A prospective randomized study to compare dexmedetomidine and dexamethasone as an adjunct to bupivacaine in transversus abdominis plane block for post-operative analgesia in caesarean delivery

Abstract

Background: Caesarean section is most frequently performed surgery worldwide. Patients experience moderate to severe pain in the first 48 hours post-operatively. Aim of this study was to evaluate the efficacy of dexmedetomidine and dexamethasone as an adjunct to bupivacaine in ultrasound guided TAP block for postoperative analgesia in patients of caesarean section.Methods: A total 120 ASA I and II patients undergoing elective and emergency caesarean section under subarachnoid block were randomly divided into three groups B, BDM, BDX to receive bupivacaine alone or dexmedetomidine or dexamethasone as an adjunct to bupivacaine in ultrasound guided TAP block. Postoperatively, the patients were evaluated for pain level at rest and on movement with a 10 cm visual analog scale (VAS) pain score (0 = no pain and 10 = worst pain), time to demand of first analgesic request, number of analgesic requirements, nausea or vomiting, sedation and patient satisfaction at 0 hours and at 2, 4, 6, 12, 18, and 24 hours.Results: VAS score was significantly higher in group B in comparison to BDM and BDX, and higher in BDX in comparison to group BDM. Mean duration of analgesia was significantly higher in group BDM in comparison to group B and BDX. Total number of rescue analgesic demands were significantly lower in group BDM in comparison to group B and BDX. Sedation score and satisfaction score was higher in group BDM as compared to group B and BDX.Conclusions: Addition of dexmedetomidine and dexamethasone as an adjunct to bupivacaine reduces postoperative pain, prolongs analgesia, decreases demand for additional analgesics and provides better maternal satisfaction as compared to plain bupivacaine group in TAP block in patients undergoing caesarean section under subarachnoid block. Among dexmedetomidine and dexamethasone, dexmedetomidine had prolonged analgesia as compared to dexamethasone group.

Full text

December 2019 · Volume 8 · Issue 12 Page 4903
International Journal of Reproduction, Contraception, Obstetrics and Gynecology
Thakur J et al. Int J Reprod Contracept Obstet Gynecol. 2019 Dec;8(12):4903-4908
www.ijrcog.org
pISSN 2320-1770 | eISSN 2320-1789
Original Research Article
A prospective randomized study to compare dexmedetomidine and
dexamethasone as an adjunct to bupivacaine in transversus
abdominis plane block for post-operative analgesia in
caesarean delivery
Jitender Thakur1, Bharti Gupta1*, Amit Gupta2, Ravinder Kumar Verma1,
Anita Verma1, Payal Shah3
DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20195342
ABSTRACT
Background: Caesarean section is most frequently performed surgery worldwide. Patients experience moderate to
severe pain in the first 48 hours post-operatively. Aim of this study was to evaluate the efficacy of dexmedetomidine
and dexamethasone as an adjunct to bupivacaine in ultrasound guided TAP block for postoperative analgesia in
patients of caesarean section.
Methods: A total 120 ASA I and II patients undergoing elective and emergency caesarean section under
subarachnoid block were randomly divided into three groups B, BDM, BDX to receive bupivacaine alone or
dexmedetomidine or dexamethasone as an adjunct to bupivacaine in ultrasound guided TAP block. Postoperatively,
the patients were evaluated for pain level at rest and on movement with a 10 cm visual analog scale (VAS) pain score
(0 = no pain and 10 = worst pain), time to demand of first analgesic request, number of analgesic requirements,
nausea or vomiting, sedation and patient satisfaction at 0 hours and at 2, 4, 6, 12, 18, and 24 hours.
Results: VAS score was significantly higher in group B in comparison to BDM and BDX, and higher in BDX in
comparison to group BDM. Mean duration of analgesia was significantly higher in group BDM in comparison to
group B and BDX. Total number of rescue analgesic demands were significantly lower in group BDM in comparison
to group B and BDX. Sedation score and satisfaction score was higher in group BDM as compared to group B and
BDX.
Conclusions: Addition of dexmedetomidine and dexamethasone as an adjunct to bupivacaine reduces postoperative
pain, prolongs analgesia, decreases demand for additional analgesics and provides better maternal satisfaction as
compared to plain bupivacaine group in TAP block in patients undergoing caesarean section under subarachnoid
block. Among dexmedetomidine and dexamethasone, dexmedetomidine had prolonged analgesia as compared to
dexamethasone group.
