ADDING DEXMEDETOMIDINE TO INTRATHECAL LOW DOSE BUPIVACAINE IN VAGINAL HYSTERECTOMY CO-AUTHORS PROF & HEAD.DR. I.CHANDRASEKARAN MD,DA PROF.DR.S.P.MEENAKSHISUNDARAM MD,DA ASST. PROF. DR.S.SENTHILKUMAR MD.,DA. AUTHOR DR.T.ARUNPRAKASH INSTITUTE OF ANESTHESIOLOGY MMC, MADURAI

AIM To study the effect of adding dexmeditomedine with intrathecal low dose bupivacaine for vaginal hysterectomy on sensory and motor blockade Postoperative analgesia

STUDY DESIGN Randomised double blind control study 60 patients, 30 in each group Inclusions ASA I & II Age 30 to 60 yrs Vaginal hysterectomy BMI 18.5 to 25 Exclusions Contraindications to spinal anesthesia Allergy to local anesthetics

METHODS Patients were divided into two groups B – inj 0.5 % hyperbaric bupivacaine 2cc +0.05ml of NS BD – inj 0.5 % hyperbaric bupivacaine 2cc ml of dexmedetomidine (5 μg )

18G iv cannula secured Monitors Patient in right lateral position Under strict aseptic precautions, SAB performed with 25G Quincke spinal needle in the L3- L4 interspace

OBSERVATIONS Onset of sensory block to pin prick Onset of motor block ( bromage score) Time for two segment regression Sensory recovery time to pin prick Motor recovery time( bromage score)

PR if less than 60/min inj atropine 0.6 mg iv given BP if MAP less than 70 mmHg inj ephedrine iv given in titrated doses SPO2 RR SEDATION by Ramsay Score

BROMAGE SCORE FOR MOTOR BLOCKADE GradeCriteria IFree movement of hips, legs and feet IIJust able to flex knees with free movement of feet IIIUnable to flex knees, but with free movement of feet IVUnable to move hips or legs or feet

RAMSAY SEDATION SCORE 1- Patient anxious and agitated or restless 2- Patient co-operative, oriented, and tranquil 3- Patient responds to commands only 4- Patient exhibits brisk response to light glabellar tap or loud auditory stimulus 5- Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus 6- Patient exhibits no response

Postop analgesia assessed by VAS score If VAS > 4 –study completed,inj diclofenac 75 mg IM given Side effects Hypotension Bradycardia Nausea, vomiting Pruritus

ANALYSIS Demographic datas Onset of sensory and motor blockade Maximum level of sensory blockade Offset time of sensory and motor blockade Duration of post op analgesia Side effects

STATISTICAL ANALYSIS Chi-square test If p < 0.05 is significant

DEMOGRAPHIC DATA VARIABLE BD GROUP (n = 30) B GROUP (n = 30) “p” Age in years (> 0.05) Weight (in kgs) (>0.05) Height ( in cms) (>0.05) BMI (>0.05)

AGE & BMI

ASA BD GROUP n = 30 B GROUP n = 30 ASA p = (>0.05)

ASA

ONSET OF SENSORY BLOCK Onset of sensory blockade (min) BD GROUP (n = 30) B GROUP (n = 30) Mean 2± ± 0.66 p = ( < 0.05 )

ONSET OF SENSORY BLOCK ( MIN)

ONSET OF MOTOR BLOCK Onset of motor blockade (min) BD GROUP (n = 30) B GROUP (n = 30) Mean 5.53± ± 0.64 p = ( < 0.05 )

ONSET OF MOTOR BLOCK (MIN)

MAXIMUM SENSORY LEVEL Maxmimum sensory level BD GROUP (n = 30) B GROUP (n = 30) NO. % % T T T T T

MAXMIMUM SENSORY LEVEL

TIME FOR 2 SEGMENT REGRESSION Time for two segment regression (min) BD GROUP n = 30 B GROUP n =30 Mean 115.3± ± 6.2 p = ( < 0.05 )

TIME FOR 2 SEGMENT REGRESSION (MIN)

SENSORY RECOVERY TIME TO S1 Sensory recovery time to S1 (min) BD GROUP n = 30 B GROUP n = 30 Mean 292.8± ± 9.3 p = ( < 0.05 )

SENSORY RECOVERY TIME TO S1 ( MIN)

MOTOR RECOVERY TIME Motor recovery time (min) BD GROUP (n = 30) B GROUP (n = 30) Mean 121.1± ± 6 p = ( < 0.05 )

MOTOR RECOVERY TIME (MIN)

MAP AT VARIOUS TIME INTERVALS Mean arterial pressure (mmHg) at BD GROUP (n = 30) B GROUP (n = 30) 0 minute minutes minutes minutes minutes hour hours hours hours hours

MEAN ARTERIAL PRESSURE

PULSE RATE AT VARIOUS TIME INTERVALS Mean pulse rate at BD GROUP (n = 30) B GROUP (n = 30) 0 minute minutes minutes minutes minutes hour hours hours hours hours

PULSE RATE

SEDATION SCORE Sedation scoreBD GROUP (n = 30) B GROUP (n = 30) Mean 2.39 ± p = ( < 0.05 )

SEDATION SCORE

OBSERVATION Statistical analysis between BD and B GROUP shown that GROUP BD patients have Early Sensory and motor onset time delayed Two segment regression Motor recovery time prolonged post op analgesia Good sedation Than GROUP B patients

DEXEMEDETOMIDINE IN SPINAL Intrathecal α2-agonists Depressing the release of C-fiber transmitters Hyperpolarization of post-synaptic dorsal horn neurons

The prolongation of the motor block of spinal anesthetics may result from the binding of α2- adrenergic agonists to motor neurons in the dorsal horn cells Dose related sedation is by acting at locus ceruleus and also by promoting natural sleep pathways

CONCLUSION Dexmedetomidine as an adjuvant to intrathecal low dose Bupivacaine provides Better quality of analgesia Delay in two segment regression Prolonged post op analgesia Better hemodynamic stability Good sedation without any side effects

REFERENCES Effects of adding dexmeditomedine to intrathecal bupivacaine in spinal anesthesia for gynecological procedures - American journal of applied sciences 6(5) : 882 – 887, 2009 Dexmedetomidine Enhances the Local Anesthetic Action of Lidocaine via an -2A Adrenoceptor - Anesth Analg 2008;107:96 –101

Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block Acta Anaesthesiologica Scandinavica - February 2006 Effect of dexmedetomidine added to spinal bupivacaine for urological procedures – Saudi med journal 2009 ; vol 30 (3):

THANK YOU