Published: 2016-12-21

Evaluation of intrathecal bupivacaine alone, bupivacaine with butorphanol and bupivacaine with dexmedetomidine for lower segment caesarean section: a randomized control trial

Ashem Jack Meitei, Okram Rubina, Laithangbam PKS, Joyshankar Singh I., Dilip Ingudum, Mithun Raj R.


Background: Following caesarean operation, a painless early ambulation is necessary to mother for caring of the neonate. Aim of the study is to compare more effective analgesic by intrathecal bupivacaine or combination with butorphanol or dexmedetomidine.

Methods: Ninety parturients undergoing elective caesarean section were randomly divided into three equal groups (n=30). Group B: received bupivacaine (0.5%) 2 ml + 0.5 ml of normal saline (NS); group BB, bupivacaine (0.5%) 2 ml + 25 mcg butorphanol in 0.5 ml NS and group BD, bupivacaine (0.5%) 2ml + 2.5 mcg of dexmedetomidine in 0.5 ml NS . Visual numerical rating scale (VNRS), heart rate, blood pressure, sensory and motor block levels, fetal outcome by Apgar score and umbilical cord blood pH, any side effects were noted.

Results: The onset time of modified Bromage 3 motor block was statistically significant among the groups (P=0.023) but not significant between Groups BB and BD (P=0.479). The regression time to reach modified Bromage 0 in group BD was significantly longer (P=<0.0001) than either of the groups B or BB but not significant between the later two groups (P=0.479). Time for 2-segment regression, sensory regression time to S1 dermatome and time for first rescue analgesia were significantly longer (P<0.001) in group BD but not significant between the groups B and BB. Sedation was significantly more in group BD (17/30 pts; P<0.001).

Conclusions: Addition of dexmedetomidine to spinal bupivacaine block in caesarean section increase the duration of analgesia and motor block with minimal side effect and no adverse effects on the babies.


Bupivacaine, Butorphanol, Dexmedetomidine, Caesarean Section, Spinal anaesthesia

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Combic C.R, Wong C.A. Labour analgesia and systemic outcomes, British J Anaesth. 2010;105(suppl 1):150-60.

Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Bellivean P. Epidural analgesia enhances functional exercise capacity and health related quality of life after colonic surgery: Results of a randomized trial. Anaesthesiology. 2002;97:540-9.

Sethi B.S, SWamuel M, Sreevastava D. Efficacy of analgesic effects of low dose intrarthecal clonidine as adjuvant to bupivacaine. Indian Journal of Anaesthesia. 2007;51(5):415-9.

Gantier PE, De Kock M, Fanard L, Van Steenberg A, Hody JL. Intrathecal clonidine combined with sufentanil for labour analgesia. Anaesthesiology. 1998;88:651-6.

Mercier FJ, Dounas M, Bouaziz H, Fischler M, Foiret C, Vestermann MN, et al. The effect of adding a minidose of clonidine to intrathecal sufentanil for labour analgesia. Anaesthesiology. 1988;89(3):594-601.

Benhamou D, Thorin D, Brichant JF, Dailland P, Milon D, Schneider M. Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during caesarean section. Anaesth Analg. 1998;87:609-13.

Gupta R, Bogra J, Verma R, Kohli M, Kushwaha JK, Kumar S. Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia. Ind J Anaesth 2011;55(4):347-51.

Al-Ghanem SM, Massad IM, Al-Mustafa MM, Al-Zaben KR, Qudaisat IY, Qatawneh AM, et al. Effect of adding dexmedetomidine versus fentanyl to intrathecal bupivacaine on spinal block characteristics in gynaecological procedures: a double blind controlled study. Am J of AppldSc. 2009;6(5):882-7.

Weinbroum AA, Ben-Abraham R. Dextromorphan and dexmedetomidine : new agents for the control of perioperative pain. Eur J of Surg. 2001;167(8):563-9.

Mattingly JE, D’ Allesio J, Ramanathan J. Effects of obstetric analgesics and anaesthetics on the neonate: a review. Paediatr Drugs. 2003;5:615-27.

Karaman S, Evren V, Firat V, Cankayali I. The effects of dexmedetomidine on spontaneous contractions of isolated gravid rat myometrium. Advc Therapy. 2006;23:238-43.

Toyoma H, Wagasutma T, Ejima Y, Matsubara M, Kurosawa S. Caesarean section and pulmonary hypertension : the role of intravenous dexmedetomidine. Int J Obstet Anaesth. 2009;18:262-7.

El-Tahan MR, Mowafi HA, Al Sheikh IH, Khidr AM, Al-Juhaiman RA. Efficacy of dexmedetomidine in suppressing cardiovascular and hormonal responses to general anaesthesia for caesarean section: a dose response study. Int J Obstet Anaesth. 2012;21:222-9.

