ORIGINAL ARTICLE
Year : 2022 | Volume
: 12 | Issue : 3 | Page : 277--282
Comparison of the efficacy of supraclavicular block with bupivacaine (0.5%) combined with dexmedetomidine, granisetron and magnesium sulphate in sensory and motor block and haemodynamic parameters of patients in upper-extremity orthopaedic surgery: A randomised clinical study
Hesameddin Modir1, Behnam Mahmoodiyeh1, Amir Hossein Moradi2, Fatemeh Mohseni3, Amir Almasi-Hashiani4,
1 Department of Anesthesiology, Arak University of Medical Sciences, Arak, Iran
2 Department of Orthopedy, Arak University of Medical Sciences, Arak, Iran
3 Department of Anesthesiology, Student Research Committee, Arak University of Medical Sciences, Arak, Iran
4 Department of Epidemiology, School of Health, Arak University of Medical Sciences, Arak, Iran
Correspondence Address:
Dr. Behnam Mahmoodiyeh
Department of Anesthesiology, Faculty of Medicine, Arak University of Medical Sciences, Arak
Iran
Abstract
Introduction: Peripheral nerve block leads to effective pain control. Peripheral nerve blocks are used both in general anaesthesia and as regional anaesthesia alone. The aim of this study was to compare the characteristics of the supraclavicular block with bupivacaine (0.5%) in combination with dexmedetomidine, granisetron and magnesium sulphate in upper-limb orthopaedic surgery. Materials and Methods: This double-blind clinical trial was carried out on 105 patients who were candidates for upper-limb orthopaedic surgery in Valiasr Hospital in Arak. The patients were divided into three equal groups (dexmedetomidine, granisetron and magnesium sulphate) using the block method for randomisation. Mean arterial pressure, heart rate and arterial oxygen saturation every 5 min until the end of the surgery, onset and duration of sensory and motor block, mean opioid consumption in 24 h and post-operative pain during recovery and 2 h after surgery at 4, 8, 12 and 24 h were recorded. Data were analysed by SPSS.22 software. Results: The lowest heart rate at all times and the lowest blood pressure from 40 min to the end of surgery were observed in the dexmedetomidine group (P < 0.05). The time to the onset of sensory block and the time to the onset of motor block were shorter in the magnesium sulphate and dexmedetomidine groups, respectively. Moreover, the duration of the sensory and motor block was longer in the dexmedetomidine group (P = 0.0001). In addition, pain and amount of opioid consumption were lower in the dexmedetomidine group (P = 0.0001). Conclusion: Magnesium sulphate caused earlier onset of sensory block, while dexmedetomidine increased the duration of sensory and motor block. In the dexmedetomidine group, haemodynamic changes were made in the form of a decrease in heart rate and blood pressure, which, of course, did not require special treatment. As such, magnesium sulphate as an adjuvant is recommended to be used in cases where there is a requirement for the rapid onset of sensory block. Meanwhile, dexmedetomidine should be used as an adjuvant for the rapid onset of motor block and increase of the duration of sensory and motor block when taking into account the patients' physical conditions and the anaesthesiologist's discretion.
How to cite this article:
Modir H, Mahmoodiyeh B, Moradi AH, Mohseni F, Almasi-Hashiani A. Comparison of the efficacy of supraclavicular block with bupivacaine (0.5%) combined with dexmedetomidine, granisetron and magnesium sulphate in sensory and motor block and haemodynamic parameters of patients in upper-extremity orthopaedic surgery: A randomised clinical study.Adv Hum Biol 2022;12:277-282
|
How to cite this URL:
Modir H, Mahmoodiyeh B, Moradi AH, Mohseni F, Almasi-Hashiani A. Comparison of the efficacy of supraclavicular block with bupivacaine (0.5%) combined with dexmedetomidine, granisetron and magnesium sulphate in sensory and motor block and haemodynamic parameters of patients in upper-extremity orthopaedic surgery: A randomised clinical study. Adv Hum Biol [serial online] 2022 [cited 2023 Mar 27 ];12:277-282
Available from: https://www.aihbonline.com/text.asp?2022/12/3/277/356111 |
Full Text
Introduction
Peripheral nerve block leads to effective pain control. Peripheral nerve blocks are used both in general anaesthesia and as regional anaesthesia alone. The brachial plexus can be blocked in two upper areas of the clavicle (interscalene and supraclavicular) and below the clavicle (infraclavicular and axillary).[1],[2] Indications for supraclavicular block include elbow, forearm and hand surgeries. This block is performed at the distal trunk and proximal division of the brachial plexus.[1],[3]
