Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block

Effect of Fentanyl as an Adjuvant to Brachial Plexus Block for Upper Extremity Surgeries: A Systematic Review and Meta-Analysis of RCTs

Objective. To assess if the addition of fentanyl to brachial plexus block has an impact on anesthetic outcomes and complication rates in patients undergoing upper extremity surgeries. Methods. We explore the PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases for all randomized controlled trials (RCTs) comparing adjuvant fentanyl with placebo/no drug for patients undergoing upper extremity surgery under brachial plexus block. Outcomes assessed were onset, duration of sensory and motor anesthesia, complications, and postoperative analgesia scores. Meta-analysis was conducted utilizing a random-effects model. The risk of bias was assessed using the Cochrane Collaboration’s risk of bias assessment tool 2. Certainty of evidence was assessed using GRADE. Subgroup analysis was conducted depending upon the approach of brachial plexus block and type of local anesthetic. Results. Twelve RCTs with 660 patients were included. Addition of fentanyl had no effect on onset of sensory anesthesia (11 studies; MD: 0.48; 95% CI: −1.81, 0.85; I2 = 96%; $p=0.48$ ) but significantly shortened onset of motor anesthesia (8 studies; MD: −2.36; 95% CI: −3.99, −0.74; I2 = 96%; $p=0.48$ ). Duration of sensory anesthesia (9 studies; MD: 82.81; 95% CI: 41.81, 123.81; I2 = 99%; $p<0.0001$ ) and motor anesthesia (7 studies; MD: 93.41; 95% CI: 42.35, 144.46; I2 = 99%; $p=0.0003$ ) was significantly increased with addition of fentanyl. The certainty of evidence-based on GRADE was deemed to be moderate for both onset and duration of anesthesia. The incidence of overall complications (nausea/vomiting and pruritis) was significantly higher in the fentanyl group (7 studies; OR: 2.14; 95% CI: 1.04, 4.40; I2 = 8%; $p=0.04$ ) but with low certainty of evidence. Conclusions. Adjuvant fentanyl with brachial plexus block improves the onset of motor anesthesia but not sensory anesthesia. The duration of both sensory and motor anesthesia is significantly prolonged with fentanyl by around 83–93 minutes. However, clinicians should be aware that complications such as nausea/vomiting and pruritis are increased twofold with the addition of the drug. Current evidence is limited risk of bias in the RCTs and high heterogeneity in the meta-analyses.

Regional Anesthesia Techniques for Pain Management for Laparoscopic Surgery: a Review of the Current Literature

Purpose of Review

The field of regional anesthesia has evolved tremendously in the last 15 years. New anesthesia protocols for ambulatory surgery and enhanced recovery after surgery have been developed as well. The focus of these techniques and protocols has centered on patient satisfaction and pain control while minimizing the use of opioids. The field of ambulatory surgery and anesthesia continues to evolve, and regional anesthesia and its plane techniques are at the center of these changes.

Recent Findings

Recent research has shown that regional techniques contribute to better pain control and patient experience and may decrease patient readmission rates. The safety of these techniques has been validated when performed by experienced practitioners. New techniques such as the erector spinae block (ESP) have been studied in the setting of laparoscopic surgery with promising results.

Summary

Regional anesthesia techniques for patients presenting for laparoscopic surgery are safe and seem to provide benefits. Those are related to patient experience, pain control, and readmission rates. Different techniques can be applied to a specific type of intervention. Application of these techniques depend on the clinical picture and patient. Future research may help us clarify how these techniques may improve patient satisfaction and operating room efficiency. New regional blocks may also develop based on what we know today.

Effects of adding dexmedetomidine, fentanyl, and verapamil to 0.5% ropivacaine on onset and duration of sensory and motor block in forearm surgeries: a randomized controlled trial

