Ajay Kumar Chaudhary

Evaluation of analgesic effects of intrathecal clonidine along with bupivacaine in cesarean section

Aims and Context: The objective of the present study was to evaluate the analgesic and adverse effects of intrathecal clonidine with hyperbaric bupivacaine in spinal anesthesia. Settings and Design: Randomized single blind trial. Methods: 210 ASA I-II pregnant females undergoing emergency cesarean section were randomized in a single-blind fashion to one of the three groups. In group I (n=70) patients received 12.5 mg of 0.5% hyperbaric bupivacaine intrathecally. In group II (n=70) patients received intrathecal mixture of 0.5% hyperbaric bupivacaine (8 mg) and clonidine 50 μg. In group III (n=70), patients received 0.5% hyperbaric bupivacaine (10 mg) intrathecally along with 50 μg of clonidine. Statistical Analysis Used: Groups were compared using one-way ANOVA with the Bonferroni multiple comparison post hoc test. The proportion of adverse events was compared using the chi-square test (χ2 =57.2410). Results: On adding 50 μg clonidine, we were able to reduce intrathecal dose of bupivacaine for cesarean section to 8 mg. Patients receiving intrathecal clonidine along with bupivacaine had significantly long lasting analgesia with lower bupivacaine dose [246.21±5.15 min. (group II) vs 146.0±4.55 min (group I), P=0.021; 95% confidence interval: 238.01-257.40, group II and 134.99-157.0 group I]. Conclusions: Addition of intrathecal clonidine causes some sedation in the postoperative period, but it provides adequate analgesia and motor paralysis at lower dose of bupivacaine. It also significantly prolongs postoperative pain relief.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief

INTRODUCTION Postoperative pain after thoracotomy is being considered one of the most severe pain and if not treated well, can result in various respiratory and other complications. AIM Present study was conducted with the aim to compare continuous thoracic epidural infusion with continuous paravertebral infusion for postoperative pain using Visual Analogue Scale (VAS) score and four point observer ranking. The secondary outcomes measured were pulmonary functions and any complication like hypotension, bradycardia, nausea, vomiting, urinary retention and neurological complications if any. MATERIALS AND METHODS Sixty patients of age group 18-60 years posted for anterolateral thoracotomy surgery for lung resection were randomised either to epidural or paravertebral group in this randomised prospective double blind study. In Epidural group 7.5ml bolus of 0.125% Bupivacaine with 50μg Fentanyl and in Paravertebral group 15ml bolus of 0.125% Bupivacaine with 50μg Fentanyl was given 30 minutes before the anticipated end of surgery. Bolus dose was followed by infusion of 0.125% Bupivacaine with 2μg/ml Fentanyl at the rate of 5 ml/hr in both groups. Parameters noted were Mean Arterial Pressure (MAP), Heart Rate (HR), Oxygen Saturation (SpO2), Arterial Blood Gas (PaCO2, P/F ratio), Visual Analogue Scale (VAS) and Four Point Observer Ranking Scale (FPORS) for pain, number of sensory segments blocked (by checking for pinprick sensation), requirement of infusion top ups and rescue analgesia (Tramadol), pre and postoperative pulmonary function test {(Forced Expiratory Volume (FEV)1, Forced Vital Capacity (FVC), FEV1/FVC, Peak Expiratory Flow Rate (PEFR)} and complications from start of infusion till 24 hours in the postoperative period. RESULTS Both the techniques were effective in relieving pain but pain relief was significantly better with epidural. Postoperatively, HR, SpO2, P/F ratio and PaCO2 were comparable between group E and P. There was significant decline in FeV1, FVC, FeV1/FVC and PEFR in postoperative period as compared to preoperative value in both the groups. Hypotension and bradycardia were more in group E. CONCLUSION Both the techniques, continuous thoracic epidural block and continuous thoracic paravertebral block were effective for post-thoracotomy pain relief; however, epidural block provides better pain relief. The incidence of sympatholytic complications was more in epidural group. The effect on respiratory mechanics was equivalent. Hence, paravertebral block can be used in post thoracotomy pain relief in those patients where thoracic epidural is contraindicated.

Efficacy of spinal ropivacaine versus ropivacaine with fentanyl in transurethral resection operations

Background: The low-dose ropivacaine provides differential spinal block to reduce adverse hemodynamic effects in elderly patients. Addition of intrathecal fentanyl with ropivacaine may enhance analgesia and early postoperative mobility. The present study was performed to evaluate the efficacy of intrathecal ropivacaine alone and in combination with fentanyl in transurethral resection operation. Methods: Sixty male patients aged >50 years of ASA I-III scheduled for elective transurethral resection were included in a prospective, randomized, double-blinded study and they were divided in two groups of 30 each. Group A (n = 30) received intrathecal injection of ropivacaine 2 ml (0.75%) and Group B (n = 30) ropivacaine 1.8 ml (0.75%) with fentanyl 10 μg. The characteristics of onset and regression of sensory and motor blockade, hemodynamic stability, and side effects were observed. Students t test (for parametric data) and Mann-Whitney U test (for non-parametric data) were used for statistical analyses. Results: There were no significant differences between the two groups for patient demographic data, intraoperative hemodynamic parameters, side effects, and satisfaction to patients and surgeon. The highest level of sensory block was at T10 in group A and T9 in group B (P = 0.001). Duration of motor block was longer in group B being 210.51 ± 61.25 min than in group A being 286.25 ± 55.65 min (P < 0.001). Conclusion: The addition of fentanyl to ropivacaine may offer the advantage of shorter duration of complete motor block, hemodynamic stability, and without any increase in the frequency of major side effects.

