|Year : 2022 | Volume
| Issue : 3 | Page : 266-270
Efficacy comparison of magnesium sulphate, ketamine and neostigmine adjuvants to bupivacaine 0.5% on onset, duration and quality of ultrasound-guided supraclavicular block characteristics for forearm surgery
Habib Nadimi-Bajandi1, Esmail Moshiri2, Hesameddin Modir2, Mohsen Parsi-Khamene3
1 Department of Anesthesiology, Students Research Committee, Arak University of Medical Sciences, Arak, Iran
2 Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
3 Department of Orthopedic Surgery, Arak University of Medical Sciences, Arak, Iran
|Date of Submission||08-Nov-2021|
|Date of Acceptance||29-Jul-2022|
|Date of Web Publication||15-Sep-2022|
Dr. Hesameddin Modir
Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak
Source of Support: None, Conflict of Interest: None
Introduction: This study aimed to provide an evidence-based foundation for appraising the efficacy of magnesium sulphate, ketamine and neostigmine plus bupivacaine 0.5% on key supraclavicular block (SCB) characteristics made up of onset, duration and quality for forearm surgery. Materials and Methods: This double-blind trial enrolled ninety patients who were identified as having needed forearm surgery and been hospitalised in the Arak-based Valiasr Hospital, Iran, stratified participants into triad randomised groups receiving the aforementioned adjuvants. The basic requirements were met to incorporate the underneath groups' data to be recorded and analysed within SPSS release 20: (a) haemodynamic parameters (including mean arterial pressure/heart rate/oxygen saturation) documented at 5-min intervals until the end of surgery; (b) the onset and next to the duration of complete sensory and motor block, the time to administration of the patient's first post-operative analgesia and the overall dose of analgesic administered; (c) all block failures; (d) opioid consumption during post-operative 24 h and (e) pain score measured on a visual analogue scale throughout recovery time and scheduled post-operative times (2, 4, 8, 12 and 24 h). Results: Notwithstanding the shorter onset of sensory and motor block manifested in the magnesium sulphate group and longer duration of motor block in those receiving neostigmine regimen (P < 0.001), the findings endorsed strong support for the potential efficacy of ketamine in affording the longer duration of sensory block, better clinically meaningful pain relief at all scheduled times and diminished opioid consumption during 24 h (all P < 0.001). Conclusion: Bearing in mind the lack of complication needing to be thought of and the trial's clinical findings, which bespeak the shorter onset of the block (both sensory and motor) in the group receiving magnesium sulphate versus the longer duration of motor and sensory block in the neostigmine- and ketamine-treated groups, respectively, and diminished pain score and opioid consumption in the latter, all the adjuvants, thus, could be suggested to be contributed to achieving successful SCB in forearm fracture patients, depending on the patient's general condition and the anaesthesiologist's discretion.
Keywords: Bupivacaine, forearm surgery, ketamine, magnesium sulphate, neostigmine, supraclavicular block
|How to cite this article:|
Nadimi-Bajandi H, Moshiri E, Modir H, Parsi-Khamene M. Efficacy comparison of magnesium sulphate, ketamine and neostigmine adjuvants to bupivacaine 0.5% on onset, duration and quality of ultrasound-guided supraclavicular block characteristics for forearm surgery. Adv Hum Biol 2022;12:266-70
|How to cite this URL:|
Nadimi-Bajandi H, Moshiri E, Modir H, Parsi-Khamene M. Efficacy comparison of magnesium sulphate, ketamine and neostigmine adjuvants to bupivacaine 0.5% on onset, duration and quality of ultrasound-guided supraclavicular block characteristics for forearm surgery. Adv Hum Biol [serial online] 2022 [cited 2023 Feb 7];12:266-70. Available from: https://www.aihbonline.com/text.asp?2022/12/3/266/356109
| Introduction|| |
Patients' perceived benefit from the peripheral nerve block must be a mainstay when the reputation of pain management needs to move towards becoming fundamental to anaesthesia (both general and regional). The brachial plexus block may be accomplished at two distinct anatomical sites, including above the clavicle (interscalene and supraclavicular approaches) and below the clavicle (infraclavicular and axillary approaches), among which the supraclavicular block (SCB) is indicated for procedures on the arm, elbow and forearm and performed where the brachial plexus is presented most compactly, at the distal trunk/proximal division level. Thereupon, rapid onset of reliable block can be achieved by a small volume local anaesthetic solution., The anaesthesiologist administering ultrasound-guided SCB is capable of seeing the brachial plexus structures, subclavian artery and pleura, just below the first rib.
