Content uploaded by Dinesh Sood
Author content
All content in this area was uploaded by Dinesh Sood on May 27, 2021
Content may be subject to copyright.
© 2017 Anesthesia: Essays and Researches | Published by Wolters Kluwer - Medknow
940
Original Article
IntroductIon
Pain relief after cesarean delivery is very important as the
consequences of inadequate pain relief are borne not only
by the mother but also by the newborn as well, since a
parturient who is experiencing pain nds it difcult to feed her
newborn.[1] Pain management for a parturient is challenging,
as opioids, which otherwise are the mainstay analgesics in
the postoperative period are avoided in the parturient because
of their excretion in milk predisposing the neonate to their
adverse effects.[2] Hence, other modalities for pain relief are
often selected. Nowadays, multimodal approach to pain relief
is recommended so that adverse effects of individual drugs
can be reduced. Neuraxial blocks, peripheral nerve blocks,
nonsteroidal anti-inammatory drugs (NSAIDs), and local
anesthetic inltration of wound have all been used as a part
of multimodal approach.[3]
Local wound inltration is an attractive strategy since it is
efcacious and side effects are minimal.[4] Nowadays, there
is a trend toward preferring ropivacaine over other local
anesthetic agents due to longer duration of action and better
safety prole.[5] Local anesthetic inltration, however, has a
limitation in that pain relief is offered till the effects of local
anesthetic action lasts. Efforts are being made to prolong the
Context: Dexmedetomidine, α2-adrenergic agonist, when coadministered with local anesthetics, improves the speed of onset, duration of
analgesia and decreases the dose of local anesthetic used. Aims: The aim of this study was to compare the efcacy of local subcutaneous
wound inltration of ropivacaine alone with ropivacaine plus dexmedetomidine for postoperative pain relief following lower segment cesarean
section (LSCS). Subjects and Methods: The study was a prospective, randomized control, double-blind study. Sixty female patients belonging
to physical status American Society of Anesthesiologists Grade I or II scheduled for LSCS under spinal anesthesia were randomly allocated
into two groups of thirty patients each. Group A: local subcutaneous wound inltration of 0.75% ropivacaine (3 mg/kg) diluted with normal
saline to 40 ml. Group B: local subcutaneous wound inltration of 0.75% ropivacaine (3 mg/kg) plus dexmedetomidine (1.5 µg/kg) of the
body weight diluted with normal saline to 40 ml. Standard spinal anesthesia technique was used and LSCS was conducted. The allocated
drug was administered by local subcutaneous wound inltration before closure of the skin. In postoperative period, pain was assessed using
visual analog scale (VAS) over a period of 24 h, time of giving rst rescue analgesic consumption, mean analgesic consumption, patient
satisfaction, and incidence of side effects in 24 h postoperative period was noted. Statistical Analysis Used: All observations were tabulated
and statistically analyzed using Chi-square test and unpaired t-test. Results: A total number of patients requiring rescue analgesic, mean VAS
each time rescue analgesic was given, and the mean analgesic required in 24 h postoperative period was lesser in Group B than in Group A.
Conclusions: Dexmedetomidine added to ropivacaine for the surgical wound inltration signicantly reduces postoperative pain and rescue
analgesic consumption in patients undergoing LSCS. No serious adverse effects were noted.
Keywords: Dexmedetomidine, lower segment cesarean section, postoperative pain relief, ropivacaine
Address for correspondence: Dr. Shaman Bhardwaj,
2231, 38 C, Chandigarh ‑ 160 014, India.
E‑mail: shaman.bhardwaj13@gmail.com
Access this article online
Quick Response Code:
Website:
www.aeronline.org
DOI:
10.4103/aer.AER_14_17
This is an open access arcle distributed under the terms of the Creave Commons
Aribuon-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the
new creaons are licensed under the idencal terms.
For reprints contact: reprints@medknow.com
How to cite this article: Bhardwaj S, Devgan S, Sood D, Katyal S.
Comparison of local wound inltration with ropivacaine alone or ropivacaine
plus dexmedetomidine for postoperative pain relief after lower segment
cesarean section. Anesth Essays Res 2017;11:940-5.
