Combined spinal epiduralfor hip surgery in asaiii iv pts.
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COMBINED SPINAL-EPIDURAL ANALGESIA FOR HIP SURGERY In ASA III- IV patients for both planned & emergency orthopedic procedures
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The Anesthesiologist, especially young, faces a major challenge when faced with very ill/ severly moribund, elderly, cachwexic patients with history of fall and lower extremity fractures for elective or ortho surgical procedure. Prof. mridul m. panditrao, explains various problems faced especially with GA, and the best alternatives. Two different approaches of Combined spinal epidual are discussed, with use of adjuvants and also his own randomizede trial and experience.
Transcript of Combined spinal epiduralfor hip surgery in asaiii iv pts.
COMBINED SPINAL-EPIDURAL
ANALGESIA FOR HIP SURGERY
In ASA III- IV patients for both planned & emergency orthopedic
procedures
Dr.Mridul M. Panditrao
CONSULTANTPublic Hospital Authority’s
RAND MEMORIAL HOSPITAL
FREEPORT
GRAND BAHAMA
COMMONWEALTH OF THE BAHAMAS
FOMERLY:
Professor /Head & I/C ICUDepartment of Anaesthesiology & Critical Care
&
Dean of Medical Faculty
Pad. Dr. D.Y. Patil Medical College & Research Centre,
Dr. D.Y. Patil University,
Pimpri, Pune.
INTRODUCTION
FOR ALL THE HAPPINESSMankind can gain.Is not in pleasure
But in rest from “pain”
JOHN DRYDEN
INTRODUCTION (Contd.)
Nociception: Transduction Transmission Modulation Perception
“Gate control theory of Melzac & Wall” 1965
“Reynolds Theory of ‘Supra-Spinal Descending Control in Modulation in Dorsal Horn’ ” 1969
“Woolf C.J” 1989 :- “ Supra spinal inhibition of nociception”
Hip surgeries/Lower limb orthopaedic
surgeries.
Problems in a ASA III-IV Patients Elderly, Cachexic, Bedridden patients Associated systemic problems Rapid onset is required Prolonged time required GA is a relative contra indication Post operative complications of GA: May
Require ventilator & associated problems Cost & Economy of GA Theatre pollution
Why Combined Spinal & Epidural? No sedation, drowsiness & grogginess Early ambulation is possible No respiratory depression Minimal Cardio vascular interference Low incidence of PONV Avoidance of autonomic stress response Pre emptive analgesia Superior quality of analgesia Cost effective
Adjuvants to Neuraxial Blockade: Why needed? Problems of LAAS
So alternatives to LAAs were tried
If duration of action is to be prolonged? Motor blockade causing interference with the
mobility of the patient Sympathetic blockade leading to bradycardia
and hypotension.
ALTERNATIVES TO LAAs:Problems:
Side effects of Opioids Difficulty in procuring/licensing Minimal muscle relaxation Other agents viz. Clonidine, Neostigmine,
Ketamine, Midazolam and their side effects
Advantages of Adjuvants
Improvement of quality of block Onset of analgesic effect of LAAs is enhanced Duration of action of LAAs is prolonged Dose requirement of each drug is reduced Lower incidence of side effects
Routes of Administration
In epidural space through epidural catheter when combined spinal epidural Analgesia is given
In sub-arachnoid space when only SA is given
Various drugs used as Adjuvants Opioids agonists: Morphine, Fentanyl etc.
Agonist /antagonist: Butorphanol, Buprenorphine Clonidine Neostigmine Ketamine Midazolam Tramadol Newer drugs like: Dexmedetomidine/Clonidine
Our Study: 60 adults of either sex Inclusion criteria Age range 35 – 80 yrs ASA l & ll Elective hip surgeries No or controlled systemic disorders Consent
Exclusion criteria Age below 35 or above 80 yrs Uncontrolled systemic disorders Acute infection Spinal deformities Coagulopathies Opioid dependence
Methodology Randomization, NBM status No sedatives/ hypnotics pre or intra operatively IV infusion & monitoring devices 16 G Touhy’s needle, L2-3 level 16 G Epidural Catheter in situ. 26 G Quincke/ 27G Whitacre spinal needle 0.5% Bupivacaine (heavy) 3.5 ml Top ups of LAAs as required Intra-operative monitoring