This study was aimed to compare the onset and duration of axillary block with ropivacaine 0.5% plus either dexmedetomidine, fentanyl, or verapamil in forearm surgeries. This double-blind clinical trial enrolled three equal-sized block-randomized groups of patients (n = 105) scheduled for hand and forearm surgery at Arak, Iran in 2019, who received: (i) ropivacaine (40 mL/0.5%) + dexmedetomidine (1 μg/kg), (ii) ropivacaine (40 mL/0.5%) + fentanyl (1 μg/kg), and (iii) ropivacaine (40 mL/0.5%) + verapamil (2.5 mg), respectively. We recorded some vital signs such as mean arterial pressure, heart rate and oxygen saturation, onset of complete sensory and motor block, duration of the block, opioid use, as well as pain score at recovery and certain time points (2, 4, 6, 12, and 24 hours post-operation). Adding dexmedetomidine to ropivacaine (40 mL/0.5%) prolonged the duration of sensory (P = 0.001) and motor block (P = 0.001) in compared to adding fentanyl and verapamil and it also shortens the time to onset of sensory (P = 0.001) and motor block (P = 0.001). There is a significant difference between three groups in terms of visual analog scale mean and the lowest pain score was obtained in the dexmedetomidine group (P = 0.001), significant time trend (P = 0.001), as well as the time and groups interaction (P = 0.001). Dexmedetomidine was concluded to be associated with alleviated pain; reduced opioid use; short onset of sensory block; and prolonged duration of sensory and motor block. It hence is recommended to lengthen the duration of axillary block and to help relieve postoperative pain and ultimately to move to cut down the postoperative opioid use in forearm surgery. The study was approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU. REC.1397.266), and registered on Iranian Registry of Clinical Trials (registration No. IRCT20141209020258N111) on May 9, 2019.

Comparison of the Ketamine-Lidocaine and Fentanyl-Lidocaine in Postoperative Analgesia in Axillary Block in Upper Limb Fractures By Ultrasound Guidance

Background

Regional anesthesia provides safe anesthesia for upper extremity surgery. Axillary plexus block approach for hand and forearm surgery is commonly used. The use of adjuvants in combination with local anesthetics for peripheral nerve blocks enhances the quality and duration of anesthesia and postoperative analgesia.

Methods

This double-blind clinical trial was performed on 60 patients who were candidates for the surgery of upper extremity fractures with ASA I and II classes. The patients were randomly divided into two equal groups (n = 30). The intervention group 1 received 4 mg/kg lidocaine 1% and 50 µg fentanyl and the intervention group 2 received 4 mg/kg lidocaine 1% and 30 mg ketamine during the axillary block. After the necessary monitoring, a pinprick test was performed to evaluate sensory block, and a three-point scale test for the motor block was performed for median, ulnar, radial and musculocutaneous nerves. The duration of postoperative analgesia, the time of the first request for a painkiller, and the amount of opioid received were compared in the two groups.

Results

Onset of sensory and motor block was shorter in the fentanyl group but did not differ significantly. The sensory and motor block length was slightly higher in the fentanyl group, but no significant difference was observed. The severity of pain (VAS) and the mean of received opioid (pethidine) were significantly lower in the fentanyl group 24 hours after the surgery (P < 0.0001). The duration of postoperative analgesia and the time of the first request for painkiller were longer in the fentanyl group, but there was no significant difference.

Conclusions

The severity of pain and analgesic intake in the fentanyl group decreased significantly. Therefore, fentanyl is a better drug than ketamine for using as an adjuvant in the axillary block.

[Stocktaking of local anesthetics 2020]

For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just "simple" sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic "alternative" effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α₂-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.

Prolonged Analgesic Efficacy of Articaine with the Addition of Tramadol in Axillary Brachial Plexus Block

Objectives

Articaine is a rapid-onset, short-duration, local anesthetic. The aim of this study was to study the effect of adding tramadol to articaine in an axillary block to prolong the analgesic effect.

Methods

This study was conducted with 60 patients of American Association of Anesthesiologists classification I or II and aged 18 to 60 years who underwent hand or forearm surgery with an axillary plexus block using a nerve stimulation technique. The patients were randomized into 2 groups: Group A (n=30) received 40 mL 1% articaine and Group AT (n=30) was administered 40 mL 1% articaine with 100 mg tramadol. The onset of sensory block, motor block, duration of sensorial block and motor block, duration of analgesia and hemodynamic parameters were recorded before the block and 5, 10, 20, 30, 60, 120, 180 minutes after the local anesthetic injection.

