1  

EFFECT OF ADDING DEXMEDETOMIDINE vs FENTANYL TO

INTRATHECAL BUPIVACAINE ON SPINAL BLOCK

CHARACTERISTICS IN GYNECOLOGICAL PROCEDURES:

DOUBLE BLINDED CONTROL STUDY

Dissertation submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY

in partial fulfillment for the award of the degree of

DOCTOR OF MEDICINE

IN ANAESTHESIOLOGY

BRANCH X

INSTITUTE OF ANAESTHESIOLOGY & CRITICAL CARE

MADRAS MEDICAL COLLEGE

CHENNAI – 600 003.

APRIL 2017

  

CERTIFICATE OF GUIDE   

 This is to certify that the dissertation entitled, “EFFECT OF ADDING

DEXMEDETOMIDINE vs FENTANYL TO INTRATHECAL

BUPIVACAINE ON SPINAL BLOCK CHARACTERISTICS IN

GYNECOLOGICAL PROCEDURES: DOUBLE BLINDED

CONTROL STUDY” Submitted by Dr. Sivashankari K in partial fulfillment

for the award of the degree of Doctor of Medicine in Anaesthesiology by the

Tamilnadu Dr. M.G.R. Medical University, Chennai is bonafide record of the

work done by her in the INSTITUTE OF ANAESTHESIOLOGY & CRITICAL

CARE, Madras Medical College, during the academic year 2014-2017.

  

Date:

Place : Chennai

 

 

PROF. DR. B.CHANDRIKA,M.D., D.A. PROFESSOR

DEPARTMENT OF ANAESTHESIOLOGY,

INSTITUTE OF OBSTETRICS AND

GYNAECOLOGY,EGMORE,

CHENNAI – 600 005

  

CERTIFICATE   

 This is to certify that the dissertation entitled, “EFFECT OF ADDING

DEXMEDETOMIDINE vs FENTANYL TO INTRATHECAL

BUPIVACAINE ON SPINAL BLOCK CHARACTERISTICS IN

GYNECOLOGICAL PROCEDURES: DOUBLE BLINDED

CONTROL STUDY” Submitted by Dr. Sivashankari K in partial

fulfillment for the award of the degree of Doctor of Medicine in

Anaesthesiology by the Tamilnadu Dr. M.G.R. Medical University, Chennai

is bonafide record of the work done by her in the INSTITUTE OF

ANAESTHESIOLOGY & CRITICAL CARE, Madras Medical College,

during the academic year 2014-2017.

PROF DR. B.KALA,M.D;D.A  THE DIRECTOR,

 INSTITUTE OF ANAESTHESIOLOGY & CRITICAL CARE

MADRAS MEDICAL COLLEGE CHENNAI – 600 003.

DR.M.K. MURALITHARAN M.S, MCH  DEAN,

 MADRAS MEDICAL COLLEGE &

GOVT. GENERAL HOSPITAL,

CHENNAI – 600 003. 

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DECLARATION

I, Dr. K.Sivashankari, solemnly declare that the dissertation “EFFECT OF

ADDING DEXMEDETOMIDINE vs FENTANYL TO INTRATHECAL

BUPIVACAINE ON SPINAL BLOCK CHARACTERISTICS IN

GYNECOLOGICAL PROCEDURES: DOUBLE BLINDED CONTROL

STUDY” is a bonafide work done by me in the Institute of Anaesthesiology and

Critical Care , Madras Medical College, Chennai, after getting approval from the

Ethical Committee, under the able guidance of Prof.Dr. B.Chandrika, MD.DA,

The Institute of Obstetrics and Gynaecology, Egmore, Chennai. This study was

conducted in Institute of Obstetrics and Gynaecology, Chennai, in partial fulfillment

of the regulations for the award of the degree of M.D (Anaesthesiology),

examination to be held in April 2017.

I have not submitted this dissertation previously to any journal or any university for

the award of any degree or diploma.

DATE : PLACE : CHENNAI DR.K.SIVASHANKARI

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ACKNOWLEDGEMENT   

 On completion of my dissertation I would like to acknowledge all those

who have made this possible.

I am extremely thankful to Dr. M.K.MURALITHARAN MS, MCH

Dean, MADRAS MEDICAL COLLEGE, for his kind permission to carry out this

study.

I am immensely grateful to PROF. D R . B.KALA, M.D, D.A, Director &

Professor, INSTITUTE OF ANAESTHESIOLOGY & CRITICAL CARE, for her

concern and support in conducting this study.

I am extremely grateful and indebted to my guide PROF. Dr.

B.CHANDRIKA M.D, D.A, Professor of Anaesthesiology, INSTITUTE OF

OBSTETRICS AND GYNAECOLOGY, for her concern, inspiration, meticulous

guidance, expert advice and constant encouragement in preparing this dissertation.

I am extremely thankful to my co-guide Dr. SRIDHAR, M.D, D.A,

Assistant Professor of Anaesthesiology, INSTITUTE OF OBSTETRICS AND

GYNAECOLOGY for his constant support and help in my dissertation work.

I am very much indebted to all my assistant Professors, Department of

Anaesthesiology, Institute of Obstetrics and Gynaecology, Chennai, for their

inspiration, invaluable guidance and supervision at all stages of this study.

I would like to express my thanks to the staff members of the Institute of

Obstetrics and Gynaecology, Chennai, for their ever willing help and cooperation

during the course of this study.

I would like to thank all my colleagues and friends for their whole

5  

hearted help and advice in carrying out this study.

I am grateful to my family and friends for their moral support and

encouragement.

Last but not the least, I am extremely grateful to all my patients who in

spite of all their sufferings have lent themselves to be a very valuable part of this

study and have helped me to improve my knowledge and complete this

dissertation.

Above all I pay my gratitude to the ALMIGHTY for giving me strength to

complete my work.

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TABLE OF CONTENTS 1.0 INTRODUCTION......................................................................................................................... 1 

2.0 AIM OF THE STUDY .................................................................................................................... 2 

3.0 SPINAL ANAESTHESIA ................................................................................................................ 3 

3.1 ANATOMY ............................................................................................................................. 3 

3.2 PHYSIOLOGY OF SUBARACHNOID BLOCK .............................................................................. 5 

3.2.1 CEREBROSPINAL FLUID ................................................................................................... 5 

3.2.2 MECHANISM OF SPINAL ANAESTHESIA .......................................................................... 6 

3.2.3 SPREAD OF LA IN THE SUBARACHNOID SPACE ............................................................... 6 

3.2.4 FATE OF LOCAL ANAESTHETICS IN SUBARACHNOID SPACE ........................................... 7 

3.2.5 INDICATIONS FOR SUBARACHNOID BLOCK ................................................................... 9 

3.2.6 CONTRAINDICATIONS FOR SUBARACHNOID BLOCK ..................................................... 9 

4.0 SPINAL ANAESTHESIA — TECHNIQUE ..................................................................................... 10 

4.1 PROCEDURE ........................................................................................................................ 10 

4.1.1 PREPARATION .............................................................................................................. 10 

4.1.2 POSITION ..................................................................................................................... 11 

4.1.3 PUNCTURE ................................................................................................................... 11 

4. 2 COMPLICATIONS OF SUBRACHNOID BLOCK ....................................................................... 14 

5.0 PHARMACOLOGY OF BUPIVACAINE ........................................................................................ 15 

5.1 MECHANISM OF ACTION ..................................................................................................... 16 

5.2 PHARMACODYNAMICS ....................................................................................................... 16 

5.3 PHARMACOKINETICS .......................................................................................................... 16 

5.4 METABOLISM ...................................................................................................................... 17 

6.0 PHARMACOLOGY OF DEXMEDETOMIDINE ............................................................................. 20 

6.1 PHARMACOKINETICS: ......................................................................................................... 21 

6.2 ACTIONS: ............................................................................................................................. 22 

6.2.1 EFFECTS ON THE CENTRAL NERVOUS SYSTEM: ............................................................ 22 

6.2.2 EFFECTS ON THE RESPIRATORY SYSTEM: .................................................................... 23 

6.2.3 EFFECTS ON THE CARDIOVASCULAR SYSTEM: ............................................................. 23 

6.2.4 DOSAGE AND ADMINISTRATION: ................................................................................ 24 

6.2.5 USES: ............................................................................................................................ 24 

7.0 FENTANYL PHARMACOLOGY .................................................................................................. 26 

7.1 FENTANYL ........................................................................................................................... 26 

7.2 PHARMACOKINETICS .......................................................................................................... 29 

7.3 FACTORS THAT ALTER PHARMACOKINETICS AND PHARMACODYNAMICS ......................... 30 

7  

8.0 REVIEW OF LITERATURE .......................................................................................................... 31 

9.0 MATERIALS AND METHODS .................................................................................................... 40 

9.1 SELECTION OF CASES: ......................................................................................................... 41 

9.2 PRE ANAESTHETIC EVALUATION ......................................................................................... 42 

9.3 OBSERVATION AND RESULTS .............................................................................................. 47 

10.0 STATISTICS ............................................................................................................................ 48 

10.1 DISCUSSION ...................................................................................................................... 66 

10.2 SUMMARY......................................................................................................................... 74 

10.3 CONCLUSION .................................................................................................................... 75 

11.0 BIBLIOGRAPHY ...................................................................................................................... 76 

   Annexure:  1. Ethical Committee  2. Anti‐Plagiarism Screen shot  3. Patient Information Form  4. Patient Concern Form  5. Performa  6. Master Chart

1

 

1.0 INTRODUCTION

Neuraxial blockade notably spinal Anaesthesia is used extensively for lower

abdominal and lower extremity surgeries, because it has several advantages over

general Anaesthesia. Lignocaine and Bupivacaine are the commonly used local

anesthetic agents for spinal anesthesia. The adjuvants like opioids and α2 agonist

are sometimes combined with Local anaesthetic for spinal anaesthesia. The rationale

for combining adjuvants to local anaesthetic drugs is to lower the dose of each

agent, and maintaining analgesic efficacy whilst reducing the incidence and

severity of side effects.

Surgery on the uterus and other genital organs performed under spinal or epidural

block is often accompanied by visceral pain, nausea and vomiting. Fentanyl in

various doses when added to spinal Bupivacaine increase the duration of analgesia.

Dexmedetomidine is a α2-agonist that is approved as an intravenous sedative and co-

analgesic drug.

The study was designed to evaluate the efficacy and adverse effects of 5μg

Dexmedetomidine versus 25μg of Fentanyl when added to 0.5% Hyperbaric

Bupivacaine administered intrathecally in patients undergoing elective abdominal

hysterectomy surgeries.

2

 

2.0 AIM OF THE STUDY

To compare the effect of adding Dexmedetomidine versus Fentanyl to 0.5%

Hyperbaric Bupivacaine administered intrathecally for abdominal hysterectomy

surgeries.

To evaluate the onset and duration of sensory and motor block.

To assess intra operative haemodynamics

To monitor postoperative analgesia.

Complications

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3.0 SPINAL ANAESTHESIA

Spinal (subarachnoid/ intrathecal) anaesthesia is a form of central neuraxial

block in which temporary interruption of nerve transmission is achieved by

injection of local anaesthetic and / or adjuvant solutions into the subarachnoid space.

Spinal anaesthesia is one of the most frequently employed methods of regional

anaesthesia.

3.1 ANATOMY

The Vertebral canal extends from the foramen magnum to the sacral hiatus.

It is formed by the dorsal spine, pedicles and laminae of successive vertebrae

(7cervical, 12 thoracic, 5 lumbar, and 5 sacral). The vertebrae are held together by a

series of the anterior and posterior longitudinal ligaments, ligamentum flavum,

interspinous ligament, supraspinous ligament and the intervertebral discs.

The spinal cord, a direct continuation of the medulla oblongata begins at the

upper border of the atlas and terminates distally in the conus medullaris. The distal

termination, because of the differential growth rates between the bony vertebral

canal and central nervous system varies from L3 in the infant, to the lower border of L1

in the adult.

Surrounding the spinal cord in the bony vertebral column are three membranes-

(from inside to outside); the pia mater, arachnoid mater and dura mater. The pia

mater is a highly vascular membrane that closely invests the spinal cord. The

arachnoid mater is a delicate non vascular membrane closely attached to the outer

most duramater.

4  

Between the two innermost membranes is the subarachnoid space. In this space

cerebrospinal fluid (CSF), spinal nerves, blood vessels that supply the spinal cord

and dentate ligaments are present. Although the spinal cord ends at the lower border

of L1 in adults, the subarachnoid space continues to S2 level. The outermost

membrane in the spinal cord is the longitudinally organized fibroelastic membrane,

the duramater. This layer is the direct extension of the cranial dura mater and extend

as the spinal duramater from the foramen magnum to S2, where the filum terminale

(as extension of the pia mater beginning at conus medullaris) blends with the

periosteum of the subdural space which contains only small amounts of serous fluid to

allow the dura and arachnoid move over each other. Surrounding the dura mater is

the epidural or extradural space which extends from the foramen magnum to the sacral

hiatus. Posterior to the epidural space is the ligamentum flavum. Immediately

posterior to the ligmentum flavum is the interspinous ligament. Extending from

the external occipital protuberance to the Coccyx, posterior to this structure is the

supraspinous ligament.

Lumbar puncture is routinely done below the L2 vertebrae down to the L5-S1

interspace to avoid damage to the spinal cord which ends at the lower border of L1

vertebrae in adults.

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3.2 PHYSIOLOGY OF SUBARACHNOID BLOCK 3.2.1 CEREBROSPINAL FLUID

The cerebrospinal fluid (CSF) is an ultrafiltrate of plasma. It is a clear, colourless

fluid found in the spinal and cranial subarachnoid space and in the ventricles of the

brain. The average volume in the adults ranges from 120 to 150 ml of which 35 ml in

the ventricles, 25 ml is in the cerebral subarachnoid space and 75 ml is in the spinal

subarachnoid space. It is secreted by the choroidal plexus at a rate of 0.3-0.4

ml/minute.

Physical characteristics of cerebrospinal fluid

PH 7.4

Specific gravity referred to Water

At body temperature 1.007

At 4 deg C 1.0003

Density 1.0003 g/ml

Baricity 1.000

Pressure 8-12 mm Hg / 70-80 cm H2O

Cells 3-5 /cu.mm

Proteins 20mg/dl

Glucose 45-80 mg/dl

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The CSF plays an important role in spinal anesthesia. It acts as a media for

dispersion of the local anaesthetic drug to the spinal nerve. An important factor

determining the spread of drugs in the subarachnoid space is the specific gravity of

the injected solution compared with that of CSF.

3.2.2 MECHANISM OF SPINAL ANAESTHESIA Injection of local anaesthetics into the spinal CSF allows access to sites of action

both within the spinal cord and the peripheral nerve roots. The nerve roots leaving

the spinal canal are not covered by epineurium and are readily exposed to the local

anaesthetic within the CSF. Therefore afferent impulses leaving via the ventral nerve

roots are blocked during spinal anaesthesia. Spinal local anaesthetics block sodium

channels and electrical conduction in spinal nerve roots. There are also multiple

potential action of local anaesthetics within the spinal cord at different sites. Local

anaesthetics can exert sodium channel block within the dorsal and ventral horns,

inhibiting generation and propagation of electrical activity The order in which nerve

fibers are blocked in spinal anaesthesia is preganglionic sympathetic B fibers

followed by temperature fibers (cold before warmth), fibers carrying pin prick

sensation, touch, deep pressure, and proprioceptive impulses. Recovery usually occurs

in the reverse order.

3.2.3 SPREAD OF LA IN THE SUBARACHNOID SPACE The local anaesthestic solution is diluted in the CSF and therefore its resultant

concentration is less potent than the actual solution . Spread is also determined by

the baricity of the injected solution. Baricity is a ratio comparing the density of

LA solution at a specified temperature to the density of CSF at the same temperature.

A hypobaric solution has a baricity less than 1.0000 or specific gravity less than

7  

1.0069.

A hyperbaric solution has a baricity greater than 1.0000 or specific gravity more

than 1.0069. Hypobaric and hyperbaric solutions are prepared from isobaric

solutions by addition of various amounts of sterile distilled water and dextrose

respectively. Isobaric solutions do not move under the influence of gravity in the CSF.

Spread of solution and consequently height of block is not influenced by position of

patient and is somewhat unpredictable. Hyperbaric solutions, being heavier than

CSF, settle to the most dependent aspect of the subarachnoid space, which is

determined by the position of the patient. In a supine patient, hyperbaric solutions

gravitate to the thoracic kyphosis. Hypobaric solution ‘floats’ up to the nerves

innervating the surgical site. The major factors affecting height of subarachnoid block

are the baricity of the local anaesthetic solution and the dosage (mass) of drug injected.

3.2.4 FATE OF LOCAL ANAESTHETICS IN SUBARACHNOID SPACE

Following injection of local anaesthetic solution into subarachnoid space, its

concentration falls rapidly. The initial steep fall is due to mixing with CSF and

subsequent absorption into nerve roots and spinal cord. The regress of local

anaesthetics following subarachnoid injection is primarily by vascular absorption

with no hydrolysis or degradation taking place in the CSF. Depending on the type

of the drug used, it is metabolized in plasma by pseudocholinestrease of the liver.

8  

      

9  

3.2.5 INDICATIONS FOR SUBARACHNOID BLOCK

Spinal anaesthesia can be administered safely in,

• Lower abdominal surgeries

• lower limb surgeries

• urological procedures

• obstetric procedures

• gynaecological surgeries

• perineal & rectal surgeries 3.2.6 CONTRAINDICATIONS FOR SUBARACHNOID BLOCK

An absolute contraindication for subarachnoid block is patient refusal. Other

contraindications are:

• local sepsis

• uncorrected coagulopathy

• uncontrolled blood loss/shock

• fixed cardiac output states

• documented allergy to local anaesthetics

• raised intracranial pressure

• neurological disease

• major spine deformities/previous surgery on the spine

• severe cardiac disease

10  

4.0 SPINAL ANAESTHESIA — TECHNIQUE

The first step in the successful application of spinal anaesthesia is proper

patient selection. This is accomplished by preanaesthetic evaluation of the patient

through history, physical examination, blood investigation, communication

with the patient and surgical staff about detail of the procedure. Suitable premedication

is given to the patient before performing the subarachnoid block. Intravenous access

through a large bore intravenous cannula is necessary to administer 500-1000 ml of

[15- 20ml/kg] of crystalloid to limit the hypotension that may result from the

sympathetic block produced by spinal anaesthesia. Emergency drugs and equipment

for managing airway should be readily kept. Spinal anaesthesia should be administered

to a cooperative patient who is placed on a table that can be tipped upward or

downward.

4.1 PROCEDURE 4.1.1 PREPARATION

Preparation of the equipment and drugs is essential for performing a

subarachnoid block. The choice of drug is based on the duration of block

desired, the surgical procedure and patient variables. Spinal needles of various

diameters with various types of points are available. Spinal needles fall into two main

categories; those that cut the dura and those designed to separate the dural fibers. The

former includes the Quincke – Babcock needle and the latter include the Greene,

Whitacre and Sprotte needles. In order to keep the incidence of post dural puncture

headache to a minimum, small bore needles with a rounded non- cutting bevel are

preferred.

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4.1.2 POSITION

The choice of position of the patient for performing the subarachnoid block

depends on a number of factors, the proposed surgery being the most important.

The three primary methods of positioning include lateral decubitus, sitting and prone

positions; each with its own advantages in specific situations. In the lateral decubitus

position, the patient is placed with his back parallel to the edge of the operating table

nearest the anaesthesiologist, with thigh flexed upon the abdomen and neck flexed to

allow the forehead to be as close to the knees as possible. The sitting position is

chosen when low lumbar and sacral levels of anaesthesia are adequate for the

surgical procedure, when obesity or scoliosis make identification of midline

anatomy difficult in the lateral decubitus position or when orthopaedic problems of

the hip and knee exist. The prone position is used primarily for the hypobaric

technique for rectal and perineal procedures.

