COMPARISON OF INTRATHECAL ISOBARIC ROPIVACAINE WITH HYPERBARIC BUPAVICAINE FOR SPINAL ANAESTHESIA IN LOWER LIMB SURGERIES ABSTRACT

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1 COMPARISON OF INTRATHECAL ISOBARIC ROPIVACAINE WITH HYPERBARIC BUPAVICAINE FOR SPINAL ANAESTHESIA IN LOWER LIMB SURGERIES 1 1 Tasneem Alam, Akhtar Hussain ABSTRACT Background: Spinal anesesia, is one of e commonly applied surgical anesesia. Objective: This study was conducted to compare e efficiency and safety of intraecal ropivacaine wi intraecal bupivacaine for spinal anesesia in lower limb surgeries. Material and meods: Study Design: Quasi - experimental study. Place and Duration of Study: The study was carried st out at. operation eatres of Combined Military Hospital Panoaqil Cantt from 1 December 2013 to 30 June Sixty patients of age between 20 to 60 years, males and females and American Society of Anaesesiologist physical status or, planned for lower limb surgeries were included in e study. Selected patients were divided into two groups (Group A and Group B). Group A (n = 30) received 3 ml of isobaric ropivacaine 5mg/ ml (15 mg) and Group B (n = 30) received 3 ml of hyperbaric bupivacaine 5mg/ ml (15 mg). Sensory block was tested wi pinprick and motor block was evaluated wi Bromage scale until full recovery. The primary end point was to compare e duration of sensory and motor block. Results: Bo e groups were demographically similar. Onset of sensory block at T1 (p<0.05) and e median time of onset of sensory block at T10 (p<0.05) was statistically significantly different. The time taken to achieve maximum motor blockade (group A ± min, group B ± min) was delayed wi group A compared to group B (p<0.05). The mean duration of analgesia (p<0.05) and e mean duration of motor blockade (p<0.05) was less in Group A as compare to Group B. Return of Bromage to zero (P<0.05) was faster in Group A as compared to group B and was statistically significant. Conclusion: Isobaric ropivacaine 0.5% (study group A) provided lesser grade of motor blockade and shorter duration of bo sensory and motor blockade, for short duration lower limb surgeries where prolonged motor blockade is quite undesirable and early mobilization can be planned. Keywords: Spinal anesesia, Ropivacaine, Bupivacaine, Lower limb surgeries. JSZMC 2014;5(4): INTRODUCTION Spinal Anaesesia is a safe, reliable and of accidental intravascular injections or a inexpensive technique wi e advantage of pronounced overdose. These adverse effects have providing surgical anaesesia and prolonged post prompted a search for drugs wi lesser toxicity. operative pain relief. It is also an effective Ropivacaine is a long-acting amide local anesetic treatment for operative pain and blunts autonomic, wi a structure closely related to bupivacaine and 1 4 somatic and endocrine responses. Spinal mepivacaine. Ropivacaine is a local anesetic wi anesesia is widely used for lower limb and lower a high pka and low lipid solubility at blocks e abdominal surgeries. It has been e mainstay for nerve fibers involved in pain transmission (Aä and C regional anesesia in developing countries, fibers) to a greater degree an ose controlling 5 especially in Pakistan. motor function (A_ fibers). Few studies have shown Bupivacaine is being extensively used and at 15mg 25mg of e drug can be used for produces an adequate sensory and motor 6 producing satisfactory anaesesia. The drug is less 2 blockade. However it has its own disadvantages cardiotoxic an equal concentrations of racemic and side-effects such as cardiac and central bupivacaine and has a significantly higher reshold 3 nervous system toxicity. They are usually because for CNS toxicity an racemic bupivacaine in healy 7 volunteers. Ropivacaine administered by e 1. Department of Anaesesia, Combined Military Hospital Pano Aqil, Pakistan. epidural route, is reported to be 20% less potent an 8 bupivacaine at equal dosage. It may produce less Correspondence: Dr. Tasneem Alam, Anaesesia, Department Combined Military Hospital Pano Aqil, Pakistan. tasneemalam2@gmail.com Received: Accepted: ,9 motor blockade and is of shorter duration. This study was conducted to compare e efficiency and safety of intraecal bupavaine wi ropavicaine for spinal anesesia. JSZMC Vol.5 No