Successful judicious regional anaesthesia demands the full range of the anaesthesiologist's technical skills of nerve block techniques and thorough knowledge concerning the pharmacological properties of the various local anaesthetics whose requirements rely on diverse factors, including block type, surgical procedure and patient's physiologic status. The regional block involves local anaesthetic being injected in the vicinity of a major nerve trunk while being mixed with others such as opioids, bicarbonate, adrenaline and dexamethasone for providing greater improvement in the severity and quality, alongside prolonging the duration of anaesthesia. Post-operative pain augments the cost of delivering the treatment and the length of being hospitalised. To our knowledge, the assorted studies being conducted by anaesthesiologists on various local anaesthetics targeted to prolong block and analgesia duration lead to post-surgical comfort and convenience. Based on the probabilistic peripheral opioid receptors, various opioids with local blocks were developed to provide a prolonged duration of analgesia without any severity of unwanted opioid-related adverse effects, while revealing completely different findings based on plenty of studies on structurally dissimilar local anaesthetics and opioids.
Magnesium sulphate acts as an antagonist of N-methyl- D-aspartate receptors and is a well-known compound of magnesium, as quantitatively the second most abundant intracellular cation and the fourth most abundant cation overall in the body, with analgesic properties chiefly owing to the regulation of intracellular calcium whose growing evidence suggests its vital role in analgesia mediated by local anaesthetics, whose permeability is decreasingly affected by the anaesthetics and, as clinical studies reflected, whose blockers may potentiate the analgesic effect of the agents. Magnesium can, thereby, intensify the effect of local anaesthetics, improves the quality of anaesthesia and analgesia when administered intravenously and intrathecally, and is frequently reported to be effective in facilitating the onset of block and in improving the quality and duration of anaesthesia,, while whose sulphate has proven to be a cost-effective agent for providing post-operative analgesia. It is also effective in relieving tourniquet pain and in diminishing intraoperative fentanyl consumption when used as an adjuvant to lidocaine during intravenous (IV) local anaesthesia.
Neostigmine is a quaternary amine anticholinesterase and a cholinergic agent, increasing acetylcholine levels and indirectly stimulating both the muscarinic and nicotinic receptors, administered to reverse the neuromuscular blocking action of non-depolarising muscle relaxant, with the features as follows: onset of action (IV) of 1 to 2 min, peak effect of 2 to 3 min and duration of action of 2.5 to 4 h. Epidural and intrathecal neostigmine produces analgesia through inhibition of the degradation of acetylcholine in the spinal cord, and for instance, a prospective randomised double-blinded study addressed the effects of adding neostigmine to supraclavicular brachial plexus block in chronic renal failure patients and confirmed that it does not affect the duration of the block but shortens the onset of sensory and motor block and enhances post-operative analgesia, while not causing side effects, if administered at a dose of 500 μg.
Ketamine, a non-barbiturate IV anaesthetic, can be thought of as an ideal drug for Bier's block due to how it works and its analgesic effects. A greater analgesic and sedative effects in favour of ketamine help it to work as an adjunct and complement to other analgesics. It produces a profound analgesic effect. The action is identical to that of morphine, whereas ketamine exerts pharmacological effects on mu receptors. Similarly, bupivacaine is a long-acting local anaesthetic, administered in brachial plexus blocks.
Pain-suffering patients need valuable improvement of the quality of the effect of local anaesthetics in both local and regional blocks and management of post-surgical acute pain. Different methods of performing supraclavicular brachial plexus block along with anatomical variations of brachial plexus can pioneer further studies. Thus, the present trial was designed to compare the efficacy of bupivacaine 0.5% plus either magnesium sulphate, ketamine and neostigmine on the onset, duration and quality of SCB for upper extremity surgeries, because of the lack of a three-group comparative study of the block as our study and notwithstanding of several studies investigating the effect of bupivacaine and ketamine and administering neostigmine and magnesium sulphate as an adjuvant to local anaesthetics used in different regional blocks.
| Materials and Methods|| |
This study was of a double-blind, randomised design, with an enrolment of three stratified groups of patients (n = 90) clinically identified as necessitating upper limb surgery and being admitted to the Valiasr Hospital. Written informed consent obtained indicated patients' full knowledge of the procedure. Inclusion criteria included the following: patients' age from 20 to 70-year-old, American Society of Anesthesiologists Class I and II, of both genders, scheduled for upper limb surgery, no more than one fracture in the body or surgery, absence of blood coagulation diseases and partial thromboplastin time, prothrombin time and international normalised ratio disorders, body mass index <35 kg/m2, no neurological disorders in hand, no history of allergy to the study medications and no chronic pain syndrome. Moreover, patients who refused to cooperate to perform the block, had an allergy to treatment drugs, infection at the site of the block, the block failure and surgery time >150 min and required sedation more than that of the scheduled in the plan were excluded from the study. The eligible subjects scheduled for surgery were hospitalised the night before surgery, kept nothing by mouth for 8 h and transferred to the operating room the next morning.
