CSEGA (Combined Spinal-Epidural-General
Anesthesia): The Anesthesia of the Future?
Joseph
Eldor, MD
What is
Anesthesia?
The Synergism between Regional and General Anesthesia
Total spinal
anesthesia: The origin of CSEGA
Use of
Ephedrine in CSEGA
Cardiovascular
effects of CSEGA
Cord ischemia
and preemptive analgesia
The
Serbian Experience
CSEGA
for Urologic Operations
CSEGA
for Obstetric and Gynecologic Operations
CSEGA
for Abdominal Operations
CSEGA
for Lumbar Disc Operations
CSEGA
for Pediatric Operations
CSEGA
for Orthopedic Operations
CSEGA
for Vascular Operations
CSEGA
for Cardiac Operations
CSEGA
for Laparoscopic Operations
CSEGA:
Statistics
CSEGA
and the Immune System
CSEGA
and Special Diseases
CSEGA:
Complications
CSEGA
and Emergency Operations
CSEGA
and Asthma
CSEGA
and Liver Operation
CSEGA
and Postoperative Pain
Conclusion
Each
one of the three kinds of anesthesia (spinal, epidural, general) has its
advantages and disadvantages. A new concept of combined spinal-epidural-general
anesthesia (CSEGA) is illustrated with the objective of producing a new kind of
anesthesia. The aim is to draw out the good from each compartment. CSEGA can be
based on muscle relaxation and anesthesia on its spinal part with the epidural
augmentation. The endotracheal intubation can be kept in place with a very
small dose of an inhalational anesthetic. There is no need for muscle relaxant
drugs, i.v. opioids or benzodiazepines, For postoperative analgesia serves the
epidural catheter. Very small doses of local anesthetic drugs injected into the
spinal or epidural compartments, could be all that is needed for operations on
any part of the body, including thorax and head. CSEGA is a new concept in
anesthesia. The mixing of regional anesthesia with general anesthesia affords
the anesthesiologist the opportunity to lower the local anesthetic doses, avoid
using many kinds of intravenous drugs (muscle relaxants, opioids,
benzodiazepines, etc.) and to approach a kind of anesthesia that is closer to
the ideal (1).
What is anesthesia?
Definitions of the state of anesthesia: 1. Drug-induced unconsciousness; the patient neither perceives nor recalls noxious stimulation (2). 2. Reversible oblivion and immobility (3). 3. Paralysis, unconsciousness, and attenuation of the stress response (4). 4. Sensory block, motor block, blocking of reflexes, and mental block (5). 5. All separate effects used to protect the patient from the trauma of surgery (6). Jorgensen et al. (7) studied the anesthetic choice of 705 patients of outpatient surgery candidates prior to speaking to the anesthesiologist. Sixty five percent preffered general anesthesia, 22% - spinal anesthesia, and 12% were unsure. Of those who had spinal anesthesia previously, only 33% would select it in the future. Conversely, 70% of patients who had general anesthesia would prefer it again. Concerns about spinal anesthesia were: paralysis, nerve damage, being awake, infection, inadequate anesthesia, backache, fear of needle and headache. The use of regional anesthesia in residency training programs has increased from 21.3% in 1980 to 29.8% in 1990, primarily because of a two-fold rise in the use of epidural anesthesia (8). Advantages of spinal anesthesia: Obviates the need for deep general anesthesia, profound muscle relaxation, cheap, easy to perform, danger of toxic drug signs - negligible. Disadvantages of spinal anesthesia: hypotension, postoperative headache, some patients prefer to be asleep during operation. The combined spinal-epidural anesthesia combines the rapid onset and good muscle relaxation of subarachnoid block with the ability to supplement analgesia through the epidural catheter, intraoperatively and after the operation. Reynolds et al. (9) using plain lumbar x-rays and CT after injection of iodized oil into the extradural space of 19 subjects recorded the depth of the extradural space at the caudal end: 8.3 ±1.95 mm (at the level of T12). Westbrook et al. (10) found even a smaller ligamentum flavum-dura mater depth at the L2-3 level: 3.95±1.1 mm by using the magnetic resonance imager of 39 subjects. Pitkin (11) describing spinal anesthesia in 1928 wrote that "in 1912, its use was confined to very elderly people, those considered as `bad risks` and to whom we were afraid to give ether". Koster (12) described in 1928 his experience of spinal anesthesia also in operations of the head, neck and thorax. He wrote: "Any one who can do a lumbar puncture can induce spinal anesthesia; the method is reasonably `fool proof` ". Babcock (13) in 1928 summarized his experience of 24 years with spinal anesthesia: "In no other known way can so profound and extensive an anesthesia be produced by so small a dose of a drug and with so little general toxicity". Bromage (14) stated in 1967 that "the beautiful precision and economy of a subarachnoid block is lacking in epidural anesthesia". Greene and Brull (15) in their preface to the fourth edition of "Physiology of Spinal Anesthesia" have written: "Epidural and spinal anesthesia are indeed related to each other, but only to the same extent as cousins or, at best, siblings; monozygotic twins they are not".
The Synergism between Regional and
General Anesthesia
Perimedullary anesthetic
techniques (epidural or spinal anesthesia), by themselves or combined with
general anesthesia offer several advantages in the postoperative period when
compared with general anesthesia alone (17). The incidence of postoperative
respiratory and cardiovascular complications is decreased. The physiologic
stress reaction, with its associated hypercoagulable state and immune depression,
is attenuated. Finally, the resumption of gastrointestinal function is
hastened. These benefits of central neural blockade are noted most clearly when
the techniques are used for several days postoperatively, most often by
catheter based epidural analgesia. The use of local anesthetic agents in the
analgesic mixture would appear to be important. This is likely because these
substances inhibit the sympathetic nervous system and spinal reflex axes. The
role of this inhibition in the advantages of perimedullary techniques is
probably important. It is important to note that inhibition of the
sympathatetic nervous system can be associated with indesirable consequences in
certain patients. These techniques must therefore be used cautiously, and
patients who benefit from them must receive careful surveillance.
Lipophilic opioids,
especially fentanyl and sufentanil, are increasingly being administered
intrathecally as adjuncts to spinal anesthesia. Hamber and Viscomi (18)
analyzed the efficacy of these opioids for subarachnoid anesthesia. Medline
search of the literature from 1980 to the present and a survey of recent
meeting abstracts were reviewed. A significant number of citations regarding
intrathecal lipophilic opioids as adjuncts to spinal anesthesia were found: 59
were cited in this review. Most clinical experience has been in obstetric
surgery, but lipophilic spinal opioid administration is being used with greater
frequency for other surgical procedures as well. The benefits include reduction
of minimal alveolar concentration (MAC) when general anesthesia is combined
with spinal anesthesia and enhancement of the quality of spinal anesthesia
without prolongation of motor block. Intrathecal fentanyl and sufentanil allow
clinicians to use smaller doses of spinal local anesthetic, yet still provide
excellent anesthesia for surgical procedures. Furthermore, lipophilic
opioid/local anesthetic combination permits more rapid motor recovery; short
outpatient procedures are therefore more amenable to spinal anesthesia.
Finally, the side-effect profiles of intrathecal lipophilic opioids are now
well characterized and appear less troublesome than intrathecal morphine. The
anesthesia-enhancing properties and side-effect profile of lipophilic opioids
administered intrathecally suggest significant roles for these agents as
adjuncts to spinal anesthesia for obstetric and outpatient procedures.
Endoh and Matsuda (19)
compared the efficacy of epidurally administered buprenorphine (0.2 mg) after
combined spinal-epidural anesthesia (CSE group) and that after general
anesthesia combined with epidural anesthesia (EPI + GEN group). Postoperatively
epidural buprenorphine was administered for initial pain relief significantly
later in CSE group than in EPI + GEN group. The duration of pain relief with
epidural buprenorphine was similar in both groups (about 11 hours). The time
period until postoperative first walk and the number of pain relief medication
were also similar in both groups. There was the impression that the onset of pain
relief was faster in CSE group, probably because there might be flux of
buprenorphine through a dural hole just after epidural administration.
