Section ?

Original Research Article A PROSPECTIVE RANDOMIZED CONTROLLED

TRIAL COMPARING THE EFFICACY OF EPIDURAL
BUPIVACAINE (0.5%) WITH DEXMEDETOMIDINE
(0.5 µG/KG) AND MAGNESIUM SULPHATE (50 MG)
AS AN ADJUVANT IN PATIENTS UNDERGOING
MAJOR LOWER LIMB ORTHOPEDIC SURGERIES

R.Srilekha1, R Ganessan2, R.Iniya3

Received : XX/XX/2023
Received in revised form : XX/XX/2023 1
Accepted : XX/XX/2023 Senior Assistant Professor, Department of Anesthesiology, Government Mohan Kumaramangalam
Medical College and Hospital, Salem, Tamilnadu, India.
2
Associate Professor, Department of Anesthesiology, Kapv Govt Medical College & Mgm Hospital,
Keywords: Tiruchirapalli, Tamilnadu, India.
Epidural bupivacaine, 3
Assistant Professor, Department of Anesthesiology, Vinayaka Mission Medical College, Karaikal,
Dexmedetomidine, Lower limb, Puducherry, India.
Orthopaedic surgery, Analgesia,
Sedation score.
Abstract
Corresponding Author: Background: Epidural anaesthesia is a recent evidence-based regimen for peri-
Dr. R.Iniya
Email: [email protected] operative and post-operative pain relief after surgeries. The study aimed to
compare the efficacy of epidural bupivacaine (0.5%) with dexmedetomidine
DOI: 10.47009/jamp.2023.5.3.X
(0.5 µg/kg) or Magnesium sulphate (50 mg) as an adjuvant in American Society
Source of Support: Nil, of Anaesthesiologists (ASA) I and II patients undergoing major lower limb
Conflict of Interest: None declared
orthopaedic surgeries. Materials and Methods: This prospective randomised
Int J Acad Med Pharm control trial was conducted on 50 patients who came for elective lower limb
2023; 5 (3); XX-XX surgeries at the Government Mohan Kumaramangalam Medical College and
Hospital, Salem, Tamil Nadu, for two years. Subjects were randomised into
groups BD and BM. Group BD: Bupivacaine 0.5% (12 ml) + Dexmedetomidine
0.5 µg/kg (1 ml), and Group BM: Bupivacaine 0.5% (12 ml) + Magnesium
sulphate 50 mg (1ml). A detailed history of medical illness, prior surgeries,
anaesthetic exposure, drug intake, allergies, premedication, monitoring of
NIBP, ECG, SpO2, heart rate, and baseline cardio-respiratory parameters was
recorded. Results: No significant difference in gender, ASA, age, weight, or
duration of surgery between groups. Heart rate, SPO2, and MAP decreased
gradually in both groups, with no significant difference. The dexmedetomidine
group had longer sensory and motor block duration but no difference in time for
sensory regression. Dexmedetomidine had a higher sedation score than
magnesium sulphate, with 19 (76%) of the dexmedetomidine group having a
sedation score >2. Bradycardia was only present in the dexmedetomidine group.
Conclusion: Dexmedetomidine is a better adjuvant than magnesium sulphate
with 0.5% bupivacaine, providing exceptional post-operative analgesia and
superior sedative quality without side effects.

INTRODUCTION decreasing hospital stay duration and increasing

quality of life.[1-3]
Epidural anaesthesia is (peridural or extradural) Epidural anaesthesia is a recent evidence-based
obtained by blocking spinal nerves in the epidural regimen for peri-operative and post-operative pain
space as the nerves emerge from the dura and then relief after surgeries. It has been found to reduce
pass into vertebral foramina. It provides prolonged surgical stress, hemodynamic stability, recovery of
duration and differential blockade extended its use in gastrointestinal function, early ambulation, and
post-operative analgesia and acute and chronic pain thromboembolic events in high-risk patients. It
relief. But it has some disadvantages like patchy provides more post-operative pain relief than
motor block and delayed onset than spinal systemic drugs and is safer with fewer systemic side
anaesthesia. Various techniques are tried to overcome effects.[4-5] Local anaesthetics are useful and effective
these points. Proper and non-complicated in treating acute and chronic post-operative pain.
management of peri-operative and post-operative Still, the limitations like short duration of action and
pain is crucial for ideal surgical patient care, adverse effects on the Cardio-Vascular System
(CVS)and Central Nervous System (CNS) curb its

