|Year : 2018 | Volume
| Issue : 1 | Page : 77-82
A comparative study between combined spinal anesthesia with bilateral thoracic paravertebral block and general anesthesia in laparoscopic cholecystectomy
Eman H Abd El-Wahab Abu Shanab, Mohamad G Ayaad, Ahmed A El-Dabe, Sanaa M El-Nomany
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||11-Mar-2017|
|Date of Acceptance||02-Nov-2017|
|Date of Web Publication||26-Jul-2018|
Eman H Abd El-Wahab Abu Shanab
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, El-Gharbia, Tanta, 31726
Background Paravertebral block is a common regional anesthetic technique such as intraoperative anesthesia and perioperative analgesia used in multiple surgical procedures. Many studies have demonstrated that laparoscopic cholecystectomy (LC) with the patient under spinal anesthesia (SA) was feasible and safe and was associated with stable hemodynamics and better postoperative pain control.
Aim The aim is to compare the anesthetic effect of combined SA with bilateral thoracic paravertebral block and general anesthesia in LC.
Patients and methods Sixty patients undergoing LC were randomized into two groups: group I receiving general anesthesia and group II receiving SA with bilateral thoracic paravertebral block at the level of T7 with a catheter on the right side, and then injecting 10 ml plain bupivacaine 0.5% on the left side through the epidural needle without catheter as a single shot. Patients were still in the sitting position, and then SA was performed using a 25 G spinal needle at L2–L3 intervertebral space. 2 ml=10 mg of hyperbaric bupivacaine hydrochloride (0.5%) was injected intrathecally.
Results Intraoperatively, there was significant increase in stress response including mean arterial blood pressure and heart rate in group I than in group II at 30 min and at the end of operation. Significant decrease in intraoperative opioid requirement as fentanyl in group II than in group I was observed. The time of first analgesic requirement within 8 h in the postoperative period if the Visual Analogue Scale more than 3 was significantly increased in group II than in group I. As regards intraoperative end tidal CO2, oxygen saturation, operative time, nausea, vomiting, headache and patient satisfaction, there was insignificant difference between the two groups.
Conclusion LC can be performed under SA and bilateral thoracic paravertebral block at low pressure pneumoperitoneum, providing hemodynamic stability and with no respiratory complications.
Keywords: general anesthesia, laparoscopic cholecystectomy, spinal anesthesia, thoracic paravertebral block
|How to cite this article:|
Abd El-Wahab Abu Shanab EH, Ayaad MG, El-Dabe AA, El-Nomany SM. A comparative study between combined spinal anesthesia with bilateral thoracic paravertebral block and general anesthesia in laparoscopic cholecystectomy. Tanta Med J 2018;46:77-82
|How to cite this URL:|
Abd El-Wahab Abu Shanab EH, Ayaad MG, El-Dabe AA, El-Nomany SM. A comparative study between combined spinal anesthesia with bilateral thoracic paravertebral block and general anesthesia in laparoscopic cholecystectomy. Tanta Med J [serial online] 2018 [cited 2018 Nov 14];46:77-82. Available from: http://www.tdj.eg.net/text.asp?2018/46/1/77/237620
| Introduction|| |
Regional anesthesia in laparoscopic cholecystectomy (LC) was done only for patients who were unfit for general anesthesia (GA), especially in patients with severe chronic obstructive airway disease. Regional anesthesia has also been used for laparoscopy in healthy patients with GA to decrease pain in the postoperative period .
Regional block (low thoracic epidural, spinal, and combined spinal–epidural blocks) have been used in patients with some medical problems. Some authors consider that spinal anesthesia (SA) seems more suitable for LC ,,.
Paravertebral administration of local anesthetics, used for many surgical procedures such as LC, has been found to produce the duration of postoperative analgesia to be more than the expected duration of the local anesthetics used ,.
Paravertebral blockade can make GA unnecessary for some procedures such as those in breast cancers, allowing the patients to be awake and cooperative during surgery. Para vertebral block (PVB) is associated with less postoperative nausea, vomiting (PONV), fewer pulmonary complications and less pain and analgesic consumption, especially opioids ,.
