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Background: Nalbuphine, a synthetic k-agonist and µ-antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain. Methods: A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS). Results: The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h (P < 0.01). Group M had lower CMU than group N at 24 h (P < 0.01) and 48 h (P < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively (p = 0.04), and group N had significantly shorter LHS compared to group M (P < 0.001). Conclusion: Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS. [ABSTRACT FROM AUTHOR]

Aim:Aim of this study was to compare the characteristics of spinal block, hemodynamic changes, and postoperative analgesia, following administration of intravenous dexmedetomidine (0.25 mcg/kg and 0.5 mcg/kg) in patients undergoing TURP under spinal anaesthesia. Methods:90 patients of ASA grade I and II posted for elective transurethral resection of prostate surgeries were included in the study and randomly allocated into three groups. All three groups received 3ml of intrathecal 0.5% bupivacaine heavy, followed by infusion of study drug.Group D5 received intravenous dexmedetomidine 0.5mcg/kg over 10 min,Group D2 intravenous dexmedetomidine 0.25mcg/kg over 10 min and Group NS received infusion of same volume of normal saline as placebo.Duration of analgesia,time to 1st analgesia request,VAS score,hemodynamics and side effects were recorded and analyzed. Results:The prolongation in duration of analgesia in D5 group was statistically significant in comparison to other groups. Time to 1st analgesia request was delayed in group D5 compared to other groups which was statistically significant. Hemodynamic stability was well maintained in both dexmedetomidine group. Conclusion:Intravenous dexmedetomidine not only increased the duration of spinal analgesia but also maintained hemodynamic stability. IV Dexmedetomidine in a dose of 0.5 mcg/kg was more effective than 0.25 mcg/kg without increasing the risk of adverse effect. [ABSTRACT FROM AUTHOR]

The use of intrathecal (IT) dexamethasone during subarachnoid block (SAB) has not been evaluated. There are no pooled data available to decide on the optimal regimen of IT dexamethasone during SAB, irrespective of the type of surgery. There is uncertainty about its dosage, effectiveness, and safety, and a need to establish clear guidelines on its use. Our objective was to evaluate the effectiveness and safety of use of IT dexamethasone during SAB. We performed a meta-analysis (PROSPERO, CRD42022304944) of trials that included patients who underwent a variety of surgical procedures under SAB. Patients received concomitant IT dexamethasone as an adjuvant to spinal local anesthetics. The analyzed outcomes included sensory and motor effects as well as adverse and/or beneficial side effects. Subgroup analysis was planned based on different doses used. Trial sequential analysis (TSA) was used to estimate the required sample size information (RIS) for each outcome. Eighteen studies (2531 participants) were included in this analysis. Addition of IT dexamethasone (4-8 mg) to heavy bupivacaine effectively prolonged the duration of sensory blockade (mean difference, MD = 63.8 minutes; [95% confidence interval, CI, 33.1-94.5], P < 0.0001), two-segment regression time (MD = 20.1[95% CI, 0.96-39.2], P = 0.04) and first rescue analgesic time (MD = 143.3 [95% CI, 90.3-196.0], P = 0.001). Subgroup analyses revealed superior effects of 8 mg dose over 4 mg for sensory and analgesic effects. The effect of dexamethasone on duration of motor blockade was inconclusive. Additionally, lower risk ratios (RRs) were recorded for spinal anesthesia-related hypotension (RR = 0.74 [95% CI, 0.6-0.9], P = 0.0003) and nausea/vomiting (RR = 0.62 [95% CI, 0.41-0.93], P = 0.02) in the dexamethasone group. For outcomes such as sensory blockade, analgesia, and hypotension, the required information size was reached during TSA. In conclusion, IT dexamethasone, used as an adjuvant to spinal local anesthetic, especially at the dose of 8 mg, increases sensory blockade duration and the time for request of the first rescue analgesic. SAB-induced side effects such as hypotension, nausea, and vomiting are lesser with the use of IT dexamethasone. However, further studies are necessary to draw meaningful conclusions on its safety profile. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain management can be achieved by adjuvant medications during the analgesia procedure. The study investigated the effect of intrathecal dexamethasone-bupivacaine combination with bupivacaine alone in spinal anesthesia for cesarean delivery. Methods: This randomized, double-blind clinical examination included 50 females who had previously experienced a cesarean section. The participants were assigned randomly into two categories: the intervention group, received intrathecal bupivacainedexamethasone, and the control group, received intrathecal bupivacaine-normal saline. Levels of pain were evaluated using a 10 cm visual analog scale (VAS) at intervals of 30 minutes, 1 hour, 2 hours after the operation. The span of the sensory block and postoperative analgesia were assessed. Results: The inclusion of intrathecal dexamethasone with bupivacaine resulted in a significant enhancement in the duration of pain relief during the intervention, lasting for an average of 473.4 ± 39.95 minutes (p<0.001). The duration of sensory and motor block analgesia in the intervention group was more than the control group (128.32 ± 7.30 vs. 92.84 ± 7.84) and (155.6±12.34 vs. 126.16±11.89), respectively (p<0.001). Pain score on the VAS scale at 30, 60, and 120 minutes was significantly lower in the intervention group (p<0.001). There was no difference in side effects and onset time between the study groups. Conclusion: The inclusion of intrathecal dexamethasone alongside bupivacaine has demonstrated enhancement in the duration of sensory block during spinal anesthesia. This improvement was observed without any alterations in the time it takes for the anesthesia to take effect and without any adverse effects during the postoperative period. [ABSTRACT FROM AUTHOR]

Background: When it comes to orthopedic surgeries involving the lower limbs, spinal anesthesia offers the most predictable block due to the strong sensory as well as motor block that it provides, with the benefits of avoiding the risks of general anesthesia. This study aimed for comparing intrathecal dexamethasone versus intravenous dexamethasone on the quality of spinal anesthesia in lower limb orthopedic surgeries. Methods: We carried out this prospective randomized controlled study on 63 adult patients who undergoing orthopedic lower limb procedures under the influence of spinal anesthesia; they were randomized into three equal groups (each containing 21 patients): group C (control), group V (intravenous dexamethasone) and group S (intrathecal dexamethasone). The Visual Analogue Scale (VAS) was done at first admission to the PACU, then at 1, 3, 6,12, and 24 hours at rest and during movement with an assessment of complications postoperatively. Results: A significant longer duration of sensory block was revealed in group S compared to both group C and group V (191.43 ± 25.94, 109.52 ± 7.4, 110.67± 11.14, respectively). The visual analogue scale (VAS) was higher in the control group at 1, 3, and 6 hours postoperatively, especially at 3 hours. A statistically significant difference existed between the studied groups as regards intraoperative complications (P<0.001) in the control group; only six patients (28.6%) passed uncomplicated versus 76.2% of the patients who was given intravenous dexamethasone and 81% of the patients who was given intrathecal dexamethasone. Conclusion: Adding Intrathecal dexamethasone to bupivacaine in spinal anesthesia was associated with longer duration and level of sensory block, lower VAS and the total amount of rescue analgesia with decreasing complications of spinal anesthesia as hypotension, shivering, and vomiting compared to intravenous route administration. [ABSTRACT FROM AUTHOR]

Nowadays, obstetrical anesthesia-related mortality is a very rare complication in industrialized countries. The recommended choice of intrathecal opioid for spinal anesthesia in the context of a multimodal peripartum pain management concept is discussed in this narrative review. Nowadays, there is a consensus that a perioperative multimodal pain concept should be used for caesarean delivery. This pain concept should include neuraxial opioids for spinal anesthesia, acetaminophen, NSAIDs, intravenous dexamethasone, and postoperative local or regional anesthetic procedures. Long-acting lipophobic opioids (diamorphine and morphine) have a significant analgesic advantage over short-acting lipophilic opioids (sufentanil and fentanyl). The risk of clinically relevant respiratory depression after neuraxial long-acting opioids is nowadays considered negligible, even if the data situation is weak in this regard. The question remains as to whether a pain concept that is ideally adapted to a neuraxial short-acting opioid shows benefit to a pain concept that is optimally adapted to neuraxial morphine. If long-acting opioids are used, the timing of each additional component of the multimodal analgesia strategy could ideally be adjusted to this longer duration of action. [ABSTRACT FROM AUTHOR]

