Details
Category: Volume 06 Issue 08 August 2018
Hits: 1182

Title: Comparison of Fentanyl and Dexmedetomidine added to low dose Bupivacaine Heavy for Spinal Anaesthesia in Lower Abdominal Surgeries

Authors: Dr Krishna Priya R, Dr Letha.J

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i8.71

Abstract

Introduction

Spinal anaesthesia is the most commonly used technique for below umbilical surgeries. It is economical, easy to administer and relatively safer. It is important to limit the block level for minimizing hemodynamic changes during the spinal anesthesia in elderly and those with cardiopulmonary, endocrine and other comorbidities.

Low-dose local anesthetics can limit the block level and induce rapid recovery from anesthesia, but sometimes these low-dose local anesthetics may not provide an adequate anesthetic level for surgery. Intrathecal opioids or clonidine are frequently co-administered with local anesthetics to improve the anesthetic quality and postoperative analgesia.

The side effects of bupivacaine are dose dependent. This can be reduced by lowering it’s dose and use of adjuvants like fentanyl, clonidine, dexmedetomidine. Opioids used as adjuvants with local anaesthetics improve the quality and duration of post operative analgesia. It has beneficial effect of early ambulation because of minimal motor block. Use of lipophilic opiates have a favourable pharmacokinetic and pharmacodynamic profile. Morphine was the first opioid to be used intrathecally but side effects like delayed respiratory depression limited its utility.

Fentanyl being highly lipid soluble diffuses rapidly into spinal cord and binds to opioid receptors in dorsal horn when administered intrathecally. This produces rapid onset of analgesia with minimal cephalic spread. Hence the risk of delayed respiratory depression is less.

