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Effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the catheter-related bladder discomfort after tubeless percutaneous nephrolithotomy: A prospective randomized study.
Session: MP-04c
Thurs, April 19, 3:30-5:00 pm
Plymouth (Shubert Complex), 6th floor

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Title :Effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the catheter-related bladder discomfort after tubeless percutaneous nephrolithotomy:  A prospective randomized study.
 Dinesh J Prajapati, Manoj Patel,  Pankaj Patel, Deepak Mistry, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India


•CRBD associated with discomfort in the suprapubic region, urinary urgency, frequency and a burning sensation with or without urge incontinence. (1,2)
•The incidence of CRBD is ranging from 50%-90%. (2,3-5).
•The higher incidence of CRBD may be responsible for increased incidence of postoperative morbidity.
•Despite of availability of so many  treatment option,  all are associated with  adverse effect with variable response.
•Therefore, we need to establish the effective treatment and preventive option for CRBD.
•The caudal epidural block, first described in 1933, is one of the most common regional techniques performed in pediatric anesthesia. (6)
•There has been recent and ongoing interest regarding the use of caudal epidural blockade to provide postoperative analgesia in adults.(7-10)
•The role of CEB to minimize the CRBD was not studied previously. So, the randomised control trial (RCT) was conducted at our hospital.
•Indication of tubeless PCNL :

-Duration < 2 hours  -Minimum blood loss    -No pelvic wall perforation  -Single tract                   -Complete clearance   -Absence of need for second look   -Moderate stone bulk < 3 cm



•Primary objective
To compare the effect of  Caudal bupivacaine,  bupivacaine- fentanyl and bupivacaine-nalbuphine to minimise the catheter related bladder discomfort (CRBD) during after tubeless percutenous nephrolithotomy (PCNL).
•Secondary objective
Duration of analgesia
Total number of dosages of analgesics requirement in 24 hours
Patient comfort 
Materials and Methods
•After obtaining  ethical committee approval & written informed consent from patients.
•We have selected 99 patients.
•All patients were  posted for tubeless PCNL in prone position, they have received standard  general anaesthesia
•We have conducted this study from April 2016 to March 2017. 
•For randomization, we have used computer generated number list  for sealed envelopes.
•Inclusion criteria: Age ≥ 18 years  & ASA physical status I&II
•Exclusion criteria:
Allergic to study drugs
Obesity (BMI>30)
Long term opioid use
Bladder outflow obstruction
Benign prostatic hyperplasia
OAB (frequency >3 times at night or >8 times within 24 hours)
•The patients were randomly divided in three groups:

Group B    (n=33): received Bupivacaine 0.125% 15 ml.

Group BF  (n=33): received Bupivacaine 0.125% 15ml with Fentanyl  1 mcg/kg

Group BN (n=33): received Bupivacaine 0.125% 15ml with Nalbuphine 0.2mg/kg.

•The caudal epidural injection given  in prone position and  under ultrasound guidance at the end of the procedures
•The Statistical Analysis was done by using PS – Power and Sample size calculation Version 3.0 Jan.2009 and SPSS (Statistical Package for the Social Science) Version 15.0. 
•With level of significance, α = 0.05 or 5% and Power of test, 1-β= 0.80 or 80% with the target of applying the Student’s t-test for testing the significance among the means of the parameters understudy. 
•ANOVA (Analysis of Variance) was carried for within group analysis.
•The Chi-square test was used for testing the significance of the occurrence of an event. 
•When patient recovered from the anesthesia after tubeless PCNL procedure, the first complaint of a patient was urinary catheter discomfort in majority.  Sometimes patient may become irritable, extremely restless and may try to pull out the catheter.
•There are many modalities of treatment available to minimize the severity of CRBD like, oxybutynin, tolterodine(3,11) and butylscopolamine(12), non-steriodal anti inflammatory drugs (NSAID), tramadol, ketamine(4), paracetamol(13), pregabaline and gabapentin.(14)
•But, these are associated with dosage related systemic side effects.
•The CEB is not popular for the adult patients because of its limitation like, difficult to palpate the landmark and high chance of failure rate.  But, we can increase the success rate of CEB with the help of imaging modality like ultrasonography and fluoroscopy.(15,16)
•The volume for caudal epidural space is variable from 10 to 30 ml. The suggested dosages for adults are 15-20 ml to block the lower limb and perineum.(17)
•Our idea behind this study was to prolong the effect of analgesia by help of adjuvant. It was studied that bupivacaine with opioid has the synergistic effect to prolong the duration the analgesia.
•Nalbuphine is the synthetic opioid agonist-antagonist analgesic. It has agonistic action at kappa and antagonist activity at µ opioid receptors.(18)
Fentanyl is a synthetic opioid agonist. It binds mainly mu receptors within the spinal cord. Fentanyl easily crosses the lumbar dura and enters into the spinal cords
•CEB is a better alternative to minimize the severity of the CRBD.
•There is always an advantage of using the regional block for postoperative pain management over the systemic administration of analgesia drugs.
•The successfully given CEB with opioid adjuvant is the more efficient preventive and treatment option for the CRBD. 
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