|Year : 2016 | Volume
| Issue : 3 | Page : 353-357
A randomized study comparing the efficacy and safety of epidural anesthesia versus general anesthesia in patients undergoing percutaneous nephrolithotomy
Tanuj Kumawat1, Varsha Kothari1, Shivam Priyadarshi2, Tuhin Mistry MD 1, Sanjay Morwal1
1 Department of Anaesthesiology and Critical Care, Sawai ManSingh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
2 Department of Urology, Sawai ManSingh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
|Date of Submission||23-May-2015|
|Date of Acceptance||30-May-2016|
|Date of Web Publication||31-Aug-2016|
Resident Doctor’s Hostel, SMS Medical College, JLN Marg, Jaipur 302004, Rajasthan
Source of Support: None, Conflict of Interest: None
Percutaneous nephrolithotomy (PCNL) is the preferred surgical technique for large renal stones (>2 cm in diameter), which involves keyhole surgery through a 1 cm incision on the skin overlying the kidney. It can be performed under local, regional, as well as general anesthesia (GA). We have compared the efficacy and safety of regional epidural anesthesia (EA) and GA in patients undergoing PCNL.
Patients and methods
In this prospective study, a total of 112 patients of American Society of Anesthesiologists physical status I and II undergoing PCNL were randomized into two groups. Patients in group A (n=56) received regional EA (with lignocaine and bupivacaine), and group B (n=56) patients received standard GA. The postoperative visual analog scale (VAS) score, amount of postoperative analgesic use, adverse effects, operative time, and blood loss were evaluated and compared between the two groups.
The mean VAS score at 1 h was 1.25 in group A and 5.21 in group B (P<0.001), at 3 h it was 3.05 in group A and 5.04 in group B (P<0.001), and at 6 h it was 3.04 in group A and 4.79 in group B (P<0.001). Less analgesia was required in the EA group compared with the GA group (P<0.001). Five (8.92%) patients in group A and 21 (37.50%) patients in group B had postoperative nausea (P<0.05). Pain score at 18 and 24 h, operative time, postoperative hemoglobin level, and adverse effects were not significantly different between the two groups.
EA is a good alternative anesthetic technique for PCNL with less analgesic consumption and fewer complications as compared to GA.
Keywords: epidural anesthesia, general anesthesia, percutaneous nephrolithotomy
|How to cite this article:|
Kumawat T, Kothari V, Priyadarshi S, Mistry T, Morwal S. A randomized study comparing the efficacy and safety of epidural anesthesia versus general anesthesia in patients undergoing percutaneous nephrolithotomy. Ain-Shams J Anaesthesiol 2016;9:353-7
|How to cite this URL:|
Kumawat T, Kothari V, Priyadarshi S, Mistry T, Morwal S. A randomized study comparing the efficacy and safety of epidural anesthesia versus general anesthesia in patients undergoing percutaneous nephrolithotomy. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 11];9:353-7. Available from: http://www.asja.eg.net/text.asp?2016/9/3/353/189568
| Introduction|| |
Percutaneous nephrolithotomy (PCNL) allows fragmentation and removal of large calculi from the kidney and ureter. This minimally invasive percutaneous procedure is indicated in the management of stag-horn calculi (stone >2 cm in diameter or >500mm2 of surface area), multiple stones >1 cm in diameter and proximal ureteral stones >1 cm in diameter. It is also considered for lower pole stones >1 cm in diameter, calcium oxalate monohydrate and cystine stones, stones refractory to other treatments, stones in the calyceal diverticulum, and stones with ureteropelvic junction obstruction or poor drainage; such as horseshoe kidney .
PCNL is mostly performed in the prone position under general anesthesia (GA). Besides the common complications such as side-effects of medications and costs of GA, the problems during change of position from supine to prone include displacement of the endotracheal tube, lung atelectasis, eye and brachial plexus injury as well as other neurological complications, and occasional spinal cord injury .