16
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556
use in recent times.6 Adjuvants or additives are Inclusion criteria: Patients of either gender aged 18-
frequently used with local anaesthetics for their 65 years with ASA grade I & II and posted for
combined and additive effect by extending the period elective lower limb surgery were included.
of sensory-motor block and restricting the increasing Exclusion criteria: Patients with a history of adverse
dose necessity of local anaesthetics.[7] reaction to any study drugs, spinal deformity,
The collection of local anaesthetic adjuvants has previous spinal surgery, any C/I to epidural
progressed from opioids to an extensive collection of anaesthesia like coagulation profile, with ASA II &
drugs with varying action mechanisms. A large range IV, and patients who refused were excluded.
of opioids, from morphine, fentanyl and sufentanil to A detailed history of medical illness, present and
hydromorphone, buprenorphine and tramadol, was past, along with a history of prior surgeries and
used earlier, which are restricted by their adverse anaesthetic exposure and their details, were recorded.
effects like respiratory depression, nausea, vomiting History of drug intake and allergies to drugs and latex
and pruritus, especially with its neuraxial use. Alpha were recorded. Routine investigations and that on the
2 adrenoreceptor antagonists like clonidine and surgery were done. General, systemic and thorough
dexmedetomidine are among the most extensively airway assessments of the patients were done. In the
used local anaesthetic adjuvants. Other drugs like preoperative period, all patients were instructed about
steroids (dexamethasone), anti-inflammatory agents the benefits of epidural analgesia. Inj. Ranitidine and
(parecoxib and lornoxicam), midazolam, ketamine, Inj. Metoclopramide was given as premedication.
magnesium sulfate and neostigmine have also been NIBP, ECG, SpO2, and heart rate were monitored
used with varied achievements. Local Anaesthetic continuously. 18G IV cannula were inserted and
peripheral nerve block adjuvants' success in preloaded with RL 10 ml/kg.
prolonging analgesia is an extensively researched Subjects were randomised into groups BD and BM.
topic.[8] The apprehension concerning the safety Group BD: Bupivacaine 0.5% (12 ml) +
outline of these adjuvants for prolongation of Dexmedetomidine 0.5 µg/kg (1 ml), and Group BM:
epidural analgesia demand further exploration in this Bupivacaine 0.5% (12 ml) + Magnesium sulphate 50
track. mg (1ml). Baseline cardio-respiratory parameters
Dexmedetomidine, an α2 adrenergic receptor like heart rate, blood pressure, and oxygen saturation
agonist, possesses hypnotic, sedative, anxiolytic, were recorded every 5 mins after administering study
sympatholytic, and analgesic properties without drugs.
producing significant respiratory depression. Its The sensory block was assessed using a short
sympatholytic effect decreases mean arterial pressure bevelled sterile 26G hypodermic needle along the
(MAP) and heart rate (HR) by reducing mid-clavicular line bilaterally, and the duration to
norepinephrine release.[9-11] Dexmedetomidine has a achieve up to the T10 level was noted. A modified
broad range of pharmacological properties, including Bromage scale was used to assess motor blockades.
sedation associated with arousability and orientation Scale 0 indicated no motor block, scale 1 indicated
and without respiratory depression.[12-14] Magnesium the inability to raise an extended leg, able to move
sulphate (MgSO4) has anti-nociceptive effects knees and feet, scale 2 indicated the inability to raise
primarily based on physiological calcium an extended leg and move knees, able to move feet,
antagonism, that is, voltage-dependent regulation of and scale 3 indicated a complete block of a motor
calcium influx into the cell and non-competitive limb.
antagonism of N-methyl D-aspartate (NMDA) Sedation was graded by using a five-point sedation
receptors, thereby preventing central sensitisation scale. Scale 1 indicated alert and wide awake, scale 2
induced by peripheral nociceptive stimuli.[15] indicated arousable to verbal command, scale 3
This study aimed to compare the efficacy of epidural indicated arousable with gentle tactile stimulation,
bupivacaine (0.5%) with dexmedetomidine (0.5 scale 4 indicated arousable with vigorous shaking,
µg/kg) or Magnesium sulphate (50 mg) as an and scale 5 indicated unarousable. Monitoring
adjuvant in American Society of Anaesthesiologists consisted of heart rate, non-invasive blood pressure,
(ASA) I and II patients undergoing major lower limb ECG, and SpO2 in both groups. The hemodynamic
orthopaedic surgeries. parameters and sedation were monitored
continuously during the intraoperative period and
MATERIALS AND METHODS recorded at 5, 10, 15, 20, 25, 30, 45, and 60 minutes
after giving the block. Time in the operating room
This prospective randomised control trial was and duration of surgery were recorded. Any side
conducted at the Department of Anaesthesia, effects, including hypotension, bradycardia, nausea,
Government Mohan Kumaramangalam Medical vomiting, sedation, and shivering, were noted.
College and Hospital, Salem, Tamil Nadu, for two Statistical analysis
years. It was done on 50 patients who came for Numerical variables like age, HR, NIBP, SPO2, time
elective lower limb surgeries. Institutional Ethical in the operating room, and duration of surgery were
Committee approval was obtained before the start of represented in mean, median, mode and standard
the study. Informed written consent was obtained deviation. Categorical variables like gender and
from each participant. complications were expressed in frequencies and

