Evaluation of analgesic effects of intrathecal clonidine along with bupivacaine in cesarean section

Clonidine Effect on Pain After Cesarean Delivery: A Randomized Controlled Trial of Different Routes of Administration

BACKGROUND

Intrathecal clonidine prolongs spinal anesthesia. We evaluated the effects of the addition of intrathecal or intravenous clonidine (75 µg) to standard cesarean delivery spinal anesthesia on postoperative pain and neonatal outcomes.

METHODS

In a randomized, placebo-controlled, double-blind trial, 64 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated and compared among 3 groups: intrathecal clonidine 75 µg, intravenous clonidine 75 µg, and placebo. The primary outcome was acute postoperative pain. A sample size of 26 individuals per group (N = 78) was planned.

RESULTS

From April 2015 to April 2016, 64 women were analyzed (14 excluded). No differences in postoperative pain scores were found (Numerical Verbal Scale for pain at movement at 24 hours of postcesarean delivery: 4.53 ± 3.0 vs 4.45 ± 2.73 vs 3.93 ± 3.07 for control, intrathecal, and intravenous, respectively, P = .771). Intrathecal and intravenous clonidine led to more sedation, in comparison to the control group, during the intraoperative period (Richmond Agitation and Sedation Scale: -0.3 ± 0.47 vs -1 ± 0.53 vs -0.73 ± 0.45 for control, intrathecal, and intravenous, respectively, overall P < .001; Dunn correction: P < .001 for intrathecal versus control; P = .021 for intravenous versus control; and P = .208 for intrathecal versus intravenous).

CONCLUSIONS

Intrathecal or intravenous clonidine had no effect on postoperative pain after cesarean delivery. Both intrathecal and intravenous clonidine caused more sedation.

A Comparative Study of Intrathecal Bupivacaine and Bupivacaine with Different Doses of Clonidine in Lower Limb Surgeries

Background:

Intrathecal clonidine is a very safe, nonopioid adjuvant to local anesthetics to prolong the duration of analgesia without any major side effects.

Objective:

The purpose of the present study was to evaluate the efficacy of clonidine in two different doses as an adjuvant to bupivacaine intrathecally in lower limb surgeries.

Materials and Methods:

A total of 75 adult patients scheduled to undergo lower limb surgeries were randomly allocated into either of three groups of 25 patients. Group I received 12.5 mg bupivacaine, Group II patients received bupivacaine 12.5 mg with clonidine 15 μg, and patients in Group III received bupivacaine 12.5 mg with clonidine 30 μg intrathecally. A total volume of 3 ml was made in all groups using normal saline. The hemodynamic parameters, onset, and duration of sensory block, highest dermatomal level of sensory block, motor block onset, time to complete motor block recovery, and mean time to request of the first analgesic were recorded. Side effects or any other complications were noted.

Results:

The mean time of onset of sensory block and motor block was less in clonidine groups. The mean duration of sensory block was significantly prolonged in clonidine groups as compared to study group. The duration of motor block (in minutes) was significantly prolonged in Group III (171.60 ± 38.20) as compared to Group I (113.20 ± 35.79) and Group II (115.20 ± 38.41). The time of analgesic request in Group I was 148.16 ± 43.99 min, 190.60 ± 38.08 in Group II, and 200.80 ± 59.85 min in Group III.

Conclusions:

The addition of intrathecal clonidine 15 μg to small dose bupivacaine increased the spread, duration of analgesia, and produced effective spinal anesthesia with stable hemodynamics and did not prolong postoperative motor block.

Clinical Study to Determine the Efficacy of Clonidine as an Adjuvant to Intrathecal Bupivacaine in Patients Undergoing Cesarean Section

Introduction

Spinal anesthesia with bupivacaine is associated with hypotension and inadequate postoperative analgesia. The addition of clonidine as an adjuvant to intrathecal bupivacaine is beneficial in reducing the dose of the local anesthetic and also provides prolonged postoperative analgesia.

Methodology

One hundred and five American Society of Anesthesiologists physical status Classes 1 and 2 parturient women undergoing elective cesarean section were randomly divided into three groups. Patients in Group C (control) received 2 ml of 0.5% of heavy bupivacaine (10 mg) with 0.5 ml of 0.9% saline to a total volume of 2.5 ml, those in Group H (high dose of bupivacaine) received 2 ml of 0.5% of heavy bupivacaine (10 mg) with 1 μg/kg of clonidine and 0.9% saline to make a total volume of 2.5 ml, and those in Group L (low dose of bupivacaine) received 1.5 ml of 0.5% of heavy bupivacaine (7.5 mg) with 1 μg/kg clonidine and 0.9% saline to make a total volume of 2.5 ml. Patients were observed for onset and duration of sensory and motor block and for postoperative analgesia.

