D

N
A
E
N
I
D
I
N
O
L
C
L
A
H
C
E
T
A
R
T
N
I
E
S
O
LOW D
C
I
R
A
B
R
E
P
Y
H
O
FENTANYL ADDED T
N
I
A
I
S
E
G
L
A
N
A
S
G
N
O
L
O
R
P
E
N
I
A
C
A
V
BUPI
Y
R
E
G
R
U
S
L
A
C
I
G
GYNECOLO
TALWAR
NA
DA
AN
V
,
A
PR
HO
C
GE AND
JA
LE
O
OL
PO
C
AL
IC
ED
M
IR
AV
AH
RE, VARDHMAN M
A
C
E
IV
NS
TE
IN
ND
A
IA
ES
DEPARTEMENT OF ANAESTH
ELHI, INDIA
D
EW
N
,
AL
IT
SP
O
H
G
AN
RJ
SAFDA

INTRODUCTION
The study was planned to ascertain if a small dose
of clonidine (30 mcg) when added to a bupivacainefentanyl mixture improves spinal analgesia, without
producing side effects, as compared to a
bupivacaine-fentanyl or a bupivacaine-clonidine
mixture.

Haemodynamic profile

Onset and Level of

Sensory Blockade

Duration of Analgesia

Intraoperative and
Postoperative Pain
Score

Side effects and

sedation

MATERIAL
AND
METHODS

Obtaining Ethic Approval

Prospective Double Blind Randomize Study

Inclusion and exclusion criteria

Patients were randomly allocated to receive either Bupivacaine
Fentanyl (Group BF), Bupivacaine Clonidine (Group BC), Bupivacaine
Fentanyl Clonidine (Group BFC)

INCLUSION CRITERIA
75 FEMALE PATIENTS ASA (AMERICAN SOCIETY OF
ANESTHESIOLOGIST) GRADE I-II, AGED BETWEEN 45-65 YEARS,
WHO WERE SCHEDULED FOR VAGINAL HYSTERECTOMY WITH
PELVIC FLOOR REPAIR OR NON DESCENT VAGINAL HYSTERECTOMY
UNDER SPINAL ANAESTHESIA.

EXCLUSION CRITERIA
PATIENT REQUIRED GENERAL ANESTHESIA IN THIS STUDY DUE TO
MAJOR DISCOMFORT

 GROUP BF: 0.5% HYPERBARIC BUPIVACAINE (2.3 ML) AND FENTANYL (15 MCG)
WITH SALINE 0.2 ML

GROUP BC

: 0.5% HYPERBARIC BUPIVACAINE (2.3 ML) AND CLONIDINE (30

MCG) WITH SALINE 0.3 ML

GROUP BCF

: 0.5% HYPERBARIC BUPIVACAINE (2.3 ML) AND FENTANYL (15

MCG)

AND CLONIDINE (30 MCG) WITH SALINE 0.2 ML

Premedication
Oral Alprazolam 0.25 mg (night
and 2 hours prior to surgery

SAB
Patients were randomly assigned
to one of three groups
SAB was performed in the L3-L4 or
L4-L5 interspace using 25G Quinke
spinal needle in the lateral
position

RESULTS

PATIENT CHARACTERISTIC
Height (cm)
Weight (kg)
Age (years)
Surgery duration
(minutes)

Group BF
N=25

Group BC
N=25

Group BCF
N=25

153 4
50 4.4
46.2 8.6
127.8 25.7

154 4
53.5 8.8
51.6 8.2
112.8 26.4

157 5
59.6 7.6
43.5 7.4
108 35.7

ANALGESIC DATA
Variables

Group BF
N=25

Group BC
N=25

Group BCF
N=25

15 2

16 2

17 2

Onset of sensory block (minutes)

17.2 5.4

10.48 4.2

12.88 4.1

Intraoperative pain (% of patients)

40 (n=10)

12 (n=3)

75 30

95 56

111 30

Dermatomal Spread after intratechal

injection (dermatomes blocked)

Regresion to two segment (minutes)

ANALGESIC DATA
Variables

Group BF
N=25

Group BC
N=25

Group BCF
N=25

142.2 14.7

177.8 43.8

221 33.3

Duration of effective analgesia (minutes)

176 40.8

323 99.5

426 152

Number of diclofenac injection in 24

hours

2.66 (2-3)

1.16 (1-2)

1.06 (1-2)

Duration of sensory block (minutes)

INTRAOPERATIVE PARAMETERS
Intraoperative Variables

Group BF
N=25

Group BC
N=25

Group BCF
N=25

Duration of motor block (minutes, mean

SD)

142.2 14.7

177.8 43.8

221 33.3

Nausea and Vomitting (% of patients)

176 40.8

323 99.5

426 152

Shivering (% of patients)

2.66 (2-3)

1.16 (1-2)

1.06 (1-2)

Sedation (% of patients)

12 (n=3)

88 (n=2)

20 (n=5)

DISCUSSION

CLONIDINE - MECHANISM OF ACTION

PREDOMINANTLY ALPHA 2 ADRENERGIC AGONIST ACTIVITY
DECREASE SYMPATHETIC ACTIVITY, SYSTEMIC VASCULAR RESISTANCE, HEART RATE,
BLOOD PRESSURE

