Nalbuphine given intrathecally as an adjuvant to LAAs


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Dr. Minnu M. Panditrao, shares her own experience of adding nalbuphine, a newer, agonist- antagonist to bupivacaine as an adjuvant in elderly males coming for lower limb surgeries

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Nalbuphine given intrathecally as an adjuvant to LAAs

  1. 1. To Study The Effects Of Addition Of Nalbuphine ToBupivacaine Used For Elderly Patients UndergoingSpinal Anaesthesia: A Randomized Double Blind,Controlled Study Authors Dr. (Mrs) M.M.Panditrao CONSULTANT, ANESTHESDIOLOGY, Rand Memeorial Hopsital Freepeort, Grand Bahama The Bahamas
  2. 2. INTRODUCTION• Spinal Anaesthesia: still the most popular technique• However there is limitation of duration• Many adjuvants have been used to prolong the duration/ provide analgesia, but have their own disadvantages
  3. 3. AIMS & OBJECTIVESTo compare -• Quality of block• Duration of post-operative analgesia• Adverse effects, if any when Nalbuphine was added to HyperbaricBupivacaine 0.5%, in patients undergoing lowerabdominal & lower limb surgeries.
  4. 4. MATERIAL & METHODS• IEC approval• Informed consent• 40 ASA I & II• Age range: 50-70 yrs• Either sex• Patients scheduled for lower abdominal & lower extremity surgeries (<180 min)• Patient not fit for Spinal anaesthesia were excluded
  5. 5. • Thorough pre-operative evaluation• NBM for 6-8 hrs• Randomization: 2 groups by lottery method- Group 1 (Study group): Inj. Bupivacaine (0.5%) 3 ml + Inj. Nalbuphine (0.5mg) 0.5 ml intrathecally Group 2 (Control group): Inj. Bupivacaine (0.5%) 3 ml + Inj. Normal saline 0.5ml intrathecally
  6. 6. • Sedatives and Hypnotics avoided in pre, intra & post-operative period• IV line secured with 20 G cannula• Preload: Ringer lactate @ 10ml/kg• Monitoring: Pulse, B.P., SPO2, RR
  7. 7. • ↓ AAP, SAB given in • Respective agents injected sitting position with according to group 26G Quincke needle
  8. 8. • Following parameters were observed -1) Time of onset of sensory blockade (T1)2) Time of onset of motor blockade (T2)3) Time of peak sensory blockade (T3)4) Time of peak motor blockade (T4)5) Time of post-operative analgesia (T5)
  9. 9. • Fall in MAP>20% of basal value: Treated with Inj. Mephentermine• Bradycardia, HR>20% fall from basal value or <55 bpm: Treated with Inj. Atropine• Rescue analgesia: Inj. Tramadol 100mg or Inj. Diclofenac 75mg I.M.
  10. 10. RESULTS Demographic profile of age 60 Age (years) 40 AM 20 SD 0 Group I Group II Groups P Value =0.666 • No significant difference in average Age in two groups Male : Female distribution ASA GradingNo. of patients No. of patients 15 20 10 Male 15 I 10 5 Female II 5 0 0 Group I Group II Group I Group II Groups Groups • There was no significant difference between two groups with respect to Sex and ASA grading
  11. 11. Onset Of Sensory & Motor Blockade Onset of sensory On set of Motor Tim ( in Seconds) 150 80Time (sec) 60 AM 100 AM 40 SD SD 50 20 0 0 Group I Group II group I group II Groups Groups P Value =0.45 P Value =0.48 • Time for onset of sensory & motor blockade in both groups was comparable
  12. 12. Peak Sensory & Motor Blockade• Time for onset of peak sensory & peak PEAK SENSORY PEAK MOTOR TIME (SECONDS) TIME (SECONDS) motor blockade in both groups 500 400 300 AM 200 AM• was same 300 200 SD 100 SD 100 0 0 Group I Group II Group I Group II GROUPS GROUPS P = 0.96 P = 0.28• Time for onset of peak sensory & peak motor blockade in both groups was similar
