Continuous Spinal Anesthesia Group Research Articles

Transüretral Cerrahi Vakalarinda, Sürekli Spinal ve Tek Doz Spinal Anestezi Tekniklerinin Hemodinami, Duyusal ve Motor Blok Seviyesi Üzerine Etkilerinin Karşilaştirilmasi

Aim: In this study, it was aimed to compare in patients undergoing transurethral resection surgery: 1- The effectiveness of single-dose and continuous spinal anesthesia techniques, 2- Hemodynamic changes, sensory-motor block levels and durations, anesthetic drug doses and side effects. Method: Forty American Society of Anesthesiology I–III patients in the age group of 40–75 years who were scheduled for transurethral surgery were randomly divided into two groups: single dose spinal anesthesia (Group 1) (n = 20) and continuous spinal anesthesia (Group 2) (n = 20). The patients' hemodynamic data, analgesia status and motor block levels were evaluated. Results: With regard to the hemodynamic parameters, the mean values of systolic–diastolic blood pressure and heart rate were found to be significantly lower in the single dose spinal anesthesia group (Group 1) than in the continuous spinal anesthesia group (p < 0.05). In terms of sensory and motor block levels, the maximum block level was T9 in the continuous spinal anesthesia group, while it was T8 in the single dose spinal anesthesia group (p < 0.05). Upon reaching T10, two-segment regression and sensory and motor block termination times were found to be significantly lower in the continuous spinal anesthesia group when compared to the single dose spinal anesthesia group (p < 0.05). There was no difference between the two groups in terms of Bromage score values (p > 0.05). In the continuous spinal anesthesia group, the mean dose and volume of the local anesthetic required to achieve analgesia in the T10 dermatome were found to be 7.12 ± 1.46 ml and 1.4 ± 0.29, respectively. Furthermore, the amount of fluid administered intraoperatively was found to be significantly lower in the continuous spinal anesthesia group than in the single dose group (p < 0.05). Conclusion: With the continuous spinal anesthesia method, it can be titrated and by using lower doses of local anesthetic, a level of sensory-motor blockade close to the single-dose spinal anesthesia method and a more stable hemodynamics can be achieved.

COMPARATIVE STUDY BETWEEN CONTINUOUS SPINAL ANESTHESIA AND COMBINED SPINAL EPIDURAL ANESTHESIA IN KNEE ARTHROPLASTY

Background: Continuous spinal anesthesia (CSA) and combined spinal epidural anesthesia (CSE) are safe and reliable anesthesia methods in knee arthroplasties. Objectives: This study aimed at comparing the efficacy and hemodynamic changes of CSA technique versus single interspace CSE technique in knee arthroplasties intra & postoperatively, and the potential adverse effects for both techniques. Patients and Methods: After approval of Institutional ethical committee and obtaining written informed consents, forty patients aged 18 to 55 years of both sexes and American Society of Anesthesiologists (ASA) class I, II, were scheduled for elective knee arthroplasties. All Patients were assigned randomly by using a computerized program to one of the two equal groups: Group CSA: Patients undergoing elective knee arthroplasty received continuous spinal anesthesia. Group CSE: Patients undergoing elective knee arthroplasty received single interspace combined spinal epidural anesthesia. The following parameters were assessed: Hemodynamics: including heart rate and systolic (SBP) and diastolic arterial blood pressures (DBP), and percentage of oxygen saturation (SpO2) were obtained then recorded at 5th, 15th, 30 minutes, and at 1st, 2nd, 4th hours intra-operatively till the end of surgery. Postoperatively, they were obtained at 0, 1 hour and every four hours for first 24 hours. Anesthetic complications: PDPH, urine retention, and Postoperative nausea and vomiting (PONV). Postoperative pain was evaluated at rest using a 10-cm Visual analogue scale (VAS) (0 cm=no pain; 10 cm=worst pain possible) and pain scores were recorded at 30 min and 1st, 2nd, 4th, 6th, 12th and 24th hours post-operatively. This prospective randomized clinical trial study was conducted at Al- Azhar University Hospitals (Al- Hussein and Bab-Al-Shaarya) at the orthopedics operating theatre from March 2019 till September 2019. Results: No significant difference between the two groups regarding the length of surgery, hypoxia, post-operative nausea and vomiting (PONV), post-operative pain score. The application time of the anesthetic technique was significantly shorter in the CSA group than CSE group. The heart rate was significantly higher in the CSE group at 1st minutes while SBP and DBP were significantly lower in the CSE group at 1st minutes than the CSA group. Post dural puncture headache (PDPH), and urine retention was significantly higher in the CSA group than the CSE group. PDPH occurred in 35% of the CSA group compared to 10 %. Urine retention occurred in 25% of the CSA group compared to 5% of the CSE group. The total dose of bupivacaine (0.5%) collectively given intra-operatively and morphine postoperatively were significantly lower in the CSA group than the CSE group. Conclusion: The study revealed that CSA and CSE were both effective and safe techniques for knee arthroplasties with superiority of CSA in hemodynamic stability intraoperative at 1st minutes of surgery. CSA offered many advantages over epidural anesthesia by using smaller anesthetic dose with rapid onset and recovery of motor and sensory blockade with better cardiovascular stability than CSE.

