Comparison of unilateral spinal anaesthesia using low dose bupivacaine with or without fentanyl in lower limb surgery
Keywords:Unilateral spinal anaesthesia, Bupivacaine, Intrathecal fentanyl, Lower limb surgeries
Background: Intrathecal opioids are synergistic with local anesthetics and intensifies sensory block without increasing motor block. This combination makes it possible to achieve spinal anesthesia without hemodynamic instability and adverse effects that are associated with higher doses of bupivacaine. Hence we conducted this comparative study using 5 mg of hyperbaric bupivacaine with or without fentanyl (25 µg) in unilateral spinal anaesthesia for lower limb surgery.
Methods: Sixty patients were randomized into two groups with Group B receiving 0.5% bupivacaine and Group BF receiving 0.5% bupivacaine + 25 µg fentanyl intrathecal. Sensory and motor block quality and duration, post anesthesia care unit stay (PACU) and adverse effects were compared.
Results: The onset of sensory block (6.17±1.44) was faster in Group B compared Group BF (6.73±1.52) and duration of sensory blockade was intensified by addition of intrathecal fentanyl in Group BF. The onset and duration of motor blockade was similar in both the groups and was not affected by addition of fentanyl in Group BF. The number and mean duration stay in PACU was found to be significantly higher in patients 24 [80%]; 30 minutes receiving fentanyl suggesting it prolonged duration of recovery. No patient in either group had hypotension, respiratory depression, sedation, nausea, vomiting, PDPH and TNS. Only 1 patient in each group experienced bradycardia and 4 patients in Group BF had mild pruritus.
Conclusions: Unilateral spinal anaesthesia with 5 mg hyperbaric bupivacaine with 25 µg fentanyl is a better choice than 5 mg hyperbaric bupivacaine alone in short procedure of lower limb in orthopaedic surgery.
Korhonen AM, Valanne J, Jokela R, Ravaska P, Korttila K. Intrathecal hyperbaric bupivacaine 3mg + fentanyl 10mg for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand. 2003;47:342-6.
Hamp KF, Schnieder MC, Ummenhofer W, Drewe J. Transient neurologic symptoms after spinal anaesthesia. Anesth Analg. 1995;81:1148-53.
Poolock JE, Neal JM, Stephenson CA, Wiley CE. Prospective study of the incidence of transient radicular irritation in patients undergoing spinal anaesthesia. Anesthesiology. 1996;84:1361-7
Tarkkila P, Hubtala J, Tuominen M. Transient radicular irritation after spinal anaesthesia with hyperbaric 5% lignocaine. Br J Anaesth. 1995;74:328-9
Sjostrom S, Blass J. Severe pain in both legs after spinal anaesthesia with hyperbaric 5% lignocaine solution. Anaesthesia. 1994;49:700-2
Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anaesthesia: an epidemiologic study of 1863 patients. Anaesthesiology. 1998;89:633-41.
Valanne V, Korhonen A, Jokela R, Ravaska P, Korttila KK. Selective spinal anaesthesia: A comparison of hyperbaric bupivacaine 4mg versus 6mg for outpatient knee arthroscopy. Anesth Analg. 2001;93:1377-9.
Tarkkila P, Hubtala J, Tuominen M. Home readiness after spinal anaesthesia with small doses of hyperbaric 0.5% bupivacaine. Anaesthesia. 1997;52:1157-60.
Casati A, Fanelli G, Cappelleri G, Borghi B, Cedrati V, Torri G. Low dose hyperbaric bupivacaine for unilateral spinal anaesthesia. Can J Anaesth. 1998;45(9):850-4.
Casati A, Fanelli G, Aldegheri G, Colnaghi E, Casaletti E, Cedrati V, et al. Frequency of hypotension during conventional or asymmetric hyperbaric spinal block. Reg Anesth Pain Med. 1999;24:214-9.
Borghi B, Stagni F, Bugamelli S, Paini MB, Nepoti ML, Montebugnoli M, et al. Unilateral spinal block for outpatient knee arthroscopy: A dose finding study. J Clin Anesth. 2003;15:351-6.
Fanelli G, Borghi B, Casati A, Bertini L, Montebugnoli M, Torri G. Unilateral bupivacaine spinal anaesthesia for outpatient knee arthroscopy. Can J Anaesth. 2000;47(8):746-51.
Enk D. Unilateral spinal anaesthesia – gadget or tool? Current opinion. Anesthesiology. 1998;11:511-5.
Casati A, Fanelli G, Beccaria P, Aldegheri G, Berti M, Senatore R, et al. Block distribution and cardiovascular effects of unilateral spinal anaesthesia by 5% hyperbaric bupivacaine: A clinical comparison with bilateral spinal block. Minerva Anesthesiol. 1998;64:307-12
Kuusneimi KS, Pihlajamaki KK, Irjala JK, Jaakkola PW, Pitkänen MT, Korkeila JE. Restricted spinal anaesthesia for ambulatory surgery: A pilot study. Eur J Anaesthesiol. 1999;16:2-6.
Casati A, Fanelli G, Cappelleri G, Aldegheri G, Leoni A, Casaletti E, et al. Effects of spinal needle type on lateral distribution of 0.5% hyperbaric bupivacaine. Anesthesiology. 1998;87:355-9.
Casati A, Fanelli G, Cappelleri G, Leoni A, Berti M, Aldegheri G. Does speed of intrathecal injection affect the distribution of 0.5% hyperbaric bupivacaine. Br J Anaesth. 1998;81:355-7.
Casati A, Fanelli G, Cappelleri G, Aldegheri G, Berti M, Senatore R, et al. Effects of speed of intrathecal injection in unilateral spinal block by 1% hyperbaric bupivacaine: A randomized, double blind study. Minervo Anesthesiol. 1999;65:5-10.
Serpell MG, Gray WM. Flow dynamics through spinal needles. Anaesthesia. 1997;52:229-36.
Belzarena SD. Clinical effects of intrathecally administered fentanyl in patients undergoing caesarean section. Anesth Analg. 1992;74:653-7.
Butterworth JF IV, Strichartz GR. Molecular mechanisms of local anaesthesia: A review. Anesthesiology. 1900;72:711-34.
Singh H, Yang J, Thornton K, Giesecke AH. Intrathecal fentanyl prolongs sensory bupivacaine block. Can J Anesth. 1995;42(11):987-91.
Ben-David B, Solomon E, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: better anaesthesia without prolonging recovery. Anesth Analg. 1997;85:560-5.
Enk D, Prien T, Van Aken H, Mertes N, Meyer J, Brüssel T. Success rate of unilateral spinal anesthesia is dependent on injection flow. Reg Anesth Pain Med. 2001;26:420-7.
Fanelli G, Borghi B, Casati A, Bertini L, Montebugnoli M, Torri G. Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy. Italian Study Group on Unilateral Spinal Anesthesia. Can J Anaesth. 2000;47:746-51.
Kuusniemi KS, Pihlajamäki KK, Pitkänen MT. A low dose of plain or hyperbaric bupivacaine for unilateral spinal anesthesia. RegAnesth Pain Med. 2000;25:605-10.
Breebart M, Vercauteren M, Hoffman V, Adriaeensen H. Urinary bladder scanning after day-case arthroscopy under spinal anaesthesia: comparison between lidocaine, ropivacaine and levobupivacaine. Br J Anesth. 2003;90:309-15.
Reuben SS, Donn SM, Sullivan P. An intrathecal fentanyl dose - response study in lower extremity revascularization procedures. Anesthesiology. 1994;81(6):1371-5.
Varassi G, Celleno D, Capogna G. Ventilatory effects of subarachnoid fentanyl in elderly. Anaesthesia. 1992;47:558-62.
Biswas BN, Rudra A, Bose B. Intrathecal fentanyl with hyperbaric bupivacaine improves analgesia during caesarean delivery and in early postoperative period. Indian J Anaesth. 2002;46(6):469-72.
Khanna M, Singh I. Comparative evaluation of bupivacaine plain versus bupivacaine with fentanyl in spinal anaesthesia in geriatric patients. Indian J Anaesth. 2002;46(3):199-203.
Manullang TR, Viscomi CM, Pau NL. Intrathecal fentanyl is superior to intravenous ondansetron for prevention of perioperative nausea during caesarean delivery with spinal anaesthesia. Anesth Analg 2000; 90: 1162-6.
Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anaesth Analg. 1999;88:508.
Mulroy M. Effect of short acting spinal and epidural anaesthesia on voiding. Anaesthesiology. 2002;97:315-9.