Cardiac surgeries often result in significant postoperative pain, leading to considerable use of opioids for pain management. However, excessive opioid use can lead to undesirable side effects and chronic opioid use. This systematic review and meta‑analysis aimed to evaluate whether preoperative intrathecal morphine could reduce postoperative opioid consumption in patients undergoing cardiac surgery requiring sternotomy. We conducted a systematic search of Cochrane, EMBASE, and MEDLINE databases from inception to May 2022 for randomized controlled trials that evaluated the use of intrathecal morphine in patients undergoing cardiac surgery. Studies that evaluated intrathecal administration of other opioids or combinations of medications were excluded. The primary outcome was postoperative morphine consumption at 24 h. Secondary outcomes included time to extubation and hospital length of stay. The final analysis included ten randomized controlled trials, with a total of 402 patients. The results showed that postoperative morphine consumption at 24 h was significantly lower in the intervention group (standardized mean difference ‑1.43 [‑2.12, ‑0.74], 95% CI, P < 0.0001). There were no significant differences in time to extubation and hospital length of stay. Our meta‑analysis concluded that preoperative intrathecal morphine is associated with lower postoperative morphine consumption at 24 h following cardiac surgeries, without prolonging the time to extubation. The use of preoperative intrathecal morphine can be considered part of a multimodal analgesic and opioid‑sparing strategy in patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: It might be difficult to treat hypotension after spinal or epidural anesthesia in older adults. There is a danger of volume overload or cardiac compromise when PSA hypotension is treated with fluids (colloids or crystalloids) or vasoconstrictors. When decreased peripheral vascular resistance is present, dexamethasone is utilized as a treatment. Methods: Eighty patients, aged 60 years or more were recruited to receive a single preoperative intrathecal dose of dexamethasone 8 mg (dexamethasone group) (40 patients), and 40 patients were given placebo receiving normal saline (Control group) in a randomized, double-blind trial. Variations in blood pressure and heart rate in addition to the needs of ephedrine and/or atropine following spinal anesthesia (SA) were recorded. Result: The mean age of patients in 4dexamethasone group was 67.8±6.8 years and most of them were females (72.5%). The mean arterial blood pressure showed no significant difference between the studied groups regarding their baseline and all measures of mean arterial blood pressure. However, at all measures the MAP was higher in the dexamethasone group than the control group. Conclusion: Post-spinal anesthesia hypotension in elderly patients was less common after receiving a single preoperative intrathecal dose of dexamethasone 8 mg than control. [ABSTRACT FROM AUTHOR]

CP is an amino-ester local anesthetic with a very short half-life. It was introduced and has been successfully used for spinal anesthesia since 1952. Sodium bisulfite was then added as a preservative after 1956 to the commercially available CP preparation. The drug was used as an epidural anesthetic for obstetric patients. After obtaining the approval from institutional review board and the ethical committee, 60 ASA Grade I and Grade II patients who met inclusion and exclusion criteria who were undergoing short duration urology, lower limb and perianal surgeries were selected. The independent 't' test result shows that there is a significant difference in mean of return to bromage 0 (min) between the groups with Chloroprocaine with fentanyl group taking longer time to bromage 0 (<0.001*). The independent 't' test result shows that there is a significant difference in mean of time to rescue analgesia(min) between the groups with Chloroprocaine with fentanyl group requiring longer time for analgesia (<0.001*). [ABSTRACT FROM AUTHOR]

Introduction: Intrathecal fentanyl and dexmedetomidine are adjuvants that can be used along with bupivacaine in spinal anesthesia to enhance the quality and duration of analgesia. Fentanyl is a potent opioid that acts on the muopioid receptors in the spinal cord, which inhibits the transmission of pain signals. Dexmedetomidine is a selective alpha-2 adrenergic agonist that acts on the spinal cord to reduce sympathetic outflow and modulate pain transmission. Material and Methods: 100 ASA I and II patients scheduled for major surgeries under spinal anaesthesia were chosen for the study. Under strict asepsis, using 25 G Quincke spinal needle, lumbar puncture was performed at L 3 - L 4 space. Group F received 3ml, 0.5 % hyperbaric bupivacaine + 25 μg Fentanyl (vol 0.5ml). Group D received 3ml, 0.5 % hyperbaric bupivacaine + 5 μg Dexmedetomidine (vol 0.5 ml). Intra-operatively pulse rate, non-invasive blood pressure, electrocardiogram, SpO2 was recorded. 50 patients in Group F (Fentanyl) and 50 patients in Group D (Dexmedetomidine) were taken to study the changes in haemodynamics and side effects. Chi-square test, Anova test and student' 't' test was done to analyse the data and p value was determined. Results: Dexmedetomidine performed better than Fentanyl as an adjuvant based on the various parameters. Conclusions: Dexmedetomidine is a safe and effective adjuvant for intrathecal administration in the management of postoperative pain as compared to Fentanyl. [ABSTRACT FROM AUTHOR]

Background: Spinal anaesthesia has its unique place in modern anaesthetic practice. In past, most of the surgeries, irrespective of the site of surgery, were performed in general anaesthesia but now in the modern anaesthetic field, spinal anaesthesia has markedly replaced general anaesthesia, specifically in obstetrics, lower limbs, and abdominal surgeries. Methods: A total of 100 patients fit to undergo lower limb surgery between the ages of 20 to 70 years were included in the study. 50 patients were in 0.5% hyperbaric bupivacaine (Group A) while 50 patients were in the 0.75% hyperbaric bupivacaine group (Group B). Patients with a history of allergies to local anaesthetics, ischemic heart disease and contraindications to spinal anaesthesia were excluded. At the end of the injection, the patient was immediately laid down and tilted to 30 degrees lateral on the operative side for unilateral anaesthesia. Mean arterial pressure at baseline, 15, 30, 45 and 60 minutes was recorded by trainee anaesthesia. A baseline was taken of mean arterial pressure measured 15 minutes before induction of spinal anaesthesia in a lying position. Results: The mean baseline arterial pressure of patients in group A was 88.72±1.71 mmHg and in group B was 88.94±1.95 mmHg. Mean arterial pressure MAP at 15, 30, 45 and 60 minutes in both groups was as follows; 86.22±2.55 vs 81.78±1.52 mmHg, 83.72±3.36 vs 75.84±1.34 mmHg, 80.02±3.40 vs 70.90±0.97 mmHg and 77.14±4.24 vs 66.06±1.62 mmHg respectively (p-value <0.05). Conclusion: This study concluded that the hemodynamic parameters in terms of mean arterial pressure remained more stable by deviating less from the baseline value with the use of a low dose of 0.5% hyperbaric bupivacaine instead of 0.75% hyperbaric bupivacaine in patients undergoing lower limb surgery under unilateral spinal anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Many intrathecal adjuvants are being used with local anesthetics to prolong the intraoperative anesthesia and postoperative analgesia. Clonidine and buprenorphine are known to potentiate the effects of local anesthestics. Aims and Objectives: This study was designed to compare the duration of postoperative analgesia as well as duration of sensory and motor block onset, intraoperative hemodynamic changes, and perioperative complications between buprenorphine and clonidine when used as an adjuvant to intrathecal hyperbaric bupivacaine. Materials and Methods: A randomized double-blind study for 80 patients undergoing lower abdominal surgeries and lower limb surgeries was designed with Group B receiving 50 mcg of buprenorphine and Group C receiving 50 mcg of clonidine with 15 mg of hyperbaric bupivacaine 0.5%. Student's t-test and Chi-square were used for comparing the data. Results: The time of onset of duration of post-operative analgesia as well as sensory and motor block was significantly higher in buprenorphine group as compared to clonidine group. In present study, incidence of bradycardia as well as hypotension was significantly higher in group C as compared to group B (P<0.05). Conclusion: Addition of intrathecal buprenorphine and clonidine potentiates the duration of analgesia, sensory and motor block, with buprenorphine has a longer analgesic effect when compared to clonidine. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is used as an adjuvant to local anesthetic agents in spinal anesthesia and is believed to increase quality of sensory and motor blocks. Our aim was to assess the effects of dexmedetomidine as an adjunct on block quality of spinal anesthesia in orthopedic procedures. Methodology: A systematic review of randomized control trials was conducted to assess the effect of intrathecal dexmedetomidine added to local anesthetic agents on the block quality of spinal anesthesia in orthopedic surgeries. PubMed, Google scholar, and Medline databases were searched for randomized controlled clinical trials. Studies met our inclusion criteria, if they used intrathecal 5 µg dexmedetomidine as an additive to 2.5-3 ml (12.5-15 mg) bupivacaine or ropivacaine, and these were included in our meta-analysis. Results: Eight trials comprising 510 patients matched our inclusion criteria. Time to one sensory segment block regression (mean difference 139.72 min; 95% confidence interval (CI) 35.18-244.26; P = 0.009), two sensory segments block regression (mean difference 54.8 min; 95% CI [31.36-78.24]; P < 0.001), and Bromage score of zero (mean difference 93.66 min; 95%CI [30.20-157.12]; P = 0.004) were significantly prolonged in dexmedetomidine group. There were no significant differences between dexmedetomidine group and control group in duration of surgery (P = 0.33) or time till block reaches T10 dermatomal level (P = 0.30). Finally, time to reach Bromage score of III following injection was significantly shorter in dexmedetomidine group (mean difference 2.62 min; 95%CI [-5.12--0.13]; P = 0.04). Conclusion: Dexmedetomidine was found to achieve extended motor and sensory block when needed, bearing in mind higher cost and potential side effects. [ABSTRACT FROM AUTHOR]

