“COMPARISON OF 0.25% BUPIVACAINE WITH 0.375% ROPIVACAINE FOR FIELD BLOCK IN INGUINAL HERNIA REPAIR” Dissertation submitted to The Tamil Nadu Dr.M.G.R. Medical University Chennai – 600032. In partial fulfilment of the regulations for the Degree of M.D.ANAESTHESIOLOGY BRANCH – X Under the guidance of Dr.R.SELVAKUMAR M.D., D.A., Professor and Head of the Department DEPARTMENT OF ANAESTHESIOLOGY K.A.P.VISWANATHAM GOVT. MEDICAL COLLEGE, TRICHY. APRIL - 2017 BONAFIDE CERTIFICATE This is to certify that this dissertation titled “COMPARISON OF 0.25 % BUPIVACAINE WITH 0.375% ROPIVACAINE FOR FIELD BLOCK IN INGUINAL HERNIA REPAIR” is a bonafide work of Dr.J.RAMYA, Post Graduate in M.D.Anaesthesiology, Department of Anaesthesiology, K.A.P.V. Government Medical College, Trichy and has been prepared by her under our guidance. This has been submitted in partial fulfilment of regulations of The Tamil Nadu Dr. M.G.R. Medical University,Chennai-32 for the award of M.D. Degree in Anaesthesiology. Prof. Dr.S.LILY MARY Dr. R.SELVAKUMAR. M.D, D.A Dean, Professor and Head of Department, K.A.P.V. Govt. Medical College, Department of Anaesthesiology Trichy. K.A.P.V. Govt. Medical College, Trichy Place:Trichy Date: DECLARATION I Dr.J.RAMYA, solemnly declare that this dissertation titled “COMPARISON OF 0.25% BUPIVACAINE WITH 0.375% ROPIVACAINEFOR FIELD BLOCK IN INGUINAL HERNIA REPAIR”, is a bonafide work done by me at K.A.P.V. Government Medical College, during 2015-2016 under the guidance and supervision of Dr.R.SELVAKUMARM.D.,D.A., Professor and Head Of the department, Department of Anaesthesiology, K.A.P.V. Government Medical College, Trichy. The dissertation is submitted to The TamilnaduDr. M.G.R. Medical University, towards the partial fulfillment of requirement for the award of M.D. Degree in Anaesthesiology Branch X. PLACE :TRICHY DATE : Dr. J.RAMYA,M.B.B.S., Post Graduate Student, Department of Anaesthesiology, K.A.P.V. GOVT. Medical College, Trichy. COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that The Dr.M.G.R Medical University, Chennai, shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic /research purpose. Dr. J.RAMYA, M.B.B.S., Post Graduate Student, Department of Anaesthesiology, K.A.P.V. GOVT. Medical College, Trichy. Place: Trichy Date: ACKNOWLEDGEMENT I thank our DEAN Prof.Dr.S.MARY LILLY, K.A.P.V. Govt. Medical College, Trichy for permitting me to conduct this study in the Department of Anaesthesiology, K.A.P.V. Government Medical College, Trichy. My sincere thanks to Prof. Dr.R.SELVAKUMAR,M.D.,D.A., Head of Department of Anaesthesiology, for helping and guiding me during this study. My heartfelt gratitude to Prof. Dr.G.SIVAKUMAR M.D.,D.A., Prof. Dr.M.SURESH,M.D.,D.A.,and Prof. Dr.P.ElANGO M.D for their esteemed guidance and valuable suggestions. It is my privileged duty to thank Asst.Prof.DR.L.R.GANESSAN M.Dand DR.BALASUBRAMANIAGUHAN M.D., for their constant help and encouragement in preparing this dissertation. My sincere thanks to all my Assistant Professors who have put in countless hours in guiding me in many aspects of this study and also in honing my anaesthetic skills. I thank my fellow Post graduates who helped me in conducting the study. I am greatly indebted to all my patients without whom this study would not have been a reality. I thank all the anaesthesia assistants and staff nurses