Results

The sensory block duration in Group AT (187.5±13.0 min) was significantly longer than that of group A (140.78±8.74 min) (p<0.02). The motor block duration in Group AT (137.4±3 min) was significantly longer than that seen in Group A (93.71±9.6 min) (p<0.01). The duration of analgesia was longer in Group AT (218.8±18.2 min) than in Group A (170.8±17.2 min) (p<0.05). In group AT, 2 patients experienced the side effect of nausea and 1 patient had hypotension in the postoperative period.

Conclusion

This study demonstrated that the addition of 100 mg of tramadol to articaine used for an axillary plexus block prolonged analgesia.

Effect of Dexamethasone on Characteristics of Supraclavicular Nerve Block with Bupivacaine and Ropivacaine: A Prospective, Double-blind, Randomized Control Trial

Background:

Dexamethasone as an adjuvant to bupivacaine and ropivacaine for supraclavicular brachial plexus (SCBP) block prolongs motor and sensory blockade. However, comparison of effect of dexamethasone (8 mg) when added to these two local anesthetics has not been well studied. This study was conducted to compare analgesic efficacy of dexamethasone as adjuvant to bupivacaine and ropivacaine in SCBP block.

Subjects and Methods:

Nerve stimulator-guided SCBP block was given to 120 patients, randomly assigned to one of four groups: (n = 30 in each group) Group B, BD, R, and RD received 30 ml (0.5%) bupivacaine + 2 ml saline, 30 ml (0.5%) bupivacaine + dexamethasone 8 mg, 30 ml (0.5%) ropivacaine + 2 ml saline, and 30 ml (0.5%) ropivacaine + dexamethasone 8 mg, respectively. Time for request of the first rescue analgesic, 24-h analgesic consumption, and different block characteristics were assessed. Student's t-test, Chi-square test, ANOVA were used for statistical analysis.

Results:

Dexamethasone significantly prolonged time for request of the first rescue analgesic of both ropivacaine (1211.83 ± 32.86 vs. 283.17 ± 7.71 min){ p R, RD < 0.001} and bupivacaine (1205.17 ± 34.32 vs. 364.67 ± 16.50 min) {p B, BD < 0.001}. 24-h requirement for rescue analgesics was more in Groups B and R when compared to Groups BD and RD. The increase in duration of analgesia was more when Groups R and RD (928.66 min) were compared than Groups B and BD (840.5 min). Similar results were seen with onset times and duration of sensory and motor block.

Conclusion:

The addition of dexamethasone to bupivacaine and ropivacaine in SCBP block prolonged time for first rescue analgesia and reduced the requirement of rescue analgesics with faster onset and prolonged duration of sensory and motor block, with the effect being stronger with ropivacaine.

Effect of addition of dexamethasone to ropivacaine on post-operative analgesia in ultrasonography-guided transversus abdominis plane block for inguinal hernia repair: A prospective, double-blind, randomised controlled trial

Background and Aims:

Ultrasonography (USG)-guided transversus abdominis plane (TAP) block is an abdominal field block with high efficacy. This study was undertaken with the aim of determining the effect of the addition of dexamethasone to 0.5% ropivacaine on post-operative analgesia in USG-guided TAP block for inguinal hernia repair.

Methods:

A double-blind randomised control study was conducted on sixty patients posted for inguinal hernia repair with the American Society of Anesthesiologists physical Status I or II, who were allocated two groups of 30 each. Patients in Group RS received 0.5% ropivacaine (20 ml) and normal saline (2 ml) whereas patients in Group RD received 0.5% ropivacaine (20 ml) and dexamethasone (2 ml, i.e., 8 mg), in USG-guided TAP Block on the same side, after repair of inguinal hernia under spinal anaesthesia. Visual analogue scale (VAS) scores, time for request of first analgesia and total tramadol consumption in first 24 h were compared. Unpaired Student's t-test and Mann–Whitney U-test were performed using SPSS 23 Software.

Results:

Patients in Group RD had significantly lower VAS scores as compared to Group RS from 4^th to 12^th h, postoperatively. Duration of analgesia was significantly more in Group RD (547.50 [530,530] min) when compared with Group RS (387.50 [370,400] min) (P < 0.001). The demand for intravenous tramadol was significantly low in Group RD (223.33 ± 56.83 mg) as compared to Group RS (293.33 ± 25.71 mg) (P < 0.001).

