1. Dr. ANJU PADMALAYAN PG CO AUTHORS: Prof.& HOD Dr.I.CHANDRASEKARAN MD, DA Prof.Dr.GANESH PRABHU MD, DA., Asst.Prof.Dr. SIVAPRASATH MD., INSTITUTE OF ANAESTHESIOLOGY MADURAI MEDICAL COLLEGE

2. AIM.  To assess the efficacy of epidural magnesium for post operative analgesia.

3. REFERENCES  Epidural magnesium reduces postoperative analgesic requirement. British Journal of Anaesthesia 2007 98(4):519-523  Combined intrathecal and epidural magnesium sulfate supplementation of spinal anesthesia to reduce post-operative analgesic requirements in patients undergoing major orthopedic surgery. Acta Anaesthesiologica scandinavica vol.51 issue 4, Mar 2007

4.  Randomized double blinded study  INCLUSION CRITERIA 40 Patients ASA I & II AGE 20 -60 Years HERNIOPLASTY  EXCLUSION CRITERIA ASA III&IV C/I for performing Regional anaesthesia Adverse reaction to study medication

5. MATERIALS AND METHODS..  Ethical committee approval  Informed written consent  Group F – Epidural FENTANYL 2mics/ml in 10 ml NS  Group FM– Epidural FENTANYL 2mics /ml + MAGNESIUM SULPHATE 50mg in 10 ml NS

6. CLINICAL PROTOCOL..  MONITORS: NIBP, Pulseoximetery  PRE LOADING: 500 ml RL sol

7. TECHNIQUE Patient in Right lateral position Under strict aseptic precaution, Epidural performed with 16 G tuohy needle with loss of resistance to air Catheter threaded Test dose given

8. Cont..  SAB performed in a space below injecting 0.5% hyperbaric Bupivacaine,  Surgery proceeded  After the completion of the surgery  Pt observed in the IRCU

9. PARAMETERS OBSERVED..  Pulse rate  Blood pressure  Oxygen saturation  Ventilator requirement  Duration of analgesia  Sedation score  Visual analogue score  Side effects

10.  VISUAL ANALOGUE SCORE: 0 – 10 NO PAIN LITTLE PAIN CONSIDERABLE PAIN LOT OF PAIN WORST PAIN  RAMSAY SEDATION SCORE: LEVELS 1 -3 patient awake LEVEL 1-anxious and agitated or restless or both LEVEL 2-cooperative and oriented LEVEL 3-responds to commands only LEVEL 4-6 patient asleep, responds to light glabellar tap or loud auditory stimulus LEVEL 4 –Brisk response LEVEL 5 – Sluggish response LEVEL 6 –No response

11. STATISTICAL TOOLS  Data analysis was done with the help of computer using Epidemiological Information Package (EPI 2008).  Kruskul Wally’s chi square was used to test the significance of relationship. A ‘p’ value less than 0.05 is taken to denote significant relationship.

12. RESULTS..  Two groups were comparable for their demographic data and baseline hemodynamic variable.

13. DATA COLLECTED. GROUPFMF‘P’ AGE IN YRS 39.2±9.940.2± 8.40.7341 Not significant SEX MALE FEMALE 90% 10% 90% 10% 1.0 Not significant

14. MEAN AGE (in years)

15. PULSE RATE AT FM GROUPF GROUP“p” 0 minute87 + 9.186.5 + 10.5 0.9028 Not significant 30 minutes84.5 + 13.793.8 + 14.60.0445 Significant 60 minutes77.9 + 11.0101 + 16.20.0001 Significant 120 minutes73.1 + 7.7101.7 + 16.10.0001 Significant 180 minutes72.8 + 7.5101.7 + 14.20.0001 Significant

16. PULSE RATE

17. SYSTOLIC BLOOD PRESSURE SYSTOLIC B.P. AT FM GROUPF GROUP“p” 0 minute119.7 + 10.7124.1 + 11.40.1967 Not significant 30 minutes117.4 + 9.2120.5 + 90.2179 Not significant 60 minutes115.2 + 7.4118 + 7.30.3584 Not significant 120 minutes115.7 + 8.4118.5 + 80.2333 Not significant 180 minutes120.2 + 7.4122.7 + 4.70.4703 Not significant

18. SYSTOLIC BLOOD PRESSURE

19. DIASTOLIC BLOOD PRESSURE DIASTOLIC B.P. AT FM GROUPF GROUP“p” 0 minute90 + 6.287.6 + 6.60.2872 Not significant 30 minutes85.3 + 5.485.4 + 5.50.845 Not significant 60 minutes85.7 + 4.989.3 + 5.30.8057 Not significant 120 minutes86.4 + 4.986.6 + 5.20.9673 Not significant 180 minutes86.6 + 4.486.5 + 5.40.7746 Not significant

20. DIASTOLIC BLOOD PRESSURE

21. OXYGEN SATURATION VARIABLE FM GROUPF GROUP“p” SPO298.4 + 0.998.5 + 1.10.6896 Not significant

22. SPO2

23. SEDATION SCORE FM GROUPF GROUP No.% % 31050735 410501365 Total2010020100 Mean S.D. 3.5 0.51 3.65 0.49 ‘p’0.3434 Not Significant

24. SEDATION SCORE

25. VISUAL ANALOGUE SCORE VAS AT FM GROUPF GROUP“p” 0 minute3.1 + 1.32.7 + 1.0 0.3126 Not significant 30 minutes0.15 + 0.370.65 + 0.490.0014 Significant 60 minutes0.2 + 0.410.8 + 0.40.0013 Significant 120 minutes2.75 + 0.963.4 + 0.680.0271 Significant 180 minutes3.4 + 0.883.95 + 0.220.0214 Significant

26. VISUAL ANALOGUE SCALE

27. ONSET OF ANALGESIA  There was no significant difference in the onset of analgesia in both groups.

28. ANALGESIA DURATION. VARIABLE FM GROUPF GROUP“p” Duration of analgesia ( in minutes) 148.7 + 34.4128.5 + 28.70.0295 Significant

29. DURATION OF ANALGESIA ( in minutes)

30. DISCUSSION.  Magnesium sulphate – Non competitively antagonizes NMDA receptor channels.  Non-competitive NMDA receptor antagonists can have an effect on pain when used alone, but it has also been shown that they can reveal the analgesic properties of opioids.  Magnesium supplement enhances the analgesic effect of opioids

31. NMDA RECEPTORS  NMDA receptors –central nociceptive transmission  Recent studies show NMDA receptors are also present in skin, muscles & knee jt  Mg- physiological blocker of NMDA  In inactive state NMDA receptor is blocked by centrally positioned Mg ion

33. TO SUMMARISE.  The purpose of this study is to assess the efficacy of epidural magnesium.  Study..  Postoperative analgesic duration Group F 128.50 min, FM 148.70 min.  Group FM had prolonged duration of analgesia.

34. TO CONCLUDE.  Magnesium when given epidurally along with opioids will increase the duration of analgesia without any side effects.  Magnesium potentiates the analgesic property of opioids and hence the quality of analgesia.

35. Thank You