Subsequently, alternative anesthetic techniques have been successfully used in PCNL; ranging from regional anesthesia to assisted local anesthesia (local infiltration with sedation) ,. However, there are limited number of studies regarding the applicability and feasibility of epidural anesthesia (EA) in patients undergoing PCNL. The aims of our study were to evaluate the feasibility of performing PCNL under single-shot EA and to compare the efficacy and safety of EA with GA.
| Patients and methods|| |
This study was conducted at a tertiary-care center from September 2013 to December 2013 after approval from the Institutional Ethical Committee. This prospective, randomized study included 112 patients of American Society of Anesthesiologists (ASA) physical status I and II, aged 20–60 years, with height more than 145 cm, who underwent PCNL.
Patients who had any contraindications to EA, history of convulsion, allergy to the drugs used, coagulation disorders, uncooperative patients and patients with medical illnesses such as cardiac disease, respiratory disease and neurological deficit were excluded from the study.
Preanesthetic checkup was performed on the day before the surgery and included a complete history of the patient, any known drug allergy, general and systemic examination and local examination of the lumbar spine area. Pulse rate, non invasive blood pressure (NIBP), respiratory rate and height of the patients were recorded. Routine relevant investigations were carried out in all the patients.
Written informed consent was obtained from all the patients after proper explanation about the study protocol and the procedure. The visual analog scale (VAS) was explained to the patients [Table 1].
The patients were randomized into two groups: 56 patients were included in each group by chit-in-box method on the day of surgery. In group A 56 patients underwent PCNL under EA and in group B 56 patients underwent PCNL under GA.
After shifting the patient to the operating theatre, two large bore (18 G) intravenous accesses were obtained, and lactated Ringer’s solution infusion was initiated at the rate of 10 ml/kg/h. Standard monitors (pulse oximeter, NIBP, five-lead ECG) were connected.
In group A, 56 patients received EA in the lateral decubitus position. With all aseptic precautions, the skin was cleaned with povidone iodine and draped. The L2–L3 space was identified, and the skin was infiltrated with 2% lignocaine to render the procedure painless. Next, an 18-G Tuohy needle (Romsons epidural needle; Romsons Scientific & Surgical Industries Pvt. Ltd., Nunhai, Agra, India) was inserted, and the epidural space was located by the loss-of-resistance to saline technique. A test dose of 3 ml of 2% lignocaine with adrenaline was administered and the patients were observed for 5 min to exclude any intravascular or intrathecal injection. The patients were then given 20 ml of 0.25% bupivacaine and 10 ml of 2% lignocaine (total volume 30 ml) to achieve a sensory block up to the T8 level. The patients were then placed in the supine position until the desired effect was achieved. Perioperative sedation was achieved by using midazolam 0.02 mg/kg intravenously.
In group B, 56 patients received GA. All patients were premedicated with intravenous glycopyrrolate (0.005 mg/kg), fentanyl (2 μg/kg) and midazolam (0.01 mg/kg). After preoxygenation with 100% O2 for 3 min, GA was induced with thiopental sodium (5 mg/kg), followed by atracurium (0.5 mg/kg) to facilitate direct laryngoscopy and orotracheal intubation. All the patients were mechanically ventilated at a fresh gas flow rate of 4 l/min, and anesthesia was maintained with sevoflurane (minimum alveolar concentration of 0.8‑1.0) in N2O and O2 mixture (60:40) and atracurium (0.1 mg/kg every 20 min) throughout the surgical procedure. During mechanical ventilation, a respiratory rate of 12–14/min and tidal volume of 8–10 ml/kg were used, and they were adjusted to maintain normocapnia and normoxia with oxygen saturation of 98% or more.
Following the induction of anesthesia, patients were placed in the lithotomy position. A ureteral catheter (5–6 F) was inserted into the renal pelvis by the urologist, and the patients were subsequently changed to the prone position.
Demographic data were recorded for both groups. The hemodynamic status and any adverse events following regional anesthesia and GA were recorded before, during, and after surgery. The VAS scores at 1, 3, 6, 12, 18, and 24 h after the surgery were recorded. One hundred milligram of tramadol was intravenously administered when patients had a VAS score more than 4. Stone clearance rate (success rate), operative time, postoperative analgesic requirements, and preoperative and postoperative hemoglobin and hematocrit levels were recorded. Patient satisfaction was evaluated using a three-point score [Table 2] based on any pain or discomfort experienced during surgery and in the postoperative period.
