|Year : 2020 | Volume
| Issue : 2 | Page : 176-182
Comparison of bupivacaine (0.5%) and bupivacaine (0.5%) with dexmedetomidine (1 microgram/kg) in paravertebral block for inguinal hernia repair
Sheetal K Madavi1, Jayashree Sen1, Bitan Sen2, Surekha Shinde3
1 Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, India
2 Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
3 Department of Anaesthesia, B.J. Medical College, Pune, Maharashtra, India
|Date of Submission||04-May-2020|
|Date of Decision||08-May-2020|
|Date of Acceptance||12-May-2020|
|Date of Web Publication||21-Dec-2020|
Dr. Jayashree Sen
Department of Anaesthesia, JNMC and AVBRH, DMIMS, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Paravertebral block(PVB),for inguinal hernia repair has been found to be effective than conventional spinal anaesthesia in terms of anaesthetic and analgesic technique , early ambulation and better postoperative pain score. Bupivacaine, an amide local anaesthetic, having a slow onset of action, provides early onset , prolonged duration of analgesia and adequate sedation in case of PVB with an adjuvant dexmedetomidine ,a highly selective alpha2 adrenergic agonist. Aims: To compare the efficacy as well as onset and duration of sensory and motor block ,duration of post operative analgesia ,any complication of the drugs bupivacaine and a combination of bupivacaine with dexmedetomidine in paravertebral block for inguinal hernia repair. Material and Method: 60 patients aged between 18-60 yrs of ASA physical status I and II , randomized in two groups of 30 to receive bupivacaine (0.5%) 1mgkg—1 in control group A and bupivacaine (0.5%) 1mgkg —1combined with dexmedetomidine (1 μgkg—1) in study group B for PVB. Results: Gr A vs Gr B was significant (P < 0.05) in sensory block ,8.2 ± 0.89 vs 4.95 ± 0.53 min in onset, 191.27 ± 7.12 vs 436.10 ± 16.33 min in duration , in motor block 12.20 ± 0.96 vs 7.66 ± 1.00 min in onset, 267.17 ± 9.67 vs 498.03 ± 22.94 min in duration. Duration of analgesia in Gr A vs Gr B was significant (P < 0.05) , 267.17±9.67 vs 498.03±22.94 min with no adverse effect. Conclusions: Bupivacaine dexmeditomine combination is superior to bupivacaine alone in onset, duration of sensory and motor block, postoperative analgesia in paravertebral block for inguinal hernia surgeries.
Keywords: Bupivacaine, dexmedetomidine, inguinal hernia, paravertebral block
|How to cite this article:|
Madavi SK, Sen J, Sen B, Shinde S. Comparison of bupivacaine (0.5%) and bupivacaine (0.5%) with dexmedetomidine (1 microgram/kg) in paravertebral block for inguinal hernia repair. J Datta Meghe Inst Med Sci Univ 2020;15:176-82
|How to cite this URL:|
Madavi SK, Sen J, Sen B, Shinde S. Comparison of bupivacaine (0.5%) and bupivacaine (0.5%) with dexmedetomidine (1 microgram/kg) in paravertebral block for inguinal hernia repair. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 26];15:176-82. Available from: http://www.journaldmims.com/text.asp?2020/15/2/176/304231
| Introduction|| |
International association for the study of pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”
Especially for treating postoperative pain, various methods exist which include systemic narcotics, nonsteroidal anti-inflammatory drugs, patient controlled analgesia, regional anesthesia techniques, epidural local anesthetic with different narcotic mixtures, paravertebral block (PVB), cryoanalgesia, transcutaneous electric nerve stimulation, psychological methods, etc., PVB is a technique of injecting local anesthetic adjacent to vertebra close to where spinal nerves emerge from intervertebral foramina. This results in ipsilateral somatic and sympathetic nerve blockage in multiple continuous dermatomes above and below the site of injection. It may be used in patients undergoing thoracic, abdominal, pelvic surgeries, and surgery on the breast.
