Efficacy of epidural 0.25 ml fentanyl versus 0.5 ml dexmedetomidine with 0.75% ropivacaine in lower abdominal surgeries

Background: Epidural anesthesia alloyed with opioids facilitates a dose sparing effect of local anesthetic and superior analgesia. The drugs such as dexmedetomidine and fentanyl are effective adjuvants to ropivacaine to provide efficient post-operative analgesia. Still, the findings are contradictory. Aims and Objectives: The aims of the study were to assess the efficacy of 0.75% ropivacaine with 0.25 ml fentanyl and 0.5 ml dexmedetomidine in the patients undergoing lower abdominal surgeries. Materials and Methods: A total of 80 cases undergoing lower abdominal surgeries above 21 years were recruited. Group RF administered with 18ml of 0.75% ropivacaine + 0.25 ml fentanyl. Group RD administered with 18ml of 0.75% ropivacaine + 0.5 ml dexmedetomidine. During intraoperative period, parameters such as sensory block, motor block by modified Bromage scale, pain score, and hemodynamic parameters were recorded. The sedation score was assessed using Ramsay sedation score. Results: The mean difference of the events of sensory block and motor block between two study groups was statistically significant (P < 0.05). The mean systolic blood pressure (SBP) was comparatively less in Group RD than Group RF during the entire study period. The mean difference of SBP, heart rate, and mean arterial pressure was statistically significant (P < 0.05). Preoperatively, the diastolic blood pressure was higher in Group RD; later stages, the levels were lesser than Group RF. The mean sedation score was less in Group RD till 15 min, later, it was higher in Group RD than Group RF. Bradycardia was commonly associated post-operative complication in both the study groups followed by nausea and vomiting. Conclusion: The fentanyl and dexmedetomidine are effective adjuvants to ropivacaine. However, dexmedetomidine has better efficacy in terms of prolonged duration of sensory block, motor block, and postoperative analgesia, minimal requirement of rescue analgesia and with less post-operative complications.

Study the Effect of a Single Dose of Intravenous Magnesium Sulphate on Postoperative Pain after Lower Abdominal Surgery

Background: Uncontrolled post-operative pain may produce arange of detrimental acute and chronic effects. Relief fromsevere pain arising from deep or visceral structures, ashappens in surgical procedures, requires the use of opioids.The aim of this study to assess the degree and duration ofpostoperative pain and requirements of rescue analgesia afterIntravenous use of magnesium sulphate preoperatively in lowerabdominal surgery.Materials & Methods: This is a hospital based randomizeddouble blind interventional analytic study done on 50 patientsadmitted in surgery department for lower abdominal surgery atS.M.S. medical college and attached hospital, Jaipur. Aftertaking informed consent and confirming overnight fasting,patient was taken on the recovery room and baseline vitalslike B.P., pulse rate, respiratory rate recorded. Patients at restwas evaluated by using a 0 – 10 cm. visual analogue score(VAS) or by using a 0 - 4 verbal rating score (VRS) atemergence from anaesthesia and1/2, 1, 2, 4, 6, 12 and 24 hrs.after surgery.Results: There was no significant difference in mean age ofpatients between two groups (P > 0.05). The mean of totaldose of analgesia requested was 87.00+ 27.49 mg in MgSO4group and 240.00 + 30.00 mg in C group. It means that therewas clinically and statistically highly significant (P<.001). Themean duration of analgesia was 189.60+18.70 minutes inMgSO4 group and 24.40 + 5.16 minutes in C group. In ourstudy occurrence of nausea and vomiting were more in Cgroup then the MgSO4 group. But these adverse effects werestatistically insignificant in both the groups and did not requireany supplementary management.Conclusion: We concluded that patients receiving Magnesiumsulphate during preoperative period have better pain relief,more sedated and fewer requirements of rescue analgesics inthe postoperative period, without any major side effects.