Comparison of Local Wound Infiltration with Ropivacaine Alone
or Ropivacaine Plus Dexmedetomidine for Postoperative Pain
Relief after Lower Segment Cesarean Section
Shaman Bhardwaj, Sumeet Devgan1, Dinesh Sood, Sunil Katyal
Departments of Anaesthesiology and 1Urology and Kidney Transplant, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Abstract
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
Bhardwaj, et al.: Comparison of ropivacaine wound inltration with or without dexmedetomidine for post – operative pain relief after
lower segment cesarean section
941
Anesthesia: Essays and Researches ¦ Volume 11 ¦ Issue 4 ¦ October-December 2017 941
duration of action of local anesthetic skin inltration, and
dexmedetomidine is one such agent which can potentiate and
prolong the duration of local anesthetic wound inltration
for pain relief. A lot of literature is available for the role
of dexmedetomidine as an adjuvant to ropivacaine for
peripheral nerve blocks and intrathecally as a part of spinal
anesthesia.[6] However, only limited data are available for the
use of dexmedetomidine as an adjuvant to local inltration
of surgical wound.[7-9] We, therefore, planned to compare
the safety and efcacy of dexmedetomidine as an adjuvant
to ropivacaine local infiltration of surgical wound for
postoperative pain relief after cesarean delivery.
subjects and methods
This study was conducted at a tertiary level hospital in
a randomized double-blinded manner on a total of sixty
parturients belonging to physical status American Society of
Anesthesiologists (ASA) Grade I or II, scheduled for cesarean
delivery under spinal anesthesia. Prior approval from the
Institutional Ethics Committee was obtained, and informed
consent was obtained from all patients. The exclusion criteria
were a history of drug abuse, psychiatric disease, obesity with
weight >100 kg, allergic reaction to local anesthetics, opioids
and/or dexmedetomidine, inability to comprehend visual
analog scale (VAS), or failed spinal anesthesia with subsequent
conversion to general anesthesia. Patients were enrolled
in the study after a thorough preanesthetic checkup and
routine investigations which included a complete hemogram,
coagulation prole, and random blood sugar. All patients were
shown and explained regarding the VAS and instructed to its
use in the postoperative period, and they were also informed
that they can request an analgesic at any time after surgery if
they feel pain.
After shifting the patients to the operation theater, preinduction
heart rate (HR), noninvasive blood pressure, respiratory
rate (RR), oxygen saturation (SpO2), and electrocardiography
were recorded. These parameters were monitored throughout
the procedure and recorded every 5 min. An intravenous (IV)
access was achieved, and normal saline infusion commenced.
After preloading with 10 ml/kg body weight of IV uids, all
patients were administered subarachnoid block in the left
lateral position under all aseptic precautions using a 26-gauge
Quincke’s needle at L3–4/L4–5 vertebral level injecting 2.0 ml
of 0.5% heavy bupivacaine. The onset of sensory block was
dened as the time between intrathecal injection of anesthetic
agent and the absence of pain at T8 dermatome, assessed by
pinprick. Time for motor block was assumed when modied
Bromage score became one. Grade 1 = complete block (unable
to move feet or knees); Grade 2 = almost complete block
(able to move feet only); Grade 3 = partial block (just able to
move knees); Grade 4 = detectable weakness of hip exion
while supine (full exion of knees); Grade 5 = no detectable
weakness of hip exion while supine; and Grade 6 = able to
perform partial knee bend. Surgery was allowed to proceed
after complete sensory block was achieved at T8 dermatome
as assessed by pinprick. The duration of spinal anesthesia was
dened as the period from intrathecal injection of the drug to
the rst occasion when the patient complained of pain in the
postoperative period.
In case of partial/failed spinal anesthesia, general anesthesia
was administered, and the patient was excluded from the study.
Intraoperative complications such as hypotension, bradycardia,
and nausea/vomiting were managed as per departmental policy
in both the groups. After the closure of uterus and muscle layer
but before closure of skin, the allocated drug as per random
grouping based on coded sealed envelope technique was
administered by local subcutaneous wound inltration at the
incision site, by the obstetrician who was blinded to the study
drug administered. The investigator scoring patient outcome
after surgery was also blinded to the protocol.
