ABSTRACT DIFFERENT DOSES OF DEXMEDETOMIDINE AS AN ADJUVENT

ABSTRACT

BACKGROUND

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 IN ORDER TO INCREASE THE DURATION OF ACTION OF
SPINAL ANAESTHESIA, INTRATHECAL DEXMEDETOMIDINE IS ADDED AS ADJUVENT TO LOCAL
ANAESTHETICS FOR ABDOMINAL HYSTERECTOMY SURGERIES .NOT MUCH STUDIES HAVE BEEN
DONE TO EVALUATE DIFFERENT DOSES OF DEXMEDETOMIDINE AS A ADJUVENT.

AIM

TO
ACCESS THE EFFICACY  AND SAFETY OF TWO
DIFFERENT DOSES  OF DEXMEDETOMIDINE AS AN
ADJUVENT TO ISOBARIC ROPIVACAINE,INTRATHECALLY 
ON ABDOMINAL HYSTERECTOMY SURGERIES.

MATERIALS
AND METHODS

SIXTY
PATIENTS SCHEDULED FOR HYSTERECTOMY SURGERIES ARE RANDOMIZED INTO TWO GROUPS A
AND B.GROUP A RECEIVED 2.6ML OF ISOBARIC ROPIVACAINE AND 10µ DEXMEDETOMIDINE.GROUP
B RECEIVED 2.6ML OF ISOBARIC ROIVACAINE AND 15 µ DEXMEDETOMIDINE.

