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ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 638-643  

Effect of added alpha 2 agonists with local anaesthetic in infraclavicular brachial plexus block: A comparative study between dexmedetomidine and clonidine


1 Department of Anaesthesiology, Believers Church Medical College, Thiruvalla, Kerala, India
2 Department of Anaesthesiology, Sree Gokulam Medical College and Research Foundation, Thiruvanthapuram, Kerala, India

Date of Submission05-Apr-2021
Date of Acceptance28-Apr-2021
Date of Web Publication27-May-2021

Correspondence Address:
Dr. R Sreeja
Department of Anaesthesiology, Believers Church Medical College, Pathanamthitta, Thiruvalla, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_54_21

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   Abstract 

Background: Many adjuvant drugs are added with local anesthetics to increase the quality of regional blocks. Aim: To compare the effects of dexmedetomidine and clonidine added to bupivacaine in infraclavicular brachial plexus block in prolonging the duration of analgesia in patients undergoing orthopedic surgery of forearm or hand and also to compare the duration of sensory and motor block, sedation, and hemodynamic changes like bradycardia and hypotension in two groups. Settings and Design: This was an observational study conducted in a tertiary care hospital. Materials and Methods: A study was conducted among 60 patients admitted for elective upper limb surgeries under ultrasound-guided infraclavicular block. Patients who received bupivacaine 0.5% (20 mL) + Clonidine 1 μg.kg−1 were classified as Group A and those received bupivacaine 0.5% (20 mL) + dexmedetomidine 1 μg.kg−1 were classified as Group B. Statistical Analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 25. Results: Duration of analgesia was significantly higher in Group B as compared to Group A (mean + standard deviation = 764 ± 17.573 min vs. 526 ± 9.958 min, respectively, P = 0.001). The mean time for onset of a sensory block as well as motor block was significantly less in Group B when compared to Group A (P = 0.001). The mean duration of both sensory block and motor block was higher in Group B as compared to Group A (P = 0.001). Conclusions: The dexmedetomidine group (Group B) provides a quicker and prolonged analgesic action without major adverse effects.

Keywords: Clonidine, dexmedetomidine, infraclavicular block


How to cite this article:
Sreeja R, Mathew A, Velayuden M. Effect of added alpha 2 agonists with local anaesthetic in infraclavicular brachial plexus block: A comparative study between dexmedetomidine and clonidine. Anesth Essays Res 2020;14:638-43

How to cite this URL:
Sreeja R, Mathew A, Velayuden M. Effect of added alpha 2 agonists with local anaesthetic in infraclavicular brachial plexus block: A comparative study between dexmedetomidine and clonidine. Anesth Essays Res [serial online] 2020 [cited 2021 Jun 17];14:638-43. Available from: https://www.aeronline.org/text.asp?2020/14/4/638/316981


   Introduction Top


Managing pain after upper limb procedures is a great challenge to the anesthesiologist. To improve analgesia and facilitate mobilization, regional anesthesia can be made of use. Regional anesthesia reduces the incidence of perioperative complications such as deep vein thrombosis, pulmonary embolism, blood loss, respiratory complications, and death.[1] Regional anesthesia also leads to reduction in stress response, systemic analgesic requirements, opioid-related side effects, and development of chronic pain. Mixing local anesthetic with adjuvant drugs is an attempt to prolong analgesia from nerve blocks. The objective of this study is to compare clonidine and dexmedetomidine in peripheral nerve blocks in terms of duration of motor and sensory blockade and postoperative analgesia and hemodynamic changes and sedation.


