1. Dr.K.VENKATESAN MD II YEAR
SYNERGISTIC EFFECT OF MAGNESIUM SULPHATE AND FENTANY ADDED TO INTRATHECAL BUPIVACAINE FOR MILD PREECLAMSIA
Dr.K.VENKATESAN MD II YEAR

2. GUIDE
PROF&HOD.DR.P.S.SHANMUGAM MD,DA. DEPARTMENT OF ANESTHESIA KILPAUK MEDICAL COLLEGE & HOSPITAL CHENNAI

3. aim of the study
To study and compare the effect of added fentanyl 25(mic gm) & Mgso4 0.1cc 50%(50mg) to 0.5% 2cc(10mg)bupivacaine in spinal anesthesia
Patients undergoing elective LSCS
With mild gestational hypertension(PIH)

4. background
Adequate analgesia following caesarian section decreases morbidity , improves patient ambulation &outcomes ,facilitate care of the new born.
Intrathecal MgSO4 , NMDA antagonist has been shown to prolong analgesia without significant side effects in healthy parturients
Correlation was found between serum & CSF Mg concentration in patients with preeclampsia

5. METHODS Ethical committee approval Informed patient consent
Randomised double blind controlled study
Statistical significance is ‘p’ value less than 0.05
SAB performed
With pt in right lateral position
25G quincke needle

6. Patient selection
60 patient ASA risk I &II undergoing elective caesarian section with mild PIH .
IV line secured with 18G venflon, and preloaded with RL 10-12ml /kg
All pts received 5L of O2 / min through face mask throughout procedure
Pts treated with titrated doses of
Inj.ephedrine 6mgI.V if BP<90mmhg
Inj.Atropine 0.6mg if HR<60/min
After delivery of baby Inj. Syntocin 10 IU in drip and 10 IU IM given

7. METHODOLOGY
Mild PIH is defined as SBP 140 – 160 and DBP 90 – 110mm Hg with or without proteinuria after 20 wk. gestation
60 pts with average age of 18 – 35 undergoing elective LSCS under SA were randomized into three groups of 20 each
Minimal fasting period is 8hrs
All pts received premedication with Inj. Ranitidine 50mg IV and Inj. Metoclopramide 10 mg IV, 15 min before surgery

8. criteria Age between 18-35 years Elective LSCS under spinal anesthesia
Mild PIH (BP<160/110mmhg)
ASA I/II
Contraindication to regional anesthesia
Heart disease
Fetal distress
Seizure disorder
Severe eclampsia
Pts with coagulation defect
Allergy to LA
INCLUSION
EXCLUSION

9. groups Group C: Group F: Group M:
control group,(N=20) patients 0.5% 2cc(10mg)bupivacaine + 0.6cc normal saline .
Group F:
Fentanyl(N= 20) patients received 0.5% 2cc bupivacaine +0.5cc( 25mic gm )fentanyl +0.1cc NS.
Group M:
Mgso4 group (N=20),0.5% 2cc bupivacaine +0.5cc fentanyl +0.1cc 50%(50mg) Mgso4 .

10. STATISTICS Variables were analysed by ANOVA
Variables analysed and interperted by post Hoc test
Statistical significance is ‘p’ <0.05

11. INTRA OP MONITORING NIBP PULSEOXIMETER ECG RESPIRATORY RATE
URINE OUTPUT

12. BROMAGE MOTOR SCALE GRADE RESPONSE DEGREE OF BLOCK NO MOTOR BLOCK
NO MOTOR BLOCK
NIL(0%) 1
UNABLE TO STRAIGHT LEG RAISE
PARTIAL(33%) 2
UNABLE TO FLEX KNEE AGAINST RESISTANCE
ALMOST COMPLETE(66%) 3
UNABLE TO FLEX ANKLE
COMPLETE

13. Ramsey sedation score SCORE RESPONSE 1 ANXIOUS OR RESTLESS OR BOTH 2
COPERATIVE, ORIENTED & TRANQUIL 3
RESPONDS TO COMMANDS 4
BRISK RESPONSE TO STIMULUS 5
SLUGGISH RESPONSE TO STIMULUS 6
NO RESPONSE TO STIMULUS

14. Sens0ry score SCORE RESPONSE NORMAL SENSATION 1
NORMAL SENSATION 1
ANALGESIA (LOSS OF PIN PRICK SENSATION) 2
ANAESTHESIA (LOSS OF TOUCH SENSATION)

