Senthil Kumar, A (2010) Effect of Combined Spinal and Epidural Magnesium on the Analgesic requirements of Patients Undergoing Lower Limb Orthopedic Surgeries. Masters thesis, Stanley Medical College, Chennai.
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Abstract
INTRODUCTION: Regional anaesthesia is a safe, inexpensive technique with the advantage of prolonged postoperative pain relief. Effective treatment of postoperative pain blunts autonomic, somatic, and endocrine responses. It has become a common practice to use a polypharmacological approach for the treatment of postoperative pain, because no drug has yet been identified that specifically inhibits nociception without associated side effects. Magnesium is the fourth most plentiful cation in the body. It has anti-nociceptive effects in animal and human models of pain. These effects are primarily based on the regulation of calcium influx into the cell, that is natural physiological calcium antagonism and antagonism of N-methyl-D-aspartate receptor. It has been reported that intrathecal magnesium enhances opioid anti-nociception in an acute incisional model. These effects have prompted the investigation of magnesium as an adjuvant for postoperative analgesia. There are studies concerning different routes of magnesium administration such as i.v or intrathecally or epidurally that improve anaesthetic and analgesic quality. This study is designed to assess the effectiveness of using intrathecal and epidural magnesium (Mg) in reducing intra and post operative analgesic requirements and to compare the quality of analgesia of intrathecal bupivacaine-fentanyl-magnesium mixture with intrathecal bupivacaine-fentanyl mixture. AIMS AND OBJECTIVES: 1. To assess the effectiveness of using intrathecal and epidural magnesium (Mg) in reducing intra and post operative analgesic requirements. 2. To compare the quality of analgesia of intrathecal bupivacainefentanyl- magnesium mixture with intrathecal bupivacaine-fentanyl mixture. 3. To evaluate the hemodynamic response of intrathecal and epidural magnesium. MATERIALS AND METHODS: Patient Selection: The study population consist of 40 ASA I & ASA II patients in the age group of 18 years to 65 years admitted to undergo elective orthopaedic lower limb surgeries at Govt. Stanley Hospital, Chennai during the period of May 2009 to August 2009. After getting approval from the institutional ethical committee and after obtaining written informed consent from each patient, the study was conducted. Inclusion criteria: 1. Age Group 18 – 65 years, 2. ASA I and ASA II, 3. Elective orthopaedic lower limb surgeries, 4. Duration of Surgery between 1:00 to 2:30 hours. Exclusion criteria: 1. Patient refusal, 2. Patients with preexisting renal problems, 3. Allergy to any of the study medications, 4. Preoperative hypotension, 5. Local infection at lumbar area, 6. Pre-existing neurological disorders, 7. Coagulation defects and patient on anticoagulants. STATISTICS AND ANALYSIS: 40 Patients were allocated randomly into two equal groups (20 in each group). Group P (placebo) received intrathecal 10 mg of hyperbaric bupivacaine 0.5% (2 ml) plus 25 μg of fentanyl (0.5 ml) plus 0.9% NaCl solution (1 ml). Total intrathecally injected volume is 3.5 ml. Epidural infusion of 0.9% NaCl solution is given in first hour of surgery at the rate of 5 ml/hr. Group M ( Magnesium) received intrathecal 10 mg of hyperbaric bupivacaine 0.5% (2 ml) plus 25 μg of fentanyl (0.5 ml) plus 50 mg of 5% magnesium sulphate (1 ml). Total intrathecally injected volume is 3.5 ml. Epidural infusion of 2 % magnesium sulphate is given at the rate of 100 mg/hr (5 ml/hr) during first hour of surgery. A standard anaesthetic technique was followed in all patients. The patient were assessed by the same observer in the postoperative period. All the data were expressed as mean ± standard deviation (SD). Qualitative variables were compared with `Chi-square test’ and quantitative variables were compared with ‘the student ‘t’ test’. The level of statistical significance was set at P < 0.05. SUMMARY: This randomized control study was designed to assess the effectiveness of using intrathecal and epidural magnesium (Mg) in reducing intra and post operative analgesic requirements and to compare the quality of analgesia of intrathecal bupivacaine-fentanyl-magnesium mixture with intrathecal bupivacaine-fentanyl mixture. Forty ASA I & II patients undergoing elective orthopaedic lower limb surgical procedure under epidural anaesthesia were randomly allocated into one of the two groups. Group P (placebo) received intrathecal 10 mg of hyperbaric bupivacaine 0.5% (2 ml) plus 25 μg of fentanyl (0.5 ml) plus 0.9% NaCl solution (1 ml) . Total intrathecally injected volume is 3.5 ml. Epidural infusion of 0.9% NaCl solution is given in first hour of surgery at the rate of 5 ml/hr. Group M (Magnesium) received intrathecal 10 mg of hyperbaric bupivacaine 0.5% (2 ml) plus 25 μg of fentanyl (0.5 ml) plus 50 mg of 5% magnesium sulphate (1 ml). Total intrathecally injected volume is 3.5 ml. Epidural infusion of 2 % magnesium sulphate is given at the rate of 100 mg/hr (5 ml/hr) during first hour of surgery. Pain in the post-operative period was assessed using a verbal rating scale (VRS). Time of first rescue analgesic (TFA) and the supplementary analgesic doses required for 24 hours were noted for the two groups. Pain score were significantly less in Group M at 2, 4, 6, 8, 12, 24, 48 hours (P <0.05) than in group P. Overall pain score over 48 hours period also revealed better pain relief in group M (P<0.05) as compared to Group P. Time of first rescue analgesic (TFA) in group M was significantly prolonged compared with group P. The postoperative analgesic consumption was also significantly less in group M than in group P. The incidence of hypotension did not differ significantly between the two groups & there was no bradycardia in both the groups. So this study demonstrates that addition of magnesium to bupivacaine-fentanyl mixture definitely improves the quality of analgesia by reducing the overall pain score, prolonging the duration of the time of first rescue analgesia and causing reduction of total analgesic consumption in the postoperative period without any hemodynamic instability. CONCLUSION: 1. Single dose administration of intrathecal and epidural magnesium to intrathecal bupivacaine-fentanyl mixture provides effective postoperative analgesia in patients undergoing elective orthopaedic lower limb surgeries, without any hemodynamic instability. 2. Epidural magnesium significantly reduces the postoperativeanalgesic requirements.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Combined Spinal and Epidural Magnesium ; Analgesic requirements ; Patients ; Undergoing Lower Limb Orthopedic Surgeries. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 22 Apr 2018 16:14 |
| Last Modified: | 28 Apr 2018 16:19 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7251 |
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