|Year : 2019 | Volume
| Issue : 3 | Page : 196-201
The Effect of intrathecal magnesium sulfate to bupivacaine-fentanyl subarchanoid block for infraumblical surgeries
Shreshtha Singh, Jayashree Sen
Department of Anesthesiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
|Date of Submission||02-May-2019|
|Date of Decision||10-Jun-2019|
|Date of Acceptance||22-Jul-2019|
|Date of Web Publication||2-May-2020|
Dr. Jayashree Sen
Department of Anesthesiology, Jawaharlal Nehru Medical College, Sawangi (M), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Subarachnoid block is a safe and inexpensive technique , most versatile regional block for infraumbilical surgeries. Adjuvants such as Fentanyl is the most commonly used. It has been shown that the duration of postoperative analgesia also can be prolonged when magnesium is given as an adjunct for peripheral nerve blocks. Aim and Objectives: the present study was designed to examine whether addition of intrathecal magnesium sulfate would enhance the analgesic efficacy of intrathecal bupivacaine and fentanyl in patients undergoing infra umbilical surgeries. And with the primary objective to study the efficacy, onset and duration of analgesia , hemodynamic variability during block and duration of motor block and secondary objective to know adverse effect of the drugs. Setting and Design Prospective, randomised controlled observational study. Material and Methods: 70 patients were selected , they were randomly allocated into two groups of 35 each using computer generated data. Group S: Intrathecal administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 1 mL of normal saline. Group M: Intrathecal administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl +1.0 ml (50 mg) of magnesium sulphate. Statistical Analysis- done by using descriptive and inferential statistics using chisquare test and student's unpaired t test and software used in the analysis were SPSS 22.0 version and Graph Pad Prism 6.0 version and p<0.05 is considered as level of significance. Results: We conclude that when magnesium is added in the mixture of bupivacaine and fentanyl through spinal route it significantly prolonged postoperative analgesia without any significant haemodynamic variations and adverse effects. Conclusion: Adding magnesium in the mixture of bupivacaine and fentanyl through spinal route for effective postoperative analgesia is without significant haemodynamic variations and adverse effects.
Keywords: Fentanyl, magnesium sulphate, postoperative analgesia, sub arachnoid block Fentanyl, magnesium sulphate, postoperative analgesia, sub arachnoid blockFentanyl, magnesium sulphate, postoperative analgesia, subarachnoid block
|How to cite this article:|
Singh S, Sen J. The Effect of intrathecal magnesium sulfate to bupivacaine-fentanyl subarchanoid block for infraumblical surgeries. J Datta Meghe Inst Med Sci Univ 2019;14:196-201
|How to cite this URL:|
Singh S, Sen J. The Effect of intrathecal magnesium sulfate to bupivacaine-fentanyl subarchanoid block for infraumblical surgeries. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Sep 28];14:196-201. Available from: http://www.journaldmims.com/text.asp?2019/14/3/196/283603
| Introduction|| |
“Pain is a more terrible lord of mankind than even death itself.“ The surgical stress response peaks during the postoperative period and has major effects on almost all body systems. A pain-free postoperative period definitely reduces morbidity and mortality of any surgical operation. Karl August Bier in 1898 introduced spinal anesthesia into clinical practice. Even today, spinal anesthesia remains one of the most popular techniques for both elective and emergency surgical procedures. The versatility of spinal anesthesia is afforded by a wide range of local anesthetics and additives that allow control over the level, the time of onset, and the duration of spinal anesthesia.
Hyperbaric bupivacaine, a local anesthetic, is most commonly used for spinal anesthesia. However, for most of surgeries, high-quality longer duration of analgesia on the operative side is needed. Diverse classes of drugs have been added as adjuvants to local anesthetics in an attempt to prolong analgesia and reduce the incidence of side effects.,
Fentanyl a synthetic μ-opioid receptor agonist is preferred as an adjuvant in spinal anesthesia because of its rapid onset and short duration of action with lesser incidence of respiratory depression. However, the use of opioids may be limited by significant side effects such as pruritus, urinary retention, respiratory depression, hemodynamic instability, occasionally severe nausea, and vomiting.
A few clinical trials have examined the effect of adding intrathecal magnesium sulfate (MgSO4) to anesthetic agents such as bupivacaine., In the first randomized human study of intrathecal (IT) magnesium as an antinociceptive modulator, the addition of IT magnesium, acting as a noncompetitive N methyl D aspartic (NMDA) antagonist, has shown prolongation of the analgesic effect of opioids in spinal analgesia. However, the role of IT magnesium has not extensively studied in patients undergoing different infraumbilical surgeries.
