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CLINICAL INVESTIGATION
Year : 2007  |  Volume : 51  |  Issue : 5  |  Page : 409 Table of Contents     

Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique


1 MD, Associate Prof., Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam, India
2 PG Student, Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam, India

Date of Acceptance12-Aug-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Rajib Bhattacharyya
Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam
India
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Double space combined spinal epidural anaesthesia (CSEA) is one of the techniques of anaesthetic armamentarium, which can be used as the sole technique of anaesthesia and continued for relief of postoperative pain. A prospective, randomized, and controlled study was conducted involving 90 patients of ASA physical status I& II coming for elective lower limb orthopaedic surgeries, carried under spinal anaesthesia with 2.5 ml bupivacaine heavy(0.5%) given intrathecally. Epidurally,0.125% bupivacaine alone, or along with morphine 2.5 mg or tramadol 75 mg was administered postoperatively, at two segment sensory regression. The duration of analgesia or the time to first top-up dose in the study groups were 206.8 ± 97.5minutes, 507.3 ± 228.6 minutes and 399.3 ± 152.1 minutes respectively, in bupivacaine group, morphine-bupivacaine group and tramadol-bupivacaine group. None of the patients in the study groups demonstrated motor block after 2 hours of observation period. None of the patients in the study groups had respiratory depression. The double space technique is also economical to the patients, which is a major advantage in our country.

Keywords: Double space CSEA, Postoperative analgesia.


How to cite this article:
Bhattacharyya R, Dutta B. Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique. Indian J Anaesth 2007;51:409

How to cite this URL:
Bhattacharyya R, Dutta B. Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique. Indian J Anaesth [serial online] 2007 [cited 2014 Nov 23];51:409. Available from: http://www.ijaweb.org/text.asp?2007/51/5/409/61172


   Introduction Top


Double space combined spinal epidural anaesthe­sia (CSEA) is one of the techniques of anaesthetic ar­mamentarium, which can be used as the sole technique for carrying out surgical procedures and managing post­operative pain, using various drug regimes. Epidural ad­ministration of opioids, in combination with local anaes­thetic agents in low dose offers new dimensions in the management of postoperative pain. The rationale for this relatively new technique in post-operative pain manage­ment is a better quality of analgesia than that achieved by systemically administered analgesics, a lower inci­dence of side-effects, improved surgical outcome and high levels of patient satisfaction [1].

Aims and objectives of the study were:

  1. To compare the degree and duration of postopera­tive analgesia, effectiveness and complications of the drugs used.
  2. Assess the cardiovascular and respiratory changes in the postoperative period upto 24 hrs.
  3. Observe the complications of the procedure.



   Methods Top


This prospective, randomized, and controlled study was conducted involving 90 patients of both sexes be­tween the age group of 30 - 60 years and 30 - 70 kg of weight, with ASA physical status I & II coming for elec­tive lower limb orthopaedic surgeries, after taking approval from the hospital ethical committee. Patients un­der anticoagulant therapy, vertebral column disease or backache, any neurological or psychotic disorder, with difficulty in communication, septicaemia and those on MAO inhibitors were excluded from the study.

Grouping of cases: All the patients in the three groups received 2.5 ml bupivacaine heavy (0.5%) intrathecally before surgery, followed by the epidural bolus postoperatively, at two segment sensory regression, in the following manner -

Group B : 7 ml of 0.125 % bupivacaine + 3ml distilled water. Epidural top up (5 ml of 0.125% bupivacaine+ 2 ml distilled water) injected whenever VAS score becomes 4 or more.

Group BM : 7 ml of 0.125 % bupivacaine + 3 ml / 2.5 mgmorphine. Epidural top up (5 ml of 0.125 % bupivacaine + 2 ml / 0.5 mg morphine) injected whenever VAS score becomes 4 or more.

Group BT : 7 ml of 0.125 % bupivacaine + 3ml / 75 mg tramadol. Epidural top up (5 ml of 0.125 % bupivacaine + 2 ml / 15 mg tramadol) in­jected whenever VAS score becomes 4 or more.

