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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 48-52

A comparative study of nalbuphine and fentanyl as adjuvants to bupivacaine in spinal anesthesia in lower limb orthopedic surgeries


Department of Anesthesiology, Critical Care, and Pain Management, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan 302022, India

Date of Submission22-Feb-2022
Date of Acceptance06-Jun-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Khushbu M Parekh
Room No. 202, Ashish Heights Flats, Opposite Mahatma Gandhi Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DYPJ.DYPJ_17_22

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  Abstract 

Background: Subarachnoid block is the most common technique employed for lower limb orthopedic surgeries. Adjuvants such as fentanyl and nalbuphine are added to increase the duration of post-operative analgesia. This study aimed to compare the efficacy of nalbuphine and fentanyl as adjuvants to bupivacaine in providing intra-operative anesthesia and post-operative analgesia in lower limb orthopedic surgeries. Objectives: The aim of this article is to compare the characteristics of sensory and motor block, hemodynamic parameter, time of first rescue analgesia, and adverse effects between the two groups. Materials and Methods: In this clinical trial, 80 patients undergoing elective lower limb orthopedic surgeries under spinal anesthesia were randomly allocated into two groups. In group BN, the patients received 0.5% 3 mL (H) bupivacaine + 800 mcg nalbuphine. In group BF, the patients received 0.5% 3 mL (H) bupivacaine + 25 mcg fentanyl. In both the groups, characteristics of sensory and motor block and time for first rescue analgesia were compared. Results: The onset of motor block, the maximum level of the block, and time to reach the peak level of the block were significantly faster in the BF group. Duration of motor block and time for first rescue analgesia were significantly prolonged in the BN group. However, there was no significant difference in time for two-segment regression [P = 0.157 (NS)] and hemodynamic changes. Conclusion: We conclude that combination of fentanyl as adjuvant to bupivacaine provides higher segmental level sensory blockage and faster sensory and motor blockage than nalbuphine. But nalbuphine gives longer time of post-operative analgesia than fentanyl did.

Keywords: Bupivacaine, fentanyl, nalbuphine, subarachnoid block


How to cite this article:
Parekh KM, Gupta N, Sachdeva S, Jethava D. A comparative study of nalbuphine and fentanyl as adjuvants to bupivacaine in spinal anesthesia in lower limb orthopedic surgeries. D Y Patil J Health Sci 2022;10:48-52

How to cite this URL:
Parekh KM, Gupta N, Sachdeva S, Jethava D. A comparative study of nalbuphine and fentanyl as adjuvants to bupivacaine in spinal anesthesia in lower limb orthopedic surgeries. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Nov 27];10:48-52. Available from: http://www.dypatiljhs.com/text.asp?2022/10/2/48/361364




  Introduction Top


“For all the happiness, mankind can gain is not in pleasure, but in rest from

Pain”- John Druden (1931-1701)

Effective pain control is essential for optimal care of all surgical patients. As per the International Association for Study of Pain (IASP), description of pain is “an awful sensitive and emotional experience associated with factual or remarkable tissue damage, or descried in term of similar damage.” Excellent control of post-operative pain leads to earlier rallying, smaller pulmonary and cardiac complications, a lower chance of deep vein thrombosis, before recovery with lower likeliness of the progression of neuropathic agony, drop cost of care, enhancing patients’ satisfaction.[1]

The point of good agony with pain management is to diminish it to a comfortable level. A multi-disciplinary way is to deal with pain management by providing regional anesthesia. Centrally acting analgesics such as paracetamol, peripheral non-steroidal anti-inflammatory drugs, and opioids enhance pain relief, better patients’ outcomes, improve efficacy, and reduce drawbacks, including the long-term satisfaction of reduced risk of developing chronic pain.[2]

Spinal anesthesia is simple to perform, offers quick onset of action, and relatively has less drawbacks. So, it is the choice of technique for lower limb surgeries.[3] There are numerous benefits of neuraxial anesthesia over general anesthesia, like decline in incidence of strain reaction to surgery with post-operative analgesia. But only one local anesthetic drug given as spinal anesthesia provides a brief period of analgesia post-operatively.[4]

Bupivacaine, synthesized by Ekenstam in 1957, has protracted duration of action and low toxicity.[5] Various adjuvants such as morphine, midazolam, dexmedetomidine, and clonidine have been added and practiced with local anesthetics in regional anesthesia to nullify intra-operative visceral and somatic agony and to offer prolonged duration of post-operative agony.[6]

Opioids particularly lessen nociceptive input from A delta and C fibers unaccompanied by influencing dorsal root axons or somatosensory-evoked potentials. Various u-agonist opioids such as morphine, tramadol, nalbuphine, and fentanyl are added as additives to hyperbaric bupivacaine to lengthen its clinical efficacy and to lessen the need of post-operative analgesics.[4]

In this study, we compare nalbuphine and fentanyl as adjuvants to hyperbaric bupivacaine for lower limb orthopedic surgeries.


  Materials and Methods Top


A detailed pre-anesthetic evaluation of the patient was performed by an anesthesiologist a day before the surgery. The patient was kept nil by mouth for 8 h. Preliminary investigation was noted.