4.1.3 PUNCTURE

The spinal puncture can be performed either by a midline or a paramedian

approach, usually at the L2-L3. L3-L4 or L4-L5 interspaces. The procedure is

carried out under strict aseptic conditions. The patient’s back is widely prepared

with an antiseptic solution and sterile drapes applied. A line from the highest point

of the iliac crest passes through either the spinous process of L4 or the L4-L5

interspace. The midline approach with patient in sitting position is used in our study.

Depending on the interspace and approach selected, a subcutaneous skin wheal is

raised over the intended puncture site with local anaesthetic solution. If an

introducer is not used, the skin and soft tissue are fixed against the bony landmarks

which straddle the interspace by the second and third fingers of the non-dominant hand

12  

of the anaesthesiologist. The needle is inserted in midline in the middle of the

interspace with bevel parallel to the longitudinal dural fibers. After traversing the

skin and subcutaneous tissue, the needle is advanced in a slightly cephalad direction

with the long axis of the vertebral column. A characteristic change in resistance

occurs as the needle traverses the supraspinous ligament, interspinous ligament,

ligmentatum flavum, dura and pierces the arachnoid which becomes quite

recognisable as experience is gained. The stylet is removed and appearance of

cerebrospinal fluid at the hub of the needle confirms the correct position of the needle

tip. The hub of the needle is firmly held between the thumb and index finger of

the anaesthesiologist’s non-dominant hand and the back of that hand placed against

patient’s back to steady the needle, while syringe containing anaesthetic

solution is firmly attached to the needle.

After confirming the flow of spinal fluid by aspiration, the anaesthetic solution

is injected. The patient is placed in supine position. Cardiovascular and respiratory

functions are monitored. Analgesia is checked by loss of sensation to pinprick.

13  

       

 

14  

4. 2 COMPLICATIONS OF SUBRACHNOID BLOCK IMMEDIATE

1. Hypotension

2. Bradycardia

3. Toxicity due to intravascular injection

4. Allergic reaction to local anaesthetic

5. Hypoventilation (brain stem hypoxia) LATE

1. Post dural puncture headache

2. Retention of urine

3. Backache

4. Meningitis

5. Transient lesions of cauda equina

6. Sixth nerve palsy

7. Anterior spinal artery syndrome

8. Horner’s syndrome

15  

5.0 PHARMACOLOGY OF BUPIVACAINE Bupivacaine is an amide local anaesthetic, synthesized by A.F. Ekenstam in 1957 and

brought into clinical use in 1963. It is produced for clinical use in a racemic

mixture, containing equal proportions of the ‘S’ and ‘R’ enantiomers. It is supplied

for clinical use as a hydrochloride salt.

Chemical Structure Description : ± 1 — Buty-N-(2, 6-dimethylphenyl)-2-piperidine

Decarboxamide Hydrochloride monohydrate.

Physico-chemical Profile

Molecular Weight (base) - 288

pKa - 8.1

Solubility in Alchohol - 1 in 8

Water - 1 in 25

Octanol /Water partition coefficient - High

Lipid solubility - 28

Plasma Protein Binding - 95%

16  

5.1 MECHANISM OF ACTION

Bupivacaine acts by inhibition of sodium channels. It acts to block conduction in

the nerves by decreasing or preventing the large transient increases in permeability of

the cell membrane to sodium ions that follows depolarization of the membrane.

Bupivacaine also reduces the permeability of the resting nerve membrane to potassium

as well as sodium ions.

5.2 PHARMACODYNAMICS Bupivacaine has a stabilizing action on all excitable membranes. In the central

nervous system, stimulation can occur producing restlessness, tremors and

convulsions in over dosage. Bupivacaine also causes a reduction in the automaticity of

the heart.

The clinical profile of nerve blockade produced by Bupivacaine differs from that

of lignocaine. It is four times more potent than lignocaine, but the onset of action is

slower. The duration of action is considerably longer. The sensory block produced by

Bupivacaine tends to be more marked than the motor block.

5.3 PHARMACOKINETICS

Bupivacaine is rapidly absorbed from the site of injection. The rate of rise in

plasma Bupivacaine concentration and the peak plasma concentrations obtained

depend on the route of administration. There is also some inter individual variation

and peak systemic concentrations may occur between five (5) and thirty (30) minute

after administration.

17  

PHARMACOKINETIC PROFILE

Volume of distribution at steady rate (Vdss) 72 litres

Clearance 0.47 L.min

T 1/2 α 2.7min

T ½ β 28min

T ½ γ 3.5hrs

5.4 METABOLISM

Possible pathways for metabolism of Bupivacaine include aromatic

hydroxylation, N-dealkylation, amide hydrolysis and conjugation. Only the N-

dealkylated metabolite N-desmethylbupivacaine has been measured in blood and urine

after epidural and spinal administration. The degradation of Bupivacaine takes place

in the liver. Renal disease is unlikely to alter the kinetics of Bupivacaine. Less than

10% of the drug is excreted unchanged in urine.

The onset of action of Bupivacaine occurs 20 — 30 minutes after a

peripheral nerve block and duration lasts for 8-9 hours

Clinical Applications

• Infiltration anaesthesia

• Peripheral nerve blocks

• Central neruraxial blocks (intrathecal, epidural and caudal)

Contraindications

• Paracervical block (in obstetrics)

• Known hypersensitivity to amide local anesthetics

• Intravenous regional anaesthesia (IVRA)

18  

Preparations Available

0.25%, 0.5% solutions in 10ml and 20ml vials.

5mg/ml (0.5%) Bupivacaine and Plain 80mg dextrose in 4 ml ampoules

for intrathecal injection (Baricity 1.0207)

Recommended Safe Dose

Concentration Used

Maximum Permitted

Dose

0.125%-0.5% 3mg/kg body weight

0.75%(not to be used in obstertric epidurals)

Max.over 4 Hrs—150mg Max.during 24Hrs-400mg

0.5% plain / hyperbaric solution (intrathecal use)

20 mg.

Adverse Reactions

Adverse reactions are associated mainly with excess plasma levels of the drug,

which may be due to over dosage, unintentional intravascular injection or slow

metabolic degradation.

CNS Reactions

Excitation characterized by restlessness, anxiety, dizziness, tinnitus, blurred

vision or tremors possibly proceeding to convulsions, followed by drowsiness,

unconsciousness and cardiac arrest.

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Cardiovascular System Effects

Part of the cardiac toxicity that occurs from high plasma concentrations of

Bupivacaine occurs because of blockade of cardiac sodium channels. Accidental

intravenous injection of Bupivacaine causes cardiac dysarrthymias, atrioventricular

block, verticular tachycardia and ventricular fibrillation. Pregancy increases

the sensitivity of cardiotoxic effects of Bupivacaine.

Allergic Reactions

Manifests as urticaria, pruritus, angioneurotic edema etc. Cross sensitivity among

members of amide type local anaethetics has been reported.

20  

6.0 PHARMACOLOGY OF DEXMEDETOMIDINE

Dexmedetomidine is a highly selective α2 adrenergic agonist that produces

sedation, hypnosis and analgesia.

STRUCTURE OF DEXMEDETOMIDINE CHEMISTRY:-

- 4[cs]-alpha,2,3-Trimethylbenzyl)imidazole

- Dexmedetomedine Hydrochloride is the s-enantiomer of medetomidine

and is chemically described as:

- (+)-4-(s)-[1-(2,3-dimethylphenyl)ethyl]-1H-imidazolemonohydrochloride

Molecular formula: C13H16N2.Hcl

Molecular Weight: 236.74

21  

PHARMACOLOGICAL PROFILE:

Dexmedetomidine is highly selective α2 adrenergic agonist. It shows a high

ratio of specificity for the α2 receptor [α2:d1, 1600:1] compared with clonidine

[α2:d1 200:1] making it a complete α2 agonist. Dexmedetomidine belongs to the

imidazole subclass of α2 agonists. Dexmedetomidine is the active s-enantiomer of

meditomedine. It is highly water soluble and is available as a parenteral and

preservative free formulation.

6.1 PHARMACOKINETICS: T1/2-6 minutes. It is 94% protein bound and its concentration ratio in whole blood

and plasma is 0.66.

METABOLISM:

Dexmedetomidine undergoes biotransformation by conjugation [41%], N-

methylation [21%] or hydroxylation followed by conjugation in liver. The inactive

metabolites excreted in urine and faces. The elimination half-life of Dexmedetomidine

is two (2) to three (3) hours, with a context-sensitive half time ranging from four (4)

mins after a ten (10) minute infusion to two hundred and fifty (250) minutes after an 8-

hour infusion. Pharmacokinetics are similar in young adults and elderly.

MECHANISM OF ACTION:

Dexmedetomidine is a highly selective α2 agonist. There are 3 types of α2

adrenoreceptors in humans: α2A, α2B, α3C. The α2A adrenoreceptors are primarily

distributed in the periphery where as α2B and α2C receptors are located in the

Brain and Spinal cord.

22  

Presynaptic activation of α2 adrenoreceptors inhibits the release of nor-

epinephrine.

Post synaptic activation of α2-adrenoreceptors in the central nervous system

inhibits sympathetic activity and decreases blood pressure and heart rate producing

sedation and anxiolysis.

Analgesia is produced through binding of dexmedetomidine to α2 adrenergic

receptors in the spinal cord.

The overall response to α2 adrenoreceptor agonists is related to the stimulation of

α2 adrenoreceptors located in the CNS and spinal cord.

Dexmedetomidine produces sedation and hypnosis by action on α2 receptors in

the locus ceruleus and analgesic effect by acting at α2 receptors with in the locus

ceruleus and with in the spinal cord.

6.2 ACTIONS: 6.2.1 EFFECTS ON THE CENTRAL NERVOUS SYSTEM:

SEDATION

The α2 agoinst acts through the endogenous sleep-promoting pathways to exert

their sedative effect.

It produces good sedative effect-yet arousable, alert and able to respond without

becoming uncomfortable. Despite sound levels of sedation with Dexmedetomidine,

there is limited respiratory depression.

ANALGESIA:

The analgesic effects of Dexmedetomidine are complex. They have an

analgesic effects when injected through the intrathecal or epidural route. The

primary site of action is thought to be the spinal cord.

23  

Systemic use of Dexmedetomidine shows narcotic sparing. narcotic

requirements were reduced by 50% in patients receiving Dexmedetomidine.

OTHER EFFECTS:

Dexmedetomidine in animal models of incomplete cerebral ischaemia and

reperfusion reduces cerebral narcosis and improves cerebral outcome by reducing

the intra cerebral catecholamine outflow and the reduction of the excitatory

neurotransmitter glutamate during injury.

Dexmedetomidine also reduces muscle rigidity after high-dose opioid

administration.

6.2.2 EFFECTS ON THE RESPIRATORY SYSTEM:

Dexmedetomidine of concentrations producing significant sedation reduces

minute ventilation but retains hyper capnic ventilation response. The changes in

ventilation appeared similar to those observed during natural sleep. Dexmedetomidine

has been implicated in blocking histamine – induced broncho constriction in dogs.

6.2.3 EFFECTS ON THE CARDIOVASCULAR SYSTEM:

The basic effects of Dexmedetomidine on the cardiovascular system are

decreased heart rate, decreased systemic vascular resistance and indirectly decreased

myocardial contractility and systemic Blood pressure.

The effects of Dexmedetomidine on blood pressure shows a Biphasic response

an initial increase in Blood pressure that occurred of 5 mins after administration

[due to the vaso constrictive effects of Dexmedetomidine on peripheral α2

adrenoreceptors] followed by decreased in Blood pressure due to action on central α2

adrenoreceptor activity.

24  

The incidence of Hypotension and Bradycardia may be related to the

administration of loading dose. Omitting the loading dose or restricting the dose up

to only 0.4μg/kg reduces the incidence of Hypotension. Giving the loading dose

over 20 minutes also minimizes the transisent Hypertension.

6.2.4 DOSAGE AND ADMINISTRATION:

Dexmedetomidine is supplied in 2ml ampoule, 100μg-ml & 1ml ampoule

50μg/ml. Preservative free

• Loading dose – 0.5 – 1.0μg/kg over to10 minutes

• Maintenance dose – 0.3 – 0.7μg/kg/hr 6.2.5 USES:

Dexmedetomidine has been approved as a short-term sedative for adult intubated

patients in ICU.

1. INTENSIVE CARE UNIT:

• Dexmedetomidine has following advantages for sedation in mechanically

ventilated patients. Decreased requirement for opioids >50% when

compared with propofol or Benzobiazepines.

• Providing adequate sedation with minimal respiratory depression. Can be

used when weaning patients from ventilator.

• Dexmedetomidine has been used in the treatment of alcohol and drug

withdrawal of narcotics, benzodiazepines and recreational drugs.

25  

2. ANAESTHESIA:

• Dexmedetomidine at doses of 0.3-0.67μg/kg given 10-15 minutes before

induction attenuates the hemodynamic response to intubation.

• As a premedication 2.5μg/kg IM.

• Used for securing the airway during fibreoptic intubation.

• Sedation during regional Anaesthesia.

• As an anaesthetic adjuvant in Bariatric surgery, sleep apnea patients.

Vascular surgery, CABG surgery, Craniotomy ancurysm,

evoked potential study, thoracic surgery.

CONTRA INDICATIONS:

• Infusions over 24 hrs

• In caesarean deliveries, as the safety has not been studied

• Patients with preexisting Bradycardia and related Bradyarythmias.

• Patients with impaired ventricular function –Ef<30%]

• Hypovolemic or Hypotensive patients.

• Patients with raised intra cranial tension.

26  

7.0 FENTANYL PHARMACOLOGY 7.1 FENTANYL

Fentanyl is a potent lipophilic synthetic opioid, μ receptor agonist with a short

onset time and moderate duration of action. Fentanyl citrate is the synthetic

parent opioid from which sufentanil and alentanil are derived.

CHEMISTRY

Fentanyl citrate (sublimaze, durageric, duragesic)

C22H28N2OC6H8O7

N-phenyl-N-[1 (2-phenylethyl)-4piperidinyl] propanamide citrate The phenylpiperidine (synthetic) opioid fentanyl skeleton structure.

Molecular weight (free base) 528.5(336.5)

pKa (amino) 8.43 Solubility in alcohol 1 in 140 in water 1 in 40

Octonol / water partition coefficient 955

27  

Fentanyl is a μ agonist. It has a more rapid onset and shorter duration of action

than morphine. The greater potency and more rapid onset of action reflect the

greater lipid solubility of fentanyl compared with that of morphine.

Fentanyl produces dose related analgesia. Small doses of 0.5-3.0μgkg-1may be

used as a supplement in spontaneously breathing anaesthetized patients. Doses of

5.0μgkg-1 upward will suppress somatic and autonomic responses to surgical

stimulation in ventilated patients.

Doses of 50μgkg-1 in conjunction with muscle relaxant and mechanical

ventilation, may be used to induce and maintain anaesthesia.

Fentanyl is a potent respiratory depressant and reduces brain stem respiratory

responsiveness to CO2 and peripheral chemoreceptor input during hypoxemia.

Fentanyl exerts minimal effects on the circulation. There is a vagally

mediated bradycardia and a slight fall in systemic vascular resistance.

Skeletal muscle rigidity and clonic movements can hinder mechanical

ventilation. This effect is reversed by naloxone and overcome by neuromuscular

blocking drugs. Rigidity may also occur during emergence from anaesthesia. High dose

fentanyl obtunds the metabolic and hormonal response to surgery.

There is a reduction in metabolic activity following fentanyl and hence in oxygen

consumption. Nausea and vomiting are the result of stimulation of the chemoreceptor

trigger zone. Cough suppression, pupillary constriction and itching of the nose also

occur.

28  

Fentanyl has been found to significantly increase intracranial pressure in patients

with severe head injury. Fentanyl also significantly decreases cerebral perfusion

pressure. Fentanyl may cause a rise in biliary intraluminal pressure. Fentanyl will

reduce intraocular pressure independent of changes in arterial blood pressure.

Relative contraindications for fentanyl are

1. Hypovolemia

2. Respiratory inadequacy

3. Raised ICP  

29  

7.2 PHARMACOKINETICS

A three-compartment model is typically used to describe plasma fentanyl

concentration decay. The lungs exert a significant first pass effect and transiently

take up approximately 75 percent of an injected dose of fentanyl.

As is typical of the fentanyl both volume of distribution (3-6Lkg-1) and

clearance (10-20 mlkg-1 min-1) are high.

Approximately 80% of fentanyl is bound to plasma proteins, and significant

amount (40%) are taken up by red blood cells. As the pKa of fentanyl is high

(8.4) at physiologic pH, it exists mostly in the ionized from (> 90%). Fentanyl’s lipid

solubility is also high, a finding that explains in part its large volume of distribution.

The tissue/blood partition coefficient of fentanyl is found to be 2-30 fold higher

than those of alfentanil. Because fentanyl is distributed so widely in the body, it

must ultimately be returned to the blood to be metabolized in the liver. Fentanyl is

relatively long acting, in large part because of its widespread distribution in body

tissues.

Fentanyl is primarily metabolized in the liver by β-dealkylation and

hydroxylation. Fentanyl has a high hepatic clearance (approaching hepatic blood

flow) and a high hepatic extraction ratio (approaching 1.0). Metabolism begins to

appear in the plasma as early as 1.5 min after injection. Norfentanyl, the primary

metabolite, is detectable in the urine for upto 48 hours after IV fentanyl in

humans. The activity of fentanyl’s metabolites is unclear, but it is thought to be

minimal. Little fentanyl is excreted in the urine unchanged.

30  

7.3 FACTORS THAT ALTER PHARMACOKINETICS AND PHARMACODYNAMICS

• Age: The elimination of fentanyl in neonates is prolonged. With

advanced age although pharmacokinetics changes may play a minor role.

• Weight: Fentanyl pharmacokinetics is not grossly different in lean versus

obese subjects.

• Renal failure: For the fentanyl congeners the clinical importance of

kidney failure is less marked.

• Hepatic failure: Reduction in liver blood flow that result from either

liver disease or some other disorder will delay the decline of fentanyl

plasma concentration.

• Cardiopulmonary bypass: Fentanyl pharmacokinetics is extensively

altered by CPB.

• Acid-base changes: Acidosis increase ionized fentanyl in the interstitial

space, draws unionized fentanyl out of the intracellular compartment,

where a 13-fold accumulation of fentanyl occurs, further augmenting

opioid effects, i.e. ventilatory depression.

31  

8.0 REVIEW OF LITERATURE

1. Subhi M. Al-Ghanem et al 19(American Journal of applied Science 6[5] 882-

887- 2009) studied to evaluate the onset and duration of sensory and motor

block as well as operative analgesia and adverse effects of

DEXMEDETOMIDINE or fentanyl given intrathecally with plain. Bupivacaine

for spinal anaesthesia. 78 patients were scheduled for vaginal hysterectomy,

vaginal wall repair and tension free vaginal tape were prospectively studied

patients were randomly allocated to receive intrathecally either 10mg of isobaric

bupivacaine plus 5μg of DXM [Group [n=38] or 10mg of isobaric bupivacaine

plus 25μg of fentanyl [Group F n=38], the onset time, peak sensory and motor

level, the regression time for both sensory and motor Blockade, hemodynamic

changes and side effects were recorded. Patients in Group-D had significant

longer sensory and motor block times than patients in Group-F the mean

time of sensory regression to S1 was 274±73 min in group D and 179±41 min

group F [p < 0.001]. The regression time of motor block to reach modified

Bromage 0 was 240±60 min in group D and 179±47 min in Group F [p <

0.001]. The results suggested that 10mg plain Bupivacaine with 5μg DXM

produces prolonged motor and sensory block compared with 25μg Fentanyl.

