MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - TRAN THI CAM NHUNG RESEARCH ON EFFICACY OF INTRAOPERATIVE ANESTHESIA AND POSTOPERATIVE ANALGESIA BY MIXTURE OF BUPIVACAINE WITH DEXMEDETOMIDINE IN BRACHIAL PLEXUS BLOCK FOR UPPER EXTREMITY BONE SURGERY Speciality: Anesthesiology Code: 62720122 ABSTRACT OF MEDICAL DISSERTATION Hanoi - 2020 THE THESIS HAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisors: Prof Dr Nguyen Van Chung Dr.Tong Xuan Hung Reviewers: Prof Dr Nguyen Huu Tu Ass Prof Dr Bui Van Manh Ass Prof Dr Le Van Doan Archives: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences INTRODUCTION Upper extremity fractures are a common and they appear in every subject According to statistics of Nguyen Duc Chinh et al from 2016 to 2018, 90011 patients of accidents at Viet Duc Hospital, the proportion of this cases had accounted for 53.2% with lower and upper extremity injuries The study of Karl in the United States, the epidemiology of upper extremity fractures accounted for 677/100000 patients in 2009 Among anesthesia methods for upper extremity surgery, brachial plexus block is usual technique due to simple but highly effective anesthesia for this surgery To reduce dose of local anesthetic, increase effect this anesthetic in brachial plexus block, prolong the analgesic effect after surgery, many authors have had researches adding local anesthetics with drug such as sufentanil, fentanyl, morphine, dexamethasone, ketorolac, clonidine, or dexmedetomidine In Viet Nam, there has been no any research on a combination of local anesthetic with dexmedetomidine, so we have conducted a project "Research on efficacy of intraoperative anesthesia and postoperative analgesia by mixture of bupivacaine with dexmedetomidine in brachial plexus block for upper extremity bone surgery”, following two objectives: To compare intraoperative anesthetic and postoperative analgesic efficacy of 75mg bupivacaine and 100mcg dexmedetomidine mixture with bupivacaine alone by brachial plexus block for upper extremity bone surgery To evaluate on blood pressure, heart rate, sedative effect and some adverse effects of 75mg bupivacaine and 100mcg dexmedetomidine mixture by brachial plexus block for upper extremity bone surgery Chapter OVERVIEW 1.1 Upper extremity fracture Causes of the upper extremity fractures are popular due to domestic accidents, machinery, playground injury or road traffic accidents In particular, the author Rubin and his colleagues reported 103465 cases of traffic accidents which had 17263 situations of upper extremity fractures, the ratio of open fractures accounted for 16.7%, about 18.1% at adults and 13.2.% at children In the Netherlands, the frequency of upper extremity fractures had accounted about 824/100 000 people for years from 2004 to 2012 and tended to grow up following next time, more regularly in a group of 16-35 years old, more man than female 1.2 Anesthetic techniques for upper extremity bone surgery There are many anesthetic techniques for upper extremity surgeries, such as intravenous regional anesthesia (Bier block), brachial plexus block, general anesthesia Advantages of brachial plexus block are not only simple technique, but also reducing or losing provisional sensation and movement of upper extremity Patients still awaken, recovery early, lessen caring of health care staff and family’patient Especially, it is lower cost than general anesthesia 1.3 Brachial plexus block The brachial plexus is formed from five roots, the anterior rami of the spinal nerves from C5 - T1, they connect together to form trunks, after the roots pass between the scalene muscles they meet the subclavicular artery and divide into divisions In the three trunks, the superior trunk arises from the union of the C5 - C6 root The middle trunk is formed by the C7 root The inferior trunk is formed by the C8 - T1 root Each trunk continues to divide into two: the anterior and posterior division After that, six dividions connect together and form three cords The lateral cord is formed from connection of two anterior divisions from the superior trunk and the middle trunk The medial cord is an anterior division of the inferior trunk and the posterior cord is composed of three posterior divisions The three cords give rise to major nerves which control sensation and movement of upper extremity, are musculocutaneous nerve, radial nerve, median nerve and ulnar nerve The benefit of supraclavicular brachial plexus block is