ADDING DEXMEDETOMIDINE TO INTRATHECAL LOW DOSE

BUPIVACAINE IN VAGINAL HYSTERECTOMY

CO-AUTHORSPROF & HEAD .DR. I.CHANDRASEKARAN MD ,DA

PROF .DR.S.P.MEENAKSHISUNDARAM MD,DAASST. PROF . DR.S.SENTHILKUMAR MD.,DA.

AUTHOR DR.T.ARUNPRAKASH INSTITUTE OF ANESTHESIOLOGY

MMC , MADURAI

AIM

• To study the effect of adding dexmeditomedine with intrathecal low dose bupivacaine for vaginal hysterectomy on

• sensory and motor blockade

• Postoperative analgesia

STUDY DESIGN• Randomised double blind control study • 60 patients , 30 in each group

• Inclusions• ASA I & II • Age 30 to 60 yrs• Vaginal hysterectomy • BMI 18.5 to 25

• Exclusions• Contraindications to spinal anesthesia• Allergy to local anesthetics

METHODS • Patients were divided into two groups

• B – inj 0.5 % hyperbaric bupivacaine 2cc

+0.05ml of NS

• BD – inj 0.5 % hyperbaric bupivacaine 2cc +

0.05 ml of dexmedetomidine (5μg)

• 18G iv cannula secured

• Monitors

• Patient in right lateral position

• Under strict aseptic precautions , SAB performed with 25G Quincke spinal needle in the L3- L4 interspace

OBSERVATIONS

• Onset of sensory block to pin prick• Onset of motor block ( bromage score)• Time for two segment regression • Sensory recovery time to pin prick •Motor recovery time( bromage score)

• PR if less than 60/min inj atropine 0.6 mg iv given

• BP if MAP less than 70 mmHg inj ephedrine iv given in titrated doses

• SPO2

• RR • SEDATION by Ramsay Score

BROMAGE SCORE FOR MOTOR BLOCKADE

Grade Criteria

I Free movement of hips, legs and feet

II Just able to flex knees with free movement of feet

III Unable to flex knees, but with free movement of feet

IV Unable to move hips or legs or feet

RAMSAY SEDATION SCORE

1- Patient anxious and agitated or restless2- Patient co-operative, oriented, and tranquil3- Patient responds to commands only4- Patient exhibits brisk response to light glabellar tap or loud

auditory stimulus5- Patient exhibits a sluggish response to light glabellar tap or

loud auditory stimulus6- Patient exhibits no response

•

• Postop analgesia assessed by VAS score• If VAS > 4 –study completed,inj diclofenac 75

mg IM given • Side effects

• Hypotension • Bradycardia• Nausea , vomiting • Pruritus

ANALYSIS

• Demographic datas• Onset of sensory and motor blockade• Maximum level of sensory blockade• Offset time of sensory and motor blockade• Duration of post op analgesia• Side effects

STATISTICAL ANALYSIS

Chi-square test

If p < 0.05 is significant

DEMOGRAPHIC DATA

VARIABLE BD GROUP

(n = 30)

B GROUP

(n = 30)

“p”

Age in years 48.9 + 8.5 49.2 + 7.4 0.8411

(> 0.05)

Weight (in kgs) 48.9 + 5.3 48.5 + 4.6 0.6284

(>0.05)

Height ( in cms) 143.1 + 3.8 143 + 3.5 0.9109

(>0.05)

BMI 23.9 + 2.76 23.8 + 2.64 0.579

(>0.05)

AGE & BMI

ASA

BD GROUP n = 30

B GROUP n = 30

ASA p = 1.000 (>0.05)

ASA

ONSET OF SENSORY BLOCK

Onset of sensory blockade (min)

BD GROUP (n = 30)

B GROUP

(n = 30)

Mean 2± 0.74 4.67± 0.66

p = 0.0001 ( < 0.05 )

ONSET OF SENSORY BLOCK( MIN)

ONSET OF MOTOR BLOCK

Onset of motor blockade (min)

BD GROUP (n = 30)

B GROUP

(n = 30)

Mean 5.53± 2.42 8.07± 0.64

p = 0.0001 ( < 0.05 )

ONSET OF MOTOR BLOCK(MIN)

MAXIMUM SENSORY LEVEL

Maxmimum sensory level

BD GROUP (n = 30)

B GROUP (n = 30)

NO. % NO. %

T6 2 6.7 - - T7 5 16.7 - -

T8 19 63.3 17 56.7 T9 4 13.3 10 33.3 T10 - - 3 10

MAXMIMUM SENSORY LEVEL

TIME FOR 2 SEGMENT REGRESSION

Time for two segment regression (min)