  13. 13. Duration Of Analgesia RESCUE ANALGESIA TIME (Minutes) 600 400 AM 200 SD 0 Group I Group II GROUPSPARAMETER GROUP I GROUP II P SIGNIFICANCE AM + SD AM + SD VALUE Highly T5 516 + 155 159.5 + 18.42 0.000 Significant • Mean time of post-operative analgesia (T5) in Study group (8 to 9 hrs) was highly significantly longer than in Control group (2 to 3hrs)
  14. 14. Comparison of pulse rate 90 Pulse rate 85 80 Group I 75 Group II 70 65 0 3 15 30 45 60 90 120 150 Time (min)• Clinically not significant, but statistically slightly significant at 150 minutes
  15. 15. comparison of SBP 150 Group I SBP 100 50 Group II 0 ts ts ts ts ts in in in in in m m m m m 0 0 15 45 90 15 Time in minutes• Statistically significant difference between two groups, but clinically insignificant
  16. 16. Comparison of DBP 100 Group I DBP 50 Group II 0 0 15 45 90 150 time (min)• Statistically significant difference between two groups, but clinically insignificant
  17. 17. • Respiratory rate and SPO2 were almost similar in two groups and no difference found• No adverse effects• No morbidity
  18. 18. DISCUSSION• SAB: Technique of choice for lower abdominal & lower extremity surgeries• Since SAB with Bupivacaine has post-operative analgesia for short period, many adjuvants have been used in past to prolong it
  19. 19. • Present study: Nalbuphine 0.5 mg added as an adjuvant to Bupivacaine• Duration of analgesia post-operatively - In Study group with added adjuvant Nalbuphine : 8 to 9 hours - In Control group with plain Bupivacaine: 2 to 3 hours
  20. 20. • Nalbuphine is a synthetic opioid with mixed agonist & antagonist properties• Mechanism of analgesia: By its agonist action, Nalbuphine stimulates Kappa receptors which inhibits release of neurotransmitters like substance P that mediate pain.• In addition it acts as a post-synaptic inhibitor on the interneurons & output neurons of the Spino-thalamic tract which transport nociceptive information
  21. 21. • In the Nalbuphine group , almost 25% of the elderly patients were controlled Hypertensives, however no cardio-pulmonary adverse effects were seen.• Improved quality of block• Prolonged & long lasting post-operative analgesia• No adverse effects like other opioids ( respiratory depression, nausea, vomiting, pruritus)• Cost effective
  22. 22. CONCLUSION• Nalbuphine provides better quality of block as compared to Bupivacaine alone• Nalbuphine provides post-operative analgesia for almost 8-9 hrs when used as an adjuvant to Bupivacaine• From present study, we feel this is an excellent method of providing post-operative analgesia without any adverse effects for patient undergoing Surgery under SAB
  23. 23. THANK YOU
  24. 24. REFRENCES• Stanley F Malamed; Neurophysiology in Hand book of local anesthesia 2nd Edition, Jaypee brothers: 1986:20• Ready BL Acute perioperative pain. In Miller RD. Anaesthesia5th Edition, Chruchill Livingstone, Philadelphia, 2000: 2323:50• Park House J Simpson BRJ; The Problem of postoperative pain, BJA 1961; 33; 336-343 Atkinson, Rushman & Davies Lee’s synopsis of anaesthesia, 11th Edition,Butterwoth Heinemann• Culebrasx Gaggero G, Zatloukal J, etal. Advantages ofintrathecal nalbuphine compared with intathecal morphine after cesarean delivery an evaluation of postoperative analgesia and adverse effect. Anesth Analg 2000; 91:601-5 (Astract/Freefull Text)• Lin ML. The analgesic effect of subarachnoid administration oftetracaine combinedn albuphine for post operative pain reliefafter total hip replacement [abstract]. Anesthesiology 1998; 89: A867