Sample size was calculated at 80% study power, with an α level of 0.05, assuming a SD of 1.88 in the VAS score after 12 h postoperatively as per the previous study for a minimum detectable difference of one in the VAS score; therefore, 56 patients were required in each group to obtain the significant sample size.
The statistical analysis was carried out using χ2, Student’s t-test, and Mann–Whitney U-test by statistical package for the social sciences software (version 21; SPSS Inc., Chicago, Illinois, USA). Data are presented as means±SD. A P-value of less than 0.05 and less than 0.001 were considered significant and highly significant, respectively.
| Results|| |
A total of 112 patients were included in this prospective, randomized trial, and none of them was excluded from the final analysis. No statistically significant differences were found with respect to age, sex, height, ASA grading, and duration of surgery between the two groups [Table 3]. Stone position and size, access tract, and success rate were comparable between the two groups ([Table 3] and [Table 4]).
There were no statistically significant differences in mean heart rate and mean arterial pressure at different time periods between the two groups ([Figure 1] and [Figure 2]).
|Figure 1 Comparison of mean heart rate between the two groups at different time periods. Bpm, beats per minute.|
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|Figure 2 Comparison of mean arterial pressure (MAP) between the two groups at different time periods.|
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In group A, a statistically significant reduced VAS score was found at 1, 3 and 6 h postoperatively compared with group B [Table 5].
Patients who underwent PCNL under GA (group B) consumed more analgesic drugs [Table 6].
Preoperative and postoperative hemoglobin and hematocrit values showed no significant differences between the two groups [Table 7].
Patients under regional EA (group A) had lower incidence of nausea and greater satisfaction with the anesthetic technique ([Table 2] and [Table 8]).
| Discussion|| |
In most of the studies in literature, preferred method of regional anesthesia for PCNL is combined spinal–epidural anesthesia (CSEA) or spinal anesthesia (SA). In our institute, we practise single-shot EA rather than CSEA/SA for PCNL.
GA, although preferred in many centers for performing PCNL, can be challenging in some situations, such as in patients with chronic obstructive pulmonary disease or cardiovascular diseases . Owing to possibility of fluid absorption and electrolyte imbalance, especially in stag-horn calculi and also in morbid obesity patients, regional anesthesia may be a good alternative for GA .
PCNL performed under EA was reported to confer some advantages over GA; such as lower postoperative pain, lower dose requirement for analgesic drugs, and avoidance of the side-effects from multiple medications during GA .
Movasseghi et al.  compared SA with GA, and concluded that SA is a faster and safer method of anesthesia during PCNL surgeries. Patients in the SA group needed smaller amounts of analgesics and showed better hemodynamic stability during surgery and recovery time. In addition, the SA technique provides decreased blood loss and shortened surgery as well as anesthesia times compared with GA . Gonen and Basaran  evaluated the impact of SA in patients undergoing tubeless PCNL, and concluded that SA is a good alternative for GA in adult patients as it decreases postoperative analgesic requirements .
Singh et al.  compared CSEA with GA in patients undergoing PCNL, and observed that the mean VAS score and analgesic use were significantly less in the CSEA group. The length of hospitalization was also significantly less in the CSEA group .
Tangpaitoon et al.  compared the efficacy and safety of EA with GA in patients who underwent PCNL; EA was accomplished with a continuous infusion of levobupivacaine (5 ml/h) into the epidural space between L1 and L2 levels. They observed that patient satisfaction was more in the EA group, and there were less early postoperative pain and less adverse effects with the same efficacy and safety compared with GA.
Bajwa et al.  compared GA with EA in patients undergoing renal surgeries, and concluded that EA can be safely and effectively used as compared with the conventionally used GA technique.
In our study, the EA was superior to the GA with regard to less postoperative pain, less analgesic requirements, and less incidence of nausea. There were no significant differences between the two groups in postoperative hemoglobin and hematocrit levels, operative time, postoperative complications and success rate.
| Conclusion|| |
EA is an equally effective alternative to GA during PCNL with reduced morbidity in terms of early postoperative recovery, less postoperative pain, less systemic analgesic requirements, less nausea/vomiting, and overall higher patient satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]