Revista Brasileira DE Anestesiologia
Revista Brasileira DE Anestesiologia
Revista Brasileira DE Anestesiologia
2014;64(2):89---97
REVISTA
BRASILEIRA DE
ANESTESIOLOGIA
SCIENTIFIC ARTICLE
KEYWORDS
Levobupivacaine;
Continuous spinal
anesthesia;
Spinal anesthesia;
Transurethral
prostate resection
Abstract
Background: The aim of the study is to compare the efcacy of levobupivacaine induced continuous spinal anesthesia (CSA) versus single dose spinal anesthesia (SDSA) in patients who are
planned to undergo transurethral prostate resection.
Methods: Sixty years or older, ASA I---II or III, 50 patients were included in the study. 12.5 mg
0.5% levobupivacaine were administered intrathecally in SDSA group. In CSA group, initially
2 mL of 0.25% levobupivacaine were administered through spinal catheter. In order to achieve
sensory block level at T10 dermatome, additional 1 mL of 0.25% levobupivacaine were administered through the catheter in every 10 min. 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.
Results: CSA technique provided better hemodynamic stability compared to SDSA technique
particularly 90 min 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.
Corresponding author.
E-mail: [email protected] (B.S. Yurtlu).
0104-0014 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. Este um artigo Open Access sob a licena de CC BY-NC-ND
http://dx.doi.org/10.1016/j.bjane.2013.03.007
90
Y. Baydilek et al.
Conclusion: CSA technique with 0.25% levobupivacaine can be used as a regional anesthesia
method for elderly patients planned to have TUR-P operation.
2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda.
Este um artigo Open Access sob a licena de CC BY-NC-ND
Introduction
Anesthesia is applied in 10---20% of urologic interventions.
Anesthetic methods chosen within general principles are
topical, regional and general.1,2 Most patients with bladder
obstruction caused by benign prostatic hyperplasia are successfully treated by transurethral resection of the prostate
(TUR-P).3 TUR-P is often performed on older patients with
impaired renal function, cardiovascular and respiratory
problems. Research has found many side effects of TUR-P
including bleeding, transurethral resection syndrome (TUR),
bladder perforation, hypothermia, intraoperative and early
postoperative occurrence of disseminated intravascular
coagulation, with high reported morbidity rates. To minimize hemodynamic changes in these patients it is important
to provide stable anesthesia. General anesthesia may make
identication of complications such as TUR syndrome and
bladder perforation difcult, so regional anesthesia is the
preferred method in suitable TUR-P cases.4---7
Single-dose spinal anesthesia (SDSA) is widely used in
these interventions though it has the disadvantage of not
providing the required duration in operations that run longer
than expected. With the continuous spinal anesthesia (CSA)
technique, local anesthetic dose can repeated, thus making
it possible to use this spinal anesthesia method in operations
with long duration.8---12 Another advantage of CSA is that it
enables to titrate the dose of local anesthetic thus allowing better control of sensory and motor block level, no risk
of local anesthetic toxicity and providing shorter recovery
periods. Compared to SDSA, its most important advantage
is that it provides perfect hemodynamic stability. Furthermore, spinal catheter may be inserted in regional anesthesia
preparation room before the operation, thus preventing loss
of time between operations.10,13,14
Levobupivacaine, a bupivacaine S isomer commonly used
in spinal anesthesia (SA), has less side effects on the
cardiovascular (CVS) and central nervous systems (CNS)
than bupivacaine with similar effective onset time and
duration.7,15---17 Although levobupivacaine use in various
regional anesthesia techniques have been reported previously, description of its use in CSA is limited. We have
hypothesized that levobupivacaine provides better hemodynamic stability when used in CSA compared to SDSA. In order
to test this hypothesis, patients scheduled to have TUR-P
operation were administered either SDSA or CSA with levobupivacaine; hemodynamics, sensory-motor block levels,
anesthetic quality and complications were compared.
Statistical analysis
SPSS 11.5 program was used for statistical analysis of data.
The data was analyzed for normal distribution using the
91
Table 1
Group
Group CSA
(n = 25)
Group SDSA
(n = 25)
Age (year)
Weight (kg)
Operation time
(min)
ASA (I/II/III)
71.04 6.62
79.6 11.39
50.00 7.79
70.68 5.68
80.24 11.06
51.44 8.78
0.838
0.841
0.543
3/13/9
2/15/8
0.818
Results
The study comprised a total of 50 patients in 2 groups, all
patients completed the protocol.
Demographic data
There were no statistically signicant differences between
the two groups in terms of age, body weight, height, ASA
risk class and operation duration (Table 1).