BD GROUP n = 30

B GROUP

n =30

Mean

115.3± 7.6 100.6 ± 6.2

p = 0.0001 ( < 0.05 )

TIME FOR 2 SEGMENT REGRESSION(MIN)

SENSORY RECOVERY TIME TO S1

Sensory recovery time to S1 (min)

BD GROUP n = 30

B GROUP n = 30

Mean 292.8± 19.4 173.7± 9.3

p = 0.0001 ( < 0.05 )

SENSORY RECOVERY TIME TO S1( MIN)

MOTOR RECOVERY TIME

Motor recovery time (min)

BD GROUP (n = 30)

B GROUP

(n = 30)

Mean 121.1± 7 88.4 ± 6

p = 0.0001 ( < 0.05 )

MOTOR RECOVERY TIME (MIN)

MAP AT VARIOUS TIME INTERVALS

Mean arterial pressure (mmHg) at

BD GROUP (n = 30)

B GROUP (n = 30)

0 minute 90.9 + 4.1 90.2 + 4.3

5 minutes 88.7 + 3.6 88.2 + 4.1

10 minutes 85.5 + 4.0 86.6 + 4.2

15 minutes 80.7 + 3.9 82.9 + 5.2

30 minutes 76.9 + 4.9 80.1 + 6.2

1 hour 73.3 + 6 77.7 + 8.3

2 hours 78.5 + 4.7 81.1 + 7.0

3 hours 81.7 + 4.6 83.3 + 5.7

4 hours 85.1 + 3.9 87 + 4.0

5 hours 88.5 + 3.5 88.5 + 3.6

MEAN ARTERIAL PRESSURE

60

70

80

90

100

0 min. 5 min. 10 min.

15 min.

30 min.

1 hour 2 hrs 3 hrs 4 hrs 5 hrs

Chart Title

DEXMEDITOMEDINE GROUP CONTROL GROUP

PULSE RATE AT VARIOUS TIME INTERVALS

Mean pulse rate at BD GROUP (n = 30)

B GROUP (n = 30)

0 minute 86.2 + 9.4 81.1 + 9.3

5 minutes 84.4 + 7.3 81.4 + 6.0

10 minutes 81.7 + 7.2 79.2 + 5.1

15 minutes 78.6 + 5.8 77.1 + 4.8

30 minutes 74.7 + 6.7 73.9 + 5.9

1 hour 70.1 + 6.2 73.1 + 6.3

2 hours 75.2 + 4.8 76.5 + 5.0

3 hours 78.9 + 4.4 77.3 + 4.3

4 hours 83 + 4.0 80.6 + 6.0

5 hours 85 + 5.2 83.3 + 5.4

PULSE RATE

SEDATION SCORE

Sedation score BD GROUP (n = 30)

B GROUP (n = 30)

Mean 2.39 ± 0.20 1.00

p = 0.0001 ( < 0.05 )

SEDATION SCORE

OBSERVATION

Statistical analysis between BD and B GROUP shown that

GROUP BD patients have• Early Sensory and motor onset time• delayed Two segment regression• Motor recovery time• prolonged post op analgesia• Good sedation

Than GROUP B patients

DEXEMEDETOMIDINE IN SPINAL

Intrathecal α2-agonists

Depressing the release of C-fiber transmitters

Hyperpolarization of post-synaptic dorsal horn neurons

The prolongation of the motor block of spinal anesthetics may result from the binding of α2-adrenergic agonists to motor neurons in the dorsal horn cells

Dose related sedation is by acting at locus ceruleus and also by promoting natural sleep pathways

CONCLUSION

Dexmedetomidine as an adjuvant to intrathecal low dose Bupivacaine provides

Better quality of analgesia Delay in two segment regression Prolonged post op analgesia Better hemodynamic stability Good sedation without any side

effects

REFERENCES

• Effects of adding dexmeditomedine to intrathecal bupivacaine in spinal anesthesia for gynecological procedures - American journal of applied sciences 6(5) : 882 – 887 , 2009

• Dexmedetomidine Enhances the Local Anesthetic Action of Lidocaine via an -2A Adrenoceptor - Anesth Analg 2008;107:96 –101

• Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block Acta Anaesthesiologica Scandinavica - February 2006

• Effect of dexmedetomidine added to spinal bupivacaine for urological procedures – Saudi med journal 2009 ; vol 30 (3): 365- 370

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