatvarioustimeperiods Group2. (p–value0.05).

Table:Onsetofsensoryblock Standard Talueith roup Sample Mean Palue Deiation degreesoffreedom Dexmedetomidine 20 11.40 .575 2.4(8) 0.0240.05 Dexamethasone 20 14.45 4.594

Table:Onsetofmotorblock Standard Talueith roup Sample Mean Palue Deiation degreesoffreedom Dexmedetomidine 20 15.57 4.475 2.918(8) 0.0060.01 Dexamethasone 20 20.25 5.159

Table:DurationofSensorylock Standard Talueith roup Sample Mean Palue Deiation degreesoffreedom Dexmedetomidine 20 1005.10 201.814 .206(8) 0.000.01 Dexamethasone 20 82.75 152.50

Table:DurationofMotorlock Standard Talueith roup Sample Mean Palue Deiation degreesoffreedom Dexmedetomidine 20 98.10 196.756 2.465(8) 0.0180.05 Dexamethasone 20 8.25 187.6

eartrate

Fig:Comparisonofeartrateamongtwogroups

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 EvaluationinSupraclavicularrachialPlexuslockbetweenDexmedetomidineand 166 dexamethasoneasanAdjuvanttoLocalAnesthetic:ADouble-lindProspectiveStudy

Discussion change from baseline of 780 1185 beats per minute to 755 11578 beats per minute at zero The brachial plexusblockfor upper limb surgery minute.Meanheartrateatveminutes,tenminutes, has proved to be a safer and effective method of twenty minutes, forty minutes, sity minutes, eighty regionalanesthesia.utitisacommonobservation minutes, hundred minutes and one hundred and that surgeries on upper limb are still being twenty minutes were 71 1141, 7010 1020, performedmainlyundergeneralanesthesiadespite 81510277,7451014,85511180,825 unanimousconsensustowardregionalanesthesia, 11088,7201070,7751047beatsminute duetooneortheotherreasons.Variousapproaches respectively. With use of dexamethasone there have been described such as supraclavicular, was a mean heart rate change from baseline of interscalene, trans scalene, infraclavicular and 75 17 beats per minute to 875 14825 axillary, but they all are associated with some beats per minute at zerominute. Comparison of technical difculties, in-adeuate blocks and baselineheartrateinthetwoGroupsindicatesthat signicant complications. The rate of conversion thereisnosignicantdifferencebetweenthetwo or supplementation with general anesthesia from Groups. The mean heart rate is lower in Group brachial block is uite high. The supraclavicular 1 (Dexmedetomidine) as compared to Group 2 blockofthebrachialplexushasmanyadvantages (Dexamethasone) at ero minute ve minutes, ten over other approaches to brachial plexus block minutes,twentyminutes,fortyminutes,sityminutes, ,4,5.Ithasthereputationofprovidingmost eighty minutes, hundred minutes and one hundred complete and reliable anesthesia for upper limb and twenty minutes. Statistical analysis proved surgery.Itisperformedatthetrunklevelwherethe that there is signicant difference in mean heart plexusispresentedmostcompactly. rate of the two groups at various time periods (p-value0.05). Our study revealedthatmeanagesinGroup1 (Dexmedetomidine)andGroup2(Dexamethasone) Swami et al in 2012 concluded that were41201444yearsand00118years dexmedetomidine (1 gg) when added to local respectively. This difference in the ages between anesthetic (bupivacaine 0.25) in supraclavicular thetwoGroupswasstatisticallynotsignicant(p– brachial plexus blocken hanced the duration of value0.220.05). sensory and motor block and also the duration of analgesia.9 hang et al in 2014 also reported In our study, there were 1 male patient and prolonged sensory and motor blockade duration 7 female patients in Group 1 (Dexmedetomidine) patients who received dexmedetomidine.10 and 10 male and 10 female patients in Group 2 Agarwal, et al concluded, that dexmedetomidine (Dexamethasone).Ourstudyrevealedthatthereis when added to bupivacaine for supraclavicular nosignicantdifference(p–value0.70.05) brachial plexus block shortens the onset times betweenGroup1(Dexmedetomidine)andGroup2 for sensory and motor blocks and prolongs their (Dexamethasone) with respect to gender of the duration. The signicantly prolonged duration of patientsincludedinthestudy. analgesia the need for any additional analgesics. In our study, mean of onset of sensory block The added advantage of conscious sedation, in Group 1 (Dexmedetomidine)is 1140 575 hemodynamic stability, and minimal side effects minute and in Group 2 (Dexamethasone) is 1445 makes it a adjuvant for nerve blocks.7 athuria, 454minute.Onsetofsensoryblockwasearliest et al In 2015 concluded that in supraclavicular in group 1 (Dexmedetomidine) and this was brachialplexusblockadditionofdexmedetomidine statisticallysignicantwhencomparedtoGroup2 asadjuvantshortensthesensoryandmotorblock (Dexamethasone)(pValue0.0240.05). onset time, prolongs both sensory and motor In our study, mean duration of motor block block duration. It also signicantly delays the in Group 1 (Dexmedetomidine) is 810 rst demand for analgesia supplementation, 175 minute and in Group 2 (Dexamethasone) decreases 24 hranalgesic consumption and is not 825 187 minute. Mean duration of motor associatedwithanymajorside-effect.Theactionof blockwas higherin Group 1 (Dexmedetomidine) dexmedetomidineismostprobablyperipheralthan and this was statistically signicant when centrallymediated.11 compared to Group 2 (Dexamethasone) Gandhi et al reported that dexmedetomidine (p–value0.0180.05). hasbetterhemodynamicstabilityandgreaterpost- Our study revealed that with use of operative analgesia.12 Shrestha et al reported that dexmedetomidine there was a mean heart rate dexamethasonewhenaddedasadjuvanttomixture

