Rev Bras Anestesiol.

2014;64(2):89---97

REVISTA
BRASILEIRA DE
ANESTESIOLOGIA

Ofcial Publication of the Brazilian Society of Anesthesiology

www.sba.com.br

SCIENTIFIC ARTICLE

The comparison of levobupivacaine in continuous or single dose

spinal anesthesia for transurethral resection of prostate surgery
Yunus Baydilek a , Blent Serhan Yurtlu b, , Volkan Hanci c , Hilal Ayo
glu b ,
b
d
e
gan Kayhan , Hsn Tokgz , Grkem Mungan f ,
Rahs
an Dilek Okyay , Gulay Erdo
ak b
Is
l zkoc
a

Clinic of Anesthesiology Sani Konuko

glu Hospital, Gaziantep, Turkey
Department of Anesthesiology and Reanimation, Bulent Ecevit University, Zonguldak, Turkey
c
Department of Anesthesiology and Reanimation, C
anakkale Onsekiz Mart University, C
anakkale, Turkey
d
Department of Anesthesiology and Reanimation, Inon University, Zonguldak, Turkey
e
Department of Urology, Bulent Ecevit University, Zonguldak, Turkey
f
Department of Biochemistry, Bulent Ecevit University, Zonguldak, Turkey
b

Received 1 May 2012; accepted 20 March 2013

Available online 11 October 2013

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.

Materials and methods

After receiving permission from Bulent Ecevit University
Medical Faculty Hospital Ethics Committee (06.12.2007,

Decision no. 2007/09/17), this research was carried out in

the Department of Anesthesiology and Reanimation between
December 2007 and June 2008. Fifty patients over the age
of 60 scheduled to have elective TUR-P interventions at ASA
I---III risk groups were included in the study after reading the
informed consent form. The patients were randomized into
either continuous spinal anesthesia group (Group CSA, n:25)
or single-dose spinal anesthesia group (Group SDSA, n:25) by
randomized numbers table.
Exclusion criteria were refusing to be included in the
study, allergies to the research drugs, severe cardiac failure
(unstable coronary artery disease, 2nd and 3rd degree heart
block, congestive heart failure, ventricular tachyarrhythmia) and valvular heart disease (serious aortic stenosis),
coagulation abnormalities, low molecular weight heparin
administration in the previous 12 h, intake of non-steroidal
anti-inammatory drug within the 24 h, history of alcohol or
drug addiction, presence of neurologic disorders or psychiatric disease.
All the patients were premedicated with 0.03 mg/kg
midozolam (Dormicum ) intramuscularly 30 min prior to
their arrival to operation theater. Patients were taken to
the preoperative preparation unit and were monitored (noninvasive blood pressure, heart rate and peripheral oxygen
saturation while breathing room air) these values were
recorded as control values. Patients were given 4 l/min
oxygen through a mask, a 20 G cannula was inserted for
intravenous access and 10 mL/kg 0.09% saline was infused
within 30 min, afterwards the rate was set at 5 mL kg/h.
Blood samples taken from each patient while opening the
vein was centrifuged to separated plasma from serum and
stored in a freezer at 20 C.
All patients had lumbar puncture under aseptic conditions, while sitting, between L3---4 or L 2---3 according to
anesthesists preference. The lumbar puncture level was
recorded. Skin and subcutaneous 2 mL 2% lidocaine (Aritmal
5 mL ampoule) inltration anesthesia was given with a 22 G
needle. Anesthesia was begun for Group CSA with 2 mL 0.25%
levobupivacaine after a 22 G spinal catheter (Spinocath )
was placed 2---3 cm into the intrathecal interval. After the
10th min if the level of sensory block had not reached T10,
an extra 1 mL 0.25% levobupivacaine was given through the
catheter, this was repeated at 10 min intervals until T10
block level was reached. The total dose of levobupivacaine
was recorded.
Spinal anesthesia was induced in group SDSA patients
with 12.5 mg (2.5 mL) 0.5% levobupivacaine injected into the
intrathecal interval with a 22 G Quinke needle.
After the injection blood pressure, heart rate, SpO2 , pinprick test for sensory block level, and modied Bromage
scale (MBS) were used to evaluate degree of motor block
every 2.5 min up to the 15th min and every 5 min between