Introduction: Hyperbaric bupivacaine (0.5 %) has been the gold standard drug for the safe conduct of spinal anaesthesia in recent times. Various additives have been used along with hyperbaric bupivacaine to prolong the duration of analgesia. Out of these, fentanyl and midazolam have been two of the most commonly used. Here a clinical study was undertaken to compare the effects of intrathecal midazolam and fentanyl as additives to intrathecal bupivacaine for spinal anaesthesia. Aims: To compare the effects of intrathecal midazolam 1mg and fentanyl 25 µg as additives to 3ml of 0.5% hyperbaric bupivacaine (15mg) for spinal anaesthesia with respect to the onset and duration of sensory and motor blockade, duration of effective analgesia, perioperative hemodynamic changes and any side effects of these drugs. Methodology: This is a prospective randomized study studied in 100 patients posted for various elective lower limb, lower abdominal, gynaecological and urological surgeries under spinal anaesthesia. They were randomly divided into two groups, Group A (Midazolam) and Group B (Fentanyl) each consisting of 50 patients in the age group of 18 years to 60 years posted for elective surgeries under spinal anesthesia. Subarachnoid block was administered in L3-L4 intervertebral space. The data collected were statistically analyzed. Results: Addition of 25 µg intrathecal fentanyl to hyperbaric bupivacaine resulted in a statistically significant duration of sensory blockade (Group A; 206.56 min; Group B; 230.06 min) and motor blockade (Group A; 225.56 min; Group B; 251.88 min). The duration of effective analgesia was also significantly longer in group B (Group A; 246.2 min; Group B; 264.32 min). Incidence of hypotension and bradycardia is found to be similar in both groups. There was no significant difference between the two groups with respect to the occurrence of nausea. 4% of people in fentanyl group developed pruritus where as none in midazolam group developed it. None of them had urinary retention, respiratory depression, lower limb weakness or any other neurological deficits. There were no statistical differences in the sedation scores between the two groups. Conclusion: The results suggest that the use of 25 µg intrathecal fentanyl provides longer surgical analgesia, prolongs the duration of sensory and motor blockade, and offers relative hemodynamic stability with minimal side effects. Hence fentanyl is an excellent additive to Bupivacaine for prolangation of spinal anaesthesia. [ABSTRACT FROM AUTHOR]

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Aims: To compare the incidence of hypotension after intrathecal administration of hyperbaric bupivacaine and fentanyl in two different syringes against standard single injection of mixed fentanyl with hyperbaric bupivacaine. Methods: This was a prospective comparative study conducted in 174 parturients undergoing elective caesarean section at Paropakar Maternity & Women's Hospital. Hemodynamic effects and characteristics of block were monitored and recorded and compared between the two groups, group S (single syringe) and group D (double syringe). Results: The incidence of hypotension was almost similar in the two groups but the drop in systolic blood pressure and mean arterial pressure at 5 minutes and 7.5 minutes after subarachnoid block was significant in group S as compared to group D (p<0.005 and p<0.005 respectively). Conclusion: Hyperbaric bupivacaine with fentanyl, which when injected separately without mixing, is associated with lesser incidence of hypotension following subarachnoid block. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia with bupivacaine is very common for infraumbilical surgeries. Various adjuvants are added to it to improve the quality of the block and post-operative analgesia. The study period for this study was from October 2017 to March 2018, and it was a randomized double-blinded prospective observational study. In this study, we aim to compare nalbuphine and MgSO4 (magnesium sulfate) as adjuvant to hyperbaric bupivacaine in terms of sensorimotor blockage characteristics, hemodynamic stability, and postoperative analgesia. Ninety patients of ASA grades I and II, between 18 and 60 years of age of either sex posted for elective infraumbilical surgeries, after approval from the institutional review board and written informed consent, were allocated into 3 groups of 30 patients each. With the help of the randomization table, random numbers were generated, and the randomization was done at the time of giving intrathecal anesthesia. Group A: 3 mL of 0.5% heavy bupivacaine 15 mg + 0.2 mL of 0.9% normal saline to a total volume of 3.2 mL Group B: 3 mL of 0.5% heavy bupivacaine 15 mg + 0.1 mL of 1 mg preservative-free nalbuphine with 0.1 ml of 0.9% normal saline to a total volume of 3.2 mL Group C: 3 mL of 0.5% heavy bupivacaine 15 mg + 0.2 ml of 50% preservative-free (100 mg) magnesium sulfate to a total volume of 3.2 mL The primary outcome was to assess the postoperative analgesia, and the secondary outcome was to assess the perioperative hemodynamic stability and adverse effects during the study period. Results: The onset of sensory and motor blockade was earlier in the nalbuphine group as compared with the other two groups. It was also observed that the duration of postoperative analgesia was longer in the patients who received magnesium sulfate as compared with the patients in the other two groups. Adverse effects (pruritus, nausea, vomiting) were more in the nalbuphine group as compared with the other two groups. Conclusions: In a nutshell, preservative-free intrathecal 1 mg nalbuphine and 100 mg magnesium sulfate both are good adjuvants to hyperbaric bupivacaine. Nalbuphine provides faster sensory and motor onset than magnesium sulfate, whereas magnesium sulfate provides prolonged postoperative analgesia than nalbuphine. [ABSTRACT FROM AUTHOR]

Background: Data related to clinical efficacy of intrathecal dexmedetomidine as an adjuvant to isobaric ropivacaine in spinal anesthesia were found to be inadequate, but the efficacy of newer molecules as an adjuvant is investigated constantly. Considering the favorable profile of dexmedetomidine, it could have a potential role as an adjuvant to ropivacaine. Aims and Objectives: The aim of the study was to evaluate the benefits of adding intrathecal dexmedetomidine as an adjunctive along with ropivacaine. The aim of the study was to assess and compare the safety and efficacy, post-operative analgesia, complications, duration of analgesia, and time of rescue analgesia for intrathecal ropivacaine versus a combination of intrathecal ropivacaine with dexmedetomidine. Materials and Methods: An observational study was carried out in 80 patients of either sex between 25 and 60 years of age, ASA Grade 1 and 2, undergoing elective abdominal, and lower limb surgeries. Subjects selected as per set inclusion/exclusion criteria and divided into two groups for spinal anesthesia. Group A: 3 ml of intrathecal 0.75% isobaric ropivacaine with 0.5 ml of normal saline. Group B: 3 ml of intrathecal 0.75% isobaric ropivacaine with 5 mcg preservative free dexmedetomidine in 0.5 ml of normal saline. Vital parameters were noted at 0 min, 1 min, 2 min, 5 min, 10 min, and thereafter every 15 min, till the surgery continued. Onset and the time for maximum sensory blockade were assessed and VAS scoring was done every 10 min till 30 min and thereafter every 15 min. The duration of effective analgesia was recorded along with the duration of sensory regression to S1, and time for administration of rescue analgesia was noted. Results: The combination of ropivacaine with dexmedetomidine was statistically found to be efficacious when compared to ropivacaine alone, as evidenced by statistically significant differences (P<0.05) in VAS scores at 80, 180, and 360 min and duration of regression to S1 level. The differences in time for rescue analgesia were also statistically significant (P<0.05), further proving the advantage for longer lasting analgesia without any additional adverse effects. Conclusion: 5 mcg dexmedetomidine is an attractive alternative as an adjuvant to spinal ropivacaine in surgical procedures, as opposed to ropivacaine alone, without any additional adverse effects. [ABSTRACT FROM AUTHOR]