Conclusion:

Addition of dexamethasone to ropivacaine in USG-guided TAP block significantly reduces post-operative pain and prolongs the duration of post-operative analgesia, thereby reducing analgesic consumption.

Comparative Study of the Efficacy of Dexmedetomidine and Fentanyl as Adjuvants to Ropivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block

Objective

Supraclavicular brachial plexus block is preferable to general anaesthesia in upper limb surgeries. Various adjuvants have been added to improve the quality of the block and prolong postoperative analgesia. The aim of the present study was to compare the onset and duration of sensory and motor blockade with the quality of perioperative analgesia and postoperative complications provided by dexmedetomidine and fentanyl as adjuvants to ropivacaine under ultrasound (USG) guidance in supraclavicular block.

Methods

A total of 80 patients with American Society of Anesthesiologists grade I/II scheduled for elective upper limb surgeries were randomly allocated into two groups. Group A received 30 mL of 0.5% ropivacaine with 1 μg kg^-1 dexmedetomidine, and group B received 30 mL of 0.5% ropivacaine with 1 μg kg^-1 fentanyl for supraclavicular brachial block using USG guidance. The onset and duration of sensory and motor block, time for requirement of rescue analgesia and adverse events during the perioperative period were noted.

Results

The onset of sensory blockade was 13.95±1.34 min in the dexmedetomidine group and 14.18±1.41 min in the fentanyl group. There was a highly significant statistical difference in terms of the duration of the sensory blockade, i.e. 801.75±46.07 min with dexmedetomidine compared to 590.25±40.41 min with fentanyl (p<0.0001). The duration of motor blockade was highly statistically significant with 649.56±42.73 min in group A compared to 456.75±32.93 min in group B.

Conclusion

Dexmedetomidine prolongs the duration of sensory and motor block and postoperative analgesia as compared to fentanyl when used as an adjuvant to ropivacaine in supraclavicular brachial plexus block and is not associated with any major adverse events.

Analgesic Efficacy of Transverse Abdominal Plane Block after Elective Cesarean Delivery - Bupivacaine with Fentanyl versus Bupivacaine Alone: A Randomized, Double-blind Controlled Clinical Trial

Background:

The analgesic benefit of transversus abdominis plane (TAP) blocks for cesarean delivery remains controversial. In our study, we compared the analgesic efficacy of TAP block using local anesthetic bupivacaine and adjunct fentanyl with bupivacaine alone in patients undergoing elective cesarean section.

Methods:

Our study was a randomized, double-blind, controlled clinical trial where sixty patients undergoing elective cesarean delivery under subarachanoid block (2 ml of 0.5% bupivacaine) were randomized into two groups, A and B. At the end of the surgical procedure, bilateral TAP block was performed guided by the ultrasound. Group A received 38 ml of 0.25% bupivacaine and 2 ml of 50 μg of fentanyl, whereas Group B received 38 ml of 0.25% bupivacaine + 2 ml of normal saline. The total volume was divided equally and administered bilaterally. Each patient was assessed for 24 h after TAP block, for time to rescue analgesia, pain using visual analog scale (VAS) score at rest and on movement, hemodynamic parameters (heart rate and blood pressure), nausea, vomiting, and sedation. Diclofenac 75 mg was given as rescue analgesia when the patient complained of pain or when VAS score >4.

Results:

Prolonged postoperative analgesia was noticed with both the groups, with a mean time to rescue analgesia of approximately 6.5 h. There was no significant difference in time to rescue analgesia (6.49 ± 0.477 vs. 6.5 ± 0.480) when both the groups were compared among themselves. The pain scores among the two groups when compared did not show any added benefit. Incidence of nausea, vomiting, and sedation when compared between both the groups showed no difference.

Conclusion:

The TAP block as a part of a multimodal analgesic regimen definitely has a role in providing superior analgesia in the postoperative period. However, adjunct fentanyl to local anesthetic bupivacaine was found to have no added advantage when quality and duration of analgesia was compared.

To Evaluate the Efficacy of Fentanyl and Dexmedetomidine as Adjuvant to Ropivacaine in Brachial Plexus Block: A Double-blind, Prospective, Randomized Study

Context:

Anesthesia and analgesia for surgeries to the upper extremity are commonly provided using brachial plexus anesthesia. There are limited or almost no studies comparing the use of ropivacaine with fentanyl to ropivacaine with dexmedetomidine.