New justification for the
use of regional anaesthesia, either alone or in combination with general
anaesthesia, has been provided with reports of some unexpected influences on
outcome. A reduction in the incidence of postoperative thrombotic episodes and
vascular graft occlusion is strongly suggested in patients with generalized
vascular disease. Application of a variety of drugs, including local
anaesthetics, opioids and adrenergic agonists, in the region of the spinal cord
reduces afferent input during surgery and also the metabolic stress response.
Evidence is increasing that this multi-modal approach to anaesthesia has
important consequences in the spinal cord which result in modification of the
postoperative requirement for analgesia. Premedication with opioid and other
analgesics may also enhance this pre-emptive effect. New general anaesthetic
and analgesic drugs are available that are more suited to these combined
techniques. They have shorter duration of action so that plasma concentration
can be rapidly adjusted to match a variable surgical stimulus(20).
The neuroprotective potential of halothane anesthesia was explored in a
weight-drop model of spinal trauma in the rat (N = 252) (21). In initial
experiments, animals were subjected to 25, 50 or 100 g cm impact injuries at
T10 during pentobarbital or halothane anesthesia and their outcomes determined
using somatosensory-evoked potentials, blinded neurologic evaluations for two
weeks, and post-mortem analysis of spinal serotonin levels. Subsequently,
halothane anesthesia was combined with either pentobarbital or nitrous oxide or
given as a late treatment to pentobarbital anesthetized rats subjected to 50 g
cm injuries. A series of acute studies were then performed in order to assess
the hemodynamic and respiratory concomitants of halothane vs. pentobarbital, as
well as the effect of mechanical ventilation and bicarbonate treatment upon
halothane neuroprotection. Finally, the effect of a 50 g cm impact upon local
white matter spinal cord blood flow was measured during halothane or
pentobarbital anesthesia using laser-Doppler flowmetry. Results demonstrate an active
neuroprotective action for halothane anesthesia that is not altered by the
presence of other anesthetics and is most prominent at severe injury levels.
The data suggest the importance of immediate injury responses in this action.
Late halothane treatment was ineffective when given as early as 10 minutes
postinjury while both the electrophysiological and hemodynamic effects of
halothane vs. pentobarbital were apparent during this 10 minute period. Thus,
halothane was associated with the prevention of spinal ischemia during the
first 10 minutes after trauma in comparison to pentobarbital.
Lo Presti et al. (22)
reviewed the advantages and disadvantages of general and regional anesthesia in
bad clinical conditions. The purpose of this study was to evaluate the efficacy
of Blended Anesthesia (association of general anesthesia with a regional
technique) in 25 patients belonging to ASA classes II-III-IV, undergoing
surgery for various disease. General anesthesia was provided by perfusion of
propofol, after a peridural or subarachnoid continuous anesthesia was started.
Patients were either in spontaneous or controlled ventilation. There were no
cases of hypotension or other important side effects and the majority of
patients judged good the anesthetic technique in regard to lack of pain,
exhaustion and recall of operation.
Morley et al. (23)
conducted a prospective, randomized, controlled trial to establish the effect
of epidural blockade on isoflurane requirements for equivalent intraoperative
electroencephalographic (EEG) suppression. Fifty patients undergoing abdominal
hysterectomy received combined epidural and general anesthesia or general
anesthesia alone with isoflurane and alfentanil. Isoflurane was administered by
computer-controlled closed-loop feedback to maintain an EEG 95% spectral edge
frequency of 17.5 Hz, a target chosen on the basis of a pilot study. In
epidural patients, end-tidal isoflurane concentration (FE'(ISO)) was 0.19%
smaller (95% confidence interval [CI], -0.32% to -0.06%; P < 0.01), mean arterial
blood pressure was 17 mm Hg lower (95% CI,
Total
spinal anesthesia: The origin of CSEGA
Evans (24) described in 1928 the
possible complications of spinal anesthesia. Concerning respiratory paralysis
he wrote:" If respiration should cease , keep cool. Raise the lower jaw,
pull the tongue forward and begin artificial respiration at a uniform rate.
Mouth to mouth insufflation is the most convenient and efficacious method of
artificial respiration". Twenty years before, in September 1908, before
the Congress of the International Society of Surgery, in
Use of Ephedrine in CSEGA
Ephedrine is the sympathomimetic drug which is most widely used to sustain blood pressure during spinal anesthesia. The active principal was isolated from the chinese herb ma huang in 1885 by Yamanashi (45). Butterworth et al. (46) found that a mixed adrenergic agonist such as ephedrine more ideally corrected the noncardiac circulatory sequelae of total spinal anesthesia in dogs than did either a pure alpha (phenyl-ephrine) or a pure beta-adrenergic agonist (isoproterenol). Butterworth et al. (47) also demonstrated in dogs the effectiveness of dobutamine and dopamine as possible alternatives to ephedrine for the pharmacologic correction of the noncardiac circulatory sequela of total spinal anesthesia. Goertz et al. (48) investigated the effect of ephedrine on left ventricular function in patients without cardiovascular disease under high thoracic epidural analgesia combined with general anesthesia. Ephedrine improved left ventricular contractility without causing relevant changes of left ventricular afterload.
Cardiovascular effects of CSEGA
Combining epidural analgesia with general anesthesia in humans reduces the hemodynamic demand on the heart (49-51) and provides more stable intraoperative hemodynamics (52). In animal experiments epidural analgesia has inhibited sympathetic coronary constriction secondary to a flow-limiting stenosis (53), reduced infarct size (54) and reduced ST-segment changes on the electrocardiogram in an acute coronary artery occlusion model (55). However, Mergner et al. (56) investigated epidural analgesia combined with general anesthesia in a swine model with a tight coronary artery stenosis. Distal to the coronary stenosis was a moderate decrease in regional myocardial function and a severe reduction in blood flow. The epidural analgesia reaching the level of T1 was added to an animal which already had a decreased blood pressure and sympathetic tone from the isoflurane/fentanyl anesthesia. No correction of the reduced blood pressure was done in this study. Stenseth et al. (57) investigated the cardiovascular and metabolic effects of T1-T12 epidural block in 18 patients receiving chronic beta-adrenergic blocker medication and scheduled for aortocoronary bypass surgery. Thoracic epidural analgesia induced a moderate decrease in mean arterial pressure, coronary perfusion pressure, free fatty acids and myocardial consumption of free fatty acids. Blomberg et al. (58,59) also found no cardiac effects after a T1-T8 or T1-T6 block in beta-adrenergic blocked patients with ischemic heart disease. Christensen et al. (60) evaluated myocardial ischemic events by Holter monitoring of ST-segment depression in 14 patients with angina pectoris given spinal analgesia for minor surgery. Ephedrine in doses of 5 mg was given, if rapid infusion of saline did not improve the arterial pressure.The first ischemic event occurred at a mean of 338 minutes after spinal analgesia, and not in association with the onset of block, with the decrease in mean arterial pressure after spinal analgesia or with the administration of ephedrine. This could be explained by increased cardiac pre- and afterload, probably further aggravated by the volume load.
Cord ischemia and preemptive analgesia
Breckwoldt
et al. (61) investigated the effect of intrathecal tetracaine on the
neurological sequelae of spinal cord ischemia and reperfusion with aortic
occlusion in rabbits. They found that intrathecal tetracaine significantly and
dramatically abrogated the neurological injury secondary to spinal cord
ischemia and reperfusion after aortic occlusion at 30 minutes. Peripheral
tissue injury provokes two kinds of modification in the responsiveness of the
nervous system: peripheral sensitization and central sensitization. The optimal
form of pain treatment may be one that is applied both pre-, intra-, and
postoperatively to preempt the establishment of pain hypersensitivity during
and after surgery. Woolf and Chong (62) in their review of preemptive analgesia
concluded that "although evolution has conserved sensitization in humans,
the capacity to inflict `controlled injury` during surgery has clearly not been
anticipated".