Comparative study of intrathecal fentanyl, tramadol, clonidine mixed with bupivacaine for peri and post operative pain relief in lower limb and lower abdominal surgery

Background: Pain relief is of paramount importance in patients undergoing surgery during perioperative and post-operative period. After effective pain relief a smoother post-operative period and early discharge from the hospital is anticipated. Intrathecal and epidural narcotics have been widely used to relieve pain and provide post-operative analgesia. Here three drugs tramadol, fentanyl, and clonidine used as adjuvant with bupivacaine in intrathecal injection for post-operative pain relief and comparative study had been done.Methods: After the study protocol was approved by the Ethical clearance committee of the DMCH, Laheriasarai, Bihar. Study design was prospective, randomized and double-blind techniques. A group of 80 patients undergoing lower abdominal and lower limb surgery were included in the study. Every patient was fully explained about the anaesthesia and surgical procedure before inclusion in the study. The patients were in the (25-65) years age group and belonged to the American Society of Anaesthesiologist (ASA) physical status class I-II and scheduled for lower abdominal and lower limbs surgery were randomly allocated to four groups with equal number: group B [Bupivacaine (35)% 3 cc + 0.4 cc normal saline], group BT [Bupivacaine (5)% 3 cc + 25 mg tramadol], BC [Bupivacaine (0.5)% 3 c.c + 30 μg clonidine], BF [Bupivacaine (0.5)% 3 c.c + 20 μg fentanyl]. All additive drugs used intrathecally were preservative free. All intrathecal punctures were performed in the lateral (Right or Left) position with a (25G) Quinke needle, using the midline approach at the L3-L4 intervertebral space.Results: The study revealed that administration of additives in group BC and group BF did prolong analgesia. In group B, duration of analgesia and mean duration of rescue analgesic requirement was (3.57±0.45) hrs. For group BC it was (9.47±0.85) hrs, for group BF (7.6±1.14) hrs, for group BT (3.72±0.42) hrs.Conclusions:Addition of adjuvants (Fentanyl, Clonidine) to intrathecal bupivacaine for perioperative pain relief does prolong postoperative analgesia and improves the intraoperative quality of analgesia than bupivacaine alone.Background: Pain relief is of paramount importance in patients undergoing surgery during perioperative and post-operative period. After effective pain relief a smoother post-operative period and early discharge from the hospital is anticipated. Intrathecal and epidural narcotics have been widely used to relieve pain and provide post-operative analgesia. Here three drugs tramadol, fentanyl, and clonidine used as adjuvant with bupivacaine in intrathecal injection for post-operative pain relief and comparative study had been done.Methods: After the study protocol was approved by the Ethical clearance committee of the DMCH, Laheriasarai, Bihar. Study design was prospective, randomized and double-blind techniques. A group of 80 patients undergoing lower abdominal and lower limb surgery were included in the study. Every patient was fully explained about the anaesthesia and surgical procedure before inclusion in the study. The patients were in the (25-65) years age group and belonged to the American Society of Anaesthesiologist (ASA) physical status class I-II and scheduled for lower abdominal and lower limbs surgery were randomly allocated to four groups with equal number: group B [Bupivacaine (35)% 3 cc + 0.4 cc normal saline], group BT [Bupivacaine (5)% 3 cc + 25 mg tramadol], BC [Bupivacaine (0.5)% 3 c.c + 30 μg clonidine], BF [Bupivacaine (0.5)% 3 c.c + 20 μg fentanyl]. All additive drugs used intrathecally were preservative free. All intrathecal punctures were performed in the lateral (Right or Left) position with a (25G) Quinke needle, using the midline approach at the L3-L4 intervertebral space.Results: The study revealed that administration of additives in group BC and group BF did prolong analgesia. In group B, duration of analgesia and mean duration of rescue analgesic requirement was (3.57±0.45) hrs. For group BC it was (9.47±0.85) hrs, for group BF (7.6±1.14) hrs, for group BT (3.72±0.42) hrs.Conclusions: Addition of adjuvants (Fentanyl, Clonidine) to intrathecal bupivacaine for perioperative pain relief does prolong postoperative analgesia and improves the intraoperative quality of analgesia than bupivacaine alone.

Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series / Bloqueio bilateral do plano eretor da espinha torácica inferior em cirurgia oncológica ginecológica aberta por via abdominal: série de casos

Abstract Objective and background: Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients. Method: Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded. Results: Pain scores ranged from 0 to 4 among the three patients and 48 h opioid consumption in oral morphine equivalents of 4, 6 and 18 mg. No adverse events were recorded up to patient discharge from the hospital. Conclusions: Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Resumo Justificativa e objetivo: O bloqueio do plano do músculo eretor da espinha é um novo bloqueio troncular analgésico popularizado devido à sua facilidade de aplicação e segurança percebida. O bloqueio do plano do músculo eretor da espinha foi postulado para atingir os ramos ventrais e os ramos comunicantes dos nervos espinhais, proporcionando analgesia somática e visceral. Nesta casuística, descrevemos nossa experiência com o bloqueio do plano do músculo eretor da espinha bilateral depositado no nível torácico inferior em cirurgia oncológica ginecológica aberta em três pacientes. Método: Os bloqueios do plano do músculo eretor da espinha guiados por ultrassom foram administrados no pré-operatório, entre o 8° e o 10° processo transverso do tórax bilateralmente. Os valores de uma escala de classificação numérica para dor e consumo de opioides nas primeiras 48 horas de pós-operatório foram registrados. Resultados: Os escores de dor variaram de 0-4 entre as três pacientes e o consumo de opioide em 48 horas equivaleu à morfina oral (4, 6 e 18 mg). Nenhum evento adverso foi registrado até a alta hospitalar das pacientes. Conclusões: O bloqueio do plano do músculo eretor da espinha proporcionou analgesia efetiva em nossa casuística. Embora o mecanismo de ação verdadeiro permaneça obscuro, os relatos de casos disponíveis mostram resultados analgésicos encorajadores, sem eventos adversos registrados. Ensaios prospectivos randômicos formais estão em andamento para fornecer mais evidências sobre sua eficácia, taxa de falha e segurança.

Comparison of commonly used vasopressors for treating hypotension after spinal anaesthesia in elective lower abdominal surgery: a randomized, observational, case-control study

Background: During caesarean section hypotension due to spinal block is secondary to the sympathetic blockade and aorto-caval compression by the uterus. It can have important consequences for the mother and may affect neonatal outcome. The present study was aimed to compare intravenous bolus doses of phenylephrine and ephedrine to treat maternal hypotension during spinal block for elective caesarean section.Methods: After fulfilling the inclusion criteria, 100 parturient were randomly allocated into two groups of fifty each. For spinal anesthesia lumber puncture was done and 12.5mg, 0.5% hyperbaric bupivacaine was given intra-thecally. In this observational study, patients who developed hypotension under spinal anesthesia were selected for the study. According to their group, patients received either ephedrine 6mg (Group E) or phenylephrine 75µg (Group P) as vasopressor. During the study, number of vasopressor boluses, hemodynamic response and time taken to recover from hypotension was noted.Results: Ephedrine and phenylephrine were used in the mean doses of 6.72±1.97mg and 91.5±31.38µg respectively. In 88% parturient single bolus dose of ephedrine was effective in treating hypotension while phenylephrine was effective in 78% parturient. There was no significant difference observed in total number of boluses used. No significant difference was seen in mean systolic blood pressure, mean diastolic blood pressure and mean arterial pressure over a given period of time in Group E and Group P. Mean systolic BP was less than 20% when compared to baseline in both the groups at different time intervals. In Group P the mean heart rate was significantly lower as compared to the Group E (p<0.05).Conclusions: Intravenous phenylephrine and ephedrine are both similar in performance in treating hypotension after spinal anesthesia for elective caesarean section and the hypotensive control offered is comparable.