PVB also provides optimal anesthesia with stable hemodynamic condition and minimal adverse effects and has been found to be more advantageous in terms of early ambulation and better postoperative pain score,, than conventional spinal anesthesia for inguinal hernia repair.
Regardless of the anesthetic drug used, the desired effect is to block the transmission of afferent nerve signals from peripheral nociceptors. Sensory signals from the site are blocked, thereby eliminating pain.
Bupivacaine, a local anesthetic drug belonging to the amino-amide group, is commonly used for nerve blockage.
Dexmedetomidine is highly selective alpha2 (α2) adrenergic agonist. Although it was approved in USA in 1999 for sedation and analgesia in the intensive care unit, in last few years, it has emerged as an effective therapeutic drug in anesthesia due to its sympatholytic, sedative, analgesic effect and hemodynamic stability. Presynaptic activation of alpha-2A adrenoceptor in the locus ceruleus inhibits the release of nor-epinephrine and results in the sedative and hypnotic effects. Centrally, α2-agonists cause analgesia and sedation by the inhibition of substance P release in the nociceptive pathway at the level of the dorsal root neuron and by activation of α2-adrenoceptors in locus coeruleus.
Perineural administration of dexmedetomidine prolongs duration of analgesia and augments the effect of local anesthetic drug.
Aims and objectives
The aim is to compare the efficacy and clinical profile of α2 adrenergic agonist dexme-detomidine combined with bupivacaine over bupivacaine alone in PVB.
The objectives are to study the
- onset of sensory and motor block
- duration of intra-and postoperative analgesia and sedation
- occurrence of side effects and complications if any.
| Materials and Methods|| |
This prospective, randomized, double-blind, single center study was conducted in a tertiary care level institute. A synopsis of the study protocol was submitted to the Institutional Review Board/Ethics committee and approval was obtained.
Randomization was done in the block of 2 as per a computer-generated code from http://www.randomization.com.
The drug solution to be used for PVB was prepared by another anesthesiologist according to the randomization chart. The randomization code of the drug and the patients were sealed in an envelope.
Sixty patients were randomly allocated to two groups of 30 patients for inguinal herniorraphy in PVB. The sample size calculated was based on results from a similar study. Assuming the average duration of analgesia of 16.25 and standard deviation (SD) of 1.66 h, keeping power at 80% and confidence interval at 95% (alpha error at 0.05), a sample size of 19 patients would have been required to detect a minimum of 10% difference in duration of analgesia between 2 groups. We included 30 patients in each group to compensate for possible drop out.
- Group A (control group) received bupivacaine 0.5% 1 mg/kg (10 ml).
- Group B (study group) received bupivacaine 0.5% 1 mg/kg (10 ml) combined with dexmedetomidine (1 μg/kg).
- American Society of Anesthesiologists (ASA) physical status class: I, II
- Age between: 18 and 60 years
- Gender: Male patient.
- Patients with H/O hypertension, diabetis mellitus, drugs abuse, preexisting peripheral neuropathy
- Psychiatric disease
- Cardiac, hepatic, renal, pulmonary disease and metabolic disorders
- Bleeding disorders, haematological disorders and coagulation disease
- Obstructed emergency hernia
- Known allergy to dexmedetomidine and related drugs.
- After taking written, informed consent, 18G intravenous (IV) cannula was inserted
- Preloading was done with Ringer lactate solution (10 ml/kg)
- Electrocardiography (ECG) and SpO2 monitors were attached
- Sitting position given
- Drug doses in premedication: both groups were given injection glycopyrrolate 5 μg/kg intramascular, half hour prior to the procedure, inj ondansetron 0.08 mg/kg IV.