Patients in Group A were administered local subcutaneous
wound inltration of 0.75% ropivacaine 3 mg/kg (rounded to
nearest multiple of ten) diluted with normal saline to a total
volume of 40 ml, whereas Group B patients were given local
subcutaneous wound inltration of 0.75% ropivacaine 3 mg/kg
(rounded to nearest multiple of ten) plus dexmedetomidine
1.5 µg/kg (rounded to nearest multiple of ten, using a 1 cc
syringe) diluted with normal saline to 40 ml.
The time of subcutaneous inltration of test drug was labeled
as 0 and observations started from this time onward and
patient shifted to postanesthesia care unit (PACU). On arrival
to PACU, patients were asked to rate the pain using VAS
rulers having slide indicator with 0–10 analog scale etched on
the front. Patients were asked to bring the slider on the scale
on to the point that they feel represents their current state of
pain with “0” mark corresponding to no pain and “10” mark
representing worst imaginable pain. Patients were monitored
for postoperative pain and any analgesic requirement for a
period of 24 h.
Any patient complaining of pain or reporting VAS ≥4 at
any time was administered tramadol 100 mg IV slowly
over 2–3 min. If pain was not relieved after 30 min and patients
still complained of pain, additional doses of tramadol 50 mg
IV were given, and this dose could be repeated every 30 min
up to a total dose of 250 mg in 6 hourly and maximum of
400 mg of tramadol over 24 h. Time of rst rescue analgesic
administration and total rescue analgesic consumed in 24 h
postoperatively was noted. Patients were also evaluated for
any adverse effects, 24 h postoperatively.
In the PACU, the following parameters were observed and
recorded.
• HR, blood pressure, RR, SpO2 every 10 min for 1 h, and
then every half hourly for the next 2 h followed by every
hour till 24 h
• Assessment of pain using VAS whenever patient
complained of pain and 10 min after giving rescue
analgesic
• Time of first rescue analgesic administration in the
postoperative period
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
Bhardwaj, et al.: Comparison of ropivacaine wound inltration with or without dexmedetomidine for post – operative pain relief after
lower segment cesarean section
942 Anesthesia: Essays and Researches ¦ Volume 11 ¦ Issue 4 ¦ October-December 2017
942
• Total analgesic consumption in the 24 h postoperative
period
• Patients were also observed for any adverse effect such
as postoperative nausea with or without vomiting,
skin rash (redness or itching), hypotension (dened as
blood pressure <15% of baseline values), sedation (as
per Ramsay sedation scale[10]), respiratory depression
(dened as RR <10/min), need for supplemental oxygen
(saturation <93%), bradycardia (HR <60 beats/min), and
any redness or signs of inammation at the skin incision
site
• Patient satisfaction was graded as
o Excellent (4)
o Good (3)
o Moderate (2)
o Poor (1).
Analysis of data
After completion of the study, observations obtained were
tabulated, and data were expressed as mean and 95%
condence interval of mean for continuous variables (height,
weight, duration, and age). Data were analyzed using Statistical
Package for the Social Sciences (SPSS) version 15 (SPSS
Inc., Chicago, IL, USA). Comparison of continuous data
between groups was done using independent t-test (ANOVA
of means). Comparison of nominal data was done using
Chi-square analysis and ordinal data using Mann–Whitney
test. P < 0.05 was considered statistically signicant between
groups.
Sample size for the study was estimated by taking into
consideration the results of a previous study by Kang.[7] This
study had found that VAS scores were signicantly lower
until 24 h after surgery, and fentanyl consumption and the
frequency to push button of patient-controlled analgesia (PCA)
pump were signicantly lower in group receiving local wound
infiltration with ropivacaine plus dexmedetomidine until
postoperative 12 h (601.54 ± 111.65) compared with that of
group receiving ropivacaine alone (735.85 ± 158.43). Based
on this, a sample size of 54 patients was needed to detect 10%
difference with 90% power and α of 0.05. As dropout cases
would be expected due to failure of spinal anesthesia and
conversion to general anesthesia, a sample size of sixty was
selected for the study.
results
There was no signicant difference among the two groups
with respect to mean age, height, weight, and gestational age.
