INTRODUCTION: Orthopedic upper arm surgeries forms a signicant group of orthopedic trauma.The surgeries can be done under general anaesthesia or regional anaesthesia. Regional anaesthesia has several advantages over general anaesthesia like improved postoperative pain, decreased post operative 1opioid administration and reduced recovery time Anaesthesiologist has a choice of technique for providing anaesthesia and analgesia during upper extremity surgery by brachial plexus block through various routes like interscalene, supraclavicular infraclavicular and axillary. Systematic reviws has shown that infraclavicular block is a safe and simple technique with efcacy comparable to other brachial plexus block. The advantage of infraclavicular block includes a lower likelihood of tourniquet pain during surgery and more reliable blockade of the musculocutaneous and axillary nerve and signicantly shorter block performance 2time. Ropivacaine the single S isomer long acting amide local anaestheticis is well tolerated regional anaesthetic, effective for surgical anaesthesia as well as relief of post operative pain. The efcacy of ropivacaine is similar to that of racemic 3bupivacaine and levobupivacainr for peripheral nerve blocks. Levobupivacaine, another single S isomer amide local anaesthetic has similar efcacy but an enhanced safety prole when compared to bupivacaine, a major advantage in 4regional anaesthesia. Both drugs are useful in clinical situation where risk of systemic toxicity related to overdosing or unwanted intravascular injection is high as during 5peripheral nerve block. Ropivacaine and laevobupivacaine in peripheral nerve block provide comparable clinical prole and post operative analgesia while other studies show that levobupivacaine produce approximately 30% longer duration in each modality 6and long lasting analgesia. Clonidine , an alpha 2 adrenergic agonists helps to improve 7the reliability and efcacy of regional anaesthesia 8 prolonging duration of block and perineural use is 9recommended. The rationale of the study was to nd out efcacy and safety of ropivacaine and laevobupivacaine with clonidine as an adjuvant when used in infrac;lavicular block for lower arm surgeries. MATERIAL AND METHODS: This was a prospective ,randomized, double blind study. Institutional ethical committee approval was taken. Source of study population was patients posted for elbow and forearm surgeries. Sample size calculated was 60. Convenient sample was used. Screening of patient done and patient fullling inclusion criteria like age 20-60yrs of either gender, height of 150-170 cm,weight 50-70kg,ASA grade I and II were included. Exclusion criteria was allergy to local anaesthetics, history of drug abuse, neurological disease, cardiac disease, chronic obstructive disease, diabetes mellitus and local infection at puncture site. After taking informed consent, patients were randomized by computer generated random number table into two groups, Group A-Inj Ropivacaine 0.5%, 30cc and Inj. Clonidine 1ug/kg and Group B-Inj. Laevobupiacaine 0.5%, 30 cc and inj. Clonidine 1ug/kg. Group allocation concealment done by opaque sealed envelope technique.The drugs syringes were prepared by a resident who did not take part part in further study. Asenior resident performed all the blocks. The principal investigator who was blind to group allocation recorded the study parameters. On day of surgery,infraclavicular brachial plexus bolck was given by coracoid approach. A 10cm 20g insulated needle attached to nerve stimulator (NSML 100,INMED)was inserted. Initial stimulating current was set at 0.6-0.8mA.The brachial plexus was reached at 4cm-6cm and stimulating current was than decreased to elicit motor response at 0.3mA.Only motor COMPARATIVE STUDY OF ROPIVACAINE AND LAEVOBUPIVACAINE WITH CLONIDINE AS AN ADJUVANT IN INFRACLAVICULAR BRACHIAL PLEXUS BLOCK FOR LOWER ARM SURGERIES Original Research Paper Dr Srihari Gutte Senior resident Department of Anaesthesiology Government medical College Aurangabad X 51GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Anaesthesiology Introduction: Infraclavicular block is a safe and simple technique for providing surgical anaesthesia of the lower arm with an efcacy comparable to other brachial plexus block Ropivacaine and Levobupivacaine has similar efcacy to bupivacaine with enhanced safety prole. Clonidine improves the reliability and efcacy of peripheral nerve block. Aims and Objectives: To compare the block characteristics of ropivacaine and laevobupivacaine with clonidine as an adjuvant in infraclavicular brachial plexus block. Material and Methods: For this prospective study ,60 patients were randomized into two groups ,Group A-0.5% ropivacaine 30 cc and inj. clonidine 1ug/kg and Group B-0.5% laevobupivacaine 30cc and inj.clonidine 1ug/kg and infraclavicular brachial plexus block