COMPARATIVE STUDY BETWEEN CONTINUOUS SPINAL ANESTHESIA AND COMBINED SPINAL EPIDURAL ANESTHESIA IN KNEE ARTHROPLASTY

Background: Continuous spinal anesthesia (CSA) and combined spinal epidural anesthesia (CSE) are safe and reliable anesthesia methods in knee arthroplasties. Objectives: This study aimed at comparing the efficacy and hemodynamic changes of CSA technique versus single interspace CSE technique in knee arthroplasties intra & postoperatively, and the potential adverse effects for both techniques. Patients and Methods: After approval of Institutional ethical committee and obtaining written informed consents, forty patients aged 18 to 55 years of both sexes and American Society of Anesthesiologists (ASA) class I, II, were scheduled for elective knee arthroplasties. All Patients were assigned randomly by using a computerized program to one of the two equal groups: Group CSA: Patients undergoing elective knee arthroplasty received continuous spinal anesthesia. Group CSE: Patients undergoing elective knee arthroplasty received single interspace combined spinal epidural anesthesia. The following parameters were assessed: Hemodynamics: including heart rate and systolic (SBP) and diastolic arterial blood pressures (DBP), and percentage of oxygen saturation (SpO2) were obtained then recorded at 5th, 15th, 30 minutes, and at 1st, 2nd, 4th hours intra-operatively till the end of surgery. Postoperatively, they were obtained at 0, 1 hour and every four hours for first 24 hours. Anesthetic complications: PDPH, urine retention, and Postoperative nausea and vomiting (PONV). Postoperative pain was evaluated at rest using a 10-cm Visual analogue scale (VAS) (0 cm=no pain; 10 cm=worst pain possible) and pain scores were recorded at 30 min and 1st, 2nd, 4th, 6th, 12th and 24th hours post-operatively. This prospective randomized clinical trial study was conducted at Al- Azhar University Hospitals (Al- Hussein and Bab-Al-Shaarya) at the orthopedics operating theatre from March 2019 till September 2019. Results: No significant difference between the two groups regarding the length of surgery, hypoxia, post-operative nausea and vomiting (PONV), post-operative pain score. The application time of the anesthetic technique was significantly shorter in the CSA group than CSE group. The heart rate was significantly higher in the CSE group at 1st minutes while SBP and DBP were significantly lower in the CSE group at 1st minutes than the CSA group. Post dural puncture headache (PDPH), and urine retention was significantly higher in the CSA group than the CSE group. PDPH occurred in 35% of the CSA group compared to 10 %. Urine retention occurred in 25% of the CSA group compared to 5% of the CSE group. The total dose of bupivacaine (0.5%) collectively given intra-operatively and morphine postoperatively were significantly lower in the CSA group than the CSE group. Conclusion: The study revealed that CSA and CSE were both effective and safe techniques for knee arthroplasties with superiority of CSA in hemodynamic stability intraoperative at 1st minutes of surgery. CSA offered many advantages over epidural anesthesia by using smaller anesthetic dose with rapid onset and recovery of motor and sensory blockade with better cardiovascular stability than CSE.

