MATERIALS AND METHODS

A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFICACY OF LEVOBUPIVACAINE WITH CLONIDINE AND LEVOBUPIVACAINE WITH DEXMEDETOMIDINE IN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK Neelima Tandon 1, Manish Gua 2, Jiendra Agrawal 3, Ashish Mahur 4, Suman Gua 5, Sayendra Yadav 6, Preei Goyal 7, Bhanu Choudhary 8 1Associae Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 2Former Pos Graduae Suden, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 3Assisan Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 4Assisan Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 5Assisan Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 6Assisan Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 7Associae Professor, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. 8Professor and HOD, Dearmen of Anaeshesia, G. R. Medical College, Gwalior, Madhya Pradesh. ABSTRACT OBJECTIVE The objecive of his sudy is o comare clonidine and dexmedeomidine as an adjuvan o levobuivacaine in suraclavicular brachial lexus block wih resec o onse, duraion of sensory and moor block and duraion of analgesia. MATERIALS AND METHODS A oal of 90 ASA grade I and II aiens of eiher sex, aged 18-60 yrs. scheduled for elecive uer limb surgeries under suraclavicular brachial lexus block were divided ino 3 equal grous in a randomized fashion. Grou L (n=30) received 1 ml NS, grou LC (=30) received 1 ml (150 g) clonidine and grou LD (n=30) received 1 ml (100 g) dexmedeomidine added o 30 ml of 0.5% levobuivacaine. Onse and recovery ime of sensory and moor block, duraion of analgesia and qualiy of block were sudied in all hree grous. RESULTS Onse ime of sensory and moor was 12.43±2.56 min and 17.96±3.05 min resecively in grou L, 9.03±1.60 min and 15.00±2.40 min resecively in grou LC and 8.13±2.51 min and 12.13±2.89 min resecively in grou LD. sensory and moor was 660.16±44.28 min and 535.33±50.66 min resecively in grou L, 880.16±55.48 min and 771.83±54.19 min resecively in grou LC and 930.66±48.02 min and 811.83±52.08 min resecively in grou LD. Time of rescue analgesia was 728.86±45.12 min in grou L, 1013.5±59.01 min in grou LC and 1159.8±56.8 min in grou LD (<0.05). CONCLUSION Dexmedeomidine when added o LA in suraclavicular brachial lexus block rolongs he duraion of sensory and moor and also he ime for rescue analgesia as comared o clonidine. Dexmedeomidine also enhances qualiy of block (LD>LC>C). KEYWORDS Suraclavicular Brachial Plexus Block, Levobuivacaine, Clonidine, Dexmedeomidine. HOW TO CITE THIS ARTICLE: Tandon N, Gua M, Agrawal J, e al. A comaraive clinical sudy o evaluae he efficacy of levobuivacaine wih clonidine and levobuivacaine wih dexmedeomidine in suraclavicular brachial lexus block. J. Evoluion Med. Den. Sci. 2016;5(19):925-929, DOI: 10.14260/jemds/2016/215 INTRODUCTION Periheral nerve blocks are gaining wide oulariy in anaeshesia clinical racice and can be used in variey of surgical rocedures, for surgical anaeshesia and osoeraive ain. Suraclavicular aroach gives he mos effecive block for uer exremiy and is carried ou a he level of runks of brachial lexus. 1 he lexus is blocked where i is mos comac. 2 i.e. a he middle of brachial lexus, resuling in homogeneous sread of anaesheic hroughou he lexus wih a fas onse and comlee block. 3 Financial or Oher, Comeing Ineres: None. Submission 22-01-2016, Peer Review 18-02-2016, Acceance 23-02-2016, Published 04-03-2016. Corresonding Auhor: Dr. Neelima Tandon, Fla-304, Phase 3, Garden Homes, Ciy Cener Gwalior, Madhya Pradesh. E-mail: dr.neelimaandon21@gmail.com DOI: 10.14260/jemds/2016/215 The racemic mixure of buivacaine resuled in cardiac and cenral nervous sysem oxic effecs in some aiens. 