to anesthetize whole upper extremity Thus, it should be considered "spinal block for upper extremity", and indicated for arm, elbow, forearm and hand surgeries Because almost the brachial plexus merges into a mass, blocking this position can anesthesia for all branches and rapid onset time of sensory block due to small nerves and minimum local anesthetic Supraclavicular brachial plexus block may have some complications such as about 0.04 - 1% pneumothorax, subclavicular artery puncture, Claude Bernard Horner syndrome, phrenic nerve block rarely 1.4 Using drug in brachial plexus block of our study Bupivacaine which is local anesthetic, is exerted to block recoverable conduction of nerve impulse, through mechanism to inhibit depolarization of neural membrane by preventing of Na+ to pass this membrane Bupivacaine inhibits stronger sensory fibers than motor fibers, because motor fibers have myelin sheath and diameter of these fibers larger than sensory fibers The duration time has about - hours Dexmedetomidine is a highly selective a2 adrenoreceptor agonist which has eight times higher effective than clonidine’s The ratio of a2:a1 adrenoreceptor of dexmedetomidine is approximately 1620:1, to have anxiolytic, sedative and analgesic effect Four analgesic mechanism of dexmedetomidine in brachial plexus block are demonstrated by Brummett C (2008) through stimulation of central and peripheral α2 adrenoreceptor, causing central analgesic effect, vasoconstriction around injection site, anti-inflammatory and direct analgesic effect on peripheral nerves Dexmedetomidine connects with anesthetic drug helps to prolong the duration of anesthesia and analgesia on the peripheral nerve through the indirect mechanism due to vasoconstriction at the injection site, however, the vasoconstrictive level of dexmedetomidine is less than epinedrine’s It is important that high doses of dexmedetomidine has not affected the histopathology of the neural axon and myelin which were monitored at 24 hours and 14 days Chapter SUBJECTS AND METHODS 2.1 STUDYING SUBJECTS Male and female patients, who had been undergone elective surgeries of arm or/and forearm fracture by supraclavicular brachial plexus block 2.1.1 Selection criteria for study patients Patients who agreed to participate in the study, aged 15-75 years, ASA grade I – III 2.1.2 Exclusive criteria - Patients had disorder of atrial-ventricular conduction, bradycardia < 50beats/minute Psychiatric disorder, epilepsy, neuromuscular diseases Renal or hepatic failure - History of allergy local anesthetics, alcoholism or drug abuse - Pregnancy or lactating women, patient’s weigh < 35 kg 2.1.3 Rejective criteria from study Patient had multiple injuries, combined upper extremity surgery with other surgeries, surgical complication or not collected enough data 2.2 TIME AND LOCATION OF STUDY The study was practiced from February, 2016 to May, 2017 at Anesthesia and Orthopedic Department in Can Tho Central General Clinic Hospital 2.3 RESEACH METHODOLOGY 2.3.1 Study Design: It was a controlled, randomized, interventional prospective clinical study 2.3.2 Sample size and division of patient group Using the test formula for comparison of two average numbers 2C ( ES ) α is the probability of type error, α = 5%, β is the probability of n type error, β = 20%, to look at table and get a constant C = 7.85 In a study of Agarwal S (2014), μ1 which is postoperative analgesic time of bupivacaine with dexmedetomidine group, is 776 minutes and σ1 which is standard deviation of postoperative analgesic time, is 130.8 minutes μ2 is the expected postoperative analgesic time in our study when we will use a connection of bupivacaine with dexmedetomidine, increasing about 10% postoperative analgesic time of Agarwal’s study, so this time is 850 minutes Filling this parameters into this formula, and calculating n = 49.1 Therefore, we selected 54 patients for each group 2.3.3 Devices, facilities and drugs of research - Ultrasound machine with linear probe, frequency - 12MHz of Ezono AG company - Stimuplex A needle for brachial plexus block of B Braun company - VAS (Visual Analog Scale) ruler - Multi-parameters monitoring of Nihon Kohden company - Bupivacaine Aguettant 20 ml 0.5% of Delpharm Tours, France - Dexmedetomidine (PrecedexR), 200mcg/2ml of Hospira.Inc, North Chicago - Emergency drugs: atropine, ephedrine, adrenaline, noradrenaline, intralipid 20% - Kinds of infusion: lactate ringer, sodium chloride 0.9%, 3.4 