Hemodynamic changes
Comparing the groups blood pressure in the 90, 100, 120,
150, 180 min and 4, 6, 9, 12, 15, 18 and 24 h after intrathecal
injection the CSA group was signicantly higher than the
SDSA group (p < 0.05) (Fig. 1).
Within the CSA group blood pressure in the 2.5, 5, 7.5, 10,
12.5, 15, 20, 25 and 30 min after intrathecal injection was
signicantly lower than the control values (p < 0.05) (Fig. 1).
Within the SDSA group when blood pressure changes were
examined they were found to be signicantly lower than the
control values at all times (p < 0.05) (Fig. 1).
There was no statistical difference between heart rate in
the two groups at any measurement time (p > 0.05) (Fig. 2).
Within each group heart rate was signicantly lower
than control values at all times after intrathecal injection
(p < 0.05) (Fig. 2).
92
Y. Baydilek et al.
Group CSA
mmHg
Group SDSA
102
96
90
24 h
18 h
15 h
12 h
4h
6h
9h
150 min
180 min
110 min
120 min
90 min
100 min
80 min
70 min
60 min
50 min
45 min
35 min
40 min
30 min
20 min
25 min
15 min
10. min
12.5 min
7.5 min
0. min
2.5. min
5. min
Control
84
Figure 1 Changes in mean arterial blood pressure (MAP). *p < 0.05 (between Group CSA and Group SDSA). p < 0.05 (signicant
difference compared with Group CSA control values). p < 0.05 (signicant difference compared with Group SDSA control values).
Group CSA
Group SDSA
76
HR (beat/min)
72
68
64
Control
0. min
2.5. min
5. min
7.5 min
10. min
12.5 min
15 min
20 min
25 min
30 min
35 min
40 min
45 min
50 min
60 min
70 min
80 min
90 min
100 min
110 min
120 min
150 min
180 min
4h
6h
9h
12 h
15 h
18 h
24 h
60
Time
p0.05 (significant difference compared with group CSA control values)
p0.05 (significant difference compared with group SDSA control values)
Figure 2 Changes in heart rate (HR). p < 0.05 (signicant difference compared with Group CSA control values). p < 0.05 (signicant difference compared with Group SDSA control values).
Anesthetic properties
Lumbar puncture was performed at L2---L3 interval in 8 and
at L3---L4 interval in 17 patients in the CSA group; 6 patients
had lumbar puncture at L2---L3 interval and 19 patients at
L3---L4 interval in the SDSA group. There was no statistically
signicant difference in lumbar puncture level between the
two groups (p > 0.05).
Comparing the groups modied Bromage scores (MBS)
from 5 to 120 min values were signicantly higher in group
SDSA than in group CSA (p < 0.05) (Fig. 3).
93
Group CSA
Group SDSA
MBS
150 min
180 min
4h
6h
9h
12 h
15 h
110 min
120 min
50 min
60 min
70 min
80 min
90 min
100 min
35 min
40 min
45 min
20 min
25 min
30 min
7.5 min
10. min
12.5 min
15 min
Control
0. min
2.5. min
5. min
Time
p0.05 (between group CSA and group SDSA)
Figure 3
Table 2
MBS changes in the groups. *p < 0.05 (between Group CSA and Group SDSA).
Block times
31.64
79.28
18.56
13.04
170.28
268.88
11.94
18.66
6.31
7.10
51.32
94.52
25.10
90.08
13.08
6.04
186.04
253.60
p
0.019*
0.030*
0.010*
0.000*
0.211
0.566
5.89
14.66
4.34
2.30
35.13
92.46
Group SDSA
Group CSA
Th5
Level
Th
L1
L5
15 h
9h
12 h
6h
4h
180 min
150 min
120 min
110 min
90 min
100 min
80 min
70 min
60 min
45 min
40 min
35 min
30 min
25 min
20 min
15 min
10. min
12.5 min
7.5 min
0. min
2.5. min
5. min
Control
S4
50 min
Time
p0.05 (between group CSA and group SDSA)
Figure 4
Sensory level changes in the groups. *p < 0.05 (between Group CSA and Group SDSA).