Continuous spinal versus continuous thoracic epidural anesthesia for major abdominal surgery in patients with chronic obstructive pulmonary disease

Background Most anesthetists preferred general anesthesia for major abdominal surgery which was not devoid of complications in cases with chronic obstructive pulmonary disease (COPD). Recently, the use of neuraxial anesthesia is supported to avoid or decrease these complications. This study aimed at the description, evaluation, and comparison between the use of continuous spinal anesthesia (CSA) and continuous thoracic epidural anesthesia (CTEA) as a sole anesthesia for major abdominal surgeries in cases with COPD. Patients and methods Sixty patients of both sexes aged 40–75 years with American Society of Anesthesiologists physical status classes II and III complaining of COPD scheduled for various elective major abdominal operations were included. According to the neuraxial block type, the patients were randomly assigned into two equal groups with 30 patients in each. The first group (CSA group) received continuous lumbar spinal anesthesia and the second group (CTEA group) received continuous thoracic epidural anesthesia. The data recorded included patients’ demographic data, characteristics of the used neuraxial blockade, hemodynamic changes, changes in pulmonary functions, incidence of the various side effects, and postoperative pain severity. Results The final statistical analysis included 55 patients where five patients were excluded from the study. Although there were no statistically significant differences between both groups regarding demographics, hemodynamics, changes in pulmonary functions, side effects, surgeon, and patients’ satisfactions, and postoperative visual analog scale. The CSA group has faster block onset with less local anesthetic dose compared with the CTEA group (P<0.001). Also, there were statistically significant decrease in peak expiratory flow rate, forced expiratory volume in 1 s, and forced expiratory volume in 1 s/forced vital capacity at 1, 2, and 6 h postoperatively compared with the preoperative baseline values in both groups (P<0.05). Hypotension was significantly more frequent in the CTEA group than in the CSA group (P=0.047). Conclusion Although both CSA and CTEA can be used for anesthesia and for postoperative analgesia in major abdominal surgery in COPD patients, the CSA was easier, safer, had faster onset, gave more predictable block, with less hemodynamic instability, and less technical failure compared with CTEA. The preoperative optimization of the lung functions, intraoperative close observation, and postoperative neuraxial analgesia with chest physiotherapy improved the outcome.

Randomized comparison of continuous spinal anesthesia versus continuous epidural anesthesia in high-risk elderly patients undergoing major orthopedic lower limb surgeries

Background Continuous spinal anesthesia (CSA) is a reliable method for providing effective anesthesia and offers considerable advantages over ‘single-shot’ spinal or epidural anesthesia, as it provides the performance of well-controlled anesthesia using small doses of local anesthetics and a definite end point with less failure rate. Materials and methods A total of 100 patients of American Society of Anesthesiology grades III–IV were scheduled for elective major orthopedic lower limb surgeries. They were divided into two groups: one received CSA using spinocath set, and the other group received continuous epidural anesthesia (CEA). The doses of local anesthetic used, hemodynamic variables, a degree of technical difficulties, and the incidence of complications were recorded. Results The performance time was significantly shorter in the CEA group. The total dose of bupivacaine and number of top-up doses were significantly smaller in the CSA group than in the CEA group. The onset of sensory blockade level and motor blockade was significantly longer with CEA. Regarding the mean arterial pressure, there was a statistically significant difference between the two groups. The number of patients treated for hypotension and total dose of ephedrine was more in CEA group, but there was no statistical difference between the two groups. No major complications were observed in any patient in both groups. Conclusion We conclude that CSA is an effective and safe choice with hemodynamic stability and negligible failure rate, for prolonged procedures in elderly high-risk patients and in those with possible difficulties in administration of general anesthesia.

Continuous spinal anesthesia versus single small dose bupivacaine–fentanyl spinal anesthesia in high risk elderly patients: A randomized controlled trial

BackgroundGreater numbers of patients are presenting for surgery with aging-related, pre-existing conditions that place them at greater risk of an adverse outcome. Hemodynamic instability due to high sympathetic block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients. In this study we aim to compare the hemodynamic stability and the incidence of hypotension in continuous spinal anesthesia (CSA) versus single low dose spinal anesthesia (SD) in elderly high risk patients.MethodsThis prospective randomized blinded study was carried on 34 ASA III & IV elderly patients aged >75 years undergoing orthopedic lower limb surgery. The patients were randomly assigned to one of the study groups. Group CSA received intermittent dosing of local anesthetic solution via an intrathecal catheter using 0.5 ml of 0.5% isobaric bupivacaine increments and 0.5 ml of fentanyl (25 μg) while group SD single dose of 1.5 ml of 0.5% isobaric bupivacaine and 0.5 ml of fentanyl (25 μg). The study groups were compared regarding hemodynamic stability, incidence of hypotension and total ephedrine consumption.ResultsIncidence of severe hypotension was significant. 52.9% of patients in SD group experienced an episode of severe hypotension versus none of them in CSA group (p 0.033∗). Total dose of fluids infused was significantly more in the SD group. The use of ephedrine was significantly more in SD group.ConclusionCSA provided fewer episodes of hypotension and no severe hypotension versus SD 7.5 mg bupivacaine. CSA offers the added advantage of the ability to titrate dose of local anesthetic as needed while maintaining hemodynamic stability.