The brachial plexus, at this point, is compressed, and with a small amount of local anaesthetic solution, a reliable block can be formed in a short time. The use of ultrasound for the supraclavicular block allows the anaesthesiologist to visualise the structure of the brachial plexus and the subclavian and pleural arteries just above the first rib.[2],[3] The use of local anaesthetics varies depending on the type of block, the surgical procedure and the physiological condition of the patient.[4] The basis of this regional block is the injection of anaesthetic drugs near the nerve root or main body of the nerve.[5],[6] In order to improve the intensity, quality, time and duration of anaesthesia in such blocks, other drugs such as opioids, bicarbonate, adrenaline and dexamethasone have been used in addition to anaesthetic agents.[5],[6],[7]
Post-operative pain leads to increased cost of treatment and length of stay. Anaesthesiologists have conducted numerous studies on ways to increase the duration of the block using various local anaesthetics.[2],[3],[4],[8] They are increasing the duration of analgesia results in patient comfort and convenience in the post-operative period. The possibility of the presence of peripheral opioid receptors has led to the use of various opioids in local blocks in an attempt to increase the duration of analgesia without any increase in the side effects. Completely different results have been reported by numerous studies using different local anaesthetics and opioids.[6],[9]
Dexmedetomidine, an agonist of α2-adrenergic, is a sedative that has analgesic effects when reducing blood pressure.[10] It can prove effective when added to local anaesthetics during peripheral nerve blocks.[11],[12] Magnesium sulphate has analgesic effects.[13] These effects primarily result from the regulation of intracellular calcium; in fact, it is an antagonist of N-methyl-D-aspartate receptors.[13],[14] As such, magnesium can enhance the effect of local anaesthetics. In addition, magnesium improves the quality of intravenous and intrathecal anaesthesia and analgesia.[15],[16] Various studies have shown that magnesium is effective in reducing the time to the onset of the block as well as in increasing the quality and duration of anaesthesia.[13],[16],[17] In addition, the importance of magnesium sulphate as an inexpensive drug in causing post-operative analgesia has been well proven.[4] Adding magnesium to lidocaine during local, intravenous anaesthesia has been shown to reduce tourniquet pain and intraoperative fentanyl use.[4],[18]
Bupivacaine is one of the long-acting local anaesthetics used in the blockade of the brachial plexus. Improving the quality of the effect of local anaesthetics in local and regional blocks, as well as post-operative acute pain management, is very important for patients experiencing pain.[19] Various methods of performing supraclavicular block of the brachial plexus and anatomical variation of this neural network have paved the way for further research.[3],[11]
Different studies[4],[6],[12],[16],[17],[20] have investigated the effect of bupivacaine with dexmedetomidine and magnesium sulphate. Granisetron has also been used as an adjuvant to local anaesthetics in different blocks, but to date, no study has compared the three drugs in the supraclavicular block as the current study. As such, the present study was undertaken in order to compare the onset, duration and quality of supraclavicular block using bupivacaine (0.5%) in combination with dexmedetomidine, granisetron and magnesium sulphate in upper-limb orthopaedic surgery.
Materials and Methods
Study setting
This double-blind clinical trial was conducted on 105 patients scheduled for upper-limb orthopaedic surgery in Valiasr Hospital of Arak, Iran. After being informed of the procedures of the research, meeting the inclusion criteria and signing a written informed consent, the patients entered the study.
Ethical consideration
The study protocol was approved by the Ethical Committee of Arak University of Medical Sciences by IR.ARAKMU.REC.1398.180 code. Moreover, the study protocol was registered and approved in the Iranian Registry Clinical Trial Centre by code number IRCT20141209020258N125.
The inclusion criteria were being within the age range of 20–70 years; American Society of Anesthesiologists grade I and II; of both sexes; candidates for upper-limb orthopaedic surgery; having no more than one fracture on the body or surgery; lack of blood coagulation diseases and disorders in partial thromboplastin time, prothrombin time and international normalised ratio; body mass index <35; no psychological problems; no pregnancy and absence of neurological disorders on the hand. Exclusion criteria included non-cooperation of the patient in performing the block, allergy to the used drugs, failure of the block, duration of surgery more than 150 min, the need for more sedation than stated in the research project and chronic pain syndrome.