Majority of the patients had no previous history of cesarean
section in either of the groups and belonged to physical status
ASA I category [Table 1].
Postoperatively, the baseline HR was comparable between
Group A and Group B (P = 0.373). On intergroup comparison
between Group A and Group B, HR was lower in Group B
than in Group A at most time intervals and was statistically
signicant. Intragroup comparison of HR showed gradual fall
with time in both the groups, but this gradual decrease in HR
was greater in Group B [Figure 1].
Baseline mean arterial pressure in the postoperative period
was similar in both the groups, being 88.67 ± 12.11 mmHg
and 88.47 ± 9.07 mmHg in Groups A and B, respectively
(P = 0.927). Intergroup comparison showed no signicant
difference in mean arterial pressure among the two groups.
Overall, there was a trend toward a fall in mean arterial pressure
with time and this decline in mean arterial pressure was more
in Group B [Figure 2].
The number of patients administered rst, second, and third
doses of rescue analgesics were signicantly greater in Group
A as compared to Group B [Table 2]. None of the patients in
Group B needed more than three doses of rescue analgesia,
whereas in Group A, 17 patients needed rescue analgesic for
4th time and three patients were administered a rescue analgesic
for 5th time. This difference was statistically signicant four
out of ve times of rescue analgesic administration [Table 2].
The need for IV rescue analgesic for the rst time was at 3.27 ± 2.03
h in Group A and at 7.00 ± 1.85 h in Group B [Table 3]. Thus, the
need for the rst dose of rescue analgesia was earlier in Group
A as compared to Group B and the difference was statistically
signicant (P < 0.001). Similarly, the need for second and third
doses of rescue analgesics was signicantly later in Group B and
the difference was statistically signicant with P < 0.001 and 0.006,
respectively. The time for fourth and fth rescue analgesic was at
20.19 ± 2.30 and at 22.20 ± 1.10 h in Group A, whereas patients
in Group B did not require any additional rescue analgesics after
that. Mean VAS was higher in ropivacaine alone group at each
time rescue analgesic was given, compared to Group B and results
were statistically signicant [Table 3].
The mean analgesic requirement in Group A was also greater
as compared to Group B and the difference was statistically
signicant (P = 0.000) [Table 4].
Table 1: Demographic profile
Group A Group B P
Mean age (years) 28.80±4.78 28.76±4.42 0.964
Mean weight (kg) 68.56±14.46 72.58±11.90 0.153
Mean height (cm) 162.35±5.58 162.24±4.60 0.357
Gestational age (weeks) 38.08±1.24 38.35±1.08 0.183
Physical status ASA Grade I (%) 66.7 68.9 0.500
Previous surgery (% age) 40 35 0.744
ASA=American Society of Anesthesiologists
Table 2: Total number of patients requiring rescue
analgesic in each group
Group A Group B P
1st time 29 15 0.000
2nd time 28 7 0.000
3rd time 26 1 0.000
4th time 17 0 0.000
5th time 30 0.076
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
Bhardwaj, et al.: Comparison of ropivacaine wound inltration with or without dexmedetomidine for post – operative pain relief after
lower segment cesarean section
943
Anesthesia: Essays and Researches ¦ Volume 11 ¦ Issue 4 ¦ October-December 2017 943
None of the patients developed skin rash, respiratory
depression, hypotension, hypoxemia, sedation, bradycardia,
or any signs of local wound inammation. The incidence of
nausea with or without vomiting was found to be comparable
in both the groups with P = 0.573 [Table 5].