Visual Analogue Scale (VAS) was used for record­ing the intensity of pain of the patients and for record­ing the quality of pain relief, Verbal Rating Scale (VRS) was used [2].

VAS (Visual Analogue Scale):



Verbal rating scale

1 - No pain : quality is - excellent analgesia.

2 - Mild pain : quality is - good analgesia.

3 - Moderate pain : quality is - fair analgesia.

4 - Severe pain : quality is - poor analgesia.

Bradycardia was defined as pulse rate < 60 beats per minute and hypotension was defined as reduction of MAP > or = 30% of baseline [3] . Respiratory rate, seda­tion score and arterial oxygen saturation were monitored to assess respiratory depression, which was defined as a fall of respiratory rate to 8 breaths or less per minute [4] or a sedation score of 3 [4] or a fall of arterial oxygen saturation value to less than 90% [5] . Bromage scale was used for the assessment of motor blockade [6] .

Sedation Score:

0 = none : Patient alert

1 = mild sedation : Occasionally drowsy; easily aroused

2 = moderate sedation : Frequently drowsy; easily aroused

3 = severe sedation : Somnolent; difficult to arouse

S = none : Normal sleep; easily aroused.

Bromage scale:

Grade 0 (poor relaxation) : no paralysis; preserva­tion of all joint move­ments.

Grade 1 (fair relaxation): inability to raise ex­tended legs; involve­ment of hip joints but preservation of knee and ankle joint move­ments.

Grade 2 (good relaxation): inability to flex knees; preservation of move­ments of ankle joint with absence of motor power of hip and knee joints.

Grade 3 (excellent relaxation): inability to flex the ankle and first toe, limb flaccid.

Technique

All patients were premedicated with midazolam 0.07 mg.kg -1 IM, 30 minutes before and preloading was done with Ringer's lactate infusion at 10 ml.kg -1 through an 18 G IV cannula, before starting the procedure. Ranitidine 50 mg was administered in the infusion.

The patients were placed in the lateral position and 18 G epidural needle was introduced in the L 3 rd - 4 th interspace. The epidural space was identified by loss of resistance to saline [7] . Simultaneously with the injection of saline, the needle-syringe assembly was rotated 90 degree anticlockwise so that the needle bevel faces ceph­alad. Then the epidural space was cannulated with an epidural catheter, advancing it for not more than 5 cm [8] . Epidural test dose with 60 mg of lidocaine and 15 µg of epinephrine was then injected through the epidural cath­eter and observed for any motor block or rise in the heart rate [9] . Next, the L 4th- 5 th interspace was identified, a 25 G spinal needle was introduced and 0.5% bupivacaine heavy, 2.5 ml was injected intrathecally. After position­ing the patients, surgeons were allowed to proceed with the operation once the desired level of block was achieved. The height of sensory block at 20 minutes af­ter spinal anaesthesia was noted and recorded.

Bolus epidural drugs were administered postopera­tively at "two segment sensory regression" time. All the parameters were recorded at 15 min, 30 min, 1 hr, 2 hr, 4 hr, 8 hr, 12 hr, 18 hr & 24 hrs postoperatively. The duration of postoperative analgesia was measured from the time of injection of the epidural bolus to a VAS (Visual Analogue Scale) score of 4 [10] . Top-up doses of drugs were administered whenever the VAS score became 4. Rescue analgesic (diclofenac sodium, 75 mg) was in­jected deep intramuscularly, when patients complained of inadequate analgesia even after 3 successive top-up doses given 20 minutes apart [10] and after receiving a total morphine dose of 6mg [4] and total tramadol dose of 200 mg [11] .

Statistical analysis

Observed data were compiled and analyzed statis­tically using paired and independent sample't' test to assess the variance between the preoperative and post­operative value, and to assess the statistical significance between the groups. A P-value of < 0.05 was consid­ered just significant, < 0.01 as highly significant and < 0.001 as very highly significant.


