Low-dose Spinal Anesthesia Research Articles

Anesthetic Management of Double Atrial Septal Defect with Moderate Pulmonary Hypertension Emergency Caesarean Section

Atrial septal defect (ASD) is common congenital heart disease in adults. Most of the cases are detected in childhood, whereas few cases reach adulthood undiagnosed. It is the most common congenital heart lesion in child bearing age group girls. ASD leads to various complications depending upon size, position of ASD and shunt flow direction and hemodynamic change. Pulmonary artery hypertension is one such complication which occurs due to large blood flow across pulmonary artery due to left to right shunting. Pulmonary hypertension is defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest or greater than 30 mmHg during exercise. We reported a case of double ASD of size 10 mm and 5 mm with moderate pulmonary artery hypertension which underwent emergency caesarean section for meconium stained liquor. Under all aseptic precaution epidural catheter was placed at L3-4 level in sitting position by loss of resistance technique and then spinal anesthesia was given at the same level with 26G needle. Total drug given in spinal was 2.5 ml which includes 2 ml of bupivacaine (heavy) and 0.5 ml fentanyl. The patient was managed successfully under regional (epidural with low dose spinal) anesthesia without facing any complication. During anesthesia our main aim was to prevent complications, like hypotension, hypoxia, hypercarbia, reversal of shunt, fluid overload and maintain systemic pulmonary vascular resistance. As these complications adversely affect the outcome in heart disease patients.

Effects of intrathecal tramadol on low-dose bupivacaine spinal anesthesia in elderly patients undergoing transurethral resection of prostate

Effects of intrathecal tramadol on low-dose bupivacaine spinal anesthesia in elderly patients undergoing transurethral resection of prostate

Retrospective analysis of mepivacaine, prilocaine and chloroprocaine for low-dose spinal anaesthesia in outpatient perianal procedures.

Perianal procedures are carried out in an outpatient setting regularly. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics (LA) for spinal anaesthesia (SPA) on operating room (OR) efficiency (perioperative process times, turnaround times) and postoperative recovery. This study aims on the determination of the optimal LA for low-dose SPA in the specific setting of a high-volume day-surgery centre. Anaesthesia records of all patients undergoing perianal outpatient surgery under saddle-block SPA at the Mannheim University Medical Centre from 2008 until 2017 were analysed. Patients were categorized as having received prilocaine, mepivacaine or chloroprocaine. Two thousand seven hundred forty-six patients were included. Postoperative recovery was faster for chloroprocaine 1% compared with both other LAs. Preoperative processes but not process times in the OR were shorter for chloroprocaine. In contrary, turnaround times were significantly prolonged when chloroprocaine had been used, leading to reduction of OR efficiency. Low-dose SPA provides reliable blocks for perianal surgery. Considerations on the choice of LA for SPA must include not only the recovery profile, but also the impact on OR efficiency. Due to shorter turnaround times and a manageable prolonged duration of stay, prilocaine is the preferable LA for low-dose SPA in perianal outpatient surgery at a high-volume day-surgery centre.

Atrio-Ventricular Septal Defect in Pregnant Women, How to Deal with It : A Case Study

Pregnancy is not always well tolerated in women with congenital heart disease (CHD) such as atrio-ventricular septal defect (AVSD), predominantly due to heart failure deterioration and increasing pulmonary hypertension (PH). Managements of those patients are challenging, especially during third trimester and after delivery care. Decision about time of termination, mode of delivery and anesthetic management are also debatable. In this article we report two similarcases of pregnant women with AVSD and severe PH. The frst patient was 27 years old, 28-29 weeks pregnant came with shortness of breath. She had history of miscarriage once. Based on her transthoracal echocardiography, she was diagnosed with AVSD partial type (primum ASD) with severe PH and then treated with intravenous furosemide, oral beraprost and oral sildenafl. The second patient was 27 years old 30-31 weeks pregnant with shortness of breathand appeared cyanotic. She delivered her frst child spontaneously without any symptoms. Based on her transthoracal echocardiography she was diagnosed with AVSD transitional type (large primum ASD with small inlet VSD) and Eisenmenger syndrome. She was treated with intravenous furosemide and oral beraprost. Those two patients underwent planned C-section under general anesthesia, both babies were survived but the patient did not survived severaldays after the procedure due to PH crisis. Until now, management PH associated with CHD in pregnant women is complex. Fluid management and pulmonary artery hypertension (PAH)- targeted therapies are important. Mode of delivery on this cases is also remain debated. Some studies stated planned C-section might be a better choice and combination epidural and lowdose spinal anesthesia might be better than general anesthesia. At the end, when a woman with CHD and PH chooses to continue pregnancy, multidisciplinary team approach is crucial to achieve good outcomes.

