Introduction A common anesthetic method for a range of lower limb orthopedic procedures is spinal anesthesia due to its ease of administration, robust sensory and motor blocking, and reliable surgical anesthesia. However, the length of spinal anesthesia caused by local anesthetics alone is often brief; for this reason, adjuvants are employed to prolong analgesia and improve block quality. The quality and duration of spinal anesthesia have been enhanced by intrathecal opioids such as morphine, fentanyl, and butorphanol used as adjuvants to local anesthetics. Material And Method Written informed permission was obtained from research participants. A computer-generated random number was used to divide the minimum number of patients who met the inclusion criteria into two groups. Group A patients got 3 milliliters of 0.5% hyperbaric bupivacaine along with 0.2 milliliters, butorphanol (200 micrograms). Group B patients got 0.15 ml of buprenorphine (150 micrograms) together with 3 ml of 0.5% hyperbaric bupivacaine. Result The gathered information was imported into Microsoft Excel 2016 and examined using IBM SPSS Statistics for Windows.Descriptive statistics were employed to characterize the data: for continuous variables, the mean and standard deviation were utilized, and for categorical variables, frequency analysis and percentage analysis. Using the Independent sample t-test, the bivariate samples in the independent groups were compared to see whether there was a significant difference. Conclusion According to our study onset of sensory blockade and faster with butorphanol and duration of sensory blockade was more in buprenorphine compared to butorphanol whereas motor blockade is comparable in both groups. Buprenorphine group required rescue analgesia at 4hrs postoperatively whereas butorphanol group required rescue analgesia at 2nd hr Hence we conclude that buprenorphine would be beneficial for lower limb orthopedic surgeries as it provides prolonged duration of analgesia although further studies need to be done in a greater number of patients and for prolonged duration of procedures..
The simplicity of administration, thick sensory and motor blocking, and dependable surgical anesthesia of spinal anesthesia make it a popular anesthetic approach for a variety of lower limb orthopedic operations. Nevertheless, local anesthetics alone frequently have a short duration of spinal anesthesia, which is why adjuvants are used to extend analgesia and enhance block quality. As adjuvants to local anesthetics, intrathecal opioids including morphine, fentanyl, and butorphanol have been used to improve the quality and duration of spinal anesthesia. [1].
In 1957, Eckenstam introduced buprevacaine, and in 1963, Telivno began using it in therapeutic settings. In practically all surgical instances, hyperbaric bupivacaine is currently utilized in conjunction with opioids. Bupivacaine is a local anesthetic of the amide type that is highly effective and slow long duration of effect and commencement (5-8 minutes). Even while intrathecal bupivacaine alone itself provides effective sensory blockage, many patients nevertheless suffer some pain and discomfort and may need intraoperative analgesic supplements. [2]
Synthetic opioids like butorphanol have agonistic effects at kappa receptors and partly agonistic and antagonistic effects at µ receptors. Its efficacy as an analgesic is four to eight times that of morphine. [3] Its ceiling impact on respiratory depression, decreased potential for addiction, sedation that is on par with or better than morphine, and lower incidence of nausea, vomiting, and pruritis—all of which are desired in the post-operative period—make it safer than pure opioid agonists.
A mixed agonist-antagonist, buprenorphine has a strong agonistic impact on µ opiate receptors and an antagonistic effect on µ opiate receptors.[4] Because of its modest intrinsic activity, this opioid can also be safely delivered in the subarachnoid region. Because of its large molecular weight and lipophilicity, it might not distribute as much in the brain. Combining intrathecal administration with 0.5%Compared to 0.5% hyperbaric Bupivacaine alone, hyperbaric Bupivacaine should offer superior postoperative analgesia. [5]
In contrast to intravenous opioids, intrathecal opioids have the advantage of having no ceiling effect. Thus, its applications have included patient-controlled analgesia and postoperative analgesia. In order to examine the analgesic effectiveness of butorphanol and buprenorphine as an adjuvant to 0.5% heavy bupivacaine in spinal anesthesia for patients undergoing orthopedic procedures on the lower limbs, this research was designed.
Study design: Randomized comparative study.
Study setting: Patients undergoing lower limb orthopedic surgeries under Spinal anaesthesia in the department of Anaesthesia in Government Medical college, Nizamabad.
Approximate total duration of the study: 1 year Number of groups studied: 2
Sample size of each group: 30 Total sample size: 60
Inclusion Criteria
Exclusion Criteria
METHODLOGY
A written informed consent was taken from patients included in the study. Minimum 60 patients who fulfilled inclusion criteria were randomized using computer generated random numbers into two groups.
Patients included in Group A received 0.5% hyperbaric bupivacaine 3ml with 0.2 ml of butorphanol (200micrograms)
Patients included in Group B received 0.5% hyperbaric bupivacaine 3ml with 0.15ml buprenorphine (150 micrograms).
All patients were given T. Ranitidine150mg night before surgery. On arrival in operating room, all basic monitors were connected such as non-invasive blood pressure, pulse oximetry and ECG. Intravenous access achieved using 20G cannula.
Paients were positioned in left lateral position and under aseptic conditions, parts painted and draped, lumbar puncture done using 25G Quinckes spinal needle in L4-L5 space.after confirming free flow of cerebrospinal fluid, the assigned drug belonging to group A or B was injected intrathecally. Patients were then positioned in supine after procedure
Table 1: Comparison Of Age Distribution Between The Groups
|
Groups |
Total |
p-value |
|||
A |
B |
|||||
Age |
21 - 30 yrs |
N |
3 |
4 |
7 |
0.853 |
% |
10.0% |
13.3% |
11.7% |
|||
31 - 40 yrs |
N |
8 |
9 |
17 |
||
% |
26.7% |
30.0% |
28.3% |
|||
41 - 50 yrs |
N |
10 |
7 |
17 |
||
% |
33.3% |
23.3% |
28.3% |
|||
51 - 60 yrs |
N |
9 |
10 |
19 |
||
% |
30.0% |
33.3% |
31.7% |
|||
Total |
N |
30 |
30 |
60 |
||
% |
100.0% |
100.0% |
100.0% |
Figure 1 Comparison Of Age Distribution Between Groups The Above Table And Figure Shows Comparison Of Age Distribution Between Groups With p>0.05 Which Shows No Statistical Significance Association.
Table 2: Comparison Of Gender Distribution Between Groups
|
Groups |
Total |
p-value |
|||
A |
B |
|||||
Gender |
Female |
N |
10 |
7 |
17 |
0.390 |
% |
33.3% |
23.3% |
28.3% |
|||
Male |
N |
20 |
23 |
43 |
||
% |
66.7% |
76.7% |
71.7% |
|||
Total |
N |
30 |
30 |
60 |
||
% |
100.0% |
100.0% |
100.0% |
Figure : 2 comparison of Gender distribution between groupsThe above table and figure shows comparison of Gender distribution between Groups p>0.05 which shows no statistical significance association between Gender and Groups
Table 3: Comparison Of Asa Grade Between The Groups
|
Groups |
Total |
p-value |
|||
A |
B |
|||||
ASA Grade |
I |
N |
13 |
12 |
25 |
0.793 |
% |
43.3% |
40.0% |
41.7% |
|||
II |
N |
17 |
18 |
35 |
||
% |
56.7% |
60.0% |
58.3% |
|||
Total |
Count |
30 |
30 |
60 |
||
% |
100.0% |
100.0% |
100.0% |
Figure 3 comparison of ASA grade between groups The above table and figure shows comparison of ASA grade between Groups p>0.05 which shows no statistical significance association between ASA grade and Groups.
Table 4: Comparison Of Time To Reach T10 Sensory Level Block (Min) Between Groups
Variable |
Groups |
N |
Mean |
SD |
t-value |
p-value |
Time for t10 level (min) |
Group A |
30 |
6.0 |
1.5 |
1.122 |
0.266 |
Group B |
30 |
6.5 |
1.7 |
Figure 4 comparison of time to reach T10 sensory level block between groupsThe above table and figure shows comparison of Time to reach T10 sensory level block (min) between Groups p >0.05 which shows no statistical significance difference between the groups.