   Results Top


The groups were comparable with regard to age, sex, height, weight and ASA physical status.

VAS Score [Table 1]: All the patients in the three groups had VAS = 0, in the immediate postoperative period and at two segment sensory regression. Group BM had least VAS score throughout observation. Group BT had intermediate VAS scores [Figure 1].

VRS Score [Table 2]: All the patients in the three groups had excellent analgesia in the immediate postop­erative period and at 2 segment sensory regression. Group BM had longest duration of excellent analgesia, while Group BT was intermediate [Figure 2].

The duration of analgesia [Table 3] or the time to first top-up was longest in Group BM (P < 0.001) and intermediate in Group BT [Figure 3].

The no. of top-up doses given in the postoperative period, was highest in Group BM, intermediate in Group BT and least in Group B (P < 0.001).

The dose of bupivacaine received by the patients in Group BM was 17.5 ± 6.23 mg, in Group BT 25.2 ± 4.78 mg and in Group B, it was 37.7 ± 5.56 mg (P < 0.001).

The average morphine dose (in mg) received by patients of Group BM was 3.9± 0.49 and that of tramadol in Group BT was 135.5 ± 11.47. In Group B, 5 patients required rescue analgesic postoperatively, unlike the other two groups.

Urinary retention was noted in maximum12 (40%) patients in Group BM, followed by 5 (16.6 %) and 4 (13.3 %) patients in Group BT and B respectively. Nau­sea and vomiting was seen in 7 (23.3%) patients in Group BM, followed by 6 (20 %) and 2 (6.67 %) patients in Group BT and B respectively. Pruritus was observed in 1 patient in Group BM. Only 3 patients (10%) in Group BM had sedation score of 1 at 2 hour observation time.

Traumatic epidural puncture was observed in 1 patient each in Group B& BM, and in 2 patients in Group BT (Total of 4.44 % in the three groups). Backache was noted in 1 patient each in Group B, BM and BT. One patient in Group B had unilateral spinal anaesthe­sia.

Pulse rate, mean arterial pressure, respiratory rate, Bromage scale & SpO 2 did not differ significantly among the patients of the three groups (P > 0.05).

In 4 patients, the study could not be carried out due to inadvertent dural puncture (1 patient - 1.11%), failure of epidural catheterization (1 patient - 1.11%) and fail­ure to give spinal anaesthesia (2 patients - 2.22%).


   Discussion Top


Any method of postoperative analgesia must meet three basic criteria; it must be effective, safe and fea­sible. The majority of the patients after surgery man­aged with parenteral drugs are left with unrelieved pain [12] . The discovery of opioid receptors in the brain and spinal cord started a new era in the field of postopera­tive analgesia [13] .

In our study the double space technique was pre­ferred to the single space CSE technique, since one can perform the epidural test dosing in this technique, with almost no chance of the catheter being pushed intrathecally [14] and it is quite economical to the patients.

The analgesic mixture was administered when the patients were still under the influence of spinal anaes­thesia, as poor analgesic response has been reported with epidural morphine when the drug was administered af­ter the onset of pain [15] . The concentration of bupivacaine exceeding 0.125% may be associated with excessive motor blockade when used in epidural infusions in the lumbar region [16] .

Post-operative analgesia using relatively small doses (2 - 4 mg intermittent boluses) of epidural mor­phine was safe on post-surgical wards [17] . We used a tramadol dose of 75 mg because, the analgesic efficacy of tramadol via the epidural route, was equipotent to morphine in a dose ratio of about 30:1 [18] .

The total 24 hour morphine dose was kept at or below 6 mg and that of tramadol at or below 200 mg, as epidural morphine dose of more than 6 mg is a risk fac­tor for developing respiratory depression [4] and epidural tramadol in a dose of 200 mg can be administered for the relief of postoperative pain [11] .

