A comparative study between the effect of verapamil versus nalbuphine as an adjuvant in supraclavicular brachial plexus block

Abstract

Background Brachial plexus block has substituted general anesthesia in the majority of patients planned for upper limb surgeries as it avoids the undesired effects of the medications used in general anesthesia as well as the stress response associated with airway manipulation. Opioid agonist–antagonists such as nalbuphine are used as adjuvant to improve the anesthetic properties of bupivacaine. Verapamil has an additive effect in brachial plexus blockade in the form of decreasing the consumption of analgesics in the postoperative period with reducing onset time and extending the duration of motor and sensory blockade. The aim of this study is to investigate the adjuvant effect of verapamil versus nalbuphine to 0.5% bupivacaine in brachial plexus block as regards onset, duration of sensory and motor blockade and postoperative analgesic augmentation. The study is randomized, prospective, double-blinded, comparative study where 90 patients subjected to arm, forearm and hand surgeries were randomized into three groups, group A received 30 ml of plain bupivacaine 0.5% plus 2 ml of normal saline, group B received 30 ml of bupivacaine 0.5% plus 2 ml verapamil equivalent to 5 mg, group C received 30 ml of bupivacaine 0.5% plus 10 mg of nalbuphine diluted in 2 ml of normal saline. Results Results of this study showed that group C and group B sensory block time onset was 7.25 ± 1.5 vs. 10.92 ± 3.84 min, P < 0.001 and was shorter than that in group A (13.2 ± 2.66 min). In addition, the motor block onset was (11.10 ± 1.24 vs. 13.50 ± 3.77 min, P < 0.001) shorter than group A (17.16 ± 1.30 min). In group C and group B, sensory block duration was 396 ± 32.17 vs. 355.83 ± 18.48 min, P < 0.001, respectively and was longer than that in group A (321.13 ± 25.08 min). Also, there was prolonged motor block duration in group C and group B recording (338.92 ± 25.2 vs. 302.93 ± 15.24 min, P < 0.001) and was longer than that in group A (280.70 ± 32.35 min). Time of demand of rescue analgesia dose was significantly long in group C and group B (449.53 ± 52.45 vs. 418.13 ± 41.12 min, P < 0.001) and was longer than group A (361.31 ± 21.42 min). Both verapamil and nalbuphine have additive effect to bupivacaine improving the all anesthetic parameters of the block. Conclusion Both drugs produce favorable enhancement of time onset and effective prolongation of duration of sensory and motor blockade and extend the period of postoperative analgesia with superiority to nalbuphine over verapamil.

A meta‐analysis showing the quantitative evidence base of perineural nalbuphine for wound pain from upper‐limb orthopaedic trauma surgery

“…Of these, seven were excluded because of irrelevant comparator (n = 5) and not being RCTs (n = 2). Subsequently, a total of 17 RCTs (1104 patients) were included in this systematic review and meta‐analysis 21,24‐39 . A flow chart for the filtering process of studies is depicted in Figure 1.…”

“…The 17 trials included a total of 1104 patients, among which 582 patients received nalbuphine as an adjuvant and 522 patients received placebo in context of BPB for upper extremity surgical procedures. For the method of nerve block localization, one study performed infraclavicular nerve block under ultrasound guidance, 21 two studies performed supraclavicular nerve block with nerve stimulation, 27,33 and the remaining 14 studies performed BPB through the supraclavicular approach using ultrasound guidance 24‐26,28‐32,34‐39 . The type and concentration of local anaesthetics were also varied: eight trials investigated the combination of nalbuphine with bupivacaine (0.375% or 0.5%), 21,25,30,33,35‐38 six with ropivacaine (0.5% to 0.75%), 26,29,31,32,34,39 one study added nalbuphine into bupivacaine (0.5%) and lidocaine (0.2%) mixture, 28 and 2 with levobupivacaine (0.25% or 0.5%) 24,27 .…”

“…Subsequently, a total of 17 RCTs (1104 patients) were included in this systematic review and meta‐analysis. 21 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 A flow chart for the filtering process of studies is depicted in Figure 1 .…”

“…For the method of nerve block localization, one study performed infraclavicular nerve block under ultrasound guidance, 21 two studies performed supraclavicular nerve block with nerve stimulation, 27 , 33 and the remaining 14 studies performed BPB through the supraclavicular approach using ultrasound guidance. 24 , 25 , 26 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 38 , 39 The type and concentration of local anaesthetics were also varied: eight trials investigated the combination of nalbuphine with bupivacaine (0.375% or 0.5%), 21 , 25 , 30 , 33 , 35 , 36 , 37 , 38 six with ropivacaine (0.5% to 0.75%), 26 , 29 , 31 , 32 , 34 , 39 one study added nalbuphine into bupivacaine (0.5%) and lidocaine (0.2%) mixture, 28 and 2 with levobupivacaine (0.25% or 0.5%). 24 , 27 Local anaesthetic solutions were injected in volumes ranging from 18 to 30 mL.…”

“… 24 , 27 Local anaesthetic solutions were injected in volumes ranging from 18 to 30 mL. Doses of perineural nalbuphine were varied from 10 to 20 mg, 21 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 38 , 39 except in one trial that administered perineural nalbuphine 0.1 and 0.2 mg/kg. 33 …”