551
Stanley Davis MBChBFFA(SA), Richard Erskine MBChBFFA(SA), Michael F.M. James MBChBPhDFFARCS
A comparison of spinal and epidural anaesthesia for hip arthroplasty
Spinal and epidural anaesthesia were compared in 65 patients undergoing hip arthroplasty, with regard to the degree of sensory and motor blockade, cardiovascular effects, operating conditions, the dose of propofol required to produce satisfactory hypnosis, and complications. Epidural anaesthesia was successful in 30 patients using an initial dose of 15 ml of 0.5% bupivicaine, and spinal anaesthesia in 32 patients, using 4 ml 0.5% isobaric bupivicaine. The two techniques were similar with regard to the level of sensory blockade (Ts), degree of hypotension and perioperative haemorrhage. Differences occurred in the degree of motor blockade (mean Bromage score of I in the spinal group vs 3.86 in the epidural group) (P < 0.05), time to achieve maximal cephalad spread (13 min in the spinal group vs 21 rain in the epidural group) (P < 0.05) and the dose of propofol required to produce adequate hypnosis (1.95 mg.kg -I "hr-I in the spinal group vs 2.89 mg "kg-j "hr-~ in the epidural group) (P < 0.05). Only seven patients required urethral catheterization in this spinal group compared with 14 in the epidural group (P < 0.05). Spinal anaesthesia also proved advantageous by providing better operating conditions for the surgeon, with a lower incidence of patient movement.
la quantit~ de propofol ngcessaire pour maintenir une hypnose au cours de l'intervention. L'anesth~sie p~ridurale est r~alisde avec succds chez 30 patients en utilisant une dose initiale de 15 ml de bupivaca;'ne 0,5%. La rachi-anesthdsie est faite avec succors chez 32 patients en utilisant 4 ml de bupivacarne 0,5% isobare. Les deux techniques sont assocides it un bloc de conduction sensitif de niveau T~. La chute de pression et les saignements p~riop~ratoires sont comparables avec une technique ou l'autre. Le bloc moteur moyen est de 1 it l'~chelle de Bromage avec la rachi-anesth~sie comparativement it 3,86 avec l'anesth~sie p~ridurale (P < 0,05). La migration cdphalade maximale de l'agent anesth~sique est plus rapide avec la rachi-anesth~sie (13 min versus 21 min; P < 0,05). La dose de propofol ngcessaire pour maintenir l'hypnose est de 1,95 mg 9kg-~ 9h-I chez les patients du groupe rachi-anesthgsie comparativement it 2,89 mg "kg-t "h-~ chez les patients du groupe pgridurale (P < 0,05). Sept patients du groupe rachianesth~sie versus 14 patients du groupe pdridurale ont besoin de cath~tdrisme vgsical (P < 0,05). La rachi-anesthgsie est associ~e it moins de mouvements des patients durant la chirurgie, et de ce fait elle permet un meilleur accbs chirurgical.
Cette gtude compare la rachi-anesth~sie et l'anesthgsie p~ridurale chez 65 patients subissant une arthroplastie de la hanche. Les paramktres ~valuds sont le niveau du bloc de conduction sensitif la qualitg du bloc moteur, les effets cardiovasculaires, la facilit~ d' acc~s chirurgical, les complications et
Key words ANAESTHESIA: regional, epidural, spinal; ANAESTHETICS, LOCAL: bupivacaine; SURGERY: orthopaedic. From the Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town, Observatory, 7925, Republic of South Africa. Address correspondence to: Dr. S. Davis. Accepted for publication 22nd February, 1992.
CAN J ANAESTH 1992 / 39:6 / pp 551--4
The complications of spinal and epidural anaesthesia, as well as the relative advantages of the two techniques, have recently been comprehensively reviewed. L2 The choice between techniques has also been the subject of recent editorial comment. 3 Although both techniques are now widely used to provide anaesthesia for hip arthroplasty, there has been no controlled trial of the comparative merits of either technique for this particular procedure, which is often carried out in elderly patients and is associated with a considerable perioperative blood loss 4 and with a high incidence of postoperative thromboembolism. Furthermore, iatrogenic bacteraemia must be avoided, as an infected prosthesis carries a severe morbidity. This prospective randomized study sets out to evaluate efficacy, cardiovascular effects, acceptability and complications of epidural vs spinal anaesthesia for hip arthroplasty.