Patients were asked to curl forward in sitting position for the block. To identify either the spinous process of L4 or the L4-L5 interspace a line was drawn between the iliac crests. Using this anatomic endpoint and moving cephalad, the spinous processes of L1, T12, and T11 were identified and marked at their most superior aspect. From the three identified spinous processes, 2.5 cm was measured laterally on the side of the surgery and marked [Figure 1].
|Figure 1: From the three identified spinous processes, 2.5 cm was measured laterally on the side of the surgery and marked|
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These marks were the three entry points for introduction of the needle. Parts will be painted and draped. After infiltration of skin with local anaesthetic (lignocaine + adrenaline + sodabicarbonate), a 25-gauge tuohy needle was inserted perpendicular to the skin and advanced to contact the transverse process (2–5 cm, depending on patient's body habitus). If the transverse process was not contacted at an appropriate depth, it was assumed that the needle was between adjacent transverse processes and it was then redirected, first cephalad and then in caudal direction. Once the transverse process was contacted, the needle was withdrawn and walked caudad off the transverse process and inserted a further 1 cm, following which, after negative aspiration, 2.5 ml of local anesthetic was incrementally injected [Figure 2]. The transverse process was again re-identified and the needle was then walked cephalad off the transverse process, advanced 1 cm further, and following negative aspiration, another 2.5 ml of local anesthetic was incrementally injected. The procedure was repeated at the other two insertion points.
|Figure 2: Once the transverse process was contacted, the needle was withdrawn and walked caudad off the transverse process and inserted a further 1 cm, following which, after negative aspiration, 2.5 ml of local anesthetic was incrementally injected|
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- Baseline observations of heart rate, blood pressure (BP), SpO2 were noted before PVB was given
- Heart rate, ECG, noninvasive BP and peripheral oxygen saturation was monitored intraoperatively [Figure 3].
Following parameters will be monitored and entered in the record
- Pulse rate.
- Onset of anaesthesia (sensory and motor).
- Duration of block: sensory and motor block.
- Postoperative analgesia and sedation.
- Any other side effects such as nausea, vomiting, hypotension, bradycardia, tachycardia, symptoms of LA toxicity, and other neurological symptoms.
1. Sensory block assessment
Using pin-prick method.
- 0-sharp pin feel
- 1-analgesia, dull sensation felt
- 2-anesthesia, no sensation felt
- Pin-prick discrimination assessment done every 5 min till 30 min
- Absent of onset of pin-prick discrimination within 15 min is taken as block failure.
Onset was defined as the time between administering the block to the absence of pinprick sensation.
Criteria for successful block:
- Onset of loss of pin-prick discrimination started within 15 min
- Sensory block was achieved within maximum time of 30 min.
2. Motor block assessment
Assessed by modified bromage scale.
Modified Bromage Scale:
3. Intra-operative heart rate, BP, ECG, SPO2 monitored.
Monitored by using the Ramsay sedation scale
Ramsay sedation scale:
- Anxious or restless or both
- Cooperative, oriented and tranquill
- Responding to commands
- Brisk response to stimulus
- Sluggish response to stimulus
- No response to stimulus.
b. Duration of analgesia
Duration of analgesia – time between onset of complete (paravertebral) block to time of first request for analgesia, i.e., Visual Analog Scale (VAS) >4. VAS consists of a 10 cm line where at one end a label as “no pain” and at the other end “unbearable pain” was anchored. The patient simply marks the line to indicate the pain intensity and the provider then measures the length of the line marked on a point scale.
- Grade 0-(0–1)-good analgesia
- Grade 1-(1–4)-moderate
- Grade 2-(4–7)-mild analgesia
- Grade 3-(7–10)-no analgesia.
- Supplement analgesia, injection diclofenac 75 mg i.m. was given when VAS > 4.
- Duration of analgesia was measured as time interval between PVB time to patients 1st request of analgesic.
- Postoperative analgesia monitored every 1 hourly for 1st 4 h after the surgery was over, then 2 hourly for 12 h.