The anaesthesiologist performed a SCB on each patient after establishing an IV line in the patient's other hand, receiving 10 mL/kg crystalloid serum and initial recording of vital signs (mean arterial pressure [MAP], heart rate [HR] and oxygen saturation [SaO2]). The drugs to treat each group were prepared by an anaesthesiologist and administered to perform the block by an anaesthesia nurse, while the medical student collected information, and the participants were both blinded to the treatment group allocation. All surgeries were performed by only one surgeon. Midazolam 2 mg was injected intravenously into all patients before the block was performed. The patient was first placed in the supine position, the head was turned to the opposite side and the area of the block was cleaned with betadine solution to ensure a successful block which then was performed using a General Electric ultrasound device, Voluson E6 and a 50 mm 18-gauge needle. Location is simplified by a plumb bob, needle approach at the upper end of the middle of the clavicle (the outer edge of the clavicular head of the sternocleidomastoid muscle), so that an ultrasound guide was used to find the exact location. Using the balanced block randomisation method by which computer software to generate random number sequences was suggested, the patients were randomly allocated to one of the three study arms.
The magnesium sulphate group
25 mL of bupivacaine 0.5% with 100 mg of magnesium sulphate, 1 mL of a 10% solution (bupivacaine 0.5%, AstraZeneca Pharmaceutical Industry Company, England, and magnesium sulphate, Shahid Ghazi Pharmaceutical Company, Tabriz, Iran).
The ketamine group
25 mL of bupivacaine 0.5% with 2 mg/kg of ketamine (ketamine, Rotexmedica, Germany).
The neostigmine group
25 mL of bupivacaine 0.5% with 500 μg of neostigmine (neostigmine vial, Caspian Tamin Pharmaceutical Company, Rasht, Iran).
The adjuvant dose was calculated, diluted to 5 ml with distilled water and added to the volume of a local anaesthetic to give a total volume of 30 mL of drug administered for the block. The anaesthetic solution was injected slowly over 30 s by the anaesthesia nurse. Patients were intraoperatively monitored for side effects, such as bradycardia, hypotension and arrhythmia, and they, if they occurred, were treated by appropriate remedial action. While the time of local anaesthetic administration was documented for each patient, the extent of sensory block was evaluated using pinprick with a 22-gauge needle every 30 s. Patient response was evaluated in the sensory dermatomes and sensory nerves of the upper extremity, as a three-point scale, where: 0 = normal; 1 = sensory loss to pinprick (analgesia) and 2 = sensory loss to touch (complete anaesthesia).
Furthermore, the motor block was also graded on a three-point scale, using a modified Bromage scale for the upper limb, in which 0 = normal motor function with full flexion and extension of elbow, wrist and fingers; 1 = reduced motor strength, with ability to move fingers alone and 2 = complete motor block with the inability to move the fingers. MAP, HR and SaO2 were measured every 5 min until the end of surgery. The onset and next to the duration of sensory and motor block, as well as the time of the first post-operative analgesia in the patient and the total dose of analgesic used in each group were recorded. All block failures and next opioid consumption were recorded in each group whose pain scores were measured using the visual analogue scale (VAS), where zero and ten correspond to the lowest and highest, at recovery, 2, 4, 8, 12 and 24 h post-operatively. We administered 50 mg of intramuscular meperidine to any patient showing VAS more than four, recorded the administration time and controlled patients for complications, for instance, relief of hypoxia (SaO2 <92%) by supplemental oxygen administration, hypotension (blood pressure <20% baseline) by crystalloid solutions or sympathomimetic drug administration, if needed, and bradycardia (HR <40) by IV atropine 0.5 mg, while recording any other potential complication and conducting further remedial action, if required.
Finally, the data were analysed in SPSS 20 SPSS version 20 (IBM Corp., Armonk, USA) at a significance level of 0.05 and analysed using Chi-square and repeated measures ANOVA.
| Results|| |
This randomised, double-blind clinical trial enrolled one ninety patient population who were scheduled for forearm surgery at the Arak Valiasr Hospital and randomly stratified to three groups being administered with magnesium sulphate, ketamine and neostigmine, with overall, 45 (47.9%) women and 45 (47.9%) men, whose minimum and maximum ages were 21 and 60, respectively and whose mean age was 36.37 ± 9.02. The analysis revealed no statistically significant intergroup difference in terms of SaO2, MAP, HR, duration of surgery and post-operative complications (P > 0.05), while the data on patient age and gender were identical in all subjects.