The Serbian Experience
Type and technique of anesthesia have an
important effect on peri-operative surgical course (63). The aim of the study
by Malenkovic, Zoric and Randelovic (64)
was prospective analyses of advantages of combined spinal, epidural and general
anesthesia (CSEGA) versus general anesthesia (GA) in abdominal surgery
according to: 1. Operative course (hemodynamic stability of patients, quality
of analgesia, undesirables effects), 2. Postoperative course (quality of
analgesia, unfavourable effects, temporary abode of patients in intensive
care). Using prospective randomized double blind controlled study, Malenkovic et al. evaluated two groups of patients whom
the same type of abdominal surgical intervention was planned and the only difference
was the type of technique of anesthesia. First group of patients (n = 34), was
treated with CSEGA and second group of patients (n = 33), was treated only with
standard (GA). Both groups had intraoperative and 24-hour-long postoperative
continued monitoring of blood pressure, central venous pressure, and diuresis.
In the 24 hours postoperative period, the following parameters were analyzed:
vigilance conditions, motor block level, pain intensity in rest and movement,
necessity for a complementary analgesia, side effects and final subjective
effect of analgesia. There was important difference in waking up the patients
after a general anesthesia. In the first group this period was shorter. In the
first 24 hours, patients from the first group didn't get any systemic
analgesic, while the patients from the second group needed fractionary
application of parenteral analgesics in the period of 4-6 hours. Patients from
the first group were also physically faster and easier recovered and they had
less respiratory complications and there was not any example of thromboembolsm
and the intestine motility was faster re-established. First group of patients
spent less time in intensive care (three days) than second group (six days).
Final subjective effect of analgesia, according to verbal descriptive scale
(VDS) of pain was satisfying with 75% of patients of the first group and 15% of
patients of the second group. According to results investigation, advantages of
CSEGA versus GA in abdominal surgery were manifold: better hemodynamic
stability and perfusion of operative region, decrease of single doses of opioid
analgesics, local and general anesthetics followed by the decrease of their
side effects, better intensity and longer duration of analgesia and improved
total functional capability of patients (64).
Zoric et al. (65) have been routinely practicing their technique of CSEGA in
big abdominal and thoraco-abdominal surgery, since 1997. Their study is a
retrospective analysis of the technique and its clinical observations, during
4.5 years, which include 293 patients. They performed combined spinal-epidural
anaesthesia (CSE) in one or two interspinal spaces, depending on the type of
surgery, but always before induction of general anaesthesia (GA). For
preemptive and intraoperative analgesia they used 0.25% plain bupivacaine (B),
both for spinal (SA) and epidural (ED) blockade. The most important detail in
their technique is analgesic solution (AS) which contained Bupivacaine (B) 4.5
mg, fentanyl (Fe) 50 mcg and morphine hydrochloride (Mo) 0.2 mg, in total
volume of 3 ml, in SA. After the ED test dose with 2% lidocaine 60 mg (3 ml),
before the induction of GA, they injected more 10 ml B, but intraoperative
analgesia was almost performed with B 3 to 5 ml in intermittent bolus doses.
This ED bolus doses was particularly important, partly to sufficiently cephalic
migration of the SA somatosensory block, as well as for intraoperative
analgesia. For very light GA only artificial ventilation with 66% N2O in O2 and
muscle relaxation with pancuronium was needed. Co analgesia with intravenous
Fe, was exceptionally seldom needed, except for induction. Intraoperative drugs
consumption was very small. With adequate liquid compensation, this technique
achieved exceptionally intraoperative hemodynamic stability in patients,
despite too long and big operations. Postoperative analgesia are supplied by SA
the first 24 hours, but for the next 72
hours it was performed with intermittent
ED bolus doses of 0.12% B with 2 mg Mo in total volume of 15 ml and 10 ml,
depending on the epidural catheter position in lumbar or thoracic part of
spine. The breakthrough of postoperative pain was between 20% to 34%, which was
suppressed with metamisol. According to the verbal rating scale (VRS < 1)
90% of patients were satisfied with this analgesia, which gave possibilities to
mobilization and rehabilitation even in the first postoperative day. All
clinical signs showed that thanks to inhibition of spinal and supraspinal
sensitization, all principles of the preemptive analgesia (PA), inhibition of
neuro-hormonal stress reaction were met and postoperative outcome was improved
and satisfied. The complications were insignificant, in time observed and
without any consequences (65).
CSEGA for Urologic Operations
The appropriate anesthesia for renal transplantation requires minimal toxicity
for patients and for the transplanted organ, as well as sufficient pain relief
and maintenance of vital functions. The aim of the study by Hadimioglu et al.
(66) was to determine how the anesthetic
technique influences the outcome in patients after renal transplantation in
terms of preoperative and intraoperative hemodynamic changes and blood gas
changes. Fifty adult patients undergoing renal transplantation were randomly
divided into two groups receiving standardized general anesthesia or combined
spinal and epidural anesthesia. Demographically both groups were similar. Total
anesthesia time (202 +/- 53 vs 186 +/- 37 minutes) and surgical time (191 +/-
52 vs 162 +/- 31 minutes) did not differ between the groups. The heart rate and
systolic blood pressure values of the groups as measured before induction and
5, 15, 20, 30, as well as 60 minutes thereafter did not differ between the
groups. Neither the frequency of bradycardia (four vs two) nor of hypotension
(six vs four) during anesthesia differed between regional versus general
anesthesia groups. Regional is an important alternative to general anesthesia
during renal transplantation surgery in adult patients.
Nakano et al. (67)
evaluated the efficacy of combined lumbar spinal and epidural (CLSE)
anesthesia in retropubic radical prostatectomy. Twenty consecutive patients who
underwent radical retropubic prostatectomy by a single surgeon (H.K.) under
CLSE anesthesia from July of 2003 to February of 2004 were selected as
subjects. They were compared with 20 consecutive patients who underwent radical
retropubic prostatectomy performed by the same surgeon under combined general
and epidural (CGE) anesthesia from April to December of 2002. Both periods were
carefully selected to exclude radical prostatectomies with intraoperative
complications to evaluate genuine effects of anesthesia. For lumbar spinal
anesthesia, 0.5% hyperbaric bupivacaine hydrochloride or 0.5% hyperbaric
tetracaine hydrochloride (dissolved in a 10% glucose solution) was used. An
epidural tube was inserted for both lumbar spinal anesthesia and general
anesthesia mainly for the purpose of controlling pain after operation.
Intraoperative blood loss was significantly less in the CLSE anesthesia group
compared with CGE anesthesia group (p = 0.024). Postoperative water drinking
was started at 0.4 days (average) for CLSE anesthesia and at 1.1 days (average)
for CGE anesthesia (p < 0.0001). Postoperative diet was begun at 0.7 days
(average) for CLSE anesthesia and at 1.5 days (average) for CGE anesthesia (p
< 0.0001). Compared with the CLSE anesthesia group, the mean of the highest
intraoperative mean blood pressure was significantly higher in the CGE
anesthesia group (p = 0.002). Intraoperative blood loss was less,
intraoperative change in blood pressure was less and recovery of postoperative
intestinal peristalsis was earlier in patients who underwent prostatectomy
under CLSE anesthesia than in patients who underwent prostatectomy under CGE
anesthesia.