Table 5: Comparison Of Time to Reach Maximum Sensory Level Block (Mins) Between Groups
Variable |
Groups |
N |
Mean |
SD |
p-value |
Time for max sensory block (mins) |
Group A |
30 |
10.1 |
1.3 |
0.510 |
Group B |
30 |
9.7 |
3.1 |
Figure 5 Comparison of time to reach maximum sensory block between Groups The above table and figure shows comparison of Time to reach maximum sensory block (mins) between Groups which shows no statistical significance difference at p > 0.05 level.
Table 6: Comparison Of Time To Reach Complete Motor Block (Mins) Between Groups
Variable |
Groups |
N |
Mean |
SD |
p-value |
Time for complete motor block (mins) |
Group A |
30 |
6.5 |
1.7 |
0.003 |
Figure 6 comparison of time to reach complete motor block between groups The above table and figure shows comparison of time to reach complete motor block (mins) between Groups which shows highly statistical significance difference at p < 0.01 level in Group A.
Since spinal anesthesia is simple to administer, provides strong sensory and motor blockage, and is a dependable surgical anesthetic, it is frequently utilized for a variety of lower limb orthopedic procedures. Unfortunately, local anesthetics alone frequently have a short duration of spinal anesthesia; thus, adjuvants are used to extend the duration of analgesia and enhance the quality of the block. In order to improve the quality and duration of spinal anesthesia, intrathecal opioids including morphine, fentanyl, and butorphanol have been used as adjuvants to local anesthetics.
Howeverorphanol was given to Group A and buprenorphine to Group B in this prospective, randomized, comparative research, which involved 60 individuals. As compared to buprenorphine, we found that butorphanol caused analgesia and total motor block to start more quickly, whereas buprenorphine caused analgesia to last longer.
In our study, butorphanol and buprenorphine enabled an earlier onset and establishment of analgesia. Onset of sensory block was faster in butorphanol when compared to buprenorphine. The time to reach T10 level was comparable in both groups. The time to reach maximum sensory blockade was comparable in both groups. The addition of these two adjuvants promotes faster onset as compared to time of onset of sensory analgesia with Bupivacaine alone.
Duration of analgesia was significantly prolonged in Buprenorphine group when compared to butorphanol. Patients who received buprenorphine did not require rescue analgesia for more than 6 hours post operatively when compared to rescue analgesia at 2-4 hours for patients who received Butorphanol. Postoperative pain relief was siginificantly improved in both groups, with buprenorphine providing the longest duration of analgesia.
In our study, onset of motor blockade was comparable in both groups and the time to reach complete motor block was significantly increased in patients who received butorphanol when compared to those who received buprenorphine.
In our present study, there were statistically no significant differences in heart rate observed at any time duration during the study period. There was statistically significant increase in systolic blood pressures (mmHg) between the two groups at 85 mins at one time during the study period. There was statistically no significant difference in diastolic blood pressure (mmHg) between the two groups at any time during the study. There is no statistically significant difference in mean arterial pressure between both groups at any time during the study. Overally, the hemodynamic status was maintained in both groups.
In our study, the pain scores was assessed using VAS were low and remained low for a significant time in the post operative period in both group A and group B. The results indicate a highly statistically significant difference at the p < 0.01 level for 3rd hr and no statistically significant difference at the p > 0.05 level for all other time durations.
While motor blockade is similar in both groups, our study found that buprenorphine caused sensory blockade to start more quickly than butorphanol and that its length was longer. While the butorphanol group needed rescue analgesia in the second hour after surgery, the buprenorphine group needed it at the fourth.Because buprenorphine offers a longer duration of analgesia, we infer that it might be advantageous for lower limb orthopedic operations. However, additional research including a larger number of patients and longer procedure length is required.