Anaesthetic Efficacy of Nalbuphine as an Adjuvant to Ropivacaine in Ultrasound Guided Supraclavicular Brachial Plexus Blockade: ARandomised Controlled Trial

Abstract

Introduction: Ultrasonography (USG) guided supraclavicular block is an excellent choice for upper limb surgeries. It not only allows smaller volumes of local anaesthetic usage but also provides optimal tourniquet coverage. Ropivacaine is structurally related to bupivacaine with reduced potential for toxicity and improved sensory and motor blocking profiles. Nalbuphine acquired a significant place in pain control but its efficacy as a local anaesthetic adjuvant is yet to be proved in peripheral nerve blockades. Aim: To evaluate the efficacy of adding nalbuphine to ropivacaine in supraclavicular brachial plexus blockade and to assess the quality of block for patients undergoing ambulatory forearm and hand surgeries. Materials and Methods: Seventy American Society of Anesthesiologists (ASA) grade 1 and 2 patients were randomised into two groups of 35 each. Group A (n=35): received 24 mL of 0.5% of ropivacaine + 1 mL of nalbuphine (10 mg) and Group B (n=35): received 24 mL of 0.5% of ropivacaine + 1 mL of normal saline. The parameters observed were duration of analgesia, onset of sensory and motor blockade, duration of motor blockade and haemodynamic changes during the procedure. Categorical variables were analysed using the Pearson’s Chi‑square test. Continuous variables were analysed using the independent sample t‑test and p<0.05 was considered as statistically significant. Results: The onset of sensory and motor blockades were faster in the nalbuphine group compared to the control group (p<0.001). The duration of sensory and motor blockades was similarly longer in nalbuphine group (p<0.001). Also, the mean duration of analgesia was significantly longer with nalbuphine group (p<0.001). Conclusion: Nalbuphine significantly prolonged the duration of analgesia and duration of block while accelerating the onset of blockade thereby improving the overall quality of blockade.

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.…”

“…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 …”

“…All studies adequately described the randomization of methods and were rated as having low risk of selection bias. However, only eight studies 21 , 24 , 25 , 30 , 32 , 36 , 38 , 39 provided sufficient details in concealed allocation with a low risk of bias, the remaining nine studies 26 , 27 , 28 , 29 , 31 , 33 , 34 , 35 , 37 were rated as having unclear risk of bias due to without sufficient details. With regard to blinding, 13 studies 25 , 26 , 27 , 28 , 30 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 mentioned the blinding of participants and investigators, and were rated as low risk of performance and detection bias.…”