Results

Patients who received clonidine as adjuvant had effective prolonged postoperative analgesia (Group H - 480 ± 40 min, Group L - 480 ± 34 min) as compared to control group (180 ± 19 min).

Conclusion

The dose of intrathecal bupivacaine 0.5% was effectively reduced to 7.5 mg by adding 1 μg/kg of clonidine as adjuvant in patients undergoing elective cesarean section.

Intrathecal clonidine as an adjuvant for neuraxial anaesthesia during caesarean delivery: a systematic review and meta-analysis of randomised trials

BACKGROUND

Clonidine is used as adjuvant to local anaesthetics for spinal anaesthesia. Its potential harm and benefits have not been systematically reviewed in obstetrics, and medical regulatory authorities do not recommend its intrathecal administration. The aim of this study was to assess the safety and efficacy of intrathecal clonidine for caesarean delivery.

METHODS

We conducted a systematic literature search in Medline, Embase, the Cochrane Library databases and trial registries for randomised trials assessing intrathecal clonidine as an adjuvant to local anaesthetics in patients undergoing caesarean delivery. Studies were assessed for quality, and data were extracted on study characteristics, safety and efficacy. Pooled data analysis using random-effects models was performed. Relative risk (RR) or mean difference with 95% confidence intervals (CI) were used to analyse outcomes.

RESULTS

Of 201 reports screened, 12 relevant clinical trials were included. Clonidine prolonged the duration of sensory block by 128.2min (95% CI 81.7 to 174.8) and motor block by 44.7min (95% CI 8.7 to 80.7). Clonidine increased sedation, RR 3.92 (95% CI 1.17 to 13.14), but did not increase the risk of hypotension, pruritus or postoperative nausea and vomiting. Apgar scores at 1 or 5min were not influenced by the addition of intrathecal clonidine.

CONCLUSION

Clonidine is an effective and safe adjuvant to local anaesthetics for spinal anaesthesia for caesarean delivery. This opens the debate as to whether intrathecal clonidine as an "off label" prescription should be reconsidered by medical regulatory authorities.

Comparison of intrathecal clonidine and fentanyl in hyperbaric bupivacaine for spinal anesthesia and postoperative analgesia in patients undergoing lower abdominal surgeries

BACKGROUND

There are many adjuvant used along with bupivacaine for subarachnoid block, but fentanyl and clonidine are commonly used as adjuvant to intrathecal bupivacaine for prolonging both sensory and motor blockade as well as postoperative analgesia in patients undergoing lower abdominal surgeries.

OBJECTIVE

There is a paucity of studies comparing the efficacy of fentanyl and clonidine as adjuvant to intrathecal bupivacaine for improving intraoperative effect and postoperative analgesia in lower abdominal surgeries instigated us compare the effect of these drugs.

METHODS

This prospective, randomized study is conducted on 100 American Society of Anesthesiologists I or II patients between 18 and 65 years of age divided into two groups of 50 each. The patients were given 2.5 ml of 0.5% hyperbaric bupivacaine with either 50 μg of clonidine (BC Group) or 25 μg of fentanyl (BF Group) intrathecally. The onset and duration of sensory and motor block, sedation score, hemodynamic parameters, total analgesia time, and potential side effects were recorded and compared.

RESULTS

Both the groups were comparable in demographic data, onset and duration of sensory and motor blockade, hemodynamic parameters, but the duration of analgesia is significantly longer in clonidine group when compared with fentanyl group. Sedation score is more in clonidine group.

CONCLUSION

Addition of clonidine to intrathecal bupivacaine offers longer duration of postoperative analgesia than fentanyl but with higher sedation.

Comparison of Intrathecal Clonidine and Fentanyl as Adjuvant to Hyperbaric Bupivacaine in Subarachnoid Block for Lower Limb Orthopedic Surgery

Background:

Many studies are there using adjuvants such as clonidine and fentanyl with bupivacaine in the subarachnoid block for prolonging postoperative analgesia. However, literature is divided regarding the dosage and efficacy of both intrathecal adjuvants. Furthermore, these adjuvants have their own side effects. Hence, search for ideal intrathecal adjuvant between clonidine and fentanyl to bupivacaine goes on.

