International Journal of Multidisciplinary Research and Development

International Journal of Multidisciplinary Research and Development


International Journal of Multidisciplinary Research and Development
International Journal of Multidisciplinary Research and Development
Vol. 8, Issue 3 (2021)

A comparative evaluation of ultralow dose bupivacaine with fentanyl versus plain bupivacaine in surgical repair of hip fractures in elderly patients


Sheetal Kumar G, Ganapathi P, Tara Nandan A

A comparative evaluation of ultralow dose bupivacaine with fentanyl versus plain bupivacaine in surgical repair of hip fractures in elderly patients

Sheetal Kumar G1*, Ganapathi P2, Tara Nandan A3

1Post graduate, Department of Anaesthesiology, K.V.G Medical College and hospital, Kurunjibagh, Sullia, DK, Karnataka, India

2 Professor and head Department of Anaesthesiology, K.V.G Medical college and hospital, Kurunjibagh, Sullia, DK, Karnataka, India

3 Assistant Professor, Department of Anaesthesiology, K.V.G Medical college and hospital, Kurunjibagh, Sullia, DK, Karnataka, India

 

 

Abstract

Introduction: Geriatric patients with significant autonomic dysfunction are the ones who present for hip fracture surgeries, hence we undertook our study which compares ultralow dose bupivacaine with fentanyl which causes minimal hemodynamic instability with conventional dose of bupivacaine. Opiods and local anaesthetics administered together intrathecally have potent synergistic analgesic effect.

Aim: To compare ultralow dose bupivacaine with fentanyl and conventional dose of bupivacaine in ASA II and ASA III patients posted for hip surgeries in regards to

  1. Hemodynamic stability, use of vasopressors and perioperative morbidity.
  2. Duration of motor and sensory block

Methodology: After obtaining approval from the Institutional Ethical Committee, the study was conducted on 52 patients belonging to physical status ASA classes II and III, aged 60–90 years, scheduled to undergo hip surgeries under spinal anesthesia. Group A will receive 1mL of 0.5% bupivacaine (5mg) + 20 mcg fentanyl and group B will receive 2mL of 0.5% bupivacaine (10 mg).

Results: The demographic data (age, weight, sex and ASA grading) were comparable and statistically non-significant. Mann- Whitney test was used for statistical analysis.

The time of onset of adequate level of sensory block (T10) was longer for group A (128.96 +/- 2.53 sec) than group B (95.57 +/- 2.41 sec) and was statistically significant.

Duration of motor block was longer in group B (111.23 +/- 3.64 min) as compared to group A (88 +/- 3.77 min) and was statistically significant.

Duration of sensory block for group B (147.5 +/- 3,46 min) was slightly more compared to group A (141.86 +/- 4.34)and was found to be statistically significant.

Conclusion: The use of ultralow dose bupivacaine plus fentanyl for spinal anaesthesia for surgical repair of hip fractures in elderly patients provides successful anaesthesia and incurs a minimum of hypotension.

 

Keywords: hip fracture, ultralow dose bupivacaine, hemodynamic stability, duration of motor and sensory block vas (visual analogue score)

 

 

 

Introduction

Geriatric patients with significant autonomic dysfunction are the ones who present for hip fracture surgeries, Hence we undertook our study which compares ultralow dose bupivacaine with fentanyl which causes minimal hemodynamic instability with conventional dose of bupivacaine. Opiods and local anaesthetics administered together intrathecally have potent synergistic analgesic effect. Low dose of bupivacaine with fentanyl causes less perioperative hypotension and decreases need for the use of vasopressors which decreases perioperative morbidity.

Thus the aim of this study is to compare ultra-low dose bupivacaine with fentanyl and conventional dose of bupivacaine in ASA II and ASA III patients posted for hip surgeries in regards to i) hemodynamic stability, use of vasopressors and perioperative morbidity and

 ii) Duration of motor and sensory block

Materials and Methods

Source of Data: All patients aged between 60-90 years undergoing hip surgeries in the department of Anaesthesiology in KVGMC, sullia from March 2019 to August 2019 was included in the study.