A comparison of pain control and complications using three different ways of anesthesia in patients undergoing transrectal ultrasound-guided prostate biopsy.

Background:We aim to compare the degree of pain control and complications in three types of anesthesia using periprostatic nerve block (PPNB) plus intrarectal local anesthesia (IRLA), low-dose spinal anesthesia, and intravenous (IV) sedation in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy.Materials and Methods:In this clinical trial study, 106 patients were participated from December 2015 to December 2016 at Alzahra Hospital, Isfahan, Iran. Patients were randomly allocated into three groups to receive PPNB plus IRLA (n = 36), low-dose spinal anesthesia (n = 35) and IV sedation (n = 35) before TRUS-guided prostate biopsy. Pain scores were recorded using a 10 point visual analog scale right after the biopsy was done. Early and late complications were assessed using a questionnaire after the procedure and in follow-up of patients.Results:Overall, the pain score in the low-dose spinal anesthesia group was significantly lower than PPNB plus IRLA and IV sedation groups (P < 0.001). The differences in pain scores between PPNB plus IRLA group and IV sedation group were not significant (P = 0.30). Urinary retraction and fever were significantly more frequent in low-dose spinal anesthesia and IV sedation, retrospectively (P = 0.04, P = 0.03). No significant difference in late complications was found among the groups.Conclusion:This study demonstrates that low-dose spinal anesthesia is superior to PPNB plus IRLA and IV sedation in terms of pain controlling and was associated with higher tolerance of the examination and patient comfort.

Anesthesia management in cesarean section with lown ganong levine syndrome

Lown Ganong Levine (LGL) which is a preexcitation syndrome is defined with paroxysmal tachycardia, dyspnea, anxiety, angina, and the complaint of fatigue accompanied by characteristic changes on ECG (short PR). Herein, we present a case of cesarean which we completed with a low-dose spinal anesthesia without problem, avoiding from general anesthesia which could be induced with numerous arrhythmogenic drugs, because of arrhythmia complication which might be mortal.

Low dose Spinal Anaesthesia for Cesarean Section in Gravida with Rheumatic Heart Disease

Low dose Spinal Anaesthesia for Cesarean Section in Gravida with Rheumatic Heart Disease

Low dose spinal anesthesia for open cholecystectomy: a feasibility and safety study

Background: Cholecystectomy is performed either open or a laparascopic route. the traditional and invasive open cholecystectomy is still in frequent practice for various reasons. Spinal anesthesia (SA) has been widely used as alternative to General Anesthesia (GA) for laparoscopic cholecystectomy. SA could be a safe and effective anaesthetic procedure for open cholecystectomy. This study was conducted to uncover feasibility and safety of low dose SA for conducting open cholecystectomy.Methods: All consented patients of ASA grade I and II of either sex scheduled for elective open cholecystectomy received SA using 2 ml of 0.5% hyperbaric Bupivacaine mixed with 100 µg Morphine. Peri-operative preparations and management were all standardized. Other drugs being only administered to manage anxiety, pain, nausea/vomiting, hypotension, and any adverse event. Open cholecystectomy by right oblique incision. Intra-operative events and post-operative events were observed for 48 hours, operative difficulty, post operative pain free interval, analgesia requirements, hospital stay and the surgeon and patient satisfaction were studied.Results: 20 patients were included in the study from 1st may 2016 to December 2016. Spinal anesthesia was adequate for surgery in all patients. Operative difficulty scores were minimal and surgery in one patient was converted to open cholecystectomy. Intraoperatively, five patients presented hypotension and Ephedrine was given. Four patients experienced pain and received Fentanyl and midazolam. Postoperatively, pain scores were minimal and paracetamol was not sufficient only in four patients who received ketoprofen and no patient received opioid. One patient required antiemetic for vomiting and two patients suffered urinary retention and one headache. 19 patients were discharged within 48 hours of surgery and patient satisfaction scores were very good.Conclusions: Spinal anesthesia is safe and effective anesthetic technic for uncomplicated open cholecystectomy in terms of peri-operative events and, in prolonged post-operative analgesia, as well as in terms of patient and surgeon’s satisfaction.