Ephedrine versus phenylephrine: effects on fetal acid-base status during spinal anesthesia for elective cesarean delivery

Background: During elective caesarean sections, post-spinal hypotension is a common problem. Prevention of this complication by sympathomimetic agents is of potential clinical significance. The objective of this study was to compare and evaluate the effects of ephedrine and phenylephrine on the fetal outcome when used in the treatment of maternal hypotension during spinal block in elective caesarean section.Methods: After fulfilling the inclusion criteria, hundred patients were enrolled in this study and were randomly allocated into two groups of fifty each. According to their group, patients received either ephedrine 6 mg (group E) or phenylephrine 75µg (group P) as vasopressor. For spinal anaesthesia lumber puncture was done in sitting position and 12.5mg, 0.5% hyperbaric bupivacaine was given intra-thecally to every patient. Throughout surgery, maternal and neonatal complications were controlled and recorded. During the study, Apgar scores on the 1st and 5th minutes, and blood gases of the umbilical cord blood were evaluated.Results: Ephedrine and phenylephrine were used in the mean doses of 6.72±1.97mg and 91.5±31.38µg respectively. There was no significant difference observed in total number of boluses used in treating post-spinal hypotension. The difference in the first- and fifth-minute Apgar scores was statistically insignificant between the group E and group P. There was a statistically significant difference observed in SaO2 and base excess in arterial gas sample between two studied groups. Similarly, a significant difference was observed in PCO2 of umbilical venous sample between two studied groups. However, none of the neonates had the true fetal acidosis.Conclusions: Intravenous phenylephrine 75µg and ephedrine 6 mg offer a comparable hypotensive control without any significant complication for mother or her fetus in elective caesarean section.

Efficiency of bupivacaine and association with dexmedetomidine in transversus abdominis plane block ultrasound guided in postoperative pain of abdominal surgery / Eficácia de bupivacaína e associação com dexmedetomidina em bloqueio do plano transverso abdominal guiado por ultrassom na dor após cirurgia abdominal

Abstract Background and objectives We aimed to evaluate the effect of bupivacaine and dexmedetomidine added to bupivacaine used in tranversus abdominis plane (TAP) block on postoperative pain and patient satisfaction in patients undergoing lower abdominal surgery. Methods Patients submitted to lower abdominal surgery were enrolled in the study. After anesthesia induction, ultrasound guided TAP block was performed. TAP block was obtained with 21 mL 0.9% saline in Group C (n = 31), 20 mL 0.5% bupivacaine + 1 mL saline in Group B (n = 31), and 20 mL 0.5% bupivacaine + 1 mL dexmedetomidine (100 µg) in Group BD (n = 31). Results Visual analog scale scores were lower in Group BD compared to Group C, at all time points (p < 0.05); it was lower in group BD than in group B at 10-24 h. In Group B, it was lower than Group C at 2-8 h (p < 0.05). Total morphine consumption was lower in Group BD compared to other groups and lower in group B than in the controls (p < 0.001). Patient satisfaction was higher in Group BD than in other groups and was higher in both study groups than in the controls (p < 0.001). Nausea-vomiting scores, antiemetic requirement, or additional analgesic administration were not significant among groups (p > 0.05). Conclusions The addition of dexmedetomidine to bupivacaine on TAP block decreased postoperative pain scores and morphine consumption; it also increased patient satisfaction in patients undergoing lower abdominal surgery. Dexmedetomidine did not have any effect on nausea and vomiting score and antiemetic requirement.

Resumo Justificativa e objetivos O objetivo do estudo foi avaliar o efeito de bupivacaína e dexmedetomidina adicionada à bupivacaína para bloqueio do plano transverso abdominal (TAP) no controle da dor e satisfação do paciente após cirurgia abdominal inferior. Métodos Pacientes submetidos à cirurgia abdominal inferior foram incluídos no estudo. Após a indução da anestesia, o bloqueio TAP guiado por ultrassom foi feito com 21 mL de solução salina a 0,9% no Grupo C (n = 31), 20 mL de bupivacaína a 0,5% + 1 mL de solução salina no Grupo B (n = 31) e 20 mL de bupivacaína a 0,5% + 1 mL de dexmedetomidina (100 µg) no grupo BD (n = 31). Resultados Os escores da escala visual analógica foram menores no Grupo BD comparado com o Grupo C em todos os tempos mensurados (p < 0,05); foi menor no Grupo BD do que no Grupo B em 10-24 horas. No Grupo B, os escores VAS foram menores do que no Grupo C em 2-8 horas (p < 0,05). O consumo total de morfina foi menor no Grupo BD em comparação com outros grupos e menor no Grupo B do que nos controles (p < 0,001). A satisfação do paciente foi maior no Grupo BD do que nos outros grupos e maior em ambos os grupos de estudo do que nos controles (p < 0,001). Os escores de náusea e vômito, necessidade de antiemético ou de analgésicos adicionais não foram significativos entre os grupos (p > 0,05). Conclusões A adição de dexmedetomidina à bupivacaína em bloqueio TAP reduziu os escores de dor e o consumo de morfina no pós-operatório, além de aumentar a satisfação em pacientes submetidos à cirurgia abdominal inferior. Dexmedetomidina não apresentou efeito sobre os escores de náusea e vômito e a necessidade de antiemético.