Various general and regional anesthesia methods are used
successfully in living-donor kidney transplantation. Sener et al. (68) compared
kidney graft function after general versus combined spinal-epidural anesthesia
for donor nephrectomy. The study groups included recipients who received grafts
from donors who had undergone nephrectomy under general anesthesia (GA group;
n=10), and recipients who received grafts from donors who had combined
spinal-epidural anesthesia (CSE group, n=10). Standard continuous epidural
anesthesia was administered during all transplantations. Graft function was
assessed using scintigraphy and Doppler ultrasonography on days 3 and 7. Urine
levels of microalbumin, creatinine, and creatinine clearance rate were
measured/calculated in 24-hour urine samples collected on postoperative days 3
and 7. There were no differences on either day 3 or day 7 with respect to
glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P
>.05 for all). There were also no differences between the groups with
respect to other scintigraphic findings on day 3 or day 7 (P >.05 for all).
Ultrasonography on day 7 showed significantly higher mean peak systolic flow in
the main renal artery in the CSE group than in the GA group (P=.035). The
results suggest that GA and CSE for donor nephrectomy have similar effects on
kidney graft function in recipients.
Fichtner et al. (69) evaluated the
possibility of a perineal radical prostatectomy (PRP) under spinal anaesthesia,
as although it is usually done under general anesthesia, there is currently a
need to minimize costs and morbidity. Between January and December 2003, there
were 337 PRPs at their institution, of which 47 were on patients under combined
spinal/epidural (CSE) anesthesia administered via a standard L3/4 or L4/5
approach. They analysed the feasibility of PRP under CSE and evaluated
perioperative morbidity, including blood loss and hospital stay. All 47
procedures were done under CSE with no need for conversion to general
anaesthesia. The mean (range) duration of PRP was 56 (43-112) min, the mean
blood loss 270 mL, and the transurethral catheter was removed at 7 days in 40
and at 14 days in the remaining seven patients. There were no complications
during surgery, e.g. rectal or ureteric lesions. The mean hospital stay was 8.2
days. PRP is safe under CSE anaesthesia; this may be helpful in minimizing
morbidity and medical costs, as well as providing an alternative in patients in
whom general anaesthesia is not recommended.
Kararmaz et al. (70)
designed a double-blinded, randomized, controlled study to evaluate the
effect of small-dose ketamine IV in combination with epidural morphine and
bupivacaine on postoperative pain after renal surgery. An epidural catheter was
inserted, and the administration of morphine and bupivacaine was started before
surgery. Forty patients were assigned to one of two groups (ketamine or
control). The ketamine group was administered a ketamine bolus and infusion
during surgery. The median visual analog pain scale (VAS) scores at rest were
significantly lower in the ketamine group during the first 6 h (P < 0.01).
VAS pain scores on coughing were also significantly lower in the ketamine group
(P < 0.01). Cumulative postoperative total analgesic consumption was less in
the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand
time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine
group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus
was more frequent in the control group (P < 0.05). In conclusion,
postoperative analgesia was more effective when spinal cord and brain
sensitization were blocked by a combination of epidural morphine/bupivacaine
and IV ketamine. Renal nociception conducted multisegmentally by both the
spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural
analgesia alone. It was demonstrated that IV ketamine had an improved analgesic
or opioid-sparing effect when it was combined with epidural bupivacaine and
morphine after renal surgery.
A variety of drugs and techniques have been introduced into ambulatory
anaesthesia. The technique as well as the drugs used may hasten or delay home
discharge. Erhan et al. (71) compared recovery profiles and side-effects of
spinal anaesthesia and total intravenous anaesthesia. Forty unpremedicated ASA
I-II patients (18-65 yr) undergoing varicocele repair were randomly divided
into two groups. Spinal anaesthesia (26-G atraumatic needle) with hyperbaric
bupivacaine 0.5% 5 mg and fentanyl 25 microg were given to patients in Group
Spinal (n = 20). Patients in Group TIVA (n = 20) received total intravenous
anaesthesia with propofol and remifentanil given by continuous infusion; a
laryngeal mask was used to secure the airway. The duration of surgery, time to
home readiness and side-effects were recorded. The two groups were comparable
with respect to patients' characteristics and duration of surgery. The times to
achieve ambulation were similar between groups (Spinal = 78.4 +/- 40.9 min,
TIVA = 75.9 +/- 13.8 min). Urinary voiding was a requirement for discharge
after spinal anaesthesia and the time for home readiness was longer in Group
Spinal (158.0 +/- 40.2 versus 94.9 +/- 18.8 min) (P < 0.05). Two patients
reported pruritus and one reported postdural puncture headache in Group Spinal,
whereas two patients reported nausea in Group TIVA. Patients in Group TIVA had
a greater need for analgesia postoperation (P < 0.05). In healthy
unpremedicated men undergoing minor urological operations, total intravenous
anaesthesia with remifentanil and propofol provided as safe and effective
anesthesia as spinal block with the advantage of earlier home readiness.
Liu et al. (72) compared the analgesic effect of lumbar intrathecal (IT) 0.5 mg
morphine (Group M, n = 10), 50 microg sufentanil (Group S, n = 10), and their
combination (Group S-M, n = 10) given before general anesthesia and
patient-controlled analgesia with IV morphine (Group C, n = 19) in a
randomized, double-blinded study performed in patients undergoing thoracotomy.
Pain visual analog scale (VAS) and morphine consumption were assessed for 24 h.
In Group S-M the number of patients initially titrated with IV morphine was
less than in group C (30 vs 84%, P < 0.05). Morphine requirement was higher
in Group C (71 +/- 30 mg) than in Groups S (46 +/- 34 mg, P < 0.05), M (38
+/- 31 mg, P < 0.05) and S-M (23 +/- 16 mg, P < 0.01). VAS scores were
significantly decreased during the first 0-11 postoperative h at rest and during
the first 0-8 postoperative h on coughing in Groups M and S-M rather than in
Group C. The incidence of side effects was infrequent except for urinary
retention. Preoperative IT morphine or combined sufentanil and morphine could
be given as a booster to achieve rapidly effective analgesia in the immediate
postoperative period. As compared with IV patient-controlled analgesia,
intrathecal morphine or combined sufentanil and morphine provided superior
postoperative pain relief both at rest (11 h) and on coughing (8 h) than did IV
patient-controlled analgesia morphine alone. IV morphine requirement was
decreased during the first postoperative day after posterolateral thoracotomy.
Urologic patients have overlap disturbances in many organ systems, especially
in urinary system with cardiovascular and respiratory system. During extensive
urologic operations Ladjevic and Vesovic (73) perform general anesthesia in
most cases. General anesthesia provides organ vital function under best
control. Patients with severe respiratory disease undergoing surgery in
regional anesthesia (spinal or epidural with or without epidural catheter, or
in combined spinal-epidural anesthesia).
The effect of combined epidural anesthesia and epidural
morphine injection is discussed (74). A group of 98 patients (group A), chosen
at random, was operated on under such combined anesthesia and compared to a
similar group of 98 patients (group B), equally chosen at random, operated on
under either spinal or general anesthesia with no epidural morphine added. Over
87% of group A needed no narcotic drugs for postoperative pain. All patients in
the group B needed 60-80 mg of morphine during the first 48 postoperative
hours. The quantity of morphine required was the main parameter for comparison.
The postoperative course in group A was considerably easier while the operative
results were equal in both groups.
CSEGA for Obstetric and Gynecologic
Operations
Spinal anesthesia is the technique most often applied in cases of scheduled cesarean
section. Many authors have tried decreasing the local anesthetic dose by adding
opioids to achieve adequate analgesia with greater hemodynamic stability,
although the ideal dose remains to be established. Guasch et al. (75) analyzed
hemodynamic stability and quality of analgesia with 2 different regimens for
administering spinal hyperbaric bupivacaine. They designed a controlled,
double-blind trial comparing 2 doses of spinal hyperbaric bupivacaine with
fentanyl in 42 patients undergoing elective cesarean section randomized to 2
groups to receive either the low dose or the conventional one. One group
received an 11 mg dose of bupivacaine and the other group received a 6.5 mg
dose, combined with 20 microg of fentanyl in both cases. The hemodynamic profile
and the level of maximum sensory block obtained were similar in the two groups.
The motor block was less intense in patients receiving the lower dose and it
was necessary to convert 2 patients (10%) to general anesthesia in that group.
Spinal anesthesia with low doses of bupivacaine and fentanyl provides
acceptable intraoperative conditions for a high percentage of patients
undergoing cesarean section, with a similar incidence of hypotension. The low
dose generates a less intense intraoperative motor blockade with similar spread
of the sensory block. The low dose was not efficacious for 10% of the patients
who received it.
A prospective survey of anesthesia for cesarean section was
performed for the year 1 January to
Machado-Joseph disease is a form of progressive spino-cerebellar ataxia with
both bulbar and peripheral neurological manifestations. General anesthesia may
be problematic because of the risk of pulmonary aspiration and hypoxia. Teo et
al. (77) described their experience with the successful use of combined
spinal-epidural in a patient with Machado-Joseph Disease (MJD). A 38-year-old
woman with MJD complicated by significant bulbar and peripheral neuropathy
presented for an elective vaginal hysterectomy. She had no other medical
history of note. After informed consent, subarachnoid block was performed by
combined spinal-epidural anesthesia at the L2-3 lumbar intervertebral space
with hyperbaric bupivacaine 12 mg, morphine 100 microg, and fentanyl 10 microg.
Surgery proceeded uneventfully, with excellent postoperative analgesia. There
was full recovery of preinduction neurologic function by the sixth
postoperative hour. Central neuraxial anesthesia is an option for patients with
MJD presenting for lower abdominal and lower extremity operations. Combined
spinal-epidural anesthesia confers hemodynamic stability yet allows for
augmentation of intraoperative anesthesia and postoperative analgesia.
Pre-eclampsia is a multisystemic disorder that is characterised by endothelial cell
dysfunction as a consequence of abnormal genetic and immunological mechanisms.
Despite active research for years, the exact etiology of this potentially fatal
disorder remains unknown. Although understanding of the pathophysiology of
pre-eclampsia has improved, management has not changed significantly over the
years. Anesthetic management of these patients remains a challenge. Although
general anesthesia can be used safely in pre-eclamptic women, it is fraught
with greater maternal morbidity and mortality. Currently, the safety of
regional anesthesia techniques is well established and they can provide better
obstetrical outcome when chosen properly. Thus, regional anaesthesia is
extensively used for the management of pain and labour in women with pre-eclampsia.
Mandal and Suprapaneni (78) highlighted the advantages and disadvantages of
regional anesthetic techniques including epidural, spinal and combined
spinal-epidural analgesia, used as a part of the management of pre-eclampsia.
Petropoulos et al. (79) compared general, epidural and
combined spinal-epidural anesthesia with respect to short-term outcome of
newborns delivered by elective Cesarean section of healthy parturients with
normal pregnancies. A total of 238 pregnant women admitted between January 1998
and July 2002, for whom elective Cesarean section was planned after 38 weeks'
gestation, were grouped according to the kind of anesthesia used for the
procedure. Maternal characteristics, birth weight, Apgar scores, and maternal
and umbilical artery (UA) acid-base parameters were analyzed. Maternal pH was
significantly lower and pCO2 and pO2 were significantly higher in the general
anesthetic group, compared to the other two groups (7.38 +/- 0.03 vs. 7.43 +/-
0.02 and 7.43 +/- 0.05, respectively; 35.03 +/- 3.88 mmHg vs. 29.25 +/- 5.05
mmHg and 29.64 +/- 4.16 mmHg, respectively; and 224.56 +/- 86.77 mmHg vs.
151.28 +/- 38 mmHg and 157.36 +/- 53.51 mmHg, respectively, p < 0.05). The
pH of the UA was higher in the general anesthetic group, compared to the
spinal-epidural group (7.29 +/- 0.02 vs. 7.26 +/- 0.06, p < 0.05). The pO2
as well as O2 saturation of the UA were higher when general anesthetic was
administered, compared to the two regional modalities (15.60 +/- 5.48 mmHg vs.
9.29 +/- 4.41 mmHg and 9.20 +/- 4.06 mmHg, respectively; and 17.37 +/- 9.79%
vs. 7.87 +/- 4.98% and 6.90 +/- 5.22%, respectively, p < 0.05). UA O2
saturation fell to zero in some cases in the combined spinal-epidural group,
without an evident effect on fetal well-being. No fetal acidemia was noted in
any group. Neonatal outcomes were similar in the three groups studied. Type of
anesthesia does not influence short-term outcomes in infants born via elective
Cesarean section, although differences in acid-base status of both the mother
and especially the newborn recommend careful use of spinal anesthesia.
Epidural blockade is an important option for anesthesia in parturients
undergoing abdominal delivery. Despite the multiple benefits of this method,
there is at least one significant downside--a relatively high occurrence of
unsatisfactory anesthesia that requires intervention. Depending on the presumed
mechanism of epidural block failure and other clinically relevant factors
(e.g., timing of diagnosis, urgency of the procedure, and so forth), certain
effective measures are recommended to successfully manage this demanding
situation. In general, it is important to make every effort to make the
pre-existing epidural effective or replace it with another regional technique,
because overall, regional anesthesia is associated with significantly lower
maternal mortality. It is important to identify a dysfunctional epidural block
preoperatively before a maximum volume of local anesthetic has been
administered. If catheter manipulation does not produce substantial
improvement, and there is no time constraint, it is safe and reasonable to
replace the epidural catheter. However, risks associated with excessive volume
of local anesthetic should be kept in mind. Additional epidural injections or a
second catheter placement might be considered under special circumstances.
Single-shot spinal anesthesia after a failed epidural may provide fast onset
and reliable surgical anesthesia. Available data, although limited and
contradictory, suggest the possibility of unpredictably high or total spinal
anesthesia. Many authors, however, believe that appropriate precautions and
modifications in technique make this a safe alternative. These modifications
include limiting the amount of epidural local anesthetic administered when
diagnosing a nonfunctioning epidural and decreasing the dose of intrathecal
local anesthetic by 20% to 30%. If there is no documented block when the spinal
is inserted, and more than 30 minutes have passed from the last epidural dose,
it is probably safe to use a normal dose of local anesthetic. Continuous spinal
anesthesia with a macro catheter might be a dependable alternative,
particularly if large amounts of local anesthetic have already been used or the
patient's airway is a cause for concern. Although there are no reports of
combined spinal epidural anesthesia being used in this context, it would appear
to be an attractive alternative. It allows the anesthesiologist to give smaller
doses intrathecally, while still offering the flexibility of augmenting the
block if needed. When inadequate epidural block becomes apparent during surgery
there are limited alternatives. Depending on the origin and the pattern of
inadequate anesthesia, options may include psychological support, supplementation
with a variety of inhalational and intravenous agents, and local anesthetic
infiltration. Induction of general anesthesia is typically left as a backup
option, but must be strongly considered if the patient continues to have
pain/discomfort (80).
Danelli et al. (81) compared the preparation and discharge
times, the side-effects and patient satisfaction after gynaecological
outpatient procedures performed using either spinal block or total intravenous
anaesthesia with propofol and remifentanil. 40 healthy females scheduled for
hysteroscopic ablation of endometrial neoplasm were randomly allocated to
receive either a spinal block with bupivacaine 0.5% hyperbaric solution 10 mg
(n = 20) or total intravenous anaesthesia with propofol and remifentanil (n = 20).
