The Value of Adding Either Meperdine or Fentanyl to Clonidine-bupivacaine

The Value of Adding Either Meperdine or Fentanyl to Clonidine-bupivacaine Mixture in Patients With Lower Limb Orthopedic Surgery Using Combined Spinal Epidural Anesthesia

The use of clonidine as an alternative to epidural opioids offers several potential benefits. Clonidine does not have respiratory depressant effects, and the incidence of vomiting and pruritus is less frequent compared with that seen after administration of epidural morphine.

Epidural clonidine have focused on the optimal doses of clonidine to be used, rather than analyzing the potential advantage of using epidural clonidine versus opioids with respect to efficacy and incidence of side effects.

Epidural fentanyl has been used effectively as an alternative to morphine and has been shown to induce fewer complications when compared with epidural morphine. However, the incidence of vomiting in patients receiving epidural fentanyl still ranges between 28% and 52% depending on the study population and concentration used. The analgesic and side effects profile of epidural clonidine compared with epidural fentanyl are unknown.

The primary aim of this randomized double-blind trial is to test the hypothesis that epidural clonidine decreases the incidence of side effects compared with epidural fentanyl.

Therefore, we compared the hemodynamic effects of the epidural bupivacaine-clonidine- fentanyl combination with those of epidural bupivacaine- clonidine- meperdine. The secondary aim of this study was to determine the analgesic efficacy of bupivacaine-clonidine- fentanyl combination in comparison to bupivacaine- clonidine- meperdine combination.

Study Overview

• Status: Completed
• Conditions: Amputation Stumps
• Intervention / Treatment: Drug: Meperdine; Drug: Fentanyl

Detailed Description

A prospective randomized double-blind clinical trial design was used in a cohort of ninety patients of both genders, physical status American Society of Anaesthesiologist (ASA) I and II who will undergo lower limb orthopedic surgery, will be enrolled into the present study.

Patients will divided randomly into two equal groups: Epidural Bupivacain-clonidine and fentanyl (BF) Group and Bupivacain-clonidine and meperdine (BM) Group, comprising of 45 patients each. Randomization will be performed by random numbers using sealed envelopes without sex stratification. Sealed envelopes indicate the group of assignment. An independent anesthesiologist, who did not participate in the study or data collection, will read the number contained in the envelope and made group assignments. Patients will be blindly randomized to the two groups; the process of inclusion into the study will go on until the requested number of patients will be reached.

Patients will be excluded from the study if their preoperative medication included opioid or non-opioid analgesics, corticosteroids, or non-steroidal anti-inflammatory drugs. Coagulation disorders, pregnancy, age less than 18 year, patient refusal, and emergency re-operation within the first 24hours also were exclusion criteria.

Under full aseptic conditions, the epidural space was identified at the L 2-3 or L 3-4 lumbar interspace using the loss-of-resistance to saline technique using 16-gauge Tuohy needle. An injection of 2 ml of hyperbaric bupivacaine will be injected into the subarachnoid space through 25 gauge spinal needle, then 15ml 0.5% bupivacaine, 25 micrograms of fentanyl and 1 ml of clonidine will be injected epidurally in fentanyl (F) Group, while 15ml 0.5% bupivacaine,25 mg of meperdine and 1 ml of clonidine will be injected epidurally in meperdine (M) Group.

The injection will be given with unlabelled syringes prepared by independent anaesthologist not involved in the patients care or in pain assessment. The specific treatment given is unknown to the patient, anesthesiologist, surgeon, or nurses in charge of pain assessment. All patients and personnel involved in patient management and data collection are unaware of the group to which the patient will be assigned.

On the evening before surgery, patients will be instructed about the use of a 10-cm visual analog scale (VAS) (0 = no pain to 10 = worst possible pain).

Postoperative pain will be assessed by independent physicians who will completely blinded to patients group assignment not sharing in the study design or data collection, visual analogue scale (VAS) ranging from 0 (no pain) to 10 (worst imaginable pain). Pain level will be recorded at PACU every 3 h for the first 24h. All patients received 15 mg/kg i.v. acetaminophen every 6 h; the first dose will be given 40 min before the end of surgery. Supplementary doses of acetaminophen i.v. will be given to patients with a VAS higher than 4. Any episodes of bradycardia (HR< 50 beats/min), hypotension (SBP< 90 mmHg), nausea, vomiting, and excessive sedation were recorded.

The primary outcome is the degree of postoperative pain score using VAS in the two groups. The secondary outcomes measures are analgesic requirement of the two groups during the first 24 h after surgery. All adverse events related to surgery and the regional anesthetic technique will be recorded.

• Study Type: Interventional
• Enrollment (Actual): 90
• Phase: Phase 4

Contacts and Locations

Study Locations

• Egypt
  • Algharbiya
    • Tanta, Algharbiya, Egypt, 35217
      • Faculty of Medicine ,Tanta University.
  • Algharbyia
    • Tanta, Algharbyia, Egypt, 35217
      • Tanta University hospitals

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults ASA I, II.
• Elective orthopedic lower limb surgery

Exclusion Criteria:

• Patients will be excluded from the study if their preoperative medication included opioid or non-opioid analgesics, corticosteroids, or non-steroidal anti-inflammatory drugs. Coagulation disorders, pregnancy, age less than 18 year, patient refusal, and emergency re-operation within the first 24hours also were exclusion criteria.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Meperdine group; 15ml 0.5% bupivacaine,25 mg of meperdine and 1 ml of clonidine will be injected epidurally in meperdine Group.	Drug: Meperdine; 15ml 0.5% bupivacaine,25 mg of meperdine and 1 ml of clonidine will be injected epidurally in meperdine Group.; Other Names: Pethedine
Active Comparator: Fentanyl group; 15ml 0.5% bupivacaine, 25 micrograms of fentanyl and 1 ml of clonidine will be injected epidurally in fentanyl Group	Drug: Fentanyl; 15ml 0.5% bupivacaine, 25 micrograms of fentanyl and 1 ml of clonidine will be injected epidurally in fentanyl Group; Other Names: fenta vera

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
the hemodynamic effects	the hemodynamic parameter (heart rate and blood pressure)	1 hour after epidural application

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
the analgesic efficacy	the analgesic efficacy using visual analogue scale (VAS)	24 hours

Collaborators and Investigators

• Sponsor: Tanta University

Publications and helpful links

General Publications

• Yousef AA, Atef AM, Awais WM. Comparison of fentanyl versus meperidine as supplements to epidural clonidine-bupivacaine in patients with lower limb orthopedic surgery under combined spinal epidural anesthesia. BMC Anesthesiol. 2015 Oct 14;15:146. doi: 10.1186/s12871-015-0126-5.

Study record dates

Study Major Dates

• Study Start: April 1, 2014
• Primary Completion (Actual): October 1, 2014
• Study Completion (Actual): October 1, 2014

Study Registration Dates

• First Submitted: April 6, 2014
• First Submitted That Met QC Criteria: April 29, 2014
• First Posted (Estimate): May 1, 2014

Study Record Updates

• Last Update Posted (Estimate): April 7, 2015
• Last Update Submitted That Met QC Criteria: April 5, 2015
• Last Verified: April 1, 2015

More Information

Terms related to this study

• Keywords: meperdine ,fentanyl, clonidine, orthopedic surgery .
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Analgesics, Opioid; Narcotics; Adjuvants, Anesthesia; Fentanyl
• Other Study ID Numbers: 1350/14