Intervention
The patients were hospitalised the night before surgery, kept fasting for 8 h and then were transferred to the operating room the next morning. After spotting an intravenous line on the patient's other hand, administering 10 ml/kg of crystalloid serum and initial recording of vital signs (mean arterial pressure [MAP]) including non-invasive blood pressure, Heart Rate (HR) and SaO2, the supraclavicular block was performed on the patient by the anaesthesiologist. In each group, the drugs were prepared by an anaesthesiologist and used to perform the block. It should be mentioned that the medical student collecting the data and the patients were not aware of the groupings.
Midazolam 2 mg/IV was injected into all patients before the blockade. In order to perform the block, the patient was first placed in the supine position. Then, the patient's face was rotated to the opposite side, and the block area was washed with betadine. All blocks were performed by an anaesthesiologist. Blocking was performed with a General Electric ultrasound machine (Voluson E6) and needle no. 18 with a 50-mm length. The needle was inserted by plumb-bob method on the upper edge of the middle part of the clavicle (on the outer edge of the clavicular head of the sternocleidomastoid muscle) in a manner that an ultrasound guide was used to find the desired location.
The patients were randomly divided into three equal groups using the block randomisation method using the relevant software. Random numbers were generated with a block pattern and remained with the epidemiologist co-researcher of the project. At the time of the study, patients were randomly assigned to the respective groups based on the order of their inclusion in the study.
The first group received 25 ml of bupivacaine 0.5% along with 1 μg/kg dexmedetomidine. The second group received 25 ml of bupivacaine 0.5% along with 100 mg of magnesium sulphate diluted with 2 ml of normal saline. Moreover, for the third group, 25 ml of bupivacaine 0.5% with 3 mg (3 ml) of granisetron was administered.
After calculating the dose of the adjuvant drug for each patient, its volume was increased to 5 ml with distilled water and then added to the volume of the local anaesthetic drug so that in all patients, a total of 30 ml of the drug was used for blocking. The anaesthetic solution was slowly injected by the nurse anaesthetist for 30 s, who was unaware of its type.
It should be mentioned that the patients were constantly monitored during the operation for side effects such as bradycardia, hypotension and arrhythmia, and in case of side effects, appropriate treatment was performed on them. At first, the time of administration of local anaesthetic was recorded for each patient. Sensory block evaluation was performed with needle number 22 every 30 s (pinprick). The patient's response in the sensory dermatome of the upper-extremity nerves was evaluated on a three-point system as follows: 0 = normal sensation, 1 = no sensation of pinprick during testing (analgesia) and 2 = absence of sensation upon touching (complete anaesthesia).
Motor block was measured using Bromage system modified for the upper extremities[21] based on a triple scoring scale as follows: score 0 = normal motor function with complete flexion and extension of the elbows, wrists and fingers; score 1 = decreased motor strength with the ability to move the fingers alone and score 2 = complete motor block with the inability of the fingers.[22]
Measurements
MAP, heart rate and arterial oxygen saturation were measured every 5 min until the end of surgery. An attempt was made to record the time elapsed to produce a complete sensory and motor block in each group and later on the duration of sensory and motor block in the groups. Furthermore, the number of consumed opioids in 24 h after surgery and the total dose of consumed analgesics as well as all cases of block failure and pain based on the Visual Analogue Scale (VAS) in recovery and 2 h after surgery and at 4, 8, 12 and 24 h were measured in each group. And finally, the results from the three groups were compared with one another. On the pain scale, 0 and 10 indicated the lowest and highest values, respectively, and if the patient had a VAS >4, 50 mg of intramuscular meperidine was administered. The complications of patients such as hypoxia (SaO2 <92%) were controlled by supplemental oxygen administration in case of hypotension (BP <20% baseline). It was controlled by crystalloid serum administration or, if necessary, by sympathomimetic administration, and in case of bradycardia (HR <40), atropine 0.5 mg IV was administered. Should there be other complications, it was recorded, and if necessary, the appropriate course of treatment was undertaken.
Statistical analysis
After data collection, the data were analysed by SPSS version 20 (IBM Corp., Armonk, USA). Chi-square test, one-way analysis of variance and analysis of variance for repeated measurements were used to compare three different groups at different times after surgery. P < 0.05 was considered statistically significant.
Results
The minimum and maximum age of the patients was 24 and 48 years, respectively, with the mean age being 36.34 ± 6.13 years. The mean body mass index was 24.66 ± 2.23. Fifty-two patients (39.5%) were male and 53 (50.5%) were female. In addition, it was found that there was no statistically significant difference between the mean percentage of oxygen saturation, duration of surgery and complications in the groups (P > 0.05). The groups were similar in terms of age, sex and body mass index.
