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Evaluation of Intravenous Magnesium Sulphate for Postoperative Analgesia in Elective Lower Limb Orthopaedic Surgeries Under Spin

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Evaluation of Intravenous Magnesium Sulphate for Postoperative Analgesia in Elective Lower Limb Orthopaedic Surgeries Under Spin EVALUATION OF INTRAVENOUS MAGNESIUM SULPHATE FOR POSTOPERATIVE ANALGESIA IN ELECTIVE LOWER LIMB ORTHOPAEDIC SURGERIES UNDER SPINAL ANAESTHESIA THIS DISSERTATION IS SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE COLLEGE IN ANAESTHESIA DR AKINYELE AYOOLA MBBS (ILORIN) 2004 MAY 2017 1 DECLARATION It is hereby declared that this work is original unless otherwise acknowledged. The work has not been presented to any other College for a Fellowship Examination, nor has it been published or submitted elsewhere for publication. Name___________________________ Signature_________________________ Date_____________________________ 2 ATTESTATION The study reported in this dissertation was done by the candidate under our supervision. We have also supervised the writing of the dissertation. 1. SIGNATURE &DATE: _______________________________________ NAME OF SUPERVISOR: _______________________________________ STATUS OF SUPERVISOR: Consultant Anaesthetist, University of Ilorin Teaching Hospital, Ilorin YEAR OF FELLOWSHIP OF SUPERVISOR: _________________________ 2. SIGNATURE & DATE: _______________________________________ NAME OF SUPERVISOR: ______________________________________ STATUS OF SUPERVISOR: Consultant Anaesthetist, University of Ilorin Teaching Hospital, Ilorin YEAR OF FELLOWSHIP OF SUPERVISOR: _________________________ 3 TABLE OF CONTENTS Title Page…………………………………………………….……………………….i Declaration ……………………………………………………………….………….ii Attestation …………………………………………………………….…..………...iii Table of contents …………………………………………………….……..………...iv Dedication……………………………………….………….…………….………….v Acknowledgement……………………………………………………….…………..vi List of Tables…………………………………………………………….…………..vii List of Figures…………………………………………………………….………….viii List of Appendices…………………………………………………………………..ix List of Abbreviations ………………………………………………...……………….x Summary ……………………………………………………………………………1-3 Introduction ………………………………………………………...……………….4-5 Aim and objectives of the Study ………………………………….…….………….6 Hypothesis ………………………………………………..…….…………………...7 Literature Review……………………………………………………..……………..8-19 Methodology…………………………………………………………...……………..20-29 Results……………………………………………………………………………….30-49 Discussion…………………………………………………………..……………….50-60 References…………………………………………………………….…………….61-69 Appendices…………………………………………………………..……………...70-82 4 DEDICATION I dedicate this work to the Almighty God for making it a reality. Without His guidance, this work would not have seen the light of the day. 5 ACKNOWLEDGEMENT I give all glory and thanks to Almighty God for the inspiration, wisdom and strength to commence and complete this work. I am tremendously indebted to my supervisors and mentors, Dr. B.O Bolaji and Dr. I.K Kolawole for their immense support, guidance, knowledge impaction and encouragement throughout my residency training and for painstakingly supervising and reviewing this work. My profound appreciation also goes to Dr. O.O Oyedepo who also contributed immensely to the successful completion of this work. I also want to thank Dr. M.B Adegboye, Dr. Z.A Suleiman and Dr. O.A Ige for their brotherly advice and words of encouragement. Special thanks also go to my colleagues and nurses in the wards who contributed in one way or the other to the successful completion of this work. Finally, my profound appreciation goes to my family for their support and understanding throughout my residency training. 6 LIST OF TABLES PAGE Table I: Demographic profile________________________________________38 Table II: Preoperative parameters of the study participants_________________ 39 Table III: Duration of analgesia and time to first request for rescue analgesic___40 Table IV: Sensory block characteristics________________________________ 41 Table V: Showing adverse effects in both groups________________________ 42 Table VI: Patients’ satisfaction with analgesia___________________________43 Table VII: Modified Bromage Scores for onset of block___________________ 44 Table VIII: Modified Bromage Scores for duration of block________________ 45 7 LIST OF FIGURE PAGE Figure 1: Pain scores (using mean scores)……………………………………................46 Figure 2: Comparison of intraoperative blood pressures (SBP, DBP, MAP) …………..47 Figure 3: Comparison of intraoperative heart rates and respiratory rates)…………….. 48 Figure 4: Comparison of intraoperative peripheral capillary oxygen saturation (spo2).. 49 8 LIST OF APPENDICES PAGE Appendix I: Patient information sheet……………………………………….70-71 Appendix II: Consent form…………………………………………………. 72 Appendix III: Study profoma……………………………………………….. 