In the operating room, standard five-lead ECG, non-invasive blood pressure (NIBP), and pulse oximetry (SpO2) were attached and baseline parameters were noted. Intravenous (IV) access was secured using a 20G cannula on the dorsum of the hand.

Under all aseptic precautions, a subarachnoid block was given after local infiltration of the skin with 2% lignocaine using a 25G Quincke spinal needle at the level of L3-4 or L4-5 interspace via the midline approach in the sitting position.

After free flow of the cerebrospinal fluid, the following combination was given:

Group N received 3 mL of 0.5% heavy bupivacaine with 800 mcg nalbuphine (diluted in normal saline to make a total volume of 3.5 mL) intrathecally.

Group F received 3 mL of 0.5% heavy bupivacaine and 0.5 mL (25 mcg) fentanyl (total volume 3.5 mL) injected in the subarachnoid space.

After the subarachnoid block, patients were placed supine and evaluated for sensory and motor block characteristics. Sensory block was checked using a pinprick method in a caudal-to-cephalad direction in mid-axillary line every 2 min for 15 min and then every 15 min until the completion of surgery.

The assessment of motor block was done using a modified Bromage scale:

0=able to flex the whole lower limb at hip;

1=able to flex the knee but unable to raise leg at hip;

2=able to flex the ankle but unable to flex knee;

3=no movement of lower limb.

The peak sensory block level, time to reach peak sensory block level, time for two-segment regression, onset of motor block, and duration of motor block were recorded.

Sensory and motor block was assessed every 2 min for 15 min and then every 15 min until complete regression. Hemodynamic changes such as pulse rate and blood pressure were monitored. Bradycardia was treated with inj. atropine sulfate 0.6 mg IV. Hypotension was treated with inj. mephentermine as per requirement.

Pain was assessed using a visual analog scale (VAS). It is a 0–10 pain rating scale: score 0 is considered as no pain and score >4 considered as a need for rescue analgesia. Time for first rescue analgesia was recorded, and injection paracetamol 1 g IV was given as rescue analgesia.

The duration of pain relief is defined as the time from intrathecal injection to first request for supplemental (rescue) analgesia.

Heart rate, blood pressure, respiratory rate, and sedation score were recorded.

Patients were assessed using a 10-point VAS.

Statistical analysis

Statistical analysis was performed with SPSS version 21 for Windows (SPSS Inc., Chicago, IL, USA). Categorical variables were presented as numbers (percent) and were compared between the groups using the χ2 test. Quantitative variables were presented as mean and standard deviation and were compared by Student’s t-test. Results are considered to be significant if the P-value was less than 0.05.


  Results Top


A total of 70 patients completed the study. Demographic data including age, sex, American Society of Anesthesiologists status, and surgery duration were statistically comparable in both the groups [Table 1].
Table 1: Demographic profile of participants

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[Table 2] shows that in group BF greater number of (67.50%) patients achieve level T6 compared with group N (25%), and in group BN greater number of patients achieve level T8 (55%). The difference was significant between the groups (P < 0.001). Time to reach peak block level was faster in the BF group (7.83 ± 2.22 min) than in the BN group (10.50 ± 2.26 min), whereas two-segment sensory regression in both the groups was statistically insignificant [P = 0.15 (NS)].
Table 2: Characteristics of sensory block

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[Table 3] shows motor block characteristics. Onset of motor block was significantly faster in the BF group (2.58 ± 0.84 min) than in the BN group (5.48 ± 1.32 min). The difference is statistically significant (P < 0.001). Duration of motor block and time for first rescue analgesia were significantly longer in the BN group (P < 0.001). [Table 4] shows adverse effects which are comparable in both the groups.
Table 3: Characteristics of motor block and time for first rescue analgesia

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Table 4: Adverse effects

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  Discussion Top


Surgeries below umbilicus could be practiced under local anesthesia, neuraxial block, and general anesthesia, although neuraxial block is preferred over all other options. Neuraxial block has benefits such as quick onset of action, less fear of infection, and budget friendly. Despite benefits, it also has drawbacks such as post-operative agony, which is the prime problem as the used drugs have limited durations of effect. Therefore, many intrathecal adjuvants are given with local anesthetic drug to enhance its clinical efficiency and duration of analgesia.[7]

A lipophilic narcotic like fentanyl (µ-agonist) turned into the adjuvant of decision due to its intensity, fast beginning, and brief length of activity with a lower incidence of respiratory depression because it does not move to the fourth ventricle in adequate focus to cause respiratory depression. Fentanyl is usually utilized as an intrathecal adjuvant in dosages of 10–25 mcg. Focal neuraxial narcotics are known for their incidental effects such as pruritus, urinary incontinence, and respiratory depression.[6],[8]

Nalbuphine has combined µ antagonist and k agonist effects. It can possibly keep pace with or even upgrade µ-narcotic-based analgesia, while limiting µ-opioid-related incidental effects. Nalbuphine and other k agonists are powerful pain relievers in certain types of visceral nociception. Therefore, while giving great absence of pain, it is without narcotic-related adverse impacts such as sickness, emesis, pruritus, blockage, bothersome sedation, respiratory discouragement, and the advancement of tolerance/reliance and improves the absence of pain by κ-opioid receptors.[8],[9],[10]

In the present study, we found that as an adjuvant to 12 mg hyperbaric bupivacaine in spinal anesthesia, 25 mcg fentanyl was superior to reach the far-up level of sensory block and less time is required to achieve the far-up level with significantly faster onset of complete motor block. This may be due to rapid tissue uptake and greater lipid solubility of fentanyl. There was no significant change in time for two-segment regression. However, duration of motor block and time for first rescue analgesia were significantly longer in the nalbuphine group. There was no significant difference found in side effects and hemodynamic parameter in both the groups.

