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Comparison of Intrathecal Tramadol and Magnesium Sulfate As An Indian Journal of Clinical Anaesthesia 2019;6(4):481–487 Content available at: iponlinejournal.com Indian Journal of Clinical Anaesthesia Journal homepage: www.innovativepublication.com Original Research Article Comparison of intrathecal Tramadol and Magnesium sulfate as an adjuvant to Levobupivacaine in mild Pre-eclamptic parturients undergoing caesarean section- A prospective randomized control study. Aditi A Dhimar1,*, Vallary Modh1, M R Upadhyay1 1Dept. of Anaesthesiology, Medical College and S.S.G. Hospital, Vadodara, Gujarat, India ARTICLEINFO ABSTRACT Article history: Aims and Objective: Spinal anaesthesia is advantageous as compare to general anaesthesia for cesarean Received 02-05-2019 section especially in preeclampsia as it avoids the complications of general anaesthesia. To improve the Accepted 29-08-2019 quality of sensory and motor blockade and prolong the duration of postoperative analgesia, we had used Available online 20-11-2019 tramadol and magnesium sulfate intrathecally with the primary aim to assess sensory and motor blockade and postoperative analgesia. Material and Methods: This prospective randomized control study included sixty preeclamptic parturient Keywords: having more than 36 weeks of pregnancy with controlled hypertension aged 18-40 years with single Intrathecal pregnancy, planned for caesarean section of ASAPS II, III and able to understand VAS score were included. Levobupivacaine Parturients were randomly assigned to g roup LT (injection Levobupivacaine 0.5%, 1.5ml + injection Magnesium sulfate Tramadol 25 mg,0.5ml) and group LM (injection Levobupivacaine 0.5%, 1.5ml + injection Magnesium Preeclampsia sulfate 100 mg,0.5ml) using computer generated random numbers and the assignment was sealed in Tramadol envelopes for concealment. They were assessed for sensory blockade, motor blockade and postoperative analgesia. Results: The onset of sensory block was late in group LM [102sec (102-105) sec] in comparison to group LT [69sec (66-72) sec, P<0.0001]. The time to attain peak sensory level was late in group LM [2min (1.9- 2) min] in comparison to group LT [1.6min (1.5-1.6) min, P<0.0001]. The motor block onset was delayed in group LM [93.5sec (92-95) sec] compared to group LT [60sec (58-63) sec, P<0.0001]. The duration of post-operative analgesia was extended further for group LM [570min (540-600) min], in comparison to group LT [357min (342-360) min, P<0.0001]. Conclusion: Intrathecal magnesium sulfate can be considered as a desirable adjuvant to Levobupivacaine in mild preeclamptic parturients undergoing cesarean section compared to tramadol. © 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/) 1. Introduction women and provides sympathetic blockade which is not affected by change in position. 3 But the postoperative Spinal anaesthesia (SA) is most commonly used anaesthesia analgesia is reported to be of short duration if only technique for cesarean section (CS) even in severe local anaesthetics is used for SA. Various studies reported preeclampsia, largely because of the recognition of the magnesium sulfate is an effective adjuvant to intrathecal dangers of difficult or failed intubation, which occurs local anaesthetics as far as postoperative analgesia is approximately eight times more frequently in pregnant concerned in pregnant as well as nonpregnant patients. 4,5 1,2 patients. Among the local anaesthetics, levobupivacaine Tramadol, another adjuvant to intrathecal local anaesthetics, is truly isobaric to cerebrospinal fluid(CSF) of pregnant extends the duration of postoperative analgesia but it is devoid of respiratory depression. 6 Hence, we decided to * Corresponding author. compare a centrally acting analgesic Tramadol and NMDA E-mail address: [email protected] (A. A. Dhimar). https://doi.org/10.18231/j.ijca.2019.094 2394-4781/© 2019 Innovative Publication, All rights reserved. 481 482 Dhimar, Modh and Upadhyay / Indian Journal of Clinical Anaesthesia 2019;6(4):481–487 receptor antagonist Magnesium sulfate to intrathecal noted down. Parturient was placed in left lateral decubitus levobupivacaine in mild preeclamptic parturient undergoing position and with all aseptic and antiseptic precautions, CS. Our primary aim was to assess sensory and motor 23 G Quincke’s spinal needle was inserted in third or blockade plus postoperative analgesia while secondary aim fourth lumber intervertebral space in the midline. After was to see hemodynamic parameters and complications, if confirmation of the needle tip in subarachnoid space, study any. drug was injected over 10 sec. Parturient was turned to supine position and wedge under right buttock was 2. Material and Methods kept soon after and Oxygen at the rate of 