Transdermal Buprenorphine Patches for Postoperative Pain Control in Abdominal Surgery

INTRODUCTION Buprenorphine is a semi-synthetic derivative of thebaine; its low concentration is sufficient to provide effective pain relief. AIM To evaluate the efficacy of transdermal buprenorphine patch in postoperative pain management. MATERIALS AND METHODS After ethical approval and taking informed consent from the patients, they were randomized into three groups (n=30 in each group) using a computer generated random number table. Group A: placebo patch; Group B: buprenorphine (10mg) patch and Group C: buprenorphine (20mg) patch. Haemodynamic and analgesic effects were compared by using analysis of variance (ANOVA) followed by Turkeys post hoc test. The proportion of side effects was compared using the Chi-square test. RESULTS Haemodynamic changes were not statistically different in all the three groups A, B and C, whereas at the end of surgery VAS score of Group A subjects was significantly higher (4.93±0.98) as compared to Group B (1.73±0.64) and Group C (1.40±0.50). On 2(nd) postoperative day, no pain was reported by the Group C patients and on 4(th) day after surgery, no pain was reported by Group B patients. CONCLUSION The transdermal buprenorphine patch (20mg) was effective in attenuating postoperative pain, maintaining haemodynamic stability requiring no rescue analgesia, with fewer postoperative rescue analgesic requirements in low dose of buprenorphine patch (10mg) group.

Multimodal versus Conventional Approach for Postoperative Pain Relief in Oral Cancer Patients.

INTRODUCTION Multimodal analgesia includes regional anaesthesia in the form of nerve block may improve recovery along with optimal rehabilitation and early resumption of day-to-day activity following major surgery. Conventional general anaesthesia consists of premedication, induction, intubation and maintenance. AIM The aim of the study is to compare the multimodal versus conventional approach in oral cancer surgery. MATERIALS AND METHODS The patients were randomly allocated into three groups, 30 patients in each group using the computer generated random table to one of the following groups: Group A: Fentanyl 1 μg/kg, Group B: Fentanyl 1 μg/kg + bupivacaine local infiltration, Group C: Fentanyl 1 μg/kg + bupivacaine local infiltration + Dexemedetomidine infusion (Loading 0.5 μg/kg, Maintenance 0.2μg/kg/hr). RESULTS No significant (p>0.05) difference was found in mean arterial pressure and heart rate at different time intervals among the groups. The VAS was lower in Group C than Group B and A. The ramsay sedation scale was higher in Group C than Group B and A. The rescue analgesic for 24 hour was lower in Group C than Group B and A. The time of first time analgesia requirement was significantly (p=0.001) higher in Group C than Group B and A. The rescue analgesic was significantly (p=0.001) lower in Group C (39.29±19.67) than Group B (68.33±18.49) and A (160.83±35.16). CONCLUSION Multimodal analgesia has beneficial haemodynamic effects during oral cancer surgery with reliable postoperative analgesia and sedation and less postoperative complication. Dose of drugs used in our study is not associated with any major adverse effect.

Patient Controlled Epidural Labour Analgesia (PCEA): A Comparison Between Ropivacaine, Ropivacaine-Fentanyl and Ropivacaine-Clonidine.

BACKGROUND Feeling of pain is one of the most important emotional determinants which dominate the perception of females who undergo the process of labour and delivery. Patient controlled epidural labour analgesia (PCEA) is convenient and safer technique for this purpose. Very few studies compared clonidine and fentanyl with ropivacaine in labour analgesia in past. This study was undertaken to compare fentanyl and clonidine in PCEA. AIMS To compare low concentration ropivacaine with or without fentanyl or clonidine for labour analgesia and its effect on maternal and foetal safety. SETTINGS AND DESIGN Prospective, double blind, randomized, comparative study. MATERIALS AND METHODS Ninety primegravida in labour were divided into three groups (n=30) and patient controlled epidural labour analgesia was given to them: Initial bolus of 10ml of ropivacaine 0.125% in Group I; with fentanyl 2 μg/ml in Group II and with clonidine 1μg/kg in Group III. Subsequently each group received ropivacaine 0.125% through patient controlled epidural analgesia (PCEA) as background infusion of 5 ml/hr with lockout interval time of 10min and subsequent bolus of 5ml. Hemodynamic parameters, sensory level, motor block and pain relief were noted. Total analgesic dose of local anaesthetic and feto-maternal adverse effects were also recorded. RESULTS At baseline, groups were matched demographically, hemodynamically as well as for intensity of pain. There was a statistically significant decrease in hemodynamic parameters from baseline in all groups with maximum reduction in group III. A significant difference among groups in VAS was observed at zero min and from 120min till 240min intervals and lowest values were in Group III. No significant difference was observed among the groups for mode of delivery and expulsive efforts. Total analgesic dose and PCA bolus requirement was maximum in Group I and minimum in Group III and the difference was statistically significant among groups. Six (20%) patients had shivering in Group II and hypotension was recorded in only 1 (3.3%) patient of Group III. CONCLUSION Ropivacaine 0.125% was effective in decreasing labour pain without any motor blockade. Clonidine 1μg/kg was superior to fentanyl 2μg/ml as an adjuvant in PCEA for labour without any significant feto-maternal adverse effects.