Keywords: Caesarean section, Dexmedetomidine, Dexamethasone, Postoperative pain, Transversus abdominis plane
block
1Department of Anesthesia, DRPGMC, Tanda (Kangra), Himachal Pradesh, India
2Department Obstetrics and Gynecology, DRPGMC, Tanda (Kangra), Himachal Pradesh, India
3Department Anesthesia, Zonal Hospital, Dharamsala (Kangra), Himachal Pradesh, India
Received: 23 August 2019
Revised: 08 November 2019
Accepted: 13 November 2019
*Correspondence:
Dr. Bharti Gupta,
E-mail: drbharti203@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

Thakur J et al. Int J Reprod Contracept Obstet Gynecol. 2019 Dec;8(12):4903-4908
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 8 · Issue 12 Page 4904
INTRODUCTION
Caesarean section is often associated with severe pain,
which may result in patient dissatisfaction, impaired
patient rehabilitation and prolonged hospitalization.1,2
Therefore, a well-planned analgesia regimen is required
to ensure adequate maternal satisfaction, early initiation
of breast feeding and early mobilization to prevent risk of
thrombo-embolism as a result of immobility due to pain.
Pain after caesarean section is mainly contributed to
somatic component of pain (Abdominal wall incision)
and less because of visceral pain (uterus). Thereby
requiring a multimodal approach for postoperative pain
management in the form of NSAIDS, opioids, local
infiltration by LA and neuraxial blocks in the form of
epidurals.3
Transversus abdominis plane block is used to provide
analgesia to the anterior and lateral abdominal wall. A
local anaesthetic solution (Bupivacaine) is injected into
facial plane between the internal oblique and transversus
abdominis muscle under ultrasound guidance. The
procedural simplicity of this block, along with the
reliable level of analgesia (T6-L1) and longer duration
and quality of analgesia makes TAP block a good option
for lower abdominal gynaecological surgeries, as also
been reported by American society of regional
anaesthesia (ASRA).4
Some of the adjuncts which have been used so far in
literature in TAP block are dexamethasone, magnesium
and α2 agonists. Out of these agonists, α2 agonist drugs
and Dexamethasone are most commonly used drugs,
owing to their analgesic potential and safety profile.5
A comparative study between dexmedetomidine versus
dexamethasone as an adjuvant to bupivacaine in
ultrasound guided TAP block for postoperative analgesia
in patients undergoing caesarean section under
subarachnoid block was planned. Our primary aim was to
compare the dexmedetomidine and dexamethasone as an
adjunct to bupivacaine post-operatively up to 24 hours for
duration of analgesia and demand of additional
analgesics. Secondary aims were to assess sedation,
nausea, vomiting, haemodynamic stability and maternal
satisfaction in relation with the early start of breast
feeding and early ambulation.
METHODS
The study was approved by institutional ethical
committee and was carried over a period of one year from
March 2018 to February 2019. 120 ASA I-II patients,
scheduled for emergency and elective caesarean section
under subarachnoid block were included in the study and
one patient was excluded due to block failure. Patient’s
refusal for block, local infection at the site of TAP block
and allergy to study drugs were the exclusion criteria.
It was a prospective, double blind randomized control
study. The patients were allocated to one of the three
groups by random number chart. Random number was
enclosed in a sealed opaque envelope and opened by one
of the investigators to know the study drug to be
administered. The operating surgeon and observer
anesthesiologist who collected the postoperative data
were blinded to the study drug. The study drug solution
was prepared and given to the investigator by a
nonparticipant staff.
The group B received 38 ml of 0.25% bupivacaine and 2
ml of 0.9% NS to make total volume of 40 ml, group
BDM-38 ml of 0.25% bupivacaine and 2 ml of 1 μg/kg
dexmedetomidine and group BDX-38 ml of 0.25%
bupivacaine and 2 ml of 0.1 mg/kg dexamethasone.
All patients undergoing caesarean section were given
subarachnoid block in lateral position and surgery was
started after confirmation of T6 level. Postoperatively,
after regression of sensory block to T10 dermatome.
A USG guided TAP block was given using linear probe
(6-13 MHz) in all groups with respective drug solutions.