4,5 which were aribued o he dexrobuivacaine enaniomer. 8 Levobuivacaine is he S (-) enaniomer of racemic buivacaine. I has less cardiooxiciy comared wih buivacaine. 6,7 and is harmacology and duraion of anaeshesia are similar o hose of buivacaine. 7 Clonidine, 2 receor agonis, an imidazoline derivaive is highly liid soluble, acing on boh sinal and surasinal level wihin cenral nervous sysem and has been used as cenrally acing anihyerensive agen. I has been used for many years as an addiive o local anaesheic. 8,9 Clonidine rovides aroximaely 100 addiional minues of analgesia wih long-acing local anaesheic. 10 Mos sudies used beween 100-150 g wih higher dose showing side effecs including sedaion, bradycardia and hyoension. 10 Dexmedeomidine is a highly selecive 2 adrenoceor agonis ha has been shown o have boh sedaive and analgesic effecs. 10,11 comared wih clonidine, J. Evoluion Med. Den. Sci./ eissn- 2278-4802, ISSN- 2278-4748/ Vol. 5/ Issue 19/ Mar. 07, 2016 Page 925

dexmedeomidine has an 2: 1 adrenoceor raio of aroximaely 1600:1 (Seven o eigh imes higher han clonidine). 12 Dexmedeomidine was firs roosed as an adjuvan caable of rolonging duraion of sensory and moor block roduced by nerve block by Memis and Colleagues. 13 Dexmedeomidine has shown o rolong he duraion of block and osoeraive analgesia when added o local anaesheic in various regional blocks. 13-16 In his sudy, we comare he onse and degree of sensory and moor of levobuivacaine wih clonidine and dexmedeomidine in suraclavicular brachial lexus block. MATERIALS AND METHODS Afer ehical commiee aroval and wrien informed consen, his double blind randomized, rosecive clinical sudy was carried ou in 90 aiens of ASA grade I and II of eiher sex, aged 18-60 yrs. scheduled for uer limb surgeries. Paiens wih known hisory of bleeding disorders, eriheral neuroahies allergy or sensiiviy or any oher reacion o local anaesheic of amide ye, receiving reamen wih α adrenergic agoniss/anagoniss, hose wih a hisory of cardiac, resiraory, heaic or renal failure; and regnan women were excluded from he sudy. Niney aiens who fulfilled he eligibiliy crieria were chosen, exlained abou he rocedure and wrien consen was aken. Paiens were subsequenly randomized ino hree grous of 30 each. 1. Grou L (n=30): 30 ml of 0.5% Levobuivacaine wih 1mL normal saline. (Conrol) 2. Grou LC (n=30): 30 ml of 0.5% Levobuivacaine wih 150 mcg Clonidine (1 ml). 3. Grou LD (n=30): 30 ml of 0.5% Levobuivacaine wih 100 mcg Dexmedeomidine (1 ml). Afer securing an inravenous access wih 18-G cannula, RL soluion was sared. Hear rae (HR), Sysolic blood ressure (SBP), Diasolic blood ressure, resiraory rae (RR) and oxygen sauraion (SPO2) were recorded wih muliarameer monior (Beneview T5, Mindray China) Suraclavicular brachial lexus block was erformed under all aseic recauions and afer local infilraion of 2% Lidocaine 2 ml, neural localizaion was achieved using a nerve simulaor conneced o a 22-gauge, 50mm long simulaing needle. The locaion end oin was a disal moor resonse, ha is he movemen of he fingers and he humb wih an ouu curren of 0.5mA. Onse of sensory block is defined as he ime elased beween injecion of drug and comlee loss of sensaion as analysed by inrick es using a 3-oin scale: 0=normal sensaion, 1= loss of sensaion of inrick, 2= loss of sensaion of ouch. sensory block was defined as he ime elased beween injecion of he drug and he comlee resoluion of anaeshesia on all nerves. Onse of moor block was defined as he ime elased from injecion of drug o comlee moor block. Moor block was evaluaed by humb abducion (Radial nerve), humb adducion (Ulnar nerve), humb oosiion (Median nerve), and flexion of he elbow in suinaion and ronaion of he forearm (Musculocuaneous nerve). Measuremens were erformed using a modificaion of he Love raing scale. 