|Year : 2008 | Volume
| Issue : 3 | Page : 301-304
Comparison of Effect of Intrathecal Sufentanil-Bupivacaine and Fentanyl-Bupivacaine Combination on Postoperative Analgesia
Ishwar Singh1, Monika Gupta2, Bablesh Mahawar3, Abhishek Gupta3
1 Chairperson, Department of Anaesthesiology, Jaipur Golden Hospital, 2 Institutional Area, Sector-3, Rohini, New Delhi, India
2 Consultant, Department of Anaesthesiology, Jaipur Golden Hospital, 2 Institutional Area, Sector-3, Rohini, New Delhi, India
3 Resident, Department of Anaesthesiology, Jaipur Golden Hospital, 2 Institutional Area, Sector-3, Rohini, New Delhi, India
|Date of Acceptance||25-Apr-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesiology, Jaipur Golden Hospital, 2 Institutional Area, Sector-3, Rohini, New Delhi
Source of Support: None, Conflict of Interest: None
Fifty ASA grade I/II patients scheduled for elective lower abdominal, lower limb and urological procedures were divided into two groups of 25 each .The first group (Group S) received 2.5 ml of heavy bupivacaine with 0.2. ml sufentanil made up to 3 ml with saline. The second group (Group F) received 2.5 ml of heavy bupivacaine with 0.5 ml of fentanyl. From our study it can be concluded that bupivacaine sufentanil combination although had shorter onset of action, but had more side effects especially nausea, vomiting and headache. The time for rescue analgesia in both groups was however similar.
Keywords: Intrathecal, Heavy bupivacaine, Sufentanil, Fentanyl
|How to cite this article:|
Singh I, Gupta M, Mahawar B, Gupta A. Comparison of Effect of Intrathecal Sufentanil-Bupivacaine and Fentanyl-Bupivacaine Combination on Postoperative Analgesia. Indian J Anaesth 2008;52:301-4
|How to cite this URL:|
Singh I, Gupta M, Mahawar B, Gupta A. Comparison of Effect of Intrathecal Sufentanil-Bupivacaine and Fentanyl-Bupivacaine Combination on Postoperative Analgesia. Indian J Anaesth [serial online] 2008 [cited 2020 Jun 6];52:301-4. Available from: http://www.ijaweb.org/text.asp?2008/52/3/301/60638
| Introduction|| |
Adequate postoperative pain control is essential to prevent adverse consequences of surgical insult. The administration of local anaesthetics in combination with opioids intrathecally , is an excellent technique for managing postoperative pain following abdominal, pelvic , thoracic or orthopaedic procedures on lower extremities. Discovery of opioid receptors in spinal cord triggered the usage of intrathecal opioids. 
Local anaesthetics with opioids demonstrate significant synergy. They provide excellent analgesia with fewer drug requirements and decreased side effects.
As there are a handful of studies comparing efficacy of intrathecal fentanyl  and sufentanil with bupivacaine, we decided to compare these two drugs in combination with bupivacaine in our present study and assess their effect on duration of sensory block, correlating it with duration of postoperative pain relief.
| Methods|| |
The present study was conducted in the Department of Anaesthesiology at Jaipur Golden Hospital, after obtaining institutional official committee clearance and written informed consent. Fifty ASA grade I/II patients aged 18-60 yrs scheduled for elective lower abdominal, lower limb and urological procedures were selected. Exclusion criterion taken were, known contraindication to regional anaesthesia, known sensitivity to study drugs. Patients taking drugs that modify pain perception were excluded from the study.
All patients were examined a day before surgery. All were kept fasting overnight and received diazepam 0.2mg.kg -1 orally as premedication. On the OT table, patients pulse, blood pressure,oxygen saturation,ECG were recorded, intravenous line was secured and all were preloaded with Ringer lactate 15 ml.kg -1 . These patients were randomly assigned using sealed envelop technique to two groups in a double blind manner. Group S (n=25) received 2.5 ml of heavy bupivacaine with 0.2. ml sufentanil made up to 3 ml with saline. Group F (n=25) received 2.5 ml of heavy bupivacaine with 0.5 ml of fentanyl.
The anaesthesiologist giving the subarachnoid (S A) block in lateral position in L3-4 space with 25 gauze LP needle was blinded to the solution administered intrathecally. Patients were made supine and following were noted:- time of SA block, time of onset of sensory block (assessed by pin prick), maximum level of sensory block achieved and time to achieve maximum level. Duration of surgery and time for rescue analgesia was also noted. Pulse rate and blood pressure was monitored every 5 min intraoperatively and every 30 min postoperatively till rescue analgesia was given. Hypotension was defined as >20% decrease in SBP from baseline and was treated with IV fluids and IV mephenteramine 3 mg in incremental boluses. Bradycardia (pulse <60 beats/min) was treated with IV atropine sulphate. Adverse effects such as nausea, vomiting, sedation, pruritus, urinary retention were also recorded. No other sedative or analgesic was given to the patients intraoperatively. Postoperative rescue analgesia in form of diclofenac sodium (1.5 mg.kg -1 ) i.m. was given on patient's demand. Duration of pain relief was taken from onset of SA block to time of administration rescue analgesia.
