A comparative study of hemodynamic changes and adverse effects of intrathecal bupivacaine with fentanyl and intrathecal bupivacaine with clonidine in infra-umbilical abdominal and lower limb surgery

Krishna Prasad G. V., Vipin Jaishree Sharma


Background: Adjuvants prolong the action of intrathecal local anesthetic agents. They have shown to have significant analgesic effects in the postoperative period much after the regression of the sensory and motor blockade. Our objective of the current study was to compared the hemodynamic profile and adverse effects (nausea, pruritus, sedation and respiratory depression) in two groups of adult patients undergoing infra-umbilical and lower limb surgery under spinal anaesthesia using either intrathecal clonidine or intrathecal fentanyl as an adjuvant to intrathecal bupivacaine (0.5% heavy).

Methods: This randomized, prospective and observational study was undertaken in the Department of Anaesthesiology and Critical Care, 5 Airforce Hospital, Kanpur from the period of January 2014 to February 2016 on 120 patients fulfilling the inclusion criteria. Study patients were randomly allocated to the two groups Group I: Cases who received intrathecal 0.5% heavy bupivacaine (2.5 ml) + fentanyl (50 mcg/ml) (0.5 ml) (n=60 patients) and Group II: cases who received intrathecal 0.5% heavy bupivacaine (2.5 ml) + clonidine (60 mcg/ml) (0.5 ml) (n=60 patients).

Results: Mean age of patients in Group I and Group II was 42.60±5.93 and 42.03±7.16 years, respectively. Mean BMI of patients in Group I and Group II was 22.0±1.92 and 21.54±2.14 kg/m2, respectively. Comparison of baseline hemodynamic parameters (heart rate (bpm), mean arterial pressure (mmhg), respiratory rate (/min) and oxygen saturation (%) did not show a significant difference between two groups.

Conclusions: With respect to the side effects like nausea and pruritus, these are significantly more in fentanyl group as compared to clonidine group.


Bupivacaine, Clonidine, Infra-umbilical abdominal surgery, Lower limb surgery

Full Text:



Singh PK, Saikia P, Lahakar M. Prevalence of acute post-operative pain in patients in adult age-group undergoing inpatient abdominal surgery and correlation of intensity of pain and satisfaction with analgesic management: A cross-sectional single institute-based study. Ind J Anaesthesia. 2016;60(10):737-43.

Gupta A, Kaur K, Sharma S, Goyal S, Arora S, Murthy RS. Clinical aspects of acute post-operative pain management & its assessment. J Adv Pharm Technol Res. 2010;1(2):97-108.

Verma D, Naithani U, Gokula C, Harsha. Spinal anesthesia in infants and children: A one year prospective audit. Anesth Essays Res. 2014;8(3):324-9.

Santamaria C, Woodruff A, Yang R, Kohane, D. Drug delivery systems for prolonged duration local anesthesia. Materials Today. 2017;20(1):22-31.

Swain A, Nag DS, Sahu S, Samaddar DP. Adjuvants to local anesthetics: Current understanding and future trends. World J Clin Cases. 2017;5(8):307-23.

Faiz SH, Rahimzadeh P, Sakhaei M, Imani F, Derakhshan P. Anesthetic effects of adding intrathecal neostigmine or magnesium sulphate to bupivacaine in patients under lower extremities surgeries. J Res Medic Sci. 2012;17(10):918-22.

Wiles MD, Nathanson MH. Local anaesthetics and adjuvants - future developments. Anaesthesia. 2010;65(s1):22-37.

Agarwal D, Chopra M, Mohta M, Sethi AK. Clonidine as an adjuvant to hyperbaric bupivacaine for spinal anesthesia in elderly patients undergoing lower limb orthopedic surgeries. Saudi J Anaes. 2014;8(2):209-14.

Sun S, Wang J, Bao N, ChenY, Wang J. Comparison of dexmedetomidine and fentanyl as local anesthetic adjuvants in spinal anesthesia: a systematic review and meta-analysis of randomized controlled trials. Drug Des Devel Ther. 2017;11:3413-24.

Shukla U, Prabhakar T, Malhotra K, Srivastava D. Dexmedetomidine versus midazolam as adjuvants to intrathecal bupivacaine: A clinical comparison. J Anaesthesiol. 2016;32(2):214-9.

Dash UK, Kiran S, Tandon U, Jinjil K. A comparative study on effect of addition of clonidine and fentanyl as adjuvants to local anaesthetics for subarachnoid block in patients undergoing lumbar laminectomies. Anesth Essays Res. 2016;10(3):618-23.

Pandey V, Mohindra BK, Sodhi GS. Comparative evaluation of different doses of intrathecal neostigmine as an adjuvant to bupivacaine for postoperative analgesia. Anesth Essays Res. 2016;10(3):538-45.

Yadav M, Kumar PB, Singh M, Gopinath R. Intrathecal magnesium sulfate as a spinal adjuvant in two different doses, combined with 0.5% heavy bupivacaine for infraumbilical surgeries. Anesth Essays Res. 2015;9(3):364-8.

Vasantha K, Madhusudhana R. Intrathecal bupivacaine with neostigmine and bupivacaine with normal saline for postoperative analgesia: A cost-effective additive. Anesth Essays Res. 2018;12:328-32.

Concepcion MA. Spinal anesthetic agents. Int Anesthesiol Clin. 1989;27(1):21-5.

Parameswari A, Dhev AM, Vakamudi M. Efficacy of clonidine as an adjuvant to bupivacaine for caudal analgesia in children undergoing sub-umbilical surgery. Ind J Anasthesia. 2010;54(5):458-63.

