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Karim HMR, Khan IA, Ayub A, Ahmed G. Comparison of Hemodynamic and Recovery Profile Between Segmental Thoracic Spinal and General Anesthesia in Upper Abdominal and Breast Surgeries: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e68792. [PMID: 39371870 PMCID: PMC11456287 DOI: 10.7759/cureus.68792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2024] [Indexed: 10/08/2024] Open
Abstract
Segmental thoracic spinal anesthesia (STSA) has been described primarily as case reports for performing upper abdominal and thoracic surgeries in significant respiratory comorbid patients. A few comparative studies have recently evaluated the technique as an advantageous alternative to general anesthesia (GA). However, there is no systematic evaluation and comparison of the techniques. The present systematic review evaluated the hemodynamic, comfort, and satisfaction of patients undergoing abdominal and thoracic surgeries under STSA and GA. PubMed, CENTRAL, Google Scholar Advanced, and citation tracking were performed to find suitable articles that compared STSA and GA. The primary objective-related data were hypotension and bradycardia. The secondary objective-related data in the context of postoperative nausea vomiting (PONV), pain, rescue analgesics, sedation requirement, satisfaction, and comfort were assessed. Meta-analysis was performed for dichotomous data on hypotension, bradycardia, and PONV; odds ratio (OR) and 95% confidence interval (CI) were reported. Data of 394 patients from six studies were evaluated. Patients undergoing upper abdominal and breast surgeries under STSA had significantly higher odds of hypotension (Fixed-Effect Model OR 12.23, 95% CI 2.81-53.28; I2 =0%, and the Random Effects Model OR 12.01, 95% CI 2.75-52.52; I2 =0%) and bradycardia (Fixed-Effect Model OR 10.95, 95% CI 2.94-40.74, I2 =0%, and the Random Effects Model OR 9.97, 95% CI 2.61-38.08; I2 =0%) but lower odds of PONV (Fixed-Effect Model OR 0.24, 95% CI 0.13-0.43; I2 =0%, and the Random Effects Model OR 0.24, 95% CI 0.13-0.45; I2 =0%). Most of the patients undergoing STSA were given intravenous sedation to overcome anxiety and discomfort. Overall, patient satisfaction was on par with GA. However, few surgeons were unenthusiastic about the technique while performing axillary clearances due to bothering twitches from cautery. STSA led to early post-anesthesia care unit (PACU) discharge and provided better pain control, lowering the need for rescue analgesics and opioid consumption in the first 24-hour postoperative period. STSA is associated with very high odds of hypotension and bradycardia as compared to GA. On the other hand, STSA demonstrated superior pain control, reduced opioid requirements, shorter PACU stays, and significantly reduced risk of PONV. Nevertheless, STSA patients mostly require sedation to make the patient comfortable.
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Affiliation(s)
- Habib Md R Karim
- Anesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Guwahati, Guwahati, IND
| | - Imran A Khan
- Community Medicine, Baba Raghav Das Medical College, Gorakhpur, IND
| | - Arshad Ayub
- Community and Family Medicine, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
| | - Ghazal Ahmed
- Dermatology, Venereology, and Leprosy, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
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Boykov N, Ferdinandov D, Vasileva P, Yankov D, Burev S, Tanova R. Thoracic spinal anesthesia with intrathecal sedation for lower back surgery: a retrospective cohort study. Front Med (Lausanne) 2024; 11:1387935. [PMID: 38665296 PMCID: PMC11043566 DOI: 10.3389/fmed.2024.1387935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Background Spinal anesthesia (SA) is a good alternative to general anesthesia (GA) for spine surgery. Despite that, a few case series concern the use of thoracic spinal anesthesia for short-duration surgical interventions. In search of an alternative approach to GA and a better opioid-free modality, we aimed to investigate the safety, feasibility, and patient satisfaction of thoracic SA for spine surgery. Materials and methods We analyzed retrospectively a cohort of 24 patients operated on for a degenerative and osteoporotic pathology of the lower thoracic and lumbar spine. Data was collected from medical records, including clinical notes, operative and anesthesia records, and patient questionnaires. Results Twenty-one surgeries for herniated discs, two for degenerative spinal stenosis, and one for multi-level osteoporotic vertebral body fractures were performed under spinal anesthesia with intrathecal sedation. In all cases, we applied 0.5% isobaric bupivacaine and the following adjuvants: midazolam, clonidine or dexmedetomidine, and dexamethasone. We boosted the anesthesia with local ropivacaine due to inefficient sensory block in two patients. Nobody in the cohort received intravenous opioids, non-steroidal anti-inflammatory drugs, or additional sedation intraoperatively. Postoperative painkillers were upon the patient's request. No significant complications were detected. Conclusion Thoracic spinal anesthesia incorporating adjuvants such as midazolam, clonidine or dexmedetomidine, and dexamethasone demonstrates not only efficient conditions for spine surgery, a favorable safety profile, high patient satisfaction, and intrathecal sedation but also effective opioid-free pain management.
