Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : UC17 - UC22 Full Version

Intrathecal Hyperbaric Bupivacaine 0.5% with Varying Dose of Buprenorphine in Elective Adult Lower Limb Orthopaedic Surgeries: A Randomised Control Study


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/55205.17256
Mohammed Irfan, Mohammed Mishal, Akil Hussain, Surya Prakash Chittora, Ganga Shankar Garg

1. Senior Resident, Department of Anaesthesiology, Jhalawar Medical College, Jhalawar, Rajasthan, India. 2. Senior Resident, Department of Anaesthesiology, Jhalawar Medical College, Jhalawar, Rajasthan, India. 3. Associate Professor, Department of Anaesthesiology, Jhalawar Medical College, Jhalawar, Rajasthan, India. 4. Senior Professor, Department of Anaesthesiology, Jhalawar Medical College, Jhalawar, Rajasthan, India. 5. Senior Professor, Department of Anaesthesiology, Jhalawar Medical College, Jhalawar, Rajasthan, India.

Correspondence Address :
Dr Mohammed Mishal,
Dept of Anasthesia Jhalawar Medical College, Jhalawar, Rajasthan, India.
E-mail: mishalqumar@gmail.com

Abstract

Introduction: Postoperative pain is a universal phenomenon and usually under treated and its intensity varies widely among patients. Spinal anaesthesia with opioid and local anaesthetics to prolong postoperative analgesia is common practice in recent years. Buprenorphine is an agonist - antagonist opioid. Intrathecal buprenorphine (30-150 μg) along with local anaesthetics is safe and known to increase the postoperative analgesia without affecting sensory or motor blockade and with lesser side effects.

Aim: To compare the anaesthetic characteristics and its side effects in subarachnoid block with bupivacaine 0.5% heavy and varying dose of buprenorphine (90 μg and 120 μg).

Materials and Methods: This randomised control study was conducted in the Jhalawar Medical College, Jhalawar, Rajasthan, India, from March 2019 to November 2019. The study included 90 patients belonging to American Society of Anaesthesiologists (ASA) class I and II of either sex age between 18 to 60 years posted for elective lower limb orthopaedic surgeries.The patients were divided into three groups; group A which included a patient count of 30 received plain hyperbaric bupivacaine 0.5% (2.5mL) with 0.5 mL saline. Group B which included 30 patients, receive plain hyperbaric bupivacaine 0.5% (2.5 mL) along with buprenorphine 90 μg diluted in 0.5 mL saline. Group C with a patient count of 30 received hyperbaric bupivacaine 0.5% (2.5 mL) with buprenorphine 120 μg mixed with 0.5 mL saline. Analgesic characteristics, haemodynamic parameters, side effects, sedation scores by Ramsay sedation score and pain scores by Visual Analogue Score (VAS) (0-10) were measured postoperatively till 24 hours.Statistical analyses of data were done by one Way Analysis of Variance (ANOVA) test and chi-square test where p-value less than 0.05 was considered to be a statistically significant value.

Results: The onset time of sensory blockade (group A: 5.14±1.34, group B: 4.54±1.10, group C: 4.50±1.18 in minutes), time of onset of motor blockade (group A: 10.10±1.00, group B: 9.43±1.30, group C: 9.21±1.49 in minutes) and maximum level of sensory block at T6 level (group A: n-01/30, group B: n-04/30, group C: n-04/30) were comparable between the three groups and were not statistically significant. Sensory recovery time was significantly (p<0.0001) delayed in group B and C (178.9±7.18 min and 189.23±7.4), while in group A it was 152.86±8.9 min. Duration of postoperative analgesia was significantly (p<0.0001) prolonged in group C (group A 165.53±8.5, group B 391.49±19.8, group C 493.23±18 in minutes). Side-effects like Postoperative Nausea and Vomiting (PONV) and sedation were increased with dose of buprenorphine but easily treatable and not significant (p>0.05).

Conclusion: A higher dose of buprenorphine shows to provide an adequate and longer postoperative analgesia without any major side effects.