94
Y. Baydilek et al.
Table 3
Totals
Total
Total
Total
Total
Total
8.70
8.00
0.20
0.02
1290.20
levobupivacaine
morphine
ephedrine
atropine
liquids
1.63
3.78
1.00
0.1
180.01
Preop Adrenalin
Postop Adrenalin
Preop Cortisol
Postop Cortisol
249.90
190.04
168.95
127.51
0.000*
0.278
0.160
0.561
0.315
0.00
2.83
3.31
0.13
148.86
Group
12.50
6.96
1.20
0.04
1337.60
Table 4
62.63
52.63
85.51
57.10
265.40
180.76
134.22
89.37
70.90
54.77
51.07
32.98,*
0.446
0.570
0.111
0.010
Group CSA
Group SDSA
14
Number of requests
12
10
8
6
4
2
0
50
min
60
min
70
min
80
min
90
min
100
min
110
min
120
min
150
min
180
min
4h
6h
9h
12 h 15 h 18 h 24 h
Time
p0.05 (between group CSA and group SDSA)
Figure 5
Average number of requests from the PCA unit. *p < 0.05 (between Group CSA and Group SDSA).
signicant difference between the two groups average consumption of morphine, ephedrine, atropine and liquids
(p > 0.05) (Table 3).
No difference was found in the number of doses given
by the two groups PCA machines (p > 0.05). Comparing the
number of requests to the PCA machines at 9, 18 and 24 h
the CSA group requests were signicantly higher than the
SDSA group (p < 0.05) (Fig. 5).
No signicant difference was found between the two
groups plasma adrenaline levels (p > 0.05) (Table 4).
Within each group postoperative plasma adrenalin levels
were signicantly lower than the preoperative control levels
(p < 0.05) (Table 4).
Comparing the groups postoperative serum cortisol levels, the SDSA group levels were signicantly lower than the
CSA group levels (p < 0.05) (Table 4).
Within both groups postoperative serum cortisol levels
were signicantly lower than preoperative control levels
(p < 0.05) (Table 4).
Table 5
Group
Nausea:
0
Vomiting:
0
Respiratory depression:
0
Headache:
0
Lower back pain:
9 (36%)
Rash:
0
*
Group SDSA p
(n = 25)
2 (8%)
0
0
1 (4%)
2 (8%)
0
0.153
1.000
1.000
0.317
0.018*
1.000
Discussion
This study compared continuous spinal anesthesia with
single-dose spinal anesthesia using levobupivacaine in
geriatric patients undergoing transurethral urologic interventions. We found that continuous spinal anesthesia
provided better hemodynamic stability, shorter recovery
periods and equal anesthetic quality.
In older patients increases in health problems combined
with suppressed physiologic compensatory mechanisms
means that hemodynamic instability linked to spinal anesthesia may be more serious and last longer. Rapid spread
of sympathetic block in spinal anesthesia may cause an
increase in morbidity, especially in older patients with
reduced cardiovascular adaptation mechanisms.18 One of
the most important factors to be aware of in patients of
increased age and with accompanying diseases is hemodynamic stability. In a prospective study on cardiac arrest
linked to anesthesia Biboulet et al.19 determined the most
important factors in cardiac arrest in patients over 84 and
with an ASA risk factor of 3 and above. They found inappropriate anesthetic doses, hypovolemia and hypoxia due
to difculty keeping the airway open were the most common reasons for cardiac arrest. Especially in patients who
are older, or have cardiovascular and respiratory system
problems, even low doses may result in greater anesthetic
levels, so techniques such as CSA which allow the possibility
of dose titration should be given preference compared to
SDSA.20
Favarel et al.,21 in a study comparing CSA and SDSA use
of 0.5% hyperbaric bupivacaine, showed that blood pressure lowered less in the CSA group compared to the SDSA
group. The researchers found that the CSA group had less
hemodynamic changes and that the slower start of segmental block and slow development of sympathetic block made
adaptation easier.21 De Andres et al.22 used 0.5% isobaric
bupivacaine in their comparison of CSA and SDSA and found
hypotension due to the repeated dose in the CSA group did
not need vasopressor drugs while the incidence of hypotension in the SDSA group was greater.
Klimscha et al.18 compared 0.5% isobaric bupivacaine in
CSA, SDSA and epidural anesthesia. Blood pressure in the
CSA group did not reduce, in continuous epidural anesthesia there was a 15 3% reduction and a 19 2% decrease
in the SDSA group. A comparison of SDSA with CSA by Reisli
et al.23 found a signicant reduction in blood pressure in the
SDSA group compared to the CSA group. Labaille et al.24 used
low dose 0.125% isobaric bupivacaine with CSA technique
to provide effective anesthesia with minimal hemodynamic
changes in older patients. Minville et al.25 compared SDSA
and CSA with low dose bupivacaine in planned hip operations in patients over 75 years. Occurrence of hypotension
in the CSA group was 31% and 68% in the SDSA group; serious hypotension was 8% in the CSA group and 51% in the
SDSA group. In the CSA group 4.5 2 mg ephedrine was
consumed, compared with 11 2 mg in the SDSA group.