32  

2. Mahmoud M. Al-mustafa 12 (Saudi medical journal 2009 – vol 30 [3];365-370)

et al studied to determine the effect of adding DXM to Bupivacaine for

neuraxial anaesthesia 66 patients were randomlyassigned in 3 groups each

receiving spinal bupivacaine 12.5mg combined with Normal saline (Group N),

DXM 5μg [Group D5] & DXM 10mg [Group D10]. The onset time to reach

T10 sensory and Bromage 3 motor block and the regression times to reach

S1 sensory level and Bromage 0 motor scale were recorded. The mean time of

sensory Block to reach the T10 dermatome was 4.7+/-2.0 minutes in D10 group,

6.3+/-2.7 minutes in D5 and 9.5+/-3.0 minutes in group N. The mean time to reach

Bromage 3 scale was 10.4+/-3.4 minutes in Group D10 13.0+/-3.4 minutes D5

and 18.0+/-3.3 min in Group N. The regression to Bromage 0 was 302.9+/-36.7

min in D10, 246.4+/-25.7 min in D5 and 140.1+/-32.3 minutes in Group N. The

conclusion was dexmedetomidine has a dose dependent effect on the onset and

regression of sensory and motor block when used as an adjuvant to Bupivacaine in

spinal anaesthesia.

3. Kanazi et al 9 (Acta anaesthesion scan 2006;50;222-227) studied to compare the

onset and duration of sensory and motor block as well as the hemodynamic

changes and level of sedation following intrathecal bupivacaine supplemented

with either DXM or clonidine 60 patient received 12mg of 0.5% Bupivacaine

[n=20], Group B, Group D received 12mg 0.5% Bupivacaine with 3μg of DXM

and group C received 12mg of 0.5% Bupivacaine supplement with 30μg of

clonidine. The onset times to reach peak sensory and motor levels and the

33  

sensory and motor regression times, were recorded. Hemodynamic changes

and the level of sedation were recorded. Patients in Groups D and C had a

significantly shorter onset time of motor block and significantly longer sensory

and motor regression times than patients in Group B. The mean time of

sensory regression to the S1 segment was 303±75 min in Group D, 272±38

min in group C and 190±48 min in group B. The regression of motor block to

Bromage 0 was 250±76 min in group D, 216±35 min in group C and 163±47

in group B [p valve < 0.001]. The onset and regression times were not

significantly different between groups D and C. The mean arterial pressure, heart

rate and level of sedation were similar in the three groups intra operatively and

post-operatively. DXM (3μg) or clonidine (30μg), when added to intrathecal

Bupivacaine, produces a similar prolongation in the duration of the motor and

sensory block with preserved hemodynamic stability and lack of sedation.

4. Ibrahim. F.A. Khalifa et al 7(Benha MJ Vol 26; 3;Sep 2009) studied the

effect of adding intrathecal dexmedetomidineVs sufentanyl to heavy

bupivacaine for post-op analgesia in patients undergoing inguinal hernia repair.

50 ASA Grade I/II patients, scheduled for elective inguinal hernia repair with

5μg of DXM and 5μg of sufentanyl with heavy bupivacaine 0.5% 2ml onset and

duration of sensory and motor blockade, surgical condition and side effects were

assessed. The duration of effective post-operative analgesia as assessed by VAS

was not statistically significantly in between both groups. Cardio vascular and

respiratory stability was maintained with no significant incidence of side effects in

either group. The addition of DXM 5μg and sufentanil 5μg intrathecally provide

34  

improved postoperative analgesia and hemodynamic stability Dexmedetomidine

prolongs the post-op analgesia as sufentanil but with minimal side effects.

5. Antonio Mauro Vieira et al studied the analgesia and sedation promoted by

clonidine or DXM associated to epidural ropivacaine, in the post-operative

period to subcoastal cholecystectomy 40 pts of ASA I & II received clonidine

150μg to epidural ropivacaine 0.75% [20ml], DXM 2μg/kg-1 associated to

epidural ropivacaine 0.75% 20ml. Analgesia and sedation were evaluated 216

and 24 hours anesthetic recovery. Both groups present some grade of sedation in

the moments 2 and 6 hours, with statistically significant difference between the

two moments for DXM group. There has bee analgesia in 6 and 24 hrs in the

DXM group; in the clonidine group, this statistically significant difference was

observed between the periods of 2 and 6 hours and between 2 and 24 hours. The

conclusion was allowed to conclude that the association of clonidine or DXM

to 0.75% ropivacaine induces analgesia and sedation in 2 and 6 hours after

anesthetic recovery in patients submitted to subcostal cholecystectomy and that

clonidine promotes more prolonged analgesia.

6. Saadway et al 15(Acta Anaesthesiol Scand 2009;53;251-256) studied the

effect of DXM on the characteristics of Bupivacaine in a caudal block in

pediatrics. 66 children undergoing unilateral inguinal hernia repair/orchidopexy

were allocated randomly and Group B (n=33) received a caudal injection of

Bupivacaine 2.5mg/ml, 1ml/kg; Group BD(n=33) received the same dose of

Bupivacaine mixed with Dex 1μg/kg during sevoflurane anaesthesia. Processed

EEG [BIS], heart rate, Blood pressure, pulse oximetry and end-tidal sevoflurane

35  

were recorded every 5 min. The characteristics of emergence, objective pain

score, sedation score and quality of sleep were recorded post-operatively.

Duration of analgesia and requirement for additional analgesics were noted. The

results were the end-tidal sevoflurane concentration and the incidence of

agitation were significantly lower in the BD group [p < 0.05 ]. The duration of

analgesia was significantly longer (p < 0.001) and the total consumption of

rescue analgesia was significantly lower in Group BD compared with Group B (p

< 0.01). Group BD had better quality of sleep and a prolonged duration of

sedation ( p < 0.05) and the conclusion was caudal Dexmedetomidine seems to

be a promising adjunct to provide excellent analgesia without side effects over a

24hr period. It has the advantage of keeping the patients calm for a prolonged time.

7. El. Hennawy Am et al6 (British Journal of anathesia 2009.aug 103[2];268-

274;Epub 2009. June 18) studied the addition of clonidine or dexmedetomidine

to Bupivacaine prolongs caudal analgesia in children. Undergoing lower

abdominal surgeries. 60 patients [6 months to 6 years] were evenly and randomly

assigned into three groups in a double-blinded manner. After sevoflurane in

oxygen anaesthesia, each patient received a single caudal dose of bupivacaine

0.25% [1ml kg (-1)] combined with either DXM 2μg/kg in normal saline 1ml,

clonidine 2μg/kg in normal saline 1ml or corresponding volume of normal saline

according to group assignment. Hemodynamic variables, end- tidal sevoflurane

and emergence time were monitored. Postoperative analgesia, use of analgesics

and side effects were assessed during the first 24 hr. The results were the

addition of DXM or clonidine to caudal bupivacaine significantly promoted

36  

analgesia time [median [95% confidence internal c1]; 16 (14-18) and 12(3-21)h,

respectively] than the use of sevoflurane and emergence time were monitored.

Postoperative analgesia, use of analgesics and side effects were assessed during

the first 24 hr. The results were the addition of DXM or clonidine to caudal

bupivacaine significantly promoted analgesia time [median [95% confidence

internal c1]; 16 (14-18) and 12(3-21)h, respectively] than the use of Bupivacaine

alone [ median (95%c1); 5 (4-6)h] with p<0.001. However, there was no

statistically significant difference between dexmedetomidine and clonidine as

regards the analgesia time (p=0.796). The conclusion was addition of DXM or

clonidine to caudal bupivacaine significantly promoted analgesia in children

undergoing lower abdominal surgeries with no significant advantage of

dexmedetomidine over clonidine and with out an increase in incidence of side

effects.

8. Seewal R et al17 (Regional anathesia pain medicine 2007, Jan-feb 32[1]; 20-6)

studied the effect of adding various doses of fentanyl to 2.2ml of Bupivacaine

(0.5% Hyperbaric] for spinal anaesthestic in non-obstetric population undergoing

superficial lower abdominal surgery. 60 patients received spinal anaesthetic

with 2.2 ml of bupivacaine [0.5% Hyperbaric] and saline [control group], or

Fentanyl 10, 20, 30 or 40 microgram. The volume of injected drug was kept

constant at 3 ml by adding preservative free normal saline for blinding

purposes. Subarachanoid block characteristics, drug-related side effects and post-

operative analgesia requirements were assessed and recorded. Results showed a

significant improvement in quality and duration of analgesia occurred in study

37  

groups compared with the control group p < 0.05. However no improvement in

analgesia occurred when the dose of fentanyl added was increased from 10 to

20, 30, 40 microgram. Conclusion was study group significantly improves the

quality and duration of analgesia. Seewal R – Effect of addition of various doses

of fentanyl intrathecally to 0.5% Hyperbaric Bupivacaine on perioperative

analgesia and subarachanoid block characteristics in lower abdominal surgery.

9. Bogra J, srivastara P et al1 (BMC Anaesthesiology 2005 may 17;5[1];5)

studied the synergistic effect of intrathecal fentanyl and bupivacaine in spinal

anaesthesia for caesaran section there by reducing the dose, & side effects,

caused by higher doses of intrathecal bupivacaine in cesarean section. 120

patients divided in to 6 groups, identified as B8, B10, B12.5, and 12.5mg of

bupivacaine and FB8, FB10, FB 12.5 mg received a combination of 12.5μg

intrathecal fentanyl respectively. The parameters taken into consideration were

visceral pain, hemodynamic instability, intraoperative sedation, intraoperative

and post-operative shivering and post operative pain. The results were the

onset of sensory block E0 T6 occurred faster with increasing bupivacaine

doses in bupivacaine only groups and bupivacaine – Fentanyl combination

groups. Lower concentrations of bupivacaine alone could not completely

removed the visceral pain. Blood pressure declined with the increasing

concentration of Bupivacaine and Fentanyl. Incidence of nausea and shivering

reduces significantly whereas, the post operative pain relief and hemodynamics

increased by adding fentanyl. Conclusion was there is synergistic,

potentiating effect of fentanyl on bupivacaine in spinal anesthesia for cesarian

38  

section is presented, Fentanyl is able to reduce the dose of bupivacaine and

therefore is harmful effects.

10. Biswas B.N. et al. (2002) conducted a study on forty healthy women of

ASA Gr I Scheduled for elective caesarean section. They were randomly allocated

to receive 2 ml of 0.5% inj Bupivacaine (hyperbaric) with 0.25 ml of normal

saline (Group A n = 20) or 0.25 ml (12.5 µg) fentanyl with (using a tuberculin

syringe) (Group B n = 20) 2 ml of 0.5% inj Bupivacaine (hyperbaric). Pulse rate,

blood pressure, respiratory rate and foetalheart rate were recorded. Patients were

prehydrated with 15 ml kg-1 Ringers lactate solution before spinal anaeshthesia.

The onset and duration of sensory block was assessed by pinprick method. Time

taken from intrathecal injection to the highest level of sensory block and sensory

regression to the L1 dermatome were recorded. The onset and duration of motor

block was noted. Grading of motor block was done as per Bromage score. Pain

was evaluated using a standard 10 cm linear visual analog scale (VAS). The

duration of complete analgesia (Time from SAB to first report of pain) and time of

effective analgesia (Time from subarachnoid injection to first doses of rescue

analgesic) were recorded. Vital parameters and adverse effects, i.e. pruritus,

nausea, vomiting, shivering were recorded. Every 2 minutes for first 20

minutes, then at 15 minutes interval for remainder of operation and thereafter

at 30 minutes interval until patient complained of pain. APGAR scores were

recorded at 1 and 5 minutes after delivery of baby. The highest sensory level

achieved were T7 (T6-T8) and T5 (T4-T6) in group A and B respectively. In

fentanyl group the time taken for sensory level to regress to S1 dermatome were

39  

prolonged but duration of motor blocks was not prolonged.

11. Sahar M Siddik Sayyid et al. (2002) conducted a study on 48 parturients

scheduled for elective caesarean delivery. Patients were randomized double

blinded. Patients were all classified as ASA physical status of I and II and had

no contraindication to spinal anaesthesia. The 48 subjects were allocated into

two groups by using sealed envelope technique. The IT fentanyl group received 12

mg hyperbaric bupivacaine 0.75% and 12.5 µg of IT fentanyl (23 patients). The

IV fentanyl group received 12 mg of hyperbaric bupivacaine 0.75% alone (25

patients), mix with CSF to achieve the same volume. In the OT room patient

preloaded with 500 ml of polygeline (hemacel). LP was done in sitting posture.

Immediately after intrathecal administration of drug, 12.5µg inj fentanyl IV

given in the IV fentanyl group. Immediately after SAB patient was put in a

supine position with 15°-20° left lateral tilt and 5L oxygen given via mask.

Blood pressure, pulse rate and SPO2 was measured every minute until delivery

of the baby and at the 3 min interval until the end of the surgery.

Whenever the systolic BP falls 20% below baseline 5 mg of IV ephedrine

administered. Sensory block assessed by pinprick method every minute until

block reached T6 dermatome. There after every 2 min until the maximum

sensory block level was confirmed.

40  

9.0 MATERIALS AND METHODS

This study was conducted at the Institute of obstetrics and Gynaencology,Rajiv

gandhi Government general Hospital,MMC, Chennai-600 008 betweenApril 2016 -

July 2016 on 60 patient of ASA physical status Iand11 undergoing Elective Total

abdominal Hysterectomy under subarachnoid block. This study was done after

Government General Hospital Ethical committee approval and a written informed

consent obtained from all the patients included in this study.

Study Design

This study was done in a prospective double blinded randomized manner. Each

group consisted of thirty patients.

Group D

Patients in this group received 3.0 ml of 0.5% hyperbaric bupivacaine + 5μg

[0.5 cc] of preservative free Dexmedetomidine to a total volume of 3.5 ml

intrathecally.

Group F

Patients in this group received 3.0ml of 0.5% hyperbaric bupivacaine + 25μg

[0.5 cc] of Fentanyl to a total volume of 3.5ml intrathecally. The final volume of

injected solution was 3.5ml in both groups.

In this study 0.5% hyperbaric bupivacaine in 8% dextrose, Dexmedetomidine

hydrocholoride 100μg/1ml and preservative free fentanyl 50μ/1ml. All solutions

were prepared by the OT incharge anaesthesiologist under strict aseptic precautions,

uninvolved in the administration of SAB or in the observation of results.

41  

9.1 SELECTION OF CASES:

Inclusion criteria:

Age:30yrs to 50yrs

ASA physical status Iand 11

BMI:<30kg/m2

Surgery:elective surgery

Normal liver and renal function test,coagulation profile

Who have given valid informed consent

Airway: MMS (Modified Mallampatti score) 1 OR 2

Exclusion criteria:

Not satisfying inclusion criteria.

Lack of written informed consent.

Hypersensitivity to the study drug.

Renal or Hepatic dysfunction

Bleeding diathesis

Uncontrolled labile Hypertension & Diabetes mellitus.

Patient refusal.

Infection at injection site.

Patient with anticipated difficult airway.

Patient with abnormal spinal anatomy.

42  

9.2 PRE ANAESTHETIC EVALUATION

Patients included in this study underwent through preoperative evaluation

which included the following

History

History of underlying medical illness, previous surgery and hospitalization. Physical examination:

1. Vital signs

2. Height and Weight.

3. Examination of CVS, RS, CNS, Spine

4. Airway assessment. Investigations:

Haemoglobin (Hb), BT, CT, Renal function test (RFT), Blood grouping &

Typing, ECG, Chest X-Ray (CXR), were done. Patient who satisfied the inclusion

criteria were explained about the nature of the study and the anaesthetic procedure and

written informed consent were obtained from all patients included in the study.

PRE LOADING:

In the premedication room pulse rate, BP, RR and sp02 was noted. An IV line

was secured with 16G cannula. Preloading done with RL 500ml over 20-30 minutes.

43  

Technique

In the OT appropriate equipment for airway management and emergency drugs

were kept ready. Patient was shifted from the premedication room to OT. The

horizontal position of the operating table was checked and the patient was placed

on it. NIBP, SP02, ECG leads were connected to the patient. Pre operative base line

systolic and diastolic BP, PR, SP02 and RR were recorded. The anesthesiologist who

were unaware of the drug combination performed the SAB and made observations in

all the patients involved in the study. A midline lumbar puncture was performed

using a 25G Quincke needle in Right lateral position. Then patient was placed in

supine position. The time of intrathecal injection was considered as 0 and following

parameter were observed.

Sensory Block

Sensory block was assessed by loss of sensation to cold by cold alcohol swab

along the mid clavicular line bilaterally, immediately after intrathecal injection and

continued every 15sec till loss of cold sensation at T10 level till it reaches peak [T6

level]. The level of sensory block was noted at the end of the surgery and there after

assessment was carried out at 15 mts interval till return of cold sensation at s1

dermatome, duration of sensory block was taken as the time from subarachanoid

injection to return of cold sensation to s1.

44  

Motor block

Motor block was assessed using modified BROMAGE Score

Bromage 0 – Patient is able to move the hip, knee and Ankle

Bromage 1 – Patient is unable to move the hip, but is able to move knee & ankle.

Bromage 2 – Patient is unable to move hip & knee but able to move ankle

Bromage 3 – Patient is unable to move hip, knee and ankle.

Assessment of motor block was started immediately after the

intrathecal injection. It was tested every 15 seconds till peak motor block

Bromage score was reached. The regression time for sensory and motor block

were recorded in post operative ward.

Vital Signs and side effects

The systolic and diastolic BP, RR, PR & Sp02 were recorded every 1mt for

5mts and thereafter every 5mts throughout the intra operative period. The above vital

signs at the completion of surgery were noted. Hypotension defined as fall in systolic

BP > 30% from baseline or MAP < 60mm of Hg. This was managed with Inj.

Ephedrine 6mg increments. Bradycardia was defined as heart rate <50/mt and this

was managed with Inj. Atropine 0.01mg/kg iv. Respiratory depression defined as

RR <8/mt and or Sp02 < 85%. This was planned to be managed with bag and mask

ventilation or intubation and IPPV if necessary. Blood loss more than the allowable

loss was replaced with blood. Vomiting was treated with Inj. Emeset 4mg iv.

Pruritus was noted. Since this is a benign subjective symptom which is under

reporting and usually need no treatment and need for any intra-op Analgesia was not

noted.

45  

Assessment of pain and duration of analgesia

Pain was assessed by visual analog score

0-No pain.

1-mild pain.

2-Moderate pain.

3-Severe pain.

Quality of surgical anaesthesia:

Surgical ananesthesia was graded as excellent if there was no complaint of pain at

any time during surgery. Good if there was minimal pain or discomfort which was

relieved by a small dose of iv pentazocine 0.5mg/kg and poor if GA has to be

administered.

Assessment in post operative ward:

The patient was shifted to the post operative ward after completion of

surgery. The vitals signs were recorded till the regression of both motor Block

[Bromage 0] & the sensory block [s1] pain was assessed every 15 minutes. When the

patient reaches the pain score 2 or 3Inj. Diclofenac 75mg Im was given. Duration of

effective analgesia was defined as the time interval between onset of SAB and the

time to reach pain score-2 or 3

46  

47  

9.3 OBSERVATION AND RESULTS

This study was conducted at the institute of Obstetrics and Gynaecology, Egmore,

Chennai. Sixty (60) patients were included in this double blinded randomized

controlled study. The patients were divided into two groups. Patients in Group F

received 3.0ml [15 mg] of 0.5% Hyperbaric Bupivacaine plus 25μg [0.5cc] of Fentanyl

and patients in Group D received 3.0ml [15mg] of 0.5% Hyberbaric Bupivacaine plus

5μg [0.5cc] of Dexmedetomidine (preservative free). Final volume of injected solution

was 3.5cc in both groups.