who cooperated with me at all times. My sincere thanks to Prof. Jesu raja for his help and advice on statistical methods. I take this opportunity to thank my family and my friends for their unconditional love and support. Dr.J.RAMYA, M.B.B.S., Post Graduate Student, Department of Anaesthesiology, K.A.P.V. GOVT. Medical College, Trichy. Place: Trichy Date: LIST OF ABBREVIATIONS USED (In alphabetical order) ASA - American Society of Anaesthesiologist ASIS - Anterior superior iliac spine BP - Blood pressure CNS - central nervous system CVS - cardiovascular system ECG - electrocardiography EOA - external oblique aponeurosis GA - general anaesthesia Gm - grams HR - heart rate I.M - Intramuscular IOA - internal oblique aponeurosis LA - local anaesthesia Mcg - microgram Min - Minute mmHg - Millimeter of mercury MIL - midpoint of inguinal ligament MPK - Mitogen activated protein kinase pathway RS - respiratory system SBP - Systolic blood pressure Sec - Seconds TF - transversalis fascia VAS - visual analog scale VRS - verbal rating score % - Percentage CONTENTS S. No Title Page No. 1. INTRODUCTION 1 2. AIMS AND OBJECTIVES 3 3. REVIEW OF LITERATURE 4 4. HISTORICAL REVIEW 9 5. ANATOMY OF INGUINAL FIELD BLOCK 13 6. PHARMACOLOGY 19 7. MATERIALS AND METHODS 33 8. OBSERVATION AND RESULTS 42 9. DISCUSSION 71 10. CONCLUSION 77 11. SUMMARY 78 12. BIBLIOGRAPHY 80 ANNEXURES A. PROFORMA 86 B. CONSENT FORM 89 13. C. MASTER CHART 92 LIST OF FIGURES Figure Page Title No. No. 1. LUMBAR PLEXUS 11 2. DERMATOMAL INNERVATION 12 3. TECHNIQUE OF FIELD BLOCK 15 4. CHEMICAL STRUCTURE OF 19 BUPIVACAINE 5. BUPIVACAINE HYDROCHLORIDE 19 6. CHEMICAL STRUCTURE OF 25 ROPIVACAINE 7. ROPIVACAINE HYDROCHLORIDE 25 8. VISUAL ANALOG SCALE 37 LIST OF GRAPHS Graph Page Title No. No. 1. COMPARISON OF BMI 43 2. COMPARISON OF ASA 45 3. COMPARISON OF ONSET OF BLOCK 46 4. COMPARISON OF ADEQUACY OF 53 BLOCK 5. COMPARISON OF SIDE EFFECTS 55 6. COMPARISON OF SIDE EFFECTS 56 OBSERVED 7. COMPARISON OF SURGEON 58 SATISFACTION 8. COMPARISON OF TIME REQUIREMENT 60 FOR FIRST ANALGESIC 9. COMPARISON OF MEAN HEART RATE 66 10. COMPARISON OF MEAN SYSTOLIC 69 BLOOD PRESSURE LIST OF TABLES Table Page Title No. No. 1. PAIN SCORE WITH VISUAL ANALOG SCALE 37 2. ADEQUACY OF BLOCK 38 3. VERBAL RATING SCORE 40 4. SURGEON SATISFACTION SCALE 41 5. SURGEON SATISFACTION SCORE 41 6. COMPARISON OF BMI 43 7. COMPARISON OF ASA 45 8. COMPARISON OF ONSET OF BLOCK 46 9. AVERAGE TIME OF ONSET OF BLOCK 51 10. ONSET OF BLOCK IN ACTUAL NUMBER OF 52 PATIENTS 11. COMPARISON OF ADEQUACY OF BLOCK 53 12. COMPARISON OF SIDE EFFECTS 57 13. COMPARISON OF SURGEON SATISFACTION 59 14. COMPARISON OF TIME REQUIREMENT FOR 61 FIRST ANALGESIC 15. AVERAGE DURATION OF POST-OP PAIN 63 RELIEF 16. POST-OP ANALGESIC DURATION IN ACTUAL 64 NUMBER OF PATIENTS 17. COMPARISON OF MEAN HEART RATE 65 18. COMPARISON OF MEAN SYSTOLIC BLOOD 67 PRESSURE INTRODUCTION Hernia repair is one of the commonest surgery among worldwide operations. Herniorraphy and Hernioplasty are the techniques for Inguinal hernia repair. Newer technique of laparoscopic mesh repair is also in practice. Hernia repair can be performed under spinal, epidural, general anaesthesia and inguinal field block. The preferred choice for all reducible Inguinal hernia is local since it inhibits the build up of local nociceptive receptors, hence a longer