Background: Cesarean section contributes to the major part of surgeries taking place in any hospital now a days. Hence, improving anesthesia in cesarean section is of paramount importance. Intrathecal fentanyl can produce rapid, profound analgesia for cesarean section, early labor with minimal side effects. It also has minimal respiratory depressant effect on fetus. Present study was aimed to study pain scores and need for rescue analgesia with intrathecal fentanyl as an adjuvant with 0.5% hyperbaric bupivacaine for cesarean section. Aims and Objectives: Primary Objective was to evaluate intrathecal fentanyl as an adjuvant with 0.5 % hyperbaric Bupivacaine for caesarean section. The secondary objective was to compare onset and duration of sensory and motor blockade as well as to assess pain scores, analgesic requirements and side effects. Materials and Methods: The present study was hospital-based randomized double-blind control study conducted in pregnant women of 18-35 years age, 50-70 kg weight, ASA-II, posted for elective cesarean section. 60 patients were randomly divided into Group I (study group, n=30, receiving 0.5 % hyperbaric bupivacaine 1.6 ml+intrathecal fentanyl 0.4 ml/20 mcg) and Group II (control group, n=30, receiving 0.5% hyperbaric bupivacaine 1.6 ml+0.4 ml normal saline). Results: The difference in mean time for onset of sensory block, onset of motor block, maximum time taken to achieve highest level of sensory analgesia, total duration of motor block, and degree of motor block was statistically insignificant. The difference in mean duration of time to sensory regression was statistically highly significant (P<0.0001). VAS score was used to assess pain postoperatively initially every 5 min then every 30 min up to 5 h. VAS score in post-operative period was less in Group I and difference was statistically significant. Mean Apgar Score at 1 and 5 min were comparable in both the groups with no statistically significant difference. Diclofenac consumption was significantly decreased in Group I as compared to group II. Conclusion: We conclude that the 0.5% hyperbaric Bupivacaine 8 mg with Fentanyl 20 µg is safe, effective, superior for spinal anesthesia, provided more longer duration of analgesia and significantly reduced number of rescue analgesia doses in cesarean section. [ABSTRACT FROM AUTHOR]

Background: Morphine is frequently added to spinal anaesthesia for Caesarean delivery. We aimed to determine whether intrathecal morphine for spinal anaesthesia decreases the risk of chronic postsurgical pain (CPSP).Methods: In this randomised, double-blind, placebo-controlled trial, 290 healthy parturients undergoing elective Caesarean delivery were randomly assigned in a 1:1 ratio to receive either intrathecal morphine 100 μg (n=145) or normal saline (control; n=145) as a part of spinal anaesthesia. Anaesthetic care and postoperative pain management were standardised in all patients. The primary outcome was the incidence of CPSP at 3 months. Secondary outcomes included CPSP at 6 months, pain severity, and pain interference, measured by the Brief Pain Inventory questionnaire using an 11-point numeric rating scale, at 3 and 6 months after the surgery.Results: Two hundred and seventy-six patients completed the 3-month follow-up, 139 in the morphine group and 137 in the placebo group. The incidences of CPSP at 3 months were 19% (27 of 139) in the morphine group and 18% (25 of 137) in the placebo group (odds ratio, 1.08; 95% confidence interval, 0.59-1.97; P=0.803). At 6 months, CPSP was present in 23 of 139 (16%) morphine group patients compared with 19 of 137 (14%) in the placebo group (odds ratio, 1.23; 95% confidence interval, 0.63-2.38; P=0.536). Brief Pain Inventory questionnaire scores for pain severity and pain interference at 3 and 6 months were similar between groups.Conclusions: Administration of morphine 100 μg as a component of spinal anaesthesia for elective Caesarean delivery failed to reduce the incidence of chronic pain at 3 and 6 months after surgery.Clinical Trial Registration: NCT03451695. [ABSTRACT FROM AUTHOR]

Background: Quadratus lumborum block (QLB) was introduced to provide postoperative analgesia. Objective: This randomized controlled, double-blind study aimed to evaluate bilateral posterior QLB for analgesia after cesarean section (CS) using spinal anesthesia without intrathecal morphine. Methods: One hundred ASA-II women with singleton, full-term pregnancy undergoing CS using spinal anesthesia were randomized into 2 groups (Quadratus Lumborum and Control; 50 subjects each). After completing CS, bilateral posterior QLB (20 mL bupivacaine 0.25% on each side) was performed in Quadratus Lumborum group, and bilateral sham procedure was performed in Control group. Results: The median (range) of pain score at rest at 6 h was 2 (1-6) in Quadratus Lumborum group and 5 (2-8) in Control group; median difference (95% CI) was -3 (-3.000007 to -2.99995); P <0.00001. Pain score at rest at 12 h and pain scores on movement at 6 and 12 h were lower in Quadratus Lumborum group. No significant differences in pain scores at rest and pain scores on movement at 24 h were detected between the groups. The number of subjects requesting morphine was smaller, time to the first request of morphine was longer, and total morphine dose was smaller in Quadratus Lumborum group. Patient satisfaction was greater in Quadratus Lumborum group. No significant differences in the incidence of pruritus and nausea/vomiting were detected between the groups. Conclusions: QLB provides adequate postoperative analgesia after CS using spinal anesthesia without intrathecal morphine. [ABSTRACT FROM AUTHOR]

PURPOSE: The purpose of this study is to describe the efficacy and adverse events of neuraxial anesthesia for post-operative pain control in non-ambulatory children with cerebral palsy with pre-existing intrathecal baclofen (ITB) pumps undergoing hip reconstructive or palliative surgery. METHODS: Twelve children (mean age 11.25 years) were included in the study with the following neuraxial anesthesia methods: indwelling epidural catheter (8 patients), neuraxial opioids administered through the side port of the ITB pump (3 patients), and single injection spinal anesthetic (1 patient). Observational pain scores and opioid requirements were quantified for all patients. RESULTS: There were no ITB pump or surgical complications at a mean follow-up of 2.2 years. The average length of stay was 6 days. Patients had good post-operative pain control with a mean observational pain score of 0.7 and mean morphine equivalent use of 0.26mg/kg/day. Four patients required anti-emetics to control nausea and three patients had urinary retention requiring repeat catheterization, but all medical complications resolved prior to discharge. CONCLUSION: Neuraxial anesthesia can effectively control post-operative pain in children with a pre-existing ITB pump. Utilizing the side port of the ITB pump for administration of neuraxial opioids is an option when epidural or spinal anesthesia is not possible. [ABSTRACT FROM AUTHOR]

The article examines that addressing intrathecal morphine (ITM) analgesic outcomes after total joint replacement. Topics include focuses on avoiding ITM until recently because of high opioid-induced nausea and vomiting (OINV) rates in Veterans' Hospital with its use as there is no guidance from recent or preceding antiemetic consensus guidelines addressing antiemetic/antipruritic prophylaxis (AEPPx) for the specific use of ITM.

Objectives. Dexamethasone has been shown to have analgesic properties in the general surgical population. However, the analgesic effects for women that undergo cesarean deliveries under spinal anesthesia remain unclear and may be related to the timing of dexamethasone administration. We hypothesized that intravenous dexamethasone administered before skin incision would significantly reduce postoperative opioid consumption at 24 h after cesarean delivery under spinal anesthesia with intrathecal morphine. Methods. Women undergoing elective cesarean deliveries under spinal anesthesia were randomly assigned to receive 8 mg of intravenous dexamethasone or placebo prior to skin incision. Both groups received a standardized spinal anesthetic and multimodal postoperative analgesic regime. The primary outcome was cumulative opioid consumption at 24 h. Secondary outcomes included cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores at rest and on movement at 2, 24, and 48 h. Results. 47 patients were analyzed—23 subjects that received dexamethasone and 24 subjects that received placebo. There was no difference in the median (Q1, Q3) cumulative opioid consumption in the first 24 hours following cesarean delivery between the dexamethasone group {15 (7.5, 20.0) mg} and the placebo group {13.75 (2.5, 31.25) mg} (P = 0.740). There were no differences between the groups in cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores. Conclusions. Intravenous dexamethasone 8 mg administered prior to skin incision did not reduce the opioid consumption of women that underwent cesarean deliveries under spinal anesthesia with intrathecal morphine and multimodal postoperative analgesic regimen. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia is the most commonly used technique for cesarean section as it is very economical and easy to administer. The short duration of action of local anesthetic drugs has created a matter of concern for anesthesiologists. Aim of the Work: To compare the efficacy of intrathecal dexamethasone with intravenous dexamethasone as an adjuvant to prolong the sensory block obtained by spinal anesthesia and postoperative analgesia in cesarean section. Participants and Methods: 66 pregnant women scheduled for cesarean section were randomly allocated to one of three groups including (22) patients each. All the patients received injection of heavy bupivacaine 0.5% 10 mg through spinal anesthesia, with adding 1 mL of 0.9% saline and normal saline 2 mL intravenously (control group), or 0.5 mL (2mg) dexamethasone diluted in 0.5 ml of 0.9% saline intrathecally with normal saline 2mL intravenously (IT group ), or dexamethasone 2mL (8mg) intravenously with intrathecal injection of heavy bupivacaine 0.5% 2mL plus 1mL of 0.9% saline (IV group ) with overall 3 ml volume intrathecally in each group. Duration of sensory block, postoperative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded. Results: The study groups, There was significantly higher postoperative analgesic duration (8.73 ± 2.64) hours compared to addition of Intravenous Dexamethasone (4.91 ± 1.02) hours or using hyperbaric bupivacaine alone (3.43 ± 0.71) hours with p-value <0.001. There was no effect on the time of onset of sensory block with no significant complications were detected. Conclusion: The addition of 2mg dexamethasone intrathecally as an adjuvant to spinal anesthesia during cesarean section prolong the duration of sensory block and postoperative analgesia. [ABSTRACT FROM AUTHOR]