RESULTS

THE
SENSORY BLOCKADE AND MOTOR BLOCKAGE ONSET TIME OF GROUP A IS (4.48±031MIN )
AND( 6.1±0.28 MIN) RESPECTIVELLY.THIS IS STATISTICALLY SIGNIFICANT(P<0.001) WHEN COMPARED WITH GROUP B SENSORY(5.52±028) AND MOTOR BLOCKADE ONSET TIME(6.95±0.22) . DURATION OF SENSORY AND MOTOR BLOCKADE IN GROUP A IS( 587±10.8) AND(530±15.78)RESECTIVELLY .THIS IS STATISTICALLY SIGNIFICANT(P<0.0001) WHEN COMPARED WITH GROUP B SENSORY(423±12.85) AND MOTOR(382±9.25)BLOCKADE DURATION.HOWEVER THERE WAS NO SIGNIFICANCE IN  INCIDENCE OF THE SIDE EFFECTS HYDOTENSION( P=0.774) BRADYCARDIA(P=0.109) BETWEEN TWO GROUPS.   CONCLUSION BETWEEN THE TWO DOSES STUDIED,DEXMEDETOMIDINE INCREASES THE EFFICACY OF INTRATHECAL ROPIVACAINE IN THE DOSE DEPENDENT MANNER, WITHOUT ANY CHANGE IN THE SIDE EFFECT PROFILE   A STUDY OF EFFICACY OF DIFFERENT DOSES INTRATHECAL DEXMEDETOMIDINE AS A ADJUVANT TO  isobaric ROPIVACAINE FOR HYSTERECTOMY SURGERIES INTRODUCTION            HYTERECTOMY  SURGERIES  HAVE FREQUENTLY BEEN PERFORMED UNDER SPINAL ANAESTHESIA. MANY ADJUNCTS LIKE FENTANYL, KETAMINE, TRAMADOL, NEOSTIGMINE, MAGNESIUM SULPHATE, ETC. HAVE BEEN USED TO PROLONG THE ANALGESIC EFFECT OF LOCAL ANAESTHETICS.DEXMEDETOMIDINE A SELECTIVE ALPHA-2 AGONIST, HAS RECENTLY BEEN USED INTRATHECALLY AS ADJUVANT TO SPINAL ANESTHESIA TO INCREASE ITS  DURATION(1-3).VARIOUS STUDIES SUPPORT THE USAGE OF DOSAGE IN THE RANGE OF  10µg(4) AND15µ (5) WITH HYPEPERBARIC BUIVACAINE.HOWEVER ,NOT  MUCH  STUDIES  HAVE BEEN DONE WITH 10µG AND 15 µg DEXMEDETOMIDINE WITH ISOBARIC ROPIVACAINE.WE INTEND TO SEE EFFECT OF DEXMEDETOMIDINE 10 µg AND 15µg WITH ISOBARIC ROIVACAINE ON DURATION , ONSET OF ACTION AND SIDE EFFECT PROFILE  IN HYSTERECTOMY SURGERIES. MATERIALS AND METHODS THIS IS A PROSPECTIVE  DOUBLE BLIND STUDY.AFTER THE APPROVAL FROM INSTITUITIONAL  ETHICS COMMITTEE,60 FEMALE  PATIENTS   OF ASA 1 AND ASA2, AGED 35 TO 60,WEIGHT 40 TO 60 AND HEIGHT MORE THAN 140CMS POSTED FOR ELECTIVE ABDOMINAL HYSTERECTOMY  WERE ENROLLED.THIS STUDY WAS CONDUCTED BETWEEN MAY 2016 TO DEC 2017 .WRITTEN CONSENT WAS OBTAINED FOR ALL PATIENTS. ALL PATIENTS WERE SUBJECTED TO A DETAILED PREANAESTHETIC EVALUATION AND APPROPRIATE INVESTIGATIONS  DONE .DURING THIS EVALUATION, PATIENTS ALLERGIC TO ANY OF THE DRUGS USED ,PATIENTS SUFFERING FROM NEUROLOGICAL DISEASES, COAGULOPATHY, CARDIAC DISEASES, OBESITY (BODY WEIGHT >120 KG) ,HEIGHT <150 CM, HISTORY OF ARRHYTHMIAS, PATIENTS ON ANTIHYPERTENSIVE TREATMENT ,UNCONTROLLED AND LABILE HYPERTENSION  AND OTHER GENERAL CONTRAINDICATION TO SPINAL ANAESTHESIA WERE EXCLUDED FROM THE STUDY. PATIENTS WERE RANDOMLY ALLOCATED INTO TWO GROUPS OF 30 PATIENTS EACH; GROUP A: PATIENTS WERE ADMINISTERED 2.6ML OF ISOBARIC ROPIVACAINE(0.75%) PLUS 10µg DEXMEDETOMIDINE(0.4ML) . GROUP B: PATIENTS WERE ADMINISTERED 2.6ML OF ISOBARIC ROPIVACAINE(0.75%) PLUS 15µg DEXMEDETOMIDINE (0.4ML).  TO PROVIDE DOUBLE-BLINDNESS, THREE ANESTHESIOLOGISTS WERE INVOLVED IN THE STUDY. ONE ANESTHESIOLOGIST PREPARED THE DRUG, ANOTHER GAVE SPINAL ANESTHESIA AND DATA WERE RECORDED BY AN INDEPENDENT THIRD ANESTHESIOLOGIST WHO WAS UNAWARE OF GROUP ALLOCATION, PATIENTS WERE ALSO UNAWARE OF THE DRUG  REGIMEN RECEIVED. DRUG PREPARATION FOR GROUP A DEXMEDETOMIDINE (100µg/ML ) WAS DRAWN IN A STANDARD 2ML SIRINGE.DOUBLE DILUTED WITH 1ML NORMAL SALINE( DOUBLE DILUTED SOLUTION CONTAINING 50µg/ML).EACH 0.2ML CONTAINS  5 µg.0.4ML  OF 10 µg DEXMEDETOMIDINE  IS ADDED TO 2.6ML OF 0.75% ISOBARIC ROPIVACAINE SOLUTION.   FOR GROUP B  DEXMEDETOMIDINE (100µg /ML),EACH 0.2ML CONTAINS 10MCG,.0.2ML OF DEXMEDETOMIDINE (50µg/ML) DOUBLE DILUTED PREPARED ABOVE IS ADDED TO THIS SOLUTION TO MAKE A FINAL SOLUTION OF 0.4ML CONTAINING 15µg DEXMEDETOMIDINE. 0.4ML OF 15µg DEXMEDETOMIDINE IS ADDED TO 2.6ML OF 075%ISOBARIC ROPIVACAINE SOLUTION.   ANESTHESIA TECHNIQUE BEFORE THE COMMENCEMENT OF ANESTHESIA, PATIENTS WERE EXPLAINED ABOUT THE METHODS OF SENSORY AND MOTOR ASSESSMENTS.ALL PATIENTS RECEIVED TABLET ALPRAZOLAM(0.25MG) AND TABLET RANITIDINE(150MG) AS ORAL PREMEDICATION NIGHT BEFORE SURGERY. PATIENTS WERE KEPT FASTING AS PER THE STANDARD GUIDELINES.  STANDARD MONITORING OF HEART RATE (HR),NONINVASIVE BLOOD PRESSURE (NIBP), ECG AND PULSEOXIMETRY (SPO2) WAS DONE WITH MONITORS. BASELINE VAUES WERE RECORDED..AFTER PRELOADING WITH AN INFUSION OF( 15ML/KG) RINGER LACTATE THROUGH AN 18 G PERIPHERAL INTRAVENOUS (I.V.) CANNULA, PATIENTS WERE GIVEN SPINAL ANESTHESIA IN THE LATERAL DECUBITUS POSITION UNDER ALL ASEPTIC PRECAUTIONS. LUMBAR PUNCTURE WAS PERFORMED AT L2-L3 INTERVERTEBRAL SPACE THROUGH A MIDLINE APPROACH USING 25 G QUINCKE SPINAL NEEDLE.AFTER CONFIRMATION OF FREE FLOW OF CSF , THE STUDIED DRUG IS INJECTED SLOWLY OVER A PERIOD OF 10 TO 15 SEC.AFTER INTRATHECAL INJECTION PATIENT WAS PLACED SUPINE .   THE HEIGHT OF SENSORY BLOCK WAS ASSESSED BY PINPRICK METHOD (23G HYPODERMIC NEEDLE) . MOTOR BLOCKADE WAS ASSESSED USING MODIFIED BROMAGE SCALE 0: PATIENT ABLE TO MOVE HIP, KNEE, ANKLE, 1: UNABLE TO MOVE HIP, ABLE TO MOVE KNEE AND ANKLE, 2: UNABLE TO MOVE HIP AND KNEE, ABLE TO MOVE ANKLE, 3: UNABLE TO MOVE HIP,KNEE AND ANKLE).  THE ONSET OF SENSORY BLOCK IS CALCULATED FROM THE TIME OF GIVING INJECTED DRUG INTO SUBARACHANOID SPACE  TILL THE TIME IT REACHS T6 DERMATOME  LEVEL.  MOTOR BLOCKADE ONSET IS CALCULATED  BY NOTING THE TIME TILL BLOCKADE OF BROMAGE SCALE OF 3 REACHED.   FURTHER ASSESSMENTS WERE PERFORMED  UNTIL THE TIME FOR  RECOVERY OF S2 DERMATOME (DURATION OF THE SENSORY BLOCK) AND BROMAGE SCORE OF "0" (DURATION OF THE MOTOR BLOCK) WERE NOTED   ALL PATIENTS WHERE DESIRED LEVEL OF ANESTHESIA WAS NOT ACHIEVED WITHIN 20 MIN WERE REGARDING AS BLOCK FAILURES, AND MANAGED BY PERFORMING GENERAL ANESTHESIA.  THESE CASES WERE EXCLUDED FROM THE STUDY. HEMODYNAMIC VARIABLES (HEART RATE HR, MEAN BLOOD PRESSURE MBP) WERE MONITORED CONTINUOUSLY, AND ANY INCIDENCE OF HYPOTENSION AND BRADYCARDIA  WAS DOCUMENTED . HYPOTENSION (DEFINED AS A DECREASE IN SYSTOLIC BLOODPRESSURE > 30% OF THE
BASELINE VALUE OR SYSTOLIC BLOOD PRESSURE < 90 MM HG) WAS TREATED WITH INTRAVENOUS BOLUSES OF 3 MG MEPHENTERMINE