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A STUDY TO EVALUATE THE EFFICACY OF DEXMEDETOMIDINE AND FENTANYL AS ADJUVANT TO EPIDURAL BUPIVACAINE IN PROVIDING POST-OPERATIVE ANALGESIA TO PATIENTS UNDERGOING TOTAL KNEE REPLACEMENT.
Abstract
Background: Knee osteoarthritis (OA) is the most common musculoskeletal condition affecting people worldwide. Peri-operative pain has been reported to be the major concern of patients in the post-operative period. There have been continuous searches for a pharmacological agent as an adjuvant which can prolong the analgesic action of local anaesthetic, so that the duration of analgesia can be prolonged in the post-operative period. Both dexmedetomidine and fentanyl have been used as an adjuvant to local anaesthetic delivered through epidural route for post-operative pain relief. Aim of the Study: We aim to compare the post-operative analgesic effects of dexmedetomidine and fentanyl as an adjuvant to epidural bupivacaine in patients undergoing total knee replacement. We will also note any side effects example nausea, vomiting, hypotension, bradycardia and pruritus for each of the study group. Setting and Design: This was a prospective randomized control trial in a tertiary hospital. Materials and Methods: Fifty consenting adult patients with physical status classes I and II, as determined by the American Society of Anaesthesiologists, scheduled to undergo elective total knee replacement, were randomly allocated to receive either Injection 0.5% Bupivacaine 10ml + Inj. Fentanyl 0.5 µg/kg in 2 ml NS (Group A) or injection 0.5% Bupivacaine 10ml + Inj. dexmedetomidine 0.5 µg/kg in 2 ml NS (Group B). The primary objective was to compare the post-operative analgesic effects of dexmedetomidine and fentanyl as an adjuvant to epidural bupivacaine in patients undergoing total knee replacement.. The secondary objective was to note any side effects example nausea, vomiting, hypotension, bradycardia and pruritus for each of the study group. Statistical Analysis Used: The results are discussed in the form of numerical values, percentages, mean and standard deviation. The α level for all analysis was set at 0.05 and p-value <0.05 was considered statistically signicant. Demographic data like sex, weight, age and as grades of both the groups were compared using chi-square test. Comparison of incidence of hypotension was done using Chi-Square test. The software used for statistical analysis was SPSS (statistical package for social sciences) version 21.0 Results: At 2 hours after the rst top-up dose, 15 out of 25 patients in Group B were having complete pain relief (i.e. NPRS 0) while this number in Group A was only 6. At 4 hours, none of the patients in Group A were having complete pain relief while there were 5 patients in Group B who had complete pain relief with NPRS 0. The trend of NPRS when observed at 6 hours exhibited the same pattern as at 4 hours. At 8 hours, in Group A there were just 2 patients which were having NPRS score 4 and rest of the 23 patients had complained of moderate pain with NPRS score 5. In Group B there were 7 patients with NPRS 3 at 8 hours and there were 13 patients with NPRS5. The mean time for NPRS 5 after rst top-up was found to be signicantly more in group B as compared to group A (p-value 0.004). study time required for second top-up was signicantly prolonged in group B (8.40 hours) as compares to group A (6.64hours). The incidence of hypotension is more commonly associated with dexmedetomidine as compared to fentanyl and the incidence of nausea & vomiting is more common when fentanyl is used as an adjuvant with isobaric bupivacaine. Conclusion: Isobaric bupivacaine in 0.5% concentration in combination with Dexmedetomidine as an adjuvant provides better analgesia for a longer duration of time as compared to Bupivacaine & Fentanyl combination.
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Background: Epidural adjuvants enhance the quality and duration of surgical anesthesia. The present study was aimed to compare the hemodynamic, sedative, and analgesia potentiating effects of dexmedetomidine versus fentanyl with epidural 0.5% levobupivacaine for vaginal hysterectomy. Patients and Methods: Sixty consented females of ASA physical status I and II aged 35-65 years weighing 55-75 kg, were double blindly randomized into two treatment groups. Patients received epidural 0.5% levobupivacaine 15 ml either with of 25 μg dexmedetomidine (Group LD) or 50 μg fentanyl (Group LF) and the total volume of study solution was kept 16 ml. Onset of analgesia at T10, sensory and motor block levels and duration of analgesia were observed. Intra-operatively, they were assessed for sedation, hemodynamic changes, respiratory efficiency, and side effects. The data obtained, was compiled systematically and analyzed statistically using Chi-square test and ANOVA. Value of P < 0.05 is considered significant. Result: The demographic profile was comparable between groups. The onset of sensory analgesia at T10 (7.25 ± 2.3 versus 9.27 ± 2.79 min) and time to achieve complete motor blockade (19.27 ± 4.7 versus 22.78 ± 5.57 min) was significantly earlier in patients of LD Group. The intraoperative hemodynamic changes were comparable between groups. Ramsey Sedation score was better in LD group with statistically significance. Postoperative analgesia was significantly prolonged in LD Group. Incidence of nausea, vomiting, and pruritus was high in LF group. Conclusion: Dexmedetomidine was better than fentanyl as an epidural adjuvant for providing early onset of sensory analgesia, adequate sedation with no respiratory depression and prolonged postoperative analgesia.