Continuous spinal anaesthesia versus ultrasound-guided combined psoas compartment-sciatic nerve block for hip replacement surgery in elderly high-risk patients: a prospective randomised study.

BackgroundOur aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery.MethodsSeventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 μgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T12 within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T12 level of the sensory block was achieved.ResultsThe PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5th, 10th and 20th minutes of surgery compared to the CSA group (P =0.038, P =0.029, P =0.012, P =0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012).ConclusionsCSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.

The comparison of levobupivacaine in continuous or single dose spinal anesthesia for transurethral resection of prostate surgery

BackgroundThe aim of the study is to compare the efficacy of levobupivacaine induced continuous spinal anesthesia (CSA) versus single dose spinal anesthesia (SDSA) in patients who are planned to undergo transurethral prostate resection. MethodsSixty years or older, ASA I–II or III, 50 patients were included in the study. 12.5mg 0.5% levobupivacaine were administered intrathecally in SDSA group. In CSA group, initially 2mL of 0.25% levobupivacaine were administered through spinal catheter. In order to achieve sensory block level at T10 dermatome, additional 1mL of 0.25% levobupivacaine were administered through the catheter in every 10min. Hemodynamic parameters and block characteristics were recorded. Preoperative and postoperative blood samples of the patients were drawn to determine plasma cortisone and plasma epinephrine levels. ResultsCSA technique provided better hemodynamic stability compared to SDSA technique particularly 90min after intrathecal administration. The rise in sensory block level was rapid and the time to reach surgical anesthesia was shorter in SDSA group. Motor block developed faster in SDSA group. In CSA group, similar anesthesia level was achieved by using lower levobupivacaine dose and which was related to faster recovery. Although, both techniques were effective in preventing surgical stress respond, postoperative cortisone levels were suppressed more in SDSA group. ConclusionCSA technique with 0.25% levobupivacaine can be used as a regional anesthesia method for elderly patients planned to have TUR-P operation.

Hemodynamic Profile of Target-Controlled Spinal Anesthesia Compared With 2 Target-Controlled General Anesthesia Techniques in Elderly Patients With Cardiac Comorbidities

The impact of anesthesia techniques in patients experiencing hip fracture is controversial. This study compares the effects on blood pressure of 3 anesthesia techniques that are considered safe for the elderly. Forty-five patients older than 75 years, with American Society of Anesthesiologists physical status III or IV, with cardiac comorbidities, and undergoing surgery for hip fracture, were randomized to receive continuous spinal anesthesia (CSA), propofol target-controlled infusion (TCI), or sevoflurane (SEVO). In CSA patients, a T10 metameric level target was achieved by titration of 2.5 mg of bupivacaine boluses. In patients on TCI and SEVO, a bispectral value target of around 50 guided the concentration of propofol or sevoflurane. Analgesia in the TCI and SEVO groups was provided with remifentanil. Hypotension was defined as a 30% decrease in mean arterial pressure and was treated with an intravenous bolus of ephedrine. The number of hypotension episodes was lower in the CSA group: 0 (range, 0-6) versus 11.5 (range, 1-25) in the TCI group and 10 (range, 1-23) in the SEVO group (P < 0.001). Both TCI and SEVO patients needed more ephedrine compared with CSA patients (30.5 [15.5], 26 [23], and 1.5 [2.5] mg, respectively, P < 0.001). The maximal decrease in mean arterial pressure was lower in the CSA group (26% [17%]) compared with that in the TCI group (47% [8%]) and the SEVO group (46% [12%]; P < 0.001). In elderly patients, spinal anesthesia using titrated doses of bupivacaine provided better blood pressure stability than propofol or sevoflurane anesthesia.

