Dr. Minnu M. Panditrao, shares her own experience of adding nalbuphine, a newer, agonist- antagonist to bupivacaine as an adjuvant in elderly males coming for lower limb surgeries

1. To Study The Effects Of Addition Of Nalbuphine To
Bupivacaine Used For Elderly Patients Undergoing
Spinal Anaesthesia: A Randomized Double Blind,
Controlled Study
Authors
Dr. (Mrs) M.M.Panditrao
CONSULTANT,
ANESTHESDIOLOGY,
Rand Memeorial Hopsital
Freepeort, Grand Bahama
The Bahamas

2. INTRODUCTION
• Spinal Anaesthesia: still the most popular
technique
• However there is limitation of duration
• Many adjuvants have been used to prolong the
duration/ provide analgesia, but have their own
disadvantages

3. AIMS & OBJECTIVES
To compare -
• Quality of block
• Duration of post-operative analgesia
• Adverse effects, if any
when Nalbuphine was added to Hyperbaric
Bupivacaine 0.5%, in patients undergoing lower
abdominal & lower limb surgeries.

4. MATERIAL & METHODS
• IEC approval
• Informed consent
• 40 ASA I & II
• Age range: 50-70 yrs
• Either sex
• Patients scheduled for lower abdominal &
lower extremity surgeries (<180 min)
• Patient not fit for Spinal anaesthesia were
excluded

5. • Thorough pre-operative evaluation
• NBM for 6-8 hrs
• Randomization: 2 groups by lottery method-
Group 1 (Study group):
Inj. Bupivacaine (0.5%) 3 ml +
Inj. Nalbuphine (0.5mg) 0.5 ml
intrathecally
Group 2 (Control group):
Inj. Bupivacaine (0.5%) 3 ml +
Inj. Normal saline 0.5ml intrathecally

6. • Sedatives and Hypnotics avoided in pre, intra &
post-operative period
• IV line secured with 20 G cannula
• Preload: Ringer lactate @ 10ml/kg
• Monitoring: Pulse, B.P., SPO2, RR

7. • ↓ AAP, SAB given in • Respective agents injected
sitting position with according to group
26G Quincke needle

8. • Following parameters were observed -
1) Time of onset of sensory blockade (T1)
2) Time of onset of motor blockade (T2)
3) Time of peak sensory blockade (T3)
4) Time of peak motor blockade (T4)
5) Time of post-operative analgesia (T5)

9. • Fall in MAP>20% of basal value: Treated with
Inj. Mephentermine
• Bradycardia, HR>20% fall from basal value or
<55 bpm: Treated with Inj. Atropine
• Rescue analgesia: Inj. Tramadol 100mg or Inj.
Diclofenac 75mg I.M.

10. RESULTS
Demographic profile of age
60
Age (years)
40 AM
20 SD
0
Group I Group II
Groups
P Value =0.666
• No significant difference in average Age in two groups
Male : Female distribution ASA Grading
No. of patients
No. of patients
15 20
10 Male 15 I
10
5 Female II
5
0 0
Group I Group II Group I Group II
Groups Groups
• There was no significant difference between two groups with
respect to Sex and ASA grading

11. Onset Of Sensory & Motor Blockade
Onset of sensory On set of Motor
Tim ( in Seconds)
150
80
Time (sec)
60 AM 100 AM
40 SD
SD 50
20
0 0
Group I Group II group I group II
Groups Groups
P Value =0.45 P Value =0.48
• Time for onset of sensory & motor
blockade in both groups was comparable

12. Peak Sensory & Motor Blockade
• Time for onset of peak sensory & peak
PEAK SENSORY PEAK MOTOR
TIME (SECONDS)
TIME (SECONDS)
motor blockade in both groups
500
400
300
AM 200 AM
• was same
300
200 SD 100 SD
100
0 0
Group I Group II Group I Group II
GROUPS GROUPS
P = 0.96 P = 0.28
• Time for onset of peak sensory & peak motor
blockade in both groups was similar

13. Duration Of Analgesia
RESCUE ANALGESIA
TIME (Minutes)
600
400 AM
200 SD
0
Group I Group II
GROUPS
PARAMETER GROUP I GROUP II P SIGNIFICANCE
AM + SD AM + SD VALUE
Highly
T5 516 + 155 159.5 + 18.42 0.000 Significant
• Mean time of post-operative analgesia (T5) in
Study group (8 to 9 hrs) was highly significantly
longer than in Control group (2 to 3hrs)

14. Comparison of pulse rate
90
Pulse rate
85
80 Group I
75 Group II
70
65
0
3
15
30
45
60
90
120
150
Time (min)
• Clinically not significant, but statistically
slightly significant at 150 minutes

15. comparison of SBP
150
Group I
SBP
100
50 Group II
0
ts
ts
ts
ts
ts
in
in
in
in
in
m
m
m
m
m
0
0
15
45
90
15
Time in minutes
• Statistically significant difference
between two groups, but clinically
insignificant

16. Comparison of DBP
100
Group I
DBP
50
Group II
0
0
15
45
90
150
time (min)
• Statistically significant difference
between two groups, but clinically
insignificant

17. • Respiratory rate and SPO2 were almost similar
in two groups and no difference found
• No adverse effects
• No morbidity

18. DISCUSSION
• SAB: Technique of choice for lower abdominal
& lower extremity surgeries
• Since SAB with Bupivacaine has post-operative
analgesia for short period, many adjuvants have
been used in past to prolong it

19. • Present study: Nalbuphine 0.5 mg added as an
adjuvant to Bupivacaine
• Duration of analgesia post-operatively
- In Study group with added adjuvant
Nalbuphine : 8 to 9 hours
- In Control group with plain
Bupivacaine: 2 to 3 hours

20. • Nalbuphine is a synthetic opioid with mixed agonist
& antagonist properties
• Mechanism of analgesia: By its agonist action,
Nalbuphine stimulates Kappa receptors which
inhibits release of neurotransmitters like substance P
that mediate pain.
• In addition it acts as a post-synaptic inhibitor on the
interneurons & output neurons of the Spino-thalamic
tract which transport nociceptive information

21. • In the Nalbuphine group , almost 25% of the
elderly patients were controlled Hypertensives,
however no cardio-pulmonary adverse effects
were seen.
• Improved quality of block
• Prolonged & long lasting post-operative
analgesia
• No adverse effects like other opioids ( respiratory
depression, nausea, vomiting, pruritus)
• Cost effective

22. CONCLUSION
• Nalbuphine provides better quality of block
as compared to Bupivacaine alone
• Nalbuphine provides post-operative analgesia
for almost 8-9 hrs when used as an adjuvant
to Bupivacaine
• From present study, we feel this is an excellent
method of providing post-operative analgesia
without any adverse effects for patient
undergoing Surgery under SAB

23. THANK YOU

24. REFRENCES
• Stanley F Malamed; Neurophysiology in Hand book of local
anesthesia 2nd Edition, Jaypee brothers: 1986:20
• Ready BL Acute perioperative pain. In Miller RD. Anaesthesia
5th Edition, Chruchill Livingstone, Philadelphia, 2000: 2323:50
• Park House J Simpson BRJ; The Problem of postoperative pain,
BJA 1961; 33; 336-343 Atkinson, Rushman & Davies Lee’s
synopsis of anaesthesia, 11th Edition,Butterwoth Heinemann
• Culebrasx Gaggero G, Zatloukal J, etal. Advantages of
intrathecal nalbuphine compared with intathecal morphine after
cesarean delivery an evaluation of postoperative analgesia and
adverse effect. Anesth Analg 2000; 91:601-5
(Astract/Freefull Text)
• Lin ML. The analgesic effect of subarachnoid administration of
tetracaine combinedn albuphine for post operative pain relief
after total hip replacement [abstract]. Anesthesiology 1998;
89: A867