ENHANCE PARASYMPATHETIC TONE

REDUCE CIRCULATING CATHECOLAMINE
ITS ANALGETIC EFFECT ARE MEDIATED ENTIRELY VIA PRE AND POST SYNAPTIC ALPHA 2
ADRENERGIC RESEPTOR THAT BLOCK NOCICEPTIVE TRANSMISSION

ANTIHYPERTENSIVE ACTION OCCURS VIA BINDING TO A NONADRENERGIC

(IMIDAZOLINE) RECEPTOR

Morgan 5th ed. P: 287-288

CLONIDINE - CLINICAL USES

ANTIHYPERTENSIVE AGENT
ADJUNCT FOR EPIDURAL, CAUDAL, PERIPHERAL NERVE BLOCK
USED IN THE MANAGEMENT OF PATIENT WITH CRONIC NEUROPATHIC PAIN

Morgan 5th ed. P: 287-288

THE STUDY FOUND THAT :

1. DERMATOMAL SPREAD TO BE WIDER

2. TIME OF ONSET OF ANALGESIA TO BE SIGNIFICANTLY LESS
3. DURATION OF EFFECTIVE ANALGESIA, DURATION OF SENSORY AND
MOTOR BLOCK AND TIME TO TWO SEGMENT REGRESSION WERE
SIGNIFICANTLY MORE

4. INCIDENCE OF INTRAOPERATIVE PAIN AND REQUIREMENT OF

POSTOPERATIVE ANALGESICS TO BE SIGNIFICANTLY LESS

5. 30 MCG OF CLONIDINE MIGHT NOT PRODUCE SIGNIFICANT

HEMODYNAMIC EFFECTS

CONCLUSION

30 MCG OF CLONIDINE ADDED TO BUPIVACAINE AND FENTANYL

INCREASED THE DURATION OF EFFECTIVE ANALGESIA AS WELL AS
THE DURATION OF SENSORY AND MOTOR BLOCK, AS COMPARED TO
BUPIVACAINE-FENTANYL AND BUPIVACAINE-CLONIDINE
COMBINATIONS, WITHOUT CAUSING ANY SIGNIFICANT
HEMODYNAMIC SIDE EFFECTS.

CRITICAL APPRAISAL
P : 75 female patients ASA grade I-II, aged between
45-65 years, scheduled for vaginal hysterectomy
with pelvic floor repair or non descent vaginal
hysterectomy under spinal anaesthesia
I : Hyperbaric bupivacaine + clonidine + fentanyl
C : hyperbaric bupivacaine + fentanyl and
hyperbaric
bupivacaine + clonidine
O : duration of analgesic

THERAPY WORKSHEET

Was the assignment of patients to treatments

randomised?
Was the randomisation list concealed?

Yes

Was follow-up of patients sufficiently long and

complete?

Yes

Were all patients analysed in the groups to

which they were randomised?

Yes

Were patients and clinicians kept blind to

treatment?

Yes

Were the groups treated equally, apart from the

experimental treatment?

Yes

Were the groups similar at the start of the trial?

Yes

Are the results of this single preventive or therapeutic trial valid?

Can you apply this valid, important evidence about

therapy in caring for your patient?
Do these results apply to your patient?
Is your patient so different from those

No

in the study that its results cannot

apply?
Is the treatment feasible in your
setting?

Yes

Are your patients values and preferences satisfied by the

regimen and its consequences?
Do your patient and you have a clear
assessment of their values and
preferences?

Yes

Are they met by this regimen and its

consequences?

Yes

CONCLUSION

THIS JOURNAL VALID AND

APPLICABLE

CLONIDINE

MECHANISM OF ACTION
PREDOMINANTLY ALPHA 2 ADRENERGIC AGONIST ACTIVITY
DECREASE SYMPATHETIC ACTIVITY, SYSTEMIC VASCULAR RESISTANCE, HEART RATE, BLOOD PRESSURE
ENHANCE PARASYMPATHETIC TONE
REDUCE CIRCULATING CATHECOLAMINE
ITS ANALGETIC EFFECT ARE MEDIATED ENTIRELY VIA PRE AND POST SYNAPTIC ALPHA 2 ADRENERGIC
RESEPTOR THAT BLOCK NOCICEPTIVE TRANSMISSION

ANTIHYPERTENSIVE ACTION OCCURS VIA BINDING TO A NONADRENERGIC (IMIDAZOLINE) RECEPTOR

Morgan 5th ed. P: 287-288

CLINICAL USES
ANTIHYPERTENSIVE AGENT
ADJUNCT FOR EPIDURAL, CAUDAL, PERIPHERAL NERVE BLOCK
USED IN THE MANAGEMENT OF PATIENT WITH CRONIC NEUROPATHIC PAIN

Morgan 5th ed. P: 287-288

SIDE EFECTS
SEDATION
DIZZINESS
BRADYCARDIA
DRY MOUTH
Morgan 5th ed. P: 287-288

DOSAGE
STARTED AT 30 MCG/H IN A MIXTURE WITH AN OPIOID OR A LOCAL ANESTHETIC
ORAL : 30-60 MINUTES ONSET, AND LAST 6-12H
ACUTE HYPERTENSION : 0.1 MG/HOUR, MAXIMUM 0.6MG, MAINTENANCE DOSE 2 X 0.1-0.3MG
METABOLIZED BY THE LIVER AND EXCRETED RENALLY

Morgan 5th ed. P: 287-288

DRUGS INTERACTION