A COMPARATIVE STUDY EFFECT OF INTRATHAECAL TRAMADOL (20MG) USE AS ADJUVANT WITH HYPERBARIC BUPIVACAINE (15MG) AND HYPERBARIC BUPIVACAINE FOR POSTOPERATIVE ANALGESIA IN INFRAUMBILICAL SURGERIES

Dr. Sunita Meena 1 ,Dr. Rakesh Agarwal 2 and Dr. Ramesh Chandra Sunar 3 . 1. Assistant Professor ,Department of Anaesthesia,SMS Medical College,Jaipur Rajesthan India. 2. junior specialist, ,Department of Anaesthesia,SMS Medical College,Jaipur Rajesthan India. 3. Senior Professor, ,Department of Anaesthesia,SMS Medical College,Jaipur Rajesthan India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Various types of medications can be used to overcome pain but opioids provide the most effective pain relief and are a standard of care (1).
Intrathecal opioids administration has been demonstrated to provide effective postop analgesia after a variety of surgical procedures at the cost of increased risk of respiratory depression (2). Tramadol ,in contrast to a centrally acting opioid analgesic, has minimal respiratory depressant effect (3,4), because it has 6000 fold less affinity for µ receptors compared to morphine (5,6) .It also inhibits serotonin and norephinephrine reuptake in the spinal cord and has no reported neural toxicity (7). Therefore ,tramadol has the potential to provide effective postoperative analgesia ,with no risk of respiratory depression after central neuraxial administration. . However, pruritus, nausea, vomiting, urinary retention, activation of herpes labialis [8] and risk of unpredictable respiratory depression [9,10] have directed the clinicians to use a lower dose of tramadol that can be used intrathecally to produce effective and prolonged analgesia without such complications.
In view of this we planned this present study to effect of tramadol as adjuvant with bupivacaine intrathecally on postop duration of requirement of first rescue of analgesia in various infraumbilical surgeries.

Material and method:-
This study was prospective randomized double blind placebo controlled study was conducted at SMS Medical college and attached hospital Jaipur,After taking approval by the ethical committee and obtaining a well informed written consent from patients ,total 56 patients ,ages of 30-60yrs,of either sex (ASA status grade 1&2) who were scheduled for infraumbilical surgeries likes open appendectomy,inguinal hernia repair,hydrocele,TURP,abdominal hysterectomy,orchidectomy included in study.Patients who had history of local anaesthetic drug allergy,ASAgrade 3&4,chronic opioid therapy opioid addict, patients on pain modifying drugs,contraindication of spinal anaesthesia were excluded from the study.Every patients was assessed properly in pre-anaesthetic clinic one day prior to surgery.All patients were instructed to NBM 8 hrs ,premedicated with Tab Ranitidine 150 mg and Tab Alprazolam 0.5 mg orally the night before and also on the morning of surgery.
After arrival of patient in OT an I.V. line was secured with 18G or 20G canula and standard monitoring including NIBP cuff, ECG leads and pulse oximeter were monitored.baseline parameters like NIBP,SPO2,pulse rate,respiratory rate were noted.
All selected patients were made familiar with VAS for grading of postoperativepain intensity. Patient were randomly divided into two groups of 28 each,using chit in box method in double blind manner. Group A(N-28)received 3 ml of hyperbaric bupivacaine 0.5% with 0.4ml of normal saline ,Group B (N-28) received 3 ml of hyperbaric bupivacaine 0.5% with tramadol (20mg) 0.4ml injected intrathecally. Preloading was done with ringer lactate at a dose of 10 ml /kg B.W.within 30 minutes .The procedure of SAB was explained to the patients,after taking all aseptic precautions and proper draping .Lumber interspace either L3-L4 was identified in sitting position & infiltrated with injection Xylocaine HCL 1% .Subarachnoid space was identified by using a 25 G whit-care spinal needle and once free flow of csf appeared.
Vital parameters like pulse ,blood pressure, oxygen saturation ,RR along with onset & duration of motor and sensory blockade, pain scores VAS 4 & sedation scores (Ramsey sedation score)5 were checked every minute for first 5 min every 5 min for the next 15 min and every 10 min thereafter till end of procedure.
Duration of surgery was noted at end of surgery.Patient shifted to post anaesthesia care unit for continued vital monitoring without any prophylactic analgesic .