Hemodynamic effects of continuous spinal anesthesia with ropivacaine in aged patients

Objective To compare the hemodynamic effects of continuous spinal anesthesia (CSA) and small does single injection spinal anesthesia (SA) in 75 years or older patients. Methods In a prospective study, 40 American Society of Anesthesiologists Ⅱ-Ⅲ patients (aged 75 yr or older), undergoing elective lower extremity surgery were randomLy assigned to either group CSA or group SA (n=20). Group CSA received a starting dose of 5rag of 5% hyperbaric ropicaine, followed after 15 min by reinjecion of 2.5 mg every 5 rain until a T_(12) level sensory block was reached, and SA patients received 10 mg of 5% hyperbaric ropicaine. Results There was no difference between two groups in the age, sex, main complications, fluid infusion and blood loss.Using univariate analysis, we found no differences between the groups in regards to MAP and HR from the beginning of anesthesia to one hour after anesthesia. In the CSA group, however, 2 patients experienced at least one episode of hypotention, while 8 patients in the SA group(P<0.05). In the CSA group, (5.0±0.0) mg ephedrine was injected, while(10.0±2.7) mg in the SA group(P<0.05). In the CSA group, (7.9±0.9) mg ropicaine was required, while 10 mg in the SA group (P<0.05). Conclusion In aged patients undergoing lower extremity surgery, CSA provides fewer episodes of hypotension and fewer ephedrine usage compared with SA. Key words: Hemodynamics;  Continuous spinal anesthesia;  Elderly patients;  Ropivaeaine

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 +/- 2 mg of ephedrine was injected versus 11 +/- 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.5-10) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

Anaesthetic and haemodynamic effects of continuous spinal versus continuous epidural anaesthesia with prilocaine

Background and objective: To compare, using prilocaine, the effects of continuous spinal anaesthesia (CSA) and continuous epidural anaesthesia (CEA) on haemodynamic stability as well as the quality of anaesthesia and recovery in patients undergoing transurethral resection of the prostate gland. Methods: Thirty patients (>60 yr) were randomized into two groups. Prilocaine, 2% 40 mg, was given to patients in the CSA group, and prilocaine 1% 150 mg was given to patients in the CEA group. Incremental doses were given if the level of sensory block was lower than T10 or if needed during surgery. Results: There was a significant decrease in mean arterial pressure in Group CEA compared with Group CSA (P < 0.01). The decrease in heart rate in Group CSA occurred 10 min after the first local anaesthetic administration and continued through the operation (P < 0.05). The level of sensory anaesthesia was similar in both groups. The times to reach the level of T10 and the upper level of sensory blockade (Tmax) were 18.0 ± 4.7 and 25.3 ± 7.0 min in Groups CSA and CEA, respectively, and were significantly longer in Group CEA. The duration of anaesthesia was 76.8 ± 4 min and was shorter in Group CSA (P < 0.01). Conclusions: Spinal or epidural anaesthesia administered continuously was reliable in elderly patients undergoing transurethral resection of the prostate. Continuous spinal anaesthesia had a more rapid onset of action, produced more effective sensory and motor blockade and had a shorter recovery period. Prilocaine appeared to be a safe local anaesthetic for use with either continuous spinal anaesthesia or continuous epidural anaesthesia.

Continuous spinal anaesthesia or continuous epidural anaesthesia for post-operative pain control after hip replacement?

Both continuous spinal anaesthesia and continuous epidural anaesthesia are supposed to provide adequate post-operative pain relief. The purpose of this randomized, prospective study was to compare the quality of analgesia, occurrence of side effects and patient satisfaction between spinal and epidural administration of bupivacaine during the first post-operative 72 h. One hundred and two patients scheduled for hip arthroplasty were randomly assigned to one of two groups: Group 1 received continuous spinal anaesthesia for intra-operative and post-operative management, Group 2 received continuous epidural anaesthesia. Immediately after surgery, the continuous spinal anaesthesia-group received a 1-mL bolus (bupivacaine 0.25%), followed by a continuous infusion of 10 mL over 24 h. The continuous epidural anaesthesia-group received a 10-mL bolus (bupivacaine 0.25%), followed by 2 mL h-1. The level of pain was gauged from a verbal rating score and from a visual analogue scale; the degree of motor blockade was recorded using the Bromage score. In the continuous spinal anaesthesia-group 90.2% reported complete analgesia on the verbal rating scale, but only 21.6% of the continuous epidural anaesthesia-group did. The visual analogue scale scores given by the continuous spinal anaesthesia-group were significantly lower than those of the continuous epidural anaesthesia-group. The percentage of patients with a motor block was significantly higher in the continuous spinal anaesthesia-group on the day of surgery and at the first post-operative day. During the first 24 h, nausea and vomiting occurred more often in the continuous epidural anaesthesia-group. The satisfaction was considered excellent in 92.2% of the continuous spinal anaesthesia-group and in 70.6% of the continuous epidural anaesthesia-group. It is concluded that continuous spinal anaesthesia and continuous epidural anaesthesia are effective and safe for post-operative pain relief after hip replacement. Compared with continuous epidural anaesthesia, continuous spinal anaesthesia provides faster onset of pain relief, ensures better analgesia and results in more satisfied patients.