Study procedure 2.3.4.1 Preoperative period The day before surgery: examined and measured height, weight, and classified ASA Instruct patients to identify pain level on VAS ruler Explain to the patient about the technique of anesthesia and some possible adverse-effects If the patient agreed to participate in this study, he/she would sign a consent form and be drawn to the study subgroup No one is used analgesic at the surgerical morning 2.3.4.2 At the operating room Patients would be watched for ECG, HA, breathing rate, SpO2 by monitoring and recorded these indexes at that time of study Administer 3liter/min oxygen through the nasal tube Doing intravenous line with 18G needle, and infusing ringer lactate about 30 drops/min To prepare 30 ml mixture of local anesthetics: + B Group: 15 ml of bupivacaine 0.5% plus 15 ml of 0.9% sodium chloride to obtain 30 ml of bupivacaine 0.25% + BD group: 15 ml of bupivacaine 0.5% plus 100mcg /1ml of dexmedetomidine, and 14ml of 0.9% natricloride to get 30ml mixture of bupivacaine 0.25% and 100mcg dexmedetomidine 2.3.4.3 Practice by supraclavicular brachial plexus block via ultrasound guidance The patient's position was lying on an operative table, injuried hand was closed to body, his head was faced to the opposite side of brachial plexus block An anesthesiologist used an ultrasound probe to determine location of the brachial plexus where is above the clavical bone Holding the transducer plane in a direction that was parallel to body's axis, so that ultrasound beam crossed the brachial plexus and subclavicular artery located on the first rib Once the brachial plexus was adequately identification of the neural structures as round or oval multiple hypoechoic structures, next to the subclavicular artery We injected needle slowly and observed its direction of on the screen, keeped it below the brachial plexus, next to the subclavicular artery An assistant installed the syringe containing mixture of local anesthetic with connected line of needle, drawed this syringe test if there was no blood, started to inject 3-5ml then checked again per each time after injection When anesthetic mixture was injected 15ml, needle was stopped and moved it upwards to brachial plexus, continued to inject 15ml of this anesthetic, the anesthetic mixture slowly spread around brachial plexus on screen of ultrasound To monitor the patient in 30 minutes after brachial plexus block: if the patient had completed pain sensory blockage, surgery would be performed If the patient was still moderate pain, we would give them fentanyl 1-2 mcg/kg, and/or midazolam 0.02 - 0.04 mg/kg by intravenous injection in case of anxiety Continuing this evaluation after minutes, if the patient was still severe pain, we would change to general anesthesia All patients in both groups are given paracetamol 1g/100ml at the end of the surgery 2.3.5 Accessment standards of study 2.3.5.1 General characteristics of the patient and surgery Age, gender, height, weight, historical chronic diseases, ASA classification, location and time of surgery 2.3.5.2 Comparison intraoperative anesthetic and postoperative analgesic efficacy of mixture’s bupivacaine and dexmedetomidine with bupivacaine alone by brachial plexus block - The onset time and level of pain sensory blockage dermatomes where be controlled by radial nerve, median nerve and ulnar nerve - The onset time and level of pain sensory blockage on 11 2.3.7 Standards and definitions using for study - Onset time of pain sensory blockage of each root from C5 to T2 root, radial nerve, median nerve, ulnar nerve was defined as the time from the end of local anesthetic administration until patient felt a litte loss sensory block with grade according to the classification of Agarwal, unit in minutes - Onset time of pain sensory blockage of whole upper extremity is defined as the time from the end of local anesthetic administration until patient feel loss sensory block with grade according to the classification of Agarwal, was dominated by roots from C5 to T2, and radial nerve, median nerve, ulnar nerve, unit in minutes - Duration time of pain sensory blockage of whole upper extremity was defined as the time from patient felt loss sensory block with grade until completely sensory recovery with grade according to the classification of Agarwal, unit in minutes - Onset time of motor blockage was defined as the time from the end of local anesthetic administration until patient decreased motor