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The effect of hyperbaric versus isobaric spinal bupivacaine on postoperative pain and analgesic requirements in patients undergoing lower abdominal surgery
14
Free Papers
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Central Nerve Blocks
191. The effect of hyperbaric versus isobaric spinal bupivacaine on postoperative pain and analgesic requirements in patients undergoing lower abdominal surgery
209. High thoracic epidural anesthesia for off-pump coronary artery surgery
Morozov DV, Yeremina SV [email protected] Voronezh University Hospital, Moscovskiy Prospect 151, 394000 Voronezh, Russia Geroyev Truda 5, 394043 Voronezh, Russia
Introduction: The feasibility of high thoracic epidural anesthesia (HTEA) combined with general anesthesia in patients undergoing conventional coronary artery bypass graft surgery (CABG) has been demonstrated although results regarding the outcomes are still conflicting. On the other hand, informations on HTEA combined with general anesthesia and on outcomes of patients undergoing CABG without CPB on the beating heart (OPCAB) with full sternotomy are reported only in small series of patients .
Introduction: Posture, dosage and baricity during induction of spinal anesthesia with intrathecal local anaesthetics are believed to be important in determining spread within the cerebrospinal fluid. Spinal anaesthesia is presumed to reduce dorsal horn neurons excitability and postoperative pain after surgery. Spinal anaesthesia with isobaric solutions have been shown to have significantly longer offset time compared with hyperbaric solutions. We suggested that the spread of sensory block and the blockade regression time are important for preemptive effect of spinal anaesthesia. Methods: The purpose of this study was to compare block regression time, postoperative pain level and analgesic requirement in patients undergoing lower abdominal surgery. 90 (ASA-1-2) patients were randomly divided into 3 groups (30 patients each group): group H-15 received 15 mg of intrathecal hyperbaric bupivacaine (Marcaine® spinal heavy 0,5%) at L2-L3 level in right lateral position, group I-15 consisted of 30 patients received 15 mg of intrathecal isobaric bupivacaine (Marcaine® spinal 0,5%). Group I-20 (n⫽30) received 20 mg of intrathecal isobaric bupivacaine. Immidiately after spinal injection all patients were placed in horizontal position. The characteristics of the three groups were comparable in terms of age, height, weight, gender, and ASA classification. There was no significant difference in the duration of surgery.The upper spread of sensory block was determined bilaterally using pinprick test and loss of sensation to ice. After surgery we evaluated: sensory block regression time, complete motor block recovery, time to appearance of pain on the operative site, VAS score, PCA morphine requirement. Results: Onset of motor and sensory block was rapid with no significant differences between the three groups. There was a trend for patients in the H-15 group to achieve a higher upper dermatome level of sensory block but this difference was not significant. No difference in hemodynamic effects was detected between groups. Six patients I-15 group needed supplementary analgesics and sedation during surgery and were excluded from the further study. Time to regression of sensory level, complete motor block recovery, time to appearance of pain was significantly longer in group I-20, than in groups H-15 and I-15. PCA morphine requirement was statistically significant greater in groups H-15 and I-15 than in group I-20. Pain score in group H-15 and I-15 were statistically insignificant higher than in group I-20 up to 24 hours postoperatively. Conclusion: Intrathecal administration of 15 mg plain bupivacaine at L2-L3 level is less reliable for lower abdominal surgery. Spinal anaesthesia with 20 mg isobaric bupivacaine result in longer block regression time and less postoperative pain and analgesic requirement than with huperbaric bupivacaine. Theoretically, greater distribution of hyperbaric solution leads to greater surface absorption and diffusion of local anaesthetic, resulting in shorter duration of anaesthesia. But the difference between isobaric and hyperbaric group in VAS score an PSA morphine requirement was significantly longer than the block regression time.
Salvi L, Rondello N, Merli G, Marino MR, Sisillo E [email protected] IRCCS Centro Cardiologico Monzino, Via Parea, 4, 20138 Milano, Italy
Methods: To evaluate the postoperative pain control, side effects and perioperative hemodynamics, data regarding 106 consecutive patients receiving HTEA combined with sevoflurane were retrospectively reviewed. A 19-G catheter was inserted in the epidural space at the T1-T2 or T2-T3 interspace. HTEA was induced by administration of 0.1 mL kg-1of 0.5% ropivacaine and sufentanil 2.5 mcg mL-1, as a loading dose. Induction of general anesthesia was then achieved with IV fentanyl plus thiopental; pancuronium facilitated tracheal intubation and the lungs were ventilated with sevoflurane in an air-oxygen mixture. Anesthesia was maintained by a continuous infusion of 0.2% ropivacaine and sufentanil 1 mcg mL-1 (0.1 mL kg-1 h-1) and inhalation of sevoflurane. Postoperative analgesia was performed by the infusion of 0.1% ropivacaine and sufentanil 1mcg mL-1 at a rate of 4 to 10 mL h-1 supplemented by IV ketorolac 30 mg at 8-hour intervals. Results: Insertion of the epidural catheter was successful in all but two patients, one bloody tap occurred and the dura was never punctured. No neurologic signs attributed to an epidural or spinal hematoma were found. Visual Analogue Scale scores for pain during the first 24-hours period were ⬍ 2 in all patients. Mean time to extubation was 4.6⫾2.9 hours. Average Intensive Care Unit stay was 1.5⫾0.8 days. Incidence of perioperative myocardial infarction, myocardial ischemia and atrial fibrillation were 2.8%, 7.5% and 10.6%, respectively. Heart rate, mean arterial pressure, cardiac index and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and Cardiac Index decreased (P⬍ 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. Conclusion: Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.