No statistical difference with regard to satisfaction scores was
detected [Table 6].
dIscussIon
To the best of our knowledge, only two studies have been
conducted to compare the postoperative pain outcomes of
local subcutaneous wound inltration of ropivacaine and
ropivacaine with dexmedetomidine in patients undergoing
inguinal herniorrhaphy and hemorrhoidectomy, respectively.[7,8]
Opioids are the most commonly used analgesics for the
relief of postoperative pain after cesarean section, either
by intrathecal or epidural administration before section or
oral, subcutaneous, transdermal, parenteral administration
postoperatively. However, the risk of complications such as
respiratory depression, urinary retention, pruritus, nausea, and
vomiting can cause discomfort to the patient. On the other
hand, nonopioid systemic analgesics such as cyclooxygenase
inhibitors mainly NSAIDs, α2-agonists, nitric oxide, and
N-methyl-aspartate are not potent enough to allow effective
pain control after cesarean section. In addition, NSAIDs are
associated with an increased incidence of gastrointestinal
problems, kidney dysfunction, and bleeding diathesis.
In addition to the above-mentioned interventions, incisional
inltration with local anesthetics has been demonstrated as an
effective technique for postoperative pain relief after lower
segment cesarean section (LSCS) as part of a multimodal
approach and is simple to give, safe, and cost effective.[11,12]
Patient is not only pain free but also remains alert and
cooperative with only a few of the side effects of narcotics.
Local anesthetics also have the advantage of encouraging
early mobilization and possibility of reducing the risk of deep
vein thrombosis. The mother–child contact can be established
earlier, and this contributes to their psychologic well-being.
The use of this analgesic technique does not lead to any
increase in wound dehiscence or infection in LSCS cases.[13]
Hence, we have chosen local anesthetic wound inltration for
postoperative pain relief in our study.
Ropivacaine is the local anesthetic of choice in our study
whose potency, duration of action, and cost are comparable to
bupivacaine with a signicantly reduced cardiotoxicity. The
delay in local diffusion because of intrinsic vasoconstrictive
property makes it at a lower risk for cardiovascular side effects
due to decreased systemic absorption. The recommended
dosage of ropivacaine for minor nerve block and wound
inltration for surgical anesthesia, in an adult weighing 60 kg
or more, is 225 mg of 7.5 mg/ml solution and for postoperative
analgesia is up to 200 mg of 2 mg/ml solution[14] although recent
studies on ropivacaine have demonstrated a longer duration
of skin analgesia with higher doses than used before.[13,15,16]
We have selected a dose of 3 mg/kg body weight so that
the total dose remains well below the maximum safe dose
of 300 mg[15,17] since systemic absorption and plasma
concentration, which is proportional to the weight, may be of
importance in ensuring drug safety.
65
70
75
80
85
90
95
baseline
10 min
20 min
30 min
40 min
50 min
60 min
1.5 hr
2 hr
2.5 hr
3 hr
4 hr
5 hr
6 hr
7 hr
8 hr
9 hr
10 hr
11 hr
12 hr
13 hr
14 hr
15 hr
16 hr
17 hr
18 hr
19 hr
20 hr
21 hr
22 hr
23 hr
24 hr
Mean HR
Time
Group AGroup B
Figure 1: Mean heart rate among the two groups
65
70
75
80
85
90
baseline
10 min
20 min
30 min
40 min
50 min
60 min
1.5 hr
2 hr
2.5 hr
3 hr
4 hr
5 hr
6 hr
7 hr
8 hr
9 hr
10 hr
11 hr
12 hr
13 hr
14 hr
15 hr
16 hr
17 hr
18 hr
19 hr
20 hr
21 hr
22 hr
23 hr
24 hr
Mean arterial pressure
Time
Group AGroup B
Figure 2: Postoperative mean arterial pressure
Table 3: Mean time to rescue analgesics and visual analog scale at that time interval
Timing of rescue
analgesics
Mean time to rescue analgesics (mean±SD) PMean VAS at the time of rescue analgesic P
Group A (h) Group B (h) Group A Group B
1st time 3.27±2.03 7.00±1.85 <0.001 5.86±1.069 4.59±0.584 <0.001
2nd time 9.07±2.86 14.50±1.65 <0.001 5.81±0.969 4.40±0.505 <0.001
3rd time 14.72±3.28 21.50±0.70 0.006 5.46±0.996 4.00±0.000 0.047
4th time 20.19±2.30 - - 5.42±0.809 0 0.000
5th time 22.20±1.10 - - 5.00±0.000 0 0.000
SD=Standard deviation, VAS=Visual analog scale
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
Bhardwaj, et al.: Comparison of ropivacaine wound inltration with or without dexmedetomidine for post – operative pain relief after
lower segment cesarean section
944 Anesthesia: Essays and Researches ¦ Volume 11 ¦ Issue 4 ¦ October-December 2017
944
Incisional wound inltration of ropivacaine directly into the
wound to relieve post-LSCS pain has been supported by
authors, but, it has a limited duration of action (30 min to 6 h)[14]
and no intrinsic sedative properties, leading to increased
demand of sedatives and hence respiratory depression in the
immediate postoperative period. A variety of adjuvants such as
epinephrine, α2-adrenoceptor agonists, ketorolac, magnesium,
sodium bicarbonate, and hyaluronidase to local anesthetics
have been investigated and used to overcome these problems.
