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We report a case of technically difficult spinal anesthesia in a morbidly obese woman, which was successfully implemented under fluoroscopy. Although radiological imaging is well known to guide various regional anesthetic procedures, until now, the utility of fluoroscopic imaging to facilitate spinal anesthesia had not been reported.
The influence of variations in the volume of injectate when maintaining an identical dose of a hyperbaric local anesthetic has not previously been investigated when performing spinal anesthesia. This study compares spinal anesthesia of 5 mg of lyophilized tetracaine diluted in 1 ml, 2 ml or 4 ml of 10% glucose in 45 elderly patients undergoing elective hip surgery. While supine and horizontal, each patient received double-blind one of the three solutions through a catheter inserted 4 cm into the intrathecal space at the L2-L3 or L3-L4 interspace. No difference in the anesthetic effects was found between the three groups. The median value of the maximal sensory level was T6 (range T3-L2), T4 (range T3-T9) and T5 (range T3-T11) in the 1-ml, 2-ml, and 4-ml groups, respectively. The number of patients with a motor blockade of grade 2 or 3 was 12/15, 14/15 and 13/15, and the time from the initial dose to the need for the first top-up dose (mean +/- s.d.) was 88 +/- 35 min, 75 +/- 15 min and 68 +/- 15 min for the 1-ml, 2-ml and 4-ml groups, respectively. Hemodynamic changes were also comparable between the three groups. The authors conclude that in elderly patients, undergoing spinal anesthesia while supine and horizontal, variations in volume from 1 to 4 ml do not influence the characteristics of hyperbaric spinal anesthesia while injecting an identical dose of local anesthetic.
BACKGROUND AND OBJECTIVES: Concerns of cauda equina syndrome have discouraged clinicians to use 5% lidocaine for continuous spinal anesthesia. Earlier reports indicated that single-shot spinal lidocaine 0.5% is effective for minor gynecologic and perianal surgery. In the present study, we evaluate the anesthetic and hemodynamic effects of low dose hyperbaric 0.5% lidocaine for continuous spinal anesthesia and compare with those of the 5% lidocaine solution in patients undergoing urologic surgery. METHODS: Spinal anesthesia was induced via an indwelling subarachnoid catheter in 42 elderly male patients (range, 57-84 years) undergoing transurethral prostate and bladder procedures. Patients were randomly assigned to receive an initial 30-mg bolus of hyperbaric lidocaine in the form of either 6 mL of 0.5% solution or 0.6 mL of 5% solution. Additional 30-mg boluses (to a total of 90 mg) were given, if necessary, to establish initial sensory block to T10 or higher and lower limb paralysis. Supplemental doses of 30 mg or less were given during surgery, as needed. Dermatomal level of sensory anesthesia and degree of motor blockade were assessed at regular intervals by a blinded observer. Heart rate and blood pressure (mean systolic and diastolic) values were monitored at regular intervals. RESULTS: Forty patients were studied successfully. Both hyperbaric 0.5% and 5% lidocaine provided adequate surgical anesthesia in 75% (30/40) of patients after a single 30-mg dose. A median peak sensory level of T5 (range, T2-T9) achieved within 11.1 +/- 4.5 minutes in patients receiving the 0.5% solution was significantly higher than the peak sensory level of T7 (range, T4-T12) in the 5% group (P = .043). The duration of surgical anesthesia after a 30-mg dose was similar in both groups--48.1 +/- 12.1 minutes versus 50.8 +/- 16.5 minutes respectively. Of the 30 patients (15 in each group) who received 30 mg initially, 25 required repeat lidocaine dosing through the catheter during surgery. The maximum decrease in heart rate and blood pressure values was within 10% and 20%, respectively, of baseline values in both groups. In the remaining patients (10/40), anesthesia was achieved successfully in five patients in the 0.5% group and three patients in the 5% group after two 30-mg lidocaine boluses (60 mg) and two patients in the 5% group after three 30-mg boluses (90 mg). CONCLUSIONS: Continuous spinal anesthesia produced by 0.5% lidocaine with 7.5% dextrose is as effective as that produced by the 5% lidocaine solution in elderly patients undergoing urologic surgery. An initial 30-mg bolus delivered via indwelling subarachnoid catheter was sufficient to achieve surgical anesthesia for approximately 50 minutes in most patients. Hemodynamic effects of the two lidocaine solutions were also comparable.