Comparative study between ketamine and bupivacaine intrathecally in lower abdomen and lower limb surgery

Background: There is an on-going quest to know which agent is the better agent for intrathecal anaesthesia for pain relief due to surgical stimuli. Bupivacaine is commonly used local anaesthetic agent for spinal anaesthesia but it has some disadvantages like slower onset of action. Ketamine shows beside its general anaesthetic effect, a local anaesthetic like action. Series of studies have shown a potent analgesia after spinal administration of ketamine alone or in combination with opioids and α2 agonists, suggesting that ketamine alters pain perception at the spinal level. So, the objective of this study to compare the effectiveness of Ketamine action intrathecally with that of bupivacaine in respect to onset & duration of analgesia, onset & duration of motor block, sedation, cardiovascular effects and any other side effects like nausea, vomiting. Materials and methods: In this hospital based prospective comparative study, 100 patients of ASA (American Society of Anaesthesia) I and II scheduled for lower abdominal and lower limb surgery were taken. Patients were divided into two equal groups. Group I – Received 3 ml of hyperbaric bupivacaine (0.5%). Group II – Received 3 ml of hyperbaric Ketamine [taken from 2ml of preservative free ketamine (100mg) added with 2ml of 5% dextrose]. Onset and duration of analgesia, onset and duration of motor block, central effects like sedation, effects on cardiovascular system and any other side effects were compared in both the groups. Analysis data was carried out using the available statistical package of SPSS-20 (Statistical Package for Social Science – version 20 “PASW” statistics). Results: The onset of sensory block and motor block were faster in ketamine group as compared to bupivacaine group. The duration of analgesia was longer in ketamine group as compared to Sunanda Panigrahi, Archana Mhatre. Comparative study between ketamine and bupivacaine intrathecally in lower abdomen and lower limb surgery. IAIM, 2018; 5(8): 47-54. Page 48 bupivacaine group. The duration of motor block was almost equal in both the groups. About sedation, more patients were sedated in ketamine group as compared to bupivacaine group. Patients in ketamine group were more stable cardiovascularly as compared to bupivacaine group. Conclusion: Ketamine can be used as a pure local anaesthetic for spinal anaesthesia with advantage of faster onset of analgesia and motor block as well as longer duration of analgesia. Ketamine group appeared more hemodynamically stable also. So, ketamine can be used as an alternative to bupivacaine for moderate duration of lower abdomen and lower limb surgery despite its central effect like sedation.

Laparoscopic Totally Extraperitoneal Hernia Repair after Radical Prostatectomy or Lower Abdominal Surgery Except for Appendectomy: Experience of 35 Cases

PURPOSE: Laparoscopic totally extraperitoneal (TEP) hernia repair is known to be relatively difficult in cases with a history of lower abdominal surgery. We assess the feasibility of laparoscopic TEP hernia repair in those patients. METHODS: Thirty five patients with a previous history of radical prostatectomy or lower abdominal surgery who underwent laparoscopic TEP hernia repair for inguinal hernia were reviewed retrospectively. All operations were performed by a single experienced surgeon. RESULTS: Thirty three out of the 35 patients (94%) were men. Laparoscopic TEP hernia repair was performed successfully in 30 out of 35 cases. Twenty five cases (71%) were right inguinal hernia, 6 cases (17%) were left hernias, and 4 cases (11%) had an inguinal hernia on both sides. Five cases were converted to transabdominal preperitoneal (TAPP) (n=3) or open methods (n=2). Mean operation time was 111 minutes. The patient group with previous radical prostatectomy was the largest (n=22, 63%) and required a longer operation time (124 minutes). Blood loss was less than 50 cc in all cases. Average hospital stay was 1.2 days after surgery. Voiding difficulties requiring catheterization were observed in 13 cases (37%). CONCLUSION: Laparoscopic TEP hernia repair for a patient with previous history of radical prostatectomy or lower abdominal surgery except for appendectomy can be safely performed by an experienced surgeon, but is not recommended as a standard choice because of a longer operation time and higher conversion rate.

