Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 3  |  Page : 350-355

Epidural volume extension with saline in combined spinal epidural anesthesia for dynamic hip screw surgeries using low dose of intrathecal hyperbaric bupivacaine


Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission31-Oct-2013
Date of Acceptance22-Dec-2013
Date of Web Publication27-Aug-2014

Correspondence Address:
Mahmoud M Okasha
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, 11646 Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.139565

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  Abstract 

Background
Combined spinal epidural (CSE) anesthesia is the preferred and widely used method for lower limb orthopedic surgeries. The epidural volume extension (EVE) technique is a modification of CSE in which the level of sensory analgesia obtained by subarachnoid block is increased by a small volume of saline administered through the epidural catheter.
Patients and methods
Fifty patients of both sexes, aged between 50 and 70 years scheduled for dynamic hip screw surgery were enrolled in the study. Patients were divided into two groups: group I (the CSE-EVE group) included 25 patients who were anesthetized using CSE with EVE and group II (the CSE group) included patients who were anesthetized using CSE without EVE, using the same technique and the same dose of intrathecal hyperbaric bupivacaine and fentanyl.
Results
Regarding all demographic data (age, height, weight, sex, and duration of operation), there were no statistically significant differences between the studied groups (P = 0.248, 0.901, 0.064, 0.564, and 0.967, respectively). Regarding the block profile, there was a statistically significant difference between the two groups regarding the level of maximal sensory block (P < 0.02), as five patients (20%) of group I showed sensory block level extended to T1-T2 and 20 patients (80%) showed sensory block below T2, whereas in group II, the sensory block level in all patients was limited below T2. The time required for reaching the maximal sensory block level was faster in group I, ranging from 8 to 15 min (mean ± SD: 10.7 ± 1.7), whereas in group II the time ranged from 9 to 16 min (mean ± SD: 13.4 ± 2.4; P < 0.001). Two-segment regression was faster in group II, ranging from 60 to 80 min (mean ± SD: 67.9 ± 5.1), whereas in group I it ranged from 70 to 95 min (mean ± SD: 81.0 ± 7.3; P < 0.001). The time required to reach the maximum motor block was faster in group I, ranging from 3 to 5 min (mean ± SD: 3.8 ± 0.5), whereas in group II the time ranged from 4.5 to 7.5 min (mean ± SD: 6.1 ± 0.8; P < 0.001). A volume of 10 ml bupivacaine 0.5% was injected by epidural catheter in 16 patients (64%) in group II, whereas only four patients (16%) in group I required activation of epidural anesthesia (P < 0.001). The systolic blood pressure and heart rate showed no significant changes between the two groups.
Conclusion
It can be concluded that low dose of intrathecal hyperbaric bupivacaine with EVE (10 ml saline) is associated with early onset of motor and sensory block, high level of sensory block, and shorter time of two-segment regression while maintaining hemodynamic stability.

Keywords: combined spinal epidural anesthesia, dynamic hip screw, epidural volume extension, intrathecal hyperbaric bupivacaine, local anesthetics


How to cite this article:
Okasha MM, Kamal S, Ramzy A. Epidural volume extension with saline in combined spinal epidural anesthesia for dynamic hip screw surgeries using low dose of intrathecal hyperbaric bupivacaine. Ain-Shams J Anaesthesiol 2014;7:350-5

How to cite this URL:
Okasha MM, Kamal S, Ramzy A. Epidural volume extension with saline in combined spinal epidural anesthesia for dynamic hip screw surgeries using low dose of intrathecal hyperbaric bupivacaine. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Oct 23];7:350-5. Available from: http://www.asja.eg.net/text.asp?2014/7/3/350/139565


  Introduction Top


Regional anesthesia has advantage over general anesthesia, as it is a simple, effective block with small dose of local anesthetic, economical, and safe technique [1]. One of the most important advantages is the ability to provide extended postoperative pain control that is superior to that provided by systemic opioids alone [2].

The majority of lower extremity orthopedic surgery patients are old age and many have multiple coexisting medical problems. Ensuring hemodynamic stability in these patients requires selection of the appropriate technique of regional anesthesia, focusing on maintaining a safe and desirable level of blockade, and limiting extensive sympathectomy [2]. Combined spinal epidural (CSE) anesthesia is the preferred and widely used method for lower limb orthopedic surgeries. The spinal component provides rapid onset of anesthesia and the drugs administered through the epidural catheter maintain analgesia during the postoperative period [3].

The epidural volume extension (EVE) technique is a modification of CSE in which the onset and level of block obtained by subarachnoid block is increased by a small volume of saline or local anesthetic administered through the epidural catheter [4]. Several mechanisms were reported to explain the effect of EVE with saline in the enhancement of spinal block, including the volume effect in which the theca is compressed by injected epidural saline, resulting in squeezing of cerebrospinal fluid and more cephalic spread of subarachnoid local anesthetic. This effect differs from the block enhancement caused by EVE with local anesthetic, as injected saline extends the block height by a mechanical volume effect (time-dependent effect) and has no effect on the duration of block. After two-segment regression has begun, EVE with saline has no effect on block extension and may even accelerate spinal block regression [5].

The aim of the present study was to evaluate the effectiveness of EVE in CSE anesthesia to perform adequate neuroaxial block by low dose of intrathecal hyperbaric bupivacaine (10 mg) and EVE by 10 ml 0.9% normal saline.


  Patients and methods Top


Fifty patients of both sexes, aged between 50 and 70 years, scheduled for dynamic hip screw surgery at the Orthopedic Department of Ain Shams University Hospitals were enrolled in this randomized, controlled, and single-blinded study (the researcher was aware of what belonged to both groups but the participants were not), after the approval of the Ethical Medical Committee and obtaining written informed consent from each patient. Patients with the following criteria were excluded from the study: patients who refused regional anesthesia, raised intracranial pressure, intrinsic and idiopathic coagulopathy, skin or soft-tissue infection at the proposed site of needle insertion, severe hypovolemia, and pre-existing neurologic disease (e.g. lower extremity peripheral neuropathy).

Anesthetic management

During the preoperative assessment, all enrolled patients were informed about the study objectives and protocol. Complete blood count, coagulation profile, blood sugar, renal and hepatic profile, ECG, and echocardiography were performed in all patients above 60 years and in those having ECG ischemic changes; examination of patient's back was performed for all patients. After establishing an intravenous access (16 G), a preload of 500 ml of a crystalloid (lactated Ringer) was given before CSE anesthesia. Patients were monitored for noninvasive blood pressure, ECG, and peripheral oxygen saturation.

Patients were randomly divided into two groups using a computer-generated random number table as follows.

(1) Group I (the CSE-EVE group): Twenty-five patients were anesthetized using CSE with EVE. After preparation of all requirements of both regional and general anesthesias, CSE was performed under complete aseptic conditions while patient was in the sitting position at interspace L3-L4 or L4-L5 using low dose of intrathecal hyperbaric bupivacaine (10 mg) and 25 μg fentanyl. Epidural was performed first using 18-G Tuohy needle (Perifix; B. Braun, Melsungen, Germany) using loss-of-resistance technique, and 20-G epidural catheter was inserted in a cephalad direction 4-6 cm into the epidural space and then secured. Spinal anesthesia was then performed using a 25-G Whitacre needle (Kosan, Tokyo, Japan) into a different interspace. Five minutes after performing the block, 10 ml sterile preservative-free 0.9% normal saline was injected into the epidural space.

(2) Group II (the CSE group): The patients were anesthetized using CSE without EVE using the same technique and the same dose of intrathecal hyperbaric bupivacaine and fentanyl.

The anesthetic technique and data collection were performed by the same researcher in both groups. An effective dose was defined as the one that resulted in a sensory block height to T10 level within 20 min of the intrathecal injection with no epidural top-up requirements. All ineffective doses were managed by administering epidural top-ups of 10 ml plain bupivacaine (0.5%) and were excluded from our study. Any episodes of hypotension [systolic blood pressure (SBP) <100 mmHg or <20% from baseline] were treated by administering titrated intravenous boluses of ephedrine 6 mg and intravenous fluid. Bradycardia [heart rate (HR) <55/min or <25% of the baseline value] was treated by intravenous boluses of atropine (0.5 mg). Shivering was treated by intravenous pethidine (25 mg). Postoperatively, epidural infusion of bupivacaine (0.125%) was initiated at 6 ml/h and was increased in 2 ml/h increments up to 12 ml/h according to patient satisfaction.