Continuous spinal anaesthesia or continuous epidural anaesthesia for post-operative pain control after hip replacement?

Both continuous spinal anaesthesia and continuous epidural anaesthesia are supposed to provide adequate post-operative pain relief. The purpose of this randomized, prospective study was to compare the quality of analgesia, occurence of side effects and patient satisfaction between spinal and epidural administration of bupivacaine during the first post-operative 72 h. One hundred and two patients scheduled for hip arthroplasty were randomly assigned to one of two groups: Group 1 received continuous spinal anaesthesia for intra-operative and post-operative management, Group 2 received continuous epidural anaesthesia. Immediately after surgery, the continuous spinal anaesthesia-group received a 1-mL bolus (bupivacaine 0.25%), followed by a continuous infusion of 10 mL over 24 h. The continuous epidural anaesthesia-group received a 10-mL bolus (bupivacaine 0.25%), followed by 2 mL h−1. The level of pain was gauged from a verbal rating score and from a visual analogue scale; the degree of motor blockade was recorded using the Bromage score. In the continuous spinal anaesthesia-group 90.2% reported complete analgesia on the verbal rating scale, but only 21.6% of the continous epidural anaesthesia-group did. The visual analogue scale scores given by the continuous spinal anaesthesia-group were significantly lower than those of the continuous epidural anaesthesia-group. The percentage of patients with a motor block was significantly higher in the continuous spinal anaesthesia-group on the day of surgery and at the first post-operative day. During the first 24 h, nausea and vomiting occured more often in the continuous epidural anaesthesia-group. The satisfaction was considered excellent in 92.2% of the continuous spinal anaesthesia-group and in 70.6% of the continuous epidural anaesthesia-group. It is concluded that continuous spinal anaesthesia and continuous epidural anaesthesia are effective and safe for post-operative pain relief after hip replacement. Compared with continuous epidural anaesthesia, continuous spinal anaesthesia provides faster onset of pain relief, ensures better analgesia and results in more satisfied patients.

Hemodynamic Effects of Spinal Anesthesia in the Elderly

Sixty elderly patients (> 70 yr old) undergoing surgery for hip fracture were prospectively studied in order to compare hemodynamic tolerance of titrated doses of hyperbaric bupivacaine using continuous spinal anesthesia (CSA) versus single-dose spinal anesthesia (SDSA). Patients were randomized into two groups (CSA group: n = 30; SDSA group: n = 30). The SDSA patients received 10-15 mg of 0.5% hyperbaric bupivacaine (based on age and height), and the CSA patients received a starting dose of 5 mg of 0.5% hyperbaric bupivacaine, followed after 15 min by optional reinjection of 2.5 mg every 5 min until a T10 level sensory block was reached. Onset of anesthesia, noninvasive hemodynamic variables and the need for ephedrine were studied for 4 h after induction of anesthesia. Spinal anesthesia was successful in all patients. Decreases in mean arterial pressure were significantly less frequent and less pronounced in the CSA group (19.9% +/- 1.6% of the baseline value) than in the SDSA group (40.2% +/- 1.9%, P < 0.0001). The mean dose of ephedrine was significantly less in the CSA group (1.8 +/- 0.7 mg, administered to only 37% of patients) than in the SDSA group (19.4 +/- 3.3 mg administered to all patients, P < 0.0001). No late complications related to the spinal anesthesia technique were observed in either group. We concluded that CSA, using small titrated doses of 0.5% hyperbaric bupivacaine, is safe, efficient, and provides better hemodynamic stability than SDSA in elderly patients.