Laparoscopic Totally Extraperitoneal Hernia Repair in Patients with Previous Lower Abdominal Surgery-Early Experience / 대한내시경복강경외과학회지

PURPOSE: Recently, laparoscopic totally extraperitoneal (TEP) inguinal hernia repair has established itself as a safe and effective treatment for inguinal hernia. Nevertheless, there are difficulties in learning the technique. In particular, patients with a medical history of having undergone lower abdominal surgery are generally excluded from laparoscopic hernia repair due to the technical difficulty of the procedure. This study evaluated the early surgical outcome and examined the feasibility of techniques for laparoscopic TEP inguinal hernia repair in patients who had previously undergone lower abdominal surgery. METHODS: Ten cases of laparoscopic TEP inguinal hernia repair in patients with a prior history of lower abdominal surgery between November 2006 and January 2010 were reviewed. All cases were treated by a single highly experienced laparoscopic surgeon. RESULTS: Previous operations included 5 cases of radical prostatectomies for prostate cancer, 2 cases of open suprapubic prostatectomies for benign prostate hypertrophy, 2 cases of radical cystectomies for bladder cancer and 1 case of laparoscopic low anterior resection for rectal cancer. In all 10 cases, the patients were male with 9 cases involving an indirect hernia and 1 case involving a direct hernia. The mean operation time was 136.5+/-33.7 minutes, and in 1 case, the surgical method was converted to the transabdominal preperitoneal approach. Postoperatively, there were 3 cases of urinary retention, and the administration of analgesics were required 1.0+/-0.6 times on average. The mean length of hospitalization was 1.2+/-0.8 days. During the mean 18 month (1~36 months) follow-up period, there was no recurrence and chronic pain but 1 case of mesh infection was encountered 6 months after TEP repair. CONCLUSION: Although the laparoscopic TEP inguinal hernia repair can be carried out safely on patients with previous lower abdominal surgery, it needs to be carried out by fully trained surgeons with sufficient experience in the TEP technique. Nevertheless, more extensive experience and a longer follow-up period will be needed to evaluate the feasibility and efficiency of the TEP approach.

The Feasibility of Laparoscopic Total Extraperitoneal (TEP) Herniorrhaphy after Previous Lower Abdominal Surgery

PURPOSE: We retrospectively reviewed the medical records to estimate the feasibility and surgical outcome of laparoscopic herniorrhaphies in patients with previous lower abdominal surgery. METHODS: Between December 2000 and December 2008, a total of 1,101 cases of laparoscopic herniorrhaphies were performed in 974 patients, among them 47 cases (4.27%) of laparoscopic herniorrhaphy in 40 patients who had undergone previous lower abdominal surgery were enrolled to this study. RESULTS: Most patients (23 of 24) who had a history of appendectomy successfully underwent laparoscopic totally extraperitoneal (TEP) repair. Six patients who had history of a prostatectomy and 2 patients with a Pfannenstiel incision underwent an intraperitoneal only mesh (IPOM) repair after a failed TEP repair. Five patients had lower midline incisions due to panperitonitis, among them TEP repairs were performed in 3 patients and IPOM was performed after failed TEP repairs in 2 patients who had undergone surgery due to trauma-induced rupture of the bladder. CONCLUSION: Laparoscopic TEP hernia repair could be possible and reasonable in patients after an appendectomy; however, it is difficult in patients with previous pelvic surgeries. Additional studies are needed to determine whether or not laparoscopic TEP repair for inguinal hernias is feasible in patients who have undergone other general surgical procedures.