552
Methods The study was approved by the Ethics Committee of the University of Cape Town. Sixty-five patients scheduled for primary hip arthroplasty were entered into the study after giving informed written consent. Patients with fixed cardiac output states, a bleeding disorder, skeletal abnormalities of the spine or neurological disease were excluded. All patients received premedication with oral diazepam 0.15 m g ' k g -~, two hours preoperatively. In the induction suite a Plasmalyte B preload of 12 ml' kg -~ was given, a supine baseline blood pressure was recorded using a non-invasive, blood pressure monitor (Dinamap-Critikon), whereafter patients were prepared and draped in the sitting position. Using random numbers, patients were then allocated to either an epidural or spinal group. In the epidural group the epidural space was located at L3_4using an 18-gauge Tuohy needle and loss of resistance device (Portex). Bupivicaine 0.5%, 15 ml, was injected through the Tuohy needle as two increments a 5-ml test dose, followed four minutes later by 10 ml injected over 60 sec. A catheter was then introduced into the epidural space for supplementary bupivicaine if required. In the spinal group lumbar puncture was performed in the L3_4 interspace using a 25-gauge spinal needle, and 4 ml of isobaric bupivicaine 0.5% was injected over ten seconds. The Dinamap was set to measure and record at oneminute intervals, then the patients were placed in the supine position and after 15 min the Dinarnap was reset to record at five-minute intervals, which was continued for the duration of the procedure. The cephalad spread of sensory blockade was measured by determing the upper level of analgesia to pinprick at five-minute intervals until a maximum height was reached. The degree of motor blockade of the lower limbs was measured at five-minute intervals using a Bromage score 5 (1 = complete paralysis; 2 = movement of feet only; 3 = slight flexion of knees; 4 = full flexion of knees) for 30 min or until complete paralysis occurred. In the epidural group injection of the test dose was taken as time zero. Hypnosis was provided with an infusion of propofol, initiated at a dose of 2 mg. kg -~. hr-] and adjusted according to individual response, to abolish verbal communication and movement. Intraoperative fluid therapy consisted of crystalloid (Plasmalyte B), colloid (Haemaccel) for intraoperative hypotension, defined as systolic blood pressure
Stanley Davis MBChBFFA(SA), Richard Erskine MBChBFFA(SA), Michael F.M. James MBChBPhDFFARCS
A comparison of spinal and epidural anaesthesia for hip arthroplasty
Spinal and epidural anaesthesia were compared in 65 patients undergoing hip arthroplasty, with regard to the degree of sensory and motor blockade, cardiovascular effects, operating conditions, the dose of propofol required to produce satisfactory hypnosis, and complications. Epidural anaesthesia was successful in 30 patients using an initial dose of 15 ml of 0.5% bupivicaine, and spinal anaesthesia in 32 patients, using 4 ml 0.5% isobaric bupivicaine. The two techniques were similar with regard to the level of sensory blockade (Ts), degree of hypotension and perioperative haemorrhage. Differences occurred in the degree of motor blockade (mean Bromage score of I in the spinal group vs 3.86 in the epidural group) (P < 0.05), time to achieve maximal cephalad spread (13 min in the spinal group vs 21 rain in the epidural group) (P < 0.05) and the dose of propofol required to produce adequate hypnosis (1.95 mg.kg -I "hr-I in the spinal group vs 2.89 mg "kg-j "hr-~ in the epidural group) (P < 0.05). Only seven patients required urethral catheterization in this spinal group compared with 14 in the epidural group (P < 0.05). Spinal anaesthesia also proved advantageous by providing better operating conditions for the surgeon, with a lower incidence of patient movement.