Performing LC under regional anesthesia carries several advantages. The reduction of surgical stress response is considered one of its major advantages. This is accomplished through two aspects: the laparoscopic technique which reduces the degree of tissue trauma and the injury response, and the SA itself which provides pain relief by blocking afferent neural blocks. Avoidance of airway instrumentation and lower incidence of deep vein thrombosis are other important advantages of this technique .
| Aim|| |
The aim of the study is to compare the anesthetic effect of combined SA with bilateral thoracic paravertebral block and GA in LC. Our primary outcome is the impact of regional anesthesia in maintaining hemodynamic stability of heart rate (HR) than GA in LC.
| Patients and methods|| |
After obtaining the research ethics committee approval (approval code: 3001/01/15), written consent was taken from patients A prospective randomized study was carried out in Tanta University Hospitals in General Surgery Department for 6 months from March 2015 to September 2015 on 60 patients undergoing LC of either sex, ASA I or II, between 20 and 50 years old, BMI of 30 or less and normal coagulation profile.
All cardiac, renal, respiratory, hepatic diseases, bleeding disorders, relevant drug allergy, mental dysfunction, morbid obesity, history of drug abuse, chronic use of therapy, analgesics or opioid use, patients who suffer from chronic pain, psychiatric illness, acute cholecystitis, pancreatitis, cholangitis, previous open surgery in the upper abdomen and spinal deformity are excluded from the study.
All patients were clinically examined and routine laboratory investigations were done preoperatively. The patients were divided into two groups of 30 each. Group I received GA and group II received SA with bilateral thoracic paravertebral block.
On patients’ arrival in the operating room and establishing noninvasive monitoring [ECG, arterial blood pressure including systolic, diastolic and mean arterial blood pressure (MAP), peripheral oxygen saturation (SpO2) using pulse oximetry were done]. An intravenous line was established with an 18 G cannula and 500 ml of Ringer’s solution was started intravenously. Ranitidine hydrochloride (50 mg) was intravenously administered before the induction of anesthesia for all patients.
Anesthesia was performed in all cases by the same anesthetic teamwork. All the necessary equipment for GA and resuscitation were kept ready in the case of block failure or any complication.
In group I, GA was induced with propofol (2 mg/kg), fentanyl citrate (1–2 µg/kg), and cis-atracurium (0.09 mg/kg). Balanced anesthesia was continued with isoflurane with minimal alveolar concentration one with additional doses of cis-atracurium (0.03 mg/kg). Ventilation was controlled with a tidal volume of 8–10 ml/kg and the ventilatory rate was adjusted to maintain an end tidal CO2 value of 35–45 mmHg. At the end of operation residual neuromuscular block was antagonized with 0.04 mg/kg of neostigmine methyl sulfate and 0.02 mg/kg of atropine sulfate.
In group II, before the surgical procedure, PVB was done after sterilization and giving local anesthetic 1 ml lidocaine 2%. On the right side of the patient, an 18 G needle was inserted 2.5–3 cm lateral to the spinous process of thoracic vertebra at the level of T7 and advanced to the thoracic paravertebral space. A catheter was inserted within the paravertebral spaces. The technique was performed again on the left side but without catheter. A 10 ml plain bupivacaine 0.5% (single shot) was injected into the paravertebral space on the left side through the epidural needle without a catheter.
Patients were still in the sitting position and SA was performed using a 25 G spinal needle at L2–L3 intervertebral space under aseptic conditions. After free flow of cerebrospinal fluid, 2 ml=10 mg of hyperbaric bupivacaine hydrochloride (0.5%) was injected intrathecally. Then, the patient was placed in the supine position, staying in the anti-Trendelenburg position (10–15°) for 3 min. After assessment of sensory and motor block of SA on the right side, a 10 ml plain bupivacaine 0.5% (single shot) was injected as a loading dose into the catheter into the right paravertebral space. Before induction of CO2 pneumoperitoneum, 2 mg midazolam was administered to all the patients intravenously, then oxygen at 5 l/min was started through a face mask in group II.
LC was performed with carbon dioxide at a maximum intra-abdominal pressure of 10 mmHg and by tilting of the operating table, that is, head up and left tilt to minimize diaphragmatic irritation in both groups.
In both the groups, all patients were monitored continuously with noninvasive hemodynamic monitoring as MAP and HR measured before and after induction of anesthesia at 5, 10, 15, and then every 15 min till the end of surgery. SpO2 and end tidal CO2 before the induction of anesthesia and every 15 min till the end of surgery.
