COMPARISON OF BUPIVACAINE AND BUPIVACAINE WITH FENTANYL IN LOWER LIMB ORTHOPAEDIC SURGERIES

INTRODUCTION : A commonly used technique for lower limb surgeries is subarachnoid blockade. If there is inadequate control of pain, will affect quality, and functional recovery, also there is chance of postsurgical complications, and the risk of persistent postsurgical pain. Use of epidural analgesic technique for lower limb surgeries should provide better pain relief with minimal side effects, leading to improved outcome. Bupivacaine hydrochloride is a local anaesthetic drug, which was used clinically in 1963. Bupivacaine acts mainly by blockade of voltage-gated Na+ channels in the axonal membrane and possibly has a further effect on presynaptic inhibition of calcium channels. Fentanyl is a powerful synthetic opioid which is similar to morphine but is 50 - 100 times more potent, which is used to treat patients with severe pain, especially after surgeries. MATERIAL AND METHODS : This prospective randomized study was conducted in the department of anaesthesiology at Rajiv Institute of Medical Science, to compare single shot epidural 8ml 0.5 % bupivacaine alone verses 8ml 0.5% bupivacaine along with 0.50 mcg Fentanyl. Total of 80 patients with ASA(American society of anaesthesiologists) I and II with age group between 24 to 56 years were included and 40 patients each were randomly placed in bupivacaine alone group (Group 1) and fentanyl in combination with bupivacaine group (Group 2). Written informed consent from all the patients was obtained. RESULTS: Mean (SD) systolic blood pressure was observed to be 128.45(12.47) and 130.25(11.55) in group 1 and group 2 respectively. Mean time for T 10 sensory block was significantly earlier in group 2 12.03(1.12) compared to group 1 18.24(2.54). Onset of motor block was observed to differ significantly, where onset was significantly earlier in group 2 23.17(1.77) in comparison to group 1 28.45(1.49). The first analgesic requirement in Group 1 was earlier at 198.20 + 11.49 min as compared to Group 2 at 279.34 + 18.42 min. CONCLUSION : Bupivacaine with Fentanyl enhances the onset of action and duration of effect for two segment regression. In present study the time to achieve T10 sensory block was early in Group 2 12.03(1.12) compared to group1 18.24(2.54).Onset of group2 23.17(1.77) in comparison to group1 28.45(1.49). Time of first analgesic requirement was found to be earlier at 279.34 + 18.42 minutes in group2 in comparison to group1 198.20 + 11.49 minutes.


Introduction:
For lower limb surgeries subarachnoid blockade is a commonly used technique. This procedure is easier to perform by injecting anesthetic drug into the subarachnoid space and with rapid onset of anesthesia, which provides intra-as well as postoperatively analgesia. less than half of patients who undergo surgery report adequate postoperative pain relief i . If there is inadequate control of pain, will affect quality, and functional recovery, also there is chance of postsurgical complications, and the risk of persistent postsurgical pain. Studies have shown that multimodal analgesia by various techniques is associated with better pain relief and decreased opioid consumption as compared with the use of a single medication administered through one technique ii , iii . Use of epidural analgesic technique for lower limb surgeries should provide better pain relief with minimal side effects, leading to improved outcome. iv .
Bupivacaine is chemically l-n-butyl-DL-piperidine-2carboxylic acid-2,6 dimethylanilide hydrochloride v . Bupivacaine hydrochloride is a local anaesthetic drug, which was used clinically in 1963. Bupivacaine acts mainly by blockade of voltage-gated Na+ channels in the axonal membrane and possibly has a further effect on presynaptic inhibition of calcium channels vi .
Fentanyl is a powerful synthetic opioid which is similar to morphine but is 50 -100 times more potent vii , which is used to treat patients with severe pain, especially after surgeries viii .
This study was conducted to compare the efficacy of bupivacaine alone and fentanyl in combination with bupivacaine for postoperative analgesia in lower limb orthopaedic surgery.