Aims:

To compare the efficacy of fentanyl and dexmedetomidine as adjuvants to ropivacaine for brachial plexus block among patients undergoing upper limb orthopedic surgeries.

Settings and Design:

This was a prospective, randomized, double-blinded study.

Subjects and Methods:

The patients were randomly divided into three groups of 35 each using computerized randomization table. Group I patients received 3 mg/kg of 0.75% ropivacaine with 1 μg/kg of fentanyl diluted with normal saline (NS) to make a total volume of 35 ml. Group II patients received 3 mg/kg of 0.75% ropivacaine with 1 μg/kg of dexmedetomidine diluted with NS to make a total volume of 35 ml. Group III patients received 3 mg/kg of 0.75% ropivacaine with NS making a total volume of 35 ml.

Statistical Analysis Used:

Statistical analysis was performed using Statistical Package for Social Sciences, version 15.0. Analysis of variance followed by independent samples t-test was performed for parametric data, and Kruskal–Wallis test followed by Mann–Whitney U-test was performed for nonparametric data.

Results:

Mean motor and sensory block onset time was minimum in Group I and maximum in Group III while mean duration of sensory and motor block was maximum in Group I and minimum in Group III. Time taken for first rescue analgesic dose was also maximum in Group I and minimum in Group III.

Conclusions:

It can be concluded that 3 mg/kg of 0.75% ropivacaine along with 1 μg/kg of fentanyl diluted with NS to make a total volume of 35 ml was the most efficacious regimen for brachial plexus block among patients undergoing upper limb orthopedic surgeries.

Addition of fentanyl to the ultrasound-guided transversus abdominis plane block does not improve analgesia following cesarean delivery

The present study aimed to investigate whether the addition of fentanyl to the transversus abdominis plane (TAP) block procedure may improve analgesic duration following cesarean delivery. A total of 147 nulliparous women with an American Society of Anesthesiologists physical status I-II, scheduled for elective cesarean delivery under spinal anesthesia, were enrolled in the present study. All patients underwent cesarean delivery under spinal anesthesia with 10 mg bupivacaine and 10 µg fentanyl, after which the patients underwent an ultrasound-guided bilateral TAP block with either 0.375% ropivacaine (group T_R; n=48), 0.375% ropivacaine and 50 µg subcutaneous fentanyl (group T_RS_F; n=49), or a mixture of 0.375% ropivacaine and 50 µg fentanyl (2.5 µg/ml; group T_RF; n=50) per side. The TAP block formed part of a multimodal analgesic regimen comprising patient-controlled analgesia (PCA) with intravenous fentanyl, and regular treatment with diclofenac and paracetamol. The TAP block was performed in the midaxillary line using an in-plane technique. The primary outcome was the time to the first PCA, whereas secondary outcomes were the cumulative and interval PCA consumptions, visual analogue scale (VAS) pain scores at rest and during movement, side effects assessed at 2, 6, 12, 24 and 48 h postoperatively, and patient satisfaction with postoperative analgesia. No significant differences were observed in the median time to the first PCA among the three groups (P=0.640), which were 150 min (70-720 min) in group T_R, 165 min (90-670 min) in group T_RS_F, and 190 min (70-680 min) in group T_RF. Fentanyl consumption, VAS pain scores, side effects and patient satisfaction were similar among the three groups; however, the demand for fentanyl was significantly decreased in the T_RS_F and T_RF groups at 2 h postoperatively (P=0.001 and 0.002, respectively), as compared with group T_R. No complications attributed to the TAP block were detected. In conclusion, the results of the present study suggested that the addition of 2.5 µg/ml fentanyl to the TAP block procedure was unable to improve analgesia following cesarean delivery under spinal anesthesia.

Comparative evaluation of adding different opiates (morphine, meperidine, buprenorphine, or fentanyl) to lidocaine in duration and quality of axillary brachial plexus block

Background:

There is no agreement about the effect of adding opioids to local anesthetics in peripheral nerve blocks. The aim of this study was to investigate the effect of adding different opioids with equipotent doses of lidocaine in axillary brachial plexus block using ultrasonography and nerve locator guidance.

