A Retrospective Comparison

of Spinal and General

Anesthesia for Vaginal Hysterectomy:
A Time Analysis
Michael J. Tessler,
Michel Rossignol,

MD,

FRCPP,

MD,

rhD

Departments
of Anaesthesia
McGill University, Montreal,

Ken Kardash,

and tClinica1 Epidemiology,

Quebec, Canada

MD,

Sir Mortimer

The authors sought to compare time efficiency of spinal

versus general anesthesia. The charts of 106 consecutive
patients who had undergone
a vaginal hysterectomy
were analyzed. This analysis divided the patients into
three groups: Group 1, spinal anesthesia; Group 2, general anesthesia; Group 3, spinal anesthesia with subsequent general anesthesia. The perioperative
time
course was divided into six intervals from entry into the
operating room to discharge from the postanesthesia
care unit (PACU). Total time was calculated by adding
the six intervals. There were 85 patients in Group 1,17
patients in Group 2, and 4 patients in Group 3. The

pinal anesthesia remains a useful anesthetic technique. Nevertheless, some still suggest spinal anesthesia takes too long to complete, or too often
fails (1,2).
We were uncertain whether either criticism was
valid. Consequently, we examined the use of perioperative time and the need for conversion of a spinal
anesthetic to a general anesthetic for patients undergoing vaginal hysterectomies under spinal block at
our institution. The purpose of the study was to determine 1) the frequency of converting failed spinal
anesthetics to general anesthesia, and 2) the perioperative time necessary when patients undergo spinal
or general anesthesia for vaginal hysterectomy.

Methods
With Institutional Ethics Committee approval, 106
consecutive charts of patients who had undergone
vaginal hysterectomies from April 1991 to December
1993 were evaluated.
Presented in part at the 52nd Annual Meeting of the Canadian
Anaesthetists Society, June 1995, Ottawa, Canada.
Accepted for publication May 18, 1995.
Address correspondence and reprint requests to Michael Tessler,
MD, Department of Anaesthesia, Room A-335, Sir Mortimer 8.
Davis-Jewish General Hospital, 3755 Cote Ste. Catherine Rd., Montreal, Quebec, Canada H3T IEZ.

694

FRCW,

Simcha Kleiman,
B. Davis-Jewish

Analg

1995;81:694d

FRCPC*,

Hospital

and

and

mean times for surgical readiness once the anesthesiologist was present for Group 1, Group 2, and Group 3
were 21.4 + 7.3,21.4 k 6.0, and 25.0 t 5.8 min, respectively. The total time for the three groups was 278.3 k
72.0,245.9 2 23.1, and 295.0 _C 101.2 min, respectively
(P < 0.01 Group 1 vs Group 2). The difference in total
time between Groups 1 and 2 was accounted for mainly
by the stay in the PACU. This study concludes that
there is no difference in the efficiency of operating room
time use between spinal and general anesthesia.
(Anesth Analg 1995;81:694-6)

Information was gathered only from patient files.

The heights, weights, and ages of all patients were
recorded from the nursing admission assessment
form. The anesthesiologist, surgeon, procedure, ASA
status of the patient, method of anesthesia, and medications administered were taken from the anesthesia
record. All anesthetics were administered by, or under
the supervision of a certified anesthesiologist.
The patients were divided into three groups for
comparison. Group 1 patients had their surgery performed during spinal anesthesia, Group 2 patients
underwent surgery during general anesthesia, and
Group 3 patients had spinal anesthesia with subsequent general anesthesia.
The perioperative period was divided into six discrete intervals: Interval 1, the time from the entry of
the patient into the operating room (OR) until the
anesthesiologist started the anesthetic; Interval 2, the
time from the start of the anesthetic until the start of
the surgery; Interval 3, the time from the start of the
surgery until the end of the surgery; Interval 4, the
time from the end of the surgery until the patient
exited the OR; Interval 5, the time from the patient
exiting the OR until the patient entered the postanesthesia care unit (PACU); Interval 6, the time from the
patient entering the PACU until the patient was discharged from the PACU (Fig. 1).
01995