 

Study Design: Prospective study.

Inclusion Criteria

  • Hip fracture surgeries ( intertrochanteric and neck of femur cases)
  • Patients of ASA II and III
  • 60-90 years of age
  • Patients weighing between 40­-80 Kgs

 

Exclusion Criteria

  • Patient refusal.
  • Coagulation disorders.
  • Localized infection over injection site.
  • Contraindications for FICB
  • Patients with uncompensated heart failure, unstable angina, ejection fraction <40%
  • Patients with severe aortic and mitral valve stenosis

 

Sample Size

A total of 52 patients with 26 in each group. To identify an effect size at 0.70, at Alpha: 0.05 and Beta: 0.80 level of significance, Degree of confidence-95%. Sample size was estimated to be 26 in each group.

 

n = 2 2

 

Statistical Analysis

Mann- Whitney test was used to find if there was a statistical difference between the two groups and p value <0.05 was considered as statistically significant difference.

 

Methodology

After obtaining approval from the Institutional Ethics Committee and obtaining written informed consent, the study will be conducted on 52 patients belonging to physical status ASA classes II and III, aged 60–80 years, scheduled to undergo hip surgeries under spinal anesthesia.

A day prior, preoperative visit will be made and thorough clinical evaluation will be conducted and necessary investigations will be ordered and reviewed. Written informed consent will be taken for the procedure. After shifting patients to preoperative room, baseline heart rate (HR), blood pressure (BP), mean arterial pressure (MAP), oxygen saturation (SpO2), Visual analogue score, bromage score will be recorded.Patients will be randomly allocated to two groups, group A and group B.USG guided Fascia iliaca compartment block will be given 20 mins before subarachnoid block with 20mLof 0.25% bupivacaine for both the groups. Sensory block, Bromage score and VAS score are recorded. Patients will be positioned for subarachnoid block in lateral decubitus position with side to be operated placed down once VAS score is <2. group A will receive 1mL of 0.5% bupivacaine(5mg) + 20 mcg fentanyl and group B will receive 2mL of 0.5% bupivacaine(10 mg).pulse, blood pressure and SpO2 will be recorded every 5 min for first half an hour and thereafter every 10 mins till the end of surgery. SBP of <90 mmhg or a decrease of more than 30% from baseline mean arterial pressure will be considered as hypotension and will be treated with IV bolus of ephedrine 6mg. After surgery, patients will be shifted to postanesthetic care unit and hemodynamics will be monitored. At PACU vitals, bromage score, VAS levels are assessed and recorded every 20 minutes uptill Bromage score becomes 0. Sensory block is assessed every 1 hour for 24 hours. Sensory block (duration of analgesia): time interval between onset of sensory block till the patients first reports VAS score of more than or equal to 4 The time to first postoperative rescue analgesia as evidenced by VAS ≥4 will be noted and rescue analgesia in the form of injection tramadol 1.5mg/kg will be administered IV.

 

Results

This study was done in 52 patients undergoing elective hip surgeries under spinal anaesthesia.The demographic data (age, weight, sex and ASA grading) were comparable and statistically non-significant. Equal distribution of males and females were done in both groups was done and majority of them were ASA II. Mann- Whitney test was used for statistical analysis. The time of onset of adequate level of sensory block (T10) was longer for group A (128.96 +/- 2.53 sec) than group B (95.57 +/- 2.41 sec) and was statistically significant. Duration of motor block was longer in group B (111.23 +/- 3.64 min) as compared to group A (88 +/- 3.77 min) and was statistically significant. Duration of sensory block for group B (147.5 +/- 3, 46 min) was slightly more compared to group A (141.86 +/- 4.34) and was found to be statistically significant. None of the patients required anaesthetic interventions during surgery. Less fall in blood pressure and heart rate was noted in group A compared to group B, thus there is a better hemodynamic stability.

 

Discussion

The use of ultralow dose bupivacaine plus fentanyl for spinal anaesthesia for surgical repair of hip fractures in elderly patients provides successful anaesthesia and incurs a minimum of hypotension.