2 lateral position and whole of e back draped under aseptic measures. MATERIAL AND METHODS After skin's infiltration wi 2% lidocaine, a 25G The study was carried out at operation eatres of Quinke Babcock needle was inserted at e L3/4 Combined Military Hospital Pano Aqil Cantt. The interspace in e midline. Correct needle placement st study was carried out in 07 mons from 1 was identified by free flow of cerebrospinal fluid and December 2013 to 30 June Sixty patients 3 ml (15 mg) of e study drug was injected. Patients were included who were planned for lower Limb in group A received isobaric ropivacaine 15 mg (3 ml Surgery. Divided into two groups, 30 patients in isobaric 0.5%) and in group B received hyperbaric Group A and 30 patients in Group B, after bupivacaine 15 mg (3 ml hyperbaric 0.5%). Bo 3- obtaining informed consent of e patient and ml solutions were prepared in an adjacent room by a approval by e hospital eics committee. person not involved in e subsequent evaluation of Patients in group A received isobaric ropivacaine e study patient. After e injection of e drug e 15 mg (3 ml isobaric 0.5%) and in group B spinal needle was removed and e patient placed received hyperbaric bupivacaine 15 mg (3 ml supine. hyperbaric 0.5%). Non-probability convenience Standard monitoring was used roughout e sampling techniq was used: operation. ECG and pulse oximetry were monitored Inclusion Criteria continuously while arterial pressure was measured. Age: years every 5 minutes intervals by NIBP. Heart rate and. Bo males and females arterial pressure were recorded before intraecal injection, 5 minutes after e intraecal drug. A.S.A Physical status administration, and ereafter every 10 minutes till Exclusion Criteria e end of e operation. Any hypertension (mean. Patients on anticoagulants. arterial pressure lower an 60 mmhg) or. Patients wi hypertension or cardiac bradycardia (heart rate < 45/min) incidents were diseases. treated wi ephedrine 5 mg or atropine 0.5 mg. Emergency surgery. increments. A decrease in SpO2 to < 92% was. Patient's refusal for regional anaesesia. defined as hypoxia and treated wi supplemental oxygen. The level of sensory block was evaluated by Study Design: Quasi- experimental study. Sixty loss of pinprick sensation (20-gauge hypodermic patients scheduled for lower limb surgery, were needle). included in e study. After preoperative Onset of sensory block assessed in e bo limb by assessment by history, physical examination and assessing e changes in pin prick sensation every laboratory investigations, all e patients were 1minute till no sensation (grade 2) is achieved explained about e procedure and written consent (graded according to Gromley and Hill 1996, was taken. Selected patients were divided into two {Normal sensation - 0, Blunted sensation -1, No groups. Resuscitation trolley containing all e sensation -2}) Grade 2 was taken as onset of sensory necessary drugs for resuscitation including block. We checked bilaterally S1, L3,L1, T12 and ephedrine, atropine and adrenaline, laryngoscope T10 dermatomes by needle protrusion 2 mm rough endotracheal tubes and defibrillator was made a guard and we used T4 as baseline point for normal available before giving spinal anaesesia. sensation. Intravenous cannula of appropriate size was Onset of Motor block assessed every 1 minute till passed, monitoring was done wi dynamap make complete motor block was achieved (grade 3) in e for noninvasive blood pressure, cardiac monitor to normal limb. (Graded according Modified Bromage record cardiac activity and pulse oximetery for scale {0 = no paralysis, able to flex oxygen saturation and pulse rate. After hips/knees/ankles; 1 = able to move knees, unable to identification of selected patients, base line heart raise extended legs; 2 = able to flex ankles, unable to rate and blood pressure were taken. Bo e group flex knees; 3 = unable to move any part of e lower were preloaded wi Inj. Ringer solution 500ml. limb}). Grade 3 was taken as complete motor block. Patients were premedicated wi 2 mg of midazolam intravenously and placed in e left Duration of sensory block was taken as e time from JSZMC Vol.5 No

3 e onset of sensory block to e time when e taken to achieve maximum motor blockade (group A, patient requires first dose of analgesia for post ± min group B, ± min) was operative pain. Duration of motor block (recovery statistically significant. The mean duration of of motor blockade to grade 1) was taken as e analgesia (p<0.05), e mean duration of motor time from complete motor block to when e blockade (p<0.05) and Return of Bromage to zero patient recovers e ability to flex knees i.e. grade (P<0.05) was achieved in less time in group A when 1 on Bromage scale. The data was analyzed by compared to group B and was statistically significant using e SPSS version 16.0 for windows. P value ( Table II) <0.05 was taken as significant. Student t test was applied to find out e statistical significant Table II: Comparison of sensory and motor block differences on primary variable. The primary and duration of surgery variable measured was Time taken in Minutes. Onset of sensory blockade at T1 (min), to achieve peak sensory level at T10 (min), to achieve maximum motor blockade Bromage 3 (min), duration of surgery (min), return of Bromage Scale to Zero (min) and total duration of analgesia Side effect measured included, hypotension and bradycardia RESULTS Total 60 patient were included in e study at were planned for lower Limb surgery and were divided into two group designated as Group A (patient given Inj. Ropivacaine 0.5%) and Group B (patient given Inj. Bupivacaine 0.5%). The percentage of different age range of bo e group was presented in Table I. Table I: Distribution of age in patients of group A and group B (n = 60) Age (years) Group A Group B Frequency % Frequency % Onset of sensory blockade at T1(min) To achieve peak sensory level at T10 (min) To achieve maximum motor blockade Bromage 3 (min) Duration of surgery (min) Return of Bromage Scale to Zero (min) Total Duration of Analgesia Key: Group A Group B P-value P < P < P < P > P < P < 0.05 Fig. I : Distribution of patients according to weight in bo groups n=60 Key: Demographic data showed no difference between two groups in term of weight, sex and American Society of Anaesesiologist physical status (Figure I, II and III). Onset of sensory block at T1 (p<.05) and e median time of onset of sensory block at T10 (p<0.05) was statistically significant. The study group achieved lower levels of peak sensory block compared to control group (p<0.05). The time Table III: Comparison of Hypotension and Bradycardia between two groups Group A Group B P value Hypotension P <0.05 Bradycardia 0 03 P < 0.05 JSZMC Vol.5 No