MATERIAL AND METHODS
This study was conducted in the department of anaesthesiology at Rajiv Gandhi Institute of Medical Science, Adilabad; to compare single shot epidural 8ml 0.5 % bupivacaine alone verses 8ml 0.5% bupivacaine along with 0.50 mcg Fentanyl.
Patients included were, ASA (American society of anaesthesiologists) physical status Classes I and II and those who were posted for elective lower limb surgery in orthopaedics department. Age group of patients included were 24 to 56 years. Only surgeries lasting up to 2 hours were included.
Patients with cardiac disease, renal failure, hepatic dysfunction, chronic pulmonary disease, diabetes mellitus and neuromuscular disorder were excluded from the study. Patients having infections, bleeding disorder and allergy or sensitivity to any of the study drugs were also excluded from the study.
Total of 80 patients with ASA I and II with age group between 24 to 56 years were included and 40 patients each were randomly placed in bupivacaine alone group (Group 1) and fentanyl in combination with bupivacaine group (Group 2). Written informed consent from all the patients was obtained.
Postoperatively at every 30 min interval, pain was assessed using 10-point visual analog scale (VAS). Score of 0 indicated no pain and a score of 10 indicated worst pain imaginable. Duration of analgesia was recorded as the first complaint of pain (VAS >4) in the postoperative period and rescue analgesic was administered. Rescue analgesic as 10 ml 0.25% bupivacaine was administered at the onset of pain (VAS >4) in postoperative period and at each incidence of complaint of pain (VAS >4) in next 24 h. The number of rescue analgesic epidural doses was recorded during the first 24 h. Patients were kept nil by mouth overnight or for 8 hours before surgical procedure. Preanesthetic check-up was performed on each patient; noninvasive monitors like pulse oximeter, non-invasive blood pressure (NIBP), and ECG were attached. Baseline parameters were recorded. Intravenous (IV) access was secured.
Hemodynamic parameters were recorded at baseline (B), immediately after the study drug is given (T1), then every 15 min till end of surgery and postoperatively till first analgesic was given. Postoperatively at every 30 min interval, pain was assessed using 10-point visual analog scale (VAS) . Score of 0 indicated no pain and a score of 10 indicated worst pain imaginable .Duration of analgesia was recorded as the first complaint of pain (VAS >4) in the postoperative period and rescue analgesic was administered. The number of rescue analgesic epidural doses was recorded during the first 24 h.
The statistical analysis was done using SPSS (Statistical Package for Social Sciences) software all data was entered in the Excel sheet version 2013. Values were represented in number (%) and mean ± standard deviation. P value of < 0.05 was considered as statistically significant.

OBSERVATIONS AND RESULTS
A total of 80 patients posted for elective lower limb orthopaedic surgery were included in the study and 40 patients each were randomly placed in bupivacaine alone group (Group 1) and fentanyl in combination with bupivacaine group (Group 2).  In this study it is observed that mean (SD) age of patients in group 1 was 36.27(10.24) and in group 2 was 34.56(11.44). There were 65% males and 35% females in group 1 whereas group 2 had 70% males and 30% females. The observations were not statistically significant.   The first analgesic requirement in Group 1 was earlier at 198.20 + 11.49 min as compared to Group 2 at 279.34 + 18.42 min. Difference in time of first analgesic requirement between the above two groups was found to be statistically significant (P< 0.001)

DISCUSSION
For lower limb surgeries mode of anaesthesia can be local, regional (spinal or epidural), or general anesthesia, but neuraxial blockade is the preferred mode. Recently use of adjuvants during epidural anaesthesia has gained popularity which prolong the duration of block, better success rate, patient satisfaction, and faster recovery as compared with general anaesthesia ix .With the aim of prolonging the duration of block, faster recovery, better success rate, decreased resource utilization compared with general anesthesia, and patient satisfaction, adjuvant are used during epidural anaesthesia and this use has been popular lately.
Total 80 patients posted for elective lower limb orthopaedic surgery were included in the study and 40 patients each were randomly placed in bupivacaine alone group (Group 1) and fentanyl in combination with bupivacaine group (Group 2).In present study the mean (SD) age of patients in group 1 was 36.27(10.24) and in group 2 was 34.56(11.44).
In present study it was seen that mean (SD) systolic blood pressure was 128.