The following were recorded:

Demographic data

Age (years), height (cm), weight (kg), sex, and duration of operation from skin incision to skin closure (min) were included.

Hemodynamic status

SBP in mmHg and HR in beats/min were recorded after performing spinal anesthesia every 5 min for 20 min (four recordings: SBP1 and HR1 after 5 min, SBP2 and HR2 after 10 min, SBP3 and HR3 after 15 min, and SBP4 and HR4 after 20 min of performing spinal anesthesia) then every 15 min for 1 h (four recordings: SBP5 and HR5 after 35 min, SBP6 and HR6 after 50 min, SBP7 and HR7 after 65 min, and SBP8 and HR8 after 80 min of performing spinal anesthesia).

Block profile

The primary outcome of our study included the following:

(1) Level of maximum sensory block, time to reach maximum sensory block (min), and two-segment regression time of sensory block (min) (by pin-prick method).

(2) Time to reach maximum motor block (min) (Bromage 3), time to recover from motor block (min) (using modified Bromage scale: 0 = able to move hip, knee, and ankle; 1 = unable to move hip, able to move knee and ankle; 2 = unable to move hip and knee, able to move ankle; and 3 = unable to move hip, knee, and ankle [5]).

The total dose of bupivacaine top-up doses in milliliters given through epidural catheter in case of ineffective doses for spinal anesthesia and requirements of atropine and ephedrine were recorded, which were considered the secondary outcome of our study.

Statistical analysis

Statistical presentation and analysis of data of the present study were conducted using the mean, SE, Student's t-test, the χ2 -test, Fisher's exact test, and the Mann-Whitney U-test using SPSS version 13.0 statistical software packages (IBM Corporation, Endicott, New York, USA). Description of quantitative variables was in the form of mean, SD, and range. Description of qualitative variables was in the form of frequency and percentages. Unpaired Student's t-test was used to compare between two groups in quantitative data. The χ2 -test was used to compare qualitative variables. The differences were considered significant at P-value of 0.05 or less and highly significant at P-value of 0.01 or less. The required sample size was calculated with the help of a statistician. The primary outcome measured was the difference between the two study groups with respect to the postoperative block profile. Assuming a time for maximal sensory block ranging between 11.5 (SD 1.9) and 13.5 (SD 2.4) for the two modalities, a sample size of 25 patients in each study group giving a total of 50 participants was enough to detect such difference at an a-error of 0.05 and power of test of 0.9.


  Results Top


Regarding all demographic data (age, height, weight, sex, and duration of operation)


A total of 50 patients completed this study, 25 in each group, 20 (40%) women and 30 (60%) men. The age ranged from 51 to 70 years in group I and from 53 to 70 years in group II (mean ± SD: 65± 5.5 and 67 ± 4.9, respectively). The duration of the surgery ranged from 125 to 180 min in group I and from 125 to 175 min in group II (mean ± SD: 148.2 ± 17.19 and 148 ± 16.33, respectively). There was no statistically significant difference between the two groups regarding the age, height, weight, sex, and duration of operation (P = 0.248, 0.901, 0.064, 0.564, and 0.967, respectively) ([Table 1] and [Table 2]).
Table 1 Age, weight, height, and duration of operation in the two groups

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Table 2 Sex distribution in the two groups

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Regarding the hemodynamic status

In all, 10 patients showed episodes of hypotension (five in group I and five in group II), which represented 20% of all patients who were treated by intravenous boluses of ephedrine (6 mg) and intravenous fluid [Table 3].
Table 3 Hemodynamic status in the two groups