An&h

General

MD,

by the International

Anesthesia

Research
Society
0003-2999/95/$5.00

ANESTH
ANALG
1995;81:694-6

REGIONAL

INTERVAL
pt

entry-----

to

OR

INTERVAL

IRTERVAL

ANESTHESIA

INTERVAL

Anesthesia

surgery

Interval

On arrival in the OR, all patients were monitored

with a noninvasive blood pressure machine, electrocardiogram, and pulse oximeter. An intravenous line
with infusion of a balanced salt solution was started.
Patients were then either positioned for performance
of spinal anesthesia, or a general anesthetic was induced with thiopental and succinylcholine
followed
by intubation and mechanical ventilation. After induction of either spinal or general anesthesia, patients
were positioned in the lithotomy position for surgery.
At the conclusion of surgery, patients were repositioned supine. Those who had been anesthetized and
tracheally intubated were extubated when awake. All
patients were then moved to a stretcher and transported to the PACU.
The Aldrete scoring system was used as discharge
criteria from the PACU for all patients. The total time
from the patient entering the OR until the patient was
discharged from the PACU was considered as total
time. All times data was taken from the OR or PACU
nursing records. These times are specifically entered
by the hour and minute by the circulating nurse in the
OR and by the admitting
nurse in the PACU. The
interval times were obtained by subtracting
the
appropriate beginning and finishing times and all periods were measured in minutes. The anesthesia
start time was defined as the time that intravenous
insertion was started by the anesthesiologist. The start
of surgery and end of surgery were defined by the
incision and the application of the surgical dressing,
respectively.
The demographic data were analyzed by Students
t-test. Comparison of the mean time intervals between
the group who received spinal versus general anesthesia was performed using Students t-test with Cochrans modification,
after checking the distributions.
Analyses were performed using the SAS software
(SAS Institute, Cary, NC). Since a statistical difference
was uncovered in the ages between Groups 1 and 2,
multiple linear regression was performed taking into
account the type of anesthetic and age.
The sample size in this study was sufficient to detect
a difference of 5 min between Groups 1 and 2 with a
power superior to 90%.

Results

intervals

1 + Interval

from

3 + Interval

demonstrating

TIME=

surgery

2 + Interval

1. Line

INTERVAL

---Start-------------Start-------------E~~-------------pt

TOTAL

Figure

AND PAIN MANAGEMENT

TESSLER
ET AL.
TIME EFFICIENCY
OF SPINAL
ANESTHESIA

INTERVAL

exit-----------

pt

e*tty-------------pt

OR

to

PACU

4 + Interval

5 + Interval

695

6
exit
from

PACU

of time.

Anesthetics were administered by 24 different practitioners (18 anesthesiologists and 6 residents in anesthesia). When comparing Groups 1 vs 2, those patients
undergoing vaginal hysterectomy during general anesthesia were significantly younger than those who
had the surgery performed during spinal anesthesia
(age 51.7 _t 11.3 yr vs 66.3 -t 13.0 yr; P < 0.0001).
Interval 6 and total time were statistically different
between Groups 1 and 2 (P = 0.0072 and P = 0.0014,
respectively) with Group 1 patients staying in the
PACU an average of 27.6 min longer than Group 2
patients. The total time difference from entry to
the OR to discharge from the PACU was on average
33 min between these two groups and was largely
accounted for by the difference in Interval 6. The
surgical time period was similar for both groups (see
Table 1).
The volume of intravenous fluid administered was
greater in the group that had spinal anesthesia (1812 +
820 mL vs 1392 2 406 mL; P = 0.0120).
Since Group 3 had only four patients, it was believed the number was inadequate for comparison
with the other groups. One patient in Group 3 had a
successful spinal anesthetic but a general anesthetic
was induced because a laparotomy
was needed to
repair a surgical complication.