Keywords

Postoperative analgesia, Ramsay sedation score, Visual analogue scale

Among the various regional anaesthesia techniques practised, subarachanoid block is a good option when surgery is in the lower limb (orthopaedic surgery).Subarachanoid block provides a perfect pain relief as compared to Intravenous Regional Anaesthesia (IVRA) or epidural anaesthesia. As it reduces the duration of stay in the hospital, it is beneficial to the patient in terms of money expenditure.Spinal anaesthesia is associated with few major complications like fall in blood pressure, bradycardia, delayed recovery from motor block and high spinal blockade, mainly due to the sympathetic blockade caused the local anaesthetic used.These sympatholytic effects can be minimised by administering a lower dose or a diluted concentration of the local anaesthetic. Even though, spinal anaesthesia has many benefits and adverse effects, the major drawback is the shorter duration of action associated with it (1).

Bupivacaine, an amino amide local anaesthetic causes a decrease in the entry of the sodium ions into the cell by blocking the voltage gated sodium channel, thus inhibiting depolarization. Since depolarisation is inhibited, the transmission of action potential is stopped. Bupivacaine is good lipophilic drug, so it penetrates large myelinate motor fibres Aβ and also pain transmitting Aδ, C fibers and its onset of action is around five to ten minutes with spinal blockade duration ranging around one and a half to two hours (2). To overcome the major drawback which is associated with spinal anaesthesia that has shorter duration of blockade, adjuvants to local anaesthetics are being tried and used for spinal anaesthesia (3).

Wang JK et al. in 1979,were the first to use opioids intrathecally for acute pain management. The main idea of adding an opioid adjuvant to the local anaesthetic is to improvise the quality of analgesia and to reduce the dose of postoperative pain killers (4). Now a days opioids are gaining more popularity due to adjuvants as they cause more sensory block than motor without affecting the sympathetic activity and better postoperative analgesia. The dorsal horn of the spinal cord release substance P which is blocked by the opioids administered and the impulse transmission occurring at the nerve axonal level are blocked by the local anaesthetic drug administered. These two actions together act synergistically in producing analgesia.

Buprenorphine is mixed agonist/antagonist activity with partial mu receptor agonist can be delivered in subarachnoid space safely.Rostral spread of buprenorphine is prevented by high lipophilicity and larger molecular weight, so that the occurrence of side effects like nausea, vomiting, somnolence, pruritus is lesser, making it an attractive alternative. Intrathecal varying dose of buprenorphine in combination with bupivacaine has known to improve the quality and duration of postoperative analgesia compared to bupivacaine alone. Previously studies have demonstrated safety and efficacy of buprenorphine as an adjuvant to local anaesthetics in subarachnoid block. Intrathecally dose of buprenorphine varies from 30-150 μg, however, optimal dose which provides a balance between analgesia and adverse effects has not been described yet (5),(6),(7). This study was conducted to evaluate and compare the characteristics of spinal block and its side effects in adult patient undergoing lower limb orthopaedic surgeries who received a subarachnoid block with bupivacaine 0.5% heavy with varying dose of buprenorphine (90 μg and 120 μg) to prolong postoperative analgesia.

Material and Methods

This randomised control trail study was conducted in the Jhalawar Medical College, Jhalawar, Rajasthan, India, from March 2019 to November 2019. Approval of local Institutional Ethical Committee was taken prior to trail as per order no Sr.06/07 dated 31 January 2019.

Inclusion criteria: Ninety patients aged between 18 to 60 years of physical status ASA grade 1 and 2, of either sex, of height more than 150 cm, weighted 50-80 kilograms, undergoing elective lower limb surgeries, lasting less than two hours were included in the study.

Exclusion criteria: Patients with allergy to local anaesthetics or opioids, local site infection, pregnant or lactating females, raised intracranial tension, progressive neurodegenerative disorder, Central Nervous System (CNS) infections, spine deformities, hypovolaemic shock and bleeding diathesis and coagulopathy were excluded from the study.

Ninety patients who were planned to go elective lower limb surgeries were recruited by convenient sampling method. They were randomly divided into three groups (n-30 each) by using computer generated programme. Assigned random groups were enclosed in a sealed envelope to ensure concealment of allocation sequence. Group A (30 patients) received intrathecally Bupivacaine (0.5%) 2.5 mL mixed with 0.5 mL saline, Group B which also included 30 patients received intrathecally 0.5 % hyperbaric Bupivacaine 2.5 mL with buprenorphine 90 μg in 0.5 mL saline and Group C (30 patients) received intrathecally 0.5 % hyperbaric bupivacaine 2.5 mL mixed with buprenorphine 120 μg in 0.5 mL saline (Table/Fig 1).