17 Grade 6: Normal muscular force. Grade 5: Grade 4: Grade 3: Grade 2: Grade 1: Grade 0: Slighly reduced muscular force. Pronounced reducion of muscular force. Slighly imaired mobiliy. Pronounced mobiliy imairmen. Almos comlee aralysis. Comlee aralysis. Assessmen was done a every 1min inerval from he ime of injecion of es drug unil he block was esablished. Only aien wih comlee moor block (Grade 0) were included in sudy and equal number of new cases were added o comlee he sudy. moor block was defined as ime elased beween injecions of he drug o comlee reurn of moor ower (Grade 6). Posoeraive ain was assessed using a visual analogue score scale which consised of a 10cm horizonal scale wih gradaions marked as 0 means no ain a all and 10 means unbearable ain. VAS score was recorded every 30min in he osoeraive eriod ill he conclusion of sudy. Sedaion was assessed on he basis of Chernik sedaion score. 18 0 - Comleely awake. 1 - Sleeing bu resonding o verbal command. 2 - Dee slee bu arousable. 3 - Dee slee no arousable. Any comlicaions such as nausea, vomiing, bradycardia (HR<50 beas er minue), hyoension (A 20% decrease in relaion o he baseline ), haemaoma, headache, convulsions, resiraory disress and hyoxemia (So2<90%) if occurred were recorded and reaed aroriaely. Pulse rae (PR), sysolic blood ressure (SBP), diasolic blood ressure (DBP), oxygen sauraion (SO2), resiraory rae (RR), 3-lead ECG monioring was done coninuously by muli-arameer monior (Mindray Beneview T5) hroughou he oeraive rocedure. Recording of arameers were noed a 0, 5, 10, 15, 20 and a 30min inerval u o 90min and hen every hour ill 750min. The observaions recorded in all grous were abulaed and saisical analysis was carried ou using SPSS V.17 sofware for windows. In he inergrou comarison an indeenden suden es was used. For inragrou comarisons unidirecional reeiive variance analysis was used. Saisical significance was acceed as no significan and significan a P>0.05 and P<0.05 resecively. RESULTS All hree grous were comarable in erms of age, weigh and gender. (Table 1)(>0.05): There was even disribuion of age, weigh and sex in all he hree grous. The mean (±SD) age of aiens in grou L, LC and LD were 37.96±14.79 yrs., 40.63±12.94 yrs. and 36.63±12.70 yrs. resecively. The mean (±SD) weigh of grou L, LC and LD were 66.30±8.85kg, 63.40±9.01kg and 63.10±4.28kg resecively. Ou of 90 aiens, 64 aiens (71.11%) were male as comared o 26 female aiens (28.89%). The randomly seleced grou were comarable for he weigh arameers (Saisically insignifican ( >0.05)). J. Evoluion Med. Den. Sci./ eissn- 2278-4802, ISSN- 2278-4748/ Vol. 5/ Issue 19/ Mar. 07, 2016 Page 926

Sl. No. 1. Age (yrs.) 37.96 14.79 40.63 12.94 36.63 12.70 2. Weigh (kgs) 66.30 8.85 63.40 9.01 63.10 4.28 3. Sex (M:F) 21:9 22:8 21:9 Table 1: Showing Demograhic Profile of Paiens in Three Grous Table showing demograhic rofile of aiens in hree grous according o age, weigh and sex. Sensory Blockade The onse ime of sensory (mean±sd), which was 12.43±2.56min in Grou L, 9.03±1.60min in Grou LC and 8.13±2.51min in Grou LD. The onse of sensory was found o be faser in boh grou LC and grou LD as comared o grou L and he difference was saisically significan ( <0.05), whereas onse of sensory was raid in grou LD as comared o grou LC, bu he