48  

10.0 STATISTICS Table 1: Demographics (Mean ±SD, N(%) Variable Group D Group F Age (yrs) 43.80± 5.18 42.77 ±5.01 Diagnosis

Abnormal uterine bleeding 13(43.3) 12(40) Fibroid uterus 14(46.7) 17(56.7)

Post menopausal bleeding 2(6.7) 0(0) Others 1(3.3) 1(3.3)

Procedure Total Abdominal Hysterectomy 13(43.3) 13(43.3)

Total abd. hysterectomy with BSO 17(56.7) 17(56.7) ASA classification

Class I 16(53.3) 13(43.3) Class II 14(46.7) 17(56.7)

Duration of surgery(min) 71.5 ±10.91 66± 15.05 Table 2 (* indicates statistical significance)

Comparison of sensory block level

Group D

Group F

Mean diff

S.E Mean diff

95% C.I p value Lowe

r Upper

Time to reach T10 sensory block level (min)

2.97± 0.41

2.33± 0.55

0.633 0.125 0.383 0.884 <0.01*

Time to reach T6 sensory block level (min)

4.20± 0.66

3.5± 0.63

0.7 0.167 0.365 1.035 <0.01*

The mean time required to reach T10 level sensory block was 2.97

minutes in the D group and 2.33 in the F group. The mean difference was 0.633 with

95% confidence interval from 0.383 to 0.884, the difference was statistically significant.

Patients in the F group required a shorter time to achieve T10 level sensory block

The mean time taken to reach T6 level sensory block was 4.2 minutes in

the D group and 3.5 minutes in the F group. Patients in F group required 0.7 less

minutes on an average to achieve T6 level sensory block with 95% C.I ranging from

0.465 to 1.035. The difference was statistically significant

49  

Table 3

Comparison of motor block level

Group D

Group F

Mean diff

S.E Mean diff

95% C.I p value

Lower

Upper

Time to reach T10 motor block level (min)

3.57± 0.63

2.73± 0.45

0.833 0.141 0.552 1.115 <0.01*

Time to reach T6 motor block level (min)

5.23± 0.73

4.5± 0.57

0.169 0.395 0.395 1.072 <0.01*

The mean time taken to reach T10 level motor block was 3.57 minutes in

the D group and 2.73 minutes in the F group. Patients in F group required 0.833 less

minutes on an average to achieve T10 level motor block with 95% C.I ranging from

0.552 to 1.115. The difference was statistically significant

The mean time taken to reach T6 level motor block was 5.23 minutes in

the D group and 4.5 minutes in the F group. Patients in F group required 0.169 less

minutes on an average to achieve T6 level motor block with 95% C.I ranging from

0.395 to 1.072. The difference was statistically significant

50  

The mean intra OP heart rate was compared across the two groups using independent

samples t-test. There was no statistically significant difference in the mean heart rate

across the two groups during the surgical procedure.

Mean Intra OP Heart rate

Group D Group F Mean diff

S.E Mean diff

95% C.I p value Lower Upper

Heart rate baseline

82.73 ±5.39 81.77 ±4.87 0.97 1.33 -1.69 3.62 0.47

Heart rate 0 min 80.10± 5.22 78.07± 4.81 2.03 1.30 -0.56 4.63 0.12 Heart rate 5 min 77.27± 4.73 75.63± 4.45 1.63 1.19 -0.74 4.01 0.17 Heart rate 10 min 74.6± 4.07 74.9 ±4.48 -0.3 1.11 -2.51 1.91 0.79 Heart rate 15 min 72.67 ±4.22 74.07 ±4.44 -1.4 1.12 -3.64 0.84 0.22 Heart rate 20 min 71.53± 3.47 72.3± 4.55 -0.8 1.05 -2.86 1.33 0.47 Heart rate 25 min 71.2 ±3.23 72.03± 4.23 -0.83 0.97 -2.78 1.11 0.40 Heart rate 30 min 70.37 ±3.48 71.27± 3.71 -0.9 0.93 -2.76 0.96 0.34 Heart rate 45 min 70.33± 3.66 71.33± 4.70 -1 1.09 -3.18 1.18 0.36 Heart rate 60 min 70.5 ±3.67 71.36± 3.81 -0.86 1.01 -2.89 1.17 0.40 Heart rate 75 min 70.61± 3.50 73.09 ±5.01 -2.48 1.58 -5.72 0.76 0.13 Heart rate 90 min 72.40± 3.36 74.83± 3.76 -2.43 2.17 -7.35 2.49 0.29

51  

Table 5 Mean VAS

scores Group D Group F Mean diff S.E Mean diff 95% C.I p value

Lower Upper VAS 25 min 0.0 1.1± 0.31 -1.1 0.056 -1.212 -0.988 <0.01* VAS 30 min 0 0 1.67± 0.66 -1.667 0.121 -1.908 -1.425 <0.01* VAS 45 min 0.17± 0.38 2.22 ±0.42 -2.056 0.106 -2.269 -1.843 <0.01* VAS 60 min 1.17± 0.38 2.67± 0.48 -1.5 0.121 -1.743 -1.257 <0.01* VAS 75 min 1.9 ±0.66 3± 0 -1.1 0.253 -1.613 -0.587 <0.01*

The Mean VAS score was 1.1 points lesser at 25 min in the D group with

95% C.I ranging from -1.212 to -0.988 . The difference was statistically significant.

The Mean VAS score was 1.67 points lesser at 30 min in the D group

with 95% C.I ranging from -1.908 to -1.425 . The difference was statistically

significant.

The Mean VAS score was 2.056 points lesser at 45 min in the D group

with 95% C.I ranging from -2.269 to -1.843 . The difference was statistically

significant.

The Mean VAS score was 1.5 points lesser at 60 min in the D group with

95% C.I ranging from -1.743 to -1.257 . The difference was statistically significant.

The Mean VAS score was 1.1 points lesser at 75 min in the D group with

95% C.I ranging from -1.613 to -0.587 . The difference was statistically significant.

52  

Table 6

Mean Post OP Heart rate

Group D Group F Mean diff

S.E Mean diff

95% C.I p

value Lower

Upper

Heart rate baseline

72.30 ±1.71

72.27 ±1.44 0.03 0.41 -0.78 0.85 0.94

Heart rate 0 min 72.30± 1.71

72.33± 1.47 -0.03 0.41 -0.86 0.79 0.94

Heart rate 5 min 72.30± 1.71

72.33± 1.47 -0.03 0.41 -0.86 0.79 0.47

Heart rate 10 min 72.30± 1.71

72.33 ±1.47 -0.03 0.41 -0.86 0.79 0.10

Heart rate 15 min 72.30 ±1.71

72.63 ±1.81 -0.33 0.45 -1.24 0.58 <0.01*

Heart rate 20 min 72.30± 1.71

72.63± 1.81 -0.97 0.58 -2.13 0.20 <0.01*

Heart rate 25 min 72.30 ±1.71

77.23± 3.01 -4.93 0.63 -6.20 -3.67 <0.01*

Heart rate 30 min 72.30 ±1.71

82.33± 3.89 -10.03 0.78 -11.59 -8.48 <0.01*

Heart rate 45 min 72.93± 2.79

77.63± 2.95 -12.40 0.78 -13.96 -10.84 <0.01*

Heart rate 60 min 77.63 ±2.95

90.52± 3.76 -12.89 0.94 -14.78 -11.00 <0.01*

Heart rate 75 min 83.00± 4.36

94.00 ±0.82 -11.00 1.67 -14.40 -7.60 <0.01*

The Mean postop heart rate across both the groups are compared using independent

samples t test.

Patients in the D group had a lesser heart rate on average at 15 min, 20 min, 25 min, 30

min, 45 min, 60 min and 75 min. The difference was statistically significant

53  

Table 7

Mean Post OP Respiratory rate

Group D Group F Mean diff

S.E Mean diff

95% C.I p

value Lower

Upper

Respiratory rate baseline

12.43 ±0.50

12.50 ±0.51 -0.07 0.13 -0.33 0.20 0.61

RR 0 min 12.43± 0.50

12.50± 0.50 -0.07 0.13 -0.33 0.20 0.61

RR 5 min 12.43± 0.50

12.50± 0.50 -0.07 0.13 -0.33 0.20 0.61

RR 10 min 12.43± 0.50

12.50± 0.50 -0.07 0.13 -0.33 0.20 0.61

RR 15 min 12.43± 0.50

12.53± 0.51 -0.10 0.13 -0.36 0.16 0.45

RR 20 min 12.43± 0.50

12.67± 0.61 -0.23 0.14 -0.52 0.06 <0.01*

RR 25 min 12.43± 0.50

13.90± 1.01 -1.47 0.22 -1.90 -1.04 <0.01*

RR 30 min 12.43± 0.50

15.93± 1.66 -3.50 0.32 -4.13 -2.87 <0.01*

RR 45 min 12.63± 0.77

17.07± 1.47 -4.44 0.31 -5.05 -3.83 <0.01*

RR 60 min 14.00 ±1.01

18.33± 1.11 -4.33 0.30 -4.94 -3.73 <0.01*

RR 75 min 15.93± 1.82

19.14 ±0.90 -3.21 0.71 -4.66 -1.76 <0.01*

The Mean respiratory rate in the D group was lower than the F group from 20 min, 25

min, 30 min, 45 min, 60 min and 75 min. The difference was statistically significant.

Table 9

54  

Mean Intra OP MAP

Group D Group F Mean diff S.E Mean diff95% C.I

p value Lower Upper

MAP baseline 98.24 ±4.51 94.03 ±7.22 4.21 1.56 1.10 7.33 <0.01*

MAP 0 min 94.82± 4.21 90.7± 6.27 4.08 1.38 1.31 6.84 <0.01*

MAP 5 min 90.02± 2.36 86.55± 5.64 3.47 1.12 1.23 5.70 <0.01*

MAP 10 min 87.17± 3.50 83.01 ±6.60 4.17 1.37 1.43 6.90 <0.01*

MAP 15 min 84.04 ±3.33 80.03 ±5.62 4.01 1.19 1.62 6.40 <0.01*

MAP 20 min 82.06± 79.26 79.26± 5.94 2.80 1.35 0.10 5.50 <0.01*

MAP25 min 80.84±5.29 80.28± 5.48 0.56 1.37 -2.18 3.29 0. 69

MAP 30 min 79.91 ±4.24 81.74± 5.35 -1.83 1.25 -4.33 0.66 0.15

MAP 45 min 80.52± 4.09 79.82± 4.11 0.70 1.11 -1.53 2.92 0.53

MAP 60 min 80.84 ±5.09 79.96± 5.55 0.87 1.84 -2.84 4.59 0.64

MAP 75 min 81.14± 4.08 80.38 ±3.85 0.76 1.90 -3.19 4.71 0.69 The mean intra operative Mean arterial pressure across both the group are compared

using independent samples t test. Patients in the D group had a higher MAP on average

at baseline, 0 min, 5 min, 10 min, 15 min, 20 min. The difference was statistically

significant. There was no significant difference in the intraoperative MAP during 25

min, 30 min, 45 min, 60 min and 75 min

55  

Table 10

Mean Post OP MAP

Group D Group F Mean diff S.E Mean diff95% C.I

p valueLower Upper

MAP baseline 82.06 ±1.55 76.63 ±2.84 5.43 0.59 4.25 6.62 <0.01*

MAP 0 min 83.31± 1.49 77.54± 2.29 5.77 0.50 4.77 6.77 <0.01*

MAP 5 min 83.48± 0.95 76.93± 2.34 6.56 0.46 5.63 7.48 <0.01*

MAP 10 min 84.68± 0.86 77.80±2.43 6.89 0.47 5.95 7.83 <0.01*

MAP 15 min 85.28 ±1.50 78.62 ±2.06 6.67 0.47 5.73 7.60 <0.01*

MAP 20 min 86.15± 1.58 78.81± 2.59 7.34 0.55 6.23 8.45 <0.01*

MAP25 min 87.53 ±2.71 79.77± 4.05 7.76 0.89 5.97 9.54 <0.01*

MAP 30 min 88.57 ±2.51 83.55± 6.28 5.02 1.24 2.55 7.50 <0.01*

MAP 45 min 89.64± 2.85 87.00± 5.65 2.64 1.17 0.30 4.99 <0.01*

MAP 60 min 90.11 ±2.74 71.36± 3.81 -1.97 0.98 -3.93 0.00 <0.01*

MAP 75 min 90.82± 2.58 93.85 ±2.72 -3.03 1.10 -5.26 -0.80 <0.01*

MAP 90 min 91.86±2.40 71.90 ±3.97 19.96 0.95 18.04 21.88 <0.01*

MAP 120 min 92.75± 2.77 93.85± 2.72 -1.11 1.42 -4.18 1.96 0.45 The mean postoperative MAP across both the groups are analysed using independent

samples t test. Patients in the D group had a higher MAP on average post operatively till

90 minutes. The difference was statistically significant. The postop MAP at 120 did not

differ significantly between both the groups

56  

Table 11

Side effects Group D Group F

Bradycardia 6(20) 10(33.3)

Hypotension 6(20) 10(33.3)

Nausea/vomiting 6(20) 6(20)

Pruritus 0(0) 7(23.3) 6 subjects in the D group had bradycardia while 10 subjects in the F group had

bradycardia.

Hypotension occurred in 6 members of the D group in contrast to 10 in the F group.

Same number of subjects (6) had nausea and vomiting in both groups

Pruritus occurred in 7 members in the F group while none in the D group

  

Time taken for rescue analgesia

Group D Group F Mean diff

S.E Mean diff

95% Confidence Interval p

valueLower Upper

Time (min) 94.67± 17.17

56.50± 13.47 38.167 3.983 30.193 46.14

<0.01

  

Time taken for sensory block to regress to S1

Group D Group F Mean diff

S.E Mean diff

95% Confidence Interval

p valu

e Lower Upper

Time (min) 459.03± 56.927

358.97± 46.737

100.067 13.447 73.149

126.985

<0.01

  

Time taken for motor block to regress to BO

Group D Group F Mean diff

S.E Mean diff

95% Confidence Interval

p valu

e Lower Upper

Time (min) 288.63± 31.127

212.67± 38.976

75.967 9.107 57.719 94.215

<0.01

 

57  

Statistical Graph:  

 Figure 1 

   

  

Figure 2  

58  

  

Figure 3     

  

Figure 4      

59  

 Figure 5 

      

 Figure 6 

  

   

Time taken for rescue analgesia

Group D Group F Mean diff S.E Mean

diff

95% Confidence Interval p value

Lower Upper

Time (min) 94.67± 17.17 56.50± 13.47 38.167 3.983 30.193 46.14 <0.01

60  

  

Figure 7       

 Figure 8 

   

61  

 Figure 9 

  

  

Figure 10  

62  

 Figure 11 

   

Mean Intra OP MAP

Group D Group F Mean diff

S.E Mean diff

95% C.I p value

Lower Upper MAP baseline 98.24 ±4.51 94.03 ±7.22 4.21 1.56 1.10 7.33 <0.01

MAP 0 min 94.82± 4.21 90.7± 6.27 4.08 1.38 1.31 6.84 <0.01

MAP 5 min 90.02± 2.36 86.55± 5.64 3.47 1.12 1.23 5.70 <0.01

MAP 10 min 87.17± 3.50 83.01 ±6.60 4.17 1.37 1.43 6.90 <0.01

MAP 15 min 84.04 ±3.33 80.03 ±5.62 4.01 1.19 1.62 6.40 <0.01

MAP 20 min 82.06± 4.4 79.26± 5.94 2.80 1.35 0.10 5.50 <0.01

MAP25 min 80.84±5.29 80.28± 5.48 0.56 1.37 -2.18 3.29 0.69

MAP 30 min 79.91 ±4.24 81.74± 5.35 -1.83 1.25 -4.33 0.66 0.15

MAP 45 min 80.52± 4.09 79.82± 4.11 0.70 1.11 -1.53 2.92 0.53

MAP 60 min 80.84 ±5.09 79.96± 5.55 0.87 1.84 -2.84 4.59 0.64

MAP 75 min 81.14± 4.08 80.38 ±3.85 0.76 1.90 -3.19 4.71 0.69 

  

63  

  

 Figure 12 

     

 Figure 13 

 

64  

 Figure 14 

  

 Figure 15 

     

65  

 Figure 16 

         

 Figure 17 

 

66  

10.1 DISCUSSION Subarachnoid Block is a commonly used anaesthetic technique for lower

abdominal surgeries.Additives to spinal local anaesthetics Alpha2 agonist like

Dexmedetomidine have been shown to prolong the duration of both sensory and

motor blockade and to provide extended postop analgesia.

In this study 5μg of Dexmedetomidine was added to 15mg [3.0ml] of 0.5%

Hyperbaric Bupivacaine or 25μg of fentanyl added to 15mg [3.0ml] of 0.5%

Hyperbaric Bupivacaine and its efficacy as an adjuvant to subarachanoid Bupivacaine

was studied in 60 patients undergoing elective total abdominal hysterectomy.

ONSET OF SENSORY BLOCK

The mean time to onset of sensory Block (T10 level) was 2.97mins in the

Group D and 2.33 in theGroup F. patients in the F group required a shorter time to

achieve T10 level sensory block.

Subhi M Al-Ghanem et al. who compared the effect of 5μg Dexmedetomidine

Vs fentanyl 25μg in intra operative analgesia and the duration of sensory & motor

block when added to 10mg intrathecal plain Bupivacaine and observed that there

is no statistically significant difference between the two groups as regards to the

onset time of sensory block at T10 level.

Ibrahim F.a. Khalifa et al did a comparative study of adding intrathecal 5μg

Dexmedetomedine and 5μg of sufentanyl to 10mg of heavy Bupivacaine found that

there is no statistically significant difference in the onset of sensory block T10 level

Group D = 5.5±3.7, where Group 57 = 6.2±1.3 p < 0.69.

67  

MAXIMUM LEVEL OF SENSORY BLOCK The mean time taken to reach T6 level sensory block was 4.2mins in the Group

D and 3.5mins in the Group F. patients in Fgroup required 0.7less minutes on an

average to achieveT6 level sensory block.Kanazi et al found that there is statistically

no significant difference for the maximal sensory Block for 12mg Bupivacaine

0.5% alone or combined 3μg of Dexmedetomidine or 30μg of clonidine [p = 0.3].

Mahmoud M. Al Mustafa et al found that addition of intrathecal

Dexmedetomidine in increasing doses 5μg, 10mg of Dexmedetomidine with

12.5mg of Spinal Bupivacaine increased the level of sensory block as the dose

of Dexmedetomidine increases.

Ibrahim F.A. Khalifa et al found that there is statistically no significant

difference for the maximal sensory block when compared with 5μg of

Dexmedetomedine and 5μg of sufentanyl to 10mg of heavy Bupivacaine

The study Subhi M. Al Ghanem et al who found that addition of 5μg of

Dexmedetomidine and 25μg of fentanyl with 10mg of isobaric Bupivacaine

intrathecally had no significant difference on the mean time to reach peak sensory

level 19.34 ± 2.87 in Group D and 18.39 ± 2.46 in Group F p = 0.12.

ONSET OF MOTOR BLOCK

The mean time taken to reach T10 level motor block was 3 . 5 7 mins in the

Group D and 2.73 mins in the Group F. Patients in Fgroup required 0.833 less

minutes on an average to achieve T10 level motor block. Ibrahim F. A. Khalifa et al

found that there is statistically no significant difference with 5μg of

Dexmedetomidine and 5μg of sufentanyl to 10mg of heavy Bupivacaine on the

mean time to achieve bromage 3 score.

