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A COMPARIVE STUDY OF LIGNOCAINE V/S LIGNOCAINE WITH BUTORPHANOL IN CLOSED FRACTURES BY PERIOSTEAL BLOCK :

A COMPARIVE STUDY OF LIGNOCAINE V/S LIGNOCAINE WITH BUTORPHANOL IN CLOSED FRACTURES BY PERIOSTEAL BLOCK DR S SREENIVASARAO MD,CCPPM ASST PROFESSOR DEPT OF ANAESTHESIA SVRRGGH & SVMC TIRUPATI 1

RECORD BREAKING—1MILLION IDEA CONNECTIONS SOLD IN JUST ONE DAY DUE TO ONE SIMPLE PRINTING MISTAKE OF ONE WORD IN IDEA SLOGAN:

RECORD BREAKING—1MILLION IDEA CONNECTIONS SOLD IN JUST ONE DAY DUE TO ONE SIMPLE PRINTING MISTAKE OF ONE WORD IN IDEA SLOGAN 2 OUR IDEA CAN CHANGE YOUR (L)WIFE

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INTRODUCTION:

INTRODUCTION CLOSED REDUCTION OF FRACTURES IS A COMMON PROCEDURE IN CASUALITY IV SEDATION AND ANALGESIA SINCE LAST FEW DECADES, PERIPHERAL NERVE BLOCKS FOR THESE KINDS OF PROCEDURES HAVE COME INTO PRACTICE 4

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MINIMAL SEDATION, NO AIRWAY OBSTRUCTION, MORE COMFORTABLE FOR THE PATIENT, PROVIDES POSTOP ANALGESIA 5

CONTINUOUS INFUSION OF LOCAL ANESTHETIC AND OPIOID TO A STERNAL FRACTURE SITE USING A PERIOSTEALLY POSITIONED CATHETER LED TO SUCCESSFUL ANALGESIA .:

CONTINUOUS INFUSION OF LOCAL ANESTHETIC AND OPIOID TO A STERNAL FRACTURE SITE USING A PERIOSTEALLY POSITIONED CATHETER LED TO SUCCESSFUL ANALGESIA . 1 -Duncan MA, McNicholas W, O'Keeffe D, O'Reilly M. Reg Anesth Pain Med. 2002 May-Jun;27(3):316-8 6

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THE EFFICACY AND SAFETY OF THE HEMATOMA BLOCK FOR FRACTURE REDUCTION IN CLOSED, ISOLATED FRACTURES. PAIN DIFFERNTIAL SCORE 0.8 FOR HB GROUP AND 2.7 FOR NON HB GROUP Furia J P, Alioto R J, Marquardt J D. ORTHOPEDICS 1997 MAY; 20(5): 423-6 7

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ANALGESIA FOR THE REDUCTION OF COLLES FRACTURE. A COMPARISON OF HEMATOMA BLOCK AND INTRAVENOUS SEDATION PAIN SCORE DURING REDUCTION FOR HB GROUP WERE ACCEPABLY LOW <W(MEDIAN 1.8) AND IV SEDATION UNACCEPTABLY HIGH >3(MEDIAN 8.7) Singh G K, Manglik R K, Lakhtakia P K, Singh Online J Curr Clin Trials 1992 Oct 1; Doc No.23 8

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THE EFFICACY OF THE HEMATOMA BLOCK FOR FRACTURE REDUCTION IN THE DISTAL FOREARM FRACTURES: A DOUBLE BLIND RANDOMIZED CONTROLLED TRIAL – SURAJ BAJRACHARYA ET AL PAIN DURING REDUCTION- SAME IN HB GROUP AND BPB GROUP QUALITY OF REDUCTION WAS FOUND TO BE MORE IN HB GROUP COMPARITIVELY TO BPB GROUP COMPLICATIONS WERE NILL IN HB GROUP BUT IN BPB GROUP 1/50 DEVELOPED BRONCHOSPASM NEEDING INTUBATION &ICU CARE THE INTERNET JOURNAL OF ANESTHESIOLOGY™ ISSN: 1092-406X 9