In a prospective multicentre study we investigated variations in pain management used by knee arthroplasty surgeons in order to compare the differences in pain levels among patients undergoing total knee replacements (TKR), and to compare the effectiveness of pain management protocols. The protocols, peri-operative levels of pain and patient satisfaction were investigated in 424 patients who underwent TKR in 14 hospitals. The protocols were highly variable and peri-operative pain levels varied substantially, particularly during the first two post-operative days. Differences in levels of pain were greatest during the night after TKR, when visual analogue scores ranged from 16.9 to 94.3 points.
Of the methods of managing pain, the combined use of peri-articular infiltration and nerve blocks provided better pain relief than other methods during the first two post-operative days. Patients managed with peri-articular injection plus nerve block, and epidural analgesia were more likely to have higher satisfaction at two weeks after TKR. This study highlights the need to establish a consistent pain management strategy after TKR.
Spinal anaesthesia is the most common approach which is used for lower limb surgery. Dexmedetomidine is the recent drug which acts on α2-adrenergic receptors in the dorsal horn of the spinal cord to produce analgesic effects.
Efficacy and safety of intrathecal dexmedetomidine added to ropivacaine.
Randomised double blind trial.
Sixty patients were randomly allocated to receive intrathecally either 3 ml of 0.75% isobaric ropivacaine + 0.5 ml normal saline (Group R) or 3 ml of 0.75% isobaric ropivacaine + 5 μg dexmedetomidine in 0.5 ml of normal saline (Group D).
The mean time of sensory regression to S2 was 468.3±36.78 minutes in group D and 239.33±16.8 minutes in group R. Duration of analgesia (time to requirement of first rescue analgesic) was significantly prolonged in group D (478.4±20.9 minutes) as compared to group R (241.67±21.67 minutes). The maximum visual analogue scale score for pain was less in group D (4.4±1.4) as compared to group R (6.8±2.2).
The addition of dexmedetomidine to ropivacaine intrathecally produces a prolongation in the duration of the motor and sensory block.
This is a retrospective study of the role of postoperative epidural analgesia in major spinal surgical procedures. With the number and complexity of the procedures performed on the spine ever-increasing, this method of analgesia is becoming more important.
Results of 74 consecutive cases of major spinal surgeries between January 2000 and January 2001 at the Spine Division, Amritha Institute of Medical Sciences and Research Centre, Kochi, India, were studied. 32 cases were posterior procedures and the other 42 were anterior procedures of the thoracic and lumbar regions. The use of various combinations of local anaesthetic and opioid to control postoperative pain after spinal surgery were analysed.
36 (49%) of 74 patients did not require any parenteral supplements. Of the remaining 38 patients who required supplementary parenteral analgesia in the first 48 hours, 25 (34%) received a single dose and 13 (18%) required more than one dose. The number of patients requiring parenteral analgesia immediately after operation were 11; between 2 and 6 hours were 12; and between 6 and 24 hours were 11. Of the 74 patients, 67 had a sound sleep after epidural administration. There were 2 cases of respiratory depression and 2 of transient hypotension.
Most epidural analgesic regimens significantly reduced postoperative pain, and the requirement for supplementary parenteral analgesics was minimal. Adverse effects were rare, yet we recommend that patients treated with this protocol be managed in high-dependency units.
INTRODUCTION: A commonly used technique for lower limb surgeries is subarachnoid blockade. If there is inadequate control of pain, will affect quality, and functional recovery, also there is chance of postsurgical complications, and the risk of persistent postsurgical pain. Use of epidural analgesic technique for lower limb surgeries should provide better pain relief with minimal side effects, leading to improved outcome. Bupivacaine hydrochloride is a local anaesthetic drug, which was used clinically in 1963. Bupivacaine acts mainly by blockade of voltage-gated Na+ channels in the axonal membrane and possibly has a further effect on presynaptic inhibition of calcium channels. Fentanyl is a powerful synthetic opioid which is similar to morphine but is 50 - 100 times more potent, which is used to treat patients with severe pain, especially after surgeries. MATERIAL AND METHODS: This prospective randomized study was conducted in the department of anaesthesiology at Rajiv Gandhi Institute of Medical Science, Adilabad, to compare single shot epidural 8ml 0.5 % bupivacaine alone verses 8ml 0.5% bupivacaine along with 0.50 mcg Fentanyl. Total of 80 patients with ASA(American society of anaesthesiologists) I and II with age group between 24 to 56 years were included and 40 patients each were randomly placed in bupivacaine alone group (Group 1) and fentanyl in combination with bupivacaine group (Group 2). Written informed consent from all the patients was obtained. RESULTS: Mean (SD) systolic blood pressure was observed to be 128.45(12.47) and 130.25(11.55) in group 1 and group 2 respectively. Mean time for T 10 sensory block was significantly earlier in group 2 12.03(1.12) compared to group 1 18.24(2.54). Onset of motor block was observed to differ significantly, where onset was significantly earlier in group 2 23.17(1.77) in comparison to group 1 28.45(1.49). The first analgesic requirement in Group 1 was earlier at 198.20 + 11.49 min as compared to Group 2 at 279.34 + 18.42 min. CONCLUSION: Bupivacaine with Fentanyl enhances the onset of action and duration of effect for two segment regression. In present study the time to achieve T10 sensory block was early in Group 2 12.03(1.12) compared to group1 18.24(2.54).Onset of group2 23.17(1.77) in comparison to group1 28.45(1.49). Time of first analgesic requirement was found to be earlier at 279.34 + 18.42 minutes in group2 in comparison to group1 198.20 + 11.49 minutes.