23 G spinal needle was advanced by ultrasound guided in
plane technique at the anterior axillary line between the
12th rib and iliac crest with umbilicus at the center and
exact location of the needle tip in a plane between
internal oblique muscle, transverse abdominis muscle
was identified with 1ml of normal saline.6,7
After confirmation of hypo echoic area on USG imaging,
the injection of 20 ml of drug solution was given. The
amount of 20 ml was also injected on the opposite side
using the identical technique). Postoperatively, the
patients were evaluated in post-anaesthesia care unit
(time 0 hours) and at 2, 4, 6, 12, 18, and 24 hours by an
investigator blinded to group assignment. Pain level
(somatic and visceral) at rest and on movement (knee
flexion) was quantified with a 10 cm visual analog scale
(VAS) pain score (0 = no pain and 10 = worst pain), time
to demand of first tramadol request, number of
supplemental analgesics. For the first 24 hours, the
protocol for postoperative analgesia in our institute
consisted of injection diclofenac intramuscular 8 hourly
and injection tramadol 50 mg intravenous on demand if
pain scores remain high (VAS > 4).
Nausea and vomiting were assessed on a four-point scale
(None- 1, Mild -2, Moderate- 3, Severe- 4). Injection
Ondansetron 4 mg IV was given if score was more than
2.
Level of sedation was assessed as a sedation score of 0-3,
where 0 = awake and alert, 1 = quietly awake, 2 = asleep
but easily arousable, 3 = deep sleep, responding to
painful stimulus. Patients were labeled to be sedated if
score was > 2.

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The patients were also interviewed after 24 hours of
surgery regarding satisfaction with their pain
management and comfort in view of early ambulation and
early start of breast feeding on a 3-point scale (highly
satisfied-1, satisfied-2, dissatisfied-3). In addition,
haemodynamic monitoring (systolic blood pressure,
diastolic blood pressure and heart rate) was also done at
similar study points.
Statistical analysis
Data was presented as frequency, mean, and standard
deviation whenever applicable. Categorical variables
between 2 groups were compared using Chi square test of
Fischer exact test. One-way ANOVA followed by post-
hoc analysis (Bonferroni) was used to compare
quantitative variables between 3 groups. P value <0.05
was considered significant. Statistical analysis was
performed using SPSS v21.
RESULTS
A total of 119 patients were enrolled into the study and
randomized into 3 groups - group B, BDM, and BDX.
Patient characteristics like age, weight and ASA status
were comparable in all three groups (Table 1).
Table 1: Comparison between three groups according to demographic variables.
Parameter
Group B, N = 39
Group BDM, N = 40
Group BDX, N = 40
P value
Age (years)
28.59±3.59
27.62±3.50
27.50±3.42
0.324#
Weight (kg)
64.59±7.50
63.97±7.33
64.72±7.73
0.893#
Data presented as mean±SD; #One-way ANOVA.
Figure 1: Comparison of VAS scores.
The VAS for pain was comparable in group B, BDM and
BDX at 0 hour but at 4-hour, VAS score was
significantly lower in group BDM in comparison to group
B (P = 0.037) and group BDX (0.040). At 6 and 12 hours.
VAS of the patients was comparable in group B, BDM,
and BDX. Again at 18-hour, VAS of the patients was
significantly higher in group B in comparison to group
BDM (P = 0.0003) and group BDX (P = 0.039). At 24-
hour, VAS of the patients in group B was significantly
higher than VAS of the patients in group BDM (P <
0.0001) and BDX (P < 0.0001). So, VAS score was
significantly higher in group B at 2-hour, 4-hour, 18-
hour, and 24-hour in comparison to BDM and BDX and
higher in BDX in comparison to group BDM (Figure 1).
Mean duration of analgesia (time to first rescue
analgesia) was significantly higher in group BDM
(407.99±4.60) minutes in comparison to group B
(178.99±5.00) and group BDX (325.88±5.51) (Figure 2).
Figure 2: Comparison of mean duration of
analgesia (minutes).
Figure 3: Total number of analgesic demands.
0
2
4
6
8
10
0 hour 2 hour 4 hour 6 hour 12 hour 18 hour 24 hour
VAS Score
B (n=39) BDM (n=40) BDX (n=40)
0
100
200
300
400
500
B (n=39) BDM (n=40) BDX (n=40)
Mean duration of analgesia
0
1
2
3
4
B (n=39) BDM (n=40) BDX (n=40)
Total number of analgesic demands in 24 hours
Total number of demands in 24 hours

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Figure 4: Comparison of sedation score.