Evaluation the Effects of Intravenous vs. Spinal Dexmedetomidine during Anesthesia for Cesarean Sections with Severe Pre-Eclampsia

Background: Side effects of low-dose spinal anesthesia with opioids and adjuvants raised the essential requirement to look for better alternatives like dexmedetomidine for patients with severe pre-eclampsia undergoing cesarean section to provide satisfactory spinal anesthesia and improve its outcomes.Aim: Evaluate and compare effects of intravenous and intrathecal dexmedetomidine on duration of spinal block, postoperative analgesia and incidence of adverse effects in parturient with severe Pre-eclampsia undergo Caesarean section.Settings and design: A prospective, double blind controlled randomized and comparative study.Methods: Sixty ASA II patients were randomized into 3 groups: Group I: (control group) (n=30) each patient received intrathecal hyperbaric bupivacaine 10 mg with 3 mL total volume. Group II: (Intrathecal dexmedetomidine group) (n=0) each patient received dexmedetomidine 5 μg diluted i n 0.5 ml saline and hyperbaric bupivacaine 10 mg with 3 mL total volume. Group III: (Intravenous dexmedetomidine group) (n=30) each patient received intravenous dexmedetomidine started at a loading dose of 1 μg/kg diluted in 50 ml saline and administered within 10 min. as a loading dose, followed by maintenance at a dose of 0.4 μg/kg/h diluted in 200 ml saline till the end of surgery and hyperbaric bupivacaine 10 mg in 3 ml total volume. Primary outcome is the duration of spinal block while secondary outcomes are the postoperative analgesia and the incidence of side effects.Results: Time (min) to sensory regression to s1 level in group I, II, III was (200.23 ± 3.25, 230.4 ± 2.5, 294.1 ± 15.1) respectively, showed significance increase in group III. Time to reach motor block Bromage 3 was (5.5 ± 0.2, 5.7 ± 0.9, 8.5 ± 0.3) in group I, II, III respectively, there was significance increase in group III. Time of regression to Bromage 0 was assessed as (170.5 ± 2.35, 190.6 ± 3.51, 249.2 ± 20.2) in groups I, II, III respectively, showed significance increase in group III. Onset of 1st post-operative analgesic dose was assessed in the study groups (242.23 ± 15.01, 270.15 ± 25.00, 371.25 ± 88.54), showed significance increase in group III. Side effects showed significance decrease in group III.Conclusion: Intravenously administered dexmedetomidine prolonged the duration of sensory and motor blockade with reduced side effects.

The Effects of Prophylactic Bolus Phenylephrine on Hypotension During Low-dose Spinal Anesthesia for Cesarean Section

(Int J Obstet Anesth. 2016;25:17–22) Spinal anesthesia for cesarean section is preferred in order to avoid the serious maternal complications that can occur during general anesthesia. However, spinal anesthesia is not without complications. Spinal anesthesia-induced hypotension occurs commonly and may have deleterious effects on both mother and fetus. To decrease the risk of hypotension a continuous infusion of phenylephrine is frequently administered, but there are limited data about the use of prophylactic boluses of the drug. The objective of this study was to evaluate the effects of 3 prophylactic bolus doses of phenylephrine during low-dose spinal anesthesia for cesarean section, including adverse hemodynamic effects and neonatal outcome.

Chloroprocaine 10 mg/ml for low-dose spinal anaesthesia in perianal surgery - a randomised dose finding study.

Low-dose spinal anaesthesia is a safe and reliable anaesthesia technique in outpatient perianal surgery. Regarding its short duration of action and its trend to hyperbaric characteristics, plain chloroprocaine 10 mg/ml seems to be ideal to perform low-dose spinal anaesthesia. The aim of this trial was to determine the optimal dosage of chloroprocaine for this indication. Hundred and twenty patients undergoing perianal surgery were enrolled and randomly allocated to receive 10, 20 or 30 mg of chloroprocaine 10 mg/ml intrathecally. Patients had to sit upright for at least 10 min after injection. We measured the expansion of sensory and motor block and the times until voiding, walking without assistance and home discharge. The expansion of the sensory (P ≤ 0.0059) and the motor block (P ≤ 0.0086) gained with increasing doses. At a dose of 30 mg the incidence of a profound, clinically relevant motor block was significantly higher compared to 10 and 20 mg (P ≤ 0.0004). In the 10 mg group two patients suffered from nociceptive pain due to an incomplete block and five patients announced discomfort during procedure. Doses of 10 and 20 mg led to a significantly earlier discharge compared to 30 mg (P = 0.0003; P = 0.0406). Plain chloroprocaine 10 mg/ml can successfully be used for low-dose spinal anaesthesia in perianal outpatient surgery. Regarding the unfavourable motor block and later discharge-times in the 30 mg group on the one hand and the block-failures in the 10 mg group on the other, 20 mg can be recommended as the optimal dose.

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The Importance of Subarachnoid Catheter in Low Dose Spinal Anesthesia Technique

The Importance of Subarachnoid Catheter in Low Dose Spinal Anesthesia Technique

The Importance of Subarachnoid Catheter in Low Dose Spinal Anesthesia Technique

The Importance of Subarachnoid Catheter in Low Dose Spinal Anesthesia Technique

Low Dose Spinal Anaesthesia for a Pediatric Patient with Takayasu and #8217;s Artheritis Undergoing Orthopaedic Surgery: a case Report

Takayasu’s arteritis(TAK) is an arteritis, often granulomatous, predominantly affecting the aorta, its major branches and the pulmonary arteries. Onset usually occurs before the age of 50 years usually second or third decade which is a major distinction from giant cell arteritis, whose onset usually occurs after age 50. TAK is one of the more common etiologies of renovascular hypertension in pediatric age group. Anaesthesia in patients with TAK is complicated with severe uncontrolled hypertension leading to end organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in monitoring blood pressure. The anaesthetic approach for partrutients with TAK has not been standardised yet. Although spinal anaesthesia is widely using in pediatric age group, we have not seen any report concerning spinal anaesthesia for pediatric patient with TAK. We present a case of successful low dose spinal anaesthesia management of a pediatric patient with TAK, who underwent core decompression operation by orthopedia clinic.

Low Dose Spinal Anaesthesia in Elderly & Critically Ill Patients

Low Dose Spinal Anaesthesia in Elderly & Critically Ill Patients

Cardiovascular effects of low-dose spinal anaesthesia as a function of age: An observational study using echocardiography

BackgroundSpinal anaesthesia (SA) is a widely used technique of regional anaesthesia but hypotension is an adverse effect commonly observed, especially in elderly patients. ObjectiveThe objective of this study was to assess the cardiovascular effects induced by a single injection of a low-dose SA during elective surgery by using transthoracic echocardiography (TTE) and to compare these effects in patients older and younger than 70 years of age. DesignObservational study. SettingSingle centre university hospital. Patients or other participantsForty-six patients scheduled for surgery under SA were included in the study (25 patients<70 years and 21 patients ≥ 70 years). Intervention(s)A cardiologist, blinded to all clinical parameters, interpreted the TTE. Main outcome measuresTwo TTEs were performed for each patient: one at baseline before and the second 20minutes after the placement of the SA. ResultsSixty-six percent of patients became hypotensive in the ≥ 70 years group whereas no episode of hypotension occurred in the<70 years group (P<0.0001). At baseline (i.e. prior to SA), when compared to younger patients, elderly patients had both a lower E/A ratio (0.8 [0.5–2.1] vs. 1.4 [0.7–1.6], P=0.001) as well as a lower LVEF (50.4% [37.7–72.3] vs. 60.9% [44.8–69.8], P<0.0001). SA in the elderly induced a larger decrease in the cardiac index (CI) (–0.5 L·min−1·m−2 [–0.8 to –0.3] vs. –0.2 L·min−1·m−2 [–0.8–0.1], P<0.0001), LV stroke volume (–8mL [–13–4] vs. –2mL [–14 to –1], P<0.0001) and systemic vascular resistances (SVR) (–2.2 WU [–6.7–0.3] vs. –0.8 WU [–2.3–0.1], P<0.0001). ConclusionsHypotension is more frequent among elderly patients, even after low-dose SA. Known age-related changes in cardiovascular performance, such as impaired myocardial relaxation and decreased systolic function could be responsible for the decrease in cardiac output (CO) and SVR seen in these patients.

The effects of prophylactic bolus phenylephrine on hypotension during low-dose spinal anesthesia for cesarean section

BackgroundContinuously infused phenylephrine is frequently used to reduce the incidence of hypotension in women undergoing cesarean section under spinal anesthesia, but less is known about the prophylactic bolus method. We evaluated three prophylactic bolus doses of phenylephrine during low-dose spinal anesthesia for cesarean section. MethodsOne-hundred-and-eighty-four patients were randomized to receive 0.9% saline 2mL (Control Group) or phenylephrine 1.0μg/kg (PHE1 Group), 1.5μg/kg (PHE1.5 Group), or 2.0μg/kg (PHE2 Group) immediately after induction of combined spinal-epidural anesthesia. Maternal blood pressure and heart rate were recorded at 1-min intervals until delivery. Hypotension, defined as systolic blood pressure <80% of baseline, was treated with rescue doses of phenylephrine 100μg at 1-min intervals until hypotension resolved. The incidence of nausea, vomiting, bradycardia, and hypertension, as well as Apgar scores and umbilical blood gases, were recorded. ResultsThe incidence of hypotension was 71.7% (33/46) in the Control Group, 68.9% (31/45) in the PHE1 Group, 37.0% (17/46) in the PHE1.5 Group and 45.7% (21/46) in the PHE2 Group (P=0.001). The total rescue dose of phenylephrine was greater in the Control Group than those in the PHE1.5 Group (P<0.05) and PHE2 Group (P<0.05). The incidence of hypertension increased as the dose of prophylactic phenylephrine increased (P<0.001) and was highest in the PHE2 group (37%). Other variables did not differ among the four groups. ConclusionsUnder the conditions of this study, prophylactic bolus injection of phenylephrine 1.5μg/kg was a suitable alternative method for reducing the incidence of hypotension during low-dose spinal anesthesia for cesarean section.

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.

Lithotomy versus jack-knife position on haemodynamic parameters assessed by impedance cardiography during anorectal surgery under low dose spinal anaesthesia: a randomized controlled trial.

BackgroundAlthough the prone position providing better exposure for anorectal surgery is required it can cause a reduction of cardiac output and cardiac index. The goal was to compare haemodynamic changes assessed by impedance cardiography during anorectal surgery under low-dose spinal anaesthesia in lithotomy and jack-knife position.MethodsThe prospective randomized controlled study included 104, ASA I-II adult patients admitted for elective minor anorectal surgery, assigned to be performed in lithotomy (groupL, n = 52) or jack-knife position (groupJ, n = 52). After arrival to operating room the standard monitoring, impedance cardiography device was connected to the patient, and the following variables were recorded: cardiac output, cardiac index, systemic vascular resistance, stroke index at times of arrival to operating room, placement for, start and end of surgery and placement to bed. Spinal block was made in the sitting position with 4 mg of 0.5% hyperbaric bupivacaine and 10 μg of Fentanyl injected over 2 min. Comparison was based on haemodynamic changes between and inside groups over time. Student’s t, chi square tests were used for statistical analysis with p < 0.05 regarded as statistically significant.ResultsThe reduction of cardiac output was statistically significant after placement of the patient into the prone position: from baseline 7.4+/−1.6 to 4.9+/−1.2 after placement for and 4.7+/−1.2 at the start and end of surgery (mean +/−SD l/min). The difference of cardiac output between groups was 2.0 l/min after positioning for and the start of surgery and 1.5 l/min at the end of surgery (p < 0.05). Mean cardiac index reduced from baseline 3.9+/−0.8 to 2.6+/−0.7 and 2.4+/−0.6 (mean+/−SD l/min/m2) in groupJ and between groups: by 1.0 l/min/m2 after placement for, 1.1 at the start and 0.8 at the end of surgery (p < 0.05). Systemic vascular resistance increased from baseline 1080+/−338 to 1483+/−479 after placement for, 1523+/−481 at the start and 1525+/−545 at the end of surgery in groupJ (mean+/−SD dynes/sec/cm−5, p < 0.05).ConclusionsAccording to impedance cardiography, jack-knife position after low-dose spinal anaesthesia produces transitory, but statistically significant reduction of cardiac output and cardiac index with increase of systemic vascular resistance, compared to insignificant changes in lithotomy position.Trial registrationClinical Trials NCT02115178.