Maximum duration of analgesia was with morphine­ bupivacaine (507.3 min), while it was 399.3 min with tramadol-bupivacaine and 206.8 min with bupivacaine alone. Using continuous infusion of analgesic regime and maintaining a sustained plasma level of the drugs and consequently a longer duration of analgesia (10.9 hours with epidural morphine and 16.0 hours with epidural morphine-levobupivacaine combination) was observed in patients undergoing major abdominal surgeries [16] . Kotur et al using 75 mg of tramadol with lidocaine-adrenaline reported a duration of analgesia of 327.6 ± 58.8 min [19] .

In our study, none of the patients in the study groups had respiratory depression. Absence of clinically relevant respiratory depression and safety for postoperative pain relief was reported with epidural tramadol [20] . Yaddanapudi et al using 3 mg of morphine and 50mg of tramadol for postoperative analgesia in patients under­going laminectomy did not find any occurrence of respi­ratory depression in their patients [21] .

3 (10%) of the patients in morphine-bupivacaine group had sedation score of 1 at 2 hour observation pe­riod and subsequently during the entire observation pe­riod, they had "no sedation".

Due to the very low concentration of bupivacaine none of the patients in the present study demonstrated motor block after 2 hours of observation period.

The incidence of nausea and vomiting, and that of urinary retention were comparable to previous studies [22],[23] . Magora et al explained epidural opioid-induced uri­nary retention on the basis of increased tone of detrusor muscle and vesical sphincter [24] .

Opioid-related pruritus is usually limited to the face and torso [25] . Its mechanism is not known but it appears to be centrally mediated. Release of histamine has also been considered to be a causative factor [26] and antihis­tamines often provide symptomatic relief [4] .

None of our patients reported other side effects like hypotension, bradycardia, shivering, dizziness, PDPH, convulsions etc.

Incidence of inadvertent dural puncture also, cor­relates well with the study by Giebler et al [27] .


   Conclusion Top


Tramadol is an atypical opioid which acts as a weak agonist for all types of opioid receptors. In addition, it has non-opioid mechanisms of analgesia by inhibition of noradrenaline uptake and stimulation of serotonin release, which probably account for its potent analgesia and neg­ligible opioid-related side effects, especially respiratory depression (high benefit-risk ratio). Epidural administra­tion of tramadol hydrochloride is a simple, effective and safe method to provide moderately prolonged postop­erative analgesia, but epidural morphine is a better op­tion in terms of providing excellent postoperative anal­gesia in lower limb orthopaedic surgeries.