We hypothesize that IT magnesium could potentiate opioid spinal analgesia and avoid the potential side-effect of the larger doses of intravenous magnesium that may be required to observe antinociception modulation in humans.
Therefore, the present study was designed to examine whether the addition of IT MgSO4 would enhance the analgesic efficacy of IT bupivacaine and fentanyl in patients undergoing infra umbilical surgeries. And with the primary objective to study the efficacy, onset and duration of analgesia, hemodynamic variability during block and duration of motor block. And with secondary objective to know adverse effect of the drugs.
| Materials and Methods|| |
This is prospective, randomized controlled observational study.
The study period was from September 2016 to August 2018, carried out in the Department of Anaesthesia, Acharya Vinobha Bhave Rural Hospital, a constituent of Jawaharlal Nehru Medical College Sawangi Wardha. After obtaining the Institutional Ethical Committee permission and informed consent from the patients, they were randomly allocated into two groups of 35 each using computer generated data.
- Belonging to ASA Grade I and II, posted for infra umbilical surgeries
- Who were willing to give informed consent
- Of either gender
- Age group 18–70 years
- Weight >40 kg
- Height >145 cm.
- With a past history of reaction to the study drugs
- With acid peptic disorder
- With bleeding coagulopathy
- On antiemetic medications
- Obese patient
- Pregnant patient
- Any contraindication to central neuraxial blockade.
Preanesthetic check-up was done 1 day before the surgery. The procedure of spinal anesthesia was explained to the patients and informed written consent was obtained. Routine investigations such as complete hemogram, complete urine examination, blood sugar, electrocardiogram, chest X-ray, blood grouping, blood urea, and serum creatinine were done.
All the patients included in the study were kept nil per oral since midnight.
The standard preoperative procedures were followed and 18G IV cannula was secured In the operation theater, routine monitors were attached. All the patients were preloaded with ringer lactate 10 ml/kg to prevent intraoperative hypotension. Subarachnoid block was administered to patients with the drugs depending on their groups allocated with 23G Quincke Spinal needle in lateral position the L3–L4 interspace. Patients were then immediately turned to the supine position. Oxygenation was given through a Hudson mask at the rate of 3 L/min.
| Result|| |
Group S: IT administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 1 mL of normal saline [Table 1], [Table 2], [Table 3], [Table 4].
|Table 3: Comparison of pain on Visual Analog Scale score at different time intervals in patients in both the groups|
Click here to view
Group M: IT administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 1.0 ml (50 mg) of MgSO4.
Sensory block was assessed by a pinprick test. The onset of sensory blockade, defined as the time from the injection of IT drugs to the absence of pain on prick at the T8 dermatome was recorded. Onset of motor blockade was assessed according to the modified Bromage scale. The onset of motor blockade is defined as the time from the injection of IT drugs till the Grade 3 of modified Bromage scale is attained. Blood pressure (systolic and diastolic), heart rate, respiratory rate, and peripheral oxygen saturation were recorded from the time of IT injection, i.e., at 0 min and at 5, 10, 15, 20, 25, and 30 min after the injection, and subsequently, every 15 min till 120 min. Hypotension (defined as <20% of baseline of systolic blood pressure or diastolic blood pressure) was treated with intravenous fluid initially (250 ml boluses repeated twice) and intravenous mephentermine 6 mg, if required. Bradycardia (defined as heart rate of <50 bpm was treated with intravenous 0.6 mg atropine sulfate. The duration of analgesia was recorded as the time from IT injection until the patient's request for additional rescue analgesic in postoperative period. Moreover, they were then administered intramuscular diclofenac (75 mg) as rescue analgesic on demand. The intensity of pain was assessed through Visual Analog Scale (VAS). VAS was assessed from the time of induction, i.e., the baseline T1 (0 min), T2 (30 min), T3 (1 h), T4 (4 h) T5 (8 h), till T6 (12 h) in the postoperative period. “Zero point of VAS shows no pain and 10” point of VAS shows worst possible pain. Patients were also assessed for adverse effects such as nausea, vomiting, hypotension, bradycardia, shivering, and pruritis. Recovery from the motor block was taken as the time from IT injection until the value regressed to Grade 0 of modified Bromage scale [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Statistical analysis was performed using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test and software used in the analysis were SPSS 22.0 version (Chicago, Illinois, USA) and Graph Pad Prism 6.0 version and P < 0.05 is considered as the level of statistical significance.
