Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 177-185

Perioperative maternal fetal outcome in spinal cesarean section: Intrathecal nalbuphine versus adenosine adjuvants to bupivacaine


1 Department of Anesthesia & Intensive Care, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission26-Jun-2021
Date of Decision10-Oct-2021
Date of Acceptance17-Oct-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Osama Z Tolba
El-Obour City, 6th District, El-Qaliobia
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_118_21

Rights and Permissions
  Abstract 


Objectives
To measure the perioperative fetal and maternal outcomes and the postoperative analgesic effects when using intrathecal nalbuphine as an adjuvant to bupivacaine and intrathecal adenosine as an adjuvant to bupivacaine controlled by fentanyl as an adjuvant to bupivacaine during spinal anesthesia for elective cesarean section.
Background
Spinal anesthesia for cesarean delivery is the best anesthetic technique as it is simple to perform with rapid onset of anesthesia and complete muscle relaxation. Lower incidence of failed block, less drug doses, minimal neonatal depression, and decreased incidence of aspiration pneumonitis are added advantages of spinal anesthesia.
Patients and methods
After obtaining approval from the ethical committee for our study, patients admitted to El Menoufia University Hospital for cesarean delivery were enrolled in this study. We calculated that the minimum proper sample size was 25 patients in each group to be able to reject the null hypothesis with 80% power at α=0.05 level using one-way analysis of variance test.
Results
Level of sensory block was assessed using loss of cold discrimination (ice test) and motor block (assessed by Bromage scale: 0 = none, 1 = just able to move the knee but not the hip, 2 = able to move the foot only, and 3 = unable to move the knee or foot). All patients included in the study had sensory level from T4 to S5.
Conclusion
Nalbuphine showed better maternal and fetal outcomes than adenosine in spinal anesthesia for elective cesarean section as an adjuvent to bupivacaine intrathecally and in comparison with fentanyl.

Keywords: adenosine, cesarean, gamma-aminobutyric acid, intramuscular, nalbuphine


How to cite this article:
Hassan AA, Elbahar MY, Habeeb RM, Tolba OZ. Perioperative maternal fetal outcome in spinal cesarean section: Intrathecal nalbuphine versus adenosine adjuvants to bupivacaine. Menoufia Med J 2022;35:177-85

How to cite this URL:
Hassan AA, Elbahar MY, Habeeb RM, Tolba OZ. Perioperative maternal fetal outcome in spinal cesarean section: Intrathecal nalbuphine versus adenosine adjuvants to bupivacaine. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:177-85. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/177/343092




  Introduction Top


Spinal anesthesia for cesarean delivery is the best anesthetic technique as it is simple to perform with rapid onset of anesthesia and complete muscle relaxation. Lower incidence of failed block, less drug doses, minimal neonatal depression, and decreased incidence of aspiration pneumonitis are added advantages of spinal anesthesia [1].

Intrathecal opioids are synergistic with local anesthetics and intensify the sensory block without increasing the sympathetic block [2].

Nalbuphine, a mixed agonist–antagonist opioid, has a potential to attenuate the mu-opioid effects and to enhance the kappa-opioid effects. It was synthesized in an attempt to produce analgesia without the undesirable adverse effects of a μ agonist [3].

Nalbuphine is a mixed synthetic agonist–antagonist that attenuates the opioid effects and enhances the opioid effects [2].

Adenosine concentrations in cerebrospinal fluid are increased after intrathecal, but not intravenous, administration of opioids, suggesting a role for adenosine in spinal opioid receptor activation and analgesia [4].

Fentanyl is a lipophilic opioid with a rapid onset following intrathecal injection. It does not migrate to the fourth ventricle in sufficient concentration to cause respiratory depression. It is commonly added to intrathecal bupivacaine in cesarean delivery by many anesthesiologists [5].

The aim was to measure the perioperative fetal and maternal outcomes and the postoperative analgesic effects using intrathecal nalbuphine as an adjuvant to bupivacaine and intrathecal adenosine as an adjuvant to bupivacaine controlled by fentanyl as an adjuvant to bupivacaine during spinal anesthesia for elective cesarean section.