postoperative pain relief1. Also it is safe, simple and effective without post anaesthesia side effects. Compared to other techniques spinal /General anaesthesia (GA), field block does not provide a satisfactory level. But it provides prolonged postoperative analgesia, reduced urinary retention and early ambulation. Also it is a cost effective method2,3 in day care surgery warranting a speedy recovery and also the preferred anaesthesia in geriatric patients with underlying systemic pathology. Postoperative analgesia is now regarded as an integral part of the surgical care. Insufficient analgesia can have significant pathophysiological and psychological effects in post-operative patients4. Lack of pain relief may manifest as haemodynamic changes in the form 1 of tachycardia and hypertension, tachypnoea and hypoxemia, altered gastrointestinal motility, impaired urinary tract function5. The introduction of Bupivacaine and Ropivacaine , other amide local anaesthetic agents with longer duration of action when compared with lignocaine which has a moderate duration of action6 has an added advantage of providing prolonged post op analgesia. Ropivacaine compared with bupivacaine has better cardiac stability with comparable analgesia7. Hence this study of Field block is undertaken to objectively test the efficacy of block , side effects and degree of postoperative pain relief comparing the two drugs Bupivacaine and Ropivacaine. 2 AIMS AND OBJECTIVE To study and compare the The onset of analgesia The adequacy of block The duration of postoperative pain relief Side effects if any, that occurs with the usage of the two drugs Haemodynamic changes 3 REVIEW OF LITERATURE A comparative study of 0.5% Bupivacaine and 0.5% Ropivacaine for day case inguinal herniorraphy in a Nigerian tertiary institution was done showing that Ropivacaine and Bupivacaine have comparable onset of actions and adequacy of anaesthesia8. Randomized study of 160 patients conducted by F H Andersen K Nielsen at surgical clinic Charlottenlund, Copenhagen, Denmark- combined ilioinguinal blockade and local infiltration anaesthesia for groin hernia repair, showed median intra-operative pain score reduced with additional ilioinguinal blockade. Study concluded that additional use of a preoperative ilioinguinal field block to well established local infiltration anaesthesia procedure for inguinal hernia repair improves intra-operative pain relief9. Retrospective analysis conducted by P Sanjay, A Woodward, in department of surgery of Ninewells hospital and medical school, revealed tha patient satisfaction is more in local anaesthesia. Also it was seen that local complications like wound hematoma, wound infection, recurrence readmission, postoperative hydrocele is more with local anaesthesia, but there is significant reduction of postoperative urinary retention. Study concluded that use of Local Anaesthesia (LA) results in increased day 4 case-rates, lower postoperative analgesic requirements and fewer micturition problems10. Prospective study of 454 patients of inguinal hernia repair with local anaesthesia in the outpatient by Flavio Antonio de Sa Ribeiro, Fernanda Padron, et al showed that there were no adverse effect of local anaesthetics and concluded that procedure is feasible and causes no peri- operative pain, safe and has satisfactory patient acceptance11.