17
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556
percentages. Pie charts and bar diagrams were used were entered in an MS Excel sheet and analysed
as appropriate. using SPSS software version 16. American Society
When a numerical variable is associated with the of Anaesthesiologists (ASA) physical status
numerical variables, such as Pearson's correlation test classification system (ASAPS) was used.
was used after checking for normality. When a
categorical variable is associated with a categorical RESULTS
variable, the variables are represented in tables and
bar diagrams. For the test of significance, the chi- Among the dexmedetomidine group, 5 (20%) were
square test was used. Fisher's exact test was used females, and 20 (80%) were males. Among the
when more than 20% of the cell values have an magnesium sulphate group, 8 (32%) were females,
expected cell value of less than 5. P-values less than and 17 (68%) were males].
0.05 were considered statistically significant. Data

Table 1: Patient characteristics in the study

Group BD Group BM P-value
Gender Male 20 (80%) 17 (68%) 0.26
Female 5 (20%) 8 (32%)
ASA I 18 (72%) 19 (76%) 0.50
II 7 (28%) 6 (24%)
Age 39.92 ± 7.921 39.92 ± 8.149 0.67
Weight 58.60 ± 4.778 58.40 ± 5.346 0.53
Duration of surgery 76.00 ± 9.372 75.76 ± 9.554 0.96

Among the Dexmedetomidine group, 18 (72%)

patients belong to ASA I and 7 (28%) to ASA II.
Among the Magnesium Sulphate group, 19 (76%)
belong to ASA I, and 6 (24%) belong to ASA II.
There is no significant difference in gender, ASA,
age, weight, and the duration of surgery between
groups (Table 1).

Figure 2: SPO2 between groups

The SPO2 among the groups at baseline to 60

minutes are equal among both groups (Figure 2).

Figure 1: Heart rate between groups

The heart rate decreased gradually in both groups

over time, with no significant difference between the
two groups (Figure 1).

Figure 3: Mean arterial pressure

The MAP decreased gradually in both groups over

time, with no significant difference between the two
groups (Figure 3).

Table 2: Association of intra-operative variables among groups

Group BD Group BM P-value
Time of onset of sensory block 11.5 1.39 13.7 1.16 <0.001
Time of onset of motor block 15.420 1.38 17.640 .91 <0.001*
Duration of sensory block 304.96 6.23 245.64 10.68 <0.001*

18
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556
 Duration of motor block 258.08 6.66 190.52 16.01 <0.001*
Time of sensory regression to S1 133.86 1.47 133 1.83 0.07
Duration of analgesia 596.28 31.81 280.32 25.02 <0.001*

There was statistically significant showing early onset of sensory block and onset of motor block in the
dexmedetomidine group. There was statistically significant showing a longer duration of sensory block and longer
duration of motor block in the dexmedetomidine group.
No significant difference in time for sensory regression to the S1 level between groups. There was statistically
significant showing longer duration of sedation in the dexmedetomidine group (Table 2).