4 DISCUSSION was faster in bupivacaine group as compare to It was demonstrated at e significantly faster ropivacaine group but duration of motor blockade onset and motor block was seen wi intraecal was prolonged wi bupivacaine group as compared bupivacaine, however, significantly shorter motor wi ropivacaine group. Our study supported e block duration wi intraecal plain ropivacaine above studies at ropivacaine provide slow onset of might be advantageous because it allowed a faster sensory and motor block as compare to bupivacaine discharge, and early recognition of any neurologic but ere was early recovery of motor and sensory 10 complications. In 2008, Mantouvalou et al block wi ropivacaine as compare to bupivacaine. performed a study to compare e anaesetic Regarding complication ere was significant efficacy and safety of ree local anesetic difference in hypotension and bradycardia between agents: racemic bupivacaine and its two isomers: two groups. ropivacaine and levobupivacaine, in patients undergoing lower abdominal surgery. 150 patients, ASA I-III, were randomized to receive an CONCLUSION intraecal injection of one of ree local In conclusion, intraecal administration of eier 15 anesetic solutions. Group A (n = 40) received 3 mg bupivacaine, 15 mg ropivacaine was well- ml of isobaric bupivacaine 5 mg/ml (15 mg). tolerated and provided similar, effective anesesia Group B (n=40) received 3 ml of isobaric for lower limb surgeries. In an equal milligram dose, ropivacaine 5 mg/ ml (15 mg). Group C (n=40) ropivacaine produced a shorter duration of motor and received 3 ml of isobaric levobupivacaine 5 mg/ml sensory block an bupivacaine. So intraecal (15 mg). The onset of motor block was ropivacaine may prove useful when surgical significantly faster in e bupivacaine group anesesia of a similar quality but of a shorter compared wi at in e ropivacaine group and duration an at of bupivacaine is desired. almost e same of at in e levobupivacaine group (P < 0.05). Ropivacaine presented a shorter duration of bo motor and sensory block an REFERENCES bupivacaine and levobupivacaine (P < 0.05). 1. David L. Brown, Spinal, Epidural and Caudal Bupivacaine required more often e use of a Anaesesia, Miller's Anaesesia 7 Edition, 2010, vasoactive drug (ephedrine) compared to bo Churchhill Living stone, Elsevier. ropivacaine and levobupivacaine and of a 2. Covino BG. Pharmacology of local anesetic agents. Br J sympaomimetic drug (atropine) compared to e Anaes 1986;58(7): ropivacaine group. McDonald and colleagues, 3. Kashimoto S, Kume M and Kumazawa. Functional and found at Ropivacaine 0.5% produce sensory metabolic effects of bupivacaine And lignocaine in e rat block of similar onset and extent as Bupivacaine heart-lung preparation. Br J Anaes 1990;65(4): % but it was associated wi lesser degree of 4. Akerman B, Hellberg B, Trossvik C. Primary evaluation of motor block and faster regression of bo sensory e local anaesetic properties of e amino amide agent ropivacaine (LEA 103). Acta Anaesesiol Scand and motor block. 1988;32: Whiteside et al, reported at Ropivacaine 5. Milligan KR. Recent advances in local anaesetics for provided reliable spinal anesesia of shorter spinal anaesesia. Eur J Anaesesiol. 2004; 21: duration and wi less hypotension an Khaw, Kim.S; Ngan Kee, Warwick D, Wong, Eliza; Liu, Bupivacaine. Sanchez et al in 2009, compared Justina, Chung, Raymond Spinal ropivacaine for caesarean e effects of intraecal isobaric ropivacaine section. A dose finding study Anes2001;95(6):1346- versus isobaric bupivacaine in a dose ratio of 3:2 in 1350 non-ambulatory urologic and oropedic surgery. 7. Malinovsky JM, Charles F, Kick O, et al. Intraecal They concluded at e motor blockade was anesesia: Ropivacaine versus bupivacaine. Anes longer in e Bupivacaine Group (266.5+/- 29.5) Analg. 2000; 91: compared to e Ropivacaine Groups (226.4 ± 8. Polley LS, Columb MO, Naughton NN, et al. Relative 22.3 min), (p < 0.001). analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: implications for erapeutic The results of our study showed at 15 mg indexes. Anesesiology 2000; 92: Ropivacaine and 15 mg Bupivacaine provide 9. Markham A, Faulds D. Ropivacaine. A review of its adequate block for lower limb surgeries but onset JSZMC Vol.5 No

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