was given.The onset of sensory block, motor block, the duration of sensory block and motor block, the quality of surgical anaesthesia, the duration of postoperative analgesia, VAS score, haemodynamic parameters and side effects were observed. Results: Onset of sensory block and motor block was earlier with laevobupivacaine. Duration of sensory and motor block was longer in laevobupivacaine group. Quality of surgical analgesia was excellent in 100% in both groups. Duration of post operative analgesia was same in both groups.. Haemodynamically patients were stable and there were no signicant side effects seen in either groups. Conclusion: Laevobupivacaine with clonidine and ropivacaine with clonidine are comparable in infraclavicular brachial plexus block for lower arm surgeries. ABSTRACT KEYWORDS : infraclavicular brachial plexus block, ropivacaine, laevobupivacaine,clonidine VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr Rajashri B. Sonwane* Associate Professor Department of Anaesthesiology Government Medical College Aurangabad *Corresponding Author 52 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS response (twitches)from the triceps, forearm muscles were accepted prior to local anaesthetic injection. Aspiration was performed and loading dose administered incrementally. The patient was withdrawn from study in case of failure of onset of block. Sensory block assessed by 23g hypodermic needle by Hollmen scale,1-normal sensation of pinprick, 2-weaker sensation of pinprick, 3-pinprick recognized as touch by blunt object, 4- no perception of pinprick. Motor block evaluated by bromage scale, grade1-ability to ex and extend the forearm, grade 2-ability to ex and extend only the wrist and ngers, grade3-ability to extend only the ngers, grade 4-inability to move the forearm, wrist and ngers. Quality of surgical block assessed by need of supplemental anaesthesia.Excellent-no supplementary sedative and analgesic required,good-only sedative required,fair-both sedative and analgesic required,poor-general anaesthesia required. Postoperative analgesia was assessed by using visual analogue scale (0mm-no pain to100 mm-worst pain imaginable). Duration of analgesia taken from inj. of local anaesthetic to need of rescue analgesia. Patients heart rate, systolic blood pressure, respiratory rate, oxygen saturation monitored. Also patient observed for accidental intravascular injection of drug, pleural puncture,anaphylaxis to local anaesthetic drugs. Patient observed for postoperative side effects like nausea, vomiting, shivering, pruritus, dysthesia , peripheral neuropathy. Statistical Analysis: For analysis of this data SPSS (Statistical Software for social Sciences) software version 20th was used.. Demographic data was represented in form of meam, SD and percentages. It was analyzed using chi-square test to check association between two drugs, chi square test for trend and Fisher Exact test depending on type of data. For comparison of quantitative variables of two groups, unpaired t-test was used and it was also represented in form of mean and SD etc. The duration of surgery and duration of analgesia was analyzed and evaluated by One Way ANOVA. Vital parameters like pulse rate, systolic blood pressure, respiratory rate, oxygen saturation were analyzed by Unpaired t test. Statistical signicance was indicated by conventional symbols: p <0.05: Statistically signicant, p >0.05: Statistically non-signicant. RESULTS: Demographic parameters like age, gender, weight, height, BMI,ASA grade,duration of surgery were comparable in the two groups.(table 1) Table 1: Demographic Characteristics There was statistically signicant difference between group A and group B when onse t t ime o f sensor y b lock considered(p<0.0001). There was statistically signicant difference in mean time of onset of motor block when group A and B compared(p<0.0001). Regarding duration of sensory block the difference was statist ically signicant( p<0.0001).The duration of motor block was statistically signicantwhen group A and group B compared(p<0.0001). A statistically non-signicant difference was observed amongst the groups regarding duration of analgesia th(p=0.08). At 10 hr, mean VAS scores was more than 3 in both groups and statistically not signicant (p = 0.746).( table 2) Table 2: Nerve block characteristics The quality of surgical anaesthesia in group A and group B was excellent in 100% of patients .(table 3) Table 3: Quality of Surgical anaesthesia On comparison, no statistically signicant difference was found in both the groups with respect to pulse rate (p value >0.05) (chart 1) or with respect to systolic blood pressure (p value >0.05).