Materials and Methods:

In a prospective, randomized, double-blind clinical trial study, 72 adult patients aged 18–65 years old scheduled for orthopedic surgery of the forearm and hand with axillary brachial plexus block were selected and randomly allocated to four groups. Meperidine (pethidine), buprenorphine, morphine, and fentanyl with equipotent doses were added in 40cc of 1% lidocaine in P, B, M, and F groups, respectively. The onset and duration of sensory and motor blocks, severity of patients’ pain, duration of analgesia, hemodynamic and respiratory parameters, and adverse events (such as nausea and pruritus) during perioperative period were recorded.

Results:

The onset time for the sensory block was similar in the four groups. The onset time for the motor block was significantly faster in morphine and pethidine groups (P = 0.006). The duration of sensory and motor blocks was not statistically different among the four groups. The quality of motor blockade was complete in 100% of patients receiving pethidine or morphine and 77.8% of patients receiving buprenorphine or fentanyl (P = 0.021).

Conclusion:

In the upper extremity surgeries performed under axillary brachial plexus block addition of morphine or pethidine to lidocaine may be superior to other opioids (i.e. fentanyl and buprenorphine) due to better quality and quantity of motor blockade and faster onset of the block.

Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review

Background

The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants.

Objectives

To systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks.

Methods

Randomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded.

Results

Sixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks.

Conclusions

Buprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.

Effect of addition of fentanyl to local anesthetic in brachial plexus block on duration of analgesia

Introduction/Context:

A comparative study was carried out to evaluate the analgesic efficacy and side effects of addition of fentanyl to local anesthetic undergoing surgeries on forearm and elbow. All patients were hemodynamically stable, and there were no serious side effects in any of the patients in both the groups. The difference in the mean duration of analgesia between the groups was statistically significant (P<0.01). So we can conclude- Addition of Fentanyl to local anaesthetic in brachial plexus block increases duration of analgesia.

Materials and Methods:

Patients were randomly divided into two groups: group I (control) and group II (study). All the patients were subjected to brachial plexus block with supraclavicular approach. After obtaining paraesthesia, drugs were administered as follows: Group I (control): bupivacaine 0.5% 20 mL + lignocaine 2% 10 mL + NS 1 mL Group II (study): bupivacaine 0.5% 20 mL + lignocaine 2% 10 mL + fentanyl 1 mL (50 microgm). Observations were noted. All the relevant information was recorded on a pretested, predefined, semi-open pro forma sheet. Regular monitoring of PR, BP and RR, side effects,degree of sedation were recorded. Evaluation of pain and pain relief was done according to McGill pain questionnaire (0- no pain to 5- excruciating pain). When patients complained of discomforting pain (McGill grade II), parenteral analgesic was prescribed, and the total number of doses in the 24-hour period was noted.

Results:

The duration of analgesia in group II (study) was significantly longer (695±85 min) than those in group I (415±78 min). However, onset time of analgesia was prolonged in group 2. We conclude that the addition of fentanyl to local anesthetics causes an improved success rate of sensory blockade but a delayed onset of analgesia, although this may be accounted for by the decreased pH caused by fentanyl. There was no statistically significant difference in the incidence of side effects between the two groups.

Conclusions:

This study has shown that the mean duration of analgesia is extended if fentanyl is added to local anesthetics, without increasing the side effects.

Comparative evaluation of ropivacaine and ropivacaine with dexamethasone in supraclavicular brachial plexus block for postoperative analgesia

BACKGROUND

Mixing of various adjuvants has been tried with local anesthetics in an attempt to prolong anesthesia from peripheral nerve blocks but have met with inconclusive success. More recent studies indicate that 8 mg dexamethasone added to perineural local anesthetic injections augment the duration of peripheral nerve block analgesia.

AIMS

Evaluating the hypothesis that adding dexamethasone to ropivacaine significantly prolongs the duration of analgesia in supraclavicular brachial plexus block compared with ropivacaine alone.

