Sathishakumar, K (2011) Comparative study for the purpose of safety and efficacy of 0.5% Ropivacaine without Epinephrine, 0.5% Ropivacaine with Epinephrine and 0.5% Bupivacaine in patients receiving Subclavian Perivascular Brachial Plexus Block. Masters thesis, Stanley Medical College, Chennai.
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Abstract
INTRODUCTION: Peripheral nerve blocks are gaining widespread popularity for perioperative pain management because of their distinct advantages over general and central neuraxial anesthesia. Pain relief with peripheral nerve block (PNB) is devoid of side effects such as somnolence, nausea, vomiting, hemodynamic instability and voiding difficulties inherent to general and central neuraxial anesthesia. Brachial plexus blocks (interscalene, supraclavicular and axillary blocks) provide a useful alternative to general anesthesia for upper limb surgery. Each of these routes has its own particular advantages, disadvantages and complications. They achieve ideal operating conditions by producing complete muscular relaxation, maintaining stable intraoperative hemodynamic, and the associated sympathetic block. The sympathetic block decreases postoperative pain, vasospasm and edema. Supraclavicular perivascular brachial plexus block is a very commonly practised technique in patients undergoing surgery on forearm and hand. Supraclavicular block as opposed to infraclavicular brachial plexus block generally offers denser and complete upper limb anaesthesia. Nerve stimulators are now widely seen as useful aids in nerve blocks. Its use avoids paraesthesia, decreases the chance of nerve injury and gives high success rate. Introduction of long acting local anesthetic with better safety profile as well as better equipment has further increased the usage of peripheral nerve blocks. Bupivacaine hydrochloride, a long acting local anaesthetic agent, has been used extensively for supraclavicular brachial plexus block. Ropivacaine, the S- enantiomer of S-1-propyl-2,6-pipecoloxylidide, is an amino-amide local anaesthetic with chemical structure similar to that of bupivacaine. Ropivacaine is a potent blocker of A delta and C fibres (pain fibres). It has been reported to be less toxic than Bupivacaine. In contrast to Bupivacaine which is a racemic mixture of R and S enantiomers, Ropivacaine is the first local anesthetic that has developed as a pure enantiomer. S enantiomer is considered less neurotoxic and cardiotoxic than the R enantiomer of local anesthetics, perhaps reflecting different pharmacodynamics, pharmacokinetics and toxicities. Studies have shown that Ropivacaine and Bupivacaine when given in equal volumes was similar in terms of onset and duration of sensory block and frequency of motor block. The addition of epinephrine does not prolong the duration of Ropivacaine in subclavian perivascular brachial plexus27-28 or epidural block. Low concentrations of Ropivacaine may produce clinically significant vasoconstriction which is not further increased by the addition of epinephrine. This study attempts to compare the safety and efficacy of 0.5% Ropivacaine without epinephrine and 0.5% Ropivacaine with epinephrine and 0.5% Bupivacaine in patients receiving subclavian perivascular brachial plexus block. AIM OF THE STUDY: To study the efficacy and safety of 0.5% Ropivacaine without epinephrine and 0.5% Ropivacaine with epinephrine and 0.5% Bupivacaine in patients receiving subclavian perivascular brachial plexus block. MATERIALS AND METHODS: This is a prospective randomized double blinded study conducted at Government Stanley Hospital, attached to Stanley Medical College, Chennai from April 2010 to October 2010 after approval by the departmental dissertation committee and the hospital’s ethical committee. Seventy five patients of ASA grade I or II of either sex undergoing plastic surgery (both elective and emergency) on forearm or hand were randomly allocated into three groups. Each group comprises of 25 patients. Inclusion criteria: 1. Age 18 - 45 yrs, 2. Sex (Male/ Female), 3. Weight (50-65 kg), 4. ASA grade I & II scheduled to undergo forearm and hand surgery under subclavian perivascular brachial plexus block. Exclusion criteria: 1. Coagulopathy, 2. Infection at the puncture site, 3. Hypertension, 4. Diabetes mellitus, 5. Allergy to amide local anesthetics, 6. Pregnancy, 7. Severe pulmonary pathology, 8. Mental incapacity or language barrier, 9. BMI more than 35, 10. Anatomical variations. SUMMARY: This prospective randomized double blind study compared the safety and efficacy of 0.5% ropivacaine without epinephrine, 0.5% ropivacaine with epinephrine (1:2,00,000) and 0.5% bupivacaine in patients receiving subclavian perivascular brachial plexus block using nerve locator for surgeries on forearm and hand( both elective and emergency). Seventy five patients are included in the study, they are divided in to three groups. 1. Group I (n=25) receiving 30 ml 0f 0.5% ropivacaine without epinephrine. 2. Group II (n=25) receiving 30 ml of 0.5% ropivacaine with epinephrine. 3. Group III (n=25) receiving 30 ml of 0.5% bupivacaine. After local anesthetic injection following parameters are observed. 1. Time of onset of sensory block. 2. Time of onset of motor block. 3. Duration of sensory block. 4. Duration of motor block. 5. Vital parameters. All the three groups are comparable in the distribution of age, sex and weight. The onset and duration of sensory block did not differ significantly between the groups. Similarly there is not statistically significant difference between the groups in onset and duration of motor block. The addition of epinephrine did not significantly affect the onset and duration of sensory and motor block of 0.5% ropivacaine. No hemodynamic instability is observed after the block in all the groups during the study period. There is no evidence of cardiovascular or central nervous system toxicity in the study groups with the dose of local anesthetic used in our study. Hence, Ropivacaine, a relatively new local anesthetic at a concentration of 0.5% is equally effective as 0.5% Bupivacaine. With the theoretical advantage of lesser cardiotoxicity than Bupivacaine, Ropivacaine may probably be a more safer drug than Bupivacaine in patients receiving subclavian perivascular brachial plexus block. CONCLUSION: In conclusion, 0.5% ropivacaine and 0.5% bupivacaine are found to be equally efficacious in terms of onset and duration of sensory and motor block for subclavian perivascular brachial plexus block. The addition of epinephrine to ropivacaine does not reduce the onset time or prolong the duration of sensory and motor block. There is no evidence of cardiovascular or central nervous system toxicity in all groups with the dose administered in the study. Thus, the selection of the optimal long acting local anesthetic for peripheral nerve block must take into consideration of the available local anesthetics, time to onset, duration of blockade and side effects of each drug and dose. Since it has been shown that efficacy of 0.5% ropivacaine and 0.5% bupivacaine is same and ropivacaine has a theoretical advantage of lesser cardiotoxicity over bupivacaine, it may offer clinical advantage.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | safety and efficacy ; 0.5% Ropivacaine without Epinephrine, 0.5% Ropivacaine with Epinephrine ; 0.5% Bupivacaine ; patients ; Subclavian Perivascular Brachial Plexus Block ; Comparative study. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 22 Apr 2018 16:21 |
| Last Modified: | 28 Apr 2018 17:09 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7255 |
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