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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 29  |  Issue : 1  |  Page : 41-45

Comparison of 0.5% ropivacaine alone and in combination with clonidine in supraclavicular brachial plexus block


Department of Anesthesiology, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication1-Dec-2014

Correspondence Address:
Mamta Khandelwal
Flat No. 201, B-80, Sona Enclave, Rajendra Marg, Bapu Nagar, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.145945

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  Abstract 

Background and Aims: Brachial plexus block is close to the ideal anesthetic technique for upper limb surgeries. Several clinical studies have shown that clonidine prolongs sensory motor blockade when used with bupivacaine but effect of clonidine on ropivacaine is not well defined. Present study was done to evaluate the effect of clonidine 2 μg/kg added to ropivacaine 0.5% in supraclavicular brachial plexus block. Methods: In this prospective, randomized, double blind study total 80 patients of American society of anesthesiologist, (ASA) grade I and II undergoing elective upper limb surgery under supraclavicular brachial plexus block were randomized into two groups. Patients in group 1 (n = 40) received 28 ml of 0.5% ropivacaine and in group 2 (n = 40) received 28 ml of 0.5% ropivacaine with clonidine (2 μg/kg body weight). Onset and recovery time of sensory and motor block, duration of analgesia and quality of block, hemodynamic variables, oxygen saturation and level of sedation were studied in both the groups. All the data were analyzed by using unpaired t test. P < 0.05 was considered significant. Result: Sensory and motor block onset times were similar in both the groups. The mean duration of analgesia was 1016.92 + 170.14 min and mean duration of motor block was 880.54 + 127.99 min in group 2. On comparing both the groups it was found statistically significant (P < 0.000). In group 2 four patients showed mild sedation. Group1 showed more severity of pain than group 2 and it was found to be statistically significant (P < 001). Conclusion: Clonidine 2 μg/kg body weight when added to 0.5% ropivacaine in supraclavicular brachial plexus block significantly prolonged sensory and motor block and provides better post-operative analgesia.

Keywords: Supraclavicular brachial plexus block, ropivacaine, clonidine.


How to cite this article:
Bafna U, Yadav N, Khandelwal M, Mistry T, Chatterjee C S, Sharma R. Comparison of 0.5% ropivacaine alone and in combination with clonidine in supraclavicular brachial plexus block . Indian J Pain 2015;29:41-5

How to cite this URL:
Bafna U, Yadav N, Khandelwal M, Mistry T, Chatterjee C S, Sharma R. Comparison of 0.5% ropivacaine alone and in combination with clonidine in supraclavicular brachial plexus block . Indian J Pain [serial online] 2015 [cited 2019 Dec 13];29:41-5. Available from: http://www.indianjpain.org/text.asp?2015/29/1/41/145945


  Introduction Top


Supraclavicular brachial plexus block provides anesthesia of entire upper extremity in the most consistent and time efficient manner. It provides both intraoperative anesthesia and postoperative analgesia without any systemic side-effects. [1] Various approaches to brachial plexus block have been described, but supraclavicular approach is the easiest and most consistent method for anesthesia and perioperative pain management in surgery below the shoulder joint.

Peripheral nerve block also causes sympathetic block with resultant improvement in blood flow hence lessen postoperative vasospasm, tissue anoxia, pain and edema which is more favorable in acute hand and reconstructive surgery.

Many adjuvants like adrenaline, dextran 10%, potassium chloride, clonidine, dexmeditomidine, dexamethasone, neostigmine and opioids, [2],[3],[4],[5],[6],[7],[8],[9],[10] has been added to local anesthetics to improve onset and duration of block, to decrease postoperative analgesic requirement and to reduce systemic effects in brachial plexus blockade.

Clonidine, a selective alpha 2 adrenergic agonist, has been used traditionally as an antihypertensive agent. Various studies have shown that clonidine can be used as a sole analgesic agent in intrathecal anesthesia and as an adjuvant to local anesthetics in peripheral nerve blocks. [11],[12],[13],[14]

However, the reports of its use in supraclavicular brachial plexus block along with ropivacaine are limited. In this study, we investigated whether adding clonidine to ropivacaine for supraclavicular brachial plexus block would affect the degree of sensory and motor blockade and duration of analgesia.


  Materials and Methods Top


This study was conducted in the Department of Anesthesia, at Tertiary Care Center. This prospective, randomized, double-blind, study included 80 patients, of ASA Grade I and II, age 20-50 years, body weight 50-80 kg who underwent elective surgery in upper limb. Prior ethical permission was taken from our institutional ethical committee.