Background: Selective spinal anesthesia has been safely applied for short-duration outpatient gynecological laparoscopic procedure. However, this anesthesia technique is often inadequate and not tolerated by awake patients due to pneumoperitoneum and visceral manipulation. Aims: We aimed to conduct a study to compare spinal anesthesia with bupivacaine, fentanyl, and i.v. sedation with i.v. sedation and laparoscopic port-site infiltration with local anaesthetic in outpatient laparoscopic tubal ligation procedures. Settings and Design: 100 female patients posted for elective surgeries were recruited for a prospective single blind randomised control trial in a tertiary care center in two groups. Materials and Methods: In Group S, patients receive intrathecal 3 mg hyperbaric bupivacaine 0.5% plus 20 microgram fentanyl along with intravenous (i.v.) fentanyl at 1μg.kg-1.h-1 and in Group C i.v. fentanyl at 1μg.kg-1.h-1 along with laparoscopic port site infiltration with 0.5% bupivacaine. Postoperatively, overall patient satisfaction, visual analog score (VAS) score, duration of motor blockade, sensory blockade, and time to attain discharge criteria and any adverse. Statistical Analysis: Continuous variables between the groups were compared by the independent t-test and Wilcoxon rank sum. Chi-square and Fisher exact test used for the categorical value. Results: Overall VAS was significantly lower and patient satisfaction was higher in Group S than Group C. Time to oral intake was significantly prolonged in Group C 126.33 (±29.54) compared to group S 110.81 (±29.54). The requirement of total rescue analgesia (fentanyl) was significantly higher in Group C 2.0 (±0.6) μg.kg-1 compared to group S 0.79 (±0.53) μg.kg-1. Incidence of postoperative nausea vomiting (PONV) was significantly greater in Group C while incidence of pruritus was significantly greater in Group S. Conclusion: Low-dose intrathecal anesthesia with 3 mg bupivacaine and 20 μg fentanyl provided better analgesia, patient satisfaction and with less opioids consumption. [ABSTRACT FROM AUTHOR]

Introduction: Various adjuvants to local anesthetics are used in spinal anesthesia for improving the quality and prolonging postoperative analgesia. We aim to compare the analgesic efficacy of morphine or dexmedetomidine given intrathecally as adjuvants to isobaric levobupivacaine. Materials and Methods: Seventy patients of age group 18–60 years, American Society of Anesthesiologists 1 and 2 undergoing elective abdominal hysterectomy, were randomized into two groups. Group M received spinal anesthesia with 3 mL of 0.5% isobaric levobupivacaine with 250 μg of preservative-free morphine. Group D received 3 mL of 0.5% isobaric levobupivacaine with 5 μg of dexmedetomidine. Quality of anesthesia, sensory and motor block characteristics, duration of effective analgesia, and incidence of side effects were compared. Results: The time for the first analgesic request was 320.80 ± 41.75 min in the dexmedetomidine group as compared to the morphine group (451.63 ± 38.55 min), P = 0.000. The analgesic requirement in the first 24 h was significantly higher in Group D as compared to Group M, P = 0.000. Adverse effects were similar in both the groups, except pruritus which was seen only in Group M. Conclusion: Our study shows that the use of intrathecal morphine as an adjuvant to isobaric levobupivacaine provides better analgesia than intrathecal dexmedetomidine; however, adverse effects such as nausea and pruritus may be seen. [ABSTRACT FROM AUTHOR]

Background: Many additives have been used to improve spinal anesthesia; morphine and nalbuphine are commonly used drugs. Objective: This work aimed to compare intrathecal morphine and different doses of nalbuphine in elective cesarean section (CS). Patients and Methods: This double-blinded, randomized controlled study was done on 150 patients, American Society of Anesthesiologist (ASA) grade I to II undergoing elective CS. Patients underwent spinal anesthesia 3 ml with 10 mg hyperbaric bupivacaine 0.5 % with the addition of a 1 ml volume (morphine or nalbuphine) according to the group; Group M: 150 µg morphine, Group N1: 1 mg nalbuphine, and Group N2: 2 mg nalbuphine. Results: Intraoperative and postoperative hemodynamics, respiratory rate, SPO2 and Apgar score were insignificantly different in all groups. Postoperative VAS was significantly decreased in group M and was insignificantly different between group N1 and group N2. Postoperative BROMAGE was significantly higher in group M. Time of rescue analgesia was significantly increased in group M and was insignificantly different between group N1 and group N2. Postoperative nausea and vomiting (PONV) was insignificantly different in all groups, and pruritus was significantly decreased in group N1. Conclusions: As additives to hyperbaric bupivacaine in the spinal block, morphine was superior to nalbuphine in decreasing VAS and increased time for rescue analgesia by prolonged sensory block. Increasing the dose of nalbuphine up to 2 mg did not increase the analgesic effect. Nalbuphine is superior to morphine in decreasing pruritus, and both drugs have similar effects on neonatal APGAR score and hemodynamics. [ABSTRACT FROM AUTHOR]

Objectives: To compare effectiveness of low-dose bupivacaine-fentanyl versus conventional dose of bupivacaine in parturients undergoing cesarean section and the frequency of hypotension in two regimens. Study design: Randomized clinical study Place and duration of study: Anesthesiology Department and Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, from July to December 2019. Material and methods: 52-women undergoing cesarean section were randomly allocated into two groups; 26-patients in group-A were given 10 mg bupivacaine, and 26 in group-B, 5 mg bupivacaine-25μg fentanyl. Blood pressure (BP) and heart rate were recorded. Intra-operative pain assessment was done using visual analog scale (VAS). Duration of effective analgesia was taken from the time of intra-thecal injection to a VAS score ≥4. Systolic BP (SBP)<20% of preoperative value was labelled as hypotension. Data was analyzed with SPSS 19. Results: Mean age was 26.19±4.31 years. Th ere was no significant difference among age, weight, height and ASA of patients in two groups (p=0.65, 0.052, 0.19, and 0.39, respectively). Mean baseline SBP, diastolic blood pressure (DBP), and heart rate were not significantly different. Mean final SBP was significantly different (p = 0.006), while no significant difference was seen in DBP and heart rate and duration of surgery (p=0.23, 0.42, 0.23, respectively). Th e duration of analgesia was more prolonged in group-B (p<0.001), and hypotension was significantly higher in group-A (p=0.005). Conclusion: Low-dose intra-thecal bupivacaine and fentanyl provides more effective spinal anesthesia for cesarean section with less hypotensive episodes. [ABSTRACT FROM AUTHOR]

Aim: To compare the effect of bupivacaine and bupivacaine/ fentanyl combination on cerebral oxygenation values with the Near-infrared spectroscopy (NIRS) technique in elective cesarean sections performed under spinal anesthesia. Methods: Fifty patients who underwent cesarean section under spinal anesthesia were randomly divided into two groups. 7.510 mg 0.5% hyperbaric bupivacaine was administered to the bupivacaine group (n=25) and 7.5-10 mg 0.5% hyperbaric bupivacaine+20-25 mcg fentanyl was given to the combination group (n=25). Heart rate, mean arterial pressure, peripheral oxygen saturation, mean values of regional cerebral oxygen saturation after spinal anesthesia were recorded preoperatively and the 1st, 5th, 10th, 15th and 20th minutes after anesthesia. The presence of perioperative nausea and vomiting was assessed with the Verbal Descriptive Scale. Results: Significant difference was observed in mean arterial pressure values between groups (p=0.001). There was a statistically significant change in cerebral oxygenation values during surgery in both groups (p=0.001). The frequency of nausea and vomiting was lower in the combination group (p=0.009). Conclusion: The non-invasive NIRS technique can be safely applied in the monitoring of cerebral oxygenation and hemodynamics in elective cesarean section procedures undergoing spinal anesthesia. [ABSTRACT FROM AUTHOR]