   Materials and Methods Top


An observational study was done among, those coming for orthopedic surgeries of forearm or hand for 1 year starting from October 2014 at a tertiary care hospital. The study protocol was approved by the Institutional Review Board (IEC-SGMC 12/111/03/2014). The study was done as per International Conference on Harmonization– Good Clinical Practice, Declaration of Helsinki (1964), and other regulatory guidelines. Only patients belonging to the American Society of Anesthesiologists (ASA) class I and II undergoing elective operative procedure for upper limb surgeries were included. A total of 60 patients were studied. Informed consent was taken from patients after explaining the details of the study. Patients with a history of bleeding disorders, localized infection at the site of block, those with documented neuromuscular disorders, and those with known allergy to local anesthetic drugs were excluded. Weight, basal heart rate, and blood pressure were measured during preoperative assessment of the patient. All the patients received brachial plexus block through ultrasound-guided infraclavicular approach. After sterile preparation and development of skin wheal with plain Lignocaine, ultrasound-guided infraclavicular nerve block was given after negative aspiration for blood by an experienced anesthesiologist. In this study, we compared two α agonists (clonidine and dexmedetomidine) as adjuvant to bupivacaine in infraclavicular brachial plexus block. The aim of the study was to compare the onset and duration of sensory and motor blockade with clonidine and dexmedetomidine and to compare the intraoperative and postoperative hemodynamic stability with these adjuvants. One group (Group A) received bupivacaine 0.5% (20 mL) + clonidine 1 μg.kg−1 and the other group (Group B) received bupivacaine 0.5% (20 mL) + dexmedetomidine 1 μg.kg−1. The duration of analgesia, onset, and duration of sensory block, onset and duration of motor block, heart rate, blood pressure, oxygen saturation, and sedation were recorded at the 1st min and at 5, 10, 30, 60,120, 180, 240, 360, and 480 min after completion of injection. Intraoperative monitoring included ECG, pulse oximetry, noninvasive blood pressure monitoring. Motor and sensory block of radial, median, ulnar and musculocutaneous nerves were determined at 1st min and then at 5, 10, 30, 60, 120, 180, 240, 360, and 480 min after completion of injection. Sensory block was determined by the pinprick test. Patients were requested to compare the pinprick (26 gauge needle) sensation on the test arm to that in contralateral arm as reference. A score of 0 indicates no sensation and a score of 100 indicates full sensation. Sensory block onset is defined as reduction in sensibility to 30% or less.

Duration of the sensory blockade is defined as the time interval between injection and complete recovery of sensation. Patients were asked to note the complete recovery of sensation, which will then be verified by the anesthetist. Motor block was determined by a modified British Medical Research Council rating scale ranging from 5 (normal power) to 0 (complete paralysis). Motor block onset is defined as a reduction in power to 3 or less. Postoperative pain was assessed using Visual analogue scale (VAS). (VAS 0 = no pain, 10 = worst pain imaginable). Analgesia duration was measured by the time of injection to the first demand of analgesic. Sedation score ranges from 1 (alert) to 4 (asleep, not arousable by verbal contact). The highest sedation score in first 2 h after injection were taken as the sedation score of the patient for statistical purposes. The occurrence of hypotension (fall of mean blood pressure by >30% of baseline) anytime during the monitored period was defined as the presence of hypotension. Bradycardia (<45 beats/min) was monitored. Analgesic effect was measured by the time of injection to the first demand of analgesic.

Statistical analysis

Numerical data were expressed as mean along with standard deviation (SD) or and categorical data were presented in percentage. Chi-square test was used to analyze the baseline characteristics like age and gender distribution of both groups. The duration of analgesia, onset, and duration of both sensory and motor block were compared using the Student's t-test. P < 0.05 was considered to be statistically significant. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows User (version 21; IBM, Armonk, NY, USA).


   Results Top


A total of 30 patients were studied in each group. Both the groups were comparable with respect to age and gender. The mean age and SD of Group A and Group B were 47.4 ± 14.2 and 48.3 ± 13.1 years, respectively. 60% of Group A and 53.3% of Group B were males as compared to females 40% and 46.7%, respectively. The mean weight and SD of Group A and Group B were 70.97 ± 9.04 and 71.47 ± 7.54 kg, respectively. The ASA physical status scores were compared among two groups. Thirteen (43.3%) patients in Group A were of ASA Class I and 17 (56.7%) patients were ASA Class II. 12 (40%) patients in Group B were of ASA Class I and 18 (60%) patients were class ASA II. Chi-square analysis showed no significant difference among the two groups. As shown in [Table 1], the two study groups were comparable in terms of patient characteristics such as age and gender. The two groups showed a significant difference for the duration of analgesia, onset, and duration of sensory as well as motor block [Table 2]. Sedation was found to be significantly lower in the dexmedetomidine [Figure 1]. There was no significant difference in the hemodynamic stability of both the groups [Table 3]. In our study, no adverse effects like hypotension or bradycardia were noted.
Figure 1: Comparison of groups based on sedation

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Table 1: Comparison of demographic data among Group A and Group B

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Table 2: Comparison of group based on duration of analgesia, onset of sensory and motor block, duration of sensory and motor block (n=30)

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Table 3: Comparison of group based on systolic and diastolic blood pressure and heart rate

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   Discussion Top


The brachial plexus block for upper limb surgery has proved to be an effective method of regional anesthesia. Various approaches have been described like supraclavicular, interscalene, infraclavicular, and axillary, but all of these are associated with some technical difficulties like inadequate blocks and some complications.