Patients who had local pathology at the site of injection or disability, history of convulsion, allergy to the drugs used, bleeding disorders, uncooperative and with severe neurological deficit were excluded from the study.

Preanesthetic checkup (PAC) was done the day before the surgery that included a complete history of the patient including any known drug allergy, general and systemic examination and local examination of supraclavicular area. Pulse rate, blood pressure, respiratory rate and weight of the patient were noted. Routine relevant investigations were done in all the patients.

Informed consent was obtained for performance of brachial plexus block after complete explanation about the study protocol and the procedure. Visual analogue scale (VAS) 0-10 was explained to the patient.

The patients were randomized on the day of surgery into two groups each of 40 patients by chit in box method. Patients themselves used to take out the chit from the box. Medications were prepared by one anesthetist and observations were made by another anesthetist. In Group 1, 40 patients received 28 ml of 0.5% ropivacaine and in Group 2, 40 patients received 28 ml of 0.5% ropivacaine with clonidine (2 μg/kg body weight). All the solutions were diluted with normal saline to make a total volume of 30 ml.

Fasting status, consent, PAC were checked, and intravenous access was secured in all the patients. Perioperative sedation was achieved by using midazolam 1 mg intravenously. The patient was placed in the supine position, with the head turned away, and the ipsilateral arm adducted. The interscalene groove and mid-point of the clavicle and subclavian artery was identified. After aseptic preparation of the area, at a point 1.5-2.0 centimeter posterior to the midpoint of the clavicle, a skin wheal was raised with a local anesthetic (lignocaine 2% plain). Next, a 22 gauge, 50 mm "short bevelled" needle was passed through the same point in a caudal, slightly medial and posterior direction, until either a paresthesia was elicited or the first rib was encountered. If the first rib was encountered, the needle was moved over the first rib until a paresthesia was elicited either in the hand or arm. After eliciting paresthesia and negative aspiration of blood, the study medication was injected.

Patients were evaluated for onset of sensory block every 1 min. The sensory block was assessed by pin prick with 25 gauge needle in C5-6 dermatome. The onset time of the sensory block was taken as the time interval in minutes from min-0 till the sensory block started appearing that is, score >1 [Table 1].

Motor blockade was assessed using Modified Bromage scale (MBS) [15] [Table 2]. The onset time of the motor block, that is, MBS score = 1 was also recorded in all cases.
Table 1: Sensory block assessment

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Table 2: Motor block assessment (modifi ed bromage scale)

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Heart rate, non-invasive blood pressure and Oxygen saturation (SpO 2 ) were recorded every 5 min for first ΍ h and thereafter every 15 min. Intraoperative sedation was assessed by using a four-point scale [Table 3]. [16] Postoperatively heart rate, noninvasive blood pressure and pain and motor power were recorded at 0 min, 30 min, 1 h, 3 h, 6 h, 12 h and 24 h. VAS score was measured at 6 h, 12 h and 18 h [Table 6]a.

The duration of motor block was defined as the time taken for reversal to Bromage score 1.
Table 3: Sedation assessment by using four point scale

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Rescue analgesia was given on patient's demand. Total duration of analgesia was defined as the time from injection of drug administration to the patient's first request for rescue analgesic. Injection diclofenac 75 mg IV was given as rescue analgesic.

The sample size calculation was based on the previous study to determine the difference in outcome variable (R) of both anesthetic drugs at 95% confidence interval, 5% alpha error and the power of study was 80%. To detect the minimum difference of 0.5 min (±0.8) in onset time of sensory and motor block of (median cutaneous nerve) the calculated sample size for each group was 40 patients using primer software.

Statistical analysis was performed with SPSS, version 15.0, for Windows statistical software package (SPSS inc., Chicago, IL, USA). Categorical data, that is, ASA grade, type of surgery and the incidence of adverse events (hypotension, bradycardia, dryness of mouth, nausea, vomiting and headache) were presented as % and proportions. These data were compared in two groups and the difference in the proportion was inferred by Chi-square test. Demographic data (age, weight), duration of surgery, VAS score, total duration of motor block and analgesia were expressed as mean ± standard deviation. These data were compared in two groups and differences in means were inferred by unpaired t-test. For significance P < 0.05 was considered as significant for both types of data.