Also the need for intraoperative additional drugs as fentanyl, operative time in both groups, need for intraoperative nasogastric tube insertion, time of first analgesic requirement within 8 h after end of operation given if Visual Analogue Scale (VAS) more than 3, patient satisfaction and the appearance of any undesired side effects such as intraoperative hypotension, bradycardia, and PONV and headache were recorded.
In group II, sensory testing for spinal and PVB group was assessed by loss of cold sensation on both sides; motor block was assessed by the Bromage score (0: no motor loss; 1: inability to flex the hip; 2: inability to flex the knee joint; 3: inability to flex the ankle) and intraoperative shoulder pain was classified into no pain, mild pain, moderate pain, and severe pain.
Statistical analysis of the present study was done, using the mean, SD, t-test, Mann–Whitney U-test, and χ2-test by SPSS V.24 (Statistical Package for the Social Sciences; IBM Corporation, Armonk, New York, United States). A P value of less than 0.05 was considered significant. Sample size calculation was performed by using Epi-Info software statistical package designed by WHO and by centers for Disease Control and Prevention (Atlanta, Georgia, USA). Based on the result of a previous study  at least 25 patients were required in each group to detect a significant difference of 5 beats/min in HR at an α error of 0.05, power of study of 95% and SD 4.
| Results|| |
No patients withdrew their consent and no patients were converted from SA to GA.
As regards demographic data, there was insignificant difference between the two groups.
HR and MAP showed significant increase in group I, in comparison to group II, at 30 min after anesthesia and at the end of operation as shown in [Figure 1] and [Figure 2].
|Figure 1 Heart rate (HR) changes in the two studied groups. GA, general anesthesia; SA, spinal anesthesia.|
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|Figure 2 Comparison in mean arterial blood pressure (MAP) between the two groups. GA, general anesthesia; SA, spinal anesthesia.|
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End tidal CO2, SpO2, and operative time showed insignificant changes between the two groups as shown in [Figure 3] and [Figure 4].
|Figure 3 End tidal CO2 changes in the two studied groups. GA, general anesthesia; SA, spinal anesthesia.|
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|Figure 4 Oxygen saturation changes in the two studied groups. GA, general anesthesia; SA, spinal anesthesia.|
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As regards the need for intraoperative nasogastric tube insertion, all the patients (100%) in the general group needed nasogastric tube insertion and only 10% of patients in the spinal group needed nasogastric tube insertion. This was according to the surgeon requirement to deflate the stomach to provide good view to perform LC.
There was significant difference between both groups in the intraoperative requirement of opioid.
In group II, about 13.3% of patients required intravenous fentanyl for shoulder pain (moderate or severe).
In group I, about 84% of patients required intravenous fentanyl when HR or MAP was elevated 15% from the baseline.
As regards intraoperative shoulder pain in the SA group, about 56.6% of patients had no pain, about 30% of patients had mild pain relieved by reassurance, about 13.3% had moderate pain relieved by fentanyl 0.5 μg/kg, and no patients had severe intolerable pain that required conversion from SA to GA.
As regards maximum sensory block after spinal and PVB at thoracic segments 10% reached the level of T4 and 90% of patients reached T5.
As regards maximum Bromage score, 20% of patients scored 2 and in 80% of patients it was 3.
As regards intraoperative bradycardia, it occurred in 10% of patients in both groups with insignificant difference between the two groups.
As regards intraoperative hypotension, it occurred in 6.6% of patients in the GA group and 10% in the SA group with insignificant difference between the two groups. As regards PONV, it occurred in 20% of patients in the GA group and 6.7% in the SA group with insignificant difference between the two groups.
As regards postoperative headache, no patients in the GA group and only 6.7% in the SA group complained of headache with insignificant difference between the two groups.
The time of first analgesic requirement showed a significant difference between the two groups.
In group I, the time of first analgesic requirement when VAS more than 3 ranged between 25 and 41 min with a mean value of 33.1±3.88 min.
In group II, the time of first analgesic requirement ranged between 105 and 480 min with a mean value of 324±93.31 min.