  Patients and methods Top


This was a cross-sectional study that was conducted on 75 female patients who underwent cesarean section at El Matarya Hospital. This study was performed after approval of the ethical committee.

The participants (75 patients) were randomly divided into three groups: group A (adenosine) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 500 μg adenosine (USP) as an adjuvant.

Group N (nalbuphine) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 400 μg nalbuphine (nalufin) as an adjuvant.

Group F (fentanyl) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 25 μg fentanyl citrate as an adjuvant to be a control group.

Inclusion criteria were as follows: patients were selected according to American Society of Anesthesiologists (ASA) status (ASA I and ASA II) with normal coagulation profile with the age ranged between 20 and 35 years old, BMI from 25 to 35 kg/m2, and duration of surgery did not exceed 75 min.

Exclusion criteria were as follows: (a) patient refusal, (b) infection at site of the injection or systemic infection, (c) patients with any coagulopathy disorder or receiving any anticoagulant drugs, (d) preexisting neurological disorders, (e) preeclampsia and eclampsia, (f) patients with signs suggesting cardiac or respiratory system diseases, (g) patients with known history of allergy to local anesthetic drugs, and (h) hypertensive and diabetic patients.

Methodology

Preoperative assessment: (a) in our study, all participants were clinically assessed, and routine preoperative investigations were done (e.g. complete blood count, coagulation profile, liver function tests, kidney function tests, and fasting blood sugar) for evaluation of the patient medical status. (b) Preanesthetic evaluation was done, and all details were explained to all participants about the procedure of the spinal anesthesia during the preanesthetic visit. Patients were familiarized with the visual analog scale (VAS) (0 = no pain and 10 = worst pain) a day before surgery. (c) Patients fasted for 8 h before the procedure. Oral and written consents were taken from the patients for spinal block. (d) Premedications included oral ranitidine tablets (150 mg) on the evening before and the morning of surgery.

Intraoperative: (a) on arrival to the operating room, the mother was allowed 5 min rest period in the supine position with left lateral tilt. (b) Continuous monitoring with electrocardiography, noninvasive blood pressure (BP), and pulse oximetry was initiated. (c) A suitable peripheral vein was cannulated with 16 G peripheral cannula preceded by sterilization and local anesthetic infiltration. (d) Ringer's solution 500–1000 ml over 15 min (preload) was given to patients before the procedure.

The participants (75 patients) were randomly divided into three groups: group A (adenosine) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 500 μg adenosine (USP) as an adjuvant. (i) Group N (nalbuphine) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 400 μg nalbuphine (nalufin) as an adjuvant. (ii) Group F (fentanyl) included 25 patients who received intrathecal 2.4 ml of 0.5% heavy bupivacaine plus 25 μg fentanyl citrate as an adjuvant to be a control group.

Technique: (a) The patient was put in the sitting up position with leaning forward. (b) Sterilization of the back was done by povidone iodine in a circular manner with covering the back by sterilized towels just exposing the lumber area. (c) Dural puncture was performed at L3–L4 interspace or L4–L5 with a 25-G spinal needle after infiltration of the skin at the site of lumbar puncture with 2 ml of lidocaine 2%. Then, the patient was placed in the supine position with left lateral tilt and two pillows supporting the head and shoulders; oxygen mask was used at 6 l/min.

(a) Level of sensory block was assessed using loss of cold discrimination (ice test) and motor block (assessed by Bromage scale; 0 = none, 1 = just able to move the knee but not the hip, 2 = able to move the foot only, and 3 = unable to move the knee or foot); all patients included in the study had sensory level from T4 to S5. (b) The onset of sensory blockade (defined as the time from the injection of intrathecal drug to the absence of pain at the T4 dermatome) and onset of complete motor blockade (time taken from the injection to development of Bromage grade 3 motor block) were recorded. (c) In case of failure of the spinal block, we gave the patient general anesthesia, and that patient was excluded from the study. (d) Heart rate, electrocardiography, and mean arterial blood pressure (NIBP) were measured and recorded every 1 min after spinal anesthesia for the first 10 min and then every 3 min till end of surgery. O2 saturation was recorded continuously. (e) Fetal APGAR score assessment at first minute and after 5 min was done by the attending pediatrician. (f) Fetal venous cord samples at first minute and after 5 min were taken for ABG monitoring. (g) Estimation of induction-uterine incision time and uterine incision delivery time was done. (h) Nausea, vomiting, and chest symptoms (dyspnea and tachypnea) were also recorded. (i) Hypotension (≥20% decrease in the mean arterial BP from the baseline) was treated immediately by increments of 5 mg intravenous ephedrine till normalization of BP in all groups. (j) An intravenous bolus of oxytocin 5 IU diluted in 5 ml normal saline was slowly administered after delivery ± 10–20 IU in 500 ml normal saline infusion in all groups. (k) Nausea and vomiting were treated immediately with 1 mg granisetron. (l) A urinary catheter was left in situ and removed 24 h later. (m) Observation and reporting of any complications either related to spinal block or allergic reactions to the drugs injected was done, such as (i) hypotension, (ii) bradycardia, (iii) pruritus, (iv) nausea and vomiting, (v) shivering, (vi) rash, (vii) patient satisfaction, and (vii) bronchospasm.

All patients in the three groups were assessed postoperatively for the following: (a) complications: hypotension, bradycardia, pruritis, shivering, neurotoxicity, nausea and vomiting, and chest symptoms (dyspnea or tachypnea). (b) Postoperatively, they were assessed for pain score (VAS) (it ranges from 0, indicating no pain, till 10, indicating severe intolerable pain with variable degrees of ascending pain in between). It was assessed hourly for first 4 h and at 12 and 24 h [6]. The duration of effective analgesia (time from the intrathecal injection to the first rescue analgesic requirement, VAS score >3) was noted. Pethidine 50 mg intramuscular was administered as rescue analgesic, and total number and frequency of rescue analgesics required postoperatively in 24 h period was recorded. NB analgesic rescue should be two types of drugs first rescue and second. (c) Continuous monitoring of the conscious level, respiratory rate, oxygen saturation, sensory level, and motor block was done every 15 min till complete recovery. Heart rate and noninvasive BP were recorded after 2 and 4 h. (d) The duration of analgesia was recorded. The time of the first analgesic dose was recorded (effective analgesic time: from intrathecal injection to VAS >score 4). Any complication was recorded and managed as before. (e) In addition, for vomiting, granisteron 1 mg intravenous was given; for shivering, pethidine 20 mg intravenous; for pruritis, naloxone 0.1–0.4 mg intravenous over 1 min, and for bradycardia (heart rate <50 BPM), atropine 0.5 mg intravenous respiratory depression was defined as a respiratory rate of less than 10 breaths/min, and hypoxia is defined as an oxygen saturation of less than 95.

Outcome: primary outcome was in the form of postoperative analgesia duration. Secondary outcome was in the form of heart rate, ECG, mean arterial BP, fetal APGAR score, induction-uterine incision time, and complications in the form of nausea, vomiting, and chest symptoms.

[Table 1] shows that there was a nonstatistically significant difference among three groups regarding age (years), height (cm), weight (kg), and duration of surgery (min).
Table 1: Demographic data of the participants

Click here to view


Intraoperatively:

[Table 2] shows that there was a statistically significant difference found among the three groups regarding BP systolic at baseline, 1, 6, 7, 8, 10, 16, 25, and 28 min, and there was a nonstatistically significant difference among the three groups regarding BP systolic at 2, 3, 4, 5, 9, 13, 19, 22, and 30 min.
Table 2: Comparison between adenosine (n=25), nalbuphine (n=25), and fentanyl (n=25) regarding blood pressure systolic

Click here to view


[Table 3] shows that there was a highly statistically significant difference among the three groups regarding heart rate at baseline, 2, 3, 4, 6, 7, 8, 9, 10, 16, 19, 22, 25, and 28 min, and there was a statistically significant difference among the three groups regarding heart rate at 5, 13, and 30 min, and there was a nonstatistically significant difference among the three groups regarding heart rate at 1 min.
Table 3: Comparison between adenosine (n=25), nalbuphine (n=25), and fentanyl (n=25) regarding heart rate

Click here to view


Postoperative data:

[Table 4] shows that there was a nonstatistically significant difference found among the three groups regarding BP systolic at 15 min, 30 min, 4 h, and 8 h, and there was a statistically significant difference found among the three groups regarding BP systolic at 45 min, 1 h, 2 h, 6 h, 12 h, and 24 h.
Table 4: Comparison between adenosine (n=25), nalbuphine (n=25), and fentanyl (n=25) regarding blood pressure systolic

Click here to view


[Table 5] shows that there was a nonstatistically significant difference among the three groups regarding SO2 at 15 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, and 24 h, and there was a statistically significant difference among the three groups regarding SO2 at 30 min and 6 h.
Table 5: Comparison between adenosine (n=25), nalbuphine (n=25), and fentanyl (n=25) regarding SO2

Click here to view



  Discussion Top


Cesarean section is among the most commonly performed surgeries in women, and neuroaxial anesthesia is the technique of choice for this procedure [7].

Spinal anesthesia is the preferred mean for cesarean section, being simple to perform, economical, and produces rapid onset of anesthesia and complete muscle relaxation. It carries high efficiency, involves less drug doses, has minimal neonatal depression, keeps the mother awake, and has a lesser incidence of aspiration pneumonitis. However, it also produces a fixed duration of anesthesia, postdural puncture headache, hypotension, and lesser control of block height [8].

Bupivacaine an amide type of local anesthetic has high potency, slow onset (5–8 min), and long duration of action (1.5–2 h). For cesarean section, intrathecal dose of hyperbaric bupivacaine is 12–10.8 mg. Cesarean delivery requires traction of peritoneum and handling of intraperitoneal organs, resulting in intraoperative visceral pain. With higher doses of hyperbaric bupivacaine, the incidence of intraoperative visceral pain associated with higher blocks is reduced [9].

Nalbuphine is a mixed agonist–antagonist opioid and has a potential to attenuate the μ-opioid effects and to enhance the kappa-opioid effects. It produces desirable analgesia without causing the undesirable adverse effects of a μ agonist. It was used as an adjuvant to local anesthetics in many randomized clinical studies, especially in orthopedic procedures of lower limbs in doses between 0.2 and 2.4 mg in various studies [10].

Fentanyl has a rapid onset of action when given intravenously or intrathecally. Fentanyl has less emetic activity than either morphine or pethidine [11]. Fentanyl is probably the most widely used opioid in patients undergoing cesarean section; improves quality of spinal anesthesia, reduces dose of local anesthetics, but has little effect on prolonging postoperative analgesia [12].

The first study using intrathecal fentanyl was done by Hunt et al. [13] from Brigham and Women's Hospital in Boston USA; they evaluated 0, 2.5, 5, 6.25, 12.5, 25, 37.5, and 50 μg of fentanyl added to spinal hyperbaric bupivacaine 0.75% in 56 parturients undergoing cesarean delivery. Overall, 67% of patients in the control group needed supplemental intraoperative opioids. None of the parturients who received The time for first analgesic request was 33.7 ± 30.8 min (mean ± SD) in the control group and increased to 130 ± 30 min (P < 0.05) in those women treated with 6.25 μg fentanyl. Duration of effective analgesia was significantly longer in this group [192 ± 74.9 min vs. 71.8 ± 43.2 min (P < 0.05)]. Bigger doses had no effect on effective analgesia. Itching was increased with 25 and 50 μg. There were no adverse effects in the neonates, and they concluded that the optimal dose of spinal fentanyl was 6.5 μg. Most authors reported that higher doses from 12.5 to 25 μg are safe and enhance spinal blockade, transcesarean analgesia, and immediate postsurgical analgesia, without increasing adverse effects.