Comparison of continuous spinal anaesthesia using a 32-gauge catheter with anaesthesia using a single-dose 24-gauge atraumatic needle in young patients

One hundred and twenty-eight ASA I-III patients less than 40 yr of age, undergoing orthopaedic or trauma lower limb surgery, were allocated randomly to receive either continuous spinal anaesthesia (CSA) using a 32-gauge polyimide microcatheter with a permanent stylet (Rusch/TFX Medical, Duluth, GA, USA) or single-dose spinal anaesthesia (SDSA) with a 24-gauge x 103-mm Sprotte spinal needle (Pajunk, Germany). Plain bupivacaine (0.5%) was used as the local anaesthetic. The initial doses were 1 ml (5 mg) of CSA and 3 ml (15 mg) of SDSA, while the re-injection doses were 1 ml (5 mg) in the CSA group. SDSA was quicker to perform: mean 4.4 (SD 1.6) min compared with 6.2 (2.6) min for CSA (P < 0.01). Times to onset and surgical anaesthesia were also significantly greater in the CSA group (P < 0.01). The quality of the block was better in the SDSA group (P < 0.05), but was associated with greater haemodynamic instability (P < 0.05). The segmental level of analgesia was significantly lower in the CSA group (median T10 (range T12-T8)) than in the SDSA group (T9 (T11-T5)) (P < 0.05). There were no significant differences in the incidence of postoperative complications, with two mild spinal headaches in both groups. We conclude that CSA using a microcatheter in young patients is difficult to perform and affords no advantages over SDSA with a small gauge atraumatic needle.

Incremental Dosing Versus Single-Dose Spinal Anesthesia and Hemodynamic Stability

We compared the hemodynamic stability after spinal anesthesia with two different dosing regimens in the elderly. Fifty patients, all older than 60 yr and scheduled for elective knee or hip surgery were assigned to two groups. After administration of 10 mL/kg of lactated Ringer's solution (RL) intravenously (i.v.) in the first group, we performed a continuous spinal anesthesia (CSA) by means of a 28-gauge catheter through which repetitive injections of 2.5-5 mg of plain bupivacaine 0.5% were given. In the other group, a single-dose spinal anesthesia (SS) with 20 mg of the same local anesthetic (LA) was carried out. Noninvasive mean arterial pressure (MAP), heart rate, and levels of analgesia were measured. To maintain MAP within 25% of initial value, the patients received additional i.v. fluids (RL) as first measure. When MAP could not be maintained despite hydration, incremental doses of ephedrine were given i.v. Six patients in the CSA group and 17 in the SS group developed a level of anesthesia higher than T6 (P < 0.01). In the SS group more fluid was needed (792 vs 388 ml) than in the CSA group (P < 0.01). Moreover, more patients of the SS group (11 vs 4) required ephedrine (P < 0.05). We conclude that CSA produces reliable and predictable analgesia for lower limb surgery with less need for correction of hemodynamic changes compared to SS.

Einzeitige Spinalanästhesie versus kontinuierliche Spinalanästhesie mit dem CoSPAN™-Katheter

We compared conventional single-shot spinal anaesthesia (SS) with continuous spinal anaesthesia (CS) in a randomised prospective study. Sixty patients undergoing urological surgery received either SS (n = 30) using an atraumatic needle or CS (n = 30) using a CoSPAN catheter. Prior to performing the spinal anesthesia, patients were prehydrated with 250 ml of hydroxyethyl starch 10%. Spinal anaesthesia was performed with the patients in the sitting position at L3-4 interspace. In the CS group CSF was aspirated via the catheter to check its correct position, and initially 0.5 ml of hyperbaric 5% lidocaine were injected. 0.25 ml boli at 5 min intervals were repeated as often as necessary to reach the desired sensory blockade up to the T10 segment. In patients undergoing the single-shot technique 1.5 to 3.5 ml of hyperbaric 0.5% bupivacaine was injected. After performing the block, haemodynamic parameters were assessed for 20 minutes at 2 min intervals, before and thereafter at 5 min intervals. The required time for recovery of motor activity of the legs was assessed postoperatively. The patients were visited on the 1st, 3rd and 5th postoperative day and asked about possible headache. The CoSPAN spinal catheter was easy to handle. CSF could be aspirated via this catheter within 33.1 +/- 7.6 seconds. The desired maximum cephalad spread (T10) was exceeded by a mean of 0.63 +/- 1.3 segments in the CS group and by a mean of 1.4 +/- 2.6 segments in the SS group. In the SS group a mean volume of hyperbaric 0.5% bupivacaine of 2.59 +/- 0.4 ml was used. In the CS group a mean volume of 1.08 +/- 0.4 ml of hyperbaric 5% lidocaine was necessary. In the SS group, mean arterial blood pressure was found to have significantly decreased to lower than the initial value within the first 20 min after injection at each of the 10 determinations. Maximal decrease of mean arterial pressure to 89.3 +/- 7.7% was registered 14 min after injection. In the CS group, only the measurement 14 min after injection of the initial bolus revealed a significant decrease of the mean arterial blood pressure to 94.2% of the initial value. The mean interval elapsed before motor function of the legs returned after the end of surgery was 67.7 +/- 50 min in the SS group and 26.7 +/- 15.4 min in the CS group. None of the 60 patients complained about postspinal headache. Fractionated injection of the local anesthetic via a spinal catheter was more precise in achieving the desired maximum cephalad spread than SS. The CS group revealed a significantly more stable blood pressure than the SS group. The use of a short-acting local anesthetic for CS provided an earlier postoperative return of motor function of the legs. Postspinal headache appears not to be a clinically relevant problem when 28-gauge spinal catheters are used.

Continuous Spinal Anesthesia with a Microcatheter and Low-Dose Bupivacaine Decreases the Hemodynamic Effects of Centroneuraxis Blocks in Elderly Patients

This prospective randomized study was designed to investigate the hemodynamic effects and quality of continuous spinal anesthesia (CSA) after rapid injection of a low dose of 0.5% bupivacaine through a 32-gauge microcatheter. The method was compared with continuous epidural (CEA) and single-dose spinal anesthesia (SSA). Seventy-seven elderly patients (ASA II-III) ranging from 57 to 94 yr old and undergoing lower limb surgery were assigned to CSA (n = 26), CEA (n = 26), and SSA groups (n = 25). In all three groups, mean arterial pressure (MAP) and heart rate (HR) were assessed continuously for 30 min after initial injection, as well as after every reinjection of local anesthetic in the CSA and CEA groups. Bupivacaine (0.5%) was used as a local anesthetic. The initial doses were 1 mL of CSA, 10 mL of CEA, and 3 mL of SSA. The reinjection doses were 1 mL of CSA and 5 mL of CEA. In the CSA group, MAP did not decrease, whereas in the CEA group, the maximum decrease was 15% +/- 3% (mean +/- SEM) for the initial injection, 12% +/- 2% for the first repetition, and 13% +/- 2% for the second repetition. In the SSA group, the largest decrease of MAP was 19% +/- 2%. All changes of MAP in the CEA and SSA groups were significantly larger compared with CSA group (P < 0.05). A total of seven patients in these two groups needed vasopressors due to a decrease of MAP of more than 30% from baseline values. Heart rate did not change.(ABSTRACT TRUNCATED AT 250 WORDS)

Syndrome of intermittent insufficiency of the basilar arterial system.

<h3>Background and Objectives</h3> The impact of anesthesia techniques in patients experiencing hip fracture is controversial. This study compares the effects on blood pressure of 3 anesthesia techniques that are considered safe for the elderly. <h3>Methods</h3> Forty-five patients older than 75 years, with American Society of Anesthesiologists physical status III or IV, with cardiac comorbidities, and undergoing surgery for hip fracture, were randomized to receive continuous spinal anesthesia (CSA), propofol target-controlled infusion (TCI), or sevoflurane (SEVO). In CSA patients, a T10 metameric level target was achieved by titration of 2.5 mg of bupivacaine boluses. In patients on TCI and SEVO, a bispectral value target of around 50 guided the concentration of propofol or sevoflurane. Analgesia in the TCI and SEVO groups was provided with remifentanil. Hypotension was defined as a 30% decrease in mean arterial pressure and was treated with an intravenous bolus of ephedrine. <h3>Results</h3> The number of hypotension episodes was lower in the CSA group: 0 (range, 0–6) versus 11.5 (range, 1–25) in the TCI group and 10 (range, 1–23) in the SEVO group (<i>P</i> &lt; 0.001). Both TCI and SEVO patients needed more ephedrine compared with CSA patients (30.5 [15.5], 26 [23], and 1.5 [2.5] mg, respectively, <i>P</i> &lt; 0.001). The maximal decrease in mean arterial pressure was lower in the CSA group (26% [17%]) compared with that in the TCI group (47% [8%]) and the SEVO group (46% [12%]; <i>P</i> &lt; 0.001). <h3>Conclusions</h3> In elderly patients, spinal anesthesia using titrated doses of bupivacaine provided better blood pressure stability than propofol or sevoflurane anesthesia.