Spinal anesthesia utilizing pontocaine in hypobaric solution for surgical procedures on the anorectal region

SPINAL ANESTHESIA UTILIZING PONTOCAINE IN HYPOBARIC SOLUTION FOR SURGICAL PROCEDURES ON THE ANORECTAL REGION* JOHN M.

DUPFY, JR., M.D. AND DAVID M.

LITTLE, JR., M.D.

Stamford, Connecticut

Manchester, New Hampshire

A

NESTHESIA for surgica1 procedures at the time of injection. These facts have in the anorecta1 region often prebeen we11 demonstrated by Sise,3 employing sents a probIem to which there is no hyperbaric soIutions, and both EthermgentireIy satisfactory soIution. Various techton-WiIson4 and Jones,” empIoying hyponits of genera1 and regiona anesthesia have *. baric solutions. Lund and CamerorP have been empIoyed by anesthetists and surutiIized pontocaine in hypobaric soIution geons in attempts to overcome the dishfor spinal anesthesia, empIoying what they cuIties inherent in the prone position, have termed a modified Howard Jones namely, Aexion of the patient, the necessity technic. More recentIy Lund and Rumba11 l of providing both sensory anesthesia and anesthesia reported the use of spina reIaxation of the ana sphincter, the mainutiIizing pontocaine in hypobaric soIution tenance of efficient circuIatory and respirafor deaIing with surgica1 procedures on the tory function and, on a busy surgica1 posterior aspects of the Iumbar and sacral service, the accompIishment of these tasks regions. They refer to this method as the with a minimum expenditure of time. It is prone technic since the patient is pIaced the purpose of this communication to prone and Aexed at the hips and the subredirect attention to a technic, previousIy arachnoid injection is performed in this described by Lund and RumbalI’ but position. Lund7 now adds smaI1 quantities insufficientIy utiIized by the profession, of a vasoconstrictive substance (epinephthat may offer an approach to the soIution rine or neosynephrine) to the pontocaine of these probIems. The present series of soIution in order to obtain more proIonged spinal anesthesias utilizing pontocaine in anesthesia but this shouId certainIy be hypobaric soIution for surgica1 procedures unnecessary for the type of surgicai proceinvoIving the anorecta1 region is far too dure to be discussed in this communication. Iimited numericaIIy to permit statistica The theoretica advantages accruing evaIuation. The resuIts to date have been from the use of this prone technic of spinal encouraging, however, and suggest that the anesthesia utiIizing pontocaine in hypomethod warrants further investigation. baric soIution for surgica1 procedures on The extent of spread of an anesthetic the anorecta1 region are numerous. The solution within the confines of the subpatient is in the optima1 position at the arachnoid space is governed by a number time that Iumbar puncture is performed of factors.’ Of these the controIIabIe and no additiona time must be spent in factors that are of most importance in pIacing the patient in position for the limiting the extent of anesthesia are the The rapid onset of surgica1 procedure. difference in specific gravity between the sensory anaIgesia aIIows the surgica1 interinjected soIution and the cerebrospina1 vention to be begun immediateIy. The fluid and the position of the spina canaI definite Iimitation of the extent of the anes* From the SurgicaI Service, U. S. Veteran’s HospitaI, Newington, Corm. and the Department of AnesthesioIogy, Hartford Hospital, Hartford, Conn. Published with permission of the Chief Medical Director, Department of Medicine and Surgery, Veterans Administration, who assumes no responsibility for the opinions expressed or concIusions drawn by the author.

December,

I 949

833

Duffy, Little-Spinal

Anesthesia

FIG. I. The patient is pIaced prone upon the operating tabk and then flexed 30 to 40 degrees at the hips. A piIIow, hidden by drapes in the ilIustration. is put under the peIvis and Iower abdomen to reduce the norma Iumbar Iordosis. Lumbar puncture is then performed.

thesia to the IumbosacraI dermatomes ensures an absence of circulatory depression in the majority of instances. Adequate anal sphincter relaxation is assured by the efficient concentration of the anesthetic soIution in the area providing motor innervation to the sphincters. Motor power to the Iower extremities remains intact due to the limitation of anesthesia, permitting immediate ambuIation upon compIetion of the surgica1 procedure, thereby minimizing postoperative vascuIar and respiratory compIications. These various considerations prompted a Iimited investigation of Lund and RumbaII’s prone technic of spina anesthesia utiIizing pontocaine in hypobaric soIution for surgica1 procedures on the anorecta1 region. TECHNIC

The patient is pIaced prone upon the operating tabIe and then flexed 30 to 40 degrees at the hips. (Fig. I.) A piIIow under the peIvic brim and abdomen aids materiaIIy in reducing the norma Iumbar