Table 3: An adverse effect, a maximum level of sensory block, and sedation score between groups
Group BD Group BM
The maximum level of T10 16 64.0 15 60.0
sensory block T6 3 12.0 - -
T8 6 24.0 10 40.0
Sedation score 1 6 24.0 17 68.0
2 12 48.0 6 24.0
3 7 28.0 2 8.0
Adverse effect NIL 14 56.0 19 76.0
Bradycardia 2 8.0 0 0
Hypotension 2 8.0 2 8.0
Nausea/Vomiting 4 16.0 3 12.0
Shivering 3 12.0 1 4.0

Dexmedetomidine and magnesium sulphate had Our study shows no statistical significance between
different sensory block levels, with the groups in the case of surgery duration, which
dexmedetomidine having a higher sedation score shows the accuracy of randomisation. This was
than Magnesium sulphate. There was statistically similar to other studies where age, weight, ASA,
significant, showing 19 (76%) of the gender, and duration of surgery were equally
dexmedetomidine group were having sedation distributed among groups showing successful
score>2, and only 8 (32%) in the magnesium sulphate randomisation.[16,18,19] In our study, there was
group had a sedation score >2 (p=0.006). This shows statistically significant showing early onset of
the good sedative effect of dexmedetomidine. sensory block in the dexmedetomidine group. The
Among 25 subjects in the dexmedetomidine group. onset of sensory block was defined as the time from
14 (56%) had no adverse effects, 2 (8%) had epidural injection to the occurrence of sensory block
bradycardia, 2 (8%) had hypotension, 4 (16%) had at the T10 dermatome in the mid-clavicular line.
nausea and vomiting, and 3 (12%) had shivering. Yehia et al.[17] showed that the dexmedetomidine
Among 25 study subjects in the magnesium Sulphate group showed superior analgesic criteria with onset
group, 19 (76%) had no adverse effect, 2 (8%) had at 8.25 ± 1.1 min versus 9.8 ± 1.5 min in the
hypotension, 3 (12%) had nausea and vomiting, and magnesium Sulphate group and 10.1 ± 1.3 min in
1 (4%) had shivering. This was not statistically group B (P=0.0002).
significant. Bradycardia was only present in the In our study, there was a statistically significant
dexmedetomidine group (Table 3). showing of early onset of motor block in the
dexmedetomidine group and a statistically significant
DISCUSSION showing of longer duration of sensory block in the
dexmedetomidine group. The mean ± SD duration of
The study was done among 50 subjects, 25 in the the motor block in the dexmedetomidine group was
dexmedetomidine group and 25 in the magnesium 258.08 ± 6.23 min, and the magnesium Sulphate
Sulphate group. The mean ± SD age in the group was 190.52 ± 10.68 min. This was statistically
dexmedetomidine group was 39.92 ± 7.92 years, and significant, showing a longer duration of motor block
in the magnesium sulphate group was 39.92 ± 8.15 in the dexmedetomidine group. A study by Mathur et
years. This was lesser compared to a study done by al.[16] showed that the duration of sensory block (time
Mathur et al.[16] and lower than a study done by Yehia to regression sensory sensation up to S1 level) was
et al.[17] The mean ± SD weight in the 240.4 ± 28.75 minutes and 306.1±15.32 minutes for
dexmedetomidine group was 58.6± 4.78 Kg, and in group BM and BD, respectively. The duration of the
the magnesium sulphate group was 58.4 ± 5.35 Kg, motor block was 191.7 ± 31.6 minutes for the
and this is higher than a study done by Mathur et magnesium group and 258.1 ± 15.95 minutes for the
al.[16] The result showed no significant difference for dexmedetomidine group in their study. This concord
age and weight among the groups. The absence of with other studies where dexmedetomidine has
significant difference indicates the success of shown longer sensory and motor block duration.[17-19]
randomisation, and this is similar to other studies.[16- The mean ± SD time for sensory regression to S1
19] level in the dexmedetomidine group was 133.86 ±
1.47 min, and the magnesium Sulphate group was