Postoperative analgesia, defined as the time until first analgesic request, was significantly longer in the bupivacaine–dexmedetomidine group (764.6 ± 17.5 min) while in bupivacaine–clonidine group it was 526.7 ± 9.9 min showing a mean prolongation of 237 min. A study done by Swami et al., Harshavardhana, Ammar and Mahmoud and Gandhi et al. showed significant prolongation in the duration of postoperative analgesia when dexmedetomidine was used as an adjuvant to local anesthetic.[2],[3],[4],[5]

In this study, the onset of motor block was shortened by an average of 4.5 min in dexmedetomidine group when compared to clonidine group. This has statistical significance as analyzed by t-test. A study by Swami et al. showed that onset of motor block was faster with clonidine group (3.87 ± 1.78) when compared with the dexmedetomidine group (4.65 ± 2.46) and was found that it was not a significant difference.[2]

In this study, the onset of sensory block was shortened by an average of 5.47 min in dexmedetomidine group when compared to clonidine group. This has statistical significance as analyzed by t-test. Study by Swami et al.[2] showed that onset of sensory block was faster with dexmedetomidine (1.77 ± 1.28) than Clonidine group (2.33 ± 1.21) min. But this was not statistically significant. A study done by Harshavardhana also showed that onset of sensory block was faster with dexmedetomidine (2.59 ± 2.2) than clonidine group (3.26 ± 1.4) min. which was also statistically significant.[3]

Jinjil et al. compared dexmedetomidine and clonidine as adjuvant to 0.25% ropivacaine in ultrasonography-guided supraclavicular block and found that onset of sensory block was 9.7 ± 1.5 min, dexmedetomidine group and in clonidine group, it was 12.9 ± 1.4 min. The onset of motor block in dexmedetomidine group was 15.7 ± 1.5 and in clonidine group, it was 20.4 ± 1.8 min. The onset for sensory and motor block in dexmedetomidine group was significantly faster.[6]

Dar et al. evaluated the effect of adding dexmedetomidine to ropivacaine for axillary brachial plexus blockade in 80 patients scheduled for elective forearm and hand surgeries. Sensory and motor block onset times were shorter when dexmedetomidine was added.[7]

The mean duration of sensory block in the bupivacaine-clonidine group was 477.3 ± 9.9 min while in bupivacaine–dexmedetomidine group was 738.7 ± 22.5 min. This shows a significant prolongation of the duration of the sensory block in the dexmedetomidine group by about 261 min. Duration of sensory block was 212.90 ± 24.8 min in clonidine group as compared with 413.97 ± 87.31 min in dexmedetomidine group in the study done by Swami et al.[2]

The mean duration of motor block in Group A (Clonidine) was 422.5 ± 9.05 min while in Group B (dexmedetomidine) it was 664.93 ± 20.4 min. This denotes a mean difference of 242 min and was statistically significant. Duration of motor block was 292.67 ± 59.13 min in clonidine group as compared with 472.24 ± 90.06 min in dexmedetomidine group in the study done by Swami et al. which was statistically significant.[2]

In the randomised control trial done by Esmaoglu et al. 60 patients were assigned to receive either 40 ml of 0.5% levobupivacaine with 1 ml dexmedetomidine or 40 ml of 0.5% levobupivacaine with 1 ml of saline and found that sensory and motor onset time was significantly faster in the study group compared to control group.[8]

Agarwal et al. compared the effects of adding dexmedetomidine to bupivacaine in supraclavicular brachial plexus block and they concluded that dexmedetomidine added as an adjuvant to bupivacaine for supraclavicular brachial plexus block significantly prolongs the duration of sensory and motor blocks and duration of analgesia.[9]

Biswas et al. evaluated the effect of combining dexmedetomidine with levobupivacine with respect to duration of motor and sensory block and duration of analgesia, in supraclavicular block. They found sensory and motor block durations were longer when dexmedetomidine was added as an adjuvant. The duration of analgesia was also significantly longer with the addition of dexmedetomidine.[10]

Danelli et al. evaluated the effects of adding 50 μg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy. They opined that adding 50 μg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia.[11]

McCartney et al. reviewed studies (1385 patients) using clonidine as an adjuvant to local anesthetics for a variety of peripheral nerve blocks. They concluded that clonidine was beneficial only when added to intermediate-acting local anesthetics.[12] These studies showed that dexmedetomidine and clonidine when studied independently with local anesthetics as an adjuvant had a faster onset of sensory and motor blockade with prolonged duration of sensory and motor blockade with increased duration of analgesia.