There are some studies in favor and other in partial favor of this study. Farahat et al.[11] compared 800 mcg nalbuphine and 25 mcg fentanyl as adjuvant to 12.5 mg hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. They noticed that time for T5 sensory block, time of maximum sensory block, and time for complete motor block were quicker in the fentanyl group than in the nalbuphine group. Duration of post-operative analgesia and time to two-segment regression were longer in the nalbuphine group when compared with the fentanyl group [Figure 1][Figure 2][Figure 3][Figure 4].
Figure 1: Visual analog scale

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Figure 2: Mean systolic blood pressure of patients

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Figure 3: Mean diastolic blood pressure of patients

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Figure 4: Mean heart rate of patients

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Bengali and Bande[9] used 1 mg nalbuphine and 25 mcg fentanyl as adjuvant to 15 mg hyperbaric bupivacaine in spinal anesthesia and noticed that fentanyl not only enhanced the onset of motor and sensory block but also has faster cephalic spread. Time for two-segment sensory regression, total duration of motor block, and duration of post-operative analgesia were significantly longer in the nalbuphine group.

Gomma et al.[6] compared 800 mcg nalbuphine and 25 mcg fentanyl with 10 mg hyperbaric bupivacaine in the subarachnoid block for cesarean section and found no significant difference in the onset of sensory block and duration of motor block. The onset of complete motor block was more rapid in the fentanyl group than in the nalbuphine group. Duration of post-operative analgesia was more prolonged in the nalbuphine group. As regards the side effect and hemodynamic parameter, there was no significant difference in both the groups.


  Conclusion Top


We concluded that for lower limb orthopedic surgery, addition of nalbuphine is a better alternative than fentanyl and provides longer duration of post-operative analgesia. Future conjectures with titrated dose of nalbuphine will confirm better effectiveness of different doses and different uses of nalbuphine and fentanyl.



 
  References Top

1.
Sharma R, Jatolia RPet al. Comparative study between intrathecal nalbuphine and fentanyl with hyperbaric bupivacaine for postoperative analgesia in caesarean section. SAS J Med 2018;4:64-8.  Back to cited text no. 1
    
2.
Singhal D, Chowdhary A, Mehta N Two different doses of nalbuphine as an adjuvant to bupivacaine intrathecally in lower abdominal and lower limb surgeries—A comparative study. J Med Dent Sci 2018;17:81-6.  Back to cited text no. 2
    
3.
Wulf HF The centennial of spinal anaesthesia. J Am Soc Anesthesiol 1998;89:500-6.  Back to cited text no. 3
    
4.
Gupta K, Rastogi B, Gupta PK, Singh I, Bansal M, Tyagi V Intrathecal nalbuphine versus intrathecal fentanyl as adjuvant to 0.5% hyperbaric bupivacaine for orthopaedic surgery of lower limbs under subarachnoid block: A comparative evaluation. Indian J Pain 2016;30:90.  Back to cited text no. 4
    
5.
Suryasree T, Sreelatha V, Pratiksha C Evaluation of effect of low dose fentanyl, dexmedetomidine and clonidine in spinal anaesthesia in hysterectomies and lower abdominal surgeries.  Back to cited text no. 5
    
6.
Gomaa HM, Mohamed NN, Zoheir HA, Ali MS A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after caesarean section. Egypt J Anaesth 2014;30: 405-10.  Back to cited text no. 6
    
7.
Rahimzadeh P, Faiz SH, Imani F, Derakhshan P, Amniati S Comparative addition of dexmedetomidine and fentanyl to intrathecal bupivacaine in orthopaedic procedure in lower limbs. BMC Anaesthesiol 2018;18:1-7.  Back to cited text no. 7
    
8.
Babita VM, Tak ML, Singh B A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after caesarean section. Egypt J Anaesth 30:405-10.  Back to cited text no. 8
    
9.
Bengali R, Bande N Intrathecal nalbuphine vs fentanyl with hyperbaric bupivacaine for postoperative analgesia. JMSCR 2018;6:556-63.  Back to cited text no. 9
    
10.
Bisht S, Dubey R. Nalbuphine as an intrathecal adjuvant is a good alternative to fentanyl. Indian J Anaesth Analgesia 2017;4.  Back to cited text no. 10
    
11.
Ahmed FI Intrathecal nalbuphine versus fentanyl as an adjuvant to bupivacaine in spinal anaesthesia for elective caesarean section: A randomized double-blind study. Res Opinion Anaesth Intensive Care 2019;6:112.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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