difference was saisically insignifican ( >0.05). Mean (±SD) of sensory duraion was 660.16±44.28min in Grou L, 880.16±55.48min in Grou LC and 930.66±48.02min in Grou LD. Sensory duraion is significanly rolonged in boh Grous LC and LD as comared o Grou L. sensory in Grou LD was also significanly rolonged as comared o Grou LC. (Table 2 & 3) Onse ime of sensory 12.43 2.56 9.03 1.60 8.13 2.51 Sensory 660.16 44.28 880.16 55.48 930.66 48.02 Table 2: Showing Comarison of Sensory Blockade (Min) in he Three Grous Sl. No. 1 2 Grou L vs. LC Grou L vs. LD Grou LC vs. LD Grous - Onse ime of sensory 6.14 0.00$ 6.55 0.00$ 1.65 0.10# Duraion of sensory 16.97 0.00$ 22.68 0.00$ 3.76 0.00$ Table 3: Showing Inergrou Saisical Comarison of Sensory Blockade (Min) Among Three Grous Moor Blockade Onse ime (Mean±SD) of moor was 17.96±3.05min, 15.00±2.40min and 12.13±2.89min in Grou L, LC and LD resecively. Onse of moor was found o be raid in Grou LD as comared o Grou LC and Grou L (LD>LC>L). These changes were saisically significan when comared o each oher ( <0.05). moor (mean±sd) was 535.33±50.66min in Grou L, 771.83±54.19min in Grou LC and 811.83±52.08min in Grou LD. moor was rolonged in boh Grous LC and LD as comared o Grou L. These changes were saisically significan when comared o each oher (<0.05). (Table 4 & 5). Onse ime of moor 17.96 3.05 15.00 2.40 12.13 2.89 535.33 50.66 771.83 54.19 811.83 52.08 Table 4: Showing Comarison of Moor Blockade (Min) Among Three Grous Grou L vs. LC Grou L vs. LD Grou LC vs. LD Onse ime of moor 4.17 0.00$ 0.828 0.00$ 4.168 0.00$ 17.46 0.00$ 0.995 0.00$ 2.915 0.00$ Table 5: Showing Inergrou Saisical Comarison of Moor Blockade among Three Grous Time of Rescue Analgesia Time of rescue analgesia was 728.86±45.12min in Grou L, 1013.5±59.01min in Grou LC and 1159.8±56.8min in Grou LD. The ime of rescue analgesia as assessed by VAS score was rolonged in Grou LD as comared o oher Grous (LD>LC>L). On inergrou comarison hese changes were found o be saisically significan (<0.05) (Table 6). Sl. No. 1 Grous Grou L Vs L C - - Grou L Vs L D - - Grou LC Vs L D - - Time of Rescue Analgesia (in min) 20.98 0.00$ 32.52 0.00$ 9.78 0.00$ Table 6: Showing Inergrou Saisical Comarison of Time For Rescue Analgesia (Min) Among Three Grous HEMODYNAMIC CHANGES Pulse Rae The mean (±SD) of reoeraive PR/min was 83.43±5.70 in Grou L, 85.83±5.72 in Grou LC and 88.9±7.47 in Grou LD. In Grou L ulse rae significanly decreased u o 60min (<0.00) and hereafer hese changes became insignifican (>0.05), while in Grou LC and Grou LD significan decrease in ulse rae from baseline was observed (<0.05). On inergrou analysis, changes in ulse rae beween Grou L and Grou LC and Grou L and Grou LD were saisically significan (<0.05), whereas he difference beween Grou LC and Grou LD were saisically insignifican (>0.05). J. Evoluion Med. Den. Sci./ eissn- 2278-4802, ISSN- 2278-4748/ Vol. 5/ Issue 19/ Mar. 07, 2016 Page 927

Sysolic Blood Pressure SBP fall o below basal ill 60min. Thereafer SBP sared o rise in grou L and remain above basal ill he end of sudy. In Grou LC, hese s sared o rise bu remained below baseline ill 390min and reached o basal a he end of sudy eriod. In Grou LD, his fall coninued ill he end of sudy eriod and never regains he basal ill he sudy eriod. On saisical analysis, hese changes were significan ill 60min (<0.05) in all hree grous, whereas in grou LC and LD changes were significan (<0.05) ill 330min. Diasolic Blood Pressure In Grou L changes in mean DBP were insignifican from basal ill he end of surgery. In Grou LC afer an iniial fall from basal u o 150min