Background: Intrathecal morphine prolongs analgesia after surgery, but has been implicated in postoperative respiratory depression or apnoeic episodes. However, this has not been investigated in a prospective trial using respiratory polygraphy. This randomised controlled triple-blinded trial tested the hypothesis that intrathecal morphine increases sleep apnoea severity, measured using respiratory polygraphy.Methods: Sixty subjects undergoing hip arthroplasty under spinal anaesthesia received either 15 mg isobaric bupivacaine 0.5% with 0.5 ml normal saline 0.9% (control group) or 15 mg isobaric bupivacaine 0.5% with 0.5 ml intrathecal morphine 100 μg (intrathecal morphine group). Respiratory polygraphy was performed before surgery and on the first and third postoperative nights. The primary outcome was the apnoea-hypopnoea index in the supine position (supine AHI) on the first postoperative night. Secondary outcomes included supine AHI on the third postoperative night, oxygen desaturation index (ODI), and ventilatory frequency during the first and third postoperative nights.Results: On the first postoperative night, mean (95% confidence interval) values for supine AHI were 20.6 (13.9-27.3) and 21.2 (12.4-30.0) events h-1 in the control and intrathecal morphine groups, respectively (P=0.90). There were no significant between-group differences for any of the secondary outcomes, except for a significantly higher central and mixed apnoea index preoperatively and significantly lower mean SpO2 on the third postoperative night in the control group.Conclusions: Intrathecal morphine did not increase sleep apnoea severity when measured using respiratory polygraphy. Of note, all patients had an increased number of apnoeic episodes on the third postoperative night.Clinical Trial Registration: NCT02566226. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia is a safe, reliable, and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief, and it also blunts autonomic, somatic, and endocrine responses to surgical stimulus. Aim: The aim of this study was to assess the efficacy 15 μg and 30 μg of intrathecal clonidine along with 3 mL of 0.5% isobaric levobupivacaine in comparison with plain 0.5% isobaric levobupivacaine. Setting and Design: The prospective, interventional, randomized, comparative, double-blinded study was conducted after obtaining approval from the institutional ethical committee. Materials and Methods: Seventy-five patients posted for elective lower-limb orthopedic surgeries were randomly divided into three groups with 25 patients in each group as L (levobupivacaine 0.5%), LC-15 (levobupivacaine 0.5% + clonidine 15 μg), and LC-30 (levobupivacaine 0.5% + clonidine 30 μg). All the patients were given spinal anesthesia using the study drugs, and various parameters were monitored. Statistical Analysis: The three groups were compared statistically using analysis of variance and Student's t-test (independent samples t-test). P < 0.05 was considered statistically significant. Results: There was a statistically significant difference among the three groups with respect to the onset of time for maximum sensory blockade and duration of analgesia. A statistically significant difference was noted among the three groups with respect to the onset of time for maximum motor blockade. Conclusion: Both doses of clonidine produced prolonged sensory block compared to the control. It has been found that 30 μg of clonidine as an adjuvant has produced faster onset and prolonged duration sensory block compared to 15 μg of clonidine. [ABSTRACT FROM AUTHOR]

Background: Intrathecal injection is a rare complication of spinal anesthesia and an underreported complication of epidural blood patches. Although there are other reported cases of intrathecal blood injection, these cases lack confirmatory imaging and others report injection of mixed blood with other agents.Case Presentation: We present a case report of post-laminectomy cerebrospinal fluid leak who underwent epidural blood patch placement. CT and MRI brain imaging was obtained, depicting intrathecal blood products. The patient had subsequent seizures and respiratory distress, received supportive care, and returned to baseline after several days.Conclusion: The patient's clinical course illustrates the potential complications of blood products within CSF, including seizures and respiratory distress, which improved with supportive care in this case. Importantly, to our knowledge, this is the only report that clearly depicts injection of purely blood products, without other confounding agents (such as gadolinium), into intrathecal space and with diffuse spread through the CSF as visualized on CT and MRI imaging. [ABSTRACT FROM AUTHOR]

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg-1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1-8 [-60% to 50%]) vs. 13% (5-24 [-6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1-7 [0-41 mg]) vs. 15 mg (12-20 [8-61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1-6 [0-9]) vs. 5 (3-7 [0-9]), p = 0.001; less bladder spasms (NRS 1 (0-2 [0-10]) vs. 2 (0-5 [0-10]), p = 0.001 and less sedation; NRS 2 (0-3 [0-10]) vs. 3 (2-6 [0-10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1-7 [0-10]) vs. 0 (0-1 [0-10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy. [ABSTRACT FROM AUTHOR]

Background: Regional anesthesia is the preferred technique for most of lower abdominal and lower limb surgeries as it allows the patient to remain awake and minimize the problems associated with airway management. Hyperbaric bupivacaine 0.5%, although extensively used for spinal anesthesia, has a limitation of short duration. The addition of fentanyl, a synthetic lipophilic opioid, is known to prolong postoperative analgesia. Aims: We aimed to study the effect of the addition of different doses of fentanyl to hyperbaric bupivacaine about hemodynamic changes, the extent of sensory and motor block, duration of analgesia, and complications that occur during the procedure. Settings and Design: This study was a prospective, comparative, randomized, and double-blind study. Materials and Methods: Patients were randomly allocated to three groups of 30 each. Group I (n [number of patients] = 30) received bupivacaine 0.5% heavy 2.0 mL diluted up to 2.5 mL with normal saline. Group II (n = 30) received bupivacaine 0.5% heavy 2.0 mL and fentanyl 20 μg diluted up to 2.5 mL with normal saline, and Group III (n = 30) received bupivacaine 0.5% heavy 2.0 mL and fentanyl 50 μg diluted up to 2.5 mL with normal saline. Statistical Analysis: The data were analyzed using Chi-square and Student's t-test. Results and Conclusions: The onset of sensory and motor block was early in Group III in comparison to Group I and Group II (P < 0.05). The duration of analgesia was significantly longer in Group III, followed by Group II, and least in Group I. None of the patients in Groups I and II had any complications such as hypotension, nausea, vomiting, bradycardia, and pruritus. However, the incidence of hypotension, nausea, and pruritus was more in Group III. 2 mg intrathecal bupivacaine with 20 μg fentanyl provides reliable and satisfactory sensory and motor block without increasing the incidence of side effects. [ABSTRACT FROM AUTHOR]

Background: In recent years, several adjuvants have been used to prolong the duration of the subarachnoid block. These adjuvants have either been used via intrathecal route or intravenous (i.v.) route. Dexmedetomidine and clonidine have been used as adjuvants to local anesthetic drugs by intrathecal, epidural, caudal, and i.v. routes and for peripheral nerve blocks. In this study, we endeavored at finding the efficacy of dexmedetomidine and clonidine in improving the analgesia quality and duration of the subarachnoid block. Setting and Design: A prospective, double-blind, randomized control trial comprising 70 subjects posted for elective lower limb surgeries. Materials and Methods: Seventy patients were selected at random and were allocated to two groups (Group C and Group D) of 35 each. In Group C, the patients received isobaric ropivacaine with clonidine 1.0 μg.kg−1 intravenously. In Group D, the patients received isobaric ropivacaine with dexmedetomidine 0.5 μg.kg−1 intravenously. Perioperatively, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation were recorded and documented every 5 min till the end of surgery. Time of onset, level of sensory blockade, and duration of sensory blockade were recorded. Motor block was assessed using modified Bromage scale. Data validation and analysis were carried out by SPSS version 16. A P < 0.05 was considered statistically significant. Results: Time of onset of sensory block in Dexmedetomidine group and Clonidine group was 2.70 ± 1.25 minutes and 3.50 ± 1.23 minutes respectively (P = 0.021). Time of onset of motor block in Dexmedetomidine group and Clonidine group was 3.55 ± 1.60 minutes and 4.30 ± 1.45 minutes respectively (P = 0.034). Time for 2 segment regressions of sensory block in Dexmedetomidine group and Clonidine group was 140.30 ± 12.32 minutes and 125.65±14.33minutes respectively (P = 0.047). Time of regressions of motor blockade to Bromage Scale 1 in Dexmedetomidine group and Clonidine group was 148.65 ± 15.23 minutes and 129.70 ± 19.35 minutes respectively (P = 0.032). Conclusion: The use of i.v. dexmedetomidine perioperatively prolongs the duration of sensory and motor block significantly when compared to i.v. clonidine. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to assess the dose-related efficacy of intrathecal dexmedetomidine (DEX) on hemodynamic parameters and block characteristics following ropivacaine (ROP) spinal anesthesia (SA) for cesarean section (CS). Methods: This was a double-blind trial conducted on four groups namely D2.5, D5, D7.5, and placebo. One hundred and twenty patients scheduled for nonemergency CS under SA were recruited and randomized into four groups. The first to fourth groups received 2.5 µg, 5 µg, and 7.5 µg of intrathecal DEX and 1.5 mL normal saline, respectively, in addition to ROP for SA. Blood pressure (BP), heart rate (HR), arterial blood saturation, sensory motor block, and pain score were recorded. Results: The lowest BP/HR was observed in D7.5 group (P < 0.05). Moreover, the onset and duration of sensory motor block were shorter (P = 0.0001) and showed the lowest level of pain (P = 0.0001) in D7.5 group. Decrease in BP, HR, and pain score was observed with increasing dose of DEX, whereas the onset of sensory motor block and the time to achieve sensory motor block to ≥T6 declined with increasing the dose of DEX. Conclusion: The 7.5-µg intrathecal DEX is recommended to use for stabling the hemodynamic parameters and block characteristics following ROP SA for CS. However, likely complications such as fall in both HR and BP should be taken into account simultaneously. [ABSTRACT FROM AUTHOR]