PATIENTS AND METHODS

It was a randomized, prospective, and double-blind clinical trial. Eighty patients of ASA I and II of either sex, aged 16-60 years, undergoing elective upper limb surgeries were equally divided into two groups and given supraclavicular nerve block. Group R patients (n = 40) received 30 ml of 0.5% ropivacaine with distilled water (2 ml)-control group whereas Group D patients (n = 40) received 30 ml of 0.5% ropivacaine with 8 mg dexamethasone (2 ml)-study group. The primary outcome was measured as duration of analgesia that was defined as the interval between the onset of sensory block and the first request for analgesia by the patient. The secondary outcome included maximum visual analogue scale (VAS), total analgesia consumption, surgeon satisfaction, and side effects.

RESULTS

Group R patients required first rescue analgesia earlier (557 ± 58.99 min) than those of Group D patients (1179.4 ± 108.60 min), which was found statistically significant in Group D (P < 0.000). The total dose of rescue analgesia was higher in Group R as compared to Group D, which was statistically significant (P < 0.00).

CONCLUSION

Addition of dexamethasone (8 mg) to ropivacaine in supraclavicular brachial plexus approach significantly and safely prolongs motor blockade and postoperative analgesia (sensory) that lasted much longer than that produced by local anesthetic alone.

Does intravenous ketamine enhance analgesia after arthroscopic shoulder surgery with ultrasound guided single-injection interscalene block?: a randomized, prospective, double-blind trial

Ketamine has anti-inflammatory, analgesic and antihyperalgesic effect and prevents pain associated with wind-up. We investigated whether low doses of ketamine infusion during general anesthesia combined with single-shot interscalene nerve block (SSISB) would potentiate analgesic effect of SSISB. Forty adult patients scheduled for elective arthroscopic shoulder surgery were enrolled and randomized to either the control group or the ketamine group. All patients underwent SSISB and followed by general anesthesia. During an operation, intravenous ketamine was infused to the patients of ketamine group continuously. In control group, patients received normal saline in volumes equivalent to ketamine infusions. Pain score by numeric rating scale was similar between groups at 1, 6, 12, 24, 36, and 48 hr following surgery, which was maintained lower than 3 in both groups. The time to first analgesic request after admission on post-anesthesia care unit was also not significantly different between groups. Intraoperative low dose ketamine did not decrease acute postoperative pain after arthroscopic shoulder surgery with a preincisional ultrasound guided SSISB. The preventive analgesic effect of ketamine could be mitigated by SSISB, which remains one of the most effective methods of pain relief after arthroscopic shoulder surgery.

Does the addition of tramadol and ketamine to ropivacaine prolong the axillary brachial plexus block?

Background and Objectives. A prospective, randomized, controlled, double-blind clinical trial to assess the effect of tramadol and ketamine, 50 mg, added to ropivacaine in brachial plexus anesthesia. Methods. Thirty-six ASA physical statuses I and II patients, between 18 and 60 years of age, scheduled for forearm and hand surgery under axillary brachial plexus block, were allocated to 3 groups. Group R received 0.375% ropivacaine in 40 mL, group RT received 0.375% ropivacaine in 40 mL with 50 mg tramadol, and group RK received 0.375% ropivacaine in 40 mL with 50 mg ketamine for axillary brachial plexus block. The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events (nausea, vomiting, and feeling uncomfortable) were recorded. Results. The onset time of sensorial block was the fastest in ropivacaine + tramadol group. Duration of sensorial and motor block was the shortest in the ropivacaine + tramadol group. Duration of analgesia was significantly longer in ropivacaine + tramadol group. Conclusion. We conclude that when added to brachial plexus analgesia at a dose of 50 mg, tramadol extends the onset and duration time of the block and improves the quality of postoperative analgesia without any side effects.

Comparison of Postoperative Analgesic Effect of Dexamethasone and Fentanyl Added to Lidocaine through Axillary Block in Forearm Fracture