| Discussion|| |
Major disadvantage with spinal anesthesia using local anesthetics alone is that analgesia ends with the regression of the block, which means that there is an early postoperative need for analgesia. No drug, has yet been identified which specifically inhibits nociception without its associated side-effects that can be used as adjuvant to spinal bupivacaine. Addition of IT MgSO4 to spinal bupivacaine may alter bupivacaine pharmacokinetics and cause a more rapid elimination of bupivacaine. Simpson et al. and Kroin et al. demonstrated in animals that IT MgSO4 has a safety profile. The dose of MgSO4 used in this study was based on data from Ozalevli et al. and Buvanendran et al. where 50 mg of MgSO4 potentiated opioid analgesia. The use of IT opioids is associated with the risk of respiratory depression. Fentanyl gets bound to opioid receptors to exert its spinal effect on the dorsal horn of the spinal cord. With regard to demographic data, there was no difference between groups. An equal number of surgeries were performed in both the groups. Both groups were comparable in hemodynamic parameters throughout the study period. Although i.v., magnesium is known to cause hypotension when used to treat eclampsia, the present study found no significant hemodynamic variability following the addition of magnesium to the spinal solution. This may be attributed to the absence of systemic vasodilator effects of subarachnoid magnesium,, Our results were in accordance with studies conducted by Nath et al. and Jaiswal et at. and Grewal et al. who also had observed stable hemodynamics with addition of MgSO4. The onset of sensory block was delayed in magnesium group, which was found to be statistically significant. The delayed onset in Group M could be due to the solution of MgSO4 having a different pH and baricity which might explain our findings. Furthermore, increase in metabolism of bupivacaine due to the activation of cytochrome P450 by magnesium may be responsible for the delayed onset., Our results are in concordance with Nath et al. and Jaiswal et at. and Grewal et al. They also reported similar results in the onset of sensory block. Onset of motor block in MgSO4 group is delayed when compared to control group which is statistically significant. This result was found similar to the study performed by Malleeswaran et al. in 2010 and Nath et al. The mean duration of analgesia in Group S was lesser than in Group M. This implies that the addition of IT MgSO4 to bupivacaine and fentanyl prolonged the period of analgesia. This correlates with the studies done by Vasur et al. in 2016, Nath et al., Ozalevli et al., and also Buvanendran et al. in 2002. They all concluded that addition of IT MgSO4 to bupivacaine and fentanyl prolonged the period of analgesia. The recovery from the motor block in our study group was 242.5 ± 9.4 min and in the control group, it was 236.5 ± 5.5 and the difference was found to be statistically significant. This finding was similar to the study done by Murugesan and Ramakrishnan Manjula et al. The intensity of pain was assessed by VAS. This signifies statistically that adding magnesium as an adjuvant in spinal subarachnoid block had decreased the VAS from the group where magnesium was not added. Our finding was similar to the study of Grewal et al. in 2016 and Rana et al. conducted in 2017, who also had found lower VAS score in their study groups in comparison to the control group. From our findings, we can claim that the incidence of side effects were similar in both the groups in the present study.
| Conclusion|| |
We conclude that adding magnesium in the mixture of bupivacaine and fentanyl through spinal route for effective postoperative analgesia is without significant hemodynamic variations and adverse effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schweitzer A. Pain is More Terrible Lord of Mankind than Even Death Itself. Pain Policy Palliative Care; 2011.
Parameshwara G. Spinal epidural to combined spinal epidural analgesia the history of central neuraxial block. Indian J Anaesth 2001;45:406-12.
Dureja GP, Jayalaxmi TS. Colloid preloading before spinal and epidural anaesthesia. Hosp Today 2000;11:601-3.
Racle JP, Benkhadra A, Poy JY, Gleizal B. Prolongation of isobaric bupivacaine spinal anesthesia with epinephrine and clonidine for hip surgery in the elderly. Anesth Analg 1987;66:442-6.
Lysakowski C, Dumont L, Czarnetzki C, Tramèr MR. Magnesium as an adjuvant to postoperative analgesia: A systematic review of randomized trials. Anesth Analg 2007;104:1532-9.