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Affiliation(s)
- Nikolay Boykov
- Department of Anesthesiology and Intensive Care, St. Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Dilyan Ferdinandov
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- Department of Neurosurgery, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Petra Vasileva
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- Department of Neurosurgery, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Dimo Yankov
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- Department of Neurosurgery, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Stefan Burev
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Rositsa Tanova
- Department of Anesthesiology and Intensive Care, St. Ivan Rilski University Hospital, Sofia, Bulgaria
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
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Paliwal N, Kokate MV, Deshpande NA, Khan IA. Spinal Anaesthesia Using Hypobaric Drugs: A Review of Current Evidence. Cureus 2024; 16:e56069. [PMID: 38618403 PMCID: PMC11009833 DOI: 10.7759/cureus.56069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
Spinal anesthesia is one of the most widely used techniques in modern anesthesia practice. It involves the injection of local anesthetic drugs into the cerebrospinal fluid (CSF) within the subarachnoid space. The choice of drug, its concentration, and baricity play a crucial role in determining the characteristics of the spinal block and has evolved over the years with continuous advancements in drug formulations and administration methods. Spinal anesthesia with hypobaric drugs represents a valuable technique in the armamentarium of anesthesiologists, offering distinct advantages in terms of targeted action, reduced systemic toxicity, and enhanced hemodynamic stability. This review aims to scan the characteristics of hypobaric drugs, factors influencing their spread within the spinal canal, challenges associated with their use, clinical applications in various surgical scenarios, and potential implications for patient outcomes and healthcare practice. PubMed and Google Scholar databases were searched for relevant articles and a total of 23 relevant articles were selected for the review based on inclusion and exclusion criteria. Hypobaric drugs have many advantages in high-risk morbidly ill patients for some select surgical procedures and daycare surgeries. The concentration and volume of hypobaric drugs need to be selected according to the extensiveness of the surgery and the desired block can be achieved by giving spinal injection in specific positions. The dynamic field of anesthesiology encompasses the integration of emerging technologies and evidence-based practices, which will contribute to further refining the safety and efficacy of spinal anesthesia with hypobaric drugs.
