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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 4  |  Page : 386-391

Infraclavicular brachial plexus block using nalbuphine versus midazolam as adjuvants to bupivacaine in upper limb surgery


Department of Anesthesia and Intensive Care, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission20-Sep-2018
Date of Acceptance27-Jan-2019
Date of Web Publication23-Apr-2019

Correspondence Address:
Mohamed Abdel Gawad Abdel Halim
Samanod/Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_99_18

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  Abstract 


Background Brachial plexus block is a regional anesthesia technique for different surgeries in the upper limb. It is useful as a sole regional anesthesia technique or combined with general anesthesia. The adjuvants to local anesthetics may be improving the quality and duration of analgesia of the brachial plexus block.
Objective To evaluate the efficacy of nalbuphine and midazolam as adjuvants to bupivacaine in the infraclavicular brachial plexus block.
Patients and methods The study was carried out on 70 patients of the American Society of Anesthesiologist, physical status I, II of both sexes, 20–60 years old and scheduled to forearm and hand surgeries. The patients were classified into three equal groups. Group B: using 20 ml of bupivacaine (3 mg/kg) with 1 ml of saline. Group M: using 20 ml of bupivacaine (3 mg/kg) with midazolam 5 mg (1 ml). Group N: using 20 ml of bupivacaine (3 mg/kg) with nalbuphine 1 ml (10 mg).
Results The onset time of sensory and motor blocks were significantly shorter in the adjuvant groups N and M compared with group B. There was a significant increase in the duration of postoperative analgesia in group N compared with groups M and B.
Conclusion The addition of nalbuphine and midazolam to bupivacaine in the infraclavicular brachial block improves the speed of sensory and motor onset, the quality of anesthesia, and decreases the analgesic requirements during the first 24 h postoperatively without obvious side effects. The addition of nalbuphine to bupivacaine was superior in delaying the postoperative analgesia requirement.

Keywords: bupivacaine, infraclavicular brachial block, midazolam, nalbuphine


How to cite this article:
Abdel Halim MG. Infraclavicular brachial plexus block using nalbuphine versus midazolam as adjuvants to bupivacaine in upper limb surgery. Al-Azhar Assiut Med J 2018;16:386-91

How to cite this URL:
Abdel Halim MG. Infraclavicular brachial plexus block using nalbuphine versus midazolam as adjuvants to bupivacaine in upper limb surgery. Al-Azhar Assiut Med J [serial online] 2018 [cited 2019 Aug 20];16:386-91. Available from: http://www.azmj.eg.net/text.asp?2018/16/4/386/256769




  Introduction Top


Brachial plexus block is a regional anesthesia for different surgeries in the upper limb and has provided good intraoperative anesthesia and good postoperative analgesia with reducing the incidence of complications and providing early mobilization [1]. Infraclavicular brachial plexus approaches were described by Bazy and labat in 1930 [2]. The infraclavicular block that occurs at the level of the cords provides anesthesia to the forearm and hand while affording block of the musculocutaneous and axillary nerves. A nerve stimulator or ultrasound visualization is required because there are no palpable vascular landmarks to aid in directing the needle [3].

Nalbuphine is a mixed κ agonist and µ antagonist and has strong analgesic effect. Nalbuphine has potential to enhance µ-opioid based analgesic effect and the analgesic effect of nalbuphine has been equal to the analgesic effect of morphine [4]. Nalbuphine is a synthetic opioid agonist and antagonist. Nalbuphine is a potent analgesic and can be used for preoperative sedation and postoperative analgesia [5]. Midazolam is γ aminobutyric acid and is water soluble acting on GABA-A receptors and it is desirable for anxiolytic to hypnotic effect depending on the percentage of receptor occupancy rather than plasma concentrations of the drug [6].


  Aim of the work Top


The aim of the study was to evaluate the effect of nalbuphine and midazolam as an adjuvant to bupivacaine in the infraclavicular brachial block in cases of hand and forearm surgeries.


  Patients and methods Top


The study was carried out on 70 patients, American Society of Anesthesiologist grades I or II, aged 20–60 years and of both sexes. All patients were scheduled for elective hand and forearm surgeries at El-Hussein University Hospital, from October 2017 to September 2018. After obtaining informed and written consent and approval by the ethics committee in Faculty of Medicine, Al-Azhar University, the patients were randomly divided into three groups.
  1. Group B: received infraclavicular brachial plexus block using 20 ml of bupivacaine (3 mg/kg) and 1 ml normal saline.
  2. Group M: received infraclavicular brachial plexus block using 20 ml of bupivacaine (3 mg/kg) with midazolam 5 mg (1 ml) added as adjuvant.
  3. Group N: received infraclavicular brachial plexus block using 20 ml of bupivacaine (3 mg/kg) with nalbuphine 10 mg (1 ml) added as adjuvant.


Exclusion criteria

Coagulopathy, patient refusal, uncooperative patient, infection at the site of injection. Patients of American Society of Anesthesiologist grades more than II and hypersensitivity to drugs used.

Primary outcomes

Sensory block assessment, onset, duration, motor block assessment; onset, duration, postoperative pain, and analgesic requirements.