19
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556
133 ± 1.83 min. This was not statistically significant. receptor signalling may be important in determining
The mean ± SD duration of analgesia in the the duration of acute pain. Magnesium blocks
dexmedetomidine group was 596.28 ± 31.81 min, calcium influx and non-competitively antagonises
and the magnesium Sulphate group was 280.32 ± NMDA receptor channels.[25,26]
25.02 min. This was statistically significant, showing Among 25 subjects in the dexmedetomidine group.
a longer duration of sedation in the dexmedetomidine 14 (56%) had no adverse effects, 2 (8%) had
group (p<0.001). bradycardia, 2 (8%) had hypotension, 4 (16%) had
Jain et al.21 and Shukla et al.22 observed that the nausea and vomiting, and 3 (12%) had shivering.
duration of sensory and motor block times was Among 25 study subjects in the magnesium Sulphate
significantly longer in the dexmedetomidine group group, 19 (76%) had no adverse effect, 2 (8%) had
than in the magnesium group. Dexmedetomidine can hypotension, 3 (12%) had nausea and vomiting, and
act as an α2-adrenoreceptor agonist in the peripheral 1 (4%) had shivering. This was not statistically
and CNS. This analgesic effect of intrathecal significant. Bradycardia was only present in the
dexmedetomidine occurs through inhibition of the dexmedetomidine group. The fall in blood pressure
release of C-fibre transmitters and hyperpolarisation and heart rate due to dexmedetomidine is attributed
of the postsynaptic dorsal horn neurons, which can to its central action at the brain stem level and
explain the prolonged duration of a spinal block when sympathetic outflow inhibition.[16,27,28]
dexmedetomidine was added to intrathecal Siddique et al.[18] found that dexmedetomidine as an
anaesthetics.[19,23] adjuvant with hyperbaric bupivacaine leads to the
Duration of analgesia was significantly more earlier onset and prolonged sensory and motor block
protracted in the dexmedetomidine group than in the duration compared to magnesium sulfate. Mathur et
magnesium sulphate group. Dexmedetomidine has al.[16] also found that the onset of sensory and motor
been proposed to provide analgesia by both spinal block was earlier in group BD, the duration of
and supra-spinal mechanisms. At a spinal level, it sensory and motor blockade was significantly
activates α-2a and α-2c adrenergic receptors mainly prolonged in group BD, and the incidence of sedation
in lamina II, thus reducing the release of P and was more in group BD. Shahi et al.[20] did a study to
glutamate in primary afferent terminals. It also establish the effect of adding magnesium or
activates G- protein-mediated potassium channels dexmedetomidine as an adjuvant to epidural
causing hyper-polarisation of interneurons. Supra bupivacaine in lower limb surgeries. They found that
spinally, it causes suppression of neuronal firing in analgesia in the post-operative period was better in
locus coeruleus by causing hyper-polarisation of Group D, the sensory and motor blockade duration
noradrenergic neurons and inhibiting norepinephrine was significantly prolonged, and the incidence of
release in descending pathways, terminating sedation was more in Group D. Sayed et al.[19] also
propagation of pain signals, thus causing had similar findings. Tariq et al.[29] showed that post-
analgesia.[16,18-20] operative analgesia was better in the
Among the dexmedetomidine group, 6 (24%) had a Dexmedetomidine group with less rescue analgesic
sedation score of 1, 12 (48%) had a sedation score of requirement and more incidence of sedation.
2 and 7 (28%) had a sedation score of 3. Among the
magnesium sulphate group, 17 (68%) had a sedation CONCLUSION
score of 1, 6 (24%) had a sedation score of 2 and 2
(8%) had a sedation score of 3. This was statistically The study concludes that dexmedetomidine 0.5 µg/kg
significant, showing 19 (76%) of the seems to act as a better adjuvant than magnesium
dexmedetomidine group were having sedation score sulphate (50 mg) with 0.5% bupivacaine, providing
>2, and only 8 (32%) in the magnesium sulphate exceptional post-operative analgesia and superior
group had a sedation score >2. This shows the good sedative quality without undesirable side effects.
sedative effect of dexmedetomidine (p<0.006). The Dexmedetomidine also provides early onset and
dexmedetomidine group shows considerable sedation prolonged sensory and motor block duration, which
without respiratory depression compared to the may be useful during longer orthopaedics surgeries.
magnesium sulphate group. The α2 agonist causes The prevalence of adverse effects was more, and
sedation by its action on the locus coeruleus. This bradycardia as an adverse effect was present only in
mechanism synergises with the sedation caused by the dexmedetomidine group. Non-competitive
epidural anaesthesia due to decreased afferent NMDA antagonist magnesium sulfate, administered
proprioceptor discharge. Sedation characteristics of epidurally, also prolongs the duration of analgesia,
dexmedetomidine include a normal sleep pattern and but less than epidural dexmedetomidine.
calming effect on the patients who remain quiet but Recommendation
arousable and cooperative.[24] Noxious stimulation Further studies with increased sample sizes matched
releases glutamate and aspartate neurotransmitters, for confounding factors in other settings, such as
which bind to the NMDA receptor. Activation of primary and secondary care, will represent the true
these receptors leads to calcium entry into the cell. It nature of the study findings. Further studies are
initiates a series of central sensitisation such as wind- required to determine whether larger doses of
up and long-term potentiation in the spinal cord in the epidural magnesium sulfate can produce greater
response of cells to prolonged stimuli. NMDA