Preparation and discharge times, as well as occurrence of untoward events and
anesthesia-related costs, were recorded. The median (range) preparation time
was 7 (7-10) min with general anaesthesia, and 11 (7-21) min with spinal block
(P = 0.00005). No differences in discharge time from the postanesthesia care
unit and incidence of hypotension or bradycardia, or both, were reported
between the two groups. Hospital discharge times were 156 (101-345) min after
general anaesthesia and 296 (195-720) min after spinal anesthesia (P = 0.0005).
Acceptance of the anesthesia technique was better after general (100%) than
after spinal anesthesia (75%) (P = 0.04). No differences in total costs were
reported between spinal block and propofol-remifentanil general anaesthesia.
Accurate titration of short-acting intravenous anesthetic drugs such as
propofol and remifentanil results in shorter preparation times and earlier home
discharge after outpatient gynecological procedures compared with spinal
anesthesia with hyperbaric bupivacaine 10 mg, with better patient acceptance
and no increased costs.
Ramanathan et al. (82) evaluated the quality of anesthesia for cesarean
delivery (CD), analgesia for labor (LA), hemodynamic changes, and neonatal
effects of combined spinal and epidural anesthesia (CSE) with low intrathecal
doses of bupivacaine and fentanyl in patients with severe preeclampsia. Of the
85 patients with severe preeclampsia (systolic pressures [SBP] > or = 160 mm
Hg or diastolic pressures [DBP] > or = 110 mm Hg, and proteinuria > or =
100 mg/dL), 46 underwent CD and 39 delivered vaginally. The CD group received
7.5 mg of hyperbaric bupivacaine and 25 microg fentanyl intrathecally with a
goal of obtaining a T4 sensory block. Those with levels less than T4 received
2% lidocaine epidurally to extend the block. In the LA group, the intrathecal
dose was 1.25 mg of plain bupivacaine with 25 microg of fentanyl, followed by
epidural infusion of 0.0625% to 0.125% bupivacaine with 2 to 4 microg
fentanyl/mL at 12 to 15 mL/h. In the CD group, all but 4 patients had > or =
T4 block, and these 4 patients received 2% lidocaine epidurally. None required
conversion to general anesthesia. In the LA group, sensory levels were T10
(range, T6-L2) with adequate analgesia. The baseline mean arterial pressure
(MAP) was 122 +/- 13 mm Hg in the CD group and 117 +/- 12 mm Hg in the LA
group. After CSE, MAP decreased significantly and reached a nadir within 5
minutes in both groups (103 +/- 12 mm Hg in the CD group and 96 +/- 13 mm Hg in
the LA group, P <.05). The maximum decrease in MAP was similar in the 2
groups (-15% +/- 8% in the CD group and -16% +/- 9% in the LA group). The
neonatal Apgar scores and umbilical artery (UA) pH were similar, and there were
no significant correlations between UA pH and lowest MAP before delivery or the
maximum percentage change in MAP in either group. The results indicate that CSE
with low intrathecal doses of bupivacaine and epidural supplementation, when
needed, produces adequate anesthesia for CD and analgesia for labor in patients
with severe preeclampsia. The maximum decreases in MAP after CSE were modest
and quite similar in the 2 groups.
Expert and aggressive pre-operative preparation of the woman with severe
pre-eclampsia will ultimately determine her intraoperative outcome. Such
considerations as the effect of endotracheal manipulation on intracranial
pressure, of thrombocytopenia on the potential to produce a compressive
epidural hematoma following epidural or combined spinal-epidural neuraxial
block and of adequacy of invasive monitoring for Cesarean section loom large in
the eyes of an anesthetist preparing such a patient for surgery. Time spent
pre-operatively in fluid volume optimization, in assessment of ventricular
function, filling pressures and systemic vascular resistance, on aspiration
pneumonitis and seizure prophylaxis, on control of hypertension, on correction
of coagulopathy and on attenuation of pressor responses is time well spent and
will have profound effects on the peri-operative course. The choice of agents
and techniques for control of hypertension and reduction of vascular
resistance, for induction and maintenance of general anesthesia, for eclampsia
prophylaxis and for regional anesthesia or analgesia for operative or
spontaneous delivery is, likewise, important and, at times, problematic (83).
Postoperative nausea and vomiting (PONV) are major problems after gynecological
surgery. Callesen et al. (84) studied 40 patients undergoing total abdominal
hysterectomy, allocated randomly to receive opioid-free epidural-spinal
anesthesia or general anesthesia with continuous epidural bupivacaine 15 mg h-1
or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1,
respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel
function were scored on 4-point scales for 3 days. Patients undergoing general
anesthesia had significantly higher nausea and vomiting scores (P < 0.01)
but significantly lower pain scores during rest (P < 0.05) and mobilization
(P < 0.01). More patients undergoing general anesthesia received antiemetics
(13 vs five; P < 0.05), but fewer received supplementary opioids on the ward
(eight vs 16; P < 0.05). It was concluded that opioid-free epidural-spinal
anesthesia for hysterectomy caused less PONV, but with less effective analgesia
compared with general anesthesia with postoperative continuous epidural
morphine and bupivacaine.
Incomplete anesthesia is a major clinical problem both in single
spinal and in single epidural anesthesia. The clinical efficacy of epidural
anesthesia with augmentation (aEA) and combined epidural and spinal anesthesia
(CSE) for cesarean section was investigated in a prospective randomized study
on 45 patients (85). Anesthesia extending up to Th5 was aimed for. Depending on
the patient's height, epidural anesthesia was administered with a dose of 18-22
ml 0.5% bupivacaine and spinal anesthesia with a dose of 11-15 mg 0.5%
bupivacaine. Augmentation was carried out in all cases in epidural anesthesia,
initially with 7.5 ml 1% Lidocaine with epinephrine 1:400,000, raised by 1.5 ml
per missing segment. The epidural reinjection in CSE was carried out as
necessary with 9.5-15 ml 1% lidocaine with epinephrine, depending on the height
and difference from the segment Th5. The extension of anesthesia achieved in
epidural anaesthesia after an initial dose of 101.8 mg bupivacaine and
augmenting dose of 99 mg lidocaine reached the segment Th5. The primary spinal
anesthesia dose up to 15 mg corresponding to height led to a segmental
extension to a maximum of Th3 under CSE. Augmentation was necessary in 13
patients; in 5 cases because of inadequate extent of anesthesia and 8 cases
because of pain resulting from premature reversion. The augmenting dose
required was 13.9 ml. Readiness for operation was attained after 19.8 min (aEA)
and after 10.5 min (CSE). No patient required analgesics before delivery. The
additional analgesic requirement during operation was 63.6% (aEA) and 39.1% (CSE).
Taking into account pain in the area of surgery, the requirement of analgesics
was 50% (aEA) vs. 17.4% (CSE). Antiemetics were required in 18.2 (aEA) and in
65.2% (CSE). The systolic blood pressure fell by 17.7% (aEA) and in 30.3%
(CSE). The minimum systolic pressure was observed after 13.4 min in aEA, and
after 9.5 min in CSE. The APGAR score and the umbilical pH did not show any
differences. General anesthesia was not required in any case.
Albright and Forster (86) reviewed if patients who receive combined
spinal-epidural (CSE) analgesia with subarachnoid sufentanil have an increased
incidence of emergency cesarean delivery for fetal distress when compared with
patients who receive systemic or no medication (S/NM) for labor analgesia. A
retrospective computerized analysis of data on all 2,560 deliveries at Bellevue
Woman's Hospital for 14 months summarized practice parameters for 1,240
patients who received regional analgesia (98% CSE analgesia), identified 1,140
patients who received S/NM, and classified the urgency of 479 cesarean
deliveries. In the CSE group there were 168 cesarean deliveries (emergency 16,
urgent 58, semiurgent 70, and nonurgent 24) as compared with a total of 128
(emergency 16, urgent 43, semiurgent 69, nonurgent 0) in the S/NM group.