DBP sared o rise, bu remain below basal ill he end of sudy eriod, whereas in Grou LD DBP remained below basal hroughou he sudy eriod. On saisical analysis, hese changes were saisically insignifican in Grou L (P>0.05). In Grou LC and LD changes were saisically significan hroughou he sudy eriod (<0.0.5) Sedaion In Grou L none of he aien had sedaion, in Grou LC 43.33% aiens had sedaion of grade 1, while in grou LD 66.66% aiens had sedaion of grade 2 and 23.33% aiens had sedaion of grade 1. Thus i was found ha Dexmedeomidine added o Levobuivacaine causes more sedaion han clonidine when added o Levobuivacaine Side Effecs No comlicaion was found in Grou L, while in Grou LC 6.66% and in Grou LD 30% aiens had bradycardia and 43.33% aiens in Grou LC and 90% aiens in Grou LD had sedaion (Table 7). Grou Grou Grou LC Comlicaions L LD n % n % N % Nausea - - - - - - Vomiing - - - - - - Resiraory deression - - - - - - Bradycardia - - 2 6.66 9 30 Sedaion - - 13 43.33 27 90 Table 7: Showing Comlicaion in all Three Grous DISCUSSION We comared dexmedeomidine and clonidine as an adjuvan o levobuivacaine in suraclavicular brachial lexus block and found ha here was significanly increased duraion of sensory and moor in he dexmedeomidine grou han in he clonidine grou wihou any adverse effecs. The onse and duraion of sensory was raid in dexmedeomidine grou as comared o clonidine grou, bu he difference was saisically insignifican (>0.05). These observaions were in accordance wih Esmaoglu A, e al. 19 Oher researchers also confirmed he same resuls. 20,21,22,23,24,25,26,27,28,29 The ime of onse and duraion of moor was found o be raid in dexmedeomidine as comared o clonidine grou. These changes were saisically significan when comared o each oher (<0.05). These findings are in accordance wih Chakrabory S, e al. 30 Duma e al. 20, EI Saied AH, e al. 31 Oher sudies also had similar resuls. 30,32,33,21.23,28,25,31 The ime of rescue analgesia as assessed by VAS score was rolonged in Grou LD as comared o oher Grous (LD>LC>L). On inergrou comarison, hese changes were found o be saisically significan. These findings are suored by EI Saied AH, e al. 31 who evaluaed ha addiion of clonidine o roivacaine significanly increased duraion of analgesia from 587±40min o 828±35min resecively (<0.001). Haemodynamic arameers are beer sable in dexmedeomidine grou. I was found ha Dexmedeomidine when added o Levobuivacaine causes more sedaion han clonidine when added o Levobuivacaine. Esmaoglu A e al. 21, Swami SS e al. 24 and Ammar and Mahmoud. 23 had similar exerience. The analgesic effecs of alha-2 adrenoceor agoniss could be because of vasoconsricion a injecion sie, direc suression of imulse roagaion hrough neurons, local release of enkehalin-like subsance, a decrease in localized inflammaory mediaors and an increase in ani inflammaory cyokines hrough an alha-2 adrenoceor-mediaed mechanism. Side Effecs Bradycardia and sedaion is he side effec seen in dexmedeomidine grou. Esmaoglu A e al. 21 also found bradycardia in 7 aiens of dexmedeomidine grou. CONCLUSION When dexmedeomidine added o Levobuivacaine i fasens he onse of moor, rolongs he duraion of sensory and moor as comared o Clonidine. Time for rescue analgesia is more rolonged wih dexmedeomidine han clonidine. Dexmedeomidine roduces higher degree of sedaion as comared o clonidine. Haemodynamic arameers are beer sable in dexmedeomidine grou. BIBLIOGRAPHY 1. Urmey WF. Uer exremiy blocks. In: Brown DL, edior. Regional Anaeshesia and Analgesia. Philadelhia: WB Saunders, 1996;254-278. 2. 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