Dexmedetomidine, an α2-adrenoceptor agonist, provides
analgesia and sedation without respiratory depression
when administered by IV, epidural, and intrathecal route.
A synergistic interaction between dexmedetomidine and
local anesthetics has been observed when given by these
routes.[18-20] However, scant studies are available to know the
analgesic efcacy of wound inltration of local anesthetics
with dexmedetomidine for postoperative pain relief and none
after LSCS. We have given dexmedetomidine in a dose of
1.5 mcg/kg of body weight based on the studies,[7,9] wherein
authors have administered subcutaneous dexmedetomidine in
the range of 1–2 µg/kg for postoperative pain relief.
None of the patients were excluded from our study. Both
the groups were statistically comparable with respect to
demographic prole.
The total number of patients who demanded rescue analgesic
in Group B was 15 as compared to 29 in Group A. This reects
50% decrease in patient suffering in terms of pain with the
use of ropivacaine plus dexmedetomidine in local inltration.
Total analgesic requirement for postoperative pain relief in
the form of IV tramadol was signicantly less in Group B
(P = 0.000). Mean value of tramadol required in Group A in
24 h was 153.33 ± 47.22 mg, whereas it was 41.67 ± 52.65 mg
in Group B. Thus, surgical incision inltration with ropivacaine
plus dexmedetomidine decreases the total rescue analgesic
demand by 72% in 24 h postoperative period. VAS values at
each time patient complained of pain and rescue analgesic was
given, were signicantly low in Group B patients compared to
Group A patients (P = 0.000). Furthermore, rescue analgesic
was required up to ve times in group with plain ropivacaine but
only 3 times in group with ropivacaine and dexmedetomidine in
24 h. Thus, less number of patients reported pain and demanded
rescue analgesic in Group B over 24 h indicating better pain
relief with the use of dexmedetomidine.
Our results correlate well with the observations of Kang,[7]
who studied the effect of dexmedetomidine added to
preemptive ropivacaine inltration on postoperative pain after
inguinal herniorrhaphy and found reduction in postoperative
pain after surgery. A signicant reduction in pain scores,
fentanyl consumption, and frequency of pushing the PCA
button was noted in group of patients with ropivacaine and
dexmedetomidine as compared to ropivacaine alone.
Our results are also consistent with the findings of Kim
and Kang,[8] who studied the effect of preemptive perianal
ropivacaine and ropivacaine with dexmedetomidine on pain
after hemorrhoidectomy and found that perianal ropivacaine
with dexmedetomidine is effective. Signicant reduction in
VAS scores, fentanyl use for analgesia, and frequency with
which the PCA was pushed (P < 0.005) were found until the
24 h postoperative period.
The incidence of nausea and vomiting was not found to
be statistically different among the two groups. Possible
explanation for no such difference could be a smaller number
of patients included to reach the level of signicance for
postoperative nausea and vomiting. No signicant differences
were detected between both groups in terms of patient
satisfaction.
