|Year : 2016 | Volume
| Issue : 3 | Page : 393-397
Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery
Hany K Mickhael MD 1, Josef Zekry1, Mohamed Abd Elrazek2
1 Department of Anesthesia and Intensive Care, Faculty of Medicine, Minia University, Minia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Minia University, Minia, Egypt
|Date of Submission||03-Mar-2015|
|Date of Acceptance||10-Oct-2015|
|Date of Web Publication||31-Aug-2016|
Hany K Mickhael
Department of Anesthesia and Intensive Care, Faculty of Medicine, Minia University, Minia
Source of Support: None, Conflict of Interest: None
The aim of the present study was to detect the efficacy of early postoperative calf muscle exercise to decrease the risk of deep venous thrombosis achieved by intrathecal 3 ml bupivacaine 0.25% and fentanyl 25 μg instead of 3 ml bupivacaine 0.5%. In total, 40 patients of either sex, aged between 18 and 60 years, with American Society of Anesthesiologists (ASA) I and II were included in the study.
Patients and methods
A total of 40 ASA I and II patients undergoing elective total hip replacement surgery were randomly assigned to two equal groups of 20 patients each (group A and B). Group A received bupivacaine 0.5% (3 ml) and group B received bupivacaine 0.25% (3 ml)+fentanyl 25 μg. Patients were instructed on how to do cuff muscle exercise once they regained the full strength of the lower limbs muscles postoperatively. Five venous blood samples were taken from each patient for the D-dimer assessment as an indicator for the occurrence of venous thromboembolism. The first sample was taken preoperatively at the time of induction of anesthesia; the rest of samples were then taken at 12, 24, 48 h, and 7 days postoperatively.
Group B, in which patients received intrathecal bupivacaine 0.25% plus fentanyl, had an earlier recovery of motor power; patients in this group started doing calf muscle exercise earlier than did those in group A, and this group had significantly lower postoperative D-dimer level, denoting less susceptibility to deep venous thrombosis.
Early postoperative calf muscle exercise decreased the incidence of venous thromboembolism risk as indicated by the results of the D-dimer assessment.
Keywords: capital deep venous thrombosis, D-dimer, postoperative, spinal anesthesia
|How to cite this article:|
Mickhael HK, Zekry J, Elrazek MA. Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery. Ain-Shams J Anaesthesiol 2016;9:393-7
|How to cite this URL:|
Mickhael HK, Zekry J, Elrazek MA. Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 11];9:393-7. Available from: http://www.asja.eg.net/text.asp?2016/9/3/393/189087
| Introduction|| |
Venous thromboembolism (VTE) is considered one of the common complications that occur in hospital-admitted patients, as it was estimated to complicate 2–3 per 1000 hospital admissions . VTE is categorized as deep venous thrombosis (DVT) and pulmonary embolism (PE). VTE is associated with high morbidity, especially in perioperative period .
About 60–70% of the patients with symptomatic VTE develop DVT. DVT usually appears in the calf area of the leg. The majority of the thrombi form in the deep veins below the popliteal trifurcation (distal DVT), most likely to resolve spontaneously with no symptoms. Most patients present with symptoms when distal DVT extend to the popliteal and femoral veins and other proximal veins ,.
DVT can lead to complications such as PE, postphlebitis syndrome, and death . There is a 50% risk that patients with untreated symptomatic proximal DVT would develop symptomatic PE within 3 months. PE symptoms may appear as new or worsening dyspnea, chest pain, or sustained hypotension with no alternative cause .
Another important complication of DVT is post-thrombotic syndrome, which develops in 20–50% of the patients and may result in lifelong limb pain, swelling, heaviness, edema, and leg ulcers ,.
The causes of VTE are usually not known, but are universally attributed to Virchow's triad (stasis, hypercoagulability, intimal injury). Venous stasis includes tourniquet, immobilization, and bed rest, whereas hypercoagulability includes increase in thromboplastin agent and vascular injury (surgical manipulation of the limb, endothelial injury). Thus, hip replacements are considered as strong risk factors, as total hip replacement surgery involves prolonged bed rest (~6 week postoperative); on the other hand, trauma increases thromboplastin .
Deep venous thrombosis risk stratification for surgical patients 
- Uncomplicated surgery in patients aged less than 40 years with minimal immobility postoperatively and no risk factors.
- Minor surgery in patient with additional risk factors.
- Surgery in patients in the age group 40–60 years with no additional risk factors.
- Surgery in patients aged greater than 60 years.
- Surgery in patients in the age group 40–60 years, with additional risk factors.
- No surgery in patients (>40 years) with multiple risk factors include previous venous thromboembolism, cancer, known hypercoagulable state, major orthopedic surgery (hip/knee arthroplasty), elective neurosurgery, multiple trauma, and spinal cord injury.