Data was analysed using statistical tests, ChiSquare test and Student's t-test. P<0.05 was considered statistically significant.
| Results|| |
[Table 1] and [Table 2] shows the baseline characteristics of the groups. There was no significant difference in patient's age [Table 1] and sex [Table 2] in both the groups. Maximum patients in Group S were in the range of 31-40 yrs and in Group F 21-30yrs.
The mean value of onset time of sensory block as assessed by loss of pain sensation by pin prick method in Group S was 1.88+0.92 min and in Group F was 2.72+1.51min. This difference was found statistically significant [Table 3].
Mean time to achieve peak sensory level in Group S was 6.6min and 8.48min in Group F. The difference was again statistically significant [Table 3].
The duration of surgery in Group S was 73.72+30.96 min. and Group F 103.6+44.9min.Time for rescue analgesia in Group S was 378.6+178.00 and in Group F was 331.00+131.24. The difference was not statistically significant[Table 3] in both the groups.
Hypotension and bradycardia in both groups were statistically insignificant with P value>0.05. Nausea was found significant in Group S ( 6 patients had nausea ), whereas none in Group F. Headache was found highly significant in Group S (8 patients had headache whereas none in group F) [Table 4].
| Discussion|| |
We found that onset of sensory block was faster and time to reach peak sensory level was lesser with sufentanil as compared to fentanyl. However there was no significant difference in duration of analgesia in both groups.
Side effects especially nausea and headache were significantly more in sufentanil group, headache being a highly significant finding in sufentanil group.
Not going into details of mechanism of opioid analgesia through actions on dorsal horn of spinal cord and the opioid receptors (a well studied subject)we come to the differences which we found in the actions of the two drugs used in our study i.e.fentanyl  and sufentanil. 
Sufentanil had a shorter onset of action as compared to fentanyl in our study. Also time to reach peak sensory level was shorter in sufentanil group. As we know the physiochemical feature of opioids depends on their lipid solubility, the more lipid soluble the drug the faster will be its penetration and absorption explaining faster onset with sufentanil which is twice as lipid soluble as fentanyl.  The unionized fraction of sufentanil at physiologic pH is also found to be more (sufentanil 20% unionized at pH 7.4,fentanyl <10% unionized) again explaining faster onset.
Incidence of side effects like hypotension and bradycardia were similar in both groups.
Nausea was significantly more in sufentanil group  . Opioids stimulate CTZ in prostrema of medulla possibly through delta receptors. This combined with other actions on GI tract promotes nausea and vomiting. There is little evidence suggesting that one opioid is consistently more emetogenic than other. However in our study sufentanil was found more emetogenic.
As regards headache no study till date has mentioned this side effect which was a highly significant finding in our study. Increase in ICP following sufentanil administration (which has been seen in patients with intracranial tumour given sufentanil ) could possibly explain the cause of headache  But a definite explaination yet remains to be found.
We therefore recommend the use of fentanyl over sufentanil for intrathecal administration.
| References|| |
|1.||Torda T A, Hann P , Mills G , Leon De et al. Comparison of extra dural fentanyl, bupivacaine and two fentanylbupivacaine mixtures for pain relief after abdominal surgery. British Journal of Anesthesia 1995;74:35-40. |
|2.||Tan Ping-Heng, Chia Yuan-Yi, Lo Yuan, Liu Kang, Yang Lin-Chang et al. Intrathecal bupivacaine with morphine or neostigmine for post operative analgesia after total knee replacement surgery. Canadian Journal of Anesthesia 2001;48:551-56. |
|3.||Saldman L J, Cousins M J, Mather Le. Intrathecal and epidural administration of opioids. Anesthesiology 1984;61:276-310. |
|4.||Ginosar Yehuda, Columb M O, Cohen S E, et al. The site of action of epidural fentanyl infusions on the presence of local anesthetics: A minimum local analgesic concentration infusion study in nulliparous labor. Anesthesia Analgesia 2003;97:1439-1445. |
|5.||Srivastava Uma, Kumar Aditya, Gandhi N K, et al. Hyperbaric or plain bupivacaine combined with fentanyl for spinal anesthesia during caesarean section. Indian Journal of Anesthesia 2004;48:44-46. |
|6.||Joris J L, Jacob E A, Sessler D I, Deleuse J F J, et al. Spinal mechanisms contribute to analgesia produced by epidural sufentanil combined with bupivacaine for post operative analgesia. Anesthesia Analgesia 2003;97:1446-1451. |
|7.||Cherng Chen-Hwan, Wong Chih-Shung, Ho Shung-Tai. epidural fentanyl speeds the onset of sensory block during epidural lidocaine anesthesia. Regional Anesthesia and Pain Medicine 2001;26:523-526. |
|8.||Langevin Stephan, Lessard M R, Trepanier C A, Baribault J P. Alfentanil causes less post operative nausea and vomiting than equipotent doses of fentanyl or sufentanil in outpatients. Anesthesiology 1999;91:1666-1673. |
|9.||Marx W, Shaha N, Long C, et al. Sufentanil, Alfentanil and fentanyl:Impact on cerebrospinal fluid pressure in patients with brain tumour. Journal of Neurosurgery Anesthesia1989;1:3. |
[Table 1], [Table 2], [Table 3], [Table 4]