The purpose of this study was to assess older adults to determine (a) the course of postoperative pain, (b) influences of pain and analgesics on mental status, and (c) relationships among age, mental status and pain. Sixty adults, aged 50-80 yr, who had total hip replacement surgery were included in this study. All subjects had met a preoperative criterion for mental status. Data collection took place over 5 days following surgery. Pain intensity and distress were assessed three times a day for 5 days. Recalled night pain intensity, pain distress, and sleep disturbance from pain were assessed daily in the early morning prior to assessment of mental status. Although no within day or day-to-day pain patterns were observed, the greatest decreases in pain occurred during the first 2 days. Night pain also improved after the third day. One-third of subjects recorded one or more episodes where mental status declined below criterion after surgery. Multivariate analysis indicated that pain, not analgesic intake, predicted mental status decline. Age was not related to pain or mental status. In general, pain was poorly managed in this group of subjects. The results suggest an explanation for acute confusion in older patients after surgery and recommend improved pain management.
The pain relief provided by intra-articular injection of morphine plus bupivacaine after total knee arthroplasty (TKA) plus partial synovectomy in patients with rheumatoid arthritis was compared with pain relief after TKA alone in patients with osteoarthritis. There were lower pain scores, a much smaller requirement for systemic analgesics, longer duration until the first requirement of systemic analgesics, and improvement in the range of motion of the knee joint in the patients who received intra-articular injection of analgesics. There was more pronounced postoperative analgesia in the patients with rheumatoid arthritis than in the patients with osteoarthritis in the study groups that received intra-articular injection of analgesics.
Continuous-infusion femoral nerve block (FNB) improves analgesia and rehabilitation after total knee replacement. In this study, we investigated the efficacy of single-injection FNB to achieve similar results.
A total of 30 patients were prospectively and randomly assigned to receive 40-mL injections of either 0.25% bupivacaine (group B) or saline (group S) after total knee replacement. Blinded observers evaluated the patients for postoperative pain, morphine consumption, ambulating distances, and maximal knee flexion; pain was scored on the visual analog scale (VAS).
Compared with group S patients, group B patients had significantly lower VAS pain scores (P <.01 in the postoperative anesthesia care unit, P <.05 on the day after surgery); group B patients also showed significantly lower total morphine use (P <.05) and a lower incidence of morphine-related side effects. Significantly more group B than group S patients could ambulate on the day after surgery (93% v 46%, P <.05), and mean ambulatory distance was significantly better for group B than group S patients at discharge (166 +/- 37 v 117 +/- 24 feet, P <.01). Knee flexion was significantly better for group B than group S patients on the second day after surgery (70 degrees v 60 degrees, P <.01), but the between-group difference was no longer statistically significant at discharge. Mean length of acute hospitalization was significantly shorter for group B (3 days; range, 3 to 5 days) than group S patients (4 days; range, 3 to 6 days, P <.05).
Single-injection FNB provided effective analgesia, facilitated early ambulation, and reduced the length of acute hospitalization in patients undergoing total knee replacement.
Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure.
This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared.
Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone.
Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.
There is much enthusiasm in the current field of TKA to allow high-flexion activities that might be important for Asian patients. We investigated functional disabilities and their perceived importance before surgery in 97 Korean female patients undergoing TKA for advanced osteoarthritis. The most important issues relating to functional disability were difficulty in squatting, leg deformity, difficulty in kneeling, unequal leg length, and limping. The most important issues relating to perceived importance were difficulty in walking, daytime pain, limping, difficulty in climbing stairs, and need for walking aids. The severity of functional disabilities did not correlate with the perceived importance. The most important issues concerning patients were pain immediately after surgery, pain after discharge from the hospital, chance that surgery would not alleviate pain, pain during surgery, and risk of getting AIDS from a transfusion. We found high-flexion activities were rated as the most difficult functions, but they were not perceived as being as important as other items related to pain relief and routine daily activities. The issues related to high-flexion activities were of no more concern than other issues in Korean patients.
Level of Evidence: Level II, economic or decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.