Secondary outcomes

Hemodynamic parameters (heart rate, blood pressure, respiratory rate, and peripheral oxygen saturation).

Study design

Prospective, randomized, controlled, and double-blinded study.

Materials

  1. Sterile towels, 4’x4’ gauze packs and povidone iodine.
  2. 3 ml and 20 ml syringes.
  3. Sterile gloves, marking pen, and surface electrode.
  4. One 1½’ 25 G needle for skin infiltration.
  5. A 21 G, 10 cm short-bevel insulated stimulating needle.
  6. Ultrasound machine (Mindray M7) and a 12 MHz linear probe were used.
  7. Drugs: lidocaine 2% (lidocaine injection BP 2%, 50 ml, without preservatives; Rotexmedica, Trittau, Germany), bupivacaine (0.5%, 20 ml), midazolam (5 mg), and nalbuphine (20 mg).
  8. Equipment and drugs for general anesthesia and resuscitation (e.g. suction apparatus, laryngoscope with blades of different sizes, endotracheal tubes of different sizes, DC shock, thiopental, succinylcholine, atropine, and epinephrine).


Technique

After application of monitors to the patient in supine position, a cannula (20 G size) was placed in the nonoperative hand for crystalloid infusion and emergency drugs. The coracoid process can be identified by palpating the bony prominence just medial to the shoulder while the arm was elevated and lowered. After aseptic preparation of the skin with povidone iodine and draping with sterile towels, a a 21 G, 10 cm echogenic needle was visualized by ultrasound, 21 ml of the solution was injected after negative aspiration and then the needle was withdrawn.

Statistical analysis

The sample size was depend on the duration of postoperative analgesia. A total of 70 patients were needed and was given the trial 80% power. Statistical analysis was performed using the computerized Statistical Package for the Social Sciences (SPSS for Windows, version 17; SPSS Inc., Chicago, Illinois, USA). Continuous data are described as mean±SD and analyzed using one-way analysis of variance. Categorical data are reported as numbers and analyzed using χ2 test as appropriate. P values less than 0.05 were considered to be statistically significant.


  Results Top


Seventy patients were enrolled in this study and 10 patients were excluded as shown in the CONSORT flowchart ([Figure 1]). Sixty patients were divided equally into three groups by a randomized table created by a computer software program using sealed envelopes.
Figure 1 CONSORT flowchart.

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There was no statistically significant differences among the study groups (P<0.05) ([Table 1]).
Table 1 Demographic and surgical characteristics: age (years), weight (kg), height (cm), sex, American Society of Anesthesiologist classification, type, and duration of surgery

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Onset time for sensory and motor blocks was significantly shorter in the nalbuphine group (8.6±1.4 and 14.1±2.8 min, respectively) than the other groups (groups B and M) (P<0.05) ([Table 2]).
Table 2 Comparison of sensory and motor onset time (min)

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There was no significant difference between groups as regards intraoperative surgical pain ([Table 3]).
Table 3 Comparison of intraoperative surgical pain (visual analog scale score)

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Durations of postoperative analgesia were significantly shorter in group B in comparison with adjuvant groups M and N. There was an increase of postoperative analgesia in group N compared with groups M and B ([Table 4]).
Table 4 Comparison of postoperative duration of analgesia (min)

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Requirement of postoperative analgesia was higher in group B in comparison with adjuvant groups M and N ([Table 5]).
Table 5 Requirement of postoperative analgesia

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The hemodynamic changes (heart rate, mean arterial blood pressure, peripheral oxygen saturation, and respiratory rate) recorded in this study showed a statistically insignificant difference between the three groups (P>0.05) ([Table 7]a,b,c,d,e,f).
Table 7 Intraoperative hemodynamic changes

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There was no significant differences between the three groups as regards intraoperative systolic blood pressure (P>0.05).

There was no significant difference between the three groups as regards intraoperative diastolic blood pressure (P>0.05).

There was no significant differences between the three groups as regards intraoperative mean blood pressure (P>0.05).

There was no significant difference between the three groups as regards intraoperative heart rate (P>0.05). There was no significant difference between the three groups as regards intraoperative respiratory rate (P>0.05).

There was no significant difference between the three groups as regards intraoperative arterial oxygen saturation (P>0.05).


  Discussion Top


In this study, statistical analysis of the demographic data of the patients and procedural characters were no significant differences between the three groups, as regards age, weight, and height of the patients, as well as type and duration of surgery.

Our study found that onset time for sensory and motor blocks were significantly shorter in the nalbuphine group (8.6±1.4 and 14.1±2.8 min, respectively) than other groups (groups B and M).

This result of the study agrees with Raghu et al. [7]; the onset time of sensory block in bupivacaine with the midazolam group was significantly faster than the bupivacaine only group and the onset time of motor block in the bupivacaine group with midazolam was faster in the bupivacaine only group.

Gupta et al. [8] found that there was a significant increase in the duration of postoperative analgesia in patients who received nalbuphine as an adjuvant (481.53±42.45 min) as compared with the lidocaine group (341.31±21.42 min); this enhancement may be due to the synergistic effect of nalbuphine with bupivacaine.