strength with ability to move the fingers only, grade according to the classification of Bromage, unit in minutes - Duration time of motor blockage was defined as the time from patient decreased motor strength with ability to move the fingers only (grade 1) until completely motor recovery (grade 0), unit in minutes - Postoperative analgesic time was defined as the time from the end of the surgery to the time of pain appearance, unit in minutes - Hypotension: systolic blood pressure (SPB) was less than 90 mmHg in a case of an initial SPB  110 mmHg, or SPB droped of more than 20% of the initial SPB = 90 - 109 mmHg 12 - Bradycardia: heart rate was slow when < 50 beats/minute in the initial frequency with 60 - 100 beats/minute or heart rate droped of more than 20% of the initial frequency = 50 - 59 beats/minute - Onset time of sedation was defined as the time from the end of local anesthetic administration until patient had OAA/S = score and recorded the sedative level, unit in minutes - Duration time of sedation was defined the time from patient had OAA/S = score until OAA/S = score, unit in minutes - Prevalence of patients using sedative and analgesic drugs at intraoperative time when they were supplied midazolam and/or fentanyl 2.4 DATA ANALYSIS - The data was processed and analyzed by medical statictic method with SPSS 16.0 software for Window - Quantitative variables were compared the average value of two independent groups using Student t-test, and represented as mean and standard deviation ( X ± SD), Min - Max Qualitative variables were represented by frequency and percentage, and the χ2 test was used to evaluate difference for qualitative variables Comparing differences was statistically significant when p < 0.05 2.5 MORAL ISSUES IN STUDY During study process, we always followed approval of the Ethical Committee in biomedical research under decision No 5129/2002/QD-YT on December 19, 2002 of the Health Minister 13 Diagram study Select patients to study, divided into two groups Group B, 54 patients Group BD, 54 patients Brachial plexus block, 30 ml bupivacain 0.25% (75mg) Brachial plexus block, 30 ml bupivacain 0.25% + dexmedetomidin 100 mcg General characteristics of the patient and surgery - Age - ASA classification - Gender - Historical chronic disease - Weight, height - Surgical location - BMI - Time surgery Comparing intraoperative anesthetic and postoperative analgesic efficacy - Sensory blockage: level, onset and duration time - Motor blockage: level, onset and duration time - Intraoperative anesthetic efficiency - Postoperative analgesic efficacy: analgesic time VAS score Evaluation on BP, heart rate, sedative effects and some adverse effects by mixture of bupivacaine with dexmedetomidine - Vital signs by monitor: BP, HR, ECG, SpO2 at before and after brachial plexus block - Intraoperative sedation: level, onset and duration time - Some adverse effects - Record some adverse effects 14 Chapter RESEARCH RESULTS 3.1 General characteristics of study patients Table 3.1 Age, height, weight and BMI Characteristics Group B Group BD Group n = 54 n = 54 Age (years old) 38.3 ± 16.3 37 ± 13.3 (min - max) (15 - 72) (16 - 64) Height (cm) 162.0 ± 7.1 163.4 ± 7.4 (min - max) (145 - 176) (148 - 176) Weight (kg) 59.9 ± 12.0 59.1 ± 11.0 (min - max) (37 - 105) (40 - 90) BMI (kg/m2) 22.7 ± 4.0 22.1 ± 3.4 (min - max) (16.6 - 38.6) Characteristics Conclusion: There is no (16.9 - 31.1) significant p > 0.05 > 0.05 > 0.05 > 0.05 differences about demographic characteristics such as age, height, weight and BMI in patient of both groups, p > 0.05 3.2 Intraoperative anesthetic and postoperative analgesic efficacy 3.2.1 Intraoperative anesthetic efficacy 15 Prevalence % 81.4 100 61.1 50 Group B Group BD 20.4 p < 0.05 13 18.5 5.6 Excellent Very good Anesthetic Good Figure 3.1 Intraoperative anesthetic efficacy of both groups Conclusion: The BD group has intraoperative anesthetic efficiency at excellent and very good level statistically significantly higher than that of BD group with p < 0.05 and there is any case to change general anesthesia in both groups Table 3.13 Onset and duration time of sensory and motor block Time of sensory and motor block (minutes) Group Time Onset of sensory block Duration of sensory block Onset of motor block grade Onset of motor block grade Duration of motor block (min - max) Group B (n = 54) Group BD (n = 54) 17.1  8.3 (7 - 44) 486.6  206.2 (190 - 1035) 18.7  6.3 (8 - 33) 31.1  8.7 (12 - 46) 