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Rawal Medical Journal

An official publication of Pakistan Medical Association Rawalpindi Islamabad branch

Established 1975

Volume 36 Number 2 March- June 2011

Original Article

Low-dose Bupivacaine with fentanyl spinal anesthesia to prevent

spinal-induced hypotension in adults

Mohammed Shawagfeh, Ahmad S Sbaihat, Essa A Mayyas, Ala D Alomari, SafwanG Fawaris

Department of anesthesia and surgery, Prince Rashid Hospital, Amman, Jordan

ABSTRACT

Objectives

To assess the usefulness and efficacy of low-dose Bupivacaine with Fentanyl spinal

anesthesia for prevention of hypotension while maintaining good anesthetic

conditions.

Patients and Methods

At Prince Rashid Hospital, 100 adult patients were randomized into two groups. The

study group (F) comprised of 50 patients who received spinal anesthesia with

Bupivacaine 7.5-9mg and fentanyl 25 g, while in control group (B), 50 patients

received Bupivacaine 12.5-15mg only. The homodynamic stability of the patients and

the quality of the blocks were compared.

Results

All patients had adequate duration of reliable blocks. More control group patients than

study group patients required ephedrine due to hypotension.

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Conclusion

A reduced dose of Bupivacaine in combination with fentanyl provided reliable spinal

anesthesia with few events of hypotension and little need for vasopressor support for

blood pressure. (Rawal Med J 2011;36:116-119).

Key words

Bupivacaine, fentanyl, spinal anesthesia.

INTRODUCTION

The ideal spinal anesthesia for ambulatory surgery should provide good surgical

anesthesia with rapid recovery from sensory and motor block.1 Lignocaine has been

widely advocated for ambulatory anesthesia but many studies have questioned the use

of hyperbaric 5% lignocaine for spinal anesthesia and recommended consideration of

bupivacaine as a substitute.2Bupivacaine, an amide type of local anesthetic, has high

potency, slow onset (58 minutes) and long duration of action (1.52 hours).

Although spinal anesthesia is safe but it is not devoid of complication, hypotension

and sinus bradycardia are the most complication and are attributed to the imbalance

between sympathetic and parasympathetic control of the heart rate. Stimulation of the

sympathetic system may induce myocardial ischemia by causing coronary

vasoconstriction3 and may be related to the genesis of ventricular tachyarrhythmia.4

Hypotension after spinal anesthesia is often treated with vasopressors and intravenous

fluids. This regime is controversial for the geriatric population with coronary disease5

may increase risk of pulmonary oedema in high-risk pregnant patients and has been

associated with fetal acidosis.6Bupivicaine has other side effects like increased motor

block and bladder dysfunction leading to delayed discharge.7

There has been controversy concerning the relationship between volume,

concentration and total dose of spinally administered drugs. Most of the studies

suggest that the total dosage is more important than the volume.8These concerns have

increased interest in the use of small doses of bupivacaine.9 Intrathecal opioids have

been shown to enhance analgesia from sub therapeutic doses of local anesthetics and

make it possible to achieve spinal anesthesia using otherwise inadequate doses of

local anesthetic.10,11 In this study, we focused on the usefulness and efficacy of low-

dose bupivacaine with fentanyl spinal anesthesia to prevent hypotension and other

complications while maintaining good anesthetic conditions.

PATIENTS AND METHODS

This prospective study included 100 patients who underwent lower abdominal,

anorectal, orthopedic and obstetric surgery under spinal anesthesia technique fromFebruary 2008 to December 2008 at Prince Rashid Hospital. Patients with a history of

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previous back surgery, infection at the injection site, uncontrolled hypertension,

hypersensitivity to amide local anesthetics or fentanyl, mental disturbance, or

neurologic disease coagulation disorders were excluded from the study as well as

patients who required conversion to general anesthesia. The approval of the

Institutional Ethical Studies Committee was given for the study

Patients were divided into two group each group with fifty patients. In the first group

(F), 7.5-9 mg of 0.5 percent heavy bupivcaine was injected intrathecaly plus 25 mu

fentanyl. In the second group (B), 12.5-15 mg of 0.5 percent heavy bupivcaine only

was injected intrathecaly. The study was randomized and double-blind regarding the

anesthesia solution, with the subjects being assigned to a study group or a control

group using a sealed-envelope technique.

No premedication was given. ECG, non-invasive blood pressure, heart rate and

peripheral oxygen saturation were monitored. After an intravenous access was

established the patients were received 500 ml of sodium chloride 0.9% solution over

30 min. The intravenous infusion was maintained at (8 ml/kg/1.h) during the intra-

operative period. Oxygen was continuously given via a face mask. Systolic arterial

pressure (SAP) and heart rate (HR) were recorded at 5 minute interval at the onset of

block, then at 15 minute intervals until the resolution of the block. Hypotension (SAP

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Table 1. Type of surgical procedures.