The hemodynamic stability of these patients were reflected in the minimal need for vasopressor support of blood pressure The high incidence of coronary disease in this population increases the risk of ischemia secondary to hypotension.Use of single shot low dosage local anaesthetic may limit hypotension, opiods and local anaesthetics administered together intrathecally have a synergistic effect. Based on the study by Ben David we reduced the dose of 0.5% bupivacaine to 5 mg, we found marked hemodynamic stability in our cases compared to conventional dose of bupivacaine Sachi M et al conducted prospective randomized study on sixty patients undergoing elective orthopedic lower limb surgeries concluded that SAB with lower dose bupivacaine and fentanyl is more safer and better option for elderly patients undergoing lowerlimb orthopedic surgeries.

Bruce BD et al conducted a study on twenty elderly patients undergoing surgical repair of hip fracture concluded that low dose bupivacaine with fentanyl causes less hypotension and nearly eliminated the need for vasopressor support. Sumit K et al conducted a double blinded prospective study on fifty elderly patients undergoing lower limb surgery and concluded that the dose of a local anaesthetic can be safely and significantly lowered by 40% with addition of low dose sufentanil, thereby avoiding hemodynamic fluctuation. Mehdi S et al conducted a case control clinical trial on eighty elderly patients undergoing hip surgeries and concluded that SAB with low dose bupivacaine and sufentanil is safe with hemodynamic stability.

 

Tables and Graphs

 

 

Table 1: Demographics of the Study Population

 

Parameters

Group A

Group B

U Value

Z Score

P Value

Age (yrs)

77.96 ±7.32

79.23± 8.57

303.5

-0.622

0.5352

Height (cm)

159.65±7.34

158.92±7.37

305.5

0.5856

0.5552

Duration of Surgery (min)

90.84±4.68

93.73±4.14

216.5

0.5856

0.5552

Male:Female

6:20

9:17

-

-

-

ASA Grade II:III

16:10

17:9

-

-

-

 

 

 

 

Table 2: Characteristics of Spinal Block

 

Characteristics

Group a

Group b

U value

Z score

P value

Time of onset of adequate block –T 10 (sec)

128.96±2.53

95.57±2.41

0

6.1766

<0.0001*

Duration of motor block (min)

88±3.77

111.23±3.64

0

-6.1766

<0.0001*

Duration of sensory block (min)

141.86±4.34

147.5±3.46

114.5

-4.0811

<0.0001*

 

 

Table 3: Comparison of Hemodynamic Parameters among the Two Groups

 

Hemodynamic parameters

Group a

Group b

U value

Z score

P value

Pulse rate ( min)

 

 

 

 

 

0 to 5

72.38

71.65

334.5

0.0549

0.96012

5 to 10

70.38

68.34

299

0.0549

0.48392

10 to 15

69.8

66.61

263.5

0.0549

0.17702

15 to 20

68.73

66.07

266

0.0549

0.1902

20 to 25

69.88

66.03

257.5

1.4641

0.1443

25 to 30

69.3

65.8

267

1.2902

0.19706

30 to 40

70.38

66.73

230.5

1.9582

0.0500

40 to 50

70.42

67.8

257.5

1.4641

0.1443

50 to 60

70.92

67.03

268

1.2719

0.2040

60 to 75

71.11

68.11

270

1.2353

0.2149

75 to 90

70.42

67.92

280.5

1.0431

0.2983

90 to end

71.19

69.88

311

0.48498

0.6312

Systolic blood pressure (min)

0 to 5

146.53

148.38

302.5

-0.6405

0.52218

5 to 10

142

141.53

338

0.00915

0.99202

10 to 15

134.23

134.23

335.5

-0.0366

0.9681

15 to 20

133.96

128.38

249

1.6196

0.10524

20 to 25

134.23

125

179.5

2.8915

0.00386*

25 to 30

131.23

124.46

210

2.3334

0.0198*

30 to 40

135.61

127.38

189.5

2.7085

0.00672*

40 to 50

135.07

128.61

237.5

1.8301

0.0672

50 to 60

136.38

133.3

276.5

1.1163

0.2627

60 to 90

137.5

138.03

328.5

-0.16471

0.87288

90 to end

141.69

137

276

1.12552

0.25848

Diastolic blood pressure (min)