417.7  199.3 (140 - 910) 11.1  4.6 ( - 20) 824.5  244.8 (305 - 1630) 12.2  5.3 (4 - 28) 19.6  6.0 (10 - 34) 800.5  248.9 (180 - 1530) p < 0.05 < 0.05 > 0.05 < 0.05 < 0.05 Conclusion: Onset time of sensory and motor block with grade in the BD group is statistically significant shorter than that of B group, p < 0.05 In addition, duration time of sensory and motor block in the BD group is longer than that of B group, p < 0.05 16 3.2.2 Postoperative analgesia duration Table 3.16 Duration time of postoperative analgesia Group Time Group B Group BD n = 54 n = 54 p Postoperative analgesia (minutes) 552.7  231.2 970.5  309.5 < 0.05 (min - max) (170 - 1215) (375 - 1660) Conclusion: Duration time of postoperative analgesia in BD group is statistically significantly longer than B group’s, p < 0.05 3.3 Blood pressure, heart rate, sedative effects and some adverse effects of bupivacaine and dexmedetomidine mixture by brachial plexus block 3.3.2 Effect on heart rate Heart rate (beats/minute B group BD group Time Figure 3.7 Heart rate of two research groups *: p < 0.05 Conclusion: Heart rate from T20 to T90 in BD group is statistically significantly lower than that of B group, p < 0.05 17 3.3.3 Sedative effect Prevalence % 87 100 Group B 80 60 Group BD 46.3 37 40 p < 0.05 16.7 20 9.3 3.7 OAA/S Score OAA/S OAA/S OAA/S Figure 3.8 Intraoperative sedative effect Conclusion: OAA/S = score in BD group is about 87%, more than that of B group, only about 37%, the difference is statistically significant, p < 0.05 Table 3.18 Sedative time in BD group Time of sedation (minutes) BD Group (n= 48) Onset 9.8  3.5 (min - max) (4 - 18) Duration 92.7  34.1 (min - max) (50 - 200) Conclusion: BD group has onset of sedative time which is 9.8  3.5 minutes and duration time is 92.7  34.1 minutes 18 3.3.4 Adverse effects Adverse effects Horner syndrome Group BD Group B 14.8 5,6 Vomiting 7,4 Nausea Hypotension Bradycardia * 11,1 18,5 * Prevalence % 10 20 Figure 3.12 Comparison adverse effects of both groups Conclusion: Bradycardia and nausea in BD group are statistically significantly more than B group’s, p 0.05 The average age in our study resembles to domestic author such as in Do Thi Hai’ research, age was 33 years old, the youngest was 13 years old and the highest was 56 years old 4.2 Comparing intraoperative anesthetic and postoperative analgesic efficacy of bupivacaine and dexmedetomidine mixture with bupivacaine alone We find that the result of figure 3.1 when using bupivacaine combined with dexmedetomidine, improves anesthetic effect very well, excellent and very good level in BD group accounting for 94.4%, in good about 5.6% statistically significantly higher than B group, in turn 81.5% and 18.5%, p < 0.05 The author Nguyen Van Huan’ research (2008) used axillary brachial plexus block by nerve stimulator, the rate of anesthetic effect was very good at 93.4% and good at 6.6% The successful rate of author Nguyen Thi Thanh’s research (2013) was 91.4% by nerve stimulator Tripathi A.’s research (2016), anesthetic effect in BD group had 80% at very good and 20% at good Conclusion, anesthetic efficacy of our study is similar to prevelance of domestic and foreign authors’s research In BD group of our study, onset time of sensory blockage on whole upper extremity is 11.1  4.6 minutes, minutes fastest and the 20 minutes longest, shorter than that of group B, is 17.1  8.3 minutes, 20 minutes fastest and 44 minutes longest, the difference is statistically significant between both groups, p < 0.05 Moreover, onset time of mortor blockage in BD group of our research is 19.6  6.0 minutes, statistically significantly shorter than that of B group, with 31.1  8.7 minutes In addition, according to table 3.13, duration time of sensory and motor block in BD group are respectively 824.5  244.8 minutes and 800.5  248.9, longer than B group’s, in turn 486.6  206.2 minutes and 417.7  199.3 minutes, this difference is statistically significant, p < 0.05 Therefore, addition of dexmedetomidin to local anesthetic can decrease waiting time for surgery due to quickly onset time and prolong duration time of anesthesia, thus it can be suitable for complex surgeries In the study of Gandhi R and et al (2012), the onset of sensory and motor blockage in combined dexemedetomidine group was faster than alone local anesthetic group, duration of sensory and motor blockage were 732 minutes and 660 minutes, shoter than about 100 minutes of our BD group, is 825 and 800 minutes, explaining