Procedure Number

Inguinal hernia 39

Anorectal surgery 27

orthopedic surgery 27

Obstetric surgery 5

High ligation of varicose vein 2

Total 100

The sensory and motor block in the two groups is shown in Table 2.

Table 2. Sensory and motor block variables.

Variable Group F Group B

Numberof dermatomes

blocked( mean)

13 11

Upper limit of sensory

block

T12 T11

Time to reach peak ofsensory block(minute)

8.6 9.1

Maximum motor block

(Bromage scale 0-3) mean

1 2

Duration of motor block

(minute)

110.6 134.4

Time of sensory regression

(minute)

174 191.2

Two segment

regression(minute)

55.4 64.4

The number of dermatomes blocked was relatively comparable in both groups as well

as the median upper limit of the sensory block. Recovery of motor function took place

significantly earlier in Group F compared with Group B (110.6 minute vs 134.4

minute).

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Table 3. Pain variables.

Group F B

Number of patients needing intra-operative

analgesia (intravenous fentanyl)

8 9

Average pethidine dose post operatively

(mg) per patient

245 267

VAS (intra operative 0-10) 2.7 2.8

VAS (post operative 0-10) 5.1 4.9

Time to reach of peak sensory lose was earlier in group F, however did not differsignificantly. Although the two-segment regression was slower in Group B compared

with Group F but did not seemed to be significant, but time for sensory recovery was

earlier in group F than group B, (174.3 minute vs 191.2 minute).

No differences were found between the groups in the total analgesic consumption

(Table 3), or the number of patients who required postoperative analgesics in the

recovery room.

Table 4. Adverse effects.

Group F

(number)

B

(number)

Hypotension 3 13

Total of ephedrine doses

(mg)

97.5 20.0

Bradycardia 2 1

Nausea and vomiting 1 2

Shivering 1 2

Pruritus 3 1

Respiratory depression 0 0

Transient neurological

manifestation

0 0

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Lowest SAP (

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Correspondence: Dr Issa mayyas, Department of Surger

Email:issamayyas@yahoo.com Tel: 00962777314092

Received: January 2, 2011 Accepted: February 2, 2011

REFERENCES

1. Liu S. Optimizing spinal anesthesia for ambulatory surgery. Regional

Anesthesia

1997;22:500-10.

2. Drasner K. Lidocaine spinal anesthesia. A vanishing therapeutic index?

Anesthesiology

1997;87:469-72.

3. Remme WJ. The sympathetic nervous system and ischaemic heart disease. Eur

Heart J 1998;19:F62-71.

4. Podrid PJ, Fuchs T, Candinas R. Role of the sympathetic nervous system in

the genesis of ventricular arrhythmia. Circulation 1990;82:103-13

5.

Critchley LA. Hypotension, subarachnoid block and the elderly patient.

Anaesthesia 1996;51:1139-43.

6. Lee A, Ngan Kee WD, Gin T. Prophylactic ephedrine prevents hypotension

during spinal anesthesia for cesarean delivery but does not improve neonatal

outcome: a quantitative systematic review. Can J Anaesth 2002;49:588-99.

7.

Vaghadia H. Spinal anaesthesia for outpatients: controversies and new

techniques. Can J Anaesth 1998;45:R64-70

8. Cherng Y-G, Huang H-H, Chen T-G, Huang C-L. The effect of cerebrospinal

fluid dilution of isobaric 0.5% bupivacaine used for spinal anaesthesia.

Anaesthesia1995;50:906-9

9. Ben-David B, Levin H, Solomon E. Spinal bupivacaine in ambulatory surgery:

the effect of saline dilution. Anesth Analg 1996;83:716-20.

10.-Maves TJ, Gebhart GE Antinociceptive synergy between intrathecal

morphine and lidocaine during visceral and somatic nociception in the rat.

Anesthesiology 1992;76:9l-99.

11.Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl

with small-dose dilute bupivacaine: Better anesthesia without prolonging

recovery. Anesth Ann 1997;85:560-5.

12.

Courtney MA, Bader AM, Hartwell B, Hauch M, Grennan MJ, Datta S.

Perioperative analgesia with subarachnoid sufentanil administration. Regional

Anesthesia 1992;17:274-8.

8/10/2019 27-1305144585

8/8

13.Kang FC, Tsai YC, Chang PJ, Chen TY: Subarachnoid fentanyl with dilute

small dose bupivacaine for cesarean section. Acta Anaesthesiol Sin 1998,

36:207-214.

14.Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose

bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the

aged. Anesthesiology 2000; 92: 610

15.

Vaghadia H, McLeod DH, Mitchell GW, Merrick PM, Chilvers CR. Small-

dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration

outpatient laparoscopy. I. A randomized comparison with conventional dose

hyperbaric lidocaine. Anesthesia and Analgesia 1997; 84: 5964.

16.Liu S, Chiu AA, Carpenter RL, Mulroy MF, Allen HW, Neal JM, Pollock JE.

Fentanyl prolongs lidocaine spinal anesthesia without prolonging recovery.

Anesth Analg 1995; 80:730-734.