The result of our study shows that all patients in both groups were comparable with respect to demographic profile. The onset of sensory and motor blockade was faster in Group B (dexmedetomidine) which was statistically significant. Duration of sensory and motor blockade was more in Group B (dexmedetomidine) which was also statistically significant. The duration of analgesia was more in Group B, also statistically significant. These results show that dexmedetomidine has faster onset of sensory and motor blockade, prolonged duration of sensory and motor blockade, and also increased duration of analgesia.

Dexmedetomidine acts in a manner similar to clonidine. Dexmedetomidine, due to its high selectivity to α2 receptor with α2:α1 binding selectivity ratio of 1620:1 as compared to220:1 for clonidine, reduces the unwanted side effects of α1 receptors. The patients who received Dexmedetomidine were comfortable throughout the surgery with arousable sedative effects.[13]

We conclude that in infraclavicular brachial plexus block addition of dexmedetomidine as an adjuvant to 0.25% Bupivacaine shortens the sensory and motor block onset time, prolongs both sensory and motor block duration and is not associated with any major side-effect. The added advantage of conscious sedation and hemodynamic stability makes it a potential adjuvant for nerve blocks. Thus it can be concluded that dexmedetomidine is a better adjuvant than Clonidine in infraclavicular brachial plexus block.


   Conclusions Top


In infraclavicular brachial plexus block addition of dexmedetomidine as an adjuvant to 0.25% Bupivacaine shortens the sensory and motor block onset time, prolongs both sensory and motor block duration and is not associated with any major side-effect. The added advantage of conscious sedation and hemodynamic stability makes it a potential adjuvant for nerve blocks. Thus, it can be concluded that dexmedetomidine is a better adjuvant than Clonidine in infraclavicular brachial plexus block.

Acknowledgement

Authors would like to thank the willing assistance and cooperation of all the patients participated in the study. The study would not have been possible without their assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Modig J. Influence of regional anesthesia, local anesthetics, and sympathicomimetics on the pathophysiology of deep vein thrombosis. Acta Chir Scand Suppl 1989;550:119-24.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Harshavardhana HS. Efficacy of dexmedetomidine compared to clonidine added to ropivacaine in supraclavicular nerve blocks: A prospective, randomized, double blind study. Int J Med Health Sci 2014;3:127-32.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Gandhi R, Shah A, Patel I. Use of dexmedetomidine along with bupivacaine for brachial plexus block. National J Med Res 2012;2:3.  Back to cited text no. 5
    
6.
Jinjil K, Bhatnagar V, Swapna P, Tandon U. Comparative Evaluation of Alpha Two Agonists Dexmedetomidine with Clonidine as Adjuvants to 0 . 25% Ropivacaine for Ultrasound Guided Supraclavicular Block : A Randomised Double-Blind Prospective Study; 2015. Available from: https://paper/Comparative-evaluation-of-Alpha-two-agonists-with-0-Jinjil-Bhatnagar/493a9a89309783d636fdebc2686aa6e69f6e2b85. [Last accessed on 2021 Mar 15].  Back to cited text no. 6
    
7.
Dar FA, Najar MR, Jan N. Dexmedetomidine added to ropivacaine prolongs axillary brachial plexus block. IJBAR 2013;4:719-22.  Back to cited text no. 7
    
8.
Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. Anesth Analg 2010;111:1548-51.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
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.  Back to cited text no. 10
    
11.
Danelli G, Nuzzi M, Salcuni PF, Caberti L, Berti M, Rossini E, et al. Does clonidine 50 microg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study. J Clin Anesth 2006;18:585-8.  Back to cited text no. 11
    
12.
McCartney CJ, Duggan E, Apatu E. Should we add clonidine to local anesthetic for peripheral nerve blockade? A qualitative systematic review of the literature. Reg Anesth Pain Med 2007;32:330-8.  Back to cited text no. 12
    
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Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, Young WL. Miller's Anesthesia E-Book. London: Elsevier Health Sciences; 2014. p. 4094.  Back to cited text no. 13
    


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  [Table 1], [Table 2], [Table 3]



 

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