IJAA/Volume6Number5(Part-I)/Sep-Oct2019 1664 IndianJournalofAnesthesiaandAnalgesia of local anesthetics resulted in signicantly early operativeanalgesiaaftercleftpalaterepair.EurJ onsetandlongerdurationofanalgesia.1 Anesthesiol.2010;27:280–84. ConictofInterestNonedeclared 5. anazi GE, Aouad MT, JAbbour-houry SL, et al Effects of low dose Dexmedetomidine or SourceofFundinNone clonidineon characteristics of spinal block. Acta AnesthesiolScand.2006;50:222–27. Conclusion 6. MemisD,TuranA,aramanlioglu,etalAdding dexmedetomidinetolignocaineforIVRA.Anesth Analg.2004;98:85–40. Weconcludethatinsupraclavicularbrachialplexus 7. Agarwal S, Aggarwal R, Gupta P. blockadditionofdexmedetomidineasadjuvantto Dexmedetomidine prolongs the effect of 0.25bupivacaineshortensthesensoryandmotor bupivacaine in supraclavicular brachial blockonsettime,prolongsbothsensoryandmotor plexus block. J Anesthesiol Clin Pharmacol. blockdurationandisnotassociatedwithanymajor 2014;0:6–40. side-effect. The added advantage of conscious 8. Shaikh M, Majumdar S, Das A, et al Role of sedation and hemodynamic stability makes it a dexamethasone in supraclavicular brachial potential adjuvant for nerve blocks. Thus, it can plexusblock.IOSRJournalofDentalandMedical be concluded that dexmedetomidine is a better Sciences.201;12(1):1–7. adjuvant than dexamethasone in supraclavicular 9. SwamiSS,eniyaVM,LadiSD,etalComparison brachialplexusblock. of dexmedetomidine and clonidine (-2 agonist drugs) as an adjuvant to local anesthesia in supraclavicular brachial plexus block: A eferences randomized double-blind prospective study. IndianJAnesth.2012;56:24–49. 1. Shrestha R, Maharjan S, Shrestha S, et al 10. hang , Wang CS, Shi J, et al Perineural Comparative study between tramadol and administration of dexmedetomidine in dexamethasone as an admixture to bupivacaine combination with ropivacaine prolongs axillary insupraclavicularbrachialplexusblock.JNepal brachial plexus block. Int J Clin Exp Med. MedAssoc.2007;46(168):158–64. 2014;7:680–85. 2. GolwalaMP,SwadiaVN,DhimarAA,etalPain 11. athuriaS,GuptaS,DhawanI.Dexmedetomidine relief by dexamethasone as an adjuvant to local asanadjuvanttoropivacaineinsupraclavicular anesthetics in supraclavicular brachial plexus brachial plexus block. Saudi J Anesth. block.JAnesthClinPharmacol.2009;25():285–88. 2015;9:148–54. . Esmaoglu A, egenoglu F, Akin A, et al 12. GandhiR,ShahA,PatelI.seofDexmedetomidine Dexmedetomidine added to levobupivacaine alongwithbupivacaineforbrachialplexusblock. prolongs axillary brachial plexus block. Anesth NatlJMedRes.2012;2(1):67–69. Analg.2010;111:1548–551. 1. Shrestha R, Maharjan S, Tabedar S. 4. Obayah GM, Refaie A, Aboushanab O, et al Supraclavicularbrachialplexuesblockwithand Addition of dexmedetomidine to bupivacaine without dexamethasone: A comparative study. for greater palatine nerve block prolongs post- MJ.200;1():158–160.

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