Scheduled cesarean sections (180) were excluded from the study. The incidence
of emergency cesarean delivery in 1,217 patients who received CSE analgesia
with subarachnoid sufentanil (10-15 micrograms) compared with 1,140 patients
who received S/NM for labor analgesia was 1.3% versus 1.4%, respectively. More
importantly, there was no case in which emergency cesarean delivery was
required for acute fetal distress in the absence of obstetric factors during
the 90 minutes following administration of subarachnoid sufentanil. General
anesthesia was required for emergency cesarean delivery in only one patient
(6%) in the CSE group, as against eight patients (50%) in the S/NM group who
required general anesthesia for emergency cesarean section (P < .05). This
experience indicates that patients who receive CSE analgesia do not have a
higher incidence of emergency cesarean delivery than patients who have S/NM for
labor analgesia. Emergency cesarean section for fetal distress within 90
minutes of the administration of intrathecal sufentanil only occurred in
association with obstetric factors. However, caution should be exercised in
extrapolating these results to other practice settings, particularly high-risk
referral centers.
Forty-five patients scheduled for intra-abdominal gynecological surgeries,
ranging in age from 30 to 60 years, were anesthetized with combined
spinal-epidural (CSE) method using combined spinal-epidural needles inserted at
the L2-3 interspace (87). Ten minutes after intrathecal administration of 0.4%
isobaric tetracaine solution (2.5 ml) the upper level of analgesia was examined
by pin prick method and the patients were divided into the group A (N = 7;
anesthetic level > or = Th7), B (N = 7; Th8-10) and C (N = 31; Th11-L1)
according to their anesthetic levels. Target anesthetic level (Th4-7) was
obtained in group B by peridural administration of 2% mepivacaine in a dose of
5 ml and the surgery was performed. However, in group C, mepivacaine 7 ml was
insufficient to obtain the target anesthetic level and additional mepivacaine
was necessary for the surgery. In group A, no mepivacaine was used in the first
hour of the surgery. In all patients, except one in group C, in whom general
anesthesia was used after insufficient segmental analgesia, anesthesia was
maintained by the CSE technique. It was concluded that adequate anesthetic
level for the intra-abdominal surgery can be obtained by intrathecal isobaric
tetracaine administration combined with peridural mepivacaine of a dose
calculated according to the anesthetic level ten minutes after the spinal
block.
Regional anesthesia for abdominal hysterectomy is commonly combined with heavy
sedation or light general anesthesia in order to avoid the occurrence of
visceral pain. Clinical experience has indicated that this pain can be
controlled using regional anesthesia techniques alone. In an effort to find the
optimal technique, Mihic and Abram (88) randomly assigned 200 ASA and I and II
patients who requested regional anesthesia for abdominal hysterectomy (with or
without elective appendicectomy) to one of five groups: 1) subarachnoid
bupivacaine; 2) subarachnoid bupivacaine plus intravenous midazolam and
buprenorphine; 3) epidural bupivacaine; 4) epidural bupivacaine plus epidural
morphine; 5) subarachnoid bupivacaine plus epidural morphine and bupivacaine.
The last combination provided by far the best analgesia. Only two of 40
patients complained of slight discomfort, and this was easily controlled.
Success rates correlated also with the height of the blockade. It was concluded
that the combination of subarachnoid bupivacaine plus epidural morphine and
bupivacaine represents an effective and reliable technique for abdominal
hysterectomy with or without elective appendicectomy.
A prospective study was carried out to compare the qualities of spinal block
with those of combined spinal-epidural anesthesia (CSEA)(89). It included 63
patients, ranked ASA 1 or 2, aged between 35 and 75 years, scheduled for
gynecological surgery due to last more than 2 hours, and randomly allocated to
two groups. In the first group (n = 34), spinal anesthesia was carried out with
the patients sitting, in the L3-4 interspace, using 15 mg of hyperbaric
bupivacaine with 0.4 mg of adrenaline. In the second group (n = 29), a catheter
was inserted in the epidural space through the L2-3 interspace, and spinal
anesthesia carried out as in the first group, using bupivacaine without
adrenaline. Once the highest level of analgesia had been reached, aliquots of
0.5% plain bupivacaine were injected through the epidural catheter, until
anesthesia of T5 was obtained. In the spinal group, general anesthesia was
required in 3 cases, as anesthesia only reached the T12 level in 2 cases, and
as surgery lasted longer than the spinal in the third one. In the CSEA group,
excellent analgesia was obtained in all patients. Sensory blockade lasted 308
+/- 48 min at the T12 level, versus 162 +/- 51 min in the spinal group (p <
0.025), and 361 +/- 51 min at the L2 level, versus 210 < 44 min in the other
group (p < 0.025). "Topping up" was possible with the epidural
catheter only, thus raising the level of sensory blockade, making it deeper,
and increasing its duration. It avoids the use of general anesthesia in case of
failed spinal blockade.
Dyer et al. (90) studied the neonatal outcome after spinal versus general
anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring
fetal heart trace. This study examined both markers of neonatal hypoxia and
maternal hemodynamics. Seventy patients were randomized to general (n = 35) or
spinal anesthesia (n = 35). The general anesthesia group received thiopentone,
magnesium sulfate, and suxamethonium intravenously before intubation, followed
by 50% nitrous oxide in oxygen, 0.75-1.5% isoflurane, and morphine after
delivery. The target end-tidal partial pressure of carbon dioxide (Pco2) was
30-34 mmHg. The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine
plus 10 microg fentanyl at the L3-L4 interspace. Heart rate and blood pressure
were measured at specific time points. Hypotension was treated with ephedrine.
Maternal arterial and neonatal umbilical arterial blood gas samples were taken
at delivery. Resuscitation requirements were recorded. In both groups,
hemodynamic measures remained within acceptable limits. Spinal anesthesia
patients required more ephedrine (13.7 vs. 2.7 mg). Maternal Paco2 was lower in
the spinal group (28.9 vs. 32.4 mmHg). One-minute Apgar scores were lower after
general anesthesia. Base deficit was greater (7.13 vs. 4.68 mEq/l) and neonatal
umbilical arterial pH was lower (7.20 vs. 7.23) after spinal anesthesia. Post
hoc analysis showed that if maternal diastolic blood pressure on admission was
greater than 110 mmHg, neonatal umbilical arterial base deficit was greater after
spinal anesthesia. There was no difference in the number of patients with Apgar
scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in
the requirements for resuscitation. In preeclamptic patients with a
nonreassuring fetal heart trace, spinal anesthesia for cesarean delivery was
associated with a greater mean neonatal umbilical arterial base deficit and a
lower median umbilical arterial pH. The clinical significance remains to be
established. Maternal hemodynamics were similar and acceptable with either
anesthetic technique.
Most anesthetic and analgesic agents in current use
traverse the placental barrier in varying degrees, but are well tolerated by
the fetus if judiciously administered. For labor analgesia, many options are
available. Systemic administration of opioids and sedatives is one such option.
Repeated maternal administration of opioids such as pethidine (meperidine)
results in significant fetal exposure and neonatal respiratory depression.
Patient-controlled analgesia with synthetic opioids such as fentanyl,
alfentanil, and the new ultra-short-acting remifentanil may be used for labor
analgesia in selected patients.Other options for labor analgesia include
epidural and combined spinal-epidural techniques. With such techniques,
neonatal exposure to opioids and sedatives can be minimized or totally avoided.
While limiting the fetal exposure to the harmful effects of depressant drugs,
epidural anesthesia and/or analgesia improves placental perfusion and
oxygenation of the fetus, which is beneficial, especially in conditions such as
pregnancy-induced hypertension. Regional blocks are also administered for the
majority of cesarean deliveries because of the overwhelming and unequivocal
evidence of maternal and fetal safety compared with general anesthesia for this
indication. However, in some instances, administration of general anesthesia is
unavoidable. Neonatal respiratory depression with low Apgar scores, and
umbilical arterial and venous pH associated with general anesthesia, is often
transient. A properly administered anesthetic, whether regional or general, has
no significant adverse fetal or neonatal effects (91).