Free Papers
•
Central Nerve Blocks
191. The effect of hyperbaric versus isobaric spinal bupivacaine on postoperative pain and analgesic requirements in patients undergoing lower abdominal surgery
209. High thoracic epidural anesthesia for off-pump coronary artery surgery
Morozov DV, Yeremina SV [email protected] Voronezh University Hospital, Moscovskiy Prospect 151, 394000 Voronezh, Russia Geroyev Truda 5, 394043 Voronezh, Russia
Introduction: The feasibility of high thoracic epidural anesthesia (HTEA) combined with general anesthesia in patients undergoing conventional coronary artery bypass graft surgery (CABG) has been demonstrated although results regarding the outcomes are still conflicting. On the other hand, informations on HTEA combined with general anesthesia and on outcomes of patients undergoing CABG without CPB on the beating heart (OPCAB) with full sternotomy are reported only in small series of patients .
Introduction: Posture, dosage and baricity during induction of spinal anesthesia with intrathecal local anaesthetics are believed to be important in determining spread within the cerebrospinal fluid. Spinal anaesthesia is presumed to reduce dorsal horn neurons excitability and postoperative pain after surgery. Spinal anaesthesia with isobaric solutions have been shown to have significantly longer offset time compared with hyperbaric solutions. We suggested that the spread of sensory block and the blockade regression time are important for preemptive effect of spinal anaesthesia. Methods: The purpose of this study was to compare block regression time, postoperative pain level and analgesic requirement in patients undergoing lower abdominal surgery. 90 (ASA-1-2) patients were randomly divided into 3 groups (30 patients each group): group H-15 received 15 mg of intrathecal hyperbaric bupivacaine (Marcaine® spinal heavy 0,5%) at L2-L3 level in right lateral position, group I-15 consisted of 30 patients received 15 mg of intrathecal isobaric bupivacaine (Marcaine® spinal 0,5%). Group I-20 (n⫽30) received 20 mg of intrathecal isobaric bupivacaine. Immidiately after spinal injection all patients were placed in horizontal position. The characteristics of the three groups were comparable in terms of age, height, weight, gender, and ASA classification. There was no significant difference in the duration of surgery.The upper spread of sensory block was determined bilaterally using pinprick test and loss of sensation to ice. After surgery we evaluated: sensory block regression time, complete motor block recovery, time to appearance of pain on the operative site, VAS score, PCA morphine requirement. Results: Onset of motor and sensory block was rapid with no significant differences between the three groups. There was a trend for patients in the H-15 group to achieve a higher upper dermatome level of sensory block but this difference was not significant. No difference in hemodynamic effects was detected between groups. Six patients I-15 group needed supplementary analgesics and sedation during surgery and were excluded from the further study. Time to regression of sensory level, complete motor block recovery, time to appearance of pain was significantly longer in group I-20, than in groups H-15 and I-15. PCA morphine requirement was statistically significant greater in groups H-15 and I-15 than in group I-20. Pain score in group H-15 and I-15 were statistically insignificant higher than in group I-20 up to 24 hours postoperatively. Conclusion: Intrathecal administration of 15 mg plain bupivacaine at L2-L3 level is less reliable for lower abdominal surgery. Spinal anaesthesia with 20 mg isobaric bupivacaine result in longer block regression time and less postoperative pain and analgesic requirement than with huperbaric bupivacaine. Theoretically, greater distribution of hyperbaric solution leads to greater surface absorption and diffusion of local anaesthetic, resulting in shorter duration of anaesthesia. But the difference between isobaric and hyperbaric group in VAS score an PSA morphine requirement was significantly longer than the block regression time.
Salvi L, Rondello N, Merli G, Marino MR, Sisillo E [email protected] IRCCS Centro Cardiologico Monzino, Via Parea, 4, 20138 Milano, Italy
Methods: To evaluate the postoperative pain control, side effects and perioperative hemodynamics, data regarding 106 consecutive patients receiving HTEA combined with sevoflurane were retrospectively reviewed. A 19-G catheter was inserted in the epidural space at the T1-T2 or T2-T3 interspace. HTEA was induced by administration of 0.1 mL kg-1of 0.5% ropivacaine and sufentanil 2.5 mcg mL-1, as a loading dose. Induction of general anesthesia was then achieved with IV fentanyl plus thiopental; pancuronium facilitated tracheal intubation and the lungs were ventilated with sevoflurane in an air-oxygen mixture. Anesthesia was maintained by a continuous infusion of 0.2% ropivacaine and sufentanil 1 mcg mL-1 (0.1 mL kg-1 h-1) and inhalation of sevoflurane. Postoperative analgesia was performed by the infusion of 0.1% ropivacaine and sufentanil 1mcg mL-1 at a rate of 4 to 10 mL h-1 supplemented by IV ketorolac 30 mg at 8-hour intervals. Results: Insertion of the epidural catheter was successful in all but two patients, one bloody tap occurred and the dura was never punctured. No neurologic signs attributed to an epidural or spinal hematoma were found. Visual Analogue Scale scores for pain during the first 24-hours period were ⬍ 2 in all patients. Mean time to extubation was 4.6⫾2.9 hours. Average Intensive Care Unit stay was 1.5⫾0.8 days. Incidence of perioperative myocardial infarction, myocardial ischemia and atrial fibrillation were 2.8%, 7.5% and 10.6%, respectively. Heart rate, mean arterial pressure, cardiac index and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and Cardiac Index decreased (P⬍ 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. Conclusion: Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.