Study Procedure

Preoperative evaluations of the patient were done on the day before surgery. After explaining the procedure, written and informed consent was obtained. Patients were advised overnight fasting and were premedicated with tablet Alprazolam 0.5 mg the night before the day of surgery. In the operating room, intravenous line was secured with 18G cannula and patients were preloaded with Ringer's lactate solution at 10 mL/kg.Baseline heart rate, Noninvasive Blood Pressure (NIBP), SpO2, respiratory rate was recorded using multi-parameter monitor, before starting the procedure. Under aseptic precautions with patient in lateral position or sitting position with 25G Quincke spinal needle was introduced in to L3-L4 space, after confirming clear flow of Cerebrospinal Fluid (CSF) and negative aspiration for blood, 3.0 mL of test drugs were injected intrathecally. Patients were made supine after giving the subarachnoid block and i.v. line ensured. Then pulse rate, NIBP were recorded and O2 by mask was started and then checked the onset and effect of spinal block to allow the surgery to be started. Intraoperatively, vital parameters were recorded till completion of surgery and postoperatively till 24 hours.

Parameters Assessed

Alteration in the hemodynamic parameters such as hypotension and bradycardia were treated with injection mephentermine 6 mg/mL and atropine 0.6 mg i.v bolus. Any adverse events like nausea, vomiting, pruritis, urinary retention etc. were noted and treated accordingly.

Assessment of sensory blockade and duration was tested by pin prick test using hypodermic needle with Hollmen scale and the time of onset, highest level of sensory blockade, duration of sensory block were noted. The assessment motor blockade and duration was assessed by Modified Bromage scale. Sedation were assessed with Ramsay sedation scale and recorded, score of 4 and above was considered as sedated. Quality of analgesia was assessed using VAS on a 0-10 scale, where a score of 0 represents no pain and 10 was the worst pain imaginable. Postoperatively patient was assessed every half hourly till S1 regression (great toe sensation) to measure the duration sensory block. If VAS was noted more than 4 scale then inj. diclofenac 75 mg intramuscular was given as rescue analgesia. Intravenous Inj ondansetron 4 mg was administered to the patients who compained for nausea and vomiting.

Primary objective were to study onset and duration of sensory and motor blockade, maximum level of sensory block and duration of analgesia. Secondary objectives were to study hemodynamic parameters, complications or associated side effects.

Statistical Analysis

Statistical analysis of data was done by help of Statistical Package for the Social Sciences (SPSS) 20.0 Software (trial Version), one way ANOVA test and Chi-Square test was used in data analysis. A p-value <0.05 was considered as significant. Chi-square test was used to find the association between two qualitative variables. One way ANOVA test was used to find variation between more than two groups Mean.

Results

As shown in (Table/Fig 2) there was no statistically significant (p>0.05) difference between the mean age, gender, height and weight among the three groups.

As shown in (Table/Fig 3),(Table/Fig 4) there were no significant changes in hemodynamic variability in all three groups during the operation and postoperatively as well. There was no difference in the incidence of hypotension and bradycardia in the intraoperative period. There was no significant requirement of crystalloid and vasoconstriction agents.

There was no significant difference found between the three groups (p-0.078). Maximum sensory level achieved was similar (T6 level) in all the three groups and found between T6-T10. The addition of buprenorphine to bupivacaine did not change the height of block (p-0.164). Addition of buprenorphine to bupivacaine did not change the onset of motor block much (p-0.052). The mean time of regression to S1 had significant difference between the groups C>B>A. It was observed that addition of buprenorphine increased time of sensory regression (p<0.0001). The mean duration of the motor blockade was statistically significant between the groups C>B>>A (Table/Fig 5).

The duration of analgesia was considered from the time of intrathecal administration of the study drugs to the time of demand for the rescue analgesics, and this difference was highly significant (p<0.0001) between all groups (C>B>A).