4L/min using non-rebreathing mask was given. They were assessed This prospective randomized control study was carried for sensory blockade, motor blockade and postoperative out following approval from the Scientific research analgesia. Sensory block was assessed using pin prick committee and Institutional Ethics Committee for Human method in midclavicular line bilaterally at 30 sec then every Research during the period of March to October 2017. minute till 5 min and then at 7,10 min and looked for Written informed consent of each parturient was obtained. onset of sensory block (time from drug injection to loss A thorough preanaesthetic assessment was carried out. of pin prick sensation at T12 level in sec), maximum level History was taken regarding present and past complaints, achieved, time to achieve maximum level (time elapsed personal history, medication history, history of previous from the end of injection to attain maximum level of sensory anaesthesia experience, blood transfusions, jaundice etc. block in minute), time to two segment regression of block General and systemic examination was done. Routine (checked half hourly after max height achieved in min) and and specific investigations like liver function test, bleeding duration of sensory block i.e. time interval from loss of pin time, clotting time, prothrombin time, INR and platelet prick at T12 dermatome to reappearance of pin prick at T12 count were carried out. Total sixty preeclamptic parturient dermatome in min. Motor block was assessed at 30 sec then aged 18-40 years having more than 36 weeks of pregnancy every minute till 5 min and then at 7,10 min using modified with controlled hypertension with singleton pregnancy, Bromage grade (Appendix1). 1 undergoing elective CS having normal bleeding profile (BT, CT, PT), of ASA physical status II, III and was patient 2.1. Appendix 1: modified bromage grade able to give written informed consent and understand VAS score were included. Parturient with signs of HELLP Grade 0=Patient is able to move the hip, knee and ankle. syndrome, fetal distress, patients with contraindications to Grade 1= Patient is unable to move hip, but is able to spinal anaesthesia, significant history of drug or alcohol move knee and ankle. abuse, morbid obesity (BMI >35 kg/m2), previous LSCS, Grade 2=Patient is unable to move hip and knee but is diabetic, neurological or musculoskeletal diseases, unable able to move ankle. to understand VAS, on magnesium therapy or having Grade 3=Patient unable to move hip, knee and ankle. placenta previa or abruptio placenta were excluded from We looked for onset (time to achieve bromage grade 1 the study. They were kept nil by mouth overnight. in minute), complete motor block (time to attain bromage Intravenous line was secured with a 18g veinflow. All grade 3 in minute), duration of motor block (time from parturients were preloaded using injection ringer lactate onset to when bromage grade become 0 in minute). A @ 10ml/kg over 15 minutes prior to spinal anaesthesia. visual analogue scale (VAS) score was used to assess All were premedicated with injection Glycopyrrolate 0.2 postoperative analgesia every hour up to 4 h followed by mg, injection Metoclopramide 10mg, injection Ranitidine every 2 h for 24 h. and was evaluated using a VAS as 50mg intravenously 5 min before induction. Patients were mild (0-3), moderate (4-7) and severe (8-10). Injection randomly assigned into two groups. For randomization, Diclofenac sodium 75 mg intramuscularly was given when computer generated random numbers were used. And its VAS ≥ 4 or on patient demand as a rescue analgesia. We concealment was assured by sealing it in envelopes. They observed duration of absolute analgesia (min), postoperative were assigned into Group LT (injection Levobupivacaine analgesia and the number of rescue analgesia required for 0.5%, 1.5ml + injection Tramadol 25 mg,0.5ml) and Group 24 h postoperatively. Absolute analgesia was defined as the LM (injection Levobupivacaine 0.5%, 1.5ml + injection duration from intrathecal injection of drug to first sensation Magnesium sulfate 100 mg,0.5ml.) Magnesium sulfate of any pain at the site of surgery in minutes and duration was prepared using 5 ml disposable syringe. Two ml of of postoperative analgesia as duration from completion of magnesium sulfate diluted with sterile water up to 5 ml, so surgery to first rescue analgesic in minutes. Patients were 1 ml = 200 mg and from that 0.5ml (100mg) was taken. also observed for vital parameters like pulse rate, SBP, DBP In both the groups the volume of study drug was 2 ml. and SpO2 at various interval after giving SA upto the end Inside the operation theatre, multipara monitor was used and of surgery. Duration of surgery and blood loss were
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