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VAS score,sedation score,level of sensory & motor blockade were noted every 15 min for first 2 hrs ,every 30 min next 4 hrs and thereafter at 2 hr interval for 24hrs.
Duration of analgesia was considerd as interval from time of intrathecal injection to the time of first rescue of analgesia demanded postoperatively or VAS score was more than 4.Injection Diclofenac 1.5mg/kg I.M. was used as a rescue analgesia.
The patients were followed up postoeratively till recovered completely and sensory & motor block and analgesia.
Stastical analysis was performed by computer software SPSS, version 20 for windows stastical software package (SPSS inc .,Chicago,il,USA).Discrete variables were expressed as counts (%) and compared using the Chi-sqare tests .Continuous variables were expressed as mean± S.D. and compared using students t-test.Probability was considerd to be Statistical significance if P<0.05.

Results:-
Total 56 patients were allocated randomly in two group 28 in each group .No stastically significant difference was found by applying unpaired Ttest p>0.05 in demographic data.  Changes in VAS score for pain were significant from 3.5 hrs onwards upto5hrs.Visual analog score were low in group B than group A. There was no significant difference between haemodynamic parameters(SBP,DBP.HR).
Side effects observed in group B were nausea ,vomiting in 5 patients and urinary retention in 2 patients. Two patients group A had nausea and vomiting while one had urinary retention.

Discussion:-
Pain in the post-operative period is one of the major factors that impede recovery from anaesthesia and surgery.Subarachnoid block is a easy,early and effective method of regional anaesthesia for postoperative analgesia in lower abdominal and lower limb surgeries. Various adjuvants used with local anaesthtic intrathecally to prolonged analgesia like morphine,buprenorphine,fentanyl sufantanil,ketamine ,clonidine etc.
Tramadol is a centrally acting analgesic agent with a terminal elimination half life 5.5 hrs and provides clinical analgesia for 10 hrs after epidural administration (11,12). Tramadol stimulates the µ receptors and to a lesser extent the delta and kappa receptors.It also activates spinal inhibition of pain by decreasing the reuptake norepinephrine and serotonin.Although tramadol is one fifth as potent as morphine as an analgesic ,it causes less respiratory depression and pruritus.. It was suggested by other studies that tramadol have local anaesthetic effects on peripheral nerves (7).
The present study had demonsrated that intrathecal tramadol (20 mg) used as adjuvant with 0.5% hyperbaric bupivacaine (15 mg) prolonged the postoperative analgesia in infraumbilical surgeries without any significant side effect like nausea vomiting,pruritus,respiratory depression.
In the present study there was no significant difference between groups in the pattern of decrease in systolic or diastolic blood pressure during this period. Alsheshmi et al (2003) (13) found that Intrathecal tramadol did not seem to influence the intraoperative hemodynamic profile .
Rakshith B Prasad et al 2015 (14) studied effectiveness of addition of intrathecal tramadol (10 mg)with hyperbaric bupivacaine(10 mg) in prevention of shivering in caesarean section. They were found that tramadol along with bupivacaine intrathecally significant role in reducing anaesthesia induced shivering in parturients while prolonging both sensory and motor components of subarachnoid block.They were found Mean±SD time for first postoperative analgesic request (min) in tramadol group (232.18±80.55) and bupivacaine group(176.56±47.39).
In our study Mean±SD duration of requirement of first rescue analgesia in bupivacaine -tramadol group 324±5.79min than bupivacaine group 180±8.99 min showed significant difference(p-value,0.001),thus highlighting the fact that group B had prolonged postoperative analgesia.Use of tramadol as adjuvant with bupivacaine intrathecally prolonging duration of analgesia

Conclusion:-
In our study we found that tramadol (20mg) adjuvant with bupivacaine given intrathecal route significantly early onset and prolonging duration of sensory and motor blockade, provide effective postoperative analgesia and prolongs the duration for first rescue analgesia without any significant difference in side effects and haemodynamic parameter .Tramadol (20mg) with hyperbaric bupivacaine 0.5% (15mg) intrathecally good for intra and postoperative pain and discomfort peritoneal and intestinal manipulation in various infraumbilical surgeries.