|Year : 2007 | Volume
| Issue : 5 | Page : 409
Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique
Rajib Bhattacharyya1, Bhaskar Dutta2
1 MD, Associate Prof., Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam, India
2 PG Student, Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam, India
|Date of Acceptance||12-Aug-2007|
|Date of Web Publication||20-Mar-2010|
Department of Anaesthesiology & Critical Care, Assam Medical College, Dibrugarh, Assam
Double space combined spinal epidural anaesthesia (CSEA) is one of the techniques of anaesthetic armamentarium, which can be used as the sole technique of anaesthesia and continued for relief of postoperative pain. A prospective, randomized, and controlled study was conducted involving 90 patients of ASA physical status I& II coming for elective lower limb orthopaedic surgeries, carried under spinal anaesthesia with 2.5 ml bupivacaine heavy(0.5%) given intrathecally. Epidurally,0.125% bupivacaine alone, or along with morphine 2.5 mg or tramadol 75 mg was administered postoperatively, at two segment sensory regression. The duration of analgesia or the time to first top-up dose in the study groups were 206.8 ± 97.5minutes, 507.3 ± 228.6 minutes and 399.3 ± 152.1 minutes respectively, in bupivacaine group, morphine-bupivacaine group and tramadol-bupivacaine group. None of the patients in the study groups demonstrated motor block after 2 hours of observation period. None of the patients in the study groups had respiratory depression. The double space technique is also economical to the patients, which is a major advantage in our country.
Keywords: Double space CSEA, Postoperative analgesia.
|How to cite this article:|
Bhattacharyya R, Dutta B. Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique. Indian J Anaesth 2007;51:409
|How to cite this URL:|
Bhattacharyya R, Dutta B. Postoperative Analgesia with Local Anaesthetic and Opioid Combinations, Using Double Space CSE Technique. Indian J Anaesth [serial online] 2007 [cited 2014 Apr 24];51:409. Available from: http://www.ijaweb.org/text.asp?2007/51/5/409/61172
| Introduction|| |
Double space combined spinal epidural anaesthesia (CSEA) is one of the techniques of anaesthetic armamentarium, which can be used as the sole technique for carrying out surgical procedures and managing postoperative pain, using various drug regimes. Epidural administration of opioids, in combination with local anaesthetic agents in low dose offers new dimensions in the management of postoperative pain. The rationale for this relatively new technique in post-operative pain management is a better quality of analgesia than that achieved by systemically administered analgesics, a lower incidence of side-effects, improved surgical outcome and high levels of patient satisfaction .
Aims and objectives of the study were:
- To compare the degree and duration of postoperative analgesia, effectiveness and complications of the drugs used.
- Assess the cardiovascular and respiratory changes in the postoperative period upto 24 hrs.
- Observe the complications of the procedure.
| Methods|| |
This prospective, randomized, and controlled study was conducted involving 90 patients of both sexes between the age group of 30 - 60 years and 30 - 70 kg of weight, with ASA physical status I & II coming for elective lower limb orthopaedic surgeries, after taking approval from the hospital ethical committee. Patients under anticoagulant therapy, vertebral column disease or backache, any neurological or psychotic disorder, with difficulty in communication, septicaemia and those on MAO inhibitors were excluded from the study.
Grouping of cases: All the patients in the three groups received 2.5 ml bupivacaine heavy (0.5%) intrathecally before surgery, followed by the epidural bolus postoperatively, at two segment sensory regression, in the following manner -
Group B : 7 ml of 0.125 % bupivacaine + 3ml distilled water. Epidural top up (5 ml of 0.125% bupivacaine+ 2 ml distilled water) injected whenever VAS score becomes 4 or more.
Group BM : 7 ml of 0.125 % bupivacaine + 3 ml / 2.5 mgmorphine. Epidural top up (5 ml of 0.125 % bupivacaine + 2 ml / 0.5 mg morphine) injected whenever VAS score becomes 4 or more.
Group BT : 7 ml of 0.125 % bupivacaine + 3ml / 75 mg tramadol. Epidural top up (5 ml of 0.125 % bupivacaine + 2 ml / 15 mg tramadol) injected whenever VAS score becomes 4 or more.
Visual Analogue Scale (VAS) was used for recording the intensity of pain of the patients and for recording the quality of pain relief, Verbal Rating Scale (VRS) was used .
VAS (Visual Analogue Scale):
Verbal rating scale
1 - No pain : quality is - excellent analgesia.
2 - Mild pain : quality is - good analgesia.
3 - Moderate pain : quality is - fair analgesia.
4 - Severe pain : quality is - poor analgesia.
Bradycardia was defined as pulse rate < 60 beats per minute and hypotension was defined as reduction of MAP > or = 30% of baseline  . Respiratory rate, sedation score and arterial oxygen saturation were monitored to assess respiratory depression, which was defined as a fall of respiratory rate to 8 breaths or less per minute  or a sedation score of 3  or a fall of arterial oxygen saturation value to less than 90%  . Bromage scale was used for the assessment of motor blockade  .
0 = none : Patient alert
1 = mild sedation : Occasionally drowsy; easily aroused
2 = moderate sedation : Frequently drowsy; easily aroused
3 = severe sedation : Somnolent; difficult to arouse
S = none : Normal sleep; easily aroused.
Grade 0 (poor relaxation) : no paralysis; preservation of all joint movements.
Grade 1 (fair relaxation): inability to raise extended legs; involvement of hip joints but preservation of knee and ankle joint movements.
Grade 2 (good relaxation): inability to flex knees; preservation of movements of ankle joint with absence of motor power of hip and knee joints.
Grade 3 (excellent relaxation): inability to flex the ankle and first toe, limb flaccid.
All patients were premedicated with midazolam 0.07 mg.kg -1 IM, 30 minutes before and preloading was done with Ringer's lactate infusion at 10 ml.kg -1 through an 18 G IV cannula, before starting the procedure. Ranitidine 50 mg was administered in the infusion.
The patients were placed in the lateral position and 18 G epidural needle was introduced in the L 3 rd - 4 th interspace. The epidural space was identified by loss of resistance to saline  . Simultaneously with the injection of saline, the needle-syringe assembly was rotated 90 degree anticlockwise so that the needle bevel faces cephalad. Then the epidural space was cannulated with an epidural catheter, advancing it for not more than 5 cm  . Epidural test dose with 60 mg of lidocaine and 15 µg of epinephrine was then injