INTRODUCTION:

Spinal anesthesia is widely used simple and effective  anesthetic technique for infra-umbilical surgeries that provides complete sensory and motor blockade. Bupivacaine  is a potent  commonly used local anesthetic for spinal anesthesia due to its long duration of action. However, the use of bupivacaine has some drawbacks. Levobupivacaine is a long acting local anesthetic which is as potent as bupivacaine with less systemic side effects. Addition of intrathecal opioids such as fentanyl and buprenorphine  will enhance the characteristics of block which has been proved from previous studies.

The purpose of this study is to compare the effects of  intrathecal fentanyl versus buprenorphine with levobupivacaine that is onset and duration of anaesthesia, perioperative hemodynamic changes and postoperative analgesia.

ADVANTAGES OF STUDY DRUGS:

• Levobupivacaine, a pure S(-) enantiomer of bupivacaine is a long acting amide which produces differential neuraxial block that is early onset and prolonged duration of sensory block with  shorter duration of motor block and lower cardiac and CNS toxicity.
• Further addition of intrathecal opioids relatively improve the block characteristics of intrathecally administered local anesthetics and provide prolonged post operative analgesia.
• Fentanyl , a phenylpiperidine compound and a µ receptor agonist because of its increased lipophilic quality leads to a decreased rostral spread and is a safe drug for potentiation of local anaesthetic effect .
• Buprenorphine is an opioid of the phenanthrene morphine class with extremely high affinity for µ and kappa receptors, which produces longer duration of action.It is a centrally acting partial opioid agonist with both spinal and supraspinal component of analgesia.

DISADVANTAGES OF STUDY DRUGS:

Levobupivacaine has short duration of motor blockade,  cannot be used in longer duration of surgeries alone.

Common side effects of intrathecal opioids  include drowsiness, nausea , vomiting, pruritis, urinary retention and occasionally respiratory depression.

OBJECTIVES OF THE STUDY:

AIM:

The aim of the study is to determine the efficacy  of  fentanyl versus buprenorphine when added to 0.5% hyperbaric levobupivacaine for onset, duration of sensory and motor blockade of spinal anesthesia , hemodynamic changes and duration of post operative analgesia in patients undergoing infra umbilical surgeries.

PRIMARY OBJECTIVE:

To compare the onset and duration of sensory and motor blockade  and the duration of postoperative analgesia.

SECONDARY OBJECTIVE:

To compare haemodynamic stability and adverse effects if any associated with the administration of study drugs.

REVIEW OF LITERATURE:

• Levobupivacaine is an effective alternative to bupivacaine since it has a shorter duration of  motor block, allowing early mobilization and a lower incidence of intraoperative hypotension.[Ajaysingh, anshuGupta, priyankarkumardatta, maîtrepandey 2018]
• The onset of sensory and motor block is hastened with the use of hyperbaric levobupivacaine compared to isobaric levobupivacaine.[VimolluckSananslip et al.2012]
• Intrathecal administration of 15 mg of levobupivacaine provides an adequate sensory and motor blockade  lasting for approximately 6.5 hrs.[SukhminderJitsinghbajwa et al 2013]
• Neuraxial administration of opioids in conjunction with local anaesthetic improves the quality of intraoperative analgesia and prolong the duration of postoperative analgesia. [Harbhejsingh ]
• A Study conducted in 2017 comparing efficacies of levobupivacaine plain and  levobupivacaine with fentanyl  revealed that addition of fentanyl had a dose sparing effect with earlier onset and early regression of motor block and no hemodynamic changes.
• Ali, Muhammad Asghar et aldid a double blinded randomized control trial to compare the effect of different doses [10 mcg, 15 mcg, 25mcg] of intrathecal fentanyl in parturient  undergoing cesarean section and concluded that all patients in three groups had adequate surgical anaesthesia with no statistically significant difference in the onset of block and quality of surgical anaesthesia.
• Santhosh K.Gouroji et al.did a study in 2019 comparing isobaric levobupivacaine and isobaric levobupivacaine with fentanyl in patients posted for infraumblical surgeries.  60 ASA grade 1 and 2  taken for study and block parameters like onset of sensory and motor blockade , duration of block, hemodynamic changes, rescue analgesia request time were  studied and concluded that faster onset of sensory and motor blockade with minimal hemodynamic changes , request time for rescue analgesia is prolonged in levobupivacaine with fentanyl group
• Ture,et al did a study comparing buprenorphine as an adjuvant to levobupivacaine and bupivacaine and concluded that similar onset of sensory block in both groups but with better preserved haemodynamics in patients who received buprenorphine with levobupivacaine.
• Preet hiten furia et aldid a study in 2021 comparing intrathecal fentanyl versus buprenorphine as an adjuvant to isobaric levobupivacaine in lower limb surgeries .60 patients of ASA 1 ,2 were taken for study and divided into two groups, characteristics of motor and sensory blockade, duration of postoperative analgesia, hemodynamic parameters and adverse effects were recorded.  He concluded that onset of motor block, duration of sensory block and duration of analgesia  were significantly  prolonged in buprenorphine with levobupivacaine group.

REFERENCES:

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