According to results pertaining to the heart rate [Figure 1], a statistically significant difference was found to exist among the study groups from 30 min to the end of surgery (P < 0.05). The lowest and highest heart rate was observed in the dexmedetomidine and magnesium sulphate groups, respectively. The repeated measure test indicated a statistically significant difference in that the heart rate in the dexmedetomidine group was lower than that in the other groups (P = 0.0001). As shown in [Figure 2], there was a statistically significant difference in arterial pressure in the study groups from 40 min to the end of surgery (P < 0.05). The lowest arterial pressure was observed in the dexmedetomidine group. Based on the repeated measure test, a statistically significant difference was observed, with arterial pressure being lower in the dexmedetomidine group (P = 0.001).{Figure 1}{Figure 2}
As shown in [Table 1], there was a significant difference in sensory block characteristics among the study groups (P = 0.0001). The onset of sensory block was shorter in the magnesium sulphate group, while the duration of sensory block was longer in the dexmedetomidine group than that in the other two groups. According to [Table 2], a statistically significant difference was observed in motor block characteristics in the study groups (P = 0.0001). The onset of motor block was lower in the dexmedetomidine group but had the longest duration of motor block.{Table 1}{Table 2}
As observed in [Table 3] and [Figure 3], there was a statistically significant difference in pain across the study groups from 2 h after the end of surgery (P = 0.001). The pain level was less in the dexmedetomidine group. As shown in [Table 4], a statistically significant difference was observed in the number of consumed opioids across the study groups (P = 0.0001). The amount of opioid consumption in the dexmedetomidine group was less than that in the other two groups.{Table 3}{Figure 3}{Table 4}
Discussions
Our results showed that the mean percentage of oxygen saturation and the duration of surgery in the groups were not statistically significant. The lowest and highest heart rate was observed in the dexmedetomidine and magnesium sulphate groups, respectively. The lowest arterial pressure from 40 min to the end of surgery was observed in the dexmedetomidine group. In addition, the time to onset of sensory block in magnesium sulphate group and the time to onset of motor block in the dexmedetomidine group were shorter than the other two groups. The duration of sensory and motor block in the dexmedetomidine group was longer than that in the other two groups. It was also found that the pain level, as well as the amount of consumed opioids, was lower in the dexmedetomidine group. On the whole, in the dexmedetomidine group, heart rate and blood pressure were lower than those in the other groups. Dexmedetomidine is an agonist of α2-adrenergic, which is a sedative with analgesic properties, which reduces blood pressure.[13] Adding dexmedetomidine to local anaesthetics during peripheral nerve blocking can be effective.[11],[12],[13]
Ghali et al. conducted a study in 2019 aimed at adding magnesium sulphate to bupivacaine in the supraclavicular block. They maintained that magnesium sulphate improves block quality, extends block duration and reduces pain.[23] It should be mentioned that in the current study, magnesium sulphate was also effective, but the effect of dexmedetomidine was greater.
Verma et al. conducted a study on the effect of magnesium sulphate on the supraclavicular block. They found that magnesium sulphate increases the duration of sensory and motor block, and it has greater efficacy in the dose of 250 mg.[24] Magnesium sulphate was also effective in the current study, but the effect of dexmedetomidine was greater. In 2015, Kathuria et al. carried out research about adding dexmedetomidine as an adjuvant to ropivacaine. They conclude that dexmedetomidine added to ropivacaine in brachial block prolongs the duration of sensory and motor block and increases the duration of analgesia.[25] Their results were consistent with those in the current study. In 2014, Agarwal et al.[26] evaluated the effect of dexmedetomidine added to bupivacaine on the supraclavicular block. They found that in the dexmedetomidine group, the duration of the block was longer, and the onset of the block was shorter.[26] The results of their study were consistent with those in the current study.