Total number of rescue analgesic demand in 24 hours
was significantly lower in group BDM (2.02±0.16) in
comparison to group B (2.90±0.31) and group BDX
(2.82±0.50) (Figure 3).
The PONV scores were similar in all groups. Sedation
score and satisfaction score was marginally higher in
group BDM which was not significant (Figure 4).
Heart rate was comparable between group B, group
BDM, and group BDX at all study points except at 2
hours when it was lower in group BDM (Table 2).
Table 2: Comparison of heart rate among different groups.
Heart rate
B (n = 39)
BDM (n = 40)
BDX (n = 40)
ANOVA Statistic
Post-hoc analysis
0-hour
86.97±10.27
87.00±10.15
87.35±7.47
0.980
-
2-hour
83.49±9.80
76.35±6.76
83.25±9.87
< 0.001
B versus BDM = 0.0002; B
versus BDX = 1.000; BDM
versus BDX = 0.002
4-hour
77.38±7.46
77.30±7.38
79.45±5.99
0.300
-
6-hour
79.49±8.44
79.75±8.34
81.10±6.47
0.681
-
12-hour
78.61±8.13
78.75±8.07
79.40±5.98
0.882
-
18-hour
79.84±8.29
79.60±8.33
81.95±7.12
0.351
-
24-hour
80.26±8.84
80.20±8.73
81.50±5.95
0.712
-
Data presented as mean±SD; One-way ANOVA followed by Bonferroni Post-hoc.
Table 3: Comparison of diastolic blood pressure in different groups.
Diastolic BP
B (n = 39)
BDM (n = 40)
BDX (n = 40)
ANOVA statistics
Post-hoc analysis
0-hour
73.69±5.16
71.05±5.06
68.95±5.32
< 0.0001
B versus BDM = 0.076; B versus BDX =
< 0.0001; BDM versus BDX = 0.218
2-hour
74.26±5.15
70.65±4.56
70.55±4.75
0.001
B versus BDM = 0.004; B versus BDX =
0.003; BDM versus BDX = 1.000
4-hour
75.18±5.59
69.65±5.41
71.00±4.73
< 0.0001
B versus BDM < 0.0001; B versus BDX
= 0.002; BDM versus BDX = 0.759
6-hour
73.23±7.06
71.05±4.96
69.90±5.74
0.046
B versus BDM = 0.323; B versus BDX =
0.044; BDM versus BDX = 1.000
12-hour
76.82±4.44
70.80±5.18
70.65±5.84
< 0.0001
B versus BDM < 0.0001; B versus BDX
< 0.0001; BDM versus BDX = 1.000
18-hour
76.46±4.93
70.10±5.45
68.10±12.13
< 0.0001
B versus BDM = 0.002; B versus BDX <
0.0001; BDM versus BDX = 0.835
24-hour
75.95±5.51
71.60±4.46
70.45±5.39
< 0.0001
B versus BDM = 0.001; B versus BDX <
0.0001; BDM versus BDX = 0.958
Data presented as mean±SD; # (B vs. BDM); One-way ANOVA followed by Bonferroni Post-hoc.
Diastolic BP was significantly higher in group B in
comparison to group BDX and group BDM up to 24
hours (Table 3).
DISCUSSION
The ideal analgesic regime should be efficacious without
impacting the ability of mother to take care of the neonate
and with minimal drug transfer through breast milk.
Limited availability of drugs, equipment cost and non-
availability of trained staff for monitoring are the major
issues in providing adequate post caesarian section
analgesia by epidurals.
The TAP block gives good analgesia, is cost affective,
requires less expertise, and reduces consumption of
opioids in post- operative period.