20
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556
potentiation of analgesia and reduce opioid ropivacaine in patients undergoing infraumbilical surgery: a
clinical study. Glob Anesth Perioper Med 2015;1.
requirements. 14. Afandy ME, Abusabaa MMA, Lotfy HA, Mansour RF. Effect
Limitations of the use of dexmedetomidine as a local anesthetic adjuvant
The study's limitations are that confounding factors to bupivacaine 0.125% in epidural labor analgesia:
like systemic diseases were not studied, and the time randomised controlled study. Ain-Shams J Anesthesiol.
2021;13:76.
for the first rescue analgesia was not analysed. A
15. Lysakowski C, Dumont L, Czarnetzki C, Tramèr MR.
smaller sample size decreased the chance of Magnesium as an adjuvant to post-operative analgesia: a
generalisability. Hospital-based studies in a tertiary systematic review of randomised trials. Anesth Analg.
care setting may cause bias in the selection of 2007;104:1532–9.
16. Mathur V, Jain K, Sharma K, Garg DK, Khare A, Sethi SK.
patients. Comparative study of dexmedetomidine and magnesium
Source of Funding: NIL sulphate as an adjuvant to epidural bupivacaine in lower limb
Conflict of Interest: NIL orthopaedic surgery. RUHS J Health Sci. 2020;5:66-73.
17. Yehia MF, Ahmad AEA, Esmaeil EA, Eskandar AM, Sultan
AA. Magnesium sulfate versus dexmedetomidine as adjuvants
REFERENCES to bupivacaine in post-operative epidural analgesia after total
knee replacement. Menoufia Med J 2019;32:411-6.
1. Singh M, Singh R, Jain A. An observational study to evaluate 18. Siddiqui SA, Rastogi K, Khan AL. Comparison of intrathecal
the effect of different epidural analgesia regimens on dynamic dexmedetomidine and magnesium sulphate as an adjuvant to
pain scores in patients receiving epidural analgesia for post- 0.5% hyperbaric bupivacaine in lower limb surgery. 2021;
operative pain relief after elective gynecological surgery. J 11:33-35.
Anaesthesiol Clin Pharmacol. 2018;34:362–71. 19. Sayed JA, Kamel EZ, Riad MAF, Abd-Elshafy SK, Hanna RS.
2. Ahmed A, Latif N, Khan R. Post-operative analgesia for major Dexmedetomidine with magnesium sulphate as adjuvants in
abdominal surgery and its effectiveness in a tertiary care caudal block to augment anaesthesia and analgesia in
hospital. J Anaesthesiol Clin Pharmacol. 2013;29:472–7. paediatric lower abdominal surgeries. Egyptian J Anaesth.
3. Balasubramanian G, Vijayakumar C, Sistla SC, Badhe AS, 2018;34:115–22.
Karthikeyan VS, Raj Kumar N, et al. Post-operative analgesia 20. Shahi V, Verma A, Agarwal A, Singh C. A comparative study
following elective abdominal surgery: a prospective of magnesium sulfate vs dexmedetomidine as an adjunct to
observational study. Int Surg J. 2017;4:2710–6. epidural bupivacaine. J Anaesthesiol Clin Pharmacol.
4. Mehta S, Gajbhare MN, Kamble NP. Comparison of epidural 2014;30:538–42.
analgesia using 0.2% bupivacaine and 0.2% ropivacaine for 21. Sethi S, Jain K, Jain R. Comparison of the efficacy of
the management of post-operative pain in major orthopedic intrathecal dexmedetomidine and magnesium sulfate as an
surgery. Anesthesia: Essays and Researches. 2018;12:586. adjuvant to 0.5% hyperbaric bupivacaine in patients
5. Guay J, Nishimori M, Kopp S. Epidural local anaesthetics undergoing infraumbilical surgeries under spinal anesthesia. J
