الفهرس 
I. INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The effective relief of pain is a paramount importance for patients undergoing surgery. This should be achieved for humanitarian reasons, but there is now evidence that pain relief has significant physiological effects. Not only does effective pain relief means a smoother postoperative course with earlier discharge from hospital, but it may also reduce the onset of chronic pain syndromes.
The simplicity of the technique of spinal anaesthesia and its reliability has made it one of the preferred techniques in lower limb surgery. Unexpected early regression of spinal block or prolonged operation can cause intraoperative pain. Increasing the dose of local anesthetics, addition of opioids to local anesthetics for spinal anesthesia would be helpful for prolonging the spinal blockade and maintaining prolonged postoperative analgesia.
The aim of the present work was to compare the effect of nalbuphine versus fentanyl as adjuvants to intrathecal bupivacaine, as regard the post-operative analgesia, the hemodynamic stability, the onset of sensory/motor block and the duration of action in patients undergoing internal fixation of tibia.
The present study was carried out on 50 ASA I or II patients scheduled for internal fixation of tibia under spinal analgesia, categorized into two groups:
Group: F Patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 1 ml fentanyl (50μg).
Group: N Patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 1ml nalbuphine hydrochloride (1.6 mg).
Preoperative evaluation was done by complete history taking, physical examination and necessary laboratory investigations.
Before starting the spinal anaesthesia basic monitoring was applied to the patients including electrocardiogram (ECG), noninvasive blood pressure and pulse oxymetry. Baseline readings were measured before starting spinal anaesthesia.
Patients received a volume preload in the form of 10 mL/kg lactated Ringer’s solution, within 15 minutes, then they were placed in the sitting position and midline puncture was performed at L3-4 interspace using a 25 gauge spinal needle, After injection, the patient lied supine with the head resting on a pillow. Oxygen by nasal cannula was given at 5 L/min throughout the procedure.
Measurements
1) Demographic data: Age (yrs), sex, weight (kg) and Height (cm)
2) Hemodynamic parameters: heart rate (beats/min), mean arterial blood pressure (mmHg), was recorded as base line at 5 minutes before the intrathecal injection and then at 2, 4, 6, 8, 10, minutes, and then every 15 minutes till the end of the procedure.
3) Assessment of sensation: Time (in minutes) of the onset of sensory block at T10 dermatome, Time for 2 segment regression every 15 min determined by ice cold test.
4) Assessment of motor function: Time (in minutes) of onset of motor blockade from the end of intrathecal injection till the patient reached complete motor blockade (modified Bromage score 3), Duration of motor block was recorded from the time at which the patient reached complete motor blockade (modified Bromage score 3) to the time the patient was able to rise his/her legs in bed against gravity (modified Bromage score 0) every 30 min
5) Side effects: Incidence of peri-operative side effects including (hypotension, bradycardia, respiratory depression, pruritis, shivering, nausea and vomiting) will be noted.
6) Postoperative analgesia: duration of analgesia using visual analogue scale (VAS) in the immediate postoperative period, then every 2hours for the first 8hours, then every 6hours for the rest of the first 24hours, The time of the first request analgesia.
7) Total dose of IM diclofenac sodium was calculated.
The result of the present study showed that:
• There was no statistically significant difference between the two studied groups as regards age, weight, height and duration of surgery.
• In the two groups mean arterial blood pressure significantly decreased after spinal analgesia, but there was no significant difference between the two groups as regard heart rate and mean arterial pressure all over the study time.
• There was no significant difference between the two groups as regard onset, duration of sensory block and duration of motor block all over the study time.
• Onset of motor block was significantly earlier in group F than group N
• Duration of analgesia was significantly longer in group N when compared with group F
• There was no significant difference in time of the 1st request analgesia and total dose of diclofenac sodium between the two groups.
• In the two studied groups there was no cases experienced respiratory depression or bradycardia.
• As regard hypotension, shivering, pruritus, nausea and vomiting showed no significant difference between the two studied groups all over the study time