Intra Venous Butorphanol versus Intravenous Nalbuphine for (Intra Operative) Balanced Anaesthesia and Post Operative Analgesic Effect in Patients Undergoing Laparoscopic Surgery

Laparoscopic surgery has replaced many of the open surgeries because of its advantages. Both the groups of drugs have hemodynamic stability, analgesia, sedation and decrease the requirement of other anesthetic drugs. So we have chosen Butorphanol and Nalbuphine to study the analgesia and hemodynamic changes in both groups. In our study mean heart rate was lower in Butorphanol group compare to Nalbuphine group. Similarly fifty patients of ASA I&II scheduled for elective laparoscopic surgery, were randomized in to butorphanol group and nalbuphine group. It was observed that there was significant rise in systolic blood pressure & Diastolic Blood pressure after intubation in fentanyl group compare to Butorphanol. This study finds that suppression of sympathetic response to laryngoscopy and intubation was better with Butorphanol than Fentanyl. This study analysis indicates that both Butorphanol and Nalbuphine help in maintaining a steady haemodynamic state all throughout the procedure.


INTRODUCTION
Nalbuphine is a semisynthetic opioid agonist antagonist. Indicated for the relief of moderate to severe pain. It can also be used as asupplement to balanced anaesthesia, for preoperative and postoperative analgesia, and for obstetrical analgesia during labor and delivery [1,2].
Butorphanol is a morphinantype synthetic agonistantagonist opioids analgesic. The most common indication for butorphanol is management of moderate to severe pain, as a supplement for balanced general anaesthesia. Butorphanol is also quite effective at reducing postoperative shivering [3].
Laparoscopic surgenes is also known as minimally invasive surgical procedures which are performed with assistance of video surgery pneumoperitoneum should be created by insufflation with air or carbon dioxide. The created pneumoperitoneum causes several pathophysiological changes during the surgery such as increase in systemic and pulmonary vascular resistance and extreme patient positioning.
Nalbuphine is a semisynthetic opioid agonist antagonist. Butorphanol is a morphinantype synthetic agonistantagonist opioids analgesic. Laparoscopic surgery is an invasive surgical procedures during which pneumoperitoneum is created which causes several pathophysiological changes during the surgery such as increase in systemic and pulmonary vascular resistance and extreme patient positioning [46]. Hence this study is to compare the hemodynamic stability of Intra venous Butorphanol and Intra venous Nalbuphine for (intra operative) balanced anaesthesia and postoperative analgesic effect in patients undergoing laparoscopic surgeries.

Source of Data Collection
The study group (60) comprise of patients admitted in the hospital for laparoscopic surgeries. The study group was not blinded in the study period.

Preanaesthetic Evaluation
Patients were visited on the previous day of surge ry, and the procedure was explained to them. A detailed medical history was taken, and systemic Examinations were carried out and relevant investigations were advised. Patients were given tab. Ranitidine 150 mg and tab alprazolam 0.25 mg the previous night. Nil per oral status of 8 hrs was maintained for all patients.
The study group of 60 patients (ASA I & II) physical status aged 2060 years were selected who were scheduled to undergo elective laparoscopic surgeries. They were randomized and allotted into two groups.
Group B received Inj Butorphanol 20 mc g/kg IV before induction (n=30) With Inj propofol 2 mg/kg IV and Group N received Inj Nalbuphine 0.2 mg/kg with Inj propofol 2 mg/kg Iv(n=30).

Parameters those were Observed and Analyzed
Hemodynamic stability during the surgery were assessed for the following parametersHeart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), End tidal Carbon dioxide (EtC O 2 ) and oxygen saturation were observed and recorded at baseline, after administering the drug, after intubation, insufflation of Co 2 , at 30 and 45 minutes and after extubation.

Statistical Tools
The information collected regarding all the selected cases were recorded in Master. Data analysis was done with the help of computer using Epidemiological Information Package (EPI 2008).
Using this software range, frequencies, percentages, means, standard deviations, chi square and 'p' values were calculated. Kruskul Wallis chisquare test was used to test the significance of difference between quantitative variables and Yate's test for qualitative variables. A 'p' value less than 0.05 is taken to denote significant relationship.
The study group (60) comprise of patients admitted in the hospital for laparoscopic surgeries. The patients randomly assigned to one of two groups (B&N), of which one group is Injected with Butorphanol (20 mcg/kg) and the other with Nalbuphine (0.2 mg) after which, post extubation, vital parameters, sedation score, anxiety scores were recorded.

RESULTS
Both the Groups B and N were statistically comparable with regard to the mean heart rate where it was statistically insignificant (P > 0.05) during the baseline and after administering the drug (Table 1).

DISCUSSION
Both the group of drugs has hemodynamic stability, analgesia, sedation and decreases the requirement of other anesthetic drugs. So we have chosen Butorphanol and Nalbuphine to study the analgesia and hemodynamic changes in both groups. mean heart rate was lower in Butorphanol group compare to Nalbuphine group. Postoperative sedation and analgesia remained for longer duration in Butorphanol group as compared to nalbuphine group Similar study conducted by Bill D. Atkinson, Linda J. Truitt, et al. [7,8] concluded that Butorphanol provided better hemodynamics than Fentanyl. However the rise in heart rate and blood pressure were not up to the 20% of pre operative value. There was no significant effect In oxygen saturation or EtC02 values. Rao satyanarayana V, Srinivas B, Muralidar A, et al comparison of butorphanol and fentanyl for balanced anaesthesia in patients undergoing laparoscopic surgeries under general anaesthesia. Fifty patients of ASA I & II scheduled for elective laparoscopic surgery, were randomized in to butorphanol group and nalbuphine group. There was significant rise in systolic blood pressure & Diastolic Blood pressure after intubation in fentanyl group compare to Butorphanol the observations are similar to our study. Shital S. Shweta Mhambrey, SambharanaNayak, et al. [9] study to compare effect of equipotent dose of butorphanol versus fentanyl on intraoperative and postoperative recovery characteristic in patient undergoing laparoscopic surgery. From the results it was found that Butorphanol 20mcg/kg prevents response to endotracheal intubation to a greater extent than Fentanyl 1 mcg/kg. The observations are similar to our study.

CONCLUSION
We found that Butorphanol and Nalbuphine were cardio stable, but there was significant fall in heart rate and diastolic blood pressure in patients who received Butorphanol as premedication as compared to the patients who received Nalbuphine, in which there was rise in heart rate and blood pressure intraoperatively. However the rise in heart rate and blood pressure were not up to the 20% of pre operative value. There was no significant effect in oxygen saturation or EtC02 values. Post operative sedation and analgesia remained for longer duration in Butorphanol group as compared to nalbuphine group.

CONSENT
An informed valid consent was taken from all the patients.

ETHICAL APPROVAL
The study was approved by the Institutional Ethics Committee