Background and Aims: The temperature of the local anesthetics may affect the distribution of spinal anesthesia. The aim of the current study is to compare the effects of different degrees of intrathecal levobupivacaine 0.5% on the spinal anesthesia characteristics and shivering in orthopedic surgery. Materials and Methods: A randomized, prospective, and controlled trial was conducted on 120 patients aged 40–70 years with American Society of Anesthesiologists Classes I and II and who scheduled for orthopedic surgery; they were randomly distributed into three groups: Group 1 (L 24°C) – levobupivacaine 0.5% warmed to 24°C; Group 2 (L 30°C) – levobupivacaine 0.5% warmed to 30°C; and Group 3 (L 37°C) – levobupivacaine 0.5% warmed to 37°C. Every patient had received 3 mL of 0.5% levobupivacaine intrathecally. Sensory blockade was tested using the loss of pinprick sensation, whereas the motor block was tested using the modified Bromage scale. The onset and grading of shivering after spinal anesthesia were recorded. Results: The use of intrathecal levobupivacaine 0.5% warmed to either 30°C or 37°C resulted in a significant acceleration of the onset of either sensory or motor blockade with a significant prolongation in the duration in addition to significant delay in the onset of shivering and the time of the first analgesia requirement in comparison to those of spinal anesthesia with levobupivacaine at room temperature (24°C). Notably, a nonsignificant difference in the spinal block characteristics and shivering was observed between Group L 30°C and Group L 37°C. Conclusion: The increasing the temperature of levobupivacaine 0.5% to 30 °C attains more rapid onset of sensory and motor blocks ,with prolongation of the onset of shivering. It could be considered as effective equivalent to warming levobupivacaine 0.5%to 37°C in spinal anesthesia. [ABSTRACT FROM AUTHOR]

Prilocaine is widely used for spinal anesthesia. Its intermediate effect makes it a valuable choice for one-day surgery. The duration of the motor blockade (DMB) may have an impact on the length of stay. The goal of this study was to establish a correlation between the DMB and different parameters (hyperbaric prilocaine dose, puncture level, surgical position, age, patient weight, and patient height). We prospectively enrolled adult patients scheduled for ambulatory surgery (n = 384). Univariate and multivariate regressions (backward stepwise) were applied. A P value lower than 0.05 was considered significant. We performed first analyzes on the entire population. We achieved same on a subgroup only composed of patients who received 60 mg of hyperbaric prilocaine between L4 and L5 and staying on dorsal position during surgery. The univariate analyses of the entire population demonstrate a significant correlation between DMB and 1) the prilocaine dose (P < 0.001), and 2) the BMI (P = 0.011). On the same population, the multivariate analyses confirm these two independent parameters correlated to the DMB: the patient height (P = 0.03) and the hyperbaric prilocaine dose (P < 0.001). The second analyses performed on the subgroup (n = 65), demonstrate a wide variability in the DBM (mean ± SD): 90.12 ± 30.36 minutes. For this concern, univariate analyses illustrate that only the patient height was significantly correlated to the DMB (P = 0.005). The multivariate analyses confirm that patient height could be considered as an independent parameter of DBM (P = 0.005). Within our entire population, there exists a considerable variation in the duration of the motor block after a unique injection of hyperbaric prilocaine. The prilocaine dose and the patient height were the only independent factors of the extension of the DMB. However, this relation is extremely weak and only allows explaining the variability of the DMB in a minority of the patients. This unknown pharmacological property of hyperbaric prilocaine could restrict its use for day-care surgery. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that sequential intrathecal injection of fentanyl and hyperbaric bupivacaine for cesarean section (CS) anesthesia provides a superior anesthetic effect than use of bupivacaine alone, and prolongs postoperative analgesia. Herein, we investigated whether rapid intrathecal injection of fentanyl followed by slow injection of hyperbaric bupivacaine affects the duration of postoperative analgesia, the effectiveness of anesthesia, and hemodynamic status. Methods: Fifty-six parturients with American Society of Anesthesiologists physical status I or II, aged 18-40 years, and scheduled to undergo elective CS were randomly assigned to 2 groups of 28 patients each. The normal sequential group received sequential intrathecal injections of fentanyl and hyperbaric bupivacaine at the same rate, each with a 5 ml syringe. The rapid sequential group received a rapid intrathecal injection of fentanyl with an insulin syringe, followed by a slow injection of hyperbaric bupivacaine with a 5 ml syringe. The onset of sensory block, the timing of the first rescue analgesia, the doses of rescue analgesics, the degree of postoperative pain, the onset and duration of motor block, the incidence and duration of hypotension, and spinal anesthesia-related complications were recorded. Results: While both approaches had comparable spinal anesthesia-related complications, incidence and duration of hypotension, and doses of ephedrine, the rapid sequential group exhibited a more rapid onset of sensory block, a higher sensory level, and more prolonged postoperative analgesia. Conclusions: Rapid sequential injection of fentanyl and hyperbaric bupivacaine produced superior anesthesia and more prolonged postoperative analgesia than sequential injections of both at the same rate. [ABSTRACT FROM AUTHOR]

Objectives: Transdermal nitroglycerin patch is being used as an adjuvant to neostigmine for postoperative analgesia, besides its vasodilator effects on cardiovascular system. We aimed to evaluate the transdermal nitroglycerin for its capability to enhance analgesia when used as an adjuvant to intrathecal neostigmine and bupivacaine in elective lower abdominal surgeries. Methodology: We enrolled 60 adult ASA-1 and 2 patients undergoing lower abdominal surgeries under spinal anesthesia. In this double blind randomized study, patients were assigned into two groups, Group NT received transdermal nitroglycerin patch (5 mg/24 h) and Group NE received placebo patch along with 5 μg of neostigmine and 15 mg of 0.5% hyperbaric bupivacaine. Spinal anesthesia was performed at L3-L4 level, with 25 gauge spinal needle and 3.5 ml of the drug solution was injected intrathecally per the group allocation. Sensory block was checked using pin prick method and motor block was assessed by modified Bromage scale. Pulse rate, blood pressure and SpO2 were monitored. Intra-operative complications were noted. Sample size was calculated to be 60 with a total of two groups with alpha of 0.05 and a power of 90 %. Test for analysis among two groups was done by ANOVA for quantitative and Chi‑square test for qualitative data. A p < 0.05 was considered as significant. Results: The characteristics of intraoperative block were comparable among two groups. The mean duration of analgesia in Group NT was significantly longer (p < 0.001) than in Group NE (476.9 ± 17.3 vs. 386.9 ± 17.2 min respectively). Group NE had higher VAS scores and the number of rescue analgesic requirement was significantly more in Group NE as compared to Group NT. Hemodynamic changes remained insignificant in both groups. Incidence of side effects were not significant in both the groups. Conclusion: We conclude that the transdermal nitroglycerin used as an adjuvant to intrathecal neostigmine and bupivacaine prolongs postoperative analgesia. [ABSTRACT FROM AUTHOR]

Previous case series on diagnostic lumbar punctures and spinal anesthetics in infants document comparatively high rates of traumatic or unsuccessful procedures; the latter is known as a "dry tap."1 Several studies have reported a first pass success rate of only around 60%.2 The thecal sac in quite narrow in-term and preterm newborns. Ultrasound-guided "saline myelogram": Confirmation of intrathecal drug delivery despite "dry tap" in infants for spinal anesthesia and spinal therapeutics Panels A and B represent two simulated perspectives of how the needle, ultrasound probe, and proceduralist are positioned in relation to each other gl Our 4 cases included 2 spinal anesthetics and 2 lumbar punctures in the same infant for administration of nusinersen. [Extracted from the article]