Although our study showed that additional local inltration
of dexmedetomidine improves postoperative pain and reduces
the need for rescue analgesic, the underlying mechanism of
analgesic effect of dexmedetomidine remains unclear. The
possible mechanisms suggested for this phenomenon, include:
1. Inh ibit ion of the impulse conduct ion in primary afferents,
especially C bers
2. Anti-inammatory effects by decreasing the production
of inammatory cytokines
3. Prolongation of analgesic duration by vasoconstriction
through α2-adrenergic receptor on vascular smooth
4. Inhibition of pain generation by inhibition of
tetrodotoxin-sensitive Na(+) channels, and
5. Supraspinal analgesia secondary to the absorption of
dexmedetomidine to systemic circulation.[21-24]
Table 6: Satisfaction score
Score Group Total χ2P
A B
1 (poor) 2 2 4 4.7429 0.192
2 (moderate) 7 310
3 (good) 9 514
4 (excellent) 12 20 32
Total 30 30 60
Table 4: Mean cumulative dose of rescue analgesic
requirement in 24 h (mg)
Group Mean±SD P
Rescue analgesic requirement in 24 h (mg)
A153.33±47.22 0.000
B 41.67±52.65
SD=Standard deviation
Table 5: Incidence of adverse effects
Group A
(n=30)
Group B
(n=30)
P
Nausea with or without vomiting (%) 10 (33.3) 8 (26.7) 0.573
n=Number of patients
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
Bhardwaj, et al.: Comparison of ropivacaine wound inltration with or without dexmedetomidine for post – operative pain relief after
lower segment cesarean section
945
Anesthesia: Essays and Researches ¦ Volume 11 ¦ Issue 4 ¦ October-December 2017 945
Our study has some limitations worth mentioning. First of
all, the surgeries were conducted by different surgeons, thus
causing differences in tissue handling and local anesthetic
inltration. Second, dose of dexmedetomidine was arbitrarily
selected, and blood levels of ropivacaine and dexmedetomidine
were not measured. Third, all of our patients belonged to
physical status ASA Grade I and II with no severe underlying
disease; therefore, the results of the present study should not
be generalized to all the patients.
On the other hand, few advantages of our study are worth
mentioning. First, only elective cesarean sections were
included to avoid the type, nature, and duration of pain
associated with different types of surgery. Second, all the
VAS measurements were carried out by a single observer to
eliminate any interobserver variability.
Nevertheless, reduction in a total number of patients requiring
rescue analgesics with reduced VAS pain scores, lesser
tramadol consumption, and no sedation was observed in
patients receiving ropivacaine with dexmedetomidine. The
quality of analgesia as evidenced by reduced pain intensity
and total postoperative rescue analgesic demand was better
with ropivacaine plus dexmedetomidine as compared to
ropivacaine alone. Thus, dexmedetomidine seems to be an
attractive adjuvant to ropivacaine for subcutaneous wound
inltration in patients undergoing LSCS.
conclusIons
Dexmedetomidine added to ropivacaine for the surgical wound
inltration signicantly reduces postoperative pain and rescue
analgesic consumption in patients undergoing LSCS patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
references
1. Klaus MH, Kennell JH, Plumb N, Zuehlke S. Human maternal behavior
at the rst contact with her young. Pediatrics 1970;46:187-92.
2. Dahl JB, Jeppesen IS, Jørgensen H, Wetterslev J, Møiniche S.
Intraoperative and postoperative analgesic efcacy and adverse effects
of intrathecal opioids in patients undergoing cesarean section with
spinal anesthesia: A qualitative and quantitative systematic review of
randomized controlled trials. Anesthesiology 1999;91:1919-27.
3. Sujata N, Hanjoora VM. Pain control after cesarean birth – What are the
options? J Gen Pract 2014;2:164.
4. Rawal N, Axelsson K, Hylander J, Allvin R, Amilon A, Lidegran G,
et al. Postoperative patient-controlled local anesthetic administration at
home. Anesth Analg 1998;86:86-9.
5. Whiteside JB, Wildsmith JA. Developments in local anaesthetic drugs.
Br J Anaesth 2001;87:27-35.
6. Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine
on neuraxial and peripheral nerve block: A systematic review and
meta-analysis. Br J Anaesth 2013;110:915-25.