The results in [Table 1] revealed a statistically significant intergroup difference in terms of quality of sensory block (P < 0.001), and the shorter onset of sensory block in the magnesium sulphate-sedated group, while the longer duration of sensory block in the ketamine-treated group.
|Table 1: Intergroup comparison of mean and standard deviation of quality of sensory block|
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Based on the results in [Table 2], statistically significant intergroup differences were demonstrated in terms of the quality of motor block (P < 0.001), while the onset and duration of the block were shorter in the magnesium sulphate group and longer in the neostigmine group, respectively. The results [Table 3] demonstrated statistically significant intergroup differences observed in terms of pain (P < 0.001) and less pain seen in the ketamine group, that repeated measures test confirmed the latter finding (P < 0.001). The trend of pain score after operation showed the minimum pain in the ketamine group at all times [Chart 1].
|Table 2: Intergroup comparison of mean and standard deviation of quality of motor block|
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|Table 3: Intergroup comparison of mean and standard deviation of pain score|
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The results in [Table 4] showed a statistically significant intergroup difference observed in terms of opioid consumption during 24 h (P < 0.001), whereas the lowest consumption was seen in the group receiving ketamine.
|Table 4: Intergroup comparison of the frequency and percentage of 24-h opioid consumption|
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| Discussion|| |
A total of 90 patients who were candidates for forearm surgery in Valiasr Hospital in Arak were included in the study and randomly divided into three groups (magnesium sulphate, ketamine and neostigmine), showing the shorter onset of sensory and motor block in the magnesium sulphate group versus the longer duration of sensory and motor block in the ketamine and neostigmine groups, respectively, and less pain in the ketamine group at all times and less opioid consumption in the ketamine group. These results can be generalised, and besides, no complication was noted in any of the groups.
As shown by a study (Lashgarinia et al., 2014), in line with our study on the effect of an adjuvant in ultrasound-guided supraclavicular brachial plexus block, ketamine, if added to lidocaine, can lessen the post-operative pain and need for analgesic and can be advocated by experts as an option in SCB. Elbahrawy and El-Deeb, when exploring the effects of adding neostigmine to supraclavicular brachial plexus block in chronic renal failure patients, found that the adjuvant at a dose of 500 μg though shortens the onset of sensory and motor block and enhances post-operative analgesia, but causes no side effects, it does not affect the duration of block, while our results show somewhat contrary findings in that the onset of sensory and motor block was shorter in the magnesium sulphate group, the duration of motor and sensory block were longer in the neostigmine and ketamine groups, respectively, and pain score and opioid consumption were lower in the ketamine group.
Furthermore, Verma et al. suggested that magnesium sulphate prolongs the duration of sensory and motor block in SCB, whose results were consistent with our study. Other similar findings confirmed that adding magnesium sulphate to bupivacaine affords the improved quality of block, the prolonged duration of the block and the alleviated pain. Sabra et al. published a paper on adding dexmedetomidine and ketamine in brachial plexus block, reporting no statistically significant difference seen in the onset of sensory and motor block but the prolonged duration of anaesthesia in the dexmedetomidine group. They concluded that dexmedetomidine for brachial plexus block would prolong the duration of sensory and motor block and analgesia in the patient and improve the quality of the block, while the onset of the block was shorter in our magnesium sulphate group and the duration of the block was longer in the neostigmine and ketamine groups in our study, whose difference can be attributed to the different drugs used.
| Conclusion|| |
Considering the lack of complication needing to be treated and the trial's clinical findings signifying the shorter onset of the block (both sensory and motor) in the magnesium sulphate group and the longer duration of motor and sensory block in the neostigmine and ketamine groups, respectively, and less pain score and opioid consumption in the latter, all the adjuvants, thus, could be suggested to be used to achieve successful SCB in patients with a forearm fracture, according to the patient's medical condition and the anaesthesiologist's discretion.
This study is the result of research conducted as a general medicine thesis, with Research Ethics and Clinical Trial Codes of IR.ARAKMU.REC.1400.001 and IRCT20141209020258N158, respectively. The authors would like to express a debt of gratitude to the Valiasr Hospital's clinical research council for its assistance and guidance and to the research deputy of Arak University of Medical Sciences for the help and support throughout the study.
Financial support and sponsorship
This study was financially supported by Arak University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]