68  

DURATION OF SENSORY BLOCK

In our study the duration of sensory block was 358.97 ± 46.74 mins in Group F

and 459.03 ± 56.93 mins. The addition of 5μg of Dexmedetomidine to Hyperbaric

Bupivacaine significantly prolonged the duration of sensory block. [Intrathecal

Dexmedetomidine when combined with spinal Bupivacaine prolongs the sensory block

by depressing the release of c-fibres transmitters and by hyperolarization of post-

synaptic dorsal horn neurons].

This correlated with the study

• Subhi M. Al-Ghanem et al found that the addition of 5μg of

Dexmedetomidine to 10mg of isobaric Bupivacaine 274.83 ± 73.4

significantly prolong the duration of sensory blockade while 25μg of

fentanyl to 10mg of isobaric Bupivacaine was 179.5±47.4. There was

statistically significant difference among the two groups p < 0.00

[Intrathecal Dexmedetomidine when combined with spinal Bupivacaine

prolongs the sensory block by depressing the release of c-fibers

transmitters and by hyperpolarization of post-synaptic dorsal horn

neurons].

• Kanazi et al found that the addition of 3μg of Dexmedetomidine to 12mg of

intrathecal Bupivacaine or 30μg of clonidine significantly prolonged the

sensory block.

• Al Mustafa MM et al studied that there is a significant difference in the

duration of sensory block among three groups who received spinal

Bupivacaine 12.5mg alone or combined with 5μg of Dexmedetomidine or

69  

with 10μg of Dexmedetomidine. He concluded that Dexmedetomidine has

a dose dependent effect on the onset and regression of sensory and motor

block when used in SAB.

DURATION OF MOTOR BLOCK

In our study the mean duration of motor block was 212.67 ± 38.976 mins in

Group F and 288.63 ± 31.12 mins in Group D. The addition of 5μg of

Dexmedetomidine to 0.5% Bupivacaine significantly prolonged the duration of motor

block.

• Subi M. Al-Ghanem et al found in their study that 5μg of

Dexmedetomidine to 0.5% hyperbaric Bupivacaine prolonged effect of

motor blockade than 25μg of fentanyl to 0.5% hyperbaric Bupivacaine

intrathecally.

• Kanazi et al observed that addition of 12mg of Bupivacaine

supplemented with dexmedetomidine and 12mg of Bupivacaine with

30μg of clonidine intrathecally produces similar prolongation in the

duration of motor block when compared 12mg of Bupivacaine alone.

[The prolongation of motor block produced by subarachnoid Hyperbaric

Bupivacaine combined with 5μg of Dexmedetomidine results from

binding these agonist to motor neurons in the dorsal horn of the spinal

cord].

• Mahmoud M. Al Mustafa et al found that Dexmedetomidine has a dose

dependent effect on the duration of motor blockade when added to

70  

• Ibrahim F.A Khalifa et al found that the addition of 5μg of

Dexmedetomidine to 2ml of heavy Bupivacaine and 5μg of sufentanyl to

2ml of heavy bupieracaine produces a significant difference in the

duration of motor blockade.

Quality of Surgical anaesthesia The quality of surgical anaesthesia was excellent in both groups. Though studies have shown

• Ibrahim F.A. Khalifa et al found that the quality of surgical anaesthesia

was better in patients received 5μg sufentanyl to 2ml of heavy

Bupivacaine when compared to 5μg of Dexmedetomidine to 2ml of heavy

Bupivacaine

DURATION OF ANALGESIA

In our study the mean time for Rescue analgesia is 56.50 mins in Group F and

94.67 ± 17.17mins which was statistically significant difference in the duration of

analgesia by two groups

Though studies have shown Ibrahim F.A. Khalifa et al found that the addition of 5μg of Dexmedetomidine to

10mg of Hyperbaric Bupivacaine and 5μg of sufentanyl to 10mg of Hyperbaric

Bupivacaine intrathecally produces no significant difference in the duration of pain

relief Group SF = 265.8 ± 112.3, Group D = 240. 2±77.3 mins [p < 08].

71  

Complications

In our study the incidence of Hypotension was in 10 subjects in Group F and

6subjects in Group D. The most significant side effects reported about the use of

intrathecal α2 adrenoreceptor agonists are Bradycardia and hypotension. But in

present study these side effects were not significant because small dose of intrathecal

Dexmedetomidine was used.

This correlated with the study

• Kanazi et al studied that the addition of Dexmedetomidine or clonidine to

Bupivacaine did not cause a significant decrease in the Blood pressure

intraoperatively or postoperatively. Intrathecal local anaesthetics block

the sympathetic outflow and reduce the blood pressure. The sympathetic

block is usually near-maximal with the doses used for spinal anaesthesia.

The addition of a low dose of α2 agonist to a high dose of local

anaesthetics does not further affect the near maximal sympatholysis.

• Ibrahim F.A. Khalifa et al found that the addition of 5μg of

Dexmedetomidine to spinal Bupivacaine and 5μg of sufentanyl to spinal

Bupivacaine did not produce a significant difference in the incidence of

hypotension.

• Subi M. Al-Ghanem found that hypotension was more in fentanyl group

than in the Dexmedetomidine group but it did not reach a significant

difference. Mean while, hypotension occurred 25-30 minutes after spinal

injection in 2 patients in the Dexmedetomidine group and one patient in

fentanyl group had mild episodes of Hypotension in PACU.

72  

The incidence of brady cardia was in6 subjects Group D and in10 subjects in Group

F .

Ibrahim F.A. Khalifa et al found that there is statistically no significantly

difference in the incidence of Bradycardia in both the groups with 5μg of

sufentanyl to 10mg of 0.5% Bupivacaine and 5μg of Dexmedetomidine to

10mg of 0.5% Bupivacaine.

Subi-M-Al-Ghanem et al found that there is statistically no significant

difference in the incidence of Brady cardia among two groups of 5μg of

Dexmedetomidine to 10mg of isobaric Bupivacaine and 25μg of fentanyl to

10mg of isobaric Bupivacaine intrathecally.

The incidence of pruritus was in 7 subjects in Group F and none in Group D. There

is statistically significant difference among two groups.

This correlates with the study

Ibrahim F.A. Khalifa et al found that there is significant difference in the

incidence of pruritus in the sufentanyl group.

Subi M. Al. Ghanem found that there is statistically significant difference in the

incidence of pruritus. Pruritus after intrathecal fentanyl is reported to be 40-

70% but if was only 13% in present study which can be explained by the fact

that pruritus is a benign subjective symptom which is under reporting and

usually needs to treatment

Bogra J. Srivastara P et al found there is statistically significant difference

in the incidence of pruritus with 10mg of fentanyl, 12.5mg of fentanyl, added

to hyperbaric Bupivacaine.

73  

The incidence of vomiting, sedation, was not statistically significant in both the groups.

This correlated with the study

Kanazi et al found that intrathecally administrated α2 agonist have a dose-

dependent sedative effect (36,37). The doses of clonidine and

dexmedotomedine selected in their study were at the lower end of the

dosing spectrum. This explains the lack of sedative effects between the study

groups B and C and the intraoperative anxiety one patient in Group D.

74  

10.2 SUMMARY

This double blinded prospective randomized controlled trial was designed to

evaluate the onset and duration of sensory and motor block as well as operative

analgesia and adverse effects of Dexmedetomidine vs fentanyl given intrathecally

with heavy 0.5% Bupivacaine for spinal anaesthesia in patients scheduled for total

abdominal hysterectomy, patients receiving 25μg of fentanyl with 3.0cc of

Bupivacaine intrathecally served as the control.

The Following observations were made:

The addition of Dexmedetomidine significantly prolonged the duration of

sensory and motor block.

The addition of Dexmedetomidine significantly prolonged the time for

demand analgesia.

The addition of Dexmedetomidine intrathecally prolonged onset of sensory

or motor block when compared with fentanyl.

The incidence of side effects was limited to the occurence of Hypotension,

Bradycardia in the groups that received Dexmedetomidine intrathecally.

The incidence of pruritus were more in the groups that received fentanyl

intrathecally.

The addition of Dexmedetomidine intrathecally had similar effect on

sedation when compared to fentanyl.

75  

10.3 CONCLUSION

Intrathecal Dexmedetomidine supplementation of spinal block seems to be a

good alternative to intrathecal fentanyl since it produces prolonged sensory block and

motor block. It is evident that this type of block may be more suitable for lower

abdomen and lower extremities surgeries.

A drawback of Dexmedetomidine supplemented spinal block characteristics is the

increase in the duration of motor block which may not suit short term surgical

procedures or ambulatory surgery.

 

11.0 BIBLIOGRAPHY   

1. Bogra, J., Srivastava, P., et. al., Studied the Synergistic Effect

of Intrathecal Fentanyl and Bupivacaine in Spinal Anaesthesia for

LSCS BMC Anaesthesiology 2005 May 17; 5(1); 5.

2. Eisanach J.C. [1996] ; Dekock M. Klimscha W. α2 Adrenergic

Agonists for Reginol Anesthesia. Anesthesiology; 85; 655 – 74

3. Eisanach, JC., Dekock, M., Klimscha, W. α2 Adrenersic against

for Regional Anaesthecia, Anaesthesiology 1996; 85; 655 – 74

4. Fukushima, K., Nishmi, Y., Mor, K, Takeda, J. Effect of

Epidurally Administered Dexmedetomidine on Sympathetic

Activity and Post Operative Pain in Man. Anesth Analg 1996; 82;

5(2).

5. Guo et. al. Dexmedetomidine injection into the Locus Ceruleus

Produces Antinociception Anesthesiology 1996; 84; 873 – 81

6. El. Hennawy Am et. al., addition of Clonidine or

Dexmedetomidine to Bupivacaine Prolong Caudal Analgesia in

Children. British J Anaesth. 2009. Aug 103(2); 268 – 74, Epub

2009, Jun 18.

7. Ibrahim, F.A. Khalifa, A Comparative Study of adding intrathecal

Dexmedetomedine Versus Sufentanyl to Heavy Bupivacaine for

Postop Analgesia in Patients Undergoing Inguinal Hernia Repair –

Benha M J. Vol. 26, No. 3, Sept. 2009.

 

8. Kalso E. Poyhia R, Rusenberg P. Spinal Nociception by

Dexmedetomidine, a highly selective α2 – advenergic agonist.

Pharmacol. Toxicol 1991; 68; 140 – 3.

 

9. Kanazi G.E., Effect of Low Dose Dexmedetomidine or Clonidine

on the Characteristic of Bupivacaine Spinal Block Acta

Anaesthesiol Scan 2006; 50; 222 – 227

 

10. S. Konaki, The Efficecy and Neurotoxicity of Dexmedetomidine

administered via the Epiduarl Route - European Journal of

Anaesthesiology 2008; 403 – 409.

 

11. Lawhead R.G., Blaxall, H.S. and Bylund, B.D. (1992); Alpha 2A

is the Predominant α2 Adrenergic Receptor Subtype in Human

Spinal Card Anesthesiology 77; 983 – 91

 

12. Mahmud M. Al-Mustafq, Effect of dexmedotomidine added to

spinal Bupivacaine for Urological Procedures; Saudi Med j 2009;

Vol 30 [3]; 365 – 70.

 

13. Maroof et. al., Anaesthesiology. It has been used in Epidural Space

in Humans with out any reports of Neurological Deficit –

Anaesthesiology 2004; 101; A495.

 

14. Pedersen H, Santos CA, Stinberg ES et. Al., Incidence of

Visceral Pain during Cesarean Section; the Effect of Varying

Doses of Spinal Bupivacaine; Anesth Analy 1992; 69; 46 – 9

 

 

15. I. Saadawy, Effect of Dexmedetomidine on the Characteristics

of Bupivacaine in a Caudal Block in Pediatrics – Acta

Anaesthesiol Scand 2009; 53; 251 – 256.

 

16. Salgado PF – Synergistic Effect between Dexmeditomidine and

0.75% Ropivacaine in Epiduaral Anaesthesia – Rev. Assoc. Med

Bias 2008 Mar. – Apr. 54(2); 110 – 5.

 

17. Seewal, R., Effect of Addition of Various Doses of Fentanyl

intrathecally to 0.5% Bupivacaine on Perioperative Analgesia

and Subarachanoid Block Characteristic in Lower Abdominal

Surgery – Reg. Anesth Pain Med 2007, Jan – Feb 32(1); 20 – 6

 

18. Seewal, R., Shende, D., Kashyap, L., Mohan, V. Effect of Addition

of Various Doses of Fentanyl Intrathecally to 0.5% Hyperbaric

Bupivacaine on Perioperative Analgesia and Subarachnoid Block

Characteristics in Lowere Abdominal Surgery; a Dose response

Study Reg. Anesth Pain Med. 2007 Jan – Feb; 32(1)-20-6

 

19. Subhi M. Al-Ghanem, Effect of adding Dexmedetomidine versus

Fentanyl to intrathecal Bupivacaine on Spinal Block for

Gynaecological Procedures; American Journal of Applied

Science 6 [5]; 882 – 887, 2009.

 

20. DXM enhances the local anaesthestic action of Lignocaine via an

α2 adrenoreceptor – Anesth. Analg 2008; 101; 96 – 101.

 

 

21. Effects of Intrathecel Fentanyl, Sufentanil and Placebo with

Bupivacaine for Electric Caesarean Section. Aneshthe Analgesia.,

Dec [85]; 1288 – 93[s].

 

 

 

 

 

 

 

 

 

 

 

ANNEXURES

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                                              INFORMATION TO PARTICIPANTS INVESTIGATOR                      :       Dr.  SIVASHANKARI.K  NAME OF THE PARTICIPANT: TITLE: “Effect of adding dexmedetomidine versus fentanyl to intrathecal bupivacaine on 

spinal block characteristics in gynaecological procedures: A double blind controlled 

study”. 

You are invited to take part in this research study. We have got approval from the IEC. You 

are asked  to participate because you  satisfy  the eligibility criteria. We want  to compare 

and study  the  level of sensory and motor block,  Intraoperative pain and safety of giving 

dexmedetomidine  versus  fentanyl  with  bupivacaine  on  spinal  block  characteristics  in 

gynaecological surgery. 

WHAT IS THE PURPOSE OF THE RESEARCH: 

For  gynaecological  surgery,  Inj  dexmedetomidine/fentanyl  is  added  to  bupivacaine  for 

spinal block to study 

4. Complication rate 

THE STUDY DESIGN: All the patients in the study will be divided into two groups. 

Group1‐inj dexmedetomidine with inj bupivacaine(0.5%) for spinal block 

Group 2‐inj fentanyl with inj bupivacaine(0.5%)for spinal block  

 BENEFITS Onset,  density  and  post‐operative  analgesia  are  better  with  dexmetedomidine  than fentanyl 

 DISCOMFORTS AND RISKS  Damage to neuro vascular structure.  

Hypotension 

Nausea and vomiting 

Headache 

  

This intervention has been shown to be well tolerated as shown by previous studies and if 

you do not want to participate you will have alternative of setting the standard treatment 

and your safety is our prime concern. 

 

 

1. To evaluate the onset and duration of sensory and motor block 

2. To assess  intra operative  haemodynamics 

3. To monitor postoperative analgesia. 

 

 

Confidentiality  of  data  and  details  of  study  and  patient  details  concerned  with  this 

research will be strictly maintained. 

Time  : 

Date  : 

Place  : 

 Signature / Thumb Impression of Patient Patient Name: 

 Signature of the Investigator  : ____________________________ Name of the Investigator  : ____________________________   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT CONSENT FORM 

STUDY TITLE: “Effect of adding dexmedetomidine versus fentanyl to intrathecal bupivacaine on spinal block characteristics in gynaecological procedures:A double blind controlled study”   

STUDY CENTER:   DEPARTMENT OF ANAESTHESIOLOGY, 

                               INSTITUTE OF OBSTETRICS AND GYNAECOLOGY, 

                               RAJIV GANDHI GOVT. GENERAL HOSPITAL,  

                               MADRAS MEDICAL COLLEGE, 

                               CHENNAI‐ 600008. 

Participant name:                                                Age:                         Sex:                                

I.P.No: 

 

 

         I confirm that I have understood the purpose of procedure for the above 

study. I have the opportunity to ask the question and all my questions and doubts have 

been answered to my satisfaction. 

                        I have been explained about the pitfall in the procedure.  I have been 

explained about the safety, advantage and disadvantage of the technique. 

 

                        I understand that my participation in the study is voluntary and that I am 

free to withdraw at anytime without giving any reason. 

 

                        I understand that investigator, regulatory authorities and the ethics 

committee will not need my permission to look at my health records both in respect to 

current study and any further research that may be conducted in relation to it, even if I 

withdraw from the study. I understand that my identity will not be revealed in any 

information released to third parties or published, unless as required under the law. I 

agree not to restrict the use of any data or results that arise from the study. 

Time:          

Date:                                                                                             Signature / thumb impression of 

patient  

Place:                                                                                            Patient name: 

 

Signature of the investigator: 

Name of the investigator: 

 

 

PROFORMA 

DATE:                ROLL NO:                

NAME:    

AGE:                            SEX:                          IP NO: 

DIAGNOSIS: 

 

SURGICAL PROCEDURE : 

HT:                                                                       CVS:                                    HB: 

 

Wt:                                                                       RS: 

 

AIRWAY: MMS ‐        IID      ‐      

  DENTITION ‐    

 

Examination of spine:              

   ASA: 

PRE OP ASSESSMENT: 

 

HISTORY:    Any Co‐morbid illness 

                     H/O Documented Difficult Airway 

                      H/O previous surgeries/treatment 

                      H/O Difficult spinal anaesthesia 

MEASURES OF STUDY OUTCOME: 

 

 SPINAL ANAESTHESIA :   Drugs   

1. ONSET OF SENSORY BLOCKADE (IN MINS): 

REGRESSION TO S1(IN MINS): 

 

2. ONSET OF MOTOR BLOCKADE (IN MINS): 

REGRESSION TO B0(IN MINS): 

 

 

3. HEMODYNAMICS: INTRA OPERATIVE 

  

 

 

 

 

 

Events  Time  Systolic  BP

(mmHg) 

Diastolic BP

(mmHg) 

Heart rate

Beats/min 

SPO2 

Baseline       

 Immediately 

after spinal 

anaesthesia 

     

  5 mins        

 10 mins       

 15 mins       

 20 mins       

30 mins       

45 mins       

60mins       

75 mins       

90 mins       

2 hrs       

2.30hrs       

3hrs       

3.30hrs       

4hrs       

 

4. POST OPERATIVE ANALGESIC INITIATION TIME: 

TIME  0 

mi

n 

05  

mi

n 

10 

mi

n 

 

15 

mi

n 

20 

Mi

n 

25

Mi

n 

30

Mi

n 

45

mi

n 

60

mi

n 

75

mi

n 

90

mi

n 

2

h

rs 

4

h

rs 

6 

h

rs 

1

2 

h

rs 

2

4 

H

rs 

4

8 

h

rs 

2

4 

VAS                 

HR                 

SBP                 

DBP                 

Respira

tory 

rate 

               

Resque 

analges

ia 

               

 

 

5. COMPLICATIONS: 

Bradycardia/Hypo tension/Nausea and Vomiting/ Pruritis.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SENSORY BLOCK MOTOR BLOCK

T10 T6 T10 T6 REGRESS TO S1 IN MINSREGRESS TO BO IN

MINS

1 SUMATHY 50 11062 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 3 5 90 NIL 487 248

2 SUGUNA 38 10358 F ABNORMAL UTERINE BLEEDING WITH BULKY UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 5 4 6 75 NIL 512 288

3 JANAVI 52 10952 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 4 6 90 NIL 390 271

4 AGNES 49 11040 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 3 5 75 NIL 487 293

5 SARALA 36 11048 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY I 4 6 5 7 75 NIL 436 2876 SUMATHY 35 10962 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY II 3 4 3 5 75 NIL 465 3357 ABI BUMA 42 10969 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 3 5 4 6 90 NIL 480 2568 SELVI 39 10920 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY I 3 4 3 5 75 NIL 421 267

9 MAHESHWARI 39 10822 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 4 5 60 NIL 564 303

10 JAYA 40 10824 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 4 5 60 NIL 390 211

11 JOTHI 49 10822 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 3 4 75 NIL 549 293

12 NESAMANI 50 10988 F POST MENOPAUSAL BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 4 5 4 6 60 NIL 396 277

13 VIJAYA 44 11040 F ABNORMAL UTERINE BLEEDING WITH FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 3 5 75 NIL 466 362

14 RANI 44 11072 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY I 3 4 4 5 60 NIL 579 272

15 SELVI 48 11168 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 3 4 60 NIL 376 342

16 JAYANTHI 36 11270 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY I 2 3 3 5 75 NIL 425 300

17 MAHA DEVI 44 11270 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 4 3 5 60 NIL 570 320

18 LAKSHMI 52 11072 F CHRONIC CERVICITIS WITH PELVIC INFLAMMATORY DISEASE TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 5 6 75 NIL 380 300

19 KANNAGI 49 11270 F POST MENOPAUSAL BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 4 5 90 NIL 489 338

20 LOGANAYAGI 45 11072 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 4 4 5 60 NIL 497 280

21 PRIYA 42 11270 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY I 3 4 4 6 75 NIL 437 267

22 BANUMATHY 48 11370 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 2 3 3 4 60 NIL 490 252

23 VEDHANAYAGI 46 11380 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY I 3 4 3 5 75 NIL 475 325

24 SARASWATHI 50 11486 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY II 3 5 4 6 60 NIL 400 277

25 DURGADEVI 38 11570 F FIBROID UTERUS WITH POLYP TOTAL ABDOMINAL HYSTERECTOMY I 3 5 3 5 90 NIL 430 28026 KANNANMAL 42 11672 F ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY I 2 3 3 4 75 NIL 450 290

27 MEENA 40 11560 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOO PHERECTOMY I 3 5 4 6 60 NIL 465 270

28 SAVEETHA 39 11462 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY I 3 4 4 6 60 NIL 425 29029 SAVITHRI 48 11560 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 3 5 3 5 75 NIL 440 28530 LEELAVATHI 40 11672 F FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 3 4 3 5 60 NIL 400 280

ONSET OF SENSORY BLOCK (IN MIN)

ONSET OF MOTOR BLOCK

(In MINS)DUATION OF

SURGERY (IN MINS)

RESCUE ANALGESIA (IN MINS)

ASA GROUPPROCEDURE

GROUP D INJECTION 0.5% BUPIVACAINE WITH 5 MICROGRAM DEXMETEDOMIDINE IN L3 L4 SPACE .DESIRED LEVEL OF BLOCK T6.

IP NO. DIAGNOSISS.NO NAME AGE SEX

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

75(In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 96 90 89 85 80 79 76 74 72 71 70 722 SUGUNA 38 10358 F 88 84 80 77 74 73 72 69 70 71 723 JANAVI 52 10952 F 92 90 84 83 80 76 74 67 66 65 65 694 AGNES 49 11040 F 87 80 76 72 67 65 66 68 67 64 665 SARALA 36 11048 F 84 82 79 73 75 74 75 73 72 71 736 SUMATHY 35 10962 F 82 81 78 72 70 71 72 73 75 72 707 ABI BUMA 42 10969 F 79 76 73 70 68 71 72 74 72 71 70 718 SELVI 39 10920 F 76 73 70 71 69 68 70 71 72 73 709 MAHESHWARI 39 10822 F 79 75 72 70 71 72 73 70 69 71

10 JAYA 40 10824 F 77 72 70 69 68 70 71 73 74 7211 JOTHI 49 10822 F 76 73 70 71 69 70 72 73 70 71 7212 NESAMANI 50 10988 F 88 82 78 74 71 68 65 64 66 6513 VIJAYA 44 11040 F 82 81 79 76 75 76 77 74 72 73 7414 RANI 44 11072 F 87 84 79 78 81 76 76 75 74 7515 SELVI 48 11168 F 79 78 76 73 72 71 70 69 74 7316 JAYANTHI 36 11270 F 78 76 75 74 72 70 71 69 68 70 7117 MAHA DEVI 44 11270 F 79 75 72 71 69 67 65 62 65 6718 LAKSHMI 52 11072 F 78 78 78 71 69 68 71 73 74 75 7719 KANNAGI 49 11270 F 76 74 73 71 68 70 71 72 73 74 74 7820 LOGANAYAGI 45 11072 F 87 85 82 78 77 73 72 74 72 7021 PRIYA 42 11270 F 88 84 82 76 73 70 69 67 70 73 7122 BANUMATHY 48 11370 F 79 78 76 74 70 69 67 65 61 6023 VEDHANAYAGI 46 11380 F 79 76 72 71 69 68 70 71 73 71 7024 SARASWATHI 50 11486 F 76 74 74 73 70 69 68 71 73 7625 DURGADEVI 38 11570 F 78 76 75 74 72 73 71 70 69 70 71 7226 KANNANMAL 42 11672 F 88 87 82 81 78 76 75 72 73 72 7327 MEENA 40 11560 F 86 87 84 80 79 78 74 73 70 7128 SAVEETHA 39 11462 F 87 85 80 77 76 73 72 71 70 7229 SAVITHRI 48 11560 F 84 84 78 74 70 68 66 63 61 64 6230 LEELAVATHI 40 11672 F 87 83 82 79 78 74 73 71 73 72

AGE SEXS.NO NAMESHEART RATE

IP NO

GROUP D

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

75(In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 132/70 130/90 126/78 124/86 120/70 110/70 106/68 104/64 106/70 110/86 112/78 114/722 SUGUNA 38 10358 F 138/88 134/82 128/74 120/68 112/68 110/64 106/60 104/62 108/70 110/70 112/703 JANAVI 52 10952 F 142/90 136/74 130/70 122/68 110/64 102/62 100/60 96/62 94/62 92/60 94/62 96/644 AGNES 49 11040 F 140/90 138/90 128/72 120/60 108/68 100/62 96/64 98/64 99/62 100/60 102/625 SARALA 36 11048 F 138/76 136/74 128/76 120/72 116/70 110/72 106/70 104/68 108/70 110/68 108/706 SUMATHY 35 10962 F 136/78 130/70 124/72 116/68 112/68 108/70 106/72 110/70 114/70 116/72 112/687 ABI BUMA 42 10969 F 146/86 136/80 130/70 122/68 120/70 112/70 108/68 112/70 114/72 116/70 114/68 112/708 SELVI 39 10920 F 136/78 130/70 128/68 120/70 114/68 108/68 110/70 106/68 108/70 106/64 108/689 MAHESHWARI 39 10822 F 132/78 130/72 126/72 124/70 118/68 108/62 106/68 108/70 110/72 112/70

10 JAYA 40 10824 F 140/76 136/76 130/70 122/70 110/68 106/70 104/68 102/70 108/72 114/7011 JOTHI 49 10822 F 136/74 130/70 122/72 118/70 114/70 110/7o 108/72 110/70 108/72 106/68 110/7012 NESAMANI 50 10988 F 132/70 128/74 114/68 104/68 100/62 94/62 90/60 92/64 94/68 96/6813 VIJAYA 44 11040 F 136/78 130/72 122/72 118/70 108/72 110/70 108/72 112/70 108/72 106/68 110/7014 RANI 44 11072 F 136/72 130/68 128/64 122/68 120/70 116/78 112/70 110/68 108/62 104/6815 SELVI 48 11168 F 136/70 134/72 126/68 122/68 120/70 116/70 110/72 106/70 108/72 106/6816 JAYANTHI 36 11270 F 140/72 132/70 128/70 120/68 118/64 110/62 106/64 108/60 106/62 104/64 110/6217 MAHA DEVI 44 11270 F 142/78 136/70 130/68 120/68 110/64 102/62 100/60 96/60 94/62 92/6018 LAKSHMI 52 11072 F 138/76 136/74 128/70 120/70 120/60 118/62 110/64 106/68 108/70 112/70 114/7019 KANNAGI 49 11270 F 144/70 142/70 136/70 132/74 126/70 122/70 118/70 112/72 110/68 112/70 108/70 108/7220 LOGANAYAGI 45 11072 F 138/78 136/76 130/72 128/68 120/70 116/70 112/70 110/70 112/72 114/7021 PRIYA 42 11270 F 136/74 130/70 126/72 120/70 122/72 118/68 116/70 114/72 112/70 112/72 110/7022 BANUMATHY 48 11370 F 140/72 134/72 130/70 124/72 120/70 116/72 112/70 100/60 96/64 94/6223 VEDHANAYAGI 46 11380 F 136/78 132/72 128/72 120/72 116/70 110/70 106/72 108/70 106/72 104/68 104/6224 SARASWATHI 50 11486 F 138/80 134/76 130/70 122/72 118/68 114/62 108/60 110/62 108/64 112/7225 DURGADEVI 38 11570 F 140/82 132/80 130/78 124/72 118/70 114/68 110/64 106/62 108/60 106/62 108/60 110/7026 KANNANMAL 42 11672 F 138/84 134/80 128/70 124/72 120/70 116/70 112/72 108/68 106/62 104/68 106/7027 MEENA 40 11560 F 142/84 138/80 130/70 126/72 124/68 120/70 116/70 114/72 110/68 112/7028 SAVEETHA 39 11462 F 136/82 130/80 120/76 118/72 110/70 112/70 108/72 104/70 106/70 110/7029 SAVITHRI 48 11560 F 138/84 132/80 122/74 110/70 102/66 98/64 96/64 96/62 98/64 98/66 100/7030 LEELAVATHI 40 11672 F 144/80 140/80 132/74 128/72 122/70 116/72 118/70 114/68 116/64 114/62

S.NO NAMES AGE SEX

BLOOD PRESSURE(SBP/DBP)GROUP D

IP NO

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

75(In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%2 SUGUNA 38 10358 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%3 JANAVI 52 10952 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%4 AGNES 49 11040 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%5 SARALA 36 11048 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%6 SUMATHY 35 10962 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%7 ABI BUMA 42 10969 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%8 SELVI 39 10920 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%9 MAHESHWARI 39 10822 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

10 JAYA 40 10824 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%11 JOTHI 49 10822 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%12 NESAMANI 50 10988 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%13 VIJAYA 44 11040 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%14 RANI 44 11072 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%15 SELVI 48 11168 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%16 JAYANTHI 36 11270 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%17 MAHA DEVI 44 11270 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%18 LAKSHMI 52 11072 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%19 KANNAGI 49 11270 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%20 LOGANAYAGI 45 11072 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%21 PRIYA 42 11270 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%22 BANUMATHY 48 11370 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%23 VEDHANAYAGI 46 11380 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%24 SARASWATHI 50 11486 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%25 DURGADEVI 38 11570 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%26 KANNANMAL 42 11672 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%27 MEENA 40 11560 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%28 SAVEETHA 39 11462 F 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%29 SAVITHRI 48 11560 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%30 LEELAVATHI 40 11672 F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

S.NO NAMES AGE SEX

SPO2GROUP D

GROUP D (Post operative analgesia initiation time)

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

70 (In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 0 0 0 0 0 0 0 0 1 2 3 - -2 SUGUNA 38 10358 F 0 0 0 0 0 0 0 0 0 1 1 2 33 JANAVI 52 10952 F 0 0 0 0 0 0 0 0 1 2 3 - -4 AGNES 49 11040 F 0 0 0 0 0 0 0 0 0 1 2 3 -5 SARALA 36 11048 F 0 0 0 0 0 0 0 0 0 1 1 2 36 SUMATHY 35 10962 F 0 0 0 0 0 0 0 0 0 1 1 2 37 ABI BUMA 42 10969 F 0 0 0 0 0 0 0 0 0 1 2 3 -8 SELVI 39 10920 F 0 0 0 0 0 0 0 0 0 1 2 3 -9 MAHESHWARI 39 10822 F 0 0 0 0 0 0 0 0 0 1 2 3 -

10 JAYA 40 10824 F 0 0 0 0 0 0 0 0 0 1 2 3 -11 JOTHI 49 10822 F 0 0 0 0 0 0 0 0 0 1 2 3 -12 NESAMANI 50 10988 F 0 0 0 0 0 0 0 0 1 2 3 - -13 VIJAYA 44 11040 F 0 0 0 0 0 0 0 0 0 1 1 2 314 RANI 44 11072 F 0 0 0 0 0 0 0 0 0 1 2 3 -15 SELVI 48 11168 F 0 0 0 0 0 0 0 0 0 1 2 3 -16 JAYANTHI 36 11270 F 0 0 0 0 0 0 0 0 0 1 1 2 317 MAHA DEVI 44 11270 F 0 0 0 0 0 0 0 0 0 1 2 3 -18 LAKSHMI 52 11072 F 0 0 0 0 0 0 0 0 1 2 3 - -19 KANNAGI 49 11270 F 0 0 0 0 0 0 0 0 0 1 2 3 -20 LOGANAYAGI 45 11072 F 0 0 0 0 0 0 0 0 0 1 2 3 -21 PRIYA 42 11270 F 0 0 0 0 0 0 0 0 0 1 2 3 -22 BANUMATHY 48 11370 F 0 0 0 0 0 0 0 0 0 1 2 3 -23 VEDHANAYAGI 46 11380 F 0 0 0 0 0 0 0 0 0 1 2 3 -24 SARASWATHI 50 11486 F 0 0 0 0 0 0 0 0 1 2 3 - -25 DURGADEVI 38 11570 F 0 0 0 0 0 0 0 0 0 1 1 2 326 KANNANMAL 42 11672 F 0 0 0 0 0 0 0 0 0 1 1 2 327 MEENA 40 11560 F 0 0 0 0 0 0 0 0 0 1 2 3 -28 SAVEETHA 39 11462 F 0 0 0 0 0 0 0 0 0 1 1 2 329 SAVITHRI 48 11560 F 0 0 0 0 0 0 0 0 0 1 2 3 -30 LEELAVATHI 40 11672 F 0 0 0 0 0 0 0 0 0 1 2 3 -

S.NO NAMES AGE SEX

VISUAL ANALOG SCALE

IP NO

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

70 (In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 75 75 75 75 75 75 75 75 80 84 94 - -2 SUGUNA 38 10358 F 73 73 73 73 73 73 73 73 73 76 78 85 923 JANAVI 52 10952 F 72 72 72 72 72 72 72 72 77 84 90 - -4 AGNES 49 11040 F 73 73 73 73 73 73 73 73 73 76 84 93 -5 SARALA 36 11048 F 70 70 70 70 70 70 70 70 70 75 80 83 956 SUMATHY 35 10962 F 71 71 71 71 71 71 71 71 71 76 79 85 927 ABI BUMA 42 10969 F 72 72 72 72 72 72 72 72 72 75 80 88 -8 SELVI 39 10920 F 74 74 74 74 74 74 74 74 74 76 83 90 -9 MAHESHWARI 39 10822 F 74 74 74 74 74 74 74 74 74 78 84 91 -

10 JAYA 40 10824 F 71 71 71 71 71 71 71 71 71 76 81 87 -11 JOTHI 49 10822 F 71 71 71 71 71 71 71 71 71 75 80 85 -12 NESAMANI 50 10988 F 74 74 74 74 74 74 74 74 75 81 85 - -13 VIJAYA 44 11040 F 71 71 71 71 71 71 71 71 71 76 79 84 9014 RANI 44 11072 F 74 74 74 74 74 74 74 74 74 77 83 92 -15 SELVI 48 11168 F 74 74 74 74 74 74 74 74 74 78 82 91 -16 JAYANTHI 36 11270 F 71 71 71 71 71 71 71 71 71 76 77 83 8917 MAHA DEVI 44 11270 F 70 70 70 70 70 70 70 70 70 76 80 86 -18 LAKSHMI 52 11072 F 75 75 75 75 75 75 75 75 79 84 94 - -19 KANNAGI 49 11270 F 70 70 70 70 70 70 70 70 70 75 84 88 -20 LOGANAYAGI 45 11072 F 74 74 74 74 74 74 74 74 74 78 85 90 -21 PRIYA 42 11270 F 70 70 70 70 70 70 70 70 70 79 82 91 -22 BANUMATHY 48 11370 F 73 73 73 73 73 73 73 73 73 77 85 94 -23 VEDHANAYAGI 46 11380 F 72 72 72 72 72 72 72 72 72 80 83 89 -24 SARASWATHI 50 11486 F 75 75 75 75 75 75 75 75 79 84 89 - -25 DURGADEVI 38 11570 F 71 71 71 71 71 71 71 71 71 75 79 85 9226 KANNANMAL 42 11672 F 71 71 71 71 71 71 71 71 71 75 78 84 9127 MEENA 40 11560 F 73 73 73 73 73 73 73 73 73 78 84 90 -28 SAVEETHA 39 11462 F 70 70 70 70 70 70 70 70 70 77 78 85 8829 SAVITHRI 48 11560 F 74 74 74 74 74 74 74 74 74 77 85 90 -30 LEELAVATHI 40 11672 F 71 71 71 71 71 71 71 71 71 75 85 90 -

GROUP D

S.NO NAMES AGE SEX

HEART RATE

IP NO

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

70 (In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 110/70 112/72 114/68 116/70 114/68 116/70 114/68 120/72 124/70 126/72 128/742 SUGUNA 38 10358 F 108/72 112/70 110/72 112/72 110/70 116/72 118/72 120/70 122/70 120/70 128/74 130/70 134/763 JANAVI 52 10952 F 104/68 106/70 108/68 112/70 110/72 112/68 110/68 112/70 110/72 120/744 AGNES 49 11040 F 102/70 106/68 110/68 112/70 110/72 112/70 114/72 116/70 118/72 120/70 126/72 128/705 SARALA 36 11048 F 106/72 108/74 110/70 112/74 116/70 118/72 120/72 122/72 124/72 126/72 128/74 130/70 132/706 SUMATHY 35 10962 F 102/70 106/74 108/70 110/72 112/72 114/70 110/74 112/72 110/70 112/76 114/72 122/72 126/707 ABI BUMA 42 10969 F 104/72 108/72 108/70 110/74 114/70 116/72 118/74 122/76 124/78 126/78 130/78 128/728 SELVI 39 10920 F 104/68 106/70 108/70 110/70 112/68 114/70 116/72 118/74 120/72 122/70 124/72 128/709 MAHESHWARI 39 10822 F 106/70 108/72 110/70 112/70 114/72 116/70 118/72 120/70 122/72 124/70 122/74 128/76