Eti Z, Umuroǧlu T, Takil A, Göǧüş Y. The comparison of the effects and side effects of local anesthetic and opioid combinations in epidural patient controlled analgesia. Agri 2005;17:34-9.9.
Buvanendran A, McCarthy RJ, Kroin JS, Leong W, Perry P, Tuman KJ. Intrathecal magnesium prolongs fentanyl analgesia: A prospective, randomized, controlled trial. Anesth Analg 2002;95:661-6, table of contents.
Malleeswaran S, Panda N, Mathew P, Bagga R. A randomised study of magnesium sulphate as an adjuvant to intrathecal bupivacaine in patients with mild preeclampsia undergoing caesarean section. Int J Obstet Anesth 2010;19:161-6.
Okutomi T, Saito M, Matsumoto Y, Shimizu M, Fukuoka M, Hoka S. Altered bupivacaine pharmacokinetics by MgSO4 in rats. Can J Anaesth 2004;51:93-4.
Simpson JI, Eide TR, Schiff GA, Clagnaz JF, Hossain I, Tverskoy A, et al
. Intrathecal magnesium sulfate protects the spinal cord from ischemic injury during thoracic aortic cross-clamping. Anesthesiology 1994;81:1493-9.8.
Kroin JS, McCarthy RJ, Von Roenn N, Schwab B, Tuman KJ, Ivankovich AD. Magnesium sulfate potentiates morphine antinociception at the spinal level. Anesth Analg 2000;90:913-7.7.
Ozalevli M, Cetin TO, Unlugenc H, Guler T, Isik G. The effect of adding intrathecal magnesium sulphate to bupivacaine-fentanyl spinal anaesthesia. Acta Anaesthesiol Scand 2005;49:1514-9.
Etches RC, Sandler AN, Daley MD. Respiratory depression and spinal opioids. Can J Anaesth 1989;36:165-85.
Shende D, Cooper GM, Bowden MI. The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section. Anaesthesia 1998;53:706-10.
Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol 1998;92:883-9.
Duley L, Watkins K. Magnesium sulphate for treatment of preeclampsia: A trial to evaluate the effects on women and their babies. Contemp Rev Obstet Gynaecol 1998;10:267-74.4.
Nath MP, Garg R, Talukdar T, Choudhary D, Chakrabarty A. To evaluate the efficacy of intrathecal magnesium sulphate for hysterectomy under subarachnoid block with bupivacaine and fentanyl: A prospective randomized double blind clinical trial. Saudi J Anaesth 2012;6:254-8.
Jaiswal R, Bansal T, Kothari S, Ahlawat G. The effect of adding magnesium sulphate to bupivacaine for spinal anaesthesia: A randomised, double- blind trial in patients undergoing lower limb orthopaedic surgery. Int J Pharm Pharm Sci 2013;5:179-82.2.
Grewal TK, Sharma A, Bhupal JP, Popli S. To evaluate the efficacy of intrathecal bupivacaine versus bupivacaine, fentanyl and magnesium sulphate in spinal anesthesia. 561565 August 2016;2:561-5.
Morrison AP, Hunter JM, Halpern SH, Banerjee A. Effect of intrathecal magnesium in the presence or absence of local anaesthetic with and without lipophilic opioids: A systematic review and meta-analysis. Br J Anaesth 2013;110:702-12.
Vasure R, Ashahiya ID, Narang N, Bansal R. Comparison of effect of adding intrathecal magnesium sulfate to bupivacaine alone and bupivacaine-fentanyl combination during lower limb orthopedic surgery. Int J Sci Stud 2016;3:141-6.
Murugesan BS, Ramakrishnan CD. The effect of adding intrathecal magnesium sulphate to bupivacaine-fentanyl spinal anaesthesia. J Evolution Med Dent Sci 2016;5:7185-91.1, DOI: 10.14260/jemds/2016/1626.
Manjula R, Indumati T, Sangeetha C, Mallikarjuna VV. Effects of adding magnesium sulphate to ropivacaine and fentanyl for spinal anaesthesia. IOSR J Dent Med Sci 2014;13:33-7.
Rana S, Singha D, Kumar S, Singh Y, Singh J, Verma RK. Efficacy of magnesium sulphate and/or fentanyl as adjuvants to intrathecal low-dose bupivacaine in parturients undergoing elective caesarean section. J Obstet Anaesth Crit Care 2017;7:20-5. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]