Rawal et al. [14] studied several spinal opioids in sheep, including nalbuphine; although spinal nalbuphine was not the less neurotoxic, the authors found that this opioid was associated with relatively minor behavioral and EEG changes, sedation, spinal cord mild inflammatory, and neuronal changes. Following intrathecal nalbuphine, the aforementioned changes were similar to those seen in control animals. One animal developed motor impairment during 60 min.

Duration of sensory and motor block was comparable between both the groups and showed statistically significant differences between patients. Our results are similar to the study by Thote et al. [15], where patients underwent lower abdominal surgeries using 25 μg of fentanyl and 0.5 mg of nalbuphine with 12.5 mg of 0.5% bupivacaine; the study showed longer duration of analgesia with nalbuphine group when compared with fentanyl group. The study also showed greater intensity of analgesia with nalbuphine group.

These were unlike the results found by Gomaa et al. [1], who showed that fentanyl 25 μg and nalbuphine 0.8 mg as an adjuvant to 10 mg of 0.5% bupivacaine in cesarean section patients produced similar block characteristics. Although duration of analgesia was prolonged when compared with fentanyl, the results were not statistically significant.

We observed in our study that the early postoperative VAS was quite higher, and there was also a greater percentage of patients requiring rescue analgesia in early postoperative period in nalbuphine group than compared with fentanyl group. This showed that intensity and quality of analgesia provided by the nalbuphine were inferior to fentanyl.

None of the studies done in the past have shown poor VAS with intrathecal nalbuphine. Studies done by Jyothi et al. [16] and Gomaa et al. [1] have shown lesser VAS scores with prolongation of analgesia with nalbuphine group.

Lesser potency of nalbuphine and its agonist and antagonist property might be the cause for its poor efficacy when compared with fentanyl. This pharmacodynamic property of nalbuphine needs further study involving a larger sample group [10].

Our study showed no significant differences among the three groups regarding the APGAR score that matching other studies did not find any significant effect of nalbuphine on neonatal outcome [17].

However, Wilson et al. [18] found that when nalbuphine was used as a bolus for maternal analgesia during labor, it was associated with decreased APGAR and neonatal neurobehavioral scores that contradict our results.

Our study also found that nalbuphine showed best results than using adenosine for sedation in cesarean section. There are few studies that state using adenosine in the sedation may be due to the superiority of fentanyl in the sedation than any other drugs.

The stuyd by Sharma et al. [19] supports the role of intrathecal adenosine to relieve experimental and neuropathic pain; the efficacy of this drug to relieve postoperative pain remains unproven. The results of the present study failed to show any effect of intrathecal adenosine administered in a dose of 1000 μg, preemptively or after surgery in patients undergoing abdominal hysterectomy.


  Conclusion Top


Nalbuphine showed better maternal and fetal outcomes than adenosine in spinal anesthesia for elective cesarean section as an adjuvant to bupivacaine intrathecally in cesarean section as it reduces the need for intraoperative analgesics, improves postoperative analgesia for a brief period of time of 2–4 h, and has no effect on the subsequent analgesic doses. The doses mentioned in this study are very safe for the mother and newborn, and its adverse effects are minimal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gomaa HM, Mohamed NN, Zoheir HA, Ali MS. A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after cesarean section. Egypt J Anaesth 2014; 30:405–410.  Back to cited text no. 1
    
2.
Bindra TK, Kumar P, Jindal G. Postoperative analgesia with intrathecal nalbuphine versus intrathecal fentanyl in cesarean section: a double-blind randomized comparative study. Anesth Essays Res 2018; 12:561.  Back to cited text no. 2
    
3.
Gunion MW, Marchionne AM, Anderson CT. Use of the mixed agonist–antagonist nalbuphine in opioid based analgesia. Acute Pain 2004; 6:29–39.  Back to cited text no. 3
    
4.
Eisenach JC, Carpenter R, Curry R. Analgesia from a peripherally active Kappa opioid receptors agonist in patients with chronic pancreatitis. Pain 2003; 101:89–95.  Back to cited text no. 4
    