Discussion
In attempting to compare perioperative time use between spinal and general anesthesia, we chose to
study vaginal hysterectomy cases. These operations
were all elective and required no additional invasive
monitoring.
This allowed a pure comparison of anesthetic induction times (spinal versus general) and a
comparison of overall perioperative
time use which
may be related to choice of anesthetic technique. We
believe that our study can be generalized to other
surgical procedures which meet the same criteria.
Our results indicate that spinal anesthesia and general anesthesia were equally time efficient for this

696

REGIONAL
ANESTHESIA
AND PAIN MANAGEMENT
TIME EFFICIENCY
OF SPINAL
ANESTHESIA

Table

TESSLER

ET AL.

ANESTH
ANALG
1995;81:694-6

1. Mean Times for Each Interval -CSD (min)

Interval
1

2
3
4
5
6

Total time
Group
1 = spinal anesthesia;
*P < 0.01 vs Group 2.

Group
2.6
21.4
73.9
7.1
2.0
168.7
278.3
Group

-c
k
-t
2
t

Group 2

4.2* (n = 82)
7.3 (n = 82)
23.1 (n = 85)
3.0 (n = 80)
3.0 (n = 80)

0.3
21.4
76.5
7.3
3.4

t
2
?
t
2

Group 3

1.2 (n = 17)
6.0 (n = 17)
18.9 (n = 17)
3.9 (n = 17)
4.1 (n = 17)

2.5
25.0
103.3
6.5
1.5

f
+
f
+
?I

2.9 (n = 4)
5.8 (n = 4)
84.6 (n = 4)
1.7 (n = 4)
2.6 (n = 4)

k 69.1*(n = 84)

141.1t 25.9(n = 16)

156.34 69.0 (n = 4)

+ 72.0 (n = 84)

245.9 +- 23.1 (n = 16)

295.0 I 101.2 (n = 4)

2 = general

anesthesia;

Group

3 = spina

surgery. The anesthesia start time is of critical importance in this study and depends on the recording of
the start time by the OR circulating nurse. We believe
the anesthesia start time was consistently recorded as
over the period of the study there was a small group
of nurses working in this OR suite. Since this study
was a retrospective analysis, we were unable to isolate
the duration of induction of anesthesia, but included
induction of anesthesia, positioning in the lithotomy
position, and skin preparation in Interval 2. If one
assumes that positioning and presurgical skin preparation were of similar duration in the two groups, then
the anesthetic induction time must also have been
similar.
The patients in the spinal anesthesia group remained in the PACU on average 27 min longer per
patient than those receiving general anesthesia alone.
At our institution, complete recovery from motor
block from spinal anesthesia is a PACU discharge
criterion, and this would explain our finding. Other
anesthesiologists do not believe full recovery from
motor block after spinal anesthesia is necessary prior
to discharge from the PACU (3).

anesthesia

with

subsequent

general

anesthesia.

We had a 3.3% incidence of failed spinal (3 of 90

tried). This incidence of unsuccessful spinal anesthetics is in keeping with the previously reported incidence in a university hospital (2).
In conclusion, our retrospective analysis does not
support the contention that spinal anesthesia is less
time efficient than general anesthesia for vaginal
hysterectomies.
The authors
Sarah Scholl

gratefully
acknowledge
the secretarial
in the preparation
of this manuscript.

skills

of Mrs.

References
1. Gettes MA, Kaplan JA. Anesthesia
for vascular
surgery
of the
lower extremities;
one approach
at Mount
Sinai Hospital,
New
York. In: Roizen M, ed. Anesthesia
for vascular
surgery.
New
York: Churchill
Livingstone,
1990:339-58.
2. Levy JH, Islas JA, Ghia JN, et al. A retrospective
study of the
incidence
and causes of failed spinal anesthetics
in a university
hospital.
Anesth Analg 1985;64:705-10.
3. Alexander
CM, Teller LB, Gross JB, et al. New discharge
criteria
decrease recovery
room time after subarachnoid
block. Anesthesiology
1989;70:640-3.