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The addition of 5 mg Dexamethasone effects on Bupivacaine 0.5% of the Mula and the
Old Labor Epidural Anesthesia Sensory Blockade
for Lower Extremity Orthopedic Surgery
Abstract
Lower extremity orthopedic surgery with epidural regional anesthesia has the disadvantage of a long onset of action. This study
examines the effect of the addition of 5 mg of dexamethasone on bupivacaine
0.5% against the onset and duration of sensory blockade work. The prospective study experimentally using a double blind
randomized clinical trial in 32 patients with American Society of Anesthesiologists ( ASA) I-II undergoing lower extremity orthopedic
surgery with epidural anesthesia at Hospital Dr. Hasan Sadikin in February-May 2014. Sampling was done by consecutive
sampling and random block permutation. Group I, dexamethasone 5 mg added to 15 mL of 0.5% bupivacaine. Group
II, bupivacaine 0.5% plus 15 ml 0.9% NaCl. The results were tested statistically using t-test and Mann-Whitney. The results
showed onset of sensory blockade in group I was not faster, which is 13.56 minutes compared with group II, 14.31 minutes (p =
0.27). Sensory blockade old group I work longer, which is 399.81 minutes compared with group II, namely 227.43 minutes (p =
0.00). In conclusion, the addition of dexamethasone 5 mg in 15 mL of 0.5% bupivacaine does not accelerate the onset of sensory
blockade but extend the working time of sensory blockade of 0.5% bupivacaine administered epidural.
Keywords: Epidural anesthesia, sensory blockade, bupivacaine, dexamethasone, length of employment, at work
Abstract
Lower extremity orthopedic surgery performed with regional epidural anesthesia was still have weakness the which is long onset of
time. This study was conducted to Determine the onset time and duration time of sensory blockade epidural anesthesia between the
use of dexamethasone 5 mg addition to the 0.5% bupivacaine for lower limb surgery orthophedic. The study was a randomized
controlled using blind method on 32 ASA I-II Patients undergoing lower limb orthopedic surgery under epidural anesthesia. Consecutive
sampling and random allocation of block of Permutation groups was applied. In group I, dexamethasone 5 mg was added to 15 mL of
0.5% bupivacaine in group II while 1 mL of NaCl was added to 15 mL of 0.5% bupivacaine. The results were statistically tested using
t-test and Mann-Whitney test. It was shown that the onset time of sensory blockade was not Significantly faster when dexamethasone
was added in bupivacaine 0.5%, versus 14:31 minutes 13:56 minutes (p = 0:27). The duration time of sensory blockade in
dexamethasone in bupivacaine
0.5% group was longer 399.81 minutes, Compared to the 0.5% bupivacaine group, 227.43 minutes (p = 0.00). In Conclusions, the addition
of dexamethasone 5 mg to 15 mL of 0.5% bupivacaine does not produced faster onset time. However, the duration of sensory blockade
time is longer than 15 mL of 0.5% bupivacaine is used
Key words: Bupivacaine, dexamethasone, duration time, epidural anesthesia, onset, sensory blockade
Correspondence: Irwan, dr., Span. M. Kes, the Air Force Hospital Dr. Salamun Bandung, Jalan Ciumbuleuit 203 West Java 40142, Tel. (022)
2032090, Mobile 081344225697, E-mail irwanmed93@gmail.com
109
110 Journal of Anesthesia Perioperative
The definition of local anesthesia is the loss of American Society of Anesthesiologists ( ASA) I-II
sensation of an area in the body caused by the undergoing lower extremity orthopedic surgery with
depression of the final excitation or inhibition of nerve epidural anesthesia in the operating room Central
impulse conduction in peripheral nerves. Local Hospital Dr. Hasan Sadikin in the period from February
anesthesia will give effect in the form of loss of to May 2014. Sampling was conducted in patients consecutive
sensation without loss of consciousness, it is a basic sampling and the allocation of a subject into one group
difference between local anesthesia compared with did a randomized block permutation. Based on statistical
general anesthesia. 3 calculation of the formula determining the sample size
for analytical research unpaired numerical katagorik to
Bupivacaine is a local anesthetic drug amid an examine differences in the average with a 95%
amino group that has long and widely used for regional confidence level and also the power of the test ( power
anesthesia. Isobaric 0.5% bupivacaine is a type of local test) 95%, obtained total
anesthesia that is widely used to
samples of 32 patients. Statistical analysis for the with the needle bevel facing the caudal. Epidural space
numerical data calculated based on the value of p is identified with the technique
unpaired t-test when the normal distribution of data, loss of resistance using air.
while analysis of the data are not normally distributed Epidural catheter is inserted as deep as 3 cm, and
using the Mann-Whitney test. P for categorical data is administration of test dose with 3 mL of 2% lidocaine in
calculated based on the chi-square test, with no the adrenalin 1: 200,000. Thereafter, the patient
alternative use Smirvov Kolmogorov test, the value of a returned in a supine position with the head mounted
statistical significant if p <0.05. Inclusion criteria that pillow and given oxygen 2-3 L / min through a cannula.
patients undergoing lower extremity orthopedic surgery, After waiting for 5 minutes, injected drug research with
patients with ASA physical status I-II, aged 18-60 years, the speed of 2-3 seconds / mL until the number reached
and patients are willing to do epidural anesthesia. 15 mL. Onset of sensory blockade was measured by
Exclusion criteria which patients with infection around test
the injection site epidural medication, blood clotting
disorders, and severe hypovolemia. Criteria of pinprick using needles were measured every minute.