VAS was low and remained low for a significant time in the postoperative period with addition of 90 μg and 120 μg buprenorphine to bupivacaine. The VAS scores were statistically highly significant (p<0.0001) in group B and C compare to group A. During the surgery, only two patients in control group complained of pain (VAS-2) and they did not require rescue analgesia within two hours, rest of the patients in all the three groups were comfortable.VAS scores were statistically significant from the second hour of postoperative period onwards between the groups. In control group A patients showed VAS score >4 and most of patients demanded rescue analgesia immediately after two-three hours. In Group B most of patient demanded analgesia in ranged between 5-8hours. In Group C 27 patients demanded rescue analgesia in between 08-10 hours postoperatively (Table/Fig 6).

According to Ramsay sedation score scale of 1-6 was measured intra and postoperatively. When compared with control group, the buprenorphine group patients had statistically significant (p<0.0001) sedation score. In group B and group C all patient had sedation score 2 (Table/Fig 7).

Adverse effects like nausea and vomiting was more associated with group C > B> A (Table/Fig 8). Pruritis, urinary retention, bradycardia and hypotension were not observed in any patient.

Discussion

Relief of pain in postoperative period extends the anaesthesiologists’s interest beyond the confines of the operating theatre. In postoperative period when the effect of anaesthesia disappears tissue injury still persists. Substances like prostaglandins, histamine, bradykinin, 5-Hydroxytryptamine (5HT), substance P produced during local tissue damage occuring during surgery, are transduced by nociceptors and transmitted by A and C fibers to the pain centres (8). The method for postoperative analgesia performed should have simplicity and safety. The clinical effects of intrathecally administered, 0.5% hyperbaric bupivacaine were assessed in patients who underwent lower limb orthopaedic surgery under spinal anaesthesia using preservative free buprenorphine as an adjuvant and it was observed that increasing the dose of buprenorphine resulted in increased duration of sensory regression and total duration of analgesia without any significant increase in adverse effects.

Addition of buprenorphine to bupivacaine does not result in much faster onset of sensory block. Onset time in Group A was 5.14±1.34 min , in Group B was 4.54±1.10 min and 4.50± 1.18 min in Group C, which was statistically insignificant between the three groups (p = 0.078). Khan F and Hamdani GA (9) (2006) found that onset of sensory block was 3.2±2 min with buprenorphine and 4.5±2 min in control group and found that addition of buprenorphine does not change the time of onset of sensory block. The reason for insignificant difference could be due to clinical action of local anaesthetic and opioids are additive only after some time has elapsed.

The addition of Buprenorphine to bupivacaine did not change the height of block and the highest level of analgesia achieved was T6. Borse YM et al., (10) (2015) found that maximum sensory level ranged between T6-T10 when buprenorphine 150 mcg was added to 2.5 mL of 0.5% bupivacaine heavy.

Onset of motor block in Group A was at 10.10±1.0 min, in Group B was at B 9.43±1.30 min and 9.21±1.49 min in Group C (p-0.052). Arora MV et al., (11) (2016) found that onset of motor block in group A (control) was 10.9±1.9 min and 10.2±3.7 min in group B (Buprenorphine). Borse YM et al., (10) (2015) have observed quick onset of motor block as 77±9.5 sec in control (2.5 mL 0.5% bupivacaine heavy) and 75±7.6 sec with buprenorphine 150 mcg.

Borse YM et al., (10) (2015) found that duration of sensory regression was prolonged with addition of 150 mcg buprenorphine to 215.4±26.2 min as compared to (132.8±16.5) min in control group. Another study done by Arora MV et al., (11) (2016) found that duration of sensory regression in group A (control) was 129±16.3min and with buprenorphine was 209±33.8 respectively. This prolongation of sensory recovery is attributed to the clinical action of local anaesthetic and opioids as additive only after some time following intrathecal administration. This is due to the time taken by the opioid from CSF to penetrate the deeper layer (substantia - gelatinosa) where opioid receptors are present.

The mean time of motor block had significant difference between the groups A, B and C but not statically significant between group B vs C and similar prolongation was observed by others studies also.Arora MV et al., (11)(2016) found that addition of buprenorphine 50mcg to bupivacaine prolonged duration of motor block 262±46.7min as compared to 153.8±19.3 min control group. Raju G et al., (12) (2014) found that duration of motor block increased with addition of buprenorphine (100 mcg) 182.50±8.69 min.