Aim. Regional analgesia has been introduced as better analgesic technique compared to using systemic analgesic agents, and it may decrease the adverse effects of them and increase the degree of satisfaction. Several additives have been suggested to enhance analgesic effect of local anesthetic agents such as opioids and steroids. We designed this randomized double-blind controlled study to compare the analgesic efficacy of the dexamethasone and fentanyl added to lidocaine using axillary block in patients undergoing operation of forearm fracture. Materials and Methods. Seventy-eight patients 20–60 years old were recruited in a prospective, double-blinded, randomized way. Axillary block was performed in the three groups by using 40 mL lidocaine and 2 mL distilled water (L group), 40 mL lidocaine and 2 mL dexamethasone (LD group), and 40 mL lidocaine and 2 mL fentanyl (LF group). The onset time of sensory and motor block, duration of sensory and motor block, the total analgesic dose administered during 6 hours after the surgery, and hemodynamic variables were recorded. Results. The duration of sensory and motor block was significantly longer in LD group compared to other groups (P < 0.001). Similarly, the total analgesic consumption in LD group was smaller compared to other groups (P < 0.001). Comparison of hemodynamic consequences of axillary block and surgery failed to reveal any statistically significant differences between all groups. Conclusion. Addition of dexamethasone to lidocaine significantly prolonged the duration of analgesia compared with fentanyl/lidocaine mixture or lidocaine alone using axillary block in patients undergoing forearm fracture surgery. This trial is registered with IRCT2012120711687N1.

The Effects of Postoperative Brachial Plexus Block Using MgSO(4) on the Postoperative Pain after Upper Extremity Surgery

BACKGROUND

Although a brachial plexus block can be used to provide anesthesia and analgesia for upper extremity surgery, its effects using MgSO(4) on postoperative pain management have not been reported. The aim of this study was to evaluate brachial plexus block using MgSO(4) on postoperative analgesia.

METHODS

Thirty-eight patients who were scheduled to undergo upper extremity surgery were randomly allocated into two groups: patients receiving axillary brachial plexus block with 0.2% ropivacaine 20 ml and normal saline 2 ml (group S) or 0.2% ropivacaine 20 ml and MgSO(4) 200 mg (group M). Before extubation, the blocks were done and patient controlled analgesia was started, and then, the patients were transported to a postanesthetic care unit. The postoperative visual analogue scale (VAS), opioid consumption, and side effects were recorded.

RESULTS

The two groups were similar regarding the demographic variables and the duration of the surgery. No differences in VAS scores were observed between the two groups. There was no statistically significant difference in opioid consumption between the two groups. Nausea was observed in three patients for each group.

CONCLUSIONS

Axillary brachial plexus block using MgSO(4) did not reduce the level of postoperative pain and opioid consumption.

Effect of clonidine as adjuvant in bupivacaine-induced supraclavicular brachial plexus block: A randomized controlled trial

Objective:

Clonidine has been used as adjuvant to local anesthetics in order to extend the duration of analgesia in various regional and central neuraxial blocks. It is previously reported that clonidine added to bupivacaine increases analgesia duration in brachial plexus block. We evaluated the effect of this combination in supraclavicular brachial plexus block for upper limb orthopedic procedures.

Materials and Methods:

A randomized double-blind placebo controlled trial was done with 70 patients of American Society of Anesthesiologists Grade I or II status undergoing upper limb orthopedic procedures. Group A (n = 35) patients received 25 ml of 0.5% bupivacaine and 0.2 ml (30 mcg) clonidine, whereas group B (n = 35) received 25 ml of 0.5% bupivacaine and 0.2 ml normal saline through a supraclavicular approach for brachial plexus block. Vital parameters were recorded 10 min prior to block placement and every 3 min thereafter till the end of the procedure. Onset and duration of both sensory and motor blocks and sedation score were recorded. All patients were observed in postanesthesia care unit and received tramadol injection as soon as they complained of pain as rescue analgesic. Duration of analgesia was taken as the time from placement of block till injection of rescue analgesic.

Results:

Analgesia duration was 415.4 ± 38.18 min (mean ± standard deviation) in Group A (clonidine) compared to 194.2 ± 28.74 min in Group B (control). No clinically significant difference was observed in heart rate, blood pressure, and oxygen saturation. Sedation score was higher in the clonidine group.

Conclusion:

Addition of a small dose of clonidine to 0.5% bupivacaine significantly prolonged the duration of analgesia without producing any clinically important adverse reactions other than sedation.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial

BACKGROUND

Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA).

METHODS

Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 microg) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0-10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant.

RESULTS

Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0-60] vs 60 [0-160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9-15.6] vs 3.1 [1.0-11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9-18] vs 15 [9-18] minutes, respectively; P = 0.18).

CONCLUSIONS

The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.