1
2
B (n=39) BDM (n=40) BDX (n=40)
Sedation score

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This was observed by Srivastava U et al in their study
which concluded that TAP block was effective in
providing analgesia with a substantial reduction in
tramadol use during 48h after cesarean section when used
as an adjunct to standard analgesia.8
For abdominal surgeries, TAP blocks have been
demonstrated to decrease the use of postoperative opioids
and their side effects such as sedation and PONV,
increase the time to first request for further analgesia,
provide more effective pain relief, earlier mobilization
and faster recovery.9
Different local anaesthetics alone and addition of
adjuvant to local anaesthesia may prolong the block's
duration. A systematic review and meta-analysis of
randomized controlled trials in 2015 by Zhang D and
colleagues showed that addition of Dexamethasone to
local anesthetics in ultrasound guided TAP block was a
safe and effective strategy for postoperative analgesia in
adult patients undergoing abdominal surgery.10
A systematic review for randomized controlled trials by
Fusco P et al, that assessed the efficacy of ultrasound
(US) guided TAP block following cesarean delivery and
concluded that controversy surrounds the utility of US-
guided TAP block in cesarean section, evidence suggests
that when correctly executed as part of a multimodal
analgesic regimen, TAP block may reduce postoperative
opioid consumption and opioid-related side effects,
improving postoperative pain control and patient
satisfaction.11
In our study we observed that duration of analgesia was
significantly higher in patients who received bupivacaine
along with dexmedetomidine in comparison to the
patients who received bupivacaine alone or with
dexamethasone. Similar results were observed by
Almarkbi and Kaki, who studied the effect of addition of
dexmedetomidine to bupivacaine to perform TAP
block.12,13 They concluded that the addition of
dexmedetomidine to bupivacaine in TAP block achieves
better local anesthesia and provides better pain control
post-operatively with lower heart rate from 60 min from
block to 4 hours postoperatively. Similarly, analgesia
period was significantly higher in the patients who
received bupivacaine and dexamethasone as an adjunct in
comparison to the patients who received bupivacaine
alone. Similar results have been reported by Abdeelal and
colleagues.14 Among these two adjuncts
dexmedetomidine provided longer analgesia and there
was no previous research for similar comparison.
Because of prolonged pain free period total number of
rescue analgesic demands in 24 hours were significantly
lower in group BDM in comparison to group B and group
BDX.
Sharma et al, determined the effect of the addition of
dexamethasone to 0.5% ropivacaine on post-operative
analgesia in USG guided TAP block for inguinal hernia
repair and concluded that addition of dexamaethasone to
ropivacaine in USG guided TAP block significantly
reduces post-operative analgesia and reduces analgesic
consumption.15-17 Our study observed that addition of
dexmedetomidine to bupivacaine provided more
sedation; however, the difference was not significant. Our
results also match with Aksu et al and Mishra et al who
observed that sedation was non-significantly higher in the
patients who received dexmedetomidine in addition to
bupivacaine.18,19 We found that the patients satisfaction
was non significantly higher in the patients who received
dexmedetomidine in addition to bupivacaine in
comparison to other groups. Such findings have also been
reported previously by Aksu et al and Mishra et al.18,19
We observed that heart rate, systolic and diastolic BP was
better maintained in BDX except decrease in heart rate at
2 hours was for very short time, and it can be explained
by bradycardia causing property of alpha 2 agonist.
Bradycardia is one of reported endocrine effects of
dexmedetomidine. Bradycardia may occur with ongoing
therapy mediated by central α2A adrenergic receptors,
causing decreased release of nor adrenaline from the
sympathetic nervous system.20,21 Systolic BP was
comparable in all the groups up to 24 hour while diastolic
BP was significantly lower in group BDX in comparison
to group B and BDM at all time points up to 24 hour
which can be explained by effect of alpha 2 agonist for
BDM group and comparatively higher pain scores in
group B and group BDM. Incidence of post-operative
nausea vomiting was equivalent in all groups. We found
no significant difference in age, weight, ASA class and
duration of surgery.
CONCLUSION
Dexmedetomidine and dexamethasone as an adjunct to
bupivacaine in post-operative pain scores, prolongs the
duration of analgesia, decreases demands for rescue
analgesia, and provides better patient satisfaction with
improved quality of block.
The analgesia is maximally prolonged with
dexmedetomidine without any significant adverse effects.
ACKNOWLEDGMENTS
Authors would like to thank all the patients who
participated in study.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Thakur J, Gupta B, Gupta A,
Verma RK, Verma A, Shah P. A prospective
randomized study to compare dexmedetomidine and
dexamethasone as an adjunct to bupivacaine in
transversus abdominis plane block for post-operative
analgesia in caesarean delivery. Int J Reprod
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