Patient satisfaction was assessed using a descriptive three-point verbal rating scale (3=extremely satisfied; 2=satisfied; 1=not satisfied). Patients were also asked to assess their satisfaction level with the anesthetic technique within 8 h after the end of operation. There was insignificant difference between the two groups. In group I, 50% of patients were extremely satisfied, 23.3% of patients were satisfied, and 26.7% of patients were dissatisfied. In group II, 70% of patients were extremely satisfied; 23.3% of patients were satisfied; and 6.7% of patients were dissatisfied.
| Discussion|| |
Our study has confirmed the ability and safety of performing LC under SA with bilateral thoracic paravertebral block under low pressure pneumoperitoneum. SA has the advantage of providing postoperative analgesia and muscle relaxation. The inflation pressure should be maintained at 10 mmHg during performing LC under regional anesthesia. One of the problems is the appearance of shoulder pain, which can be decreased with low intra-abdominal pressures and judicious use of fentanyl. SA reduces the incidence of nausea, vomiting, and improves postoperative pain.
PVB has been used to facilitate outpatient surgery, and provides an analgesic option, and a more stable hemodynamics than other regional techniques such as epidural anesthesia.Regional anesthesia has many advantages over GA as the patient is awake and oriented all over the operation; the immediate postoperative period is viewed positively by patients because of the absence of general anesthetic side effects and less postoperative pain due to the effect of persistent neuraxial block, and early ambulation in patients with regional anesthesia .
There is evidence that thoracic paravertebral nerve block provide a good analgesia and has been shown to be as effective as epidural analgesia and to be accompanied with lower frequency of hypotension, lower PONV, and better pulmonary function ,.
There was significant increase in HR and MAP in group I at 30 min and at the end of the operation. This may be explained by termination of action of fentanyl 30 min after induction of anesthesia, reflex sympathetic response of CO2 pneumoperitoneum, and stress response of extubation in group I which was avoided by sympathetic block in group II in LC.
Hypotension and bradycardia had a low incidence in group II due to low-pressure pneumoperitoneum and low dose of hyperbaric bupivacaine 0.5% 2 ml (10 mg) at the level of L2–L3, which was aided by bilateral thoracic paravertebral block at T7. This allowed a sensory block at T4–T5 that was required for LC to be performed and provided hemodynamic stability.
In our study, intraoperative shoulder pain was not a limitation and had low incidence and less opioid consumption in group II .This may be attributed to low pressure pneumoperitoneum at 10 mmHg; all patients received sedation with midazolam 2 mg in group II before induction of CO2 pneumoperitoneum and bilateral thoracic paravertebral block.
We believed that the nasogastric tube is uncomfortable in awake patients, and its need would be one of the criteria for conversion of the anesthesia. But only three (10%) patients in group II needed nasogastric tube and this did not affect the planned procedure and did not need conversion to GA due to lack of stomach inflation as a result of mask ventilation.
Lower incidence of PONV in both groups was due to low-pressure CO2 pneumoperitoneum at 10 mmHg. The incidence was lower in group II which may be due to avoidance of the use of inhalational anesthesia.
Regional anesthesia including spinal and PVB is important in achieving high-quality analgesia in the immediate postoperative period. Pain evaluated by the VAS was significantly less severe in group II within 8 h compared with group I. This was reflected in our study by the first analgesic requirement which was significantly delayed in group II. This difference can be attributed to the combination of several factors such as: nonperformance of tracheal intubation, the presence of residual adequate analgesia from the paravertebral block and SA in the early hours in group II.
The overall satisfaction was more in group II than in group I. This may be explained by some advantages in the SA group including the patient being awake and oriented all through the procedure; first analgesic requirement was delayed in SA group due to less postoperative pain due to residual sensory block of regional anesthesia, lack of intubation and extubation and its related problems.
| Conclusion|| |
LC can be performed under SA and bilateral thoracic paravertebral block at low pressure pneumoperitoneum and providing hemodynamic stability and without respiratory complications. Regional anesthesia in LC avoids stress response of GA and decreases the sympathetic reflex of CO2 pneumoperitoneum.
Also LC under regional anesthesia offered a major advantage of less postoperative pain which was reflected in our study by the delay in the first analgesic requirement due to residual sensory block from spinal and paravertebral block.
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Conflicts of interest
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