la quantit~ de propofol ngcessaire pour maintenir une hypnose au cours de l'intervention. L'anesth~sie p~ridurale est r~alisde avec succds chez 30 patients en utilisant une dose initiale de 15 ml de bupivaca;'ne 0,5%. La rachi-anesthdsie est faite avec succors chez 32 patients en utilisant 4 ml de bupivacarne 0,5% isobare. Les deux techniques sont assocides it un bloc de conduction sensitif de niveau T~. La chute de pression et les saignements p~riop~ratoires sont comparables avec une technique ou l'autre. Le bloc moteur moyen est de 1 it l'~chelle de Bromage avec la rachi-anesth~sie comparativement it 3,86 avec l'anesth~sie p~ridurale (P < 0,05). La migration cdphalade maximale de l'agent anesth~sique est plus rapide avec la rachi-anesth~sie (13 min versus 21 min; P < 0,05). La dose de propofol ngcessaire pour maintenir l'hypnose est de 1,95 mg 9kg-~ 9h-I chez les patients du groupe rachi-anesthgsie comparativement it 2,89 mg "kg-t "h-~ chez les patients du groupe pgridurale (P < 0,05). Sept patients du groupe rachianesth~sie versus 14 patients du groupe pdridurale ont besoin de cath~tdrisme vgsical (P < 0,05). La rachi-anesthgsie est associ~e it moins de mouvements des patients durant la chirurgie, et de ce fait elle permet un meilleur accbs chirurgical.
Cette gtude compare la rachi-anesth~sie et l'anesthgsie p~ridurale chez 65 patients subissant une arthroplastie de la hanche. Les paramktres ~valuds sont le niveau du bloc de conduction sensitif la qualitg du bloc moteur, les effets cardiovasculaires, la facilit~ d' acc~s chirurgical, les complications et
Key words ANAESTHESIA: regional, epidural, spinal; ANAESTHETICS, LOCAL: bupivacaine; SURGERY: orthopaedic. From the Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town, Observatory, 7925, Republic of South Africa. Address correspondence to: Dr. S. Davis. Accepted for publication 22nd February, 1992.
CAN J ANAESTH 1992 / 39:6 / pp 551--4
The complications of spinal and epidural anaesthesia, as well as the relative advantages of the two techniques, have recently been comprehensively reviewed. L2 The choice between techniques has also been the subject of recent editorial comment. 3 Although both techniques are now widely used to provide anaesthesia for hip arthroplasty, there has been no controlled trial of the comparative merits of either technique for this particular procedure, which is often carried out in elderly patients and is associated with a considerable perioperative blood loss 4 and with a high incidence of postoperative thromboembolism. Furthermore, iatrogenic bacteraemia must be avoided, as an infected prosthesis carries a severe morbidity. This prospective randomized study sets out to evaluate efficacy, cardiovascular effects, acceptability and complications of epidural vs spinal anaesthesia for hip arthroplasty.
552
Methods The study was approved by the Ethics Committee of the University of Cape Town. Sixty-five patients scheduled for primary hip arthroplasty were entered into the study after giving informed written consent. Patients with fixed cardiac output states, a bleeding disorder, skeletal abnormalities of the spine or neurological disease were excluded. All patients received premedication with oral diazepam 0.15 m g ' k g -~, two hours preoperatively. In the induction suite a Plasmalyte B preload of 12 ml' kg -~ was given, a supine baseline blood pressure was recorded using a non-invasive, blood pressure monitor (Dinamap-Critikon), whereafter patients were prepared and draped in the sitting position. Using random numbers, patients were then allocated to either an epidural or spinal group. In the epidural group the epidural space was located at L3_4using an 18-gauge Tuohy needle and loss of resistance device (Portex). Bupivicaine 0.5%, 15 ml, was injected through the Tuohy needle as two increments a 5-ml test dose, followed four minutes later by 10 ml injected over 60 sec. A catheter was then introduced into the epidural space for supplementary bupivicaine if required. In the spinal group lumbar puncture was performed in the L3_4 interspace using a 25-gauge spinal needle, and 4 ml of isobaric bupivicaine 0.5% was injected over ten seconds. The Dinamap was set to measure and record at oneminute intervals, then the patients were placed in the supine position and after 15 min the Dinarnap was reset to record at five-minute intervals, which was continued for the duration of the procedure. The cephalad spread of sensory blockade was measured by determing the upper level of analgesia to pinprick at five-minute intervals until a maximum height was reached. The degree of motor blockade of the lower limbs was measured at five-minute intervals using a Bromage score 5 (1 = complete paralysis; 2 = movement of feet only; 3 = slight flexion of knees; 4 = full flexion of knees) for 30 min or until complete paralysis occurred. In the epidural group injection of the test dose was taken as time zero. Hypnosis was provided with an infusion of propofol, initiated at a dose of 2 mg. kg -~. hr-] and adjusted according to individual response, to abolish verbal communication and movement. Intraoperative fluid therapy consisted of crystalloid (Plasmalyte B), colloid (Haemaccel) for intraoperative hypotension, defined as systolic blood pressure