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Peripheral opioid receptors: a new therapeutic concept to target inflammation- Christoph Stein, 12200 Berlin, Germany PERIPHERAL OPIOID RECEPTORS ARE LOCALIZED ON PRIMARY AFFERENT NEURONS. THE CELL BODIES OF THESE NEURONS IN DORSAL ROOT GANGLIA EXPRESS MU-, DELTA- AND KAPPA-OPIOID RECEPTOR mRNAS AND PROTEINS (STEIN ET AL. 2003; PÜHLER ET AL. 2004; 2006). OPIOID RECEPTORS ARE INTRAAXONALLY TRANSPORTED INTO THE NEURONAL PROCESSES (HASSAN ET AL. 1993; MOUSA ET AL. 2001) THEY ARE DETECTABLE ON PERIPHERAL SENSORY NERVE TERMINALS IN ANIMALS (STEIN ET AL. 1990) AND IN HUMANS (STEIN ET AL. 1996) 10

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‘POSTOPERATIVE ANALGESIA AFTER INCISIONAL INFILTRATION OF BUPIVACAINE V/S BUPIVACAINE WITH BUPRENORPHINE’ ADDING OF BUPRENORPHINETO LOCAL ANAESTHETICS CAN SIGNIFICANTLY ENHANCE THE QUALITY OF POST-OP ANALGESIA Tanu r mehta,Been k parikh,Guruprasad et al Journal Of Anaesthesiology Clinical Pharmacology,April -June 2011,Vol 27,Issue 2 11

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COMPARISON OF TWO DIFFERENT STRENGTHS OF BUPRENORPHINE ADDED TO LOCAL ANAESTETICS PRE-EMPTIVELY IN SUPRACLAVICULAR BLOCK: DOES IT ACT CENTRALLY OR PERIPHERALLY? THE ADDITION OF BUPRENORPHINE TO LA PROVIDES BETTER POSTOP ANALGESIA IN TERMS OF DURATION & QUALITY IN COMPARED TO IM BUPRENORPHINE BPRENORPHINE PROLONGS THE ANALGESISA WITH LESSER SIDE EFFECTS COMPARITIVE TO IM BUPRENORPHINE minnu m panditrao,binil et all INDIAN JOURNAL OF PAIN jan-april2011;25;32-38 12

AIM:

AIM TO COMPARE THE EFECTIVENESS OF ANALGESIA BY INFILTRATING PLAIN LIGNOCAINE AND LIGNOCAINE WITH BUTARPHANOL NEAR FRACTURE SITE, IN TERMS OF VAS SCORES REQUIREMENT OF OTHER ANALGESICS SEDATION LEVELS 13

PERIOSTEAL BLOCK:

PERIOSTEAL BLOCK 14

INCLUSION CRITERIA:

INCLUSION CRITERIA ASA-1, ASA-2 GRADE PATIENTS 15-75 Years of age CLOSED FRACTURES ONLY 15

EXCLUSION CRITERIA:

EXCLUSION CRITERIA PATIENTS NOT WILLING FOR THE PROCEDURE AGE <15YRS, ASA 3 & 4 PATIENTS OPEN FRACTURES INFECTED WOUNDS ON THE FRACTURE & CRUSHED WOUNDS 16

METHODOLOGY:

METHODOLOGY PREANAESTHETIC EVALUATION HISTORY CLINICAL EXAMINATION INVESTIGATIONS 17

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PREPARATION OF THE PATIENT PROCEDURE EXPLAINED TO THE PATIENT IV ACCESS SECURED MONITORS PULSE OXYMETER NIBP 18

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PREMEDICATION Inj.MIDAZOLAM-0.03mg/kgbw Inj.RANITIDINE 50mg Inj.ONDANSETRAN 4mg 19

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LIGNOCAINE 2% 2CC FOR LOCAL INFILTRATION LIGNOCAINE 1% FOR BLOCK IN GROUP-X LIGNOCAINE WITH BUTORPHANOL 1mg FOR BLOCK IN GROUP-XB RESUSCITATION DRUGS & EQUIPMENT 20

PROCEDURE:

PROCEDURE WE DEVIDED ONE HUNDRED PATIENTS IN TO TWO GROUPS GROUP-X PATIENTS WERE INFILTRATED WITH PLAIN LIGNOCAINE 1% 10 cc GROUP-XB PATIENTS WERE INFILTRARED WITH PLAIN LIGNOCAINE 1% 10cc WITH 1mg OF BUTORPHANOL 21

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PAIN WAS ASSESSED BY VAS PATIENT POSITIONED IN SUPINE OR POSITION COMFORTABLE TO THE PATIENT BLOCK SITE PAINTED WITH POVIDONE IODINE AND COVERED WITH STERILE DRAPES LOCATE THE FRACTURE SITE BY PEAK TENDERNESS & FEELING OF CREPITUS 22

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2ml of 2% LIGNOCAINE WAS INJECTED ALONG THE PATHWAY OF INJECTION 10mL 1%LIGNOCAINE WAS TAKEN IN A 10mL SYRINGE TO INFILTRATE TO GROUP-X PATIENTS & 10mL 1%LIGNOCAINE WITH 1mg BUTORPHANOL FOR GROUP-XB PATIENTS 23

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NEEDLE WAS PLACED AT THE FRACTURE SITE WHICH WAS DETERMINED BY NEEDLE SLIDES IN TO THE FRACTURE SITE INJECT THE DRUG IN TO THE FRACTURE SITE ASSESS THE PAIN BY VAS FOR EVERY TEN MINUTES IN FIRST HOUR AFTER THAT HOURLY UP TO THE RESCUE DOSE OF ANALGESIA REQUIRED 24

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RESULTS 34

Table 1: DEMOGRAPHIC DATA:

Table 1: DEMOGRAPHIC DATA GROUP-X GROUP-XB p VALUE NO OF PATIENTS 50 50 AGE IN YEARS (MEAN±SD) 40.6±11.3 38.5±11.3 P =0.12(NS) WEIGHT IN KG (MEAN±SD) 58.6±9.80 56.3±8.23 P=0.19(NS) DURATION OF BLOCKADE (HOURS) (MEAN±SD) 4.18±1.02 12.30±2.00 P<0.001(S) 35

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DURATION OF BLOCKADE - COMPARISION 36

DURATION IN UPPER LIMBS:

DURATION IN UPPER LIMBS GROUP NO OF PATIENTS DURATION (MEAN±SD) P VALUE GROUP X 26 4.26±0.96 GROUP XB 27 12.33±1.46 P<0.001(S) 37

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DURATION IN UPPER LIMBS 38

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DURATION IN LOWER LIMBS GROUP NO OF PATIENTS DURATION (MEAN±SD) P VALUE GROUP X 24 4.08±1.09 GROUP XB 23 12.26±2.52 P<0.001(S) 39

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DURATION IN LOWER LIMBS 40

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COMPLICATIONS 1.SEDATION 2.INADEQUATE BLOCKADE 41

COMPLICATIONS- SEDATION:

COMPLICATIONS- SEDATION DROWSINESS AFTER 5 MINUTES OF GIVING THE BLOCK SEEN IN GROUP-XB PATIENS ONLY THIS MAY BE DUE TO BUTARPHANOL THIS DOESN’T NEED ANY TREATMENT 42

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COMPLICATIONS RAMSAY SEDATION SCORE 43

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SECOND WAS INADEQUATE BLOCKADE IN ONE PATIENT OF GROUP-XB ONLY WE GAVE THE RESCUE ANALGESIC DOSE TO MANAGE THE INADEQUATE BLOCK 44

CONCLUSIONS :

CONCLUSIONS INJECTING PLAIN LIGNOCAINE & LIGNOCAINE WITH BUTARPHANOL INTO THE PERIOSTEAL SITE OF CLOSED FRACTURES PROVIDES PROLONGED ANALGESIA WAS NOTED IN GROUP-XB(10-16HRS) IN COMPARIVE TO GROUP-X (3-5HRS) STRONGLY SUPPORTS THE EXISTANCE OF PERIPHERAL OPIOID RECEPTORS TWO COMPLICATIONS -- SEDATION AND INADEQUATE BLOCKADE 45

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47 WHAT TRAUMA VICTIM DEMANDS FIRST IS… FREEDOM FROM PAIN

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