this difference may be due to two different assisted technique in practiced anesthesia, we did ultrasound guidance while Gandhi R used anatomical technique to brachial plexus block In addition, postoperative analgesic time was 776 minutes of added dexmedetomidine group in Agawal’s research (2014), shorter than that of our BD group with 970 minutes (table 3.16), although both studies used the same 100mcg dexmedetomidine, but we used ultrasound guidance to help this drugs access brachial plexus better Besides, research of Biwas S and et al (2014), recorded postoperative analgesic time of local anesthetic and 100mcg dexmedetomidin was 997 minutes, it is seem similar to our study Thus, combination of dexmedetomidine to local anesthetic in brachial plexus block 21 can prolong postoperative analgesic time has been shown by many studies, even if only a single dose of dexmedetomidin is used for one injection 4.3 Evaluating on blood pressure, heart rate, sedative effects and some adverse effects of bupivacaine and dexmedetomidine mixture by brachial plexus block for upper extremity bone surgery There are about 50% patients who feel anxious during perioperative time, so sedation for patients is extremely necessary, helping patients feel secure and cooperative According to the chart 3.4, BD group in our study has about 87% of OAA/S = points, higher than B group’s, only 37%, statistically significant difference, p < 0.05 (figure 3.8) Onset and duration of sedative time are 9.8  3.5 minutes and 92.7  34.1 minutes (table 3.18) Thus, our sedative time is very suitable with surgical time because of reducing to patient’s anxiety during intraoperative time In Vietnam, Hoang Quoc Thang and et al (2012) evaluated sedative effect of 0.25mcg/kg dexmedetomidine by intravenous route in colonoscopy procedure, recording the onset and duration of sedative time were 11  3.3 minutes and 37.2  6.9 minutes, achieved sedative level on the Ramsay scale, equivalent to deep sleep but easy to wake up accounting for nearly 80% Therefore, our study has onset and level of sedation similar to author Hoang Quoc Thang, although using different routes The BD group in our study has heart rate at figure 3.7 statistically significantly lower than that of B group from 20th minute to 90th minute after regional anesthesia, p < 0.05 Incidence of bradycardia and nausea in BD group accounts for 18.5% and 7.4% statistically significantly higher than B group is 1.9% and 0%, p < 0.05 (figure 3.12) However, other adverse effects such as hypotension, vomiting and Horner syndrome have not had statistically significantly different between both groups, p > 0.05 22 Comparing foreign studies with dexmdedetomidin, Agawal S (2014) reported that BD group had heart rate slower than B group’s from 30th minute to 120th minute after brachial plexus block, a statistically significant difference, p < 0.001 In addition, research of Nazir N (2016) also noted that heart rate in BD group at 30, 60, 90 and 120 minute was statistically significantly lower than that of B group, p < 0.05 This result is similar to our study Thus, addition of dexmedetomidine to local anesthetics in brachial plexus block will make bradycardia 23 CONCLUSIONS Our study of supraclavicular brachial plexus block under ultrasound guidance for 108 patients who had divided two groups, the BD group received 75mg bupivacaine and 100 mcg dexmedetomidine comparison to the B group received 75mg bupivacaine, some conclusions as follows: The BD group has onset time of sensory and motor blockage which is 11.1  4.6 minutes and 19.6  6.0 minutes faster than that of B group, gets 17.1  8.3 minutes and 31.1  8.7 minutes, p < 0.05 Moreover, the prevalence of achieved excellent and very good anesthesia which is 94.4% and 5.6% at good anesthesia in BD group statistically significantly more than group B has respectively had 81.5% and 18.5%, p < 0.05 In addition, postoperative analgesic time is 970.5  309.5 minutes in BD group more than group B, is 552.7  231.2 minutes, p < 0.05 BD group has had rested and motivational VAS score statistically significantly lower than that of B group at 12, 16 and 24 hour after brachial plexus block, p < 0.05 The BD group has had an average blood pressure from 45th minute to 120th minute lower than B group’s, p < 0.05 In addition, heart rate of BD group has shown lower than B group’s from 20th minute to 120th minute after brachial plexus block, statistically significant differences, p