expenses, in case of failure of the epidural after waiting Long sensory block was assessed every hour after drug
more than 30 minutes and more than 6 hours of research put and continued although the operation has
operation. been completed, the study ended at the time of the first
patient once complained of pain with value
After the approval of the Ethics Committee for Health numeric rating scale ( NRS) 3. If during the operation the
Research, Faculty of Medicine / Hasan Sadikin patient had complained of pain to the value of NRS 3 it
Bandung, conducted the selection of research subjects will be given the drug bupivacaine 0.5% for 35 mg via an
in accordance with the inclusion criteria and were not epidural catheter. The operation began when analgesia
included in the exclusion criteria, then made an has reached L1.
explanation to patients and their families about the
procedures that will be experienced by the patient during Blood pressure, heart rate, respiratory rate, and
the study and signed approval ( informed consent). peripheral oxygen saturation measured each
2.5 minutes in the first 30 minutes after anesthesia
drugs injected into the epidural space, then every five
Patients were divided into two groups of 16 patients minutes during surgery, every 15 minutes for patients
each group. A group is given dexamethasone 5 mg of treated in the recovery room and also last measured
0.5% bupivacaine -15 mL. Group B was given NaCl every hour during the patient was transferred to the
0.9% 1 mL of 0.5% bupivacaine -15 mL. The patients infirmary. Other data that is observed is the incidence of
then taken to the operating room, and installed hypotension, bradycardia, nausea and vomiting.
monitoring equipment such as automatic
sphygmomanometer,
If hypotension given ephedrine 5 mg intravenously. In the
pulse oximetry, pulse rate, respiratory rate, and event of bradycardia with atropine sulfate 0.1 mg given
electrocardiographic (ECG). Subsequently, the patient intravenously and in case of nausea and vomiting was given
was infused using 18G needle, given Ringer's lactate 15 ondansetron 4 mg intravenously.
ml / kg 20 minutes before injection of the epidural
needle. Epidural injection site on the skin do wear
betadin aseptic action and 70% alcohol. epidural needle Tuohy
result
18 G inserted in the midline of the intervertebral L3-4
until the epidural space with the patient to sleep Additional studies have been conducted on the drug
sideways (lateral decubitus) after previously injected dexamethasone 5 mg of bupivacaine 0.5% compared
local anesthetic lidocaine 2% and with 0.5% pure bupivacaine to block work early and
work long block on 32 patients undergoing orthopedic
surgery
Age (years)
mean ± SD 34.25 (13.84) 34 31 (12.58)
0.54
Median 40 28.5
Range 38
Junior high school elementary
education level S1 3355 1393
0.45
Height (cm)
mean ± SD 163 (6.79) 163.75 (6.15)
0.75
Median 162.5 164.5
Range 23 19
Weight (kg)
mean ± SD 59.19 (8.06) 58.31 (9.03)
0.77
Median 57.5 57.5
Range 27 30
Long operation (min)
mean ± SD 184 (65.01) 178.81 (79.09) 150
0.84
Median 182.5 253
Range 232
lower extremities. The research subjects were divided Whitney because of the requirement of normality were
into 2 groups of 16 subjects with a combination of not met, obtained onset of both groups was not
dexamethasone 5 mg group and 0.5% bupivacaine and statistically significant (p> 0.05; Table 2; Figure 1).
16 subjects with a 0.5% pure bupivacaine group. The
general characteristics of the two treatment groups Working long blocks to bupivacaine and
based on age, educational level, height, weight, and dexamethasone group gained an average of
length of surgery is not found significant differences (p> 399.81 minutes with a standard deviation of
0.05; Table 1). 137.90 minutes, the median of 355.5 minutes, and range for
534 minutes. For bupivacaine group gained an average
At block work for bupivacaine and dexamethasone of 227.44 minutes with a standard deviation of 40.02
group gained an average of minutes, median of 213 minutes, and range
13.56 minutes with a standard deviation of 4.72 minutes, the
median was 12.5 minutes, and range for 170 minutes. Based on a statistical test by using the
by 19 minutes. For bupivacaine group gained an Mann-Whitney test for normality requirements are not
average of 14.31 minutes with a standard deviation of met, then we got the job longer block the two groups
3.00 minutes, the median of 14 minutes, and range by 10 statistically significant (p <0.05; Table 3; Figure 2).
minutes. According to statistical analysis using Mann
Test
Another mechanism is locally inhibit impulse siklooksigenasi 1 and 2 in the peripheral tissues and the central
conduction myelinated nerve fibers C for corticosteroids nervous system. 9,11,12
work affects the speed of the nerve cell membrane Endogenous Steroids are part of the body's defense
synthesis lipoprotein. Corticosteroid molecules enter against things that damage cells. Center response to
cells then pass through the plasma membrane by inflammation is increased synthesis of cytokines that
passive diffusion. Corticosteroids are reacting with a activates the hypothalamic pituitary adrenal pathway
specific receptor protein in the cytoplasm of cells and resulting in increased synthesis of glucocorticoids.
formed a steroid receptor complex. The complex is Glucocorticoids will suppress the expression of
experiencing a change of formation, and then move cytokines acting on the target cells by means of negative
towards the nucleus and binds to chromatin. This bond feedback, then worked as an immunosuppressant
also stimulates transcription of RNA and synthesis of glucocorticoid to a variety of reactions in the immune
specific proteins. Induction of protein synthesis will system. 8-10
produce physiological effects of steroids. 8-11
necrosis factor,
interleukin-1, interleukin-2, interleukin-6, Inflammatory response, metabolic, hormonal, and
and also a decrease in the production of prostaglandins. immunologic result of the surgery will be activated
The decrease prostaglandins play a role in inhibiting pain immediately upon skin incision so as corticosteroids at
via suppression system the time
The immediate effects of corticosteroids applied 6. Philadelphia: Lippincott Williams and Wilkins Co.
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