Levobupivacaine: continuous & single dose spinal anesthesia

15 and 45 min. (MBS: 0 no paralysis, patient can fully ex foot
and knee; 1 Can only move knee and foot, cannot lift straight
leg; 2 cannot bend knee, can only move foot; 3 full paralysis.) After 45 min the patients were taken to the operating
room.
In both groups the time from the injection to sensory
block level reaching dermatome T10 was recorded as the
surgical anesthetic duration. It was planned that patients
who reached dermatome T10 and above sensory block level
gave permission for the operation. After spinal injection
until MBS 1 was reached was denoted the motor block initiation time. From the injection to peak dermatome that
is sensory block level reached maximum dermatome, was
called the peak dermatome time. From the start of the
surgical procedure to the end was the operation duration.
Sensory block level was checked using the pin-prick test
(needle prick). Sensory block level was assumed to have
reached the dermatome when the patient no longer felt the
needle prick.
When mean arterial blood pressure (MAP) decreased 20%
from the basal level hypotension was diagnosed and 5 mg
ephedrine HCL (Osel drugs) was administered. Heart rate
below 50 beats per min was accepted as bradycardia and
0.5 mg atropine (atropine 1 mL amp, Drogsan) was administered. Total liquids given to the patient, as well as ephedrine
and atropine doses were recorded.
Patients taken to the operating theater were monitored
using an ADU anesthetic monitor (Datex-Ohmeda S/5 Anesthetic Monitor) for 5-lead surface electrocardiogram (ECG,
DII), SpO2 and non-invasive arterial blood pressure.
After the operation nished the CSA group had the
catheter removed. Both groups were given a PCA unit
(Abbot Pain Management Provider) with iv morphine (bolus
dose: 2 mg, lock-out time 30 min) for postoperative analgesia. From intrathecal injection to rst use of the PCA was
recorded as the rst analgesic duration.
Following intrathecal injection all patients were monitored at 50, 60, 70, 80, 90, 100, 110, 120, 150, 180 min
and 4, 6, 9, 12, 15, 18 and 24 h. Values for blood
pressure, heart rate, SpO2 , VRS (verbal pain evaluation
scoring), sensory block level, MBS score, PCA machine
requests (Dem), number of times drugs were administered by PCA (Del) and total morphine given by PCA were
recorded.
Degree of pain was evaluated using VRS (0: no pain; 1
slight pain; 2 moderate pain; 3 severe pain; 4 very severe
pain; 5 unbearable pain). From peak dermatome sensory
block until it regressed two levels was recorded as the second dermatome reduction duration. From spinal injection
to MBS score of 0 was recorded as Bromage scale 0 duration. Eight hours after the operation blood samples from all
patients were centrifuged to separate serum from plasma
and stored in a freezer at 20 C. At the end of the research
serum cortisol and plasma adrenaline levels in preoperative
and postoperative blood samples were measured using the
ELISA method.

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

Demographic data (mean SD).

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

Kolmogorov Smirnoff test. The Mann Whitney U test was

used to compare the following continuous data from the two
groups: operation duration, height, weight, age, blood pressure, heart rate, sensory block level, highest sensory block
level, sensory block dermatome T10 time, sensory block
two segment regression time, MBS, VRS, time of rst analgesic dose, total analgesic use, PCA requests and number
of times drugs were administered by PCA Del/Dem values,
total atropine and ephedrine use, and cortisol and adrenalin
levels. To analyze the repetition of these data within the
groups the Wilcoxon test was used. The chi-square test
was used to analyze frequency (%) results of ASA physical classication, lumbar puncture level, nausea-vomiting
and side effects. Descriptive statistics for the data such as
mean and standard deviation (mean SD), mode and frequency (number and %) were determined. Graphs of the
changes in difference between the groups against time were
constructed. A value of p < 0.05 was accepted as signicant.

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

p0.05 (between group CSA and group SDSA)

p0.05 (significant difference compared with group CSA control values)
p0.05 (significant difference compared with group SDSA control values)

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).

Comparing the groups sensory block levels at 2.5, 5, 7.5,

10, 12.5, 15, 20, 25, 30 and 35 min after intrathecal injection
the SDSA group values were signicantly higher than the CSA
group (p > 0.05) (Fig. 4).
No statistically signicant difference was found between
VRS scores for the groups (p > 0.05). Average peak dermatome values were T8 for the CSA group and T7 for the
SDSA group. There was no signicant difference between
the two groups peak dermatome values (p > 0.05).
Comparing the groups block times average peak duration, surgical anesthetic duration, and motor block start

Levobupivacaine: continuous & single dose spinal anesthesia

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 (min) (mean SD).

Block times

Group CSA (n = 25)

Time to reach peak dermatome

Two segment regression time
Surgical operation time
Motor block start time
Time to reach MBS 0
First analgesic time

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

p < 0.05 (between Group CSA and Group SDSA).

between the two groups MBS 0 and rst use of analgesia

times (p > 0.05) (Table 2).
Group SDSA used a signicantly higher dose of levobupivacaine than group CSA (p < 0.05). There was no statistically

time in the SDSA group was signicantly shorter than in the

CSA group. At the same time the two segment regression
time was signicantly longer in group SDSA than in group
CSA (p < 0.05) (Table 2). No signicant difference was found

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

Group SDSA (n = 25)

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

Total drugs and liquids given (mean SD).

Totals

Group CSA (n = 25)

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

Group CSA (n = 22)

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

Preoperative and postoperative adrenalin and cortisol levels (mean SD).

Group

12.50
6.96
1.20
0.04
1337.60

p < 0.05 (between Group CSA and Group SDSA).

Table 4

Group SDSA (n = 25)

Group SDSA (n = 22)

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

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

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).

Comparing side effects in both groups, while there was no

difference between the groups in terms of nausea, vomiting,
respiratory depression, headache and rash, lower back pain
in group CSA was signicantly greater than in group SDSA
(p < 0.05) (Table 5).

Table 5
Group

Side effects (n, %).

Group CSA
(n = 25)

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

p < 0.05 (between Group CSA and Group SDSA).

0.153
1.000
1.000
0.317
0.018*
1.000

Levobupivacaine: continuous & single dose spinal anesthesia

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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