versus opioid-based analgesic regimens for post-operative Dr NTR Univ Health Sci 2020;9:116.
gastrointestinal paralysis, vomiting and pain after abdominal 22. Shukla D, Verma A, Agarwal A, Pandey HD, Tyagi C.
surgery. Cochrane Database Syst Rev 2016;7:CD001893. Comparative study of intrathecal dexmedetomidine with
6. Bagshaw KR, Hanenbaum CL, Carbone EJ, Lo KW, intrathecal magnesium sulfate used as adjuvants to
Laurencin CT, Walker J, et al. Pain management via local bupivacaine. J Anaesthesiol Clin Pharmacol. 2011;27:495–9.
anesthetics and responsive hydrogels. Ther Deliv. 23. Kaya FN, Yavascaoglu B, Turker G, Yildirim A, Gurbet A,
2015;6:165–76. Mogol EB, et al. Intravenous dexmedetomidine, but not
7. Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local midazolam, prolongs bupivacaine spinal anesthesia. Can J
anesthetics: Current understanding and future trends. World J Anaesth. 2010;57:39–45.
Clin Cases. 2017;5:307–23. 24. Kaya FN, Yavascaoglu B, Turker G, Yildirim A, Gurbet A,
8. Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Mogol EB, et al. Intravenous dexmedetomidine, but not
Peripheral Nerve Block Adjuvants for Prolongation of midazolam, prolongs bupivacaine spinal anesthesia. Can J
Analgesia: A Systematic Qualitative Review. PLOS ONE. Anaesth. 2010;57:39–45.
2015;10:e0137312. 25. Woolf CJ, Thompson SWN. The induction and maintenance
9. Bhattacharjee DP, Nayek SK, Dawn S, Bandopadhyay G, of central sensitisation are dependent on N-methyl-D-aspartic
Gupta K. Effects of dexmedetomidine on haemodynamics in acid receptor activation, implications for the treatment of post-
patients undergoing laparoscopic cholecystectomy-A injury pain hypersensitivity states. Pain. 1991;44:293–9.
comparative study. Journal of Anaesthesiology Clinical 26. Pockett S. Spinal cord synaptic plasticity and chronic pain.
Pharmacology. 2010;26:45–8. Anesth Analg. 1995;80:173–9.
10. Naaz S, Ozair E. Dexmedetomidine in Current Anaesthesia 27. Salgado PFS, Sabbag AT, Silva PC da, Brienze SLA, Dalto
Practice- A Review. J Clin Diagn Res. 2014;8:GE01–4. HP, Módolo NSP, et al. Synergistic effect between
11. Summaira J, Tawheed A, Saima R. Dexmedetomidine dexmedetomidine and 0.75% ropivacaine in epidural
infusion an effective intra-operative medication for patients anesthesia. Rev Assoc Med Bras (1992). 2008;54:110–5.
undergoing laparoscopic cholecystectomy. Int J Anesth 28. Saravana Babu M, Verma AK, Agarwal A, Tyagi CM,
Anesth 2018;5. Upadhyay M, Tripathi SA comparative study in the post-
12. Akin S, Aribogan A, Arslan G. Dexmedetomidine as an operative spine surgeries: Epidural ropivacaine with
adjunct to epidural analgesia after abdominal surgery in dexmedetomidine and ropivacaine with clonidine for post-
elderly intensive care patients: A prospective, double-blind, operative analgesia. Indian J Anaesth. 2013;57:371–6.
clinical trial. Curr Ther Res Clin Exp. 2008;69:16–28. 29. Tariq T, Mir A, Ganie F, Shah M, Naz S, Dar M. Efficacy of
13. Rastogi B, Singh VP, Mangla D, Gupta K, Jain M, Pandey dexmedetomidine and magnesium as adjuncts to epidural
MN. Dexmedetomidine as an adjuvant to epidural 0.75% bupivacaine for upper abdominal surgeries. World J Pharm
Res. 2017;6.

21
International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
ISSN (O): 2687-5365; ISSN (P): 2753-6556