Fyneface-Ogan S, Job O. Gogo, Enyindah C. E. Comparative effects of single shot intrathecal bupivacaine with dexmedetomidine and bupivacaine with fentanyl on labour outcome. ISRN Anaesth. 2012:ID 816984.

Lawhorn CD, McNitt JD, Fibuch EE, Joyce JT, Leadley RJ. Epidural morphine with butorphanol for postoperative analgesia after caesarean delivery. Anaesth Analg. 1991;72:53-7.

Chari VRR, Goyal AA, Singh V. A study of addition of injection butorphanol to hyperbaric injection bupivacaine given intrathecally to patients undergoing lower segment caesarean section: a randomized controlled trial. Med J of Dr. DY Patil Univ. 2013;6(2):156-60.

Kaur M, Katyal S, Kathuria S, Singh P. A comparative evaluation of intrathecal bupivacaine alone, sufentanil or butorphanol in combination with bupivacaine for endoscopic urological surgery. Saudi J Anaesth. 2011;5:202-7.

Beilin Y, Hossain S, Bodian CA. The numerical rating scale labour epidural analgesia. Anaesth Analg. 2003;96:1794-8.

Bromage PR. A comparison of the hydrochloride and carbondioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anesthesiol Scan. 1965;16:55-9.

Chernik DA, Gillings D, Laine H, Hendler J, Silver JM, Davidson AB, et al. Validity and reliability of the Observer’s Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990;10:244-51.

Kalso E, Poyhia R, Rosemberg P. Spinal antinociceptive by dexmedetomidine, a highly selective alpha-2 adrenergic agonist. Pharmacol Toxicol. 1991;68:140-3.

De Kock M, Gantier P. Intrathecal Ropivacaine and Clonidine for ambulatory Knee arthroscopy-A dose –response study. Anesthesiology. 2001.

Kanazi GE, Avirad MT, Jabour-Khoury SI, Al Jazzar MM, Alameddine, Al-Yaman, Bulloul RM, Bakara AS. Effect of low dose dexmedetomidine or Clonidine on the characteristics of bupivacaine spinal block. Acta Anesthesiol Scand. 2006;50:117-222.

Sing V, Gupta LK, Singh GP. Comparison among intrathecal fentanyl or butorphanol in combination with bupivacaine for lower limb surgeries. J Anesth Clin Pharmacol. 2006;22:371-5

Al- Mustafa MM, Abu- Halweh SA, Aloweidi AS, Murshidi MM, Ammari BA, Awwad ZM, et al. Effect of dexmedetomidine added to spinal bupivacaine for urological procedure. Saudi Med J. 2009;30:365-70.

Eid Hea, Shafie MA, Youssef H,. Dose related prolongation of hyperbaric bupivacaine spinal anaesthesia by dexmedetomidine. Ain Shams J Anaesthesiol. 2011;4:83-95.

Mahendru V, Tiwari A, Katyal S, Grewal A, Singh MR and Katyal RA. A comparison of intrathecal dexmedetomidine, clonidine and fentanyl as adjuvants to hyperbaric bupivacaine for lower limb surgery: A double blind controlled study. J Anaesthesiol Clin Pharmacol. 2013;29:496-502.

Klimscha W, Chiari A. Hemodynamic and analgesic effects of clonidine added repetitively to continuous epidural and spinal blocks. Anesth Analg. 1995;80(2):322-7.

Van Tuijl I, Van Klei WA, Van der Werff DBM and Kalkman CJ. The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain and morphine requirements after Caesarean section: a randomized controlled trial. Br J Anaesth. 2006;97:365-70.

Eisenach JC, De Kock M, Klimscha W. Alpha2 Adrenergic Agonists for Regional Anesthesia: A Clinical Review of Clonidine (1984-1995). Anesthesiology. 1996;85:655-74.

Harada Y. Nishika K, Kitahata LM, Kishikawa K, Collins JG. Visceral antinociceptive effects of spinal clonidine combined with morphine enkephalin, or U50, 488H. Anesthesiology. 1995;83:344-52.

Wang JK, Nauss LA, Thomas JK. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979;50:149-51.

Kuusneimi KS, Pihlajamaki KK, Pitkanen MT, Helenius HY, Kirvela OA. The use of inj Bupivacaine and fentanyl for spinal anesthesia for urologic surgery. Anesth Analg 2000; 91: 1452-6.

Tejwani GA, Rattan AK, McDonald JS. Role of spinal opiod receptors in the antinociceptive interactions between intrathecal morphine and bupivacaine. Anesth Analg. 1992;76:91-9.

Akerman B, Arwestron E, Post C. Local anaesthetics potentiate spinal morphine antinociception. Anesth Analg. 1988;67:943-8.