 
   References Top

1.Ferrante FM, VadeBoncouer TR. Epidural analgesia with com­binations of localanaesthetics and opioids. In:Editors - Ferrante FM, VadeBoncouer TR; 1st Edition, Postoperative Pain Man­agement. USA: Churchill Livingstone Inc 1993;305-334.  Back to cited text no. 1      
2.Seymour RA. The use of pain scales in assessing the efficacy of analysis in postoperative dental pain. Eur J Clin Pharmacol 1982; 23:441.  Back to cited text no. 2      
3.David LB. Miller's Anesthesia, 6th Edition. USA: Churchill Livingstone 2005;1653-1683.  Back to cited text no. 3      
4.Ready LB. Regional analgesia with intraspinal opioids. In: Edi­tors - JohnD. Loeser, Stephen H. Butler, C. Richard Chapman; 3rd edition, Bonica's management of pain. Lippincott Williams& Wilkins 2001;1953-1966.  Back to cited text no. 4      
5.Baraka A, S Jabbour, M Ghabash, A Nader, G Khoury and A Sibai. A comparison of epidural tramadol and epidural mor­phine for postoperative analgesia. Can JAnaesth 1993; 40:308­313.  Back to cited text no. 5      
6.Bromage PR. Philadelphia: WB Saunders; 1978: 144.  Back to cited text no. 6      
7.Armitage EN. Principles and Practice of RegionalAnaesthesia, 3 rd edition. UK: Churchill Livingstone Inc. 2003: 139-167.  Back to cited text no. 7      
8.Browne RA, Politi VL. Knotting of an epidural catheter: a case report. Can Anaesth Soc J 1979; 26:142-144.  Back to cited text no. 8      
9.Poblete B, Van Gessel EF, Gaggero G, Gamulin Z. Efficacy of three test doses to detect epidural catheter misplacement. Can J Anaesth 1999; 46:34-39.  Back to cited text no. 9      
10.P Malik, et al. Comparative evaluation of epidural tramadol and morphine for postoperative analgesia. Eg J Anaesth 2005; 21: 135 - 40.  Back to cited text no. 10      
11.Baraka A, Siddik-Sayyid, Aouad-Maroun M, Sleiman D, Sfeir M. Epidural tramadol for postoperative pain after Cesarean section. Can J Anaesth 1999; 46:731-5.  Back to cited text no. 11      
12.Moote C Technique for postoperative pain management in the adult. Can J Anaesth 1993; 63:189-195.  Back to cited text no. 12      
13.Gilbert PE, Martin WR. The effects of morphine and nalor­phine-like drugs inthe nondependent, morphine-dependent and cyclazocine-dependent chronic spinal dog. Journal of Pharma­cology and Experimental Therapeutics 1976; 198: 66-82.  Back to cited text no. 13      
14.Eldor J, Guedj P, Levine S. Delayed respiratory arrest in com­bined spinal-epidural anesthesia. Reg Anaesth 1994; 19:418­-422.  Back to cited text no. 14      
15.Chambers WA, Sinclair CJ, Scott DB. Extradural morphine for pain after surgery. Br J Anaesth 1981; 53:921-925.  Back to cited text no. 15      
16.James C. Crews,AllenH. Hord, Donald D. Denson, and Carmen Schatzman. A Comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0.005% morphine alone for the man­agement of postoperative pain in patients undergoing major abdominal surgery. Anesth Analg 1999; 89:1504.  Back to cited text no. 16      
17.Glass PSM, Estok P, Ginsberg B, et al. Use of patient-con­trolled analgesia to compare the efficacy of epidural to intrave­nous fentanyl administration. Anesth Analg 1992; 74:345-351.  Back to cited text no. 17      
18.Chrubasik J, Warth L, Wust H, et al. Pain 1988; 9:12-18.  Back to cited text no. 18      
19.Kotur PF, Suresh SN, Anupama L: www.jnmc.edu (accessed on 18/01/06).  Back to cited text no. 19      
20.Houmes RJ, Voets MA, VerkaaikA, ErdmannW and Lachmann B. Efficacy and safety of tramadol versus morphine for moderate and severe postoperative pain with special regard to respi­ratory depression. Anesthesia& Analgesia 1992; 74:510-514.  Back to cited text no. 20      
21.Yaddanapudi LN, Wig J, Singh B, Tewari MK. Comparison of efficacy and side effects of epidural tramadol and morphine in patients undergoing laminectomy : a repeated dose study. Neurol India 2000;48:398-400.  Back to cited text no. 21  [PUBMED]  Medknow Journal  
22.Delilkan AE, Vijayan R: Epidural tramadol for postoperative pain relief. Anaesthesia 1993; 48: 328-331.   Back to cited text no. 22      
23.Stenseth R, Sellevold O, Breivik. Epidural morphine for post­operative pain relief: Experience with 1085 patients. Acta Anaesthesiol Scand 1985; 29:148-156.  Back to cited text no. 23      
24.Magora F, Olshwang D, Eimerl D, et al. Observations on extra­dural morphineanalgesiain various painconditions. Br JAnaesth 1980; 52:247-251.  Back to cited text no. 24      
25.Benedetti C. Intraspinal analgesia: a historical overview. Acta Anaesthesiol Scand 1987; 31 (Suppl 85):17-24.  Back to cited text no. 25      
26.Greaves MW, Wall PD. Pathophysiology of itching. Lancet 1996; 348:938-940.  Back to cited text no. 26      
27.Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization. An­esthesiology 1997; 86: 55-63.  Back to cited text no. 27      


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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