15. Parameters observed Block onset time Duration of sensory blockade
Higher level of sensory block
Time to reach highest block
Two segment regression time
Duration of postop analgesia
Hemodynamic parameters

16. attributes
SENSORY BLOCK ONSET TIME
Time interval between end of anesthetic injection and appearance of cutaneous analgesia in dermatomes T-12,T- 10,T-8,T-6
DURATION OF MOTOR BLOCK
Administration of anesthetic and attainment of grade 0 in Bromage motor scale
DURATION OF ANALGESIA
Administration of anesthetic and disappearance of cutaneous level of sensation at each dermatomal level
POST-OP ANALGESIA DURATION
Administration of anesthetic and time of analgesic requirement in PACU

17. results
The onset of both sensory and motor block was delayed in the group M ,when compared to both C&F group(p<0.001)
Motor block and analgesic duration was prolonged in the Group M , level of significance (p<0.05)
Two segment regression time increased in M group (P<0.001)
Group M is hemodynamicaly stable when compared to other groups (p<0.019)
Attainment highest level sensory block varies from T1-T6 , delayed in group M with significance level (p<0.08)
Intensity of motor block is more with group M, but with less significance (p<0.291)

18. Contd…
Occurrence of other complications like Bradycardia , nausea ,shivering were comparable in all groups
Two Patient in group F complained of itching
Usage of vasopressors is more in group C when compared to other groups
Fetal outcome assessed by first min and fifth min APGAR was similar between groups (p>0.3)
Height and weight are similar between groups(p<0.586)
Investigations were similar between groups (p<0.32)

19. Contd..
Duration of post-op analgesia is prolonged in M group when compared to other groups (p<0.001)
Use of vasopressors is reduced in group M(p<0.03)

20. SENSORY BLOCK ONSET TIMEF C M

21. F M C

22. F M C

23. ANALGESIC & MOTOR BLOCK DURATIONF M C

24. MOTOR BLOCK ONSET TIME F M C

25. POST-OP ANALGESIA DURATIONF M C

26. MagNESIUM sulPHATE
Magnesium is the second most abundant intracellular cation
Involved in the regulation of many ion channels and enzymatic reaction
Has application in anesthesia because of its action as a non competitive NMDA receptor antagonist with anti-nociceptive effect

27. MagNESIUM sulPHATE
Mgso4 has been shown to have anti- nociceptive effects , because of its antagonistic action on the NMDA receptor
Passage of magnesium across BBB is limited
It can potentiate opioid analgesia by both central and peripheral mechanism
MgSO4 causes
1.vasodilation by ca2+ block
2.analgesic effect
3.inhibition of catecholamine release

28. Cont..
Mg inhibit calcium entry into the cell via a non-competitive NMDA receptor blockade
Mg is also a physiological calcium antagonist at different voltage gated calcium channel, it may be important for anti-nociception
Mg decreases incidence of post operative shivering
Response to NMDA receptor is greatly enhanced when ECF Mg concentration below physiological level.

29. Cont…
Decrease in pain intensity is not due to direct analgesic effect of Mg
But due to prevention of subsequent NMDA activation
Baseline CSF Mg level in pt with preeclamsia differ from normal patients which suggest base line alteration in BBB
Normal CSF Mg level was 2.2meq+/- 0.9, plasma 1.6Meq, CSF:plasma ratio 1.39
Mg is neuroprotective in ischemic as well as excitotoxic brain injury

30. Cont…
Mg may dilate cerebral blood vessel and thus responsible for relieving vasospasm in pt with preeclampsia
Clinical relevant dose of Mg has no significant effect on V MCA, autoregulation and cerebral reactivity CO2
Mg produce central desensitisation
Mg can potentiate NM junction
Spinal NMDA receptor antagonist is the reason for potentiation of LA and prolongation of post operative analgesia

31. FENTANYL It is a synthetic opioids Phenylpiperidine derivatives
Directly inhibit the NMDA receptor
Action of opioids in the bulbospinal pathways are critical for analgesic efficacy
Distribution of opioids receptors in descending pain control circuits indicates substantial overlap between µ & Κ receptors
µ receptors produce analgesia within descending pain control circuits.

33. FACTOR influencing block height

34. CONCLUSION
In parturients with mild PIH undergoing LSCS the addition of Mgso4 50mg to the intrathecal combination of bupivacaine & fentanyl
prolongs the duration of analgesia
Prolongs motor block duration
Delayed onset of sensory block
Prolongs post op analgesia
Ref.pubmed,intl.journal of obstetric anesthesia ,SOAP.

35. THANK U