CSEGA for Abdominal Operations
The choice of anesthesia for groin hernia repair is between
general, regional (epidural or spinal), and local anesthesia. Existing data
from large consecutive patient series and randomized studies have shown local
anesthesia to be the method of choice because it can be performed by the
surgeon, does not necessarily require an attending anesthesiologist, translates
into the shortest recovery (bypassing the postanesthesia care unit), has the
lowest cost, and has the lowest postoperative morbidity regarding risk of
urinary retention. Spinal anesthesia has no documented benefits for this small
operation and should be avoided owing to the risk of rare neurologic side
effects and the high risk of urinary retention. General anesthesia with
short-acting agents may be a valid alternative when combined with local
infiltration anesthesia, although an anesthesiologist is required. Despite
sufficient scientific data to support the choice of anesthesia, large
epidemiologic and nationwide information from databases show an undesirable
high (about 10-20%) use of spinal anesthesia and low (about 10%) use of local
infiltration anesthesia. Surgeons and anesthesiologists should therefore adjust
their anesthesia practices to fit the available scientific evidence (92).
Although endoscopic totally extraperitoneal inguinal
hernioplasty (TEP) confers superior early outcomes compared to those of open
repair, the requirement of general anesthesia has been held as an argument
against the application of TEP by opponents of laparoscopic surgery. To date,
the literature on TEP performed under spinal anesthesia remains scarce. The
present study reports an early experience performing TEP under spinal
anesthesia in selected patients who were medically unfit for general anesthesia
(93). Between March 2003 and March 2004, 6 male patients underwent attempted
TEP under spinal anesthesia. Selection criteria for the procedure included
reducibility of the inguinal hernia and concomitant medical conditions
precluding general aesthesia, such as impaired lung function. All patients were
conscious and able to communicate verbally during the operation. TEP was
successfully completed in 4 patients, with a mean operative time of 33 minutes.
All 4 patients were asymptomatic and experienced no pain throughout the
procedure. Conversion to open repair was required in 2 patients because of
uncooperative movement in one, and inadequate neural blockade by spinal
anesthesia in the other. Intraoperative cardiorespiratory parameters were
stable in all patients. Postoperative urinary retention occurred in 1 patient.
The mean length of follow-up exceeded 3 months, and no seroma or recurrence was
detected clinically. Successful performance of TEP under spinal anesthesia
requires the combined efforts of an experienced anesthesiologist, a skilled
surgeon, and a cooperative patient. TEP under spinal anesthesia may have a role
in selected patients who are medically unfit for general anesthesia but are
otherwise suitable for TEP.
Preincisional ilioinguinal and iliohypogastric nerve block (IINB) reduces
postoperative analgesics after inguinal herniorrhaphy. The effect of an IINB on
postoperative pain and discharge profile was therefore studied in day-surgery
patients undergoing inguinal herniorrhaphy with general or spinal anesthesia
(94). Seventy ASA I-II adult patients scheduled for inguinal herniorrhaphy
received an IINB before the surgical incision with 15 ml of 0.5% bupivacaine.
In a randomized fashion half of them received general anaesthesia with
spontaneous breathing via a laryngeal mask (GA-group) and the other half
received spinal anesthesia with 5 mg of bupivacaine diluted with sterile water
to 2.5-ml volume (SPIN-group). In the postanaesthesia care unit (PACU), pain
was assessed on a scale from 0 to 10 (VAS) and ketorolac 30 mg i.v. (VAS <
5), or fentanyl 0.05 mg i.v. (VAS > or = 5) was administered as scheduled.
In the day surgery unit and at home the analgesic was a tablet of ibuprofen 200
mg + codeine 30 mg (VAS > or = 3). Patients in the SPIN-group reported lower
postoperative pain scores at 30, 60 min (P < 0.0001) and 120 min (P < 0.05)
after surgery, and longer time to first analgesic use (P < 0.0001). Patients
in the GA-group had a shorter time to discharge without voiding (P < 0.001)
and with voiding (P < 0.05). After discharge, there were no significant
differences between the groups regarding pain scores at rest and at walking, or
the doses of analgesic. Adverse events were rare in both groups. Only a
relatively short immediate analgesic benefit could be demonstrated by a
combination of IINB with spinal anaesthesia compared with IINB combined with
general anaesthesia. The use of general anaesthesia facilitated an earlier
postoperative discharge than spinal anesthesia.
Zoric et al. (95) have been routinely
practising their technique of CSEGA in big abdominal and thoraco-abdominal
surgery, since 1997. Their study (95) is a retrospective analysis of the
technique and clinical observations, during 4.5 years, which include 293
patients. They performed combined spinal-epidural anesthesia (CSE) in one or
two interspinal spaces, depending on the type of surgery, but always before
induction of general anesthesia (GA). For preemptive and intraoperative
analgesia they used 0.25% plain bupivacaine (B), both for spinal (SA) and
epidural (ED) blockade. The most important detail in their technique is analgesic
solution (AS) which contain B 4.5 mg, fentanyl (Fe) 50 mcg and morphine
hydrochloride (Mo) 0.2 mg, in total volume of 3 ml, in SA. After the ED test
dose with 2% lidocaine 60 mg (3 ml), before the induction of GA, they inject
more 10 ml B, but intraoperative analgesia is almost performed with B 3 to 5 ml
in intermittent bolus doses. This ED bolus dose is particularly important,
partly to sufficiently cephalic migration of the SA somatosensory block, as
well as for intraoperative analgesia. For very light GA only artificial
ventilation with 66% N2O in O2 and muscle relaxation with pancuronium is
needed. Co analgesia with intravenous Fe, was exceptionally seldom needed,
except for induction. Intraoperative drugs consumption was very small. With
adequate liquid compensation, this technique achieve exceptionally
intraoperative hemodynamic stability in patients, despite long and big
operations. Postoperative analgesia is supplied by SA for the first 24 hours,
but for the next 72 hours it is performed with intermittent ED bolus doses of
0.12% B with 2 mg Mo in total volume of 15 ml and 10 ml, depending on the
epidural catheter position in lumbar or
thoracic part of spine. The breakthrough of postoperative pain was between 20%
to 34%, which was suppressed with metamisol. According to the verbal rating
scale (VRS < 1) 90% patients were satisfied with this analgesia, which gave
possibilities to mobilization and rehabilitation even in the first postoperative day. All clinical
signs showed that thanks to inhibition
of spinal and supraspinal sensitization, all principles of the preemptive
analgesia (PA), inhibition of neuro-hormonal stress reaction is met and
postoperative outcome is improved and satisfied.
Type and technique of anesthesia have an important effect on peri-operative surgical course. Malenkovic et al. (96) analysed the advantages of combined spinal, epidural and general anesthesia (CSEGA) versus general anesthesia (GA) in abdominal surgery according to: 1. Operative course (haemodynamic stability of patients, quality of analgesia, undesirables effects), 2. Postoperative course (quality of analgesia, unfavourable effects, temporary abode of patients in intensive care). Using prospective randomized double blind controlled study, they evaluated two groups of patients whom the same type of abdominal surgical intervention was planned and the only difference was the type of technique of anesthesia. First group of patients (n = 34), was treated with CSEGA and the second group of patients (n = 33), was treated only with standard (GA). Both groups had intraoperative and 24-hour-long postoperative continued monitoring of blood pressure, central venous pressure, and diuresis. In the 24 hours postoperative period, the following parameters were analyzed: vigilance conditions, motor block level, pain intensity in rest and movement, necessity for a complementary analgesia, side effects and final subjective effect of analgesia. There was important difference in waking up the patients after a general anesthesia. In the first group this period was shorter. In the first 24 hours, patients from the first group didn't get any s