  Results Top


It was observed that the mean age, body weight, ASA grading and duration of surgery were similar in both the groups and no statistically significant difference was present [Table 4]. The mean onset of sensory and motor blockade was comparable in both the groups [Table 5].
Table 4: Demographic profi le

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Table 5: Onset of sensory and motor block, total duration of analgesia and motor block

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Thirty-two out of 40 patients in Group 1 and 34 out of 40 patients in Group 2 had sensory blockade of Grade 2. Eight patients in Group 1 and six patients in Group 2 had only touched sensation and no response to any painful stimulus (Grade 1 sensory blockade).

33 patients in Group 1 and 34 patients in Group 2 showed complete motor blockade (Grade 3) with inability to flex the arm and forearm while seven in Group 1 and six in Group 2 were able to flex the forearm but unable to flex the arm (Grade 2).

The mean duration of analgesia and duration of motor block was more in Group 2 as compared to Group 1. It was statistically significant (P < 0.000) [Table 5].

In Group 1, all the patients were opening eyes spontaneously. In Group 2 four out of 40 had sedation score 2.

Group 1 showed more severity of pain than Group 2 and it was found to be statistically significant (P < 0.001) [Table 6]b. There were no significant differences between groups regarding the incidence of perioperative adverse effects.
Table 6:

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  Discussion Top


In the present study, brachial plexus blockade was achieved by classical supraclavicular approach and satisfactory surgical anesthesia was attained in all the cases for various types of upper limb surgeries. Clonidine, when added to ropivacaine, was found to be superior to ropivacaine alone.

Effect of clonidine, when added to ropivacaine, is controversial in the literature. In some studies adding clonidine to ropivacaine found to be synergistic and in others it did not the prolong duration of brachial plexus block. In one study of axillary brachial plexus block, clonidine (1 μg/kg) when added to 20 ml of ropivacaine 0.75% led to sensory analgesia that lasted for 15.2 h compared to 13.8 h in ropivacaine alone. [13]

In an another study duration of motor blockade was 721 ± 38 min and sensory anaesthesia was 828 ± 35 min when 150 μg of clonidine was added to 40 ml of 0.75% of ropivacaine compared to 552 ± 35 min motor block and 587 ± 40 min sensory anaesthesia in control group. [17]

Duration and quality of analgesia provided by an interscalene brachial plexus block (n = 30) for shoulder surgery by adding 40 μg of clonidine to 200 mg of 0.5% ropivacaine didn't prolong the sensory-motor block or improve the quality of analgesia in the early postoperative period. [16] Similarly, adding clonidine with ropivacaine did not improve overall postoperative analgesia but may increase the time to the first analgesia request in a study of 60 pediatric axillary brachial plexus blocks. [15]

Addition of clonidine has a different impact on different local anesthetics in terms of onset and duration of block. Clonidine has been found to the prolong duration of motor blockade in the mepivacaine and bupivacaine groups, but not in the ropivacaine group. [18] Same author earlier also found that the addition of clonidine to ropivacaine didn't lead to any advantage of block of the brachial plexus when compared with pure ropivacaine 0.75%. [19] None of the studies has found significant sedation and cardiovascular side effects.

The mechanism of action of clonidine in peripheral nerve blocks is highly unclear. Clonidine blocks conduction of A delta and C fibers with some preference for C fibers and intensifies the conduction of local anesthetics. Clonidine seems to exert a local action at the peripheral nerve because subcutaneous or intramuscular injection of clonidine did not increase the duration of block. [20] Controversial effect of clonidine with ropivacaine on anesthetic effect is unknown.

The present study didn't found clinically important difference in the haemodynamic parameters and adverse effects among the two groups. This may contribute to the fact that the doses of the drugs used in the study was appropriate and clonidine did not produce any adverse effects when used in peripheral nerve blocks.


  Conclusions Top


Clonidine, when added to 0.5% ropivacaine in supraclavicular brachial plexus block for upper limb surgeries, resulted into significant prolongation of sensory and motor block as compared to ropivacaine alone without any potential side effects.