Iordosis and thus facihtates the performance of Iumbar puncture. The actual insertion of the needle into the subarachnoid space is performed very sIowIy and carefuIIy to enabie the anesthetist to feel the needIe traverse the dura. When the needIe is feIt to “cIick” through the dura, the stiIet is withdrawn and the patient is asked to contract the abdomina1 muscIes; this straining often wiI1 force cerebrospina1 fluid out of the needle. Sometimes even this maneuver wiI1 faiI to produce Auid even though the anesthetist may be certain that the needIe is properIy pIaced within the subarachnoid space. On such occasions aspiration with an empty syringe may revea1 cerebrospina1 fluid and confirm the proper position of the needle. Lumbar puncture is performed with the beve1 of the spina needIe turned IateraIIy but the beve1 is turned caudad prior to subarachnoid injection of the anesthetic SOIUtion. The performance of Iumbar puncture in the prone, flexed position is the major dificuIty encountered in carrying out this technic, and it is diffIcuIt, some experience American

Journal

of Surgery

Duffy,

Little-Spinal

being required before it can be performed with facihty. One-tenth per cent pontocaine soIution is prepared by withdrawing I cc. (IO mg.) from a 2 cc. (20 mg.) ampuIe of I per cent pontocaine and adding to it g cc. of tripIedistiIIed water withdrawn from a IO cc. ampuIe. It is imperative that these measurements are absoIuteIy correct and that the two fluids are then properly mixed. The soIution may aIso be prepared by adding tripIe-distilIed water to pontocaine crystals. RecentIy 0.1 per cent pontocaine solution was made available for research purposes in 20 cc. ampules containing 20 mg. of pontocaine. The specific gravity of cerebrospinal fluid varies between I .004 and 1.006 under conditions of norma heaIth.8 7 he specific gravity of 0.1 per cent pontocaine soIution is 1.002 at room temperature (24.4’c.). The dose empIoyed varies with the extent of the surgical procedure. (TabIe I.) As IittIe as 4 mg. of pontocaine may be sufficient for the remova of externa1’ hemorrhoidal tabs may be whereas 8 mg. of pontocaine required for an extensive excision of a Iarge piIonida1 sinus. Injection of the anesthetic soIution is performed very sIowIy (IO to 20 seconds) at an even rate in order to prevent undue mixing with the cerebrospina fluid and to aIIow the anesthetic soIution to float aIong the posterior aspects of the subarachnoid space.

Anesthesia

tion within the series was unequal, there being seventy-four maIe patients and one femaIe patient. The types of operation performed, their reIative incidences and the dosages empIoyed are shown in Table I. It should be TABLE CORRELATION

OF DOSAGE

No.

Spinai anesthesia utiIizing pontocaine in hypobaric soIution was employed successfuIIy in seventy-five instances for surgica1 procedures on the anorecta1 region and was attempted but abandoned in five other instances. The average patient was a heaIthy, young, aduIt maIe veteran. Therefore, there was IittIe opportunity in this series to evaIuate the use of the technic in poor risk patients requiring this type of surgica1 intervention. Four patients were in the second decade of Iife, forty-eight in the third, sixteen in the fourth, three in the fifth and four in the sixth. The sex distribuDecember,

1949

I

EMPLOYED

OPERATIVE

WITH

THE

TYPF,

OF

PROCEDURE

of Patients

and Dosage

Operative Procedure

Employed

__-4 mg. -__

5 mg.

6 mg.

, mg.

~.

llemorrhoidectomy Fistula-in-ano.. Pilonidalcyst/sinus Perrrectal abscess. Miscellaneous..

o

Total

2

4

I

o 1

.._.

8 mg. -

8

19

I

L 0

31

;,

z

1;

5

4

16

4

o 0

3

0

I

16

44

Total _‘I ~-

0

0

0

8

3

3

2 75

noted that hemorrhoidectomies and excisions of piIonida1 cysts and sinuses made up the great buIk of the surgical procedures. The time necessary to mix the hypobaric soIution of pontocaine, perform Iumbar puncture and administer the anesthetic soIution is shown in Table II. The TABLE TIME

REQLIIREDFORTHE

Minutes 3 4 5 6

II

ADMINISTRATlON

OF ANESTHESIA

No. of Patients 7 7 II 22 IO

;: 9

RESULTS

855

IO or

Total

6

more

-

:

75

average time necessary to accompIish these duties was six minutes which approximates the time necessary for the administration of a spinal anesthetic with the patient in either a IateraI or sitting position. The time necessary for the onset of anaIgesiaafter the administration of the anesthetic soIution is shown in TabIe III. The average time was three to four minutes which is considerabIy Iess than that necessary for the onset of analgesia and fixation of the intrathecaIIy-pIaced anesthetic soIution be-

Duffy, LittIe-SpinaI

Anesthesia

out the operative period. The larger doses of pontocaine in hypobaric soIution (6 to 8 cc.) raised the IeveI of anesthesia by one or two dermatomes. However, a change in the position of the patient resulted in a marked change in the Ievel of anesthesia TABLE DURATION

OF

IV ANESTHESIA

Minutes

No.

of

Patients

6

90 120

20

150 180

25

I5 4

2x0 240

or more

TotaI

FIG. 2. Area of anesthesia.

fore the patient can be positioned and surgery begun after the ordinary spina anesthetic. This constitutes an important advantage of the hypobaric pontocaine technic since the patient is ah-eady in the optimaI position and the surgica1 procedure may be begun immediately foIIowing the onset of anaIgesia. TABLE TlME

OF

ONSET

OF

ADMINISTRATION

Minutes 2

3 4 z 7 or more TotaI

III

ANALGESIA OF

FOLLOWING

THE

ANESTHESIA

No. of Patients 14 26 25 6 I 3 75

The extent of the anesthesia was usuaIIy limited to the “saddIe-seat” area. (Fig. 2.) In the majority of instances the upper IeveI of anesthesia was beIow the fifth Iumbar dermatome and some motor function was retained in the Iower extremities through-

-

5

75

and warrants a word of warning. The patient should be defIniteIy and repeatedIy admonished not to raise his head or shouIders unti1 at Ieast twenty minutes after the administration of the anesthetic soIution. On two occasions patients failed to adhere to this caution and raised their heads and shouIders off the tabIe for a short period of time. The IeveI of anesthesia ascended rapidIy into the mid-dorsa1 region. On two other occasions the IeveI of anesthesia appeared to be too Iow for the excision of extensive piIonida1 cysts but ascended into the upper thoracic region when the patients’ heads were raised for short periods of time. The duration of anesthesia (TabIe IV) averaged two or more hours. OccasionaIIy anesthesia of sufficient intensity to permit an operative procedure was stiI1 present four hours after the administration of the hypobaric soIution. A definite correIation couId be estabIished in many instances between a given dose of pontocaine and the duration of anesthesia, nameIy, 6 mg. of pontocaine produced anesthesia Iasting from two and a haIf to three hours whereas 4 mg. of pontocaine produced anesthesia Iasting onIy from one and a haIf to two hours. There were five instances in which it was necessary to abandon the procedure as described and utiIize some other method of anesthesia. In four such instances it proved American

Journal

of Surgery

Duffy,

LittIe-SpinaI

to be impossible to perform lumbar puncture in the prone-Aexed position; this undoubtedly was due to the anesthetist’s inexperience with the technic. The fifth faiIure occurred in a twenty-six year oId, male negro who was scheduIed for a reexcision of condylomata acuminata of the ana region and in whom the original excision had been successfuIIy performed under spina anesthesia administered in the prone-flexed position. Lumbar puncture was again successfuhy performed in the prone4 exed position; however, the surgical service requested a IO cc. sampIe of cerebrospinal fIuid for anaIysis and it proved to be impossibIe to obtain this Iarge an amount. The patient was therefore turned to the IateraI decubitus position, a second lumbar puncture as performed, the necessary cerebrospina1 Auid was obtained and the spinal anesthetic was then administered. Certain compIications arose during the course of operation and were attributed to the anesthetic method. There were eight instances in which the patient, during the course of hemorrhoidectomy, compIained of a duI1, aching, abdomina1 pain often Iimited to the suprapubic region but occasionally referred to the epigastrium. This pain occurred simuItaneousIy with overdiIatation of the rectum and promptIy disappeared when such dilatation was discontinued. This was undoubtedIy referred pain travehing through visceral afferent fibers of the sympathetic nervous system to the hypogastric and aortic pIexuses. In only one instance was it necessary to administer supplementary anesthesia; a11 the other patients described the sensation as being annoying rather than truIy painfu1. In three instances the IeveI of anesthesia was inadequate for the extent of the operation contempIated and suppIementary intravenous anesthesia was necessary; these three patients had extensive piIonida1 sinus tracts. Nausea, sweating and dizziness were noted in five patients and seemed to be correIated with extreme apprehension and emotiona instabiIity. December,

I 949

Anesthesia

837

The postoperative complications noted during the period of hospitalization (TabIe v) were of three types, urinary retention, postspina1 headache and discomfort at the site of Iumbar puncture. Eleven patients required catheterization but none of these ,UC,DhNCEOF

TABLE v POSTOPERATIVE

COMi’I.IC.ATIOXS

No. of

Complication

1nstances II 4 6 4

Catheterization.. Difficulty in voiding.. Severe postspina1 headache.. . MiId postspinal headache.. .. . Low back discomfort in reIation to site of lumbar tap......................................