The D-dimer antigen is a unique marker of fibrin degradation and is formed by the sequential action of three enzymes on thrombin, factor XIIIa, and plasmin. First, thrombin cleaves fibrinogen-producing fibrin monomers, which polymerize and serve as a template for factor XIIIa and plasmin formation. Second, thrombin activates plasma factor XIII, bound to fibrin polymers to produce the active transglutaminase, factor XIIIa. Factor XIIIa catalyzes the formation of covalent bonds between D-domains in the polymerized fibrin. Finally, plasmin degrades the cross-linked fibrin to release fibrin degradation products and expose the D-dimer antigen. D-dimer antigen can exist on fibrin degradation products derived from soluble fibrin before its incorporation into a fibrin gel, or after the fibrin clot has been degraded by plasmin .
D-dimer testing is of clinical use when there is a suspicion of DVT, PE, or disseminated intravascular coagulation. The absence of a raised concentration of D-dimer implies that there is no fresh thromboembolic material undergoing dissolution in the deep veins or in the pulmonary arterial tree .
Elevated D-dimers are seen in disseminated intravascular coagulation, PE, arterial and venous thrombosis, septicemia, cirrhosis, carcinoma, sickle cell crisis, and several operative procedures .
A normal D-dimer result (≤250 ng/ml D-dimer units; ≤0.50 mcg/ml fibrinogen equivalent units) has a negative predictive value of ~95% for the exclusion of acute PE or DVT .
The degree of D-dimer increase does not definitely correlate with the clinical severity of associated disease states .
| Aim|| |
The aim of this study was to detect the efficacy of early postoperative calf muscle exercise to decrease the risk of DVT achieved by selective spinal anesthesia (SSA) by using an intrathecal injection of 3 ml bupivacaine 0.25% and fentanyl 25 μg instead of 3 ml bupivacaine 0.5%.
| Patients and methods|| |
This study was approved by the hospital ethics committee of El-Minia University Hospital. We obtained written informed consent from 40 American Society of Anesthesiologists (ASA) I–II patients undergoing elective total hip replacement surgery.
Male and female patients scheduled for total hip replacement with a history of at least 2 weeks of bed recumbency were included in the present study.
Patients with a history of back surgery, mental retardation, infection at injection sites, coagulopathy, a history of opioid and chronic analgesic use, hypersensitivity to local anesthetics or opioids, diabetes, peripheral neuropathy, coronary artery disease, advanced cardiac valve disease, or an ejection fraction less than 50% were excluded from the study.
All patients included in this study received low-molecular-weight heparin (LMWH) in the form of enoxaparin Clexane (Sanofi aventis, France) 20 IU once daily subcutaneously.
This study was conducted between May 2014 and October 2014. Patients were allocated into two groups using a random number sequence. Group A received bupivacaine 0.5% (3 ml) (Marcaine Spinal Heavy; Astra, Sodertalje, Sweden) and group B received 0.25% (3 ml) + fentanyl 25 μg (Janssen-Cilag (Germany For sunny Medical Group), a subsidiary of the Johnson & Johnson Pharmaceutical Company).
ECG, noninvasive arterial pressure, and peripheral oxygen saturation were monitored (KMA 800; Petas, Turkey).
Before administering spinal anesthesia, the patients received 7–8 ml/kg lactated Ringer's solution intravenously over 20 min. Spinal puncture was performed at L 4–5 with a 25-G Quincke needle with the patient in the sitting position. After the free flow of clear cerebrospinal fluid was observed, the drug mixture was given over 2 min, and the patients were placed in a sitting position for 2 min and then in supine position until the sensory block peaked.
We recorded time of onset of sensory block (time elapsed from injection of local anesthetic till achievement of the sensory block level), duration of sensory block (time of regression of two segments in the maximum block height), onset of motor block (assumed when modified Bromage score becomes 3), and the duration of motor blockade (the time that elapses between injection of the anesthetic and total recovery of motility by the feet). The level of sensory block, defined as the dermatomal segment with loss of pain sensation to cold alcohol swap and pin-prick test with a 22-G hypodermic needle and on each side of the mid-thoracic line, was measured every 2 min, until it reached the peak level with four consecutive tests.
Adverse effects such as hypotension, bradycardia, nausea or vomiting, pruritus, shivering, and respiratory depression were recorded during the operation and the recovery period.
Postoperatively, patients were instructed on how to do cuff muscle exercise once they regained the full strength of the lower limbs muscles.
Five venous blood samples were taken from each patient for the D-dimer assessment. The first sample was taken preoperatively at the time of induction of anesthesia; the rest of the samples were taken at 12, 24, 48 h, and 7 days postoperatively.
Statistical analysis was carried out using statistical package for the social sciences (SPSS, v. 11.0 for Windows; SPSS Inc., Chicago, Illinois, USA). Data were presented through tables. The χ2-test was used to compare proportions, and the t-test was used to compare means. Confidence intervals were reported at the 95% level throughout this study. The sample size was 20 for each group, which was calculated using EPI Info 2000 (Atlanta, Georgia (USA)) with a confidence level of 95%.
| Results|| |
There were no statistically significant differences between the two groups as regards demographic characteristics (age, sex, weight, height, and ASA status), with P-value more than 0.05 [Table 1].