7. Kang H. The effect of dexmedetomidine added to preemptive ropivacaine
inltration on post-operative pain after inguinal herniorrhaphy:
A prospective, randomized, double-blind, placebo-controlled study. Eur
Surg 2012;44:274-80.
8. Kim BG, Kang H. The effect of preemptive perianal ropivacaine and
ropivacaine with dexmedetomidine on pain after hemorrhoidectomy: A
prospective, randomized, double-blind, placebo-controlled study. Indian
J Surg 2014;76:49-55.
9. Ulgey A, Gunes I, Bayram A, Bicer C, Kurt FM, Muderis I. The
analgesic effects of incisional levobupivacaine with dexmedetomidine
after total abdominal hysterectomy. Erciyes Med J 2015;37:64-8.
10. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled
sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-9.
11. Trotter TN, Hayes-Gregson P, Robinson S, Cole L, Coley S, Fell D.
Wound inltration of local anaesthetic after lower segment caesarean
section. Anaesthesia 1991;46:404-7.
12. Ganta R, Samra SK, Maddineni VR, Furness G. Comparison of the
effectiveness of bilateral ilioinguinal nerve block and wound inltration
for postoperative analgesia after caesarean section. Br J Anaesth
1994;72:229-30.
13. Nguyen NK, Landais A, Barbaryan A, M’barek MA, Benbaghdad Y,
McGee K, et al. Analgesic efcacy of pfannenstiel incision inltration
with ropivacaine 7.5 mg/mL for caesarean section. Anesthesiol Res
Pract 2010;2010. pii: 542375.
14. Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology
and clinical use. Indian J Anaesth 2011;55:104-10.
15. Pettersson N, Berggren P, Larsson M, Westman B, Hahn RG. Pain relief
by wound inltration with bupivacaine or high-dose ropivacaine after
inguinal hernia repair. Reg Anesth Pain Med 1999;24:569-75.
16. Gottschalk A, Burmeister MA, Radtke P, Krieg M, Farokhzad F,
Kreissl S, et al. Continuous wound inltration with ropivacaine reduces
pain and analgesic requirement after shoulder surgery. Anesth Analg
2003;97:1086-91.
17. Wulf H, Worthmann F, Behnke H, Böhle AS. Pharmacokinetics and
pharmacodynamics of ropivacaine 2 mg/mL, 5 mg/mL, or 7.5 mg/mL
after ilioinguinal blockade for inguinal hernia repair in adults. Anesth
Analg 1999;89:1471-4.
18. Wahlander S, Frumento RJ, Wagener G, Saldana-Ferretti B,
Joshi RR, Playford HR, et al. A prospective, double-blind, randomized,
placebo-controlled study of dexmedetomidine as an adjunct to epidural
analgesia after thoracic surgery. J Cardiothorac Vasc Anesth 2005;19:630-5.
19. Saadawy I, Boker A, Elshahawy MA, Almazrooa A, Melibary S,
Abdellatif AA, et al. Effect of dexmedetomidine on the characteristics
of bupivacaine in a caudal block in pediatrics. Acta Anaesthesiol Scand
2009;53:251-6.
20. Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S.
Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia.
Indian J Anaesth 2011;55:347-51.
21. Gaumann DM, Brunet PC, Jirounek P. Hyperpolarizing afterpotentials
in C bers and local anesthetic effects of clonidine and lidocaine.
Pharmacology 1994;48:21-9.
22. Kim MH, Hahn TH. The effect of clonidine pretreatment on the
perioperative proinammatory cytokines, cortisol, and ACTH responses
in patients undergoing total abdominal hysterectomy. Anesth Analg
2000;90:1441-4.
23. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects
of increasing plasma concentrations of dexmedetomidine in humans.
Anesthesiology 2000;93:382-94.
24. Maruta T, Nemoto T, Satoh S, Kanai T, Yanagita T, Wada A, et al.
Dexmedetomidine and clonidine inhibit the function of Na(V) 1.7
independent of a(2)-adrenoceptor in adrenal chromafn cells. J Anesth
2011;25:549-57.
[Downloaded free from http://www.aeronline.org on Thursday, May 27, 2021, IP: 202.164.42.67]