Methodology (contd)
Post-op :- As spinal wore off: VAS: VAS ≥ 5 Group A: Inj. Butorphanol 1mg with 4 ml of
Normal Saline Epidurally Group B: Inj. Butorphanol 1mg IM VAS monitoring every 10 minutes VAS ≤ 3 – Onset Duration calculated VAS ≤ 7 - Released from study Analgesia of surgeon’s choice Side effects noted
Combined Spinal Epidural in the
Same Intervertebral
Space Using Combipack
Combined Spinal & Epidural in two different Intervertebral
Spaces
Results
58.9 58.5
160.45 160.47
55.9 56.8
0
20
40
60
80
100
120
140
160
180
AGE HT WT
COMPARISON OF MEAN AGE, HEIGHT AND WEIGHT IN TWO GROUPS
GROUP AGROUP B
93 92.4
17.66 17.75
96.88 98.62
8.92 9.03
0
20
40
60
80
100
ME
AN
V
AL
UE
PULSE RR MAP VAS
COMPARISION OF MEAN BASELINE PARAMETERS
GROUP A
GROUP B
Comparison of Parameters at regular time intervals
In group A Significant decrease in: Mean pulse from base line to at 20 minutes Mean respiratory rate from baseline to at 10 min,
20min, 30min, 1 hr &11/2 hr
In group B Significant decrease in: Mean pulse from base line to at 11/2 hr Mean respiratory rate from baseline to at 11/2 hr
There was no difference of Systolic/Diastolic/ MAP in any of the groups from baseline at any time
COMPARISON OF MEAN PULSE RATE AT REGULAR INTERVALS
84.23
9088.3
8685.56
85.36
87.36
93
87
85.25
81
86.1
88
92.4
84.25
90
80
82
84
86
88
90
92
94
BASE 10M 20 M 30M 1 HR 11/2 HR 2 HR W'ring off
ME
AN
PU
LS
E R
AT
E
GROUP A
GROUP B
COMPARISON OF MEAN RR AT REGULAR INTERVALS
14.714.75
14.2114.06
15.88
15.1
16.99
17.66
15.315.22
14.76
15.9216.0316
17
17.75
13
13.5
14
14.5
15
15.5
16
16.5
17
17.5
18
BASE 10M 20 M 30M 1 HR 11/2 HR 2 HR W'ring Off
GROUP A
GROUP B
COMPARISON OF MEAN MAP AT REGULAR INTERVALS
93.82
94.21
94.22
94.62
95
95.8496
96.88
98.5197.65
96.11
97.05
97.4
98.29898.62
93
94
95
96
97
98
99
BASE 10M 20 M 30M 1 HR 11/2 HR 2 HR W'ring Off
GROUP A
GROUP B
COMPARISION OF MEAN ONSET, PEAK, DURATION
54.83
87.5
266.3
17.83
268.3
23.5
0
25
50
75
100
125
150
175
200
225
250
275
300
ONSET PEAK DURATION
ME
AN
VA
LU
ES GROUP A
GROUP B
COMPARISION OF MEAN VAS AT REGULAR A TIME INTERVALS
7.55
2.652.32.25
2.7
4.85
6.05
8.92
7.5
7.7
3.75
2.972.85
4.32
5.9
6.9
9.03
7.9
0
1
2
3
4
5
6
7
8
9
10
BASE 10M 20M 30M 1 HR 11/2 HR 2HR 3 HR W
GROUP A
GROUP B
11
0
10
3
5
16
4
9
01
01
0
3
6
9
12
15
18
NO
.OF
PA
TIE
NT
S
0 1 2 3 4 5
V-MAX
MAXIMUM PAIN RELIEF COMPARISION
GROUP A
GROUP B
1.13
2.35
0
0.5
1
1.5
2
2.5
ME
AN
SC
OR
E
COMARISON OF MEAN VAS
COMPARSION OF MEAN V-MAX
GROUP A
GROUP B
Discussion
Celsus (Circa AD 14-37) Wang H, Nauss L, Thomas J Anaesthesiology
1979, 50:149
Pain relief by Intrathecal use of Morphine in man Murkin JM J. Cardiothorac. Vasc. Anesth 1991,
85,655 - 74
Central analgesic mechanisms : Review of opioid receptors physio-pharmacology and related anti-nociceptive system
Discussion (contd)
Dobkin AB et al Clini. Pharmacol. Ther. 1975 Butorphanol & Pentazocine intra-Muscularly in patients with severe post operative pain
Dutta S et al Anesthesiology 1992 Double-blind
epidural vs. intravenous Butorphanol Palacios QT et al Can. J. Anaesth.1991 Post LSCS
analgesia: epidural Butorphanol vs. Morphine
Conclusion
C S E is an ideal & suitable alternative to GA Especially in patients for hip surgeries Use of adjuvants to LAAs is beneficial Opioids are the most suitable adjuvants Pure agonists have their own problems Butorphanol (agonist-antagonist) by two
routes viz. IM verses Epidural was tried
Conclusion (contd)
Duration of analgesia was comparable Onset of analgesia was quicker in epidural group Peak of analgesia achieved faster in epidural group No significant difference observed in vital
parameters of both the groups Maximum pain relief in epidural was better Incidence of all the side effects was more in the intra
muscular group
Conclusion (contd)
Considering the quality of pain relief EPIDURAL route has distinct
advantage over the intramuscular route*.
*Incidentally this is the first study of it’s kind.