10 JAYA 40 10824 F 108/68 106/70 108/72 108/74 112/70 114/72 116/72 118/70 120/72 122/70 124/72 128/7211 JOTHI 49 10822 F 104/64 104/68 108/70 110/72 114/74 116/72 118/70 122/72 124/70 122/72 124/70 130/8012 NESAMANI 50 10988 F 106/68 108/68 108/70 110/72 112/70 116/72 118/70 120/72 120/72 122/70 124/7213 VIJAYA 44 11040 F 108/70 110/70 112/72 114/70 114/72 116/70 118/72 120/70 122/72 124/70 130/72 132/74 130/7214 RANI 44 11072 F 106/72 104/70 108/72 112/70 110/72 112/70 114/70 116/74 120/76 122/72 126/74 130/7615 SELVI 48 11168 F 108/72 106/70 110/72 112/72 110/70 114/72 116/70 118/72 120/70 122/70 126/74 124/7216 JAYANTHI 36 11270 F 104/70 106/72 108/70 110/70 112/72 114/70 116/72 118/70 120/72 122/70 124/70 128/78 130/8017 MAHA DEVI 44 11270 F 106/72 108/70 110/70 112/70 110/72 114/70 112/74 118/76 124/78 130/74 132/70 134/7218 LAKSHMI 52 11072 F 108/70 110/72 110/70 112/72 112/70 116/72 118/70 120/74 126/76 124/78 128/7219 KANNAGI 49 11270 F 102/70 106/72 108/70 110/70 112/72 114/74 116/72 120/70 122/72 124/74 122/70 124/7220 LOGANAYAGI 45 11072 F 106/72 106/74 108/72 110/72 112/74 114/72 112/70 118/72 122/70 124/74 128/72 134/7021 PRIYA 42 11270 F 108/68 110/70 112/70 112/72 114/70 118/72 120/70 124/74 128/76 132/78 130/72 136/7022 BANUMATHY 48 11370 F 106/70 112/74 110/72 112/70 114/74 116/76 118/78 122/80 126/82 130/80 132/82 134/8023 VEDHANAYAGI 46 11380 F 110/70 110/72 112/72 114/70 116/74 118/72 122/76 124/78 126/76 124/74 122/70 124/7224 SARASWATHI 50 11486 F 108/72 106/72 108/70 110/72 114/70 118/70 122/76 124/72 126/74 128/72 126/7025 DURGADEVI 38 11570 F 108/70 108/72 110/70 112/72 116/74 118/74 120/76 122/78 124/76 126/78 128/76 128/74 130/7226 KANNANMAL 42 11672 F 106/70 106/72 112/70 112/70 116/72 118/70 120/74 122/74 126/72 128/74 130/70 132/72 130/7427 MEENA 40 11560 F 108/72 110/72 114/70 114/72 116/70 118/72 122/72 124/70 126/72 126/70 128/72 126/7428 SAVEETHA 39 11462 F 110/70 106/72 110/70 112/72 118/74 118/76 124/76 126/70 128/72 128/70 130/74 132/76 130/7829 SAVITHRI 48 11560 F 106/68 108/70 110/70 110/70 112/72 116/70 126/78 128/76 130/74 132/72 134/74 132/7230 LEELAVATHI 40 11672 F 104/70 108/70 108/72 112/72 114/70 114/72 120/74 122/72 126/72 130/72 134/72 136/70

S.NO NAMES AGE SEX

BLOOD PRESSURE(SBP/DBP)

IP NO

GROUP D

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

70 (In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F 13 13 13 13 13 13 13 13 14 16 19 - -2 SUGUNA 38 10358 F 13 13 13 13 13 13 13 13 13 14 14 17 193 JANAVI 52 10952 F 13 13 13 13 13 13 13 13 14 16 19 - -4 AGNES 49 11040 F 12 12 12 12 12 12 12 12 12 13 15 17 -5 SARALA 36 11048 F 12 12 12 12 12 12 12 12 12 13 14 15 186 SUMATHY 35 10962 F 12 12 12 12 12 12 12 12 12 14 14 16 207 ABI BUMA 42 10969 F 12 12 12 12 12 12 12 12 12 13 15 18 -8 SELVI 39 10920 F 12 12 12 12 12 12 12 12 12 13 17 18 -9 MAHESHWARI 39 10822 F 13 13 13 13 13 13 13 13 13 14 16 20 -

10 JAYA 40 10824 F 13 13 13 13 13 13 13 13 13 14 17 18 -11 JOTHI 49 10822 F 13 13 13 13 13 13 13 13 13 14 17 19 -12 NESAMANI 50 10988 F 12 12 12 12 12 12 12 12 14 16 19 - -13 VIJAYA 44 11040 F 12 12 12 12 12 12 12 12 12 13 14 15 1814 RANI 44 11072 F 12 12 12 12 12 12 12 12 12 14 16 20 -15 SELVI 48 11168 F 13 13 13 13 13 13 13 13 13 14 16 20 -16 JAYANTHI 36 11270 F 12 12 12 12 12 12 12 12 12 13 14 15 1817 MAHA DEVI 44 11270 F 12 12 12 12 12 12 12 12 12 14 17 19 -18 LAKSHMI 52 11072 F 13 13 13 13 13 13 13 13 14 16 19 - -19 KANNAGI 49 11270 F 12 12 12 12 12 12 12 12 12 14 14 16 -20 LOGANAYAGI 45 11072 F 13 13 13 13 13 13 13 13 13 14 17 19 -21 PRIYA 42 11270 F 12 12 12 12 12 12 12 12 12 13 17 18 -22 BANUMATHY 48 11370 F 12 12 12 12 12 12 12 12 12 14 17 19 -23 VEDHANAYAGI 46 11380 F 12 12 12 12 12 12 12 12 12 14 16 20 -24 SARASWATHI 50 11486 F 13 13 13 13 13 13 13 13 14 16 19 - -25 DURGADEVI 38 11570 F 13 13 13 13 13 13 13 13 13 14 14 16 2026 KANNANMAL 42 11672 F 12 12 12 12 12 12 12 12 12 14 14 16 2027 MEENA 40 11560 F 12 12 12 12 12 12 12 12 12 13 15 17 -28 SAVEETHA 39 11462 F 12 12 12 12 12 12 12 12 12 13 14 15 1829 SAVITHRI 48 11560 F 13 13 13 13 13 13 13 13 13 13 15 17 -30 LEELAVATHI 40 11672 F 13 13 13 13 13 13 13 13 13 14 14 16 -

GROUP D

S.NO NAMES AGE SEX

RESPIRATORY RATE

IP NO

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45(In Mins)

60 (In Mins)

70 (In Mins)

90(In Mins)

2(In Hrs)

1 SUMATHY 50 11062 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -2 SUGUNA 38 10358 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given3 JANAVI 52 10952 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -4 AGNES 49 11040 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -5 SARALA 36 11048 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given6 SUMATHY 35 10962 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given7 ABI BUMA 42 10969 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -8 SELVI 39 10920 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -9 MAHESHWARI 39 10822 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -

10 JAYA 40 10824 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -11 JOTHI 49 10822 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -12 NESAMANI 50 10988 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -13 VIJAYA 44 11040 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given14 RANI 44 11072 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -15 SELVI 48 11168 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -16 JAYANTHI 36 11270 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given17 MAHA DEVI 44 11270 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -18 LAKSHMI 52 11072 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -19 KANNAGI 49 11270 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -20 LOGANAYAGI 45 11072 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -21 PRIYA 42 11270 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -22 BANUMATHY 48 11370 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -23 VEDHANAYAGI 46 11380 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -24 SARASWATHI 50 11486 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -25 DURGADEVI 38 11570 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given26 KANNANMAL 42 11672 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given27 MEENA 40 11560 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -28 SAVEETHA 39 11462 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given29 SAVITHRI 48 11560 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -30 LEELAVATHI 40 11672 F Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -

GROUP D

S.NO NAMES AGE SEX

RESCUE ANALGESIA

IP NO

BRADYCARDIA HYPOTENSIONNAUSEA & VOMITING

PRURITUS

1 SUMATHY 50 11062 F No No No No2 SUGUNA 38 10358 F No No No No3 JANAVI 52 10952 F Yes Yes Yes No4 AGNES 49 11040 F Yes Yes Yes No5 SARALA 36 11048 F No No No No6 SUMATHY 35 10962 F No No No No7 ABI BUMA 42 10969 F No No No No8 SELVI 39 10920 F No No No No9 MAHESHWARI 39 10822 F No No No No

10 JAYA 40 10824 F No No No No11 JOTHI 49 10822 F No No No No12 NESAMANI 50 10988 F Yes Yes Yes No13 VIJAYA 44 11040 F No No No No14 RANI 44 11072 F No No No No15 SELVI 48 11168 F No No No No16 JAYANTHI 36 11270 F No No No No17 MAHA DEVI 44 11270 F Yes Yes Yes No18 LAKSHMI 52 11072 F No No No No19 KANNAGI 49 11270 F No No No No20 LOGANAYAGI 45 11072 F No No No No21 PRIYA 42 11270 F No No No No22 BANUMATHY 48 11370 F Yes Yes Yes No23 VEDHANAYAGI 46 11380 F No No No No24 SARASWATHI 50 11486 F No No No No25 DURGADEVI 38 11570 F No No No No26 KANNANMAL 42 11672 F No No No No27 MEENA 40 11560 F No No No No28 SAVEETHA 39 11462 F No No No No29 SAVITHRI 48 11560 F Yes Yes Yes No30 LEELAVATHI 40 11672 F No No No No

GROUP DCOMPLICATIONS

AGE SEXS.NO NAMES IP NO

GROUP F INJ 0.5% BUPIVACAINE 3.5CC + 0.5CC OF FENTANYL IN L3 L4 SPACE DESIRED LEVEL OF BLOCK T6

SENSORY BLOCK MOTOR BLOCK

T10 (Mins)

T6 (In Mins)

T10 (In mins)

T6 (In Mins)

REGRESS TO S1 IN MINS

REGRESS TO B0 IN MINS

1 SUMATHI 42 11250 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 1 3 2 4 75 NIL 386 300

2 GLORY PREMKUMARI 50 110765 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 2 5 75 NIL 379 220

3 PUSHPALATHA 35 11362 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY 1 3 5 2 6 60 NIL 340 225

4 MUNIYAMMAL 45 11170 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 2 4 2 5 90 NIL 392 240

5 MALARVIZHI 40 11272 FEMALE FIBROID UTERUS WITH POLYP TOTAL ABDOMINAL HYSTERECTOMY II 2 4 2 4 45 NIL 394 210

6 DEVI 30 11370 FEMALE CERVICAL INTRAEPITHELIAL NEOPLASIA 3 TOTAL ABDOMINAL HYSTERECTOMY II 2 3 2 4 60 NIL 333 120

7 DAISY RANI 52 11544 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 2 4 2 4 60 NIL 361 213

8 JOYSEE 43 11088 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 2 3 2 4 60 NIL 350 210

9 SHANTHI MANI 45 11292 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 3 4 75 NIL 348 185

10 MALA 43 11380 FEMALE SUB MUCOUS FIBROID TOTAL ABDOMINAL HYSTERECTOMY 1 3 4 3 5 90 NIL 355 207

11 MANJULA 43 11044 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 2 3 3 4 90 NIL 330 210

12 LAKSHMI 45 11270 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 3 4 60 NIL 245 170

13 SARASU 49 11178 FEMALE FIBROID UTERUS WITH ADENOMYOSIS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 3 4 90 NIL 366 270

14 VASUKI 45 11478 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 2 3 3 5 60 NIL 380 285

15 MARIAMMAL 44 11576 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY 1 2 3 3 4 90 NIL 283 195

16 JEBITHA 36 11860 FEMALE FIBROID POLYP TOTAL ABDOMINAL HYSTERECTOMY 1 2 3 3 4 60 NIL 405 240

17 YASODHA 50 11664 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 3 4 3 5 90 NIL 365 180

18 JAYANTHI 47 11528 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 3 4 3 5 60 NIL 517 285

19 PRABHA 42 11222 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 3 4 3 5 60 NIL 333 185

20 SEETHA LAKSHMI 40 11004 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 2 3 3 4 75 NIL 391 205

21 RADHA 38 11288 FEMALE FIBROID POLYP TOTAL ABDOMINAL HYSTERECTOMY 1 3 3 3 5 60 NIL 390 240

22 LAKSHMI 45 11478 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 3 3 3 4 60 NIL 366 240

23 MEENAKSHI 40 11565 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 3 5 45 NIL 371 180

24 LOGANAYAKI 36 11666 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY II 3 4 3 5 45 NIL 350 190

25 VALLIYAMMAL 44 11462 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 3 4 3 5 45 NIL 368 200

26 PARVATHY 48 11566 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY II 3 4 3 4 60 NIL 365 185

27 DEVAKY 46 11448 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY 1 3 5 3 5 75 NIL 366 180

28 CHITRA 36 11230 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY 1 2 3 3 4 60 NIL 290 240

29 DHANALAKSHMI 44 11151 FEMALE ABNORMAL UTERINE BLEEDING TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPHINGOOPHERECTOMY 1 2 3 3 5 45 NIL 350 195

30 EZHILLARASI 40 11640 FEMALE FIBROID UTERUS TOTAL ABDOMINAL HYSTERECTOMY II 2 4 3 4 60 NIL 300 175

IP NORESCUE

ANALGESIA(In Mins)

ONSET OF SENSORY BLOCKS (In Mins)

ONSET OF MOTOR BLOCK (In Mins)

S.NO NAME AGE SEX DIAGNOSIS PROCEDUREASA

GROUP

DURATION OF SURGERY (In Mins )

BASE LINE (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

65 (In Mins)

70 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 78 76 74 72 68 70 71 72 76 75 73 70 69 -2 GLORY PREMKUMARI 50 110765 FEMALE 82 74 72 74 75 70 66 64 65 69 70 72 73 -3 PUSHPALATHA 35 11362 FEMALE 90 72 73 74 70 68 69 67 70 70 - - - -4 MUNIYAMMAL 45 11170 FEMALE 86 75 74 73 72 63 65 66 64 62 65 66 67 725 MALARVIZHI 40 11272 FEMALE 84 77 74 73 72 68 69 70 72 - - - - -6 DEVI 30 11370 FEMALE 83 80 78 76 75 72 70 68 69 71 - - - -7 DAISY RANI 52 11544 FEMALE 79 82 80 78 79 76 77 72 70 71 - - - -8 JOYSEE 43 11088 FEMALE 76 86 72 71 78 80 76 72 77 75 - - - -9 SHANTHI MANI 45 11292 FEMALE 80 84 80 78 79 76 74 73 72 70 71 69 71 -

10 MALA 43 11380 FEMALE 72 75 73 72 68 69 71 73 75 77 79 80 81 8211 MANJULA 43 11044 FEMALE 73 72 70 68 69 71 72 75 74 73 72 70 74 7512 LAKSHMI 45 11270 FEMALE 76 70 68 72 73 74 75 77 78 70 - - - -13 SARASU 49 11178 FEMALE 75 76 72 74 75 77 76 71 69 68 70 73 75 7214 VASUKI 45 11478 FEMALE 77 80 78 77 76 74 73 72 70 69 - - - -15 MARIAMMAL 44 11576 FEMALE 78 82 78 79 76 75 73 72 70 69 72 70 69 7516 JEBITHA 36 11860 FEMALE 84 88 84 83 80 81 79 75 73 72 - - - -17 YASODHA 50 11664 FEMALE 85 82 80 79 76 75 74 72 70 69 71 73 75 7318 JAYANTHI 47 11528 FEMALE 86 80 78 76 74 70 68 65 67 70 - - - -19 PRABHA 42 11222 FEMALE 87 80 77 76 72 77 73 74 75 74 - - - -20 SEETHA LAKSHMI 40 11004 FEMALE 90 87 85 84 82 70 68 67 65 80 81 83 82 -21 RADHA 38 11288 FEMALE 88 82 80 84 83 78 72 70 79 72 - - - -22 LAKSHMI 45 11478 FEMALE 86 80 84 83 80 72 74 76 77 73 - - - -23 MEENAKSHI 40 11565 FEMALE 82 79 75 73 68 65 69 70 71 - - - - -24 LOGANAYAKI 36 11666 FEMALE 85 76 74 70 71 72 73 77 78 - - - - -25 VALLIYAMMAL 44 11462 FEMALE 84 74 72 70 69 68 66 70 71 - - - - -26 PARVATHY 48 11566 FEMALE 80 78 76 74 77 79 80 74 70 71 - - - -27 DEVAKY 46 11448 FEMALE 79 72 70 68 66 65 64 67 62 65 66 67 68 -28 CHITRA 36 11230 FEMALE 78 70 69 71 73 74 76 77 74 72 - - - -29 DHANALAKSHMI 44 11151 FEMALE 86 76 75 72 74 70 69 66 62 - - - - -30 EZHILLARASI 40 11640 FEMALE 84 77 74 73 72 70 79 74 75 77 - - - -

S.NO NAMES HEART RATEGROUP F FENTANYL GROUP

AGE SEXIP NO

BASE LINE(In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

30 (In Min)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 136/70 130/68 124/70 120/68 114/64 110/70 112/72 108/70 110/72 108/702 GLORY PREMKUMARI 50 110765 FEMALE 128/74 126/76 120/72 116/54 110/70 114/70 118/72 116/70 112/58 108/683 PUSHPALATHA 35 11362 FEMALE 110/64 112/70 106/64 102/60 98/62 94/60 98/64 100/64 102/684 MUNIYAMMAL 45 11170 FEMALE 148/90 136/88 130/80 122/76 108/68 100/60 99/64 90/60 100/60 101/54 104/685 MALARVIZHI 40 11272 FEMALE 132/80 136/82 126/76 116/70 104/62 98/60 94/58 100/606 DEVI 30 11370 FEMALE 133/70 130/68 124/70 120/68 114/64 110/70 112/72 108/70 110/727 DAISY RANI 52 11544 FEMALE 142/87 138/75 130/73 126/75 120/70 118/65 120/70 118/68 112/708 JOYSEE 43 11088 FEMALE 134/69 126/72 118/67 115/67 118/67 115/69 110/70 112/68 105/659 SHANTHI MANI 45 11292 FEMALE 128/68 130/70 132/72 128/71 120/70 118/67 110/65 115/72 110/70 114/71

10 MALA 43 11380 FEMALE 120/70 128/72 126/68 130/70 115/65 100/65 98/60 95/60 98/61 112/64 101/6211 MANJULA 43 11044 FEMALE 131/69 138/73 132/70 129/68 122/62 125/65 120/70 110/62 122/72 115/67 110/6812 LAKSHMI 45 11270 FEMALE 130/77 126/72 115/65 104/60 115/68 120/71 105/62 110/62 108/5913 SARASU 49 11178 FEMALE 138/76 125/70 115/63 100/66 98/60 92/62 100/70 124/65 118/61 108/69 112/6214 VASUKI 45 11478 FEMALE 135/85 128/75 125/74 130/72 115/70 100/64 110/69 109/74 100/7015 MARIAMMAL 44 11576 FEMALE 145/90 130/83 120/75 125/70 115/67 120/72 105/65 112/61 120/70 100/70 110/7516 JEBITHA 36 11860 FEMALE 125/72 110/70 108/64 101/65 100/60 119/66 125/70 115/74 110/6517 YASODHA 50 11664 FEMALE 136/90 136/88 130/80 122/76 108/68 100/60 105/64 112/65 100/60 101/54 104/6818 JAYANTHI 47 11528 FEMALE 120/67 118/63 105/62 95/60 99/62 90/60 108/67 120/69 112/6519 PRABHA 42 11222 FEMALE 135/85 128/75 125/74 130/72 115/70 100/64 110/69 109/74 100/7020 SEETHA LAKSHMI 40 11004 FEMALE 135/75 130/70 132/72 128/71 110/68 95/62 90/60 115/72 110/70 120/7021 RADHA 38 11288 FEMALE 125/72 110/70 108/64 101/65 100/60 119/66 125/70 115/74 110/6522 LAKSHMI 45 11478 FEMALE 130/77 126/72 115/65 104/60 115/68 120/71 105/62 110/62 108/5923 MEENAKSHI 40 11565 FEMALE 140/80 130/75 118/70 102/65 90/56 94/62 98/68 105/6224 LOGANAYAKI 36 11666 FEMALE 125/72 110/70 108/64 101/65 100/60 119/66 125/70 130/7425 VALLIYAMMAL 44 11462 FEMALE 132/80 136/82 126/76 116/70 104/62 108/60 118/58 120/6126 PARVATHY 48 11566 FEMALE 134/69 126/72 118/67 115/67 118/67 115/69 110/70 112/68 105/6527 DEVAKY 46 11448 FEMALE 120/65 104/69 120/70 115/63 110/69 90/62 92/61 95/64 105/65 118/6028 CHITRA 36 11230 FEMALE 130/75 124/72 115/71 122/68 130/70 115/65 100/68 120/68 117/6229 DHANALAKSHMI 44 11151 FEMALE 130/74 122/62 115/68 101/61 94/57 99/59 110/62 122/6830 EZHILLARASI 40 11640 FEMALE 134/69 126/72 118/67 115/67 118/67 115/69 110/70 112/68 105/65