0 to 5

89.92

87.61

296

0.7595

0.44726

5 to 10

86.69

80.8

233.5

1.9033

0.05744

10 to 15

82.53

76.42

228

2.00398

0.0455*

15 to 20

82

73.3

181.5

2.85499

0.00438*

20 to 25

82.07

70.46

105.5

4.24588

<0.00001*

25 to 30

79.69

71

175.5

2.96479

0.00308*

30 to 40

81.46

70.73

126

3.8707

0.0001*

40 to 50

81.5

72.15

136

3.6879

0.00022*

50 to 60

83.03

73.96

133.5

3.7334

0.0002*

60 to 90

85.23

73.69

93.5

4.4654

<0.00001*

90 to end

85.84

76.76

146.5

3.4955

0.00046*

 

Table 4: Visual Analoge Score.

 

Pain intensity

Word scale

0

No pain

1-2

Least pain

3-4

Mild pain

5-6

Moderate pain

7-8

Severe pain

>9

Excruciating pain

 

 

Fig 1: Comparison of Pulse Rate

 

Fig 2: Comparison of Systolic Blood Pressure

 

 

Fig 3: Comparison of Diastolic Blood Pressure

 

 

Fig 4: Use of Vasopressors

 

Conclusion

Subarachnoid block with 1cc bupivacaine + 20mcg fentanyl was found to be more safer and better option, both in terms of hemodynamic stability and lower incidence of complications in elderly patients undergoing hip surgeries.

Fascia iliaca compartment block has been used effectively for providing analgesia during positioning and also in prolonging the duration of postoperative analgesia.

 

References

  1. Adams HA, Saatweber P, Schmitz CS, Hecker H. Postoperative pain management in orthopaedic patients: no differences in painscore, but improved stress control by epidural anaesthesia. Eur J Anaesthesiol. 2002; 19:658-665.
  2. Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients. Anesthesiology. 2007; 106:773-778.
  3. Sachi M, Himani D, Trupti D. Comparative study of low dose bupivacaine- fentanyl Vs conventional dose of bupivacaine in spinal anaesthesia foe orthopedic procedures in elderly patients. Gujarat medical J, 2015, 70(1)
  4. Bruce BD, Roman F, Tatianna A, Yuri M. Minidose bupivacaine-fentanyl spinal anaesthesia for surgical repair of hip fracture in the aged. Anaesthesiology, 2000, 92(1)
  5. Sumit K, Sukhminder J, Neuraxial opiods in geriatrics. A dose reduction study of local anaesthetic with addition of sufentanil in lower limb surgery for elderly patients. Saudi J of anaesthesia, 2011, 5(2).
  6. Mehdi S, Mostafa S, Nafiseh E, Hossein S, Mehrdad S, Shahrokh G. The hemodynamic effects of spinal block with low dose of bupivacaine and sufentanil in patients with low myocardial ejection fraction.Acta Medica Iranica. 2013; 51(7):438-443.
  7. Gopal ND, Krishnamurthy D.A Clinical Comparative Study of Fascia Iliaca Compartment Block with Bupivacaine and Bupivacaine with Dexmedetomidine for Positioning and Duration of Postoperative Analgesia in Fracture Femur under Spinal Anesthesia.AnesthEssaysRes. 2018;12(2):528-534. doi: 10.4103/aer.AER_56_18
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How to cite this article:
Sheetal Kumar G, Ganapathi P, Tara Nandan A. A comparative evaluation of ultralow dose bupivacaine with fentanyl versus plain bupivacaine in surgical repair of hip fractures in elderly patients. International Journal of Multidisciplinary Research and Development, Volume 8, Issue 3, 2021, Pages 01-04
International Journal of Multidisciplinary Research and Development International Journal of Multidisciplinary Research and Development