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The block profile

Regarding level of maximum sensory block, 20% (five patients) of group I patients showed sensory block level extended to T1-T2, whereas 80% (20 patients) showed sensory block below T2. However, in group II, the sensory level in all patients was limited below T2. Comparing between the two groups, there was a statistically significant difference regarding the level of maximum sensory block (P < 0.02) [Table 4]. Regarding the time to reach maximum sensory block, it was faster in group I ranging from 8 to 15 min (mean ± SD: 10.7 ± 1.7), whereas in group II it ranged from 9 to 16 min (mean ± SD: 13.4 ± 2.4); hence, there was a statistically significant difference between the two groups (P < 0.001). Regarding two-segment regression time of sensory block, it was faster in group II ranging from 60 to 80 min (mean ± SD: 67.9 ± 5.1), whereas in group I it ranged from 70 to 95 min (mean ± SD: 81.0 ± 7.3); hence, there was a statistically significant difference between the two groups (P < 0.001) [Table 5].
Table 4 Level of maximum sensory block in the two groups

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Table 5 Time of maximum sensory block and two-segment regression in the two groups

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Regarding motor block, the time required to reach the maximum block (Bromage 3) was faster in group I ranging from 3 to 5 min (mean ± SD: 3.8 ± 0.5) compared with group II in which it ranged from 4.5 to 7.5 min (mean ± SD: 6.1 ± 0.8); hence, there was a statistically significant difference between the two groups (P < 0.001) [Table 6].
Table 6 Time for maximum motor block in the two groups (min)

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Regarding the requirement for epidural activation by top-up doses of bupivacaine, 10 ml bupivacaine 0.5% was injected by epidural catheter in 16 patients (64%) in group II, whereas only four patients (16%) in group I required activation of epidural anesthesia. For the four patients of group I who required top-up doses of bupivacaine, the timing of top-up doses ranged from 120 to 140 min from onset of anesthesia. In group II patients who required top-up doses (16 patients), the timing ranged from 100 to 145 min from onset of anesthesia. Hence, there was a statistically significant difference between the two groups (P < 0.001) [Table 7].
Table 7 Top-up doses of bupivacaine in the two groups

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  Discussion Top


EVE is considered a modification of the CSE technique where normal saline is injected into the epidural space after the intrathecal injection of hyperbaric bupivacaine [6]. This is aimed at rapidly increasing the sensory level of subarachnoid block by raising the epidural pressure and causing thecal compression to push the intrathecal drug cephalad [6]. EVE technique is a unique technique for regional anesthesia, which offers the rapidity and reliability of spinal anesthesia with flexibility of epidural anesthesia. It is also associated with less degree of sympathectomy that accompanies spinal anesthesia when used alone, as the dose of hyperbaric bupivacaine used is low, and hence the severity of hemodynamic compromise is less [7].

The current study evaluated the effectiveness of EVE in CSE to perform adequate neuroaxial block by low dose of intrathecal hyperbaric bupivacaine (10 mg) through EVE by 10 ml 0.9% normal saline that was injected 5 min after performing the block. Frequent failure was reported in one study, if administration of epidural saline was delayed beyond 10 min [8]. In the current study, all demographic data (age, height, weight, sex, and duration of operation) were not statistically significant between the two groups.

Regarding the block profile, there was a statistically significant difference between the two groups regarding the level of maximal sensory block; 20% of patients in group I showed high sensory level extending to T1-T2, whereas in all patients of group II (100%) the sensory level was limited below T2. In addition, there was a statistically significant difference between the two groups regarding the time required for reaching the maximal sensory block level (faster in group I) and two-segment regression (shorter in group I). Regarding the time required to reach the maximum motor block (Bromage 3), there was a statistically significant difference between the two groups (faster in group I). Regarding the requirement for epidural activation by top-up doses of bupivacaine, 64% of group II patients needed top-up doses, whereas only 16% of group I patients required epidural activation. Hence, there was a statistically significant difference between the two groups.

Regarding the hemodynamic state, the SBP and HR showed no significant changes between the two groups, which emphasized the safety of EVE technique.