In the current study, the duration of the block was longer in the dexmedetomidine group, but the time to the onset of the sensory block was shorter in the magnesium sulphate group. Swami et al.[22] compared dexmedetomidine and clonidine as adjuvants in the supraclavicular block. They concluded that in the supraclavicular block, dexmedetomidine prolonged the duration of sensory and motor block as well as the duration of analgesia. It also enhanced the quality of the block as compared with clonidine.[22] The results of their study were consistent with those of the current study. In the current study, the duration of the block was also longer, but the time to the onset of the sensory block was shorter in the magnesium sulphate group. In 2004, Voog et al. examined the effect of serotonin on the analgesic effects of granisetron on temporomandibular joint (TMJ) arthritis. They maintained that TMJ range of movement increased after taking granisetron compared to the period before injection and that TMJ movement pain intensity decreased. However, granisetron was not effective in the reduction of resting pain intensity of TMJ. They injected 3 ml of granisetron (1 mg/ml) into patients. Granisetron was administered into the posterior part of the upper joint compartment of the most painful TMJ for approximately 3 min.[8] In the present study, granisetron was effective, but the effect of dexmedetomidine was greater. Granisetron, as one of the selective HT3-5 receptor antagonists, has long-term effects and a better function than ondansetron and is often used to prevent nausea and vomiting after chemotherapy.[20],[27] Moreover, Modir et al. used different doses of granisetron in order to increase the duration of analgesia in the local, intravenous block, with the results pointing to the effect of granisetron in causing longer analgesia and more favourable conditions.[28] There have been reports of several successful studies on the efficacy of this drug in preventing pain caused by propofol injection.[27],[29]
Conclusion
Based on the results of this study, among the drugs used as adjuvants to the local anaesthetic bupivacaine in the supraclavicular block, magnesium sulphate caused earlier onset of sensory block, while dexmedetomidine increased the duration of sensory and motor block. In the dexmedetomidine group, haemodynamic changes were made in the form of a decrease in heart rate and blood pressure, which, of course, did not require special treatment. As such, magnesium sulphate is recommended to be used as an adjuvant in cases where there is a requirement for the rapid onset of sensory block. Meanwhile, dexmedetomidine should be used as an adjuvant for the rapid onset of motor block and increase of the duration of sensory and motor block while taking into account the patients' physical conditions and the anaesthesiologist's discretion.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
| 1 | Héroux J, Belley-Côté E, Echavé P, Loignon MJ, Bessette PO, Patenaude N, et al. Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: A systematic review protocol. Syst Rev 2019;8:273. |
| 2 | Büttner B, Mansur A, Hinz J, Erlenwein J, Bauer M, Bergmann I. Combination of general anesthesia and peripheral nerve block with low-dose ropivacaine reduces postoperative pain for several days after outpatient arthroscopy: A randomized controlled clinical trial. Medicine (Baltimore) 2017;96:e6046. |
| 3 | Tarıkçı Kılıç E, Akdemir MS. Comparison of supraclavicular, infraclavicular, and axillary approaches for ultrasound-guided brachial plexus block for upper limb surgeries: A retrospective analysis of 182 blocks. Dubai Med J 2018;1:33-7. |
| 4 | Akhondzade R, Nesioonpour S, Gousheh M, Soltani F, Davarimoghadam M. The effect of magnesium sulfate on postoperative pain in upper limb surgeries by supraclavicular block under ultrasound guidance. Anesth Pain Med 2017;7:14232. |
| 5 | Songthamwat B, Karmakar MK, Li JW, Samy W, Mok LY. Ultrasound-guided infraclavicular brachial plexus block: Prospective randomized comparison of the lateral sagittal and costoclavicular approach. Reg Anesth Pain Med 2018;43:825-31. |
| 6 | Hussain N, Grzywacz VP, Ferreri CA, Atrey A, Banfield L, Shaparin N, et al. Investigating the efficacy of dexmedetomidine as an adjuvant to local anesthesia in brachial plexus block: A systematic review and meta-analysis of 18 randomized controlled trials. Reg Anesth Pain Med 2017;42:184-96. |