73-78 Appendix IV: Verbal rating scale……………………………………………79 Appendix V: Satisfaction scales regarding quality of pain control………….80 Appendix VI: Modified Bromage Scale……………………………………...81 Appendix VII: American Society of Anesthesiologists’ physical status classification (ASA)…………………………………………………………………………82 9 LIST OF ABBREVIATIONS American Society of Anesthesiologists ASA Diastolic blood pressure DBP Heart rate HR Hour hr Intraoperative diastolic blood pressure Intra-op DBP Intraoperative systolic blood pressure Intra-op SBP Kilogramme Kg Mean Arterial Pressure MAP Milligramme mg Millimetres of Mercury mmHg Minute min Modified Bromage Score MBS Percentage % Postoperative post-op Perioperative peri-op Preoperative pre-op Pulse Rate PR Respiratory rate RR Standard Deviation SD Systolic Blood Pressure SBP University of Ilorin Teaching Hospital UITH World Health Organization WHO 10 SUMMARY BACKGROUND Poorly managed postoperative pain remains a major cause of morbidity and mortality. Effective postoperative pain relief has not been achieved with the established methods of pain relief. Magnesium sulphate is an N-methyl-D-aspartate receptor antagonist and a calcium channelblocker. There are conflicting reports about the effectiveness of magnesium sulphate as an adjuvant analgesic. The objective of this study was to evaluate the effect of magnesium sulphate for postoperative pain relief in patients scheduled for elective lower limb orthopaedic surgeries under spinal anaesthesia. PATIENTS AND METHODS Following the approval of the institutions Ethical Review Committee, eighty-eight (88) consenting patients scheduled for lower limb orthopaedic surgeries under spinal anaesthesia were recruited into the study. The study group consisting of 44 patients received bolus intravenous magnesium sulphate of 30mg/kg over 15min after spinal anaesthesia which was followed by a continuous infusion dose of 10mg/kg/hr till the end of surgery. The control group received same volume of isotonic saline over same period. After surgery, intravenous pethidine at 1mg/kg slowly over 10 minutes was administered every 4hrs and intravenous paracetamol 15mg/kg every 6hrs was also administered for pain control. Rescue analgesic in the form of intravenous pethidine slowly over 10 minutes was administered on patient request or on recording of at least 2 or more pain scores higher than the previous value. Postoperative pain scores at immediate postoperative period, 30min, 1hr, 2hr, 4hr, 8hr, 16hr and 24hr 11 postoperatively were evaluated using verbal rating scale. The total 24hr opioid (pethidine) consumption in both groups was also noted and compared. Total duration of analgesia and incidence of side effects of magnesium sulphate was also determined. RESULTS Postoperative pain scores were significantly lower in group A(study group) at 30min, 1hr, 2hr, 4hr, 8hr, 16hr and 24hr after surgery with p-values of 0.039, 0.001,0.001,0.001,0.001,0.001 and 0.001 respectively. The 24hr-opioid(pethidine) consumption was significantly less in the study group compared to the control group [144mg(124.0mg-165.0mg) versus 265mg(225.0mg-300.0mg);p<0.001]. Also, the duration of analgesia was significantly prolonged in the study group compared to the control (296.07±82.98mins versus 177.84±32.28mins; p< 0.001). Time to first request for analgesic was significantly prolonged in the study group compared to the control group (327.66±99.90 versus 194.02±30.41; p< 0.001). Time of L1 sensory loss was significantly prolonged in the control group compared to the study group(4.93±1.33mins versus 4.00±1.33mins; p=0.003). However, the highest levels of sensory loss achieved by patients in the two groups were comparable, T10 (T8-T10). The onset of motor block was shorter in the study group compared to the control group with more patients in the study group having a higher Modified Bromage Score of 3 compared to the control group at the 2th, 5th ,10th ,15th and 20th minutes after local anaesthetic agent have been injected into the subarachnoid space. P-values at these periods were 0.134, 0.203, 1.000, 0.916 and 0.916 respectively. Also, thedegreeof motor block was more and duration longer with patients in the study group compared to patients in the control group. There were more patients in the study group having a higher MBS of 3 at the immediate postoperative period, 30th, 60th, 90th , 120th, 150th and 180th minutes postoperatively. P-values at these postoperative periods were 0.321, 0.054, 0.020, 0.015, 0.823, 0.302 and 0.043 respectively. There was no incidence of side effect of 12 magnesium sulphate administration observed in the study group. However, 7 patients representing 15.9% of patients in the control group had postoperative shivering compared to 3 patients representing 6.8% of patients in the study group(P=0.179). But this was not statistically significant. There was no incidence of flushing, hypotension, headache, nausea,
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