STUDY OBJECTIVE: To determine whether spinal anesthesia can be safely used for patients under endoluminal abdominal aortic aneurysm (AAA) repair. DESIGN: Retrospective chart review. SETTING: University hospital. PARTICIPANTS: 38 patients who underwent endoluminal AAA repair from 1999 to 2000. MEASUREMENTS AND MAIN RESULTS: The charts of 38 patients who underwent endoluminal AAA repair from 1999 to 2000 were reviewed for variables known to be associated with AAA repair. Twenty-four patients had spinal anesthesia (63%), 13 patients had general anesthesia (35%), 1 patient had epidural anesthesia (2%). Eight patients (33%) in the spinal group eventually had to have general anesthesia. Reasons included prolonged procedure in six cases and patient intolerance and anxiety in two cases. CONCLUSION: Endoluminal AAA repair can be safely performed with spinal anesthesia. The major disadvantage of spinal anesthesia is limited duration of anesthesia. The anesthesia team must be prepared to induce general anesthesia at any time. The decision regarding anesthetic technique should focus on patient and physician needs and preferences.
Since its introduction about a century ago, spinal anesthesia has been increasingly accepted by anesthesiologists. Recent studies are looking for an ideal local anesthetic. The influence of the type of anesthetic, its concentration, volume, dose, specific gravity, patient position, puncture site, injection speed, characteristics of cerebrospinal fluid and general condition of the patient are reviewed. New trends of spinal anesthesia including prolongation of the block by clonidine, pentazocine as a sole agent, and management of postspinal headache are also discussed. The review is based mainly on a computer-assisted search for articles published after 1960.
UNLABELLED: We investigated the effects of lateral decubitus positioning after spinal anesthesia with hyperbaric tetracaine on the spread of sensory blockade and hemodynamic variables. One hundred ASA physical status I or II patients scheduled for elective surgery to the lower limb received spinal anesthesia at a rate of approximately 0.1 mL/s using 0.5% tetracaine in 7.5% glucose with 0.125% phenylephrine in the lateral decubitus position with the operated side dependent. They were randomly divided into three groups: patients in Group I were placed supine immediately after spinal injection; those in Group II remained in the lateral position for 10 min before being turned supine; those in Group III were kept in the lateral position for 20 min then turned supine. Neural block was assessed by cold, pinprick, and touch sensation, and a modified Bromage scale. Hemodynamic variables included blood pressure, heart rate, and the use of ephedrine for the treatment of hypotension. The median (10th, 90th percentiles) peak dermatomal level to pinprick on the dependent side in Group III was T8 (T11, T5), which was significantly lower than that in Groups I and II, which extended to T4 (T9, T3) and T5 (T10, T2), respectively (P < 0.05). The difference in the maximal cephalad spread of sensory blockade between both sides in Group III was only one dermatome but was statistically significant (P < 0.05); in contrast, there was no significant difference in the maximal sensory level between both sides in Groups I and II. The use of ephedrine for the treatment of hypotension was significantly less frequent in Group III than the other groups. We conclude that keeping a patient in the lateral decubitus position for 20 min after hyperbaric tetracaine spinal anesthesia maintains preferential anesthetic distribution to the dependent side. Despite small differences between the two sides, the restricted spread of blockade and less hemodynamic variability may be clinically advantageous. IMPLICATIONS: The effects of posture on the spread of hyperbaric spinal anesthesia have not been adequately investigated. The results of the present study suggest an advantage of prolonged lateral decubitus positioning after intrathecal hyperbaric tetracaine.
OBJECTIVE: To determine the effect of spinal anesthesia using 26-gauge needles on hearing. METHODS: Eighteen male patients undergoing transurethral resection of the prostate (TURP) or other transurethral procedures under spinal or epidural anesthesia were studied prospectively to reveal possible auditory side effects of dural puncture or absorption of irrigation fluid to the blood stream. Measurement of auditory function by pure tone, Bekesy and speech audiometry, and measurement of serum concentrations of sodium, potassium, urea, and glucose were performed preoperatively and postoperatively. Clinical examination of cranial nerve functions was performed postoperatively. RESULTS: No mean change in hearing ability was seen in any group. One patient had severe, transient, low-frequency hearing loss with simultaneous severe postdural puncture headache. A statistically significant postoperative fall in serum osmolarity was noted in the epidural TURP group. CONCLUSION: Transient, severe hearing loss may still occur after spinal anesthesia using a 26-gauge needle. Minor hearing loss does not seem to be a problem with this needle size.