3

required it on more than one occasion. Four other patients experienced diffrcuIty in voiding but did not need to be catheterized. Four patients suffered typical and severe postspina1 headaches. Six other patients compIained of miId headaches that were neither incapacitating nor typica1. ModerateIy severe Iow back pain in reIation to the site of Iumbar puncture occurred in two instances but in onIy one was this pain correIated with any difficuIty in performing Iumbar puncture. COMMENTS

One disadvantage encountered with the technic was that of postspina1 headache. However, this compIication was not foreign to other types of spina anesthesia; and aIthough this series was Iimited numericaIIy, the incidence did not appear to be abnormaIIy high. A second disadvantage common to surgica1 procedures on the anorecta1 region under any form of anesthesia was a dehnite incidence of postoperative urinary retention. Whether this compIication was due to the anesthesia per se or due to the reffex effect produced by the surgica1 procedure on the autonomic nervous system, was a moot question. A third disadvantage was the reffex abdominal pain when the surgical procedure invoIved overdiIatation of the rectum. The Iimitation of the extent of anesthesia, one of the method’s major advantages, became a disadvantage under certain circumstances.

858

Duffy, Lit&--Spinal

The level of anesthesia proved to be too limited for some surgica1 procedures invoIving extensive piIonida1 sinus tracts. A fifth disadvantage was the position utilized in the performance of this technic, a position which was definiteIy contraindicated in patients with decreased vita1 capacity due to poor cardiac reserve, chronic puImonary disease or other conditions impairing puImonary ventiIation.s One of the outstanding advantages of the technic and a source of great appeaI to both the anesthetist and the surgeon working on a busy surgica1 service was the rapidity with which anesthesia couId be induced and operation begun. AbiIity to perform Iumbar puncture in the proneAexed position was easiIy acquired by a competent anesthetist. The onset of anaIgesia was prompt and as the patient was already in the optima1 position, operation couId be undertaken immediateIy. A second advantage was the proIonged anesthesia that was obtained at the expense of a minima1 amount of anesthetic agent. A third advantage was the definite Iimitation in the extent of anesthesia which ensured the absence of circuIatory depression and, since motor power to the Iower extremities usually remained intact, permitted immediate ambuIation upon compIetion of the minimizing surgical procedure thereby postoperative vascuIar and respiratory compIications.

Anesthesia SUMMARY

I. SpinaI anesthesia utiIizing pontocaine in hypobaric soIution and administered in the prone-ffexed position; is redescribed. 2. This technic was successfuIIy empIoyed in seventy-five instances of surgical procedures involving the anorecta1 region; in five other instances faiIures occurred. 3. CompIications arising from the use of this type of anesthesia incIuded urinary retention, postspina1 headache and discomfort at the site of Iumbar puncture. 4. The advantages and disadvantages of the technic are weighed. REFERENCES 1. LUND, P. C.

and RUMBALL, A. C. Hypobaric

pontoCaine spinal anesthesia; 1640 consecutive cases. Anestbesiology, 8: 181-199, 1947. 2. MAXSON, L. H. SpinaI Anesthesia. New York, 1936. J. B. Lippincot; Co. 3. SISE, L. F. Pontocaine-gIucose soIution for spinal anesthesia. S. C&z. Nortb America, rf: 1501-151 I, 1935. 4. ETHERINGTON-WILSON,W. IntrathecaI

nerve rootlet bIock; some contributions, a new technique. Anestb. Cf Analg., 14: 102-1 IO, 1935. 5. JONES, W. H. SpinaI anaIgesia-a new method and a new drug-percaine. Brit. J. Anestb., 7: 99-113, 1930.

6. LUND, P. C. and CAMERON, J. D. Hypobaric pontoCaine-a new technic in spina anesthesia. Anestbesiology, 6: 565-573, 1945. 7. LUND, P. C. Persona1 communication. s. MCDONALD, J. J., GREEN, J. R. and LANGE, J. CorreIative Neuroanatomv. Chicago. IO&~.Universitv MedicaI Publishers. ” 9. STEPHEN, C. R. The inffuence of posture on the mechanics of respiration and vital capacity. Anestbesiology, 9: 134-140, 1948. Yl

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