| 7 | Chazapi A, Lepetsos P, Gambopoulou Z, Siafaka I, Argyra E, Vadalouka A. Analgesic effect of the topical use of dexamethasone in ultrasound-guided axillary brachial plexus blockade: A prospective, randomized, double-blind, placebo-controlled study. Cureus 2021;13:e12971. |
| 8 | Voog U, Alstergren P, Leibur E, Kallikorm R, Kopp S. Influence of serotonin on the analgesic effect of granisetron on temporomandibular joint arthritis. Mediators Inflamm 2004;13:373-6. |
| 9 | Akhondzadeh R, Rashidi M, Gousheh M, Olapour A, Tasbihi B. Comparison of the ketamine-lidocaine and fentanyl-lidocaine in postoperative analgesia in axillary block in upper limb fractures by ultrasound guidance. Anesth Pain Med 2019;9:e92695. |
| 10 | Modir H, Moshiri E, Kamali A, Shokrpour M, Shams N. Prophylatic efficacy of dexamethasone, ketamine and dexmedetomidine against intra-and postoperative nausea and vomiting under spinal anesthesia. Formosan J Surg 2019;52:17. |
| 11 | Biswas S, Das RK, Mukherjee G, Ghose T. Dexmedetomidine an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A randomized double blind prospective study. Ethiop J Health Sci 2014;24:203-8. |
| 12 | Marhofer D, Kettner SC, Marhofer P, Pils S, Weber M, Zeitlinger M. Dexmedetomidine as an adjuvant to ropivacaine prolongs peripheral nerve block: A volunteer study. Br J Anaesth 2013;110:438-42. |
| 13 | Modir H, Modir A, Rezaei O, Mohammadbeigi A. Comparing remifentanil, magnesium sulfate and dexmedetomidine for intraoperative hypotension and bleeding and postoperative recovery in endoscopic sinus surgery and tympanomastoidectomy. Med Gas Res 2018;8:42-7. |
| 14 | Reuben SS, Reuben JP. Brachial plexus anesthesia with verapamil and/or morphine. Anesth Analg 2000;91:379-83. |
| 15 | Buvanendran A, McCarthy RJ, Kroin JS, Leong W, Perry P, Tuman KJ. Intrathecal magnesium prolongs fentanyl analgesia: A prospective, randomized, controlled trial. Anesth Analg 2002;95:661-6. |
| 16 | Wang J, Wang Z, Shi B, Wang N. The effect of adding intrathecal magnesium sulphate to bupivacaine-fentanyl spinal anesthesia: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020;99:e22524. |
| 17 | Do SH. Magnesium: A versatile drug for anesthesiologists. Korean J Anesthesiol 2013;65:4-8. |
| 18 | Turan A, Memiş D, Karamanlioğlu B, Güler T, Pamukçu Z. Intravenous regional anesthesia using lidocaine and magnesium. Anesth Analg 2005;100:1189-92. |
| 19 | Ammar AS, Mahmoud KM. Ultrasound-guided single injection infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for pain control in upper limb surgery: A prospective randomized controlled trial. Saudi J Anaesth 2012;6:109-14. |
| 20 | Ahmed A, Sengupta S, Das T, Rudra A, Iqbal A. Pre-treatment with intravenous granisetron to alleviate pain on propofol injection: A double-blind, randomized, controlled trial. Indian J Anaesth 2012;56:135-8. |
| 21 | Sane S, Shokouhi S, Golabi P, Rezaeian M, Kazemi Haki B. The Effect of Dexmedetomidine in Combination with Bupivacaine on Sensory and Motor Block Time and Pain Score in Supraclavicular Block. Pain Res Manag. 2021;2021:8858312. doi: 10.1155/2021/8858312. |
| 22 | Swami SS, Keniya VM, Ladi SD, Rao R. Comparison of dexmedetomidine and clonidine (α2 agonist drugs) as an adjuvant to local anaesthesia in supraclavicular brachial plexus block: A randomised double-blind prospective study. Indian J Anaesth 2012;56:243-9. |
| 23 | Ghali AM, Molokhia KM, Ahmed SA. The effect on outcome of adding magnesium sulphate to bupivacaine in the ultrasound-guided supraclavicular brachial plexus block anesthesia. Int J Anesth Clin Med 2019;7:13. |
| 24 | Verma V, Rana S, Chaudhary SK, Singh J, Verma RK, Sood S. A dose-finding randomised controlled trial of magnesium sulphate as an adjuvant in ultrasound-guided supraclavicular brachial plexus block. Indian J Anaesth 2017;61:250-5. |
| 25 | Kathuria S, Gupta S, Dhawan I. Dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus block. Saudi J Anaesth 2015;9:148-54. |
| 26 | Agarwal S, Aggarwal R, Gupta P. Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol 2014;30:36-40. |
| 27 | Hsu ES. A review of granisetron, 5-hydroxytryptamine3 receptor antagonists, and other antiemetics. Am J Ther 2010;17:476-86. |
| 28 | Modir H, Pazoki S, Khalili M, Salari H, Amani A. Comparison of analgesic effect of different doses of granisetron in combination with lidocaine for intravenous regional anesthesia. Med J Mashhad Univ Med Sci 2016;59:9-16. |
| 29 | Singh DK, Jindal P, Singh G. Comparative study of attenuation of the pain caused by propofol intravenous injection, by granisetron, magnesium sulfate and nitroglycerine. Saudi J Anaesth 2011;5:50-4. |
|