A case of spinal anesthesia in an extremely low birth weight male infant (body weight of 930 g at time of surgery) is presented. He was born prematurely at a gestational age of 27 weeks because of a placenta tumor and had to undergo inguinal herniotomy at 34 weeks postconceptional age. He had bronchopulmonary dysplasia and oxygen supply was still required because of frequent deterioration of oxygen saturation. Spinal anesthesia was performed successfully without any complications. Relevant aspects concerning the technique and management of spinal anesthesia in preterm infants are discussed.
The recent widespread popularity of spinal anesthesia can be traced to two events. One is the appreciation that, when used for operations below the level of the umbilicus, anesthetically induced physiologic trespass is less with spinal than with general anesthesia. The other is the recognition that modest hypotension with peripheral vasodilation, that may be seen with spinal anesthesia or intravenous infusion of nitroprusside, is, unlike hypotension associated with hypovolemia, unaccompanied by physiologically significant changes in peripheral distribution of cardiac output or changes in the balance between tissue oxygen supply and demand in the myocardium or elsewhere. Spinal anesthesia also has special advantages specific to urinary tract surgery in the geriatric patient.
Shivering is a common and complex phenomenon that occurs in many patients during spinal anesthesia. Shivering can increase oxygen consumption up to 500 per cent which may be detrimental to patients with decreased myocardial reserve. The metabolic costs and cardiorespiratory consequences of shivering are important particularly for patients with anemia, coronary arterial disease, cardiopulmonary insufficient, debilitated status or are elderly. We studied whether intrathecal meperidine could prevent shivering after spinal anesthesia. 60 patients with ASA class I-II were divided into intrathecal meperidine group (Group I) (n = 30) and control group (Group II) (n = 30). Group I received spinal tetracaine 12-16 mg with meperidine 0.2 mg/kg and Group II received spinal tetracaine 12-16 mg without meperidine. During operation the highest level of spinal anesthesia, ambient and rectal temperatures, blood pressure (BP) and heart rate (HR), presence or absence of shivering, intensity of shivering in both groups were recorded. Close observation for side effects was given post-operatively. There was a significant reduction (p < .005) in incidence of shivering in group I patients (16.7%) when compared with group II (56.7%). There was no or less side effects observed with other neuraxial opioids except nausea. We concluded that intrathecal meperidine could suppress shivering induced by spinal anesthesia.
OBJECTIVES: To compare general and spinal anesthesia in the context of thromboembolic disease after orthopedic surgery in patients receiving prophylactic therapy with low molecular weight heparins. PATIENTS AND METHOD: Of the 484 arthroplasties studied retrospectively, 209 involved total hip prostheses, 111 partial hip prostheses and 164 total knee prostheses. Spinal anesthesia (epidural or subarachnoid) was provided in 328 cases and general anesthesia in 156. Thromboembolic disease was diagnosed if the patient presented a compatible clinical picture or if there was confirmation by Doppler ultrasonography and/or venography for deep venous thrombosis or by scintigraphy for pulmonary embolism. Related factors studied were age; weight; prior fractures of the lower extremity; a history of thromboembolism, diabetes, high blood pressure or heart disease; and medication. RESULTS: Twenty-one patients experienced thromboembolic complications, 12 after general anesthesia and 9 after spinal anesthesia, the incidence in the latter being significantly lower (p < 0.01, odds ratio 3.23, 95% CI). Multivariant analysis also showed a significant increase in thromboembolic disease (p = 0.05) among patients over 70 years of age (odds ratio 2.67, 95% CI). CONCLUSIONS: Spinal anesthesia provides some protection against thromboembolic disease in arthroplasty. Age is a risk factor.
We evaluated the influence of baricity on differential blockade during spinal anesthesia using isobaric or hyperbaric 0.5% bupivacaine. Forty ASA-PS I-II patients scheduled for elective surgery (orthopedic, lower abdominal and urologic) were divided into two groups; group H, using hyperbaric 0.5% bupivacaine, and group I, using isobaric 0.5% bupivacaine. Spinal anesthesia was performed in lateral decubitus position, using a 25-gauge Quincke needle at L2-3 interspace, and 0.5% bupivacaine 2.0 ml was injected for 10 seconds. Patients were turned to supine position soon after the spinal anesthesia and the block levels were examined every 5 min for 30 min. Sympathetic blockade was detected by observer's hand, the loss of cold sensation by alcohol sponge and the loss of pain sensation by pinprick. Complete motor blockade was detected by modified Bromage scale. Significant higher sensory blockade and large number of complete motor block were observed in group H. Differential blockade between sympathetic and sensory was significant and lasted 30 min in group I, but lasted only 15 min in group H.
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Hypobaric spinal anesthesia was administered to 40 patients undergoing lower limb surgery. Twenty-nine of the patients were debilitated geriatric patients who presented with orthopedic emergencies, in most cases a fractured hip. Hypobaric spinal anesthesia was found to be a simple and safe procedure that provided adequate analgesia. Due to its inherent nature, hypobaric spinal anesthesia does not necessitate positioning of the patient on the injured, painful side (unlike hyperbaric spinal or epidural anesthesia) and, therefore, facilitates a smooth and painless transfer of the patient to the operating table. Complications encountered were similar to those following hyperbaric anesthesia.
More premature infants are now surviving because of advances in perinatal care. Premature infants often have congenital anomalies requiring operative correction and are at increased risk for developing postoperative apnea. The purpose of this study was to review our results with spinal anesthesia in infants. Twenty-two infants (average age at operation, 11 weeks) had spinal anesthesia for surgery to the spine or lower extremities. One patient with bilateral developmental dysplasia of the hip had staged operations 1 month apart. Twelve infants (55%) were considered to be at increased risk for general anesthesia. The spinal anesthetic was 1% tetracaine made hyperbaric with 10% dextrose (tetracaine dose, 0.5 mg/kg). Spinal anesthesia was successful in all 23 cases. The average follow-up was 4 years, 1 month, and no complications were attributed to the spinal. Spinal anesthesia is a safe and effective substitute for general anesthesia in infants having spinal and lower extremity operations and is particularly beneficial for high-risk infants.
Spinal anesthesia has been described for infants and premature babies undergoing minor operative procedures. The advantages of shorter operating time, avoidance of intubation, and shorter hospital stay have made this the gold standard for premature and other high-risk infants requiring minor procedures. However, little is known about this technique for major interventions in newborns and preterm infants. Recently, four infants born with gastroschisis underwent repair under spinal anesthesia. Two had accompanying intestinal atresia (one with a prenatal perforation and pan-hypopituitarism), and two had intact gastrointestinal systems. The gestational ages were 39, 33, 36, and 36 weeks, respectively. All had primary closure of the defect; one had no repair of the atresia because the bowel was thick and matted with a significant peel, and the defect was not identified. In the second case with atresia, necrosis and perforation of a localized segment of intestine was identified proximal to the intestinal atresia, and was exteriorized with the primary repair. When they arrived in the operating room, all four infants were breathing spontaneously, on room air, after appropriate fluid resuscitation. All underwent spinal anesthesia, which was the only agent used for the operation. The operative time was 45, 25, 30, and 25 minutes, respectively (mean, 31.25 minutes). The duration of anesthesia was 170 to 230 minutes (mean, 205 minutes). All infants were returned to the neonatal intensive care unit on room air and breathing spontaneously. One was given morphine postoperatively and suffered significant respiratory depression, requiring intubation. It appears that spinal anesthesia is safe and effective for major operative procedures in high-risk infants. (ABSTRACT TRUNCATED AT 250 WORDS)
The effect of spinal anesthesia on fetal heart rate is due to maternal hypotension and subsequent fetal hypoxia. Maternal hypotension of 80 mm of mercury for five minutes almost always results in hypoxic fetal bradycardia. This bradycardia is gradual in onset, and may be preceded by a short period of fetal tachycardia. There is a lag in the return of fetal heart rate to normal after maternal blood pressure has normalized. Similar bradycardia has been observed in maternal syncope unassociated with anesthesia. Maternal hypotension should be prevented, and if it occurs should be corrected early. Administration of a vasopressor drug is the treatment of choice, with oxygen and fluids as indicated.