Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Number 2
March- June
2011
Original Article
Conclusion
A reduced dose of Bupivacaine in combination with fentanyl provided reliable spinal
anesthesia with few events of hypotension and little need for vasopressor support for
blood pressure. (Rawal Med J 2011;36:116-119).
Key words
Bupivacaine, fentanyl, spinal anesthesia.
INTRODUCTION
The ideal spinal anesthesia for ambulatory surgery should provide good surgical
anesthesia with rapid recovery from sensory and motor block.1 Lignocaine has been
widely advocated for ambulatory anesthesia but many studies have questioned the use
of hyperbaric 5% lignocaine for spinal anesthesia and recommended consideration of
bupivacaine as a substitute.2 Bupivacaine, an amide type of local anesthetic, has high
potency, slow onset (58 minutes) and long duration of action (1.52 hours).
Although spinal anesthesia is safe but it is not devoid of complication, hypotension
and sinus bradycardia are the most complication and are attributed to the imbalance
between sympathetic and parasympathetic control of the heart rate. Stimulation of the
sympathetic system may induce myocardial ischemia by causing coronary
vasoconstriction3 and may be related to the genesis of ventricular tachyarrhythmia.4
Hypotension after spinal anesthesia is often treated with vasopressors and intravenous
fluids. This regime is controversial for the geriatric population with coronary disease5
may increase risk of pulmonary oedema in high-risk pregnant patients and has been
associated with fetal acidosis.6 Bupivicaine has other side effects like increased motor
block and bladder dysfunction leading to delayed discharge.7
There has been controversy concerning the relationship between volume,
concentration and total dose of spinally administered drugs. Most of the studies
suggest that the total dosage is more important than the volume.8 These concerns have
increased interest in the use of small doses of bupivacaine.9 Intrathecal opioids have
been shown to enhance analgesia from sub therapeutic doses of local anesthetics and
make it possible to achieve spinal anesthesia using otherwise inadequate doses of
local anesthetic.10,11 In this study, we focused on the usefulness and efficacy of lowdose bupivacaine with fentanyl spinal anesthesia to prevent hypotension and other
complications while maintaining good anesthetic conditions.
PATIENTS AND METHODS
This prospective study included 100 patients who underwent lower abdominal,
anorectal, orthopedic and obstetric surgery under spinal anesthesia technique from
February 2008 to December 2008 at Prince Rashid Hospital. Patients with a history of
Number
Inguinal hernia
39
Anorectal surgery
27
orthopedic surgery
27
Obstetric surgery
Total
100
The sensory and motor block in the two groups is shown in Table 2.
Table 2. Sensory and motor block variables.
Variable
Group F
Group B
Numberof dermatomes
blocked( mean)
13
11
T12
T11
8.6
9.1
110.6
134.4
174
191.2
Two segment
regression(minute)
55.4
64.4
The number of dermatomes blocked was relatively comparable in both groups as well
as the median upper limit of the sensory block. Recovery of motor function took place
significantly earlier in Group F compared with Group B (110.6 minute vs 134.4
minute).
245
267
2.7
2.8
5.1
4.9
Time to reach of peak sensory lose was earlier in group F, however did not differ
significantly. Although the two-segment regression was slower in Group B compared
with Group F but did not seemed to be significant, but time for sensory recovery was
earlier in group F than group B, (174.3 minute vs 191.2 minute).
No differences were found between the groups in the total analgesic consumption
(Table 3), or the number of patients who required postoperative analgesics in the
recovery room.
Table 4. Adverse effects.
Group
F
(number)
Hypotension
B
(number)
13
97.5
20.0
Bradycardia
Shivering
Pruritus
Respiratory depression
Transient
neurological
manifestation
Lowest SAP (<30%) occurred in Group B (13 patients) and was significantly higher
than those of Group F (3 patients), while incidence of bradycardia was comparable in
both groups (Table 4). Total amount of the ephedrine used for treatment of
hypotension was higher in Group B than Group F (97.5 mg vs 20mg respectively).
Other adverse effects seem to be comparable in both groups except for pruritus that is
higher in group F (Table 4).
DISCUSSION
Although spinal anesthesia is significantly safer than general anesthesia, morbidity
and mortality still can occurred with spinal anesthesia. Deaths in regional anesthesia
are primarily related to excessive high regional blocks and toxicity of local
anesthetics. Reduction in doses and improvement in technique to avoid higher block
levels and heightened awareness to the toxicity of local anesthetics have contributed
to the reduction of complications related with regional anesthesia.12 As bupivacaine is
used commonly for spinal and epidural anesthesia, we decided to combine it with
intrathecal fentanyl for various surgical procedures to provide adequate depth of
anesthesia with lesser doses of bupivacaine13 with better maintainance of the
hemodynamic stability of these patients.
Our results are comparable with those studies that proved the improvement of
intrathecal opioids without altering the degree of sympathetic blockade when added to
sub therapeutic doses of local anesthetics.14,15 It potentiates sensory anesthesia
without prolonging recovery from spinal anesthesia.16 However, motor recovery was
not significantly affected by the addition of intrathecal fentanyl.
Bradycardia results from the blockade of sympathetic cardio accelerator fibers and
decreased venous return to the heart. In our study, bradycardia overall occurrence was
4 % (in F group) with no significant inter group variation, while incidence of
hypotension was markedly reduced by lowering the anesthetic drug and adding
intrathecal fentanyl. We should admit that the variation in our included surgical
procedures limit us to specify our results for specific procedure but our results are
comparable with various studies for single procedure.
CONCLUSIONS
A reduced dose of bupivacaine in combination with fentanyl provided reliable spinal
anesthesia in adults for variable kinds of surgical procedures with few events of
hypotension and little need for vasopressor support of blood pressure. It offers a
reliable block, good post-operative analgesia and satisfactory for the patient and
surgeon.
13. Kang FC, Tsai YC, Chang PJ, Chen TY: Subarachnoid fentanyl with dilute
small dose bupivacaine for cesarean section. Acta Anaesthesiol Sin 1998,
36:207-214.
14. Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose
bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the
aged. Anesthesiology 2000; 92: 610
15. Vaghadia H, McLeod DH, Mitchell GW, Merrick PM, Chilvers CR. Smalldose hypobaric lidocaine-fentanyl spinal anesthesia for short duration
outpatient laparoscopy. I. A randomized comparison with conventional dose
hyperbaric lidocaine. Anesthesia and Analgesia 1997; 84: 5964.
16. Liu S, Chiu AA, Carpenter RL, Mulroy MF, Allen HW, Neal JM, Pollock JE.
Fentanyl prolongs lidocaine spinal anesthesia without prolonging recovery.
Anesth Analg 1995; 80:730-734.