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Affiliation(s)
- Naresh Paliwal
- Anesthesiology, Dr. Panjabrao Deshmukh Memorial Medical College, Amravati, IND
| | - Minal V Kokate
- Anesthesiology, Dr. Panjabrao Deshmukh Memorial Medical College, Amravati, IND
| | - Nandini A Deshpande
- Anesthesiology, Dr. Panjabrao Deshmukh Memorial Medical College, Amravati, IND
| | - Imran Ahmed Khan
- Community Medicine, Baba Raghav Das Medical College, Gorakhpur, IND
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Mahdi AH, Kahloul M, Mohammed MJ, Mohammed AK. Effects of Ketamine and Tramadol As Adjuvants to Bupivacaine in Spinal Anesthesia for Unilateral Open Ovarian Cystectomy: A Randomized Controlled Trial. Cureus 2024; 16:e54776. [PMID: 38405643 PMCID: PMC10890904 DOI: 10.7759/cureus.54776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Spinal anesthesia offers numerous advantages and desirable features. However, it is associated with various side effects related to local anesthetic agents used. Reducing the dose of local anesthetic in spinal anesthesia can help minimize side effects but may lead to a diminished analgesic effect or failure of anesthesia. Therefore, adding an adjuvant may enhance the benefits while mitigating side effects. OBJECTIVE This study aimed to evaluate the effects of ketamine and tramadol as adjuvants to bupivacaine on the duration of spinal analgesia. The objectives were to compare the three groups and prove their analgesic effects, safety, and superiority. The primary outcomes were the duration of spinal analgesia, as well as the onset and duration of both sensory and motor blocks. Secondary outcomes included the heart rate, mean arterial pressure, and the incidence of undesired effects such as nausea, vomiting, sedation, shivering, and postoperative headache. METHODS In this double-blind randomized controlled trial, 120 female patients undergoing elective open unilateral ovarian cystectomy under spinal anesthesia were studied. The inclusion criteria included patients aged 16-45 years with a physical status classified as American Society of Anesthesiologists (ASA) class I and II. Patients were randomly allocated into three groups: group B (n=40) received only bupivacaine, group BK (n=40) received bupivacaine mixed with preservative-free ketamine, and group BT (n=40) received bupivacaine mixed with preservative-free tramadol. RESULTS The mean duration of spinal analgesia, measured in minutes, showed significant differences (P < 0.001) between group BK (165 ± 4) and group B (170 ± 5). There was also a significant difference between group BT (313 ± 8) and group B (170 ± 5) (P < 0.001). Additionally, significant differences were observed between group BK (165 ± 4) and group BT (313 ± 8) (P < 0.001). CONCLUSION The administration of 25 mg of ketamine and 25 mg of tramadol as adjuvants to bupivacaine in spinal anesthesia significantly affected the postoperative duration of analgesia. Tramadol prolonged the duration of spinal anesthesia, while ketamine shortened it. The use of both adjuvants did not result in undesired effects.
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Affiliation(s)
- Ammar H Mahdi
- Department of Anesthesia and Intensive Care, Faculty of Medicine of Sousse, University of Sousse, Sousse, TUN
- Department of Anesthesia and Intensive Care, Bilad Alrafidain University College, Baqubah, IRQ
| | - Mohamed Kahloul
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital, Faculty of Medicine of Sousse, University of Sousse, Sousse, TUN
| | - Myasar J Mohammed
- Department of Anesthesia and Intensive Care, Bilad Alrafidain University College, Baqubah, IRQ
| | - Abbas K Mohammed
- Department of Anesthesia and Intensive Care, Balad Ruz General Hospital, Diyala Health Directorate, Iraqi Ministry of Health, Balad Ruz, IRQ
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Vincenzi P, Stronati M, Garelli P, Gaudenzi D, Boccoli G, Starnari R. Segmental Thoracic Spinal Anesthesia for Laparoscopic Cholecystectomy with the "Hypobaric" Technique: A Case Series. Local Reg Anesth 2023; 16:31-40. [PMID: 37188284 PMCID: PMC10178898 DOI: 10.2147/lra.s395376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/19/2023] [Indexed: 05/17/2023] Open
Abstract
Purpose Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence. Patients and Methods Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8-10 mmHg. Results Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1-3) days. Conclusion Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.
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Affiliation(s)
- Paolo Vincenzi
- Department of General Surgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | | | - Paolo Garelli
- Department of General Surgery, IRCSS-INRCA, Ancona, Italy
| | - Diletta Gaudenzi
- Department of Perioperative Services, AOU “Ospedali Riuniti di Ancona”, Ancona, Italy
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