Sarkar A, Bafila NS, Singh RB, Rasheed MA, Choubey S, Arora V. Comparison of epidural bupivacaine and dexmedetomidine with bupivacaine and fentanyl for postoperative pain relief in lower limb orthopedic surgery. Anesth Essays Res. 2018;12:572-80.

Sivevski AG, Karadjova D, Ivanov E, Kartalov A. Neuraxial Anesthesia in the Geriatric Patient. Frontiers in medicine. 2018;5:254.

Fairbanks CA, Stone LS, Wilcox GL. Pharmacological profiles of alpha 2 adrenergic receptor agonists identified using genetically altered mice and isobolographic analysis. Pharmacol Therap. 2009;123(2):224-38.

Singh RB, Chopra N, Choubey S, Tripathi RK, Prabhakar, Mishra A. Role of Clonidine as adjuvant to intrathecal bupivacaine in patients undergoing lower abdominal surgery: A randomized control study. Anesth Essays Res. 2014;8(3):307-12.

Bogra J, Arora N, Srivastava P. Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anesthesia for cesarean section. BMC Anesthesiol. 2005;5(1):5.

Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integrated Blood Pressure Control. 2014;7:9-59.

Bajwa BS, Singh AP, Rekhi AK. Comparison of intrathecal clonidine and fentanyl in hyperbaric bupivacaine for spinal anesthesia and postoperative analgesia in patients undergoing lower abdominal surgeries. Saudi J Anaesth. 2017;11(1):37-40.

Mahendru V, Tewari A, Katyal S, Grewal A, Singh R, Katyal R. A comparison of intrathecal dexmedetomidine, clonidine, and fentanyl as adjuvants to hyperbaric bupivacaine for lower limb surgery: A double blind controlled study. J Anaesthesiol Clin Pharmacol. 2013;29(4):496-502.

Singh V, Singh A, Singh B, Vijayvergiya R, Sharma N, Ghai A, Bhalla A. Midodrine and clonidine in patients with cirrhosis and refractory or recurrent ascites: a randomized pilot study. Am J Gastroenterol. 2013;108(4):560-7.

Bhure A, Kalita N, Ingley P, Gadkari CP. Comparative study of intrathecal hyperbaric Bupivacaine with Clonidine, Fentanyl and Midazolam for quality of anaesthesia and duration of post operative pain relief in patients undergoing elective caesarean section. People’s J Scie Res. 2012;5(1):19-23.

Sethi BS, Samuel M, Sreevastava D. Efficacy of analgesic effects of low dose intrathecal clonidine as adjuvant to bupivacaine. Indian J Anaesth. 2007;51:415-9.

Biswas BN, Rudra A, Bose BK, Nath S, Chakrabarty S, Bhattacharjee S. Intrathecal fentanyl with hyperbaric bupivacaine improves analgesia during caesarean delivery and in early post operative period. Indian J Anaesth. 2002;46:469-72.

Arai M, Nagasawa T, Koshihara Y, Yamamoto S, Togari A. Effects of beta-adrenergic agonists on bone-resorbing activity in human osteoclast-like cells. Biochim Biophys Acta. 2003;1640(2-3):137-42.

Joshi SA, Khadke VV, Subhedar RD, Patil AW, Motghare VM. Comparative evaluation of intrathecal midazolam and low dose clonidine: efficacy, safety and duration of analgesia. A randomized, double blind, prospective clinical trial. Ind J Pharmacol. 2012;44(3):357-61.

Gecaj-Gashi A, Terziqi H, Pervorfi T, Kryeziu A. Intrathecal clonidine added to small-dose bupivacaine prolongs postoperative analgesia in patients undergoing transurethral surgery. Canadian Urol Association J. 2012;6(1):25-9.

Dhumal P, Gunjal V, Kurhekar V. Synergistic effect of intrathecal fentanyl and bupivacaine combination for cesarean section. IJPBR. 2013;4(1):50-6.

Carvalho B. Patient-controlled epidural analgesia for labor. 2009. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews. York (UK): Centre for Reviews and Dissemination (UK). 2008.

Chopra P, Talwar V. Low dose intrathecal clonidine and fentanyl added to hyperbaric bupivacaine prolongs analgesia in gynecological surgery. J Anaesthesiol Clin Pharmacol. 2014;30(2):233-7.

Nazareth M, Ghoshal P, Namshikar V, Gaude Y. Addition of intrathecal fentanyl to bupivacaine clonidine mixture effect on quality of subarachnoid block and postoperative analgesia. Anesth Essays Res. 2013;7(1):76-82.

Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Physician. 2008;11(2):S105-20.

Asghar AM, Samina I, Muhammad S, Asiyah A. A double-blind randomized control trial to compare the effect of varying doses of intrathecal fentanyl on clinical efficacy and side effects in parturients undergoing cesarean section. J Anaesthesiol Clin Pharmacol. 2018;34(2):221-6.

Kumar K, Singh SI. Neuraxial opioid-induced pruritus: An update. J Anaesthesiol, Clinical Pharmacol. 2013;29(3):303-7.

Karnawat R, Chhabra S, Mohammed S, Paliwal B. Comparison of Effect of Epidural Bupivacaine, Epidural Bupivacaine Plus Fentanyl and Epidural Bupivacaine Plus Clonidine on Postoperative Analgesia after Hip Surgery. J Anesth Clin Res. 2013;4:373.

Khezri MB, Rezaei M, Delkhosh Reihany M, Haji Seid Javadi E. Comparison of postoperative analgesic effect of intrathecal clonidine and fentanyl added to bupivacaine in patients undergoing cesarean section: a prospective randomized double-blind study. Pain Res Treatment. 2014;2014.