Supporting the results of our study, Salman et al. [5], who studied the effect of CSE with EVE on efficacy of block during Cesarean section by comparing between three groups [single shot spinal (group 1), CSE with EVE by saline (group 2), and CSE with EVE by levobupivacaine (group 3], concluded that motor and sensory block had faster onset, lasted longer, and was of a higher level in groups 2 and 3; these effects were more pronounced in group 3. Another study conducted by Agarwal and colleagues, who studied the effect of different volumes of epidural saline (10, 15, and 20 ml) on the level of sensory block during CSE anesthesia, concluded that there was a definite increase in the dermatomal level of sensory and motor level in all patients, which was volume dependent. This extension of level was not associated with significant change in pulse rate, blood pressure, or respiratory rate after spinal anesthesia [1]. Another study supporting our results was conducted by Lew and colleagues who studied the effect of EVE with low dose of bupivacaine on efficacy of neuroaxial block during Cesarean delivery by administering 9 mg bupivacaine 0.5% intrathecally to one group and by administering CSE (intrathecal 5 mg of 0.5% bupivacaine followed 5 min later by epidural 6 ml of 0.9% isotonic NaCl solution through the catheter) to the other group. They concluded that CSE and EVE may decrease the anesthetic dose needed by 55% as well as enable sufficient anesthesia for elective Cesarean delivery and facilitate a shorter stay in the recovery room due to its associated rapid motor recovery time [9].

In contrast, Loubert and colleagues studied the effect of EVE on CSE anesthesia for Cesarean section by comparing between three groups (spinal hyperbaric bupivacaine 7.5 mg, spinal hyperbaric bupivacaine 7.5 mg followed by 5 ml saline by epidural catheter, or spinal hyperbaric bupivacaine 10 mg without EVE), and they could not demonstrate a benefit in using EVE with 5 ml saline as part of a CSE technique in parturient undergoing elective Cesarean section [10].

Limitation of the study

To pick out smaller details, a larger sample size would have been ideal. In addition, lack of funding inhibited the use of recent, better, and recommended CSE set.


  Conclusion Top


It can be concluded that low dose of intrathecal hyperbaric bupivacaine with EVE (10 ml saline) is associated with early onset of motor and sensory block, high level of sensory block, and shorter time of two-segment regression while maintaining hemodynamic stability.


  Acknowledgements Top


 
  References Top

1.Agarwal J, Yadav BB, Malik A, et al. Comparison of effect of different volumes of epidural saline during combined spinal epidural anesthesia. Anesthesia Update, Anesthesia publication of Indian society anesthiologists, CSM medical university, Lucknow, India 2010; 13:45-50.  Back to cited text no. 1
    
2. Doty R, Sukhani R. CA Wong editor. Central neuroaxial blockade for lower extremity major orthopedic surgery. Spinal and epidural anesthesia. Chapter 7. 4th ed. McGraw-Hill Professional/Jaypee Brothers Medical Publishers; 2006.  Back to cited text no. 2
    
3. Rawal N. Combined spinal-epidural anesthesia. Curr Opin Anaesthesiol 2005; 18:518-521.  Back to cited text no. 3
    
4. Cook TM. Combined spinal-epidural techniques. Anaesthesia 2000; 55:42-64.  Back to cited text no. 4
    
5. Salman C, Kayacan N, Ertuðrul F, et al. Combined spinal epidural anesthesia with epidural volume extension causes a higher level of block than single-shot spinal anesthesia. Rev Bras Anestesiol 2013; 63:267-272.  Back to cited text no. 5
    
6. McNaught AF, Stocks GM. Epidural volume extension and low-dose sequential combined spinal-epidural blockade: two ways to reduce spinal dose requirement for caesarean section. Int J Obstet Anesth 2007; 16:346-353.  Back to cited text no. 6
    
7. Tiwari AK, Singh RR, Anupam RP, et al. Epidural volume extension: a novel technique and its efficacy in high risk cases. Anesth Essays Res 2012; 6:233-235.  Back to cited text no. 7
  Medknow Journal  
8. Choi DH, Park NK, Cho HS, et al. Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery. Reg Anesth Pain Med 2000; 25:591-595.  Back to cited text no. 8
    
9. Lew E, Yeo SW, Thomas E. Combined spinal-epidural anaesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study. Anesth Analg 2004; 98:810-814.  Back to cited text no. 9
    
10.Loubert C, O'Brien PJ, Fernando R, et al. Epidural volume extension in combined spinal epidural anesthesia for elective caesarean section: a randomized controlled trial. Anaesthesia 2011; 66:341-347.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


This article has been cited by
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Sheela S,Naghma E Sehar,Nirmala B C,Santosh R
INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH. 2021; : 23
[Pubmed] | [DOI]



 

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