( chart 2) Chart 1: Heart Rate at Different Time Intervals (Beats per Minute) Chart 2: Systolic blood pressure at different time intervals (mm Hg) VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Demographic Parameters Group A (n=30) Mean ± S.D. Group B (n=30) Mean ± S.D. P value Age (years) 34.37 ± 10.516 36.87±11.74 0.38 Male (%) Female (%) 22 (73.3%) 08 (26.7%) 21(63%) 09(27%) - Weight (kg) 60.00± 6.878 58.80±7.540 0.52 Height (cm) 159.27 ± 6.40 159.27±6.400 0.99 BMI 23.73±3.085 23.14±2.40 0.41 Grade I ASA Grade II 25 (83.3%) 26(86.70%) > 0.05 05 (16.7%) 04 (13.3%) Duration of surgery 118±31.55 119.83±43.51 0.91 Block characteristics Group A Mean ± SD Group B Mean ± SD t- value P- value Onset of sensory Block 3.58 ± 0.631 1.07±0.173 21.012 0.0001 Onset of motor Block 7.53± 0.571 2.33±0.467 38.88 0.0001 Duration of sensory Block 426±24.011 507.33±19.46 -18.37 0.0001 Duration of motor Block 393±20.536 488.67±17.76 -19.30 0.0001 Duration of analgesia 618±27.96 634±40.73 -1.77 0.08 thVAS score at 10 hr 2.67+0.547 2.63+0.490 0.30 0.746 Scale Group A (%) (n=30) Group B (%) (n=30) P Value Excellent 30(100%) 30(100%) >0.05 Good 00 00 Fair 00 00 Poor 00 00 Two patient in each group complained of nausea and vomiting. Two patient in group A and one patient in group B complaint of vomiting. One patient of each group had pruritus. Incidence was found to be statistically insignicant amongst the groups (p > 0.05). DISCUSSION: In our study,demographic parameters like age, gender, height, weight, BMI, ASA grade, duration of surgery were comparable and similar to many other studies. In congruence to our study,sensory block onset was earlier with 10 levobupivacaine in one study, early with ropivacaine in 11, 12another study but few studies had equal onset in both 13,14,15,16groups Similar to our study, motor block onset was early 10with laevobupivacaine but in other study early with 11,17ropivacaine and equal in both groups in remaining 12,14,15studies Onset is related to the intrinsic physiochemical properties of individual local anaesthetic agents. Physicochemical propert ies include the pKa and hydrophobicity of local anaesthetics. Ropivacaine is about 10 times less lipophilic than levobupivacaine and is resistant to 18rapidly penetrating myelinated nerve bres. When onset time compared for sensory and motor block , it was earlier with sensory block as small myelinated axons, A gamma and A delta sensory bres are most susceptible to block followed 18by large myelinated A alpha and A beta bres Similar to our study, sensory block duration was longer with 14-17levobupivacaine, but equal duration in both groups seen in 19 one study Similar to our study, duration of motor block was 14,16longer with levobupivacaine while other studies found 15,19,20equal duration in both groups. .Duration of block is inuenced by the peripheral vascular effects of local anaesthetic drugs. Many local anaesthetic drugs have a biphasic action on vascular smooth muscle. They cause vasoconstriction at lower concentration and vasodilatation at higher concentration. Effect of local anaesthetics on vascular tone and regional nblood ow are complex and vary according to concentration, time, particular vascular bed, 18among other factors. Similar to our study quality of surgical anaesthesia was 12,1,17,19comparable in few studies but high success with 11ropivacaine seen in one study. Dissimilar from our nding one study needed intraoperative supplementation of 19analgesics. Small diameter axons such as C bres concerned with touch, pain are often stated to be more susceptile to local anaesthetic block than large diameter bres such as A bres, concern wi th motor and 18proprioception. Duration of analgesia was found to be of 10-12,15,19,20equal duration similar to our study but other studies 13,14,16found prolonged analgesia with laevobupivacaine . 10,15,19,20Similar to our study VAS score was equal in other studies It is widely believed that benet of adding clonidine is to improve the quality of block. Studies comparing ropivacaine and ropivacaine with clonidine has shown advantage in few 21,22block characteristics while other studies did not found 22advantage in some block parameters. by adding clonidine Studies comparing laevobupivacaine and laevobupivacaine 23with clonidine found advantage of clonidine but other study 24 found no advantage. Study with clonidine added to both groups showed prolonged duration of analgesia and delayed need of rescue analgesics in laevobupivacaine-clonidine 25group which did not agree with our study. In a study comparing intravenous versus perineural clonidine there was no difference in onset but duration of analgesia prolonged with intravenous clonidine. Clonidine acts on alpha 2 receptors in the central nervous system that is locus coeruleus and dorsal horn of spinal cord. Alpha 2 receptors 26are not present in the normal peripheral nerves. Data regarding effect of peripheral clonidine on quality of surgical anaesthesia is inadequate. 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