During intra-operative period, continuous monitoring of heart rate, BP, SpO2, and ECG were recorded in a multipara monitor every 5 min for first 15 min. And then, every 15 min throughout the surgery.
Inadequate sensory and motor blockade beyond 30 min following the infiltration/administration was considered as unsuccessful block.
All patients were observed for side effects such as nausea, vomiting, bradycardia, tachycardia, hypotension, and complaints such as LA toxicity, postblock neuropathy in intraoperative, and postoperative periods.
The detailed data were entered into well-tabulated Microsoft Excel sheet and subsequently analyzed statistically. The unpaired t-test was used depending upon the nature of data. The data were analyzed as mean, SD, minimum, maximum, and 95% of confidence interval. Graphical display was done for visual inspection.
Ethical approval for this study (DMIMS(DU)/IEC/2019-20/2088.) was provided by the Ethical Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) on 22/09/2019.
| Discussion|| |
PVB has emerged as a popular technique for inguinal hernia surgery which avoids the untoward effects of general anaesthesia.
Bupivacaine, an amide type local anesthetic, a racemic (50:50) mixture of S and R enantiomers, since its introduction in 1956, has been in use as the drug of choice for regional anesthesia because of its longer duration of action (3–7 h).
Dexmedetomidine has been studied by various authors as an adjuvant to local anesthetic in various types of blocks to improve analgesic intensity, increase duration of action, faster onset, acceptable analgesia with lower drug doses and thus reduced the risks of side effects.
Hence, bupivacaine with dexmedetomidine combination was selected for our study. A study carried out on volunteers showed that dexmedetomidine could be used as an additive to local anesthetics for various regional anesthetic techniques, while simultaneously prolonging perineural nerve block.
In our study, both the groups were comparable in terms of age, weight, and ASA grade.
The mean onset of sensory block was 8.2 ± 0.89 min with bupivacaine compared to 4.95 ± 0.53 min with bupivacaine dexmeditomidine combination which was significant (P < 0.05). The mean duration of sensory block in the dexmedetomidine group (436.10 ± 16.33 min) was significantly prolonged (P < 0.001) as compared to bupivacaine group (191.27 ± 7.12 min). Our finding was similar to the study conducted by Swami et al.
The mean onset of motor blockade was 12.20 ± 0.96 min with bupivacaine and 7.66 ± 1.00 min with bupivacaine dexmeditomidine combination. This difference was significant (P < 0.05).
The mean duration of motor block was significantly longer in dexmedetomidine group (498.03 ± 22.94 min) than bupivacaine group (267.17 ± 9.67 min). Our finding was similar to the study conducted by Swami et al. Shorter onset and significant prolongation of mean duration motor blockade in dexmedetomidine group was also reported by Kaygusuz et al. Adding dexmedetomidine for PVB at a dose of 1 μg/kg improves block quality by shortening the sensory block onset time, increasing the sensory and motor block duration and increasing the interval to the first analgesic rescue dose with no side effect. Similar finding were noted in study conducted by Obayah et al., Esmaoglu et al., Singelyn et al. Mean duration of analgesia was 267.17 ± 9.67 min with bupivacaine and 498.03 ± 22.94 min with bupivacaine dexmedetomidine combination. Each of these groups were compared with each other and students unpaired t-test was applied, data was statistically significant.
No adverse effect was reported in any of the groups in this study [Graph 1], [Graph 2], [Graph 3], [Graph 4], [Graph 5], [Graph 6], [Graph 7], [Graph 8], [Graph 9] and [Table 1], [Table 2], [Table 3], [Table 4].,,,,,,
|Table 3: Comparison of duration of sensory block and motor block in group A and group B|
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| Conclusion|| |
Hence, we claim that bupivacaine dexmedetomidine combination, when used for PVB in inguinal hernia repair surgeries, is superior to bupivacaine alone regarding onset, duration of sensory as well as motor block, significant prolongation of postoperative analgesia and sedation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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