References

  1. Hem Anand Nayagam, N Ratan Singh, H Shanti Singh A prospective randomised double blind study of intrathecal fentanyl and dexmedetomidine added to low dose bupivacaine for spinal anesthesia for lower abdominal surgeries. IJA. October 2015. IP:163.47-12.127.
  2. Kim SY, Cho JE, Hong JY, Koo BN, Kim JM, Kil HK. Comparison of intrathecal fentanyl and sufentanil in low‑dose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy. Br J Anaesth 2009;103:750‑
  3. Kristiina S. Kuusniemi, Kalevi K. Pihlajamaki, Mikko T. Pitkanen, Hans Y. Helenius and Olli A. Kirvela. The use of bupivacaine and fentanyl for spinal anaesthesia for urological surgeries. Anesth Analg 2000;91:1452
  4. Sarika Katiyar, Chhavi Dwivedi, Saifullah Tipu, Rajnish K Jain. Comparison of different doses of magnesium sulphate and fentanyl as adjuvants to bupivacaine for infraumbilical surgeries under subarachnoid Block.IJA .October 14,2015,IP 163.47.13.201.
  5. A study done by P.R.Dhumal, E.P.Kolhe, V.B.Gunjal, V.A.Kurhekar .Synergistic effect of intrathecal fentanyl and bupivacaine combination for cesarean section .Int JPharm Biomed Res 2013,4(1),50-56.
  6. McCorry LK .Phsiology of the Autonomic Nervous System. American Journal of Pharmaceutical Education .2007;71(4):78.
  7. Tripathi KD .Essentials of Medical pharmacology. 6 th2005:250-278.
  8. De Vos H, Georges Vauquelin G, De Keyser J, De Backer J P, Van Liefd I ,Regional Distribution of α2A-and α2B-Adrenoceptor Subtypes in Postmortem Human Brain. Journal of neurochemistry International. 1992;58 (4):1555-60.
  9. Tobias JD: Dexmedetomidine: applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med.2007 Mar;8(2):115-31
  10. Gerlach AT ,Dasta JF : Dexmedetomidine : An updated review .Ann Pharmacother 21007;41:245-252.
  11. Virtanen R, SavolaJM ,Saano V ,Nyman L: Characterization of the selectivity, specificity and potency of medetomidine as an alpha 2-adrenoreceptor agonist . Eur J Pharmacol 1988;150:9-14.
  12. Dyck JB, Maze M, HaackC , et al : Computer –controlled infusion of intravenous dexmedetomidine hydrochloride in adult human volunteers. Anesthesiology 1993;78: 821-828.
  13. Venn RM ,Bradshaw CJ, Spencer R, et al: Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia 999;54:1136-1142.
  14. Stoelting RK. Pharmacology and Physiology in anaesthesia practise .3 rd edition .McGraw Hill publishing division;2006:204-214.
  15. Bloor BC ,Ward DS ,Belleville JP, Maze M. Effects of intravenous Dexmedeto-midine in humans, II: Hemodynamic changes. Anesthesiology 1992;77:1134-42.
  16. Sudheesh K, Harsoor SS. Dexmedeto-midine in anaesthesia practice: A wonder drug ? Indian J Anaesth2011 ; 55 :323-4.
  17. Guo TZ, Jiang JY, ButtermannAE ,Maze M: Dexmedetomidine injection into the locus ceruleus produces antinociception. Anesthesiology 1996;84:873-881.
  18. Ellis, S.Feldman, W.Harrop –Griffiths Anatomy for anaesthetists 8 th Edition Part 7 The vertebral canal and its contents P 102-107.
  19. Richard Brull, Alan J.R. Macfarlane, Vincent W.S. Chan .Miller 8 th edition Spinal , Epidural and caudal Anesthesia Chapter 56 page 1685-1685
  20. Gutstein HB, Akil H. Opioid analgesics. In: Gilman AG, Hardman JG, Limbird LE, editors. Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw Hill; 2001. p. 595-6.
  21. Charles B Berde ,Gary R. Strichartz Miller 8th edition Local anesthetics Chapter 36P 1035-1036, 103-1040.
  22. Kamal Maheshwari, Mohamed A. Naguib Stoelting’s Pharmacology and Physiology in Anesthetic Practice 5 th edition Local Anesthetics Chapter 10 P282,284-286.
  23. Margaret W. Alastair W. local anaesthetic  agents  ch11,In  :Drugs  and  anesthesia Pharmacology for Anaesthesiologist,2nd edition, William and Wilkins publishers, London;319-43.
  24. Merskey .H, Bogduk. M:Description of chronic pain syndromes and definitions of pain terms.Seattle ,WA,IASP 1994 ;Miller Anaesthesia 6th Edition 73:2763
  25. Ellis, S.Feldman, W.Harrop –Griffiths Anatomy for anaesthetists 8 th Edition Part 7The anatomy of pain P 288,290,294,295.
  26. Prithvi Raj Practical MANAGEMNT OF PAIN 3 rd Edition 2000;14:17
  27. Ready L.B:Acute postoperative pain ,Miller Anaesthesia 1994;2328-2338.
  28. Hammer M:Control of post-operative , Nausea and vomiting in :Morgan M and G .M ed .Short practice of anaesthesia , Chapman and Hall medical 1998;653-658.
  29. Revill SI, Robinson JO, Rosen H, et al .The reliability of a linear analogue for evaluating pain, Anesthesia 1976;31:1191-1193 .
  30. MelzackR; Casey K.L. The skin senses, spring field IL, Charles C Thomal 1968;423-443.
  31. Kazuhiko Fukuda Miller 8 th edition Opioid analgesics Chapter 31 P 866-86,873-874.
  32. Kenneth Cummings, Mohamed A Naguib Stoelting’s Pharmacology and Physiology in Anesthetic Practice 5 th edition Opioid Agonists and Antagonists chapter 7 P218-219,221-225.
  33. Gutstein HB, Akil H. Opioid analgesics. In: Gilman AG, Hardman JG, Limbird LE, editors. Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw Hill; 2001. p. 595-6.
  34. Margaret W. Alastair W. opiod agonists and antagonists ch.7 Drugs and anesthesia. Pharmacology for Anaesthesiologist, 2ndedition, William and Wilkins publishers,London;208-236
  35. Bailey PL, Streisand JB, East KA, et al: Differences in magnitude and duration of opiod –induced respiratory depression and analgesia with fentanyl and sufentanil. Anesth Analg 1990;70:8-15
  36. Robert s.kopiod agonists and antagonists, chapter 3,In pharmacology and physiology in anaesthesia practice ,   3rd Newyork   Lippincott-   Raven publications; 1999;77-112.
  37. Fields HL, Heinricher MM, Mason P: Neurotransmitters in nociceptive modulatory circuits .Annu Rev S Neurosci 1991;14:219-245
  38. Stein C: The control of pain in peripheral tissue by opiods.NEngl J Med 1995:332;1 685-1690.
  39. Dahlgren G, Hultstrand C, Jakobsson J, Norman M, Eriksson EW, Martin H. Intrathecal sufentanil, fentanyl, or placebo added to bupivacaine for cesarean section. Anesth Analg 1997;85:1288-93.
  40. Choi DW,AhnHJ,Kim MH Bupivacaine –sparing effect of fentanyl in spinal anesthesia for Cesarean delivery RegAnesth Pain Med 2000;25:240-245.
  41. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT, Helenius HY, Kirvela OA .The use of bupivacaine and fentanyl for spinal anesthesia for urologic surgery .Anesth Analg 2000; 91:1452-1456.
  42. Palmer CM, Voulgaropoulos D, A Slves D Subarachnoid fentanyl augments lidocaine spinal anesthesia for caesarean delivery. Region Anesth Pain Med 1995;20:389-394.

Corresponding Author

Dr. Letha.J

Associate Professor, Department Of Anaesthesiology Govt. T.D Medical College, Alappuzha, India