Aim:

The aim of the present study was to compare the effect of intrathecal clonidine and fentanyl as adjuvant to bupivacaine in the subarachnoid block for lower limb orthopedic surgery.

Materials and Methods:

It was a prospective randomized study in which eighty patients posted for lower limb orthopedic surgery were divided into two groups of forty each. Group C – Received intrathecal hyperbaric bupivacaine (2.5 ml) +50 μg clonidine (diluted to 0.5 ml). Group F – Received intrathecal hyperbaric bupivacaine (2.5 ml) + fentanyl 25 μg (diluted to 0.5 ml). Duration of postoperative analgesia, sensory and motor block characteristics, hemodynamic parameters, and side effects were recorded and analyzed.

Results:

Time for first dose of rescue analgesic was delayed in Group C (510.84 ± 24.10 min) in comparison to Group F (434.95 ± 19.16 min) which was statistically significant (P < 0.001). Duration of sensory and motor block was significantly prolonged in Group C compared to Group F (P < 0.001). Sedation was more in Group C than Group F (P < 0.001). Other block characteristics, hemodynamic, and side effects were comparable in both groups.

Conclusion:

Intrathecal clonidine as adjuvant to hyperbaric bupivacaine provided prolonged postoperative analgesia with more sedation in comparison to intrathecal fentanyl.

Randomized study of postcesarean analgesia with intrathecal morphine alone or combined with clonidine

STUDY OBJECTIVE

To investigate the efficacy of the combination of intrathecal morphine with clonidine in comparison with 2 doses of intrathecal morphine alone for postcesarean analgesia.

DESIGN

Prospective, double-blinded, randomized clinical trial.

SETTING

Maternity ward of Hospital Santa Cruz, Curitiba, Paraná, Brazil (operating room and ward).

PATIENTS

The study included 195 American Society of Anesthesiologist I to III singleton parturients undergoing elective cesarean section.

INTERVENTIONS

The patients were randomized into 3 groups (M50, M100, and M/C). Patients were anesthetized intrathecally with 12 mg of 0.5% hyperbaric bupivacaine and 50 μg or 100 μg morphine (groups M50 and M100, respectively) or 50 μg morphine and 75 μg clonidine (group M/C).

MEASUREMENTS

The patients were subsequently assessed for pain levels and side effects at 9 to 11 hours and 22 to 24 hours after the injection.

MAIN RESULTS

There was no difference in the quality of pain relief among the groups. In all 3 groups, pain was more intense during the first assessment. Pruritus and nausea were more frequent in group M100, and dizziness was more frequent in group M/C; however, these results were statistically insignificant. The group receiving clonidine showed a significantly lower incidence of shivering compared with the other groups.

CONCLUSIONS

At these doses, there was no benefit of associating clonidine with morphine to improve postcesarean analgesia. Considering that higher doses of morphine were associated with more side effects, 50 μg of intrathecal morphine alone seems to be a better option for analgesia. The use of clonidine to reduce postoperative shivering must be balanced against the potential risks of hypotension, bradycardia, dizziness, and sedation.

The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain after lower segment caesarean section: A randomized control trial

Background:

Intrathecal clonidine prolongs spinal anesthesia but the optimum dose to be used in cesarean delivery is not yet known. We evaluated the effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain after lower segment caesarean section.

Methods:

A total of 105 parturients carrying a singleton fetus at term, scheduled to undergo elective LSCS under spinal anesthesia were randomized in a double blind fashion to one of the three groups. Group BF (n=35) received 2 ml of 0.5% hyperbaric bupivacaine+25 μg fentanyl, Group BC₅₀ (n=35) received 2 ml of 0.5% hyperbaric bupivacaine+50 μg clonidine, Group BC₇₅ (n=35) received 2 ml of 0.5% hyperbaric bupivacaine+75 μg clonidine.

Results:

The duration of postoperative analgesia was 184.73±68.64 min in group BF, 360.71±86.51 min in group BC₅₀ and 760.50±284.03 min in group BC₇₅, P<0.001. The incidence of hypotension was comparable, P=0.932, whereas the incidence of nausea and pruritis was significantly lower in groups BC₅₀ and BC₇₅ as compared to group BF, P<0.001. No other side effects of intrathecal clonidine were detected. Neonatal outcome was similar in all the three groups.

Conclusions:

Addition of 75 μg clonidine to hyperbaric bupivacaine in spinal anesthesia for LSCS significantly prolongs the duration of postoperative analgesia without any increase in maternal side effects. There was no difference in neonatal outcome.