BLOOD PRESSURE(SBP/DBP)S.NO NAMES AGE SEXIP NO

BASE LINE(In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Min)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% -2 GLORY PREMKUMARI 50 110765 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% -3 PUSHPALATHA 35 11362 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -4 MUNIYAMMAL 45 11170 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%5 MALARVIZHI 40 11272 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% - - -6 DEVI 30 11370 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -7 DAISY RANI 52 11544 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -8 JOYSEE 43 11088 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -9 SHANTHI MANI 45 11292 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% -

10 MALA 43 11380 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%11 MANJULA 43 11044 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%12 LAKSHMI 45 11270 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -13 SARASU 49 11178 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%14 VASUKI 45 11478 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -15 MARIAMMAL 44 11576 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%16 JEBITHA 36 11860 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -17 YASODHA 50 11664 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%18 JAYANTHI 47 11528 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -19 PRABHA 42 11222 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -20 SEETHA LAKSHMI 40 11004 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% -21 RADHA 38 11288 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -22 LAKSHMI 45 11478 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -23 MEENAKSHI 40 11565 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% - - -24 LOGANAYAKI 36 11666 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% - - -25 VALLIYAMMAL 44 11462 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% - - -26 PARVATHY 48 11566 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -27 DEVAKY 46 11448 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% -28 CHITRA 36 11230 FEMALE 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% - -29 DHANALAKSHMI 44 11151 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% - - -30 EZHILLARASI 40 11640 FEMALE 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - -

AGE SEXSPO2

S.NO NAMES IP NO

Baseline (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 0 0 0 0 0 0 1 1 2 3 - -2 GLORY PREMKUMARI 50 110765 FEMALE 0 0 0 0 0 0 1 2 3 - - -3 PUSHPALATHA 35 11362 FEMALE 0 0 0 0 0 0 1 1 2 3 - -4 MUNIYAMMAL 45 11170 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -5 MALARVIZHI 40 11272 FEMALE 0 0 0 0 0 1 2 3 - - - -6 DEVI 30 11370 FEMALE 0 0 0 0 0 0 1 2 2 3 - -7 DAISY RANI 52 11544 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -8 JOYSEE 43 11088 FEMALE 0 0 0 0 0 0 1 1 2 3 - -9 SHANTHI MANI 45 11292 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -

10 MALA 43 11380 FEMALE 0 0 0 0 0 0 1 1 2 3 - -11 MANJULA 43 11044 FEMALE 0 0 0 0 0 0 1 2 3 - - -12 LAKSHMI 45 11270 FEMALE 0 0 0 0 0 0 1 2 2 3 - -13 SARASU 49 11178 FEMALE 0 0 0 0 0 1 2 3 - - - -14 VASUKI 45 11478 FEMALE 0 0 0 0 0 0 1 2 2 3 - -15 MARIAMMAL 44 11576 FEMALE 0 0 0 0 0 0 1 1 2 3 - -16 JEBITHA 36 11860 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -17 YASODHA 50 11664 FEMALE 0 0 0 0 0 1 2 3 - - - -18 JAYANTHI 47 11528 FEMALE 0 0 0 0 0 0 1 2 2 3 - -19 PRABHA 42 11222 FEMALE 0 0 0 0 0 0 1 2 2 3 - -20 SEETHA LAKSHMI 40 11004 FEMALE 0 0 0 0 0 0 1 2 3 - - -21 RADHA 38 11288 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -22 LAKSHMI 45 11478 FEMALE 0 0 0 0 0 0 1 2 2 3 - -23 MEENAKSHI 40 11565 FEMALE 0 0 0 0 0 0 1 2 3 - - -24 LOGANAYAKI 36 11666 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -25 VALLIYAMMAL 44 11462 FEMALE 0 0 0 0 0 0 1 2 2 3 - -26 PARVATHY 48 11566 FEMALE 0 0 0 0 0 0 1 2 3 - - -27 DEVAKY 46 11448 FEMALE 0 0 0 0 0 0 1 2 3 - - -28 CHITRA 36 11230 FEMALE 0 0 0 0 0 0 1 1 2 2 3 -29 DHANALAKSHMI 44 11151 FEMALE 0 0 0 0 0 0 1 1 2 3 - -30 EZHILLARASI 40 11640 FEMALE 0 0 0 0 0 0 1 2 2 3 - -

AGE SEX

GROUP A - FENTANYL(Post operative analgesia initiation time)

S.NO NAMESVISUAL ANALOG SCALE

IP NO

Baseline (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 72 72 72 72 73 73 75 78 84 90 - -2 GLORY PREMKUMARI 50 110765 FEMALE 74 74 74 74 76 78 80 87 89 - - -3 PUSHPALATHA 35 11362 FEMALE 74 74 74 74 76 76 79 79 84 92 - -4 MUNIYAMMAL 45 11170 FEMALE 72 72 72 72 72 72 75 77 80 85 93 -5 MALARVIZHI 40 11272 FEMALE 73 73 73 73 75 79 84 92 - - - -6 DEVI 30 11370 FEMALE 72 72 72 72 72 72 75 80 83 94 - -7 DAISY RANI 52 11544 FEMALE 70 70 70 70 70 70 75 79 83 85 95 -8 JOYSEE 43 11088 FEMALE 73 73 73 73 73 73 77 80 85 94 - -9 SHANTHI MANI 45 11292 FEMALE 74 74 74 74 74 74 75 80 83 87 94 -

10 MALA 43 11380 FEMALE 72 72 72 72 72 72 75 80 84 92 - -11 MANJULA 43 11044 FEMALE 75 75 75 75 75 75 80 85 89 - - -12 LAKSHMI 45 11270 FEMALE 70 70 70 70 70 70 75 80 84 94 - -13 SARASU 49 11178 FEMALE 73 73 73 73 75 79 85 91 - - - -14 VASUKI 45 11478 FEMALE 72 72 72 72 72 72 77 83 85 92 - -15 MARIAMMAL 44 11576 FEMALE 74 74 74 74 74 74 75 80 84 93 - -16 JEBITHA 36 11860 FEMALE 71 71 71 71 71 71 75 80 83 85 94 -17 YASODHA 50 11664 FEMALE 73 73 73 73 73 79 85 91 - - - -18 JAYANTHI 47 11528 FEMALE 72 72 72 72 72 72 77 83 85 94 - -19 PRABHA 42 11222 FEMALE 72 72 72 72 72 72 77 83 85 93 - -20 SEETHA LAKSHMI 40 11004 FEMALE 71 71 71 71 71 71 75 80 87 - - -21 RADHA 38 11288 FEMALE 70 70 70 70 70 70 75 80 83 85 93 -22 LAKSHMI 45 11478 FEMALE 74 74 74 74 74 74 77 83 85 94 - -23 MEENAKSHI 40 11565 FEMALE 71 71 71 71 71 71 77 85 93 - - -24 LOGANAYAKI 36 11666 FEMALE 72 72 72 72 72 72 75 80 84 87 95 -25 VALLIYAMMAL 44 11462 FEMALE 71 71 71 71 71 71 75 80 83 94 - -26 PARVATHY 48 11566 FEMALE 74 74 74 74 74 74 78 84 90 - - -27 DEVAKY 46 11448 FEMALE 72 74 74 74 74 74 77 85 92 - - -28 CHITRA 36 11230 FEMALE 70 70 70 70 70 70 75 80 83 85 94 -29 DHANALAKSHMI 44 11151 FEMALE 74 74 74 74 74 74 80 80 85 92 - -30 EZHILLARASI 40 11640 FEMALE 71 71 71 71 71 74 77 85 89 94 - -

AGE SEXHEART RATE

SNO NAMES IP NO

Baseline (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 110/65 110/65 107/61 106/60 110/63 105/64 115/66 115/66 125/68 135/72 - -2 GLORY PREMKUMARI 50 110765 FEMALE 108/62 108/62 110/61 112/63 107/61 110/63 109/60 121/66 130/70 - - -3 PUSHPALATHA 35 11362 FEMALE 101/62 102/65 110/62 101/62 110/65 105/65 100/60 118/62 122/69 138/73 - -4 MUNIYAMMAL 45 11170 FEMALE 105/67 105/67 110/62 112/66 110/60 115/65 112/68 118/70 125/70 130/65 140/75 -5 MALARVIZHI 40 11272 FEMALE 103/63 109/62 112/63 106/66 101/68 110/67 126/67 140/72 - - - -6 DEVI 30 11370 FEMALE 98/60 100/61 110/65 105/63 100/63 105/67 110/60 115/60 125/66 136/76 - -7 DAISY RANI 52 11544 FEMALE 100/60 103/62 100/58 105/61 112/66 100/67 110/65 108/64 115/62 128/72 132/71 -8 JOYSEE 43 11088 FEMALE 103/63 109/62 112/63 106/66 101/68 110/67 108/69 115/70 122/66 131/70 - -9 SHANTHI MANI 45 11292 FEMALE 100/61 100/61 105/62 103/64 104/64 101/62 110/62 100/60 110/68 126/70 138/77 -

10 MALA 43 11380 FEMALE 105/67 105/67 110/62 112/66 110/60 115/65 112/68 118/70 129/72 139/74 - -11 MANJULA 43 11044 FEMALE 110/65 110/65 107/61 106/60 110/63 105/64 115/66 120/70 134/77 - - -12 LAKSHMI 45 11270 FEMALE 118/65 120/67 110/63 114/65 112/65 110/63 118/68 120/65 127/67 130/70 - -13 SARASU 49 11178 FEMALE 108/62 108/62 110/61 112/63 107/61 110/63 120/60 140/72 - - - -14 VASUKI 45 11478 FEMALE 103/63 109/62 112/63 106/66 101/68 110/67 120/65 120/70 129/69 138/73 - -15 MARIAMMAL 44 11576 FEMALE 110/65 110/65 107/61 106/60 110/63 105/64 115/66 120/70 121/61 132/76 - -16 JEBITHA 36 11860 FEMALE 101/62 102/65 110/62 101/62 110/65 105/65 100/60 110/60 125/62 130/70 140/70 -17 YASODHA 50 11664 FEMALE 118/63 108/62 100/70 110/69 115/67 120/70 129/69 142/78 - - - -18 JAYANTHI 47 11528 FEMALE 100/60 103/62 100/58 105/61 112/66 100/67 110/66 121/65 129/69 138/70 - -19 PRABHA 42 11222 FEMALE 100/61 100/61 105/62 103/64 104/64 101/62 110/62 107/60 122/61 130/75 - -20 SEETHA LAKSHMI 40 11004 FEMALE 100/60 103/62 100/58 105/61 112/66 100/67 110/65 130/70 140/80 - - -21 RADHA 38 11288 FEMALE 108/62 108/62 110/61 112/63 107/61 110/63 107/60 110/63 120/62 130/73 142/72 -22 LAKSHMI 45 11478 FEMALE 100/60 102/65 101/61 108/65 103/61 100/60 102/63 122/61 129/68 139/80 - -23 MEENAKSHI 40 11565 FEMALE 105/67 105/67 110/62 112/66 110/60 115/65 112/68 130/70 136/74 - - -24 LOGANAYAKI 36 11666 FEMALE 101/62 102/65 110/62 101/62 110/65 105/65 100/60 102/60 108/59 118/62 130/70 -25 VALLIYAMMAL 44 11462 FEMALE 103/63 109/62 112/63 106/66 101/68 110/67 108/69 117/60 125/65 135/75 - -26 PARVATHY 48 11566 FEMALE 100/61 100/61 105/62 103/64 104/64 101/62 110/62 120/70 130/70 - - -27 DEVAKY 46 11448 FEMALE 100/60 103/62 100/58 105/61 112/66 100/67 110/65 129/63 138/75 - - -28 CHITRA 36 11230 FEMALE 101/62 102/65 110/62 101/62 110/65 105/65 100/60 102/60 118/61 122/68 133/73 -29 DHANALAKSHMI 44 11151 FEMALE 110/65 110/65 107/61 106/60 110/63 105/64 115/66 122/65 128/68 136/71 - -30 EZHILLARASI 40 11640 FEMALE 108/62 108/62 110/61 112/63 107/61 110/63 107/60 122/61 129/69 140/75 - -

SNO NAMES AGE SEXBLOOD PRESSURE(SBP/DBP)

IP NO

Baseline (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE 12 12 12 12 12 13 13 13 16 18 - -2 GLORY PREMKUMARI 50 110765 FEMALE 13 13 13 13 13 13 14 17 19 - - -3 PUSHPALATHA 35 11362 FEMALE 12 12 12 12 12 12 13 14 16 19 - -4 MUNIYAMMAL 45 11170 FEMALE 12 12 12 12 12 12 13 14 15 18 20 -5 MALARVIZHI 40 11272 FEMALE 13 13 13 13 13 14 17 19 - - - -6 DEVI 30 11370 FEMALE 12 12 12 12 12 13 14 16 17 19 - -7 DAISY RANI 52 11544 FEMALE 13 13 13 13 13 13 14 15 17 17 19 -8 JOYSEE 43 11088 FEMALE 12 12 12 12 13 13 14 14 17 19 - -9 SHANTHI MANI 45 11292 FEMALE 12 12 12 12 12 12 13 13 15 16 18 -

10 MALA 43 11380 FEMALE 13 13 13 13 13 13 14 14 17 20 - -11 MANJULA 43 11044 FEMALE 12 12 12 12 12 12 13 17 19 - - -12 LAKSHMI 45 11270 FEMALE 12 12 12 12 12 12 14 16 17 19 - -13 SARASU 49 11178 FEMALE 13 13 13 13 13 13 16 18 - - - -14 VASUKI 45 11478 FEMALE 13 13 13 13 13 13 13 17 17 20 - -15 MARIAMMAL 44 11576 FEMALE 12 12 12 12 12 12 14 14 15 18 - -16 JEBITHA 36 11860 FEMALE 13 13 13 13 13 13 14 16 17 18 19 -17 YASODHA 50 11664 FEMALE 13 13 13 13 13 14 17 19 - - - -18 JAYANTHI 47 11528 FEMALE 13 13 13 13 13 13 14 14 15 18 - -19 PRABHA 42 11222 FEMALE 12 12 12 12 12 12 13 17 17 19 - -20 SEETHA LAKSHMI 40 11004 FEMALE 13 13 13 13 13 13 14 17 19 - - -21 RADHA 38 11288 FEMALE 13 13 13 13 13 13 14 17 17 18 20 -22 LAKSHMI 45 11478 FEMALE 13 13 13 13 13 13 13 17 17 19 - -23 MEENAKSHI 40 11565 FEMALE 12 12 12 12 12 12 14 17 19 - - -24 LOGANAYAKI 36 11666 FEMALE 13 13 13 13 13 13 14 14 15 16 18 -25 VALLIYAMMAL 44 11462 FEMALE 13 13 13 13 13 13 14 16 17 19 - -26 PARVATHY 48 11566 FEMALE 12 12 12 12 12 12 14 17 20 - - -27 DEVAKY 46 11448 FEMALE 12 12 12 12 12 12 13 16 20 - - -28 CHITRA 36 11230 FEMALE 13 13 13 13 13 13 13 17 17 17 20 -29 DHANALAKSHMI 44 11151 FEMALE 12 12 12 12 12 12 14 16 17 19 - -30 EZHILLARASI 40 11640 FEMALE 12 12 12 12 12 12 13 17 17 19 - -

AGE SEXSNO NAMESRESPIRATORY RATE

IP NO

Baseline (In Mins)

0 (In Mins)

5 (In Mins)

10 (In Mins)

15 (In Mins)

20 (In Mins)

25 (In Mins)

30 (In Mins)

45 (In Mins)

60 (In Mins)

75 (In Mins)

90 (In Mins)

1 SUMATHI 42 11250 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -2 GLORY PREMKUMARI 50 110765 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - - 3 Given3 PUSHPALATHA 35 11362 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - - 2 Nil4 MUNIYAMMAL 45 11170 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - 1 Nil5 MALARVIZHI 40 11272 FEMALE Nil Nil Nil Nil Nil Nil Nil Given - - - - 0 Nil6 DEVI 30 11370 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -7 DAISY RANI 52 11544 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -8 JOYSEE 43 11088 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -9 SHANTHI MANI 45 11292 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -

10 MALA 43 11380 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -11 MANJULA 43 11044 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - -12 LAKSHMI 45 11270 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -13 SARASU 49 11178 FEMALE Nil Nil Nil Nil Nil Nil Nil Given - - - -14 VASUKI 45 11478 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -15 MARIAMMAL 44 11576 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -16 JEBITHA 36 11860 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -17 YASODHA 50 11664 FEMALE Nil Nil Nil Nil Nil Nil Nil Given - - - -18 JAYANTHI 47 11528 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -19 PRABHA 42 11222 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -20 SEETHA LAKSHMI 40 11004 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - -21 RADHA 38 11288 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -22 LAKSHMI 45 11478 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -23 MEENAKSHI 40 11565 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - -24 LOGANAYAKI 36 11666 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -25 VALLIYAMMAL 44 11462 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -26 PARVATHY 48 11566 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - -27 DEVAKY 46 11448 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Given - - -28 CHITRA 36 11230 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Given -29 DHANALAKSHMI 44 11151 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -30 EZHILLARASI 40 11640 FEMALE Nil Nil Nil Nil Nil Nil Nil Nil Nil Given - -

AGE SEXSNO NAMESRESCUE ANALGESIA

IP NO

1 SUMATHI 42 11250 FEMALE No No No Yes2 GLORY PREMKUMARI 50 110765 FEMALE No No Yes No3 PUSHPALATHA 35 11362 FEMALE Yes Yes No No4 MUNIYAMMAL 45 11170 FEMALE Yes Yes No Yes5 MALARVIZHI 40 11272 FEMALE Yes Yes No No6 DEVI 30 11370 FEMALE No No No No7 DAISY RANI 52 11544 FEMALE No No Yes No8 JOYSEE 43 11088 FEMALE No No No Yes9 SHANTHI MANI 45 11292 FEMALE No No No No

10 MALA 43 11380 FEMALE Yes Yes No No11 MANJULA 43 11044 FEMALE No No No Yes12 LAKSHMI 45 11270 FEMALE No No No No13 SARASU 49 11178 FEMALE Yes Yes Yes No14 VASUKI 45 11478 FEMALE No No No No15 MARIAMMAL 44 11576 FEMALE No No No Yes16 JEBITHA 36 11860 FEMALE No No No No17 YASODHA 50 11664 FEMALE No No Yes No18 JAYANTHI 47 11528 FEMALE Yes Yes No No19 PRABHA 42 11222 FEMALE No No No No20 SEETHA LAKSHMI 40 11004 FEMALE Yes Yes No No21 RADHA 38 11288 FEMALE No No No No22 LAKSHMI 45 11478 FEMALE No No No No23 MEENAKSHI 40 11565 FEMALE Yes Yes No No24 LOGANAYAKI 36 11666 FEMALE No No No Yes25 VALLIYAMMAL 44 11462 FEMALE No No No No26 PARVATHY 48 11566 FEMALE No No Yes No27 DEVAKY 46 11448 FEMALE Yes Yes Yes No28 CHITRA 36 11230 FEMALE No No No No29 DHANALAKSHMI 44 11151 FEMALE Yes Yes No Yes30 EZHILLARASI 40 11640 FEMALE No No No No

S.NO NAMES PRURITUSNAUSEA & VOMITING

COMPLICATIONS

HYPOTENSIONBRADYCARDIAAGE SEXIP NO