Total duration of analgesia in group A was 165.53±8.5 min in group B 391.40±19.8 min and 493.23±18 min in group C which was highly significant (p<0.0001) between all groups (C>B>A). Borse YM et al., (10) (2015) found that duration of analgesia with buprnorphine (150mcg ) was 909±216.9 min while in control group 158±17.3 min. Harshvardhna P et al., (13) (2015) found duration of analgesia was 584.3±19.11 min with buprenorphine as compared to control group 170.03±6.7min. Raju G et al., (12) (2014) found duration of analgesia 474.42±165.68 min with 100mcg buprenorphine.Caponga G et al., (14) (1988) found that mean pain free interval were 183.06 minutes in Group B( 30 mcg), 430.16 minutes in Group C (45mcg). In Group B pain increased gradually from 5 - 8 hours. In Group C pain increased from 7 - 12 hours. Capogna G et al., (14) (1988), suggested duration of analgesia is dose dependent which supports our study. Buprenorphine has prolonged duration of action, due to complex receptor kinetics. It has high affinity to opiate receptors, it forms avid complex with the receptor and tends to persist for long duration of period. The opiate receptor affinity for buprenorphine is 50 times more than that of morphine. The high lipid solubility and high affinity for opiate receptors of buprenorphine explains buprenorphine’s longer duration of action when compared to other lipid soluble drugs like fentanyl which produces short lived analgesia due to rapid clearance from spinal cord sites (15).

The pain scores as assessed on the VAS were low and remained low for a significant time in the postoperative period with addition of 90 mcg and 120 mcg buprenorphine to bupivacaine. The VAS scores were statistically highly significant (p<0.0001) in group B and C compare to group A. All three groups of patients were comfortable during surgery except two patients in control group complained of pain but they did not require analgesia within two hours. From the second hour of postoperative period onwards, there was a significant change in the VAS reading. In control group A patients showed more than score of 4 in VAS scale and most of patients demanded analgesia immediately after two-three hours. In group B most of patient demanded analgesia in range between 5-8 hours. In Group C all patients demanded analgesia between 7-10 hours and three patients did not demand analgesia till 24 hours. Rao BD and Chandraprakash K (16) (2016) found that the pain scoring through VAS in the group BN (buorenorphine) was nil to mild pain till about twelve hours, while in the group B (control) analgesic effect was felt only till first two hours. Nelmangla K et al., (17) (2016) found that the pain intensity was significantly lower with buprenorphine (mean±SD 4.20±0.81 hrs) as evaluated by VAS score which coincides with our study.

Caponga G. et al., (14) (1988) found that intrathecal buprenorphine in higher concentration offers more prolonged analgesia with minimal change in consciousness. Sen M (18) (1992) also found that buprenorphine had prolonged postoperative analgesia with minimal disturbance of consciousness.

The incidence of nausea and vomiting was increased in postoperative ambulation. This may be due to the rostral spread of opioid in spinal fluid to intra cerebral structures including the vomiting centre and chemoreceptor trigger zone. Since most of the patients in this study were in plaster of paris immobilization and were not ambulatory so the incidence of nausea and vomiting were low. Somnolence was observed more in Group C (03/30) than Group B (01/30) and there was no case observed with somnolence in control Group.Sapkalpravin S et al., (19) (2013) observed somnolence in 03/40 patients.

Limitation(s)

The study may be under powered with small sample size. A Lower limb orthopaedic surgery usually differs in term of tissue trauma as a longer duration of postoperative analgesia in arthroscopic guided surgeries was observed than open or closed reduction and internal fixation surgeries.

Conclusion

It can be concluded that intrathecal buprenorphine along with Bupivacaine does not result in earlier sensory and motor blockade onset time but increases sensory regression to S1 time and increasing the dose of buprenorphine results in increased duration of sensory regression. Buprenorphine prolongs duration of analgesia and increasing dose of buprenorphine result in increased duration of analgesia. Adverse effects like PONV and sedation increased with dose of buprenorphine but it is easily treatable and not significant (p>0.05). Buprenorphine with increasing dose helps in providing a good and a longer postoperative analgesia with minimal side effects. So, this combination can be used to provide alonger postoperative analgesia for lower limb orthopaedic surgeries which is cost effective and safe by intrathecal route.

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DOI and Others

DOI: 10.7860/JCDR/2023/55205.17256

Date of Submission: Jan 25, 2022
Date of Peer Review: Feb 28, 2022
Date of Acceptance: Apr 18, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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