5.
Ahmed FI. Intrathecal nalbuphine versus fentanyl as an adjuvant to bupivacaine in spinal anesthesia for elective cesarean section: a randomized double-blind study. Res Opinion Anesth Intensive Care 2019; 6:112.  Back to cited text no. 5
    
6.
Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev 2018; 2:e088.  Back to cited text no. 6
    
7.
Gandhi KA, Jain K. Management of anaesthesia for elective, low-risk (Category 4) caesarean section. Indian J Anaesth 2018; 62:667–674.  Back to cited text no. 7
    
8.
Dongare PA, Nataraj MS. Anaesthetic management of obstetric emergencies. Indian J Anaesth 2018; 62:704–709.  Back to cited text no. 8
    
9.
Bogra J, Arora N, Srivastava P. Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anesthesia for cesarean section. BMC Anesthesiol 2005; 5:5.  Back to cited text no. 9
    
10.
Prabhakaraiah UN, Narayanappa AB, Gurulingaswamy S, Kempegowda K, Vijaynagar KA, Hanumantharayappa NB, et al. Comparison of nalbuphine hydrochloride and fentanyl as an adjuvant to bupivacaine for spinal anesthesia in lower abdominal surgeries: a randomized, double-blind study. Anesth Essays Res 2017; 11:859–863.  Back to cited text no. 10
    
11.
Tsen LC. Anesthesia for cesarean delivery. In: Chestnut D, Wong C, Ysen LC, Ngan W, Beilin G, Mhyre J, editors. Chestnut's obstetrics anesthesia: principles and practice. 5th ed.ition. Philadelphia: Elsevier-Saunders; 2014. p. 545–603.  Back to cited text no. 11
    
12.
Carvalho B, Butwick A. Postoperative analgesia: epidural and spinal techniques. In: Chestnut D, Wong C, Ysen LC, Ngan W, Beilin G, Mhyre J, editors. Chestnut×s obstetrics anesthesia: principles and practice. 5th ed.ition. Philadelphia: Elsevier-Saunders; 2014. p. 621–661.  Back to cited text no. 12
    
13.
Hunt CO, Naulty JS, Bader AM, Hauch MA, Vartikar JV, Datta S, et al. Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery. Anesthesiology 1989; 71:535–540.  Back to cited text no. 13
    
14.
Rawal N, Nuutinen L, Raj PP, Lovering SL, Gobuty AH, Hargardine J, et al. Behavioral and histopathologic effects following intrathecal administration of butorphanol, sufentanil, and nalbuphine in sheep. Anesthesiology 1991; 75:1025–1034.  Back to cited text no. 14
    
15.
Thote RJ, Lomate P, Gaikwad S, Paranjpe JS, Mane M. Comparison among intrathecal fentanyl and nalbuphine in combination with bupivacaine and plain bupivacaine for lower limb surgeries. Int J Recent Trends Sci Technol 2015; 14:3616.  Back to cited text no. 15
    
16.
Jyothi B, Gowda S, Shaikh SI. A comparison of analgesic effect of different doses of intrathecal nalbuphine hydrochloride with bupivacaine and bupivacaine alone for lower abdominal and orthopedic surgeries. Indian J Pain 2014; 28:1823.  Back to cited text no. 16
    
17.
Wahab SA, Askalani AH, Amar RA, Ramadan ME, Neweigy SB, Saleh AA. Effect of some recent analgesics on labor pain and maternal and fetal blood gases and pH. Int J Gynecol Obstet 1988; 26:75–78.  Back to cited text no. 17
    
18.
Wilson SJ, Errick JK, Balkon J. Pharmacokinetics of nalbuphine during parturition. Am J Obstet Gynecol 1986; 155:340–344.  Back to cited text no. 18
    
19.
Sharma M, Mohta M, Chawla R. Efficacy of intrathecal adenosine for postoperative pain relief. Eur J Anaesthesiol 2006; 23:449–453.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed538    
    Printed12    
    Emailed0    
    PDF Downloaded68    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]