There was insignificant difference between the two groups as regards time of onset of sensory and motor block and time of sensory recovery. Time of motor block was significantly prolonged in group A compared with group B ([Table 2] and [Table 3]).
As regards D-dimer values, comparison between the two groups by using the unpaired t-test showed insignificant differences at preoperative time, but there were significant differences at 12, 24, 48 h, and 7 days postoperatively [Table 4].
| Discussion|| |
DVT is a major cause of morbidity and mortality among postoperative patients. Its incidence has been reported to range between 16 and 38% among general surgery patients and may be as high as 60% among orthopedic patients. The most important clinical outcome of DVT is PE, which causes about 10% of the hospital deaths .
Varying regimens for DVT prophylaxis have been reported, including intermittent pneumatic compression with early ambulation, immediate postoperative warfarin, and LMWH. In this high-risk group, the utilizing a combination of DVT prophylaxis measures should be considered. The risk for bleeding must be weighed against the benefits of prophylaxis in determining the timing of initiation of DVT pharmacologic prophylaxis in combination with mechanical prophylaxis .
In this study, 40 patients with total hip replacement surgery, who had a history of bed stay, were divided into two equal groups and we evaluated the effects of early postoperative calf muscle exercise as a prophylactic measure against DVT as indicated by the serum D-dimer level.
Group B, in which patients received intrathecal bupivacaine 0.25% plus fentanyl, had an earlier recovery of motor power; patients in this group started calf muscle exercise earlier than did those in group A; group B had significantly lower postoperative D-dimer level, denoting less susceptibility to DVT.
The challenge today is to use spinal anesthesia that is suitable, and ensures rapid recovery and early home discharge with minimal postoperative or no side effects when compared with modern ambulatory general anesthesia .
There are many techniques for SSA by using different anesthetics to achieve sensory block suitable for surgery with minimal motor block .
Few and mild postoperative side effects allow SSA (low doses lidocaine and fentanyl) to be one of the best techniques for ambulatory anesthesia compared with general anesthesia (18). It is essential for the anesthetist to provide the best anesthetic care for ambulatory surgery to facilitate rapid return to daily work .
The results of this study demonstrated that starting calf muscle exercise as soon as possible decreased the risk for VTE.
Early ambulation should be a routine part of all postoperative care, unless absolute contraindicated, and is acceptable as VTE prophylaxis for low risk surgical patients. Early ambulation may take place in the form of exercising calf muscles and stretching the legs while the patient is in the sitting position, raising and lowering the heels while keeping the toes on the floor or raising, and lowering the toes while keeping the heels on the floor .
In their study, Geerts et al.  concluded that DVT prophylaxis should be considered in all patients undergoing surgical procedures. In many patients undergoing low-risk procedures, early ambulation may be the only DVT prophylactic measure indicated. However, in patients with a high-risk profile undergoing a high-risk procedure, an assessment of all risk factors inherent to the patient and planned procedure should dictate the appropriate DVT prophylaxis .
Most studies evaluating prophylactic strategies for bariatric patients include some form of mechanical prophylaxis because of concerns of bleeding complications associated with chemoprophylaxis (2% incidence of bleeding complications was observed in a recent systematic review when a standardized definition of hemorrhage was used) .
A retrospective study of 1692 patients evaluated VTE rates comparing LMWH 40 mg twice daily and sequential compression devices (SCDs) (N = 435) with patients who received SCDs and early ambulation (within 2 h of arrival to ward) only (N = 1257). This study represented a change in the authors’ practice protocol over time and was not a randomized trial. These authors reported DVT and PE rates of 1.6 and 1.1%, respectively, for patients who received LMWH and SCD compared with a 4% DVT rate and no PEs for patients who received mechanical prophylaxis and early ambulation. Bleeding complications were higher in the LMWH group (4.8%) compared with the mechanical prophylaxis group (0.4%). The ability to generalize these results is limited, because these findings are a result of a single study, which reported fewer complications over time and a higher mean BMI and longer operative times in the group that received chemoprophylaxis .
Another study reported a retrospective analysis of 957 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass surgery and who received no pharmacologic treatment for VTE prevention. Calf-length SCDs were placed before surgery, and early, frequent ambulation was encouraged. The authors reported 30-day DVT and PE rates of 31 and 10%, respectively, and a bleeding complication rate of 73% .
Both of these studies excluded patients who were at high risk for VTE. The authors suggest that mechanical prophylaxis is sufficient for patients without a personal or strong family history of VTE events or known hypercoagulable state. It should also be noted that the VTE rates reported were based on symptomatic patients who underwent diagnostic testing and no routine imaging or screening was performed.
From this study, we concluded that early calf muscle exercise achieved by SSA decreased the risk of DVT and PE.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]