الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Since the discovery of regional anaesthesia, there has been considerable interest in regional anaesthetic techniques particularly in peripheral nerve blockade (PNB). PNB can decrease the anaesthetic and analgesic requirements during surgery and reduce the need for opioid analgesics in the postoperative period. More effective pain relief in the early postoperative period from the residual sensory block provided by local anaesthesia can facilitate the recovery process, enabling early ambulation and discharge home.
Good postoperative analgesic management probably carries benefits other than increased patient comfort. The magnitude of the neuro-endocrine stress response, postoperative pulmonary complications and the incidence of myocardial ischemia can be decreased. Early mobilization can be achieved and the patient can be discharged from hospital sooner.
Of various local anaesthetics used for brachial plexus block, bupivacaine is an amide local anaesthetic with long duration of action. Its mechanism of action is by preventing the generation and conduction of nerve impulses by reducing sodium permeability and increasing action potential threshold.
Any adjunct to brachial plexus block should prolong the analgesic effect without incurring systemic side effects or prolonged motor block, and should also reduce the total dose of local anaesthetic. Various studies have investigated several adjuncts, including opioids, clonidine, neostigmine, hyaluronidase, and bicarbonate. The results have been inconclusive, because of associated side effects or doubtful efficacy.
The aim of the work was to compare the addition of dexamethasone alone or in combination with tramadol to bupivacaine in the axillary brachial plexus block as regards the analgesic efficacy, duration and side effects in patients undergoing hand and forearm surgery.
After receiving Institutional Ethical Committee approval and written informed consent, 60 ASA I or II adult patients scheduled for forearm and hand surgery were included in the study. All patients were premedicated with 2 mg midazolam intravenous 10 minutes before surgery. Brachial plexus block was performed using an axillary approach using a nerve locator. The selected patients were randomly allocated into three groups using closed envelope technique, each group of 20 patients:
Group (A): Received 30 ml bupivacaine 0.25% for axillary brachial plexus block.
Group (B): Received 30 ml bupivacaine 0.25% + 8mg dexamethasone for axillary brachial plexus block.
Group (C): Received 30 ml bupivacaine 0.25% + 8 mg dexamethasone and 100 mg
tramadol for axillary brachial plexus block.
The following data were recorded in all patients:
• Vital signs
- Heart rate (beat / min).
- Mean arterial blood pressure (mmHg).
- Oxygen saturation (%) .
- Respiratory rate (breath / min).
These parameters were recorded preoperatively, immediately after performance of the block, then every 15 minutes till the end of surgery.
• Sensory blockade
- Onset of sensory blockade: along skin dermatomes C4-T2 were recorded using light touch and pin-prick test.
- Duration of sensory blockade.
- Postoperative pain intensity was evaluated by the visual analogue scale (VAS).
• Motor blockade
- Onset of motor blockade.
- Duration of motor blockade.
- Motor block will be assessed using the modified Lovett score.
• Postoperative analgesics
- First time and total amount of analgesics consumed during the first 24 hours postoperatively were assessed.
- Vital signs and pain scores were recorded at 0 min, 1, 2, 3, 4, 5, 6, 12 hr and 24 hr postoperatively.
• Duration of surgical procedure (minutes) was assessed.
Results showed that mean age, sex distribution, weight and duration of surgery were similar in the three groups.
As regards intraoperative hemodynamics, it was found that, the hemodynamic status of patients in group A, B and C was stable as there were no significant differences within or in between the three studied groups as regards heart rate, mean arterial blood pressure, respiratory rate and oxygen saturation.
During the first 24 hours postoperative period, there were no significant differences within or in between the three studied groups as regards the hemodynamic status.
Sensory and motor block appeared earlier in Group B and C than in Group A (P < 0.05). Results showed statistical significant increase in the duration of sensory block in group B and C when compared with group A. However, when the mean duration of motor and sensory block was compared between group B and group C, there was no statistical significant difference between the two groups and also the same as regards the onset of the sensory and motor block.
As regards the quality of postoperative analgesia, in this study, pain scores were significantly lower in patients of group B and C. The number of patients who required rescue analgesia and the mean number of supplemental analgesic boluses required were also significantly lower in patients in group B and C. However, when pain scores, the mean number of patients who required rescue analgesia and the mean number of supplemental analgesic boluses required were compared between group B and group C, there was no statistical significant difference between the two groups.
It was concluded that the addition of dexamethasone to bupivacaine in axillary brachial plexus block improved the quality of the block as it hastened the onset of sensory and motor block, prolonged the duration of sensory and motor block, prolonged the duration of postoperative analgesia and decreased the total dose of analgesic consumption during the first 24 hours postoperatively and had no significant hemodynamic consequences. Yet, the addition of tramadol to dexamethasone and bupivacaine didn’t improve either the quality, onset and duration of the senseory and motor block, prolong the duration of postoperative analgesia nor decrease the total dose of analgesic consumption during the first 24 hours postoperatively.