The Abdelhaq and Elramely [9] study concluded that nalbuphine has significantly increased the duration of both sensory and motor blocks with prolonged postoperative analgesia which used 20 mg nalbuphine as adjuvant to 25 ml of 0.5% bupivacaine for supraclavicular brachial plexus block. Gupta et al. [8] reported that nalbuphine 10 mg was added to 0.5% bupivacaine for supraclavicular brachial plexus block in patients undergoing various forearm and hand surgeries is associated with increased duration of analgesia without any adverse effects.

Lig et al. [10] reported that bupivacaine (0.5%) in combination with midazolam quickened the onset and prolonged the duration of sensory and motor blockade of the brachial plexus for upper limb surgery with improved postoperative analgesia without any adverse events compared with plain bupivacaine (0.5%).The Raghu et al. [7] study that compares 0.375% bupivacaine with midazolam and 0.375% bupivacaine for brachial plexus block in upper limb surgeries and reported that midazolam (0.05 mg/kg) as an adjuvant to 0.375% bupivacaine in brachial plexus block increases the onset of sensory and motor blocks and prolonged postoperative analgesia without any adverse events.

In our study, the requirement of analgesia of the postoperative period is higher in group B in comparison with adjuvant groups M and N which is in agreement with Shaikh and Veena [11], who found that postoperative analgesia was significantly longer (805.04±175.75 min) in bupivacaine with the midazolam group compared with the bupivacaine group (502.2±452.68 min) and the pain score was significantly low in the bupivacaine with midazolam group compared with the bupivacaine group at 12 h postoperatively whose addition of midazolam 50 μg/kg to 30 ml of bupivacaine 0.5% for supraclavicular brachial plexus block prolonged sensory blockade and postoperative analgesia without increasing the risk of adverse effects.

None of our patients of the study developed pneumothorax, failed block, hematoma, neurological problem, or respiratory depression [Table 6]. The hemodynamic changes (heart rate, mean arterial blood pressure, peripheral oxygen saturation, and respiratory rate) recorded in this study showed a statistically insignificant difference between the groups.
Table 6 Comparison of adverse side effects in all groups

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  Conclusion Top


The addition of nalbuphine and midazolam to bupivacaine in the infraclavicular brachial block improves the speed of sensory and motor onset, the quality of anesthesia, and decreases the analgesic requirements during the first 24 h postoperatively without obvious side effects. The addition of nalbuphine to bupivacaine was superior in delaying the postoperative analgesia requirement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bruce BG, Green A, Blaine TA, Wesner LV. Brachial plexus blocks for upper extremity orthopaedic surgery. J Am Acad Orthop Surg 2012; 20:38–47.  Back to cited text no. 1
    
2.
Boezarrt A, Pershak H, Bird P, Cohen NH. Brachial plexus block. Anesthesiology 2003; 92:102–108.  Back to cited text no. 2
    
3.
Miller RD, Eriksson LI, Fleisher LA et al. α-adrenergic agonists; intravenous anesthetics; Miller’s anesthesia 7 th ed. Anesthesia and Analgesia 2009; 3:719–768.  Back to cited text no. 3
    
4.
Gunion MW, Marchionne AM, Anderson TM. Use of the mixed agonist-antagonist nalbuphine in opioid based analgesia. Acute Pain 2004; 6:29–39.  Back to cited text no. 4
    
5.
Guignard B. Monitoring analgesia. Best Pract Res Clin Anaesthesiol 2006; 20:161–180.  Back to cited text no. 5
    
6.
Amrein R, Hetzel W. Pharmacology of drugs frequently used in ICUs: midazolam and flumazenil. Intensive Care Med 1991; 17:1–10.  Back to cited text no. 6
    
7.
Raghu R, Indira P, Kiran M, Murthy R. A comparative study of 0.375% bupivacaine with midazolam and 0.375% bupivacaine for brachial plexus block in upper limb surgeries. Asian Pac J Health Sci 2015; 2:129–135.  Back to cited text no. 7
    
8.
Gupta K, Manish J, Gupta Prashant K, Rastogi B, Zuberi A, Pandey Mahesh N. Nalbuphine as an adjuvant to 0.5% bupivacaine for ultrasound guided supraclavicular brachial plexus blockade, Subharti Medical College, Swami Vivekanand University, Meerut, Uttar Pradesh, India 2018: 154.236.177.49.  Back to cited text no. 8
    
9.
Abdelhaq M, Elramely MA. Effect of nalbuphine as adjuvant to bupivacaine for ultrasound-guided supraclavicular brachial plexus block. Open J Anesthesiol 2016 6:20–26.  Back to cited text no. 9
    
10.
Lig N, Khan M.N., Araf M. Midazolam with bupivacaine for improving analgesia quality in brachial plexus block for upper limb surgeries. J Coll Physicians Surg Pak 2008; 18:674–678.  Back to cited text no. 10
    
11.
Shaikh SI, Veena K. Midazolam as an adjuvant in supraclavicular brachial plexus block. Anaesth Pain Intensive Care 2012; 16:7–11.  Back to cited text no. 11
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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