Objectives: Improvements in perioperative pain management for lower abdominal ' operations has been shown to reduce morbidity, induce early ambulation, and improve patients' long-term outcomes. Dexmedetomidine, a selective alpha-2 agonist, has recently been used intrathecally as adjuvant to spinal anesthesia to prolong its efficacy. We compared two different doses of dexmedetomidine added to hyperbaric bupivacaine for spinal anesthesia. The primary endpoints were the onset and duration of sensory and motor block, and duration of analgesia. Methods: A total of 100 patients, aged 35-60 years old, assigned to have elective abdominal hysterectomy under spinal anesthesia were divided into two equally sized groups (D5 and D10) in a randomized, double-blind fashion. The D5 group was intrathecally administered 3ml 0.5% hyperbaric bupivacaine with 5 µg dexmedetomidine in 0.5ml of normal saline and the D10 group 3ml 0.5% bupivacaine with 10µg dexmedetomidine in 0.5ml of normal saline. For each patient, sensory and motor block onset times, block durations, time to first analgesic use, total analgesic need, postoperative visual analogue scale (VAS) scores, hemodynamics, and side effects were recorded. Results: Although both groups had a similar demographic profile, sensory and motor block in the D10 group (p<0.050) was earlier than the D5 group. Sensory and motor block duration and time to first analgesic use were significantly longer and the need for rescue analgesics was lower in the D10 group than the D5 group. The 24-hour VAS score was significantly lower in the D10 group (p< 0.050). Intergroup hemodynamics were comparable (p>0.050) without any appreciable side effects. Conclusions: Spinal dexmedetomidine increases the sensory and motor block duration and time to first analgesic use, and decreases analgesic consumption in a dose-dependent manner. [ABSTRACT FROM AUTHOR]

Study objectives: We compared effect of intrathecal bupivacaine versus bupivacaine Design: This is a prospective, randomized, double-blinded study. Setting: The setting is at an operating room in Ain Shams University Hospital. Patients: 50 patients scheduled for general anesthesia were randomly allocated to the following 2 groups in equal numbers. Interventions: Spinal anaesthesia will be performed in the sitting position at L3-L4 or L4-L5 level using a 25-gauge Quincke spinal needle by the most competent experts. The sensory block level will be assessed along the mid-clavicular line bilaterally. The motor block will be assessed according to Bromage scale Measurements: Post operative (VAS) score and Time to first requested analgesia.(primary outcome), Systolic blood pressure, diastolic blood pressure, mean blood pressure and heart rate will be recorded every 5 minutes for 20 minutes then every 15 minutes till the end of surgery, Nausea and/ or vomiting as yes/no, Level of highest sensory block, Bromage score )3, Onset of sensory block and Two segment regression time (secondary outcomes) were recorded.. Main results: Results of this study showed that the addition of dexmedetomidine to bupivacaine in spinal anaesthesia significantly prolonged both sensory and motor blockades duration compared with bupivacaine alone. They also prolonged the time of postoperative analgesia as evidenced by significantly longer time to first rescue analgesia and lower NRS scores with minimal adverse effects and haemodynamic stability. Conclusions: We concluded that intrathecal dexmedetomidine increases the duration of analgesia and reduces postoperative pain without changes in the hemodynamic parameters and adverse side effects. It can be considered as an appropriate adjuvant to intrathecal local anesthetics for lower abdominal surgeries. [ABSTRACT FROM AUTHOR]

Study Objective: Previous studies have shown that prophylactic norepinephrine infusion is superior to intermittent bolus administration in preventing post-spinal hypotension. Nevertheless, it is still controversial whether manually-controlled variable-rate infusion is more effective than fixed-rate infusion. The purpose of the present study was to compare the efficacy of variable-rate infusion and fixed-rate infusion of norepinephrine for prophylaxis against maternal hypotension and maintaining hemodynamic stability during spinal anesthesia for cesarean delivery to determine more effective mode for clinical practice.Design: A prospective randomized, controlled study.Setting: Operating room, Women's Hospital, Zhejiang University School of Medicine.Patients: A total of 161 parturients scheduled for elective cesarean delivery with spinal anesthesia were randomized into Group F (fixed-rate infusion) and Group V (variable-rate infusion).Interventions: Parturients received prophylactic norepinephrine infusion concurrent with the intrathecal injection at rate started at 0.05 μg/kg/min. In Group F, norepinephrine was administered continuously at a fixed (on-off) rate, and a bolus of norepinephrine 5 μg or 10 μg was given when systolic blood pressure (SBP) decreased by 20% or more of baseline. In Group V, manually adjusted norepinephrine infusion within the range 0-0.14 μg/kg/min, according to SBP at 1-min intervals until delivery, aim to maintain values close to the baseline.Measurements: During the study period, the incidence of maternal hypotension, hemodynamic performance, the number of physician interventions, reactive hypertension, bradycardia, nausea, vomiting, norepinephrine cumulative dose (before delivery), and neonatal outcomes were recorded.Main Results: The incidence of maternal hypotension was significantly lower in Group V than that in Group F (9% versus 30%) (P < 0.001). No significant difference was found in the serial changes in SBP and heart rate (HR) for the first 15 min. Group V showed higher frequency of physician interventions compared with the Group F (P < 0.001). The incidence of hypertension, severe hypotension, nausea, vomiting, bradycardia, norepinephrine cumulative dose, and neonatal outcome were comparable between the two groups.Conclusion: When norepinephrine was infused at an initial dose of 0.05 μg/kg/min for preventing hypotension during spinal anesthesia for cesarean delivery, due to technical limitations of inadequate dose design in this study, neither a variable-rate infusion (need more physician intervention) nor a fixed-rate infusion regimen (experience more transient hypotension) was optimal. However, in terms of clinical importance, how to prevent the parturients from experiencing more incidence of hypotension might be a greater concern for anesthesiologists. [ABSTRACT FROM AUTHOR]

Regional anesthesia is widely used to perform different surgical procedures including those performed on the extremities. In this study, the anesthetic effects of adding intrathecal neostigmine or magnesium sulphate to bupivacaine in patients under lower extremities surgeries were assessed. Materials and Methods: In this double‑blind randomized clinical trial, 90 patients, candidate for lower extremities surgeries in a training hospital, were recruited. The patients with ASA class I and II aging from 20 to 65 years between 2009 and 2010 were evaluated. The selected patients were randomly assigned to receive either bupivacaine alone (Group A, n =30), or bupivacaine plus magnesium sulphate 50% (Group B, n =30), or bupivacaine plus neostigmine (Group C, n =30). Then sensory and motor onset and complete block and the time of recovery were measured. Results: The sensory block onset time were 3.03 ± 0.981 in group A, 3.90 ± 2.71 in group B and 3.7 ± 1.08 in group C and knee flexion time were not significantly different among the three groups ( P > 0.05), whereas the time to complete motor block was significantly longer in group C and motor recovery time were significantly different between groups ( P =0.001). Conclusions: According to the obtained results, it may be concluded that magnesium sulphate is a safe and effective adjuvant for increasing the onset time of motor block. [ABSTRACT FROM AUTHOR]

Despite compelling evidence for the safety and efficacy of intrathecal hydromorphone, the use of this opioid intrathecally for the pain management of patients undergoing cesarean delivery has not been widely accepted. The purpose of this retrospective study was to compare the reported efficacy and safety of pain management in women who received intrathecal hydromorphone (100 µg) vs in women who received intrathecal fentanyl (25 µg) or a local anesthetic for their cesarean delivery. The author hypothesized that intrathecal hydromorphone because of its known pharmacodynamics would provide better postoperative analgesia within the first 24 hours after cesarean delivery. The results of this retrospective chart review confirmed the hypothesis that intrathecal hydromorphone possesses the appropriate pharmacodynamics to facilitate optimal pain relief in patients undergoing cesarean delivery. It provided a comparable onset of effective pain relief, as well as a significantly prolonged duration of pain relief (P < .001) compared with intrathecal fentanyl or local anesthetic. Traditionally, intrathecal morphine was the opioid of choice for prolonged pain management during cesarean deliveries in which spinal anesthesia was selected. However, intrathecal hydromorphone was shown to be an effective and possibly even better substitute. Further research on intrathecal hydromorphone is needed. [ABSTRACT FROM AUTHOR]