Authors

Dr. (Mrs) M.M.PanditraoCONSULTANT, ANESTHESDIOLOGY, Rand Memeorial HopsitalFreepeort, Grand BahamaThe Bahamas

To Study The Effects Of Addition Of Nalbuphine To Bupivacaine Used For Elderly Patients Undergoing Spinal Anaesthesia: A Randomized Double Blind, Controlled Study

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

AIMS & OBJECTIVES

To compare -• Quality of block • Duration of post-operative analgesia  • Adverse effects, if any

when Nalbuphine was added to Hyperbaric Bupivacaine 0.5%, in patients undergoing lower abdominal & lower limb surgeries.

  

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

• 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

• 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

• ↓ AAP, SAB given in sitting position with 26G Quincke needle

• Respective agents injected according to group

• 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)

• 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.

RESULTSDemographic profile of age

0

20

40

60

Group I Group II

GroupsA

ge

(yea

rs)

AM

SD

P Value =0.666• No significant difference in average Age in two groups

Male : Female distribution

0

5

10

15

Group I Group II

Groups

No

. o

f p

atie

nts

Male

Female

ASA Grading

05

101520

Group I Group II

Groups

No

. o

f p

atie

nts

I

II

• There was no significant difference between two groups with respect to Sex and ASA grading

Onset Of Sensory & Motor Blockade

Onset of sensory

020406080

Group I Group II

Groups

Tim

e (s

ec)

AM

SD

On set of Motor

0

50

100

150

group I group II

Groups

Tim

( in

Sec

onds

)

AM

SD

P Value =0.45 P Value =0.48

• Time for onset of sensory & motor blockade in both groups was comparable

Peak Sensory & Motor Blockade

• Time for onset of peak sensory & peak motor blockade in both groups

• was same

PEAK SENSORY

0100200300400500

Group I Group II

GROUPS

TIM

E (

SE

CO

ND

S)

AM

SD

PEAK MOTOR

0

100

200

300

Group I Group II

GROUPS

TIM

E (

SE

CO

ND

S)

AM

SD

• Time for onset of peak sensory & peak motor blockade in both groups was similar

P = 0.96 P = 0.28

Duration Of AnalgesiaRESCUE ANALGESIA

0

200

400

600

Group I Group II

GROUPS

TIM

E (

Min

ute

s)

AM

SD

• 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)

PARAMETER GROUP I GROUP II P SIGNIFICANCEAM + SD AM + SD VALUE

T5 516 + 155 159.5 + 18.42 0.000Highly

Significant

Comparison of pulse rate

657075808590

0 3 15 30 45 60 90 120

150

Time (min)

Pu

lse

rate

Group I

Group II

• Clinically not significant, but statistically slightly significant at 150 minutes

comparison of SBP

050

100150

0 m

ints

15 m

ints

45 m

ints

90 m

ints

150 m

ints

Time in minutes

SB

P Group I

Group II

• Statistically significant difference between two groups, but clinically insignificant

Comparison of DBP

0

50

100

0 15 45 90 150

time (min)

DB

P Group I

Group II

• Statistically significant difference between two groups, but clinically insignificant

• Respiratory rate and SPO2 were almost similar in two groups and no difference found

• No adverse effects

• No morbidity

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

•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

• 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

• 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

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

THANK YOU

• Stanley F Malamed; Neurophysiology in Hand book of local anesthesia 2nd Edition, Jaypee brothers: 1986:20• Ready BL Acute perioperative pain. In Miller RD. Anaesthesia 5th 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 of intrathecal 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 of tetracaine combinedn albuphine for post operative pain relief after total hip replacement [abstract]. Anesthesiology 1998; 89: A867

REFRENCES