RESUMEN
Epidural opioids have the appeal of ease of administration of local anesthetic injection for surgical anesthesia. Nevertheless, the side effects linked to epidural opioid administration might retard their use in certain patient populations. Ropivacaine has both anesthetic and analgesic effects. At high dose it produces sensory and motor block, while at lower doses it produces sensory block [analgesia] with limited and non progressive motor block. Lumbar epidural anesthesia, which is the most commonly used form of this technique, is used for any lower limb surgical procedure. This combined with the avoidance of spinal headache, has made the technique increasingly popular. Non-opioid such as clonidine, ketamine, midazolam may be more suited as adjuvant rather than sole analgesics and there main role lies in reducing the dose requirements of other analgesics. Aim of the Work: To investigate the role of epidural combination of ropivacaine and midazolam versus epidural ropivacaine alone for anesthesia and postoperative analgesia in intramedullary nailing of femur shaft fracture. A total number of 32 patients with intramedullary nailing operations were included in this study. They were divided into two groups; control group [group I] included 16 patients received 1.5ml per segment epidural. ropivacaine 0.5% [total volume was 15ml] and study group [group II] included 16 patients received 1.5ml per segment [total volume was 15ml] epidural ropivacaine 0.5% plus 0.05mg/kg epidural midazolam available in Suez Canal University Hospital containing midazolam hydrochloride buffered to pH 3.5 with hydroxide and sodium hydrochloride. Patients were evaluated by history, physical examinations and laboratory investigations were requested preoperatively. Patients were being visited the day before surgery. Visual analogue scale was explained. The following parameters were assessed in this study; onset of anesthesia, duration of effective analgesic time from the onset of epidural analgesia, visual analogue scales [VAS] intraoperatively and at 2, 4, 6, 8, 10, 12 and 24 hours the top up dose, total consumption of analgesics in the first 24 hours the top up dose, modified bromage score at 6, 12, 24 hours the top up dose and sedation score at 6, 12, 24 hours postoperatively. The ropivacaine/midazolam group developed more marked degree of sedation than the ropivacaine group that develop mild sedative effect after 2, 4, and 6 hours from the top up dose due to PCA. The difference between the two groups regarding the sedative effect was statistically highly significant [p<0.001]. After 12 hours, there was no sedative effect in both groups. We concluded that epidural ropivacaine in combination with midazolam are more effective for adequate anesthesia and for prolongation of postoperative analgesia than epidural ropivacaine alone in intramedullary nailing of femur shaft fracture.