 
  References Top

1.
Khanduri KC. Regional anaesthetic techniques for orthopaedic surgeries. Med J Armed Forces India 2008;64:109.  Back to cited text no. 1
    
2.
Murphy DB, McCartney CJ, Chan VW. Novel analgesic adjuncts for brachial plexus block: A systematic review. Anesth Analg 2000;90:1122-8.  Back to cited text no. 2
    
3.
Gormley WP, Hill DA, Murray JM, Fee JP. The effect of alkalinisation of lignocaine on axillary brachial plexus anaesthesia. Anaesthesia 1996;51:185-8.  Back to cited text no. 3
    
4.
Bazin JE, Massoni C, Bruelle P, Fenies V, Groslier D, Schoeffler P. The addition of opioids to local anaesthetics in brachial plexus block: The comparative effects of morphine, buprenorphine and sufentanil. Anaesthesia 1997;52:858-62.  Back to cited text no. 4
    
5.
Bone HG, Van Aken H, Booke M, Bürkle H. Enhancement of axillary brachial plexus block anesthesia by coadministration of neostigmine. Reg Anesth Pain Med 1999;24:405-10.  Back to cited text no. 5
    
6.
Kapral S, Gollmann G, Waltl B, Likar R, Sladen RN, Weinstabl C, et al. Tramadol added to mepivacaine prolongs the duration of an axillary brachial plexus blockade. Anesth Analg 1999;88:853-6.  Back to cited text no. 6
    
7.
Karakaya D, Büyükgöz F, Baris S, Güldogus F, Tür A. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block. Reg Anesth Pain Med 2001;26:434-8.  Back to cited text no. 7
    
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Keeler JF, Simpson KH, Ellis FR, Kay SP. Effect of addition of hyaluronidase to bupivacaine during axillary brachial plexus block. Br J Anaesth 1992;68:68-71.  Back to cited text no. 8
    
9.
Khosa DS, Thind SS, Gupta HK, Jain S. Effect of adding potassium chloride to lignocaine and bupivacaine solution on the onset time and duration of brachial plexus block. Indian J Anaesth 1990;38:119-22.  Back to cited text no. 9
    
10.
Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006;102:263-7.  Back to cited text no. 10
    
11.
Büttner J, Ott B, Klose R. The effect of adding clonidine to mepivacaine. Axillary brachial plexus blockade. Anaesthesist 1992;41:548-54.  Back to cited text no. 11
    
12.
Eisenach JC, De Kock M, Klimscha W. alpha(2)-adrenergic agonists for regional anesthesia. A clinical review of clonidine (1984-1995). Anesthesiology 1996;85:655-74.  Back to cited text no. 12
    
13.
El Saied AH, Steyn MP, Ansermino JM. Clonidine prolongs the effect of ropivacaine for axillary brachial plexus blockade. Can J Anaesth 2000;47:962-7.  Back to cited text no. 13
    
14.
Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z. Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes. Anesth Analg 2001;92:199-204.  Back to cited text no. 14
    
15.
Trifa M, Ben Khalifa S, Jendoubi A, Zribi N, Regaya T, Engelhardt T. Clonidine does not improve quality of ropivacaine axillary brachial plexus block in children. Paediatr Anaesth 2012;22:425-9.  Back to cited text no. 15
    
16.
Esteves S, Sá P, Figueiredo D, Pèrez Souto A. Duration and quality of postoperative analgesia after brachial plexus block for shoulder surgery: Ropivacaine 0.5% versus ropivacaine 0.5% plus clonidine. Rev Esp Anestesiol Reanim 2002;49:302-5.  Back to cited text no. 16
    
17.
Casati A, Magistris L, Beccaria P, Cappelleri G, Aldegheri G, Fanelli G. Improving postoperative analgesia after axillary brachial plexus anesthesia with 0.75% ropivacaine. A double-blind evaluation of adding clonidine. Minerva Anestesiol 2001;67:407-12.  Back to cited text no. 17
    
18.
Erlacher W, Schuschnig C, Koinig H, Marhofer P, Melischek M, Mayer N, et al. Clonidine as adjuvant for mepivacaine, ropivacaine and bupivacaine in axillary, perivascular brachial plexus block. Can J Anaesth 2001;48:522-5.  Back to cited text no. 18
    
19.
Erlacher W, Schuschnig C, Orlicek F, Marhofer P, Koinig H, Kapral S. The effects of clonidine on ropivacaine 0.75% in axillary perivascular brachial plexus block. Acta Anaesthesiol Scand 2000;44:53-7.  Back to cited text no. 19
    
20.
Gaumann DM, Brunet PC, Jirounek P. Clonidine enhances the effects of lidocaine on C-fiber action potential. Anesth Analg 1992;74:719-25.  Back to cited text no. 20
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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