They found the CSA group was hemodynamically more stable.
However Pitkanen et al.26 compared CSA and SDSA techniques in planned hip and knee operations in 40 patients and
found no signicant difference in hemodynamic stability of
the groups.
95
This study found both groups had lower blood pressure
than the control values. In the CSA group 4% of patients
developed hypotension compared to 12% in the SDSA group,
subsequently the dose of ephedrine used was lower in the
CSA group. The lower blood pressure in the SDSA group compared to the CSA group is similar to results from previous
studies. Results from the use of levobupivacaine for CSA
showed that it provides more hemodynamic stability than
bupivacaine in CSA, in agreement with previously published
research.
Patients under spinal anesthesia show a reduction in
heart rate due to preganglion ber blockage and a reduction in left atrium pressure.8 Shenkman et al.27 used low
doses of local anesthetic with the CSA technique to provide
good control of hemodynamics and this advantage over the
SDSA technique made it suitable for use in older and more
high risk patients. They found a maximum reduction in heart
rate of 7.2% using 0.1% bupivacaine for CSA in ASA III---IV risk
group patients. The researchers found that using CSA they
could modify the sensory block level in a controlled fashion
and reduce the risk of hemodynamic instability.27 Favarel
et al.21 found no signicant difference in heart rate using
hyperbaric bupivacaine for CSA and SDSA. Similar research
nding no signicant difference in heart rate when using CSA
compared to SDSA is available.18,25,28 This study found no signicant difference in heart rate between the CSA and SDSA
groups at any time interval, similar to the literature.
Research evaluating CSA using levobupivacaine are
limited. The only research in literature by Sell et al.14
found the minimum effective dose of local anesthetic was
11.7 mg using levobupivacaine for CSA in hip replacement
operations. Our study found an average dose of 8.7 mg levobupivacaine provided sufcient anesthesia. We are of the
opinion that the difference may be due to demographics,
position, intended block level and other such factors.
This study found the time to reach dermatome T10
sensory block level was signicantly longer in the CSA
group than the SDSA group. This is similar to times to
reach sensory block levels that allow surgery in previous
research.21,22,29 While there was no signicant difference in
peak dermatome, the time for the CSA group to reach peak
dermatome was signicantly longer. This result conforms
with previous studies.18,28
Comparing Bromage scale evaluations of motor block
level the CSA group was signicantly lower than the SDSA
group. While motor block is a desirable characteristic in
surgeries such as orthopedics, it delays neurologic evaluation postoperatively and obstructs mobilization. For this
reason an early end to motor block is a desirable property.
The lower degree of, and early end to, motor block in the
CSA group could be seen as an advantage.
SDSA group patients required an average of 12.5 mg levobupivacaine compared to 8.7 mg for the CSA group. Though
the CSA group used less local anesthetic, sufcient anesthetic level, similar to the SDSA group, was achieved.
No signicant difference was found between the groups
in terms of pain levels evaluated using VRS. While there was
no difference in the two groups use of morphine and number of time drugs were given by the PCA unit, there were
signicantly more requests from the PCA units by the CSA
group 9, 18 and 24 h after the operation. We believe this
may be due to greater complaints of back pain by the CSA
96
group compared to the SDSA group. It may also be due to
the lower local anesthetic dose and lower nerve block level
in the CSA group.
It is known that epidural and spinal anesthesia at different levels suppresses the neuroendocrine stress response
better than general anesthetic. High level spinal block is
necessary to suppress the andrenergic response.30 Seitz
et al.31 found cortisol increased during surgery in lower
extremity operations using general anesthetic, while the
epidural anesthetic group had lower levels compared to values from before surgery. Pfug et al.32 found higher levels of
adrenalin postoperatively compared to control values. Low
level spinal anesthesia prevents this increase, the high level
spinal anesthetic group had values lower than the controls.
While Moller et al.33 found no difference in cortisol levels in
the late postoperative period comparing spinal and general
anesthesia, during surgery and in the early postoperative
period cortisol levels were lower in the spinal anesthesia
group. Comparing the postoperative plasma adrenalin and
serum cortisol levels in both groups in this study, both groups
had lower levels compared to control values. The SDSA
group postoperative serum cortisol levels were signicantly
lower. The higher nerve block level in the SDSA group may
be responsible for greater suppression of afferent neural
impulses originating in the splanchnic sympathetic nerves.
In conclusion continuous spinal anesthesia using 0.25%
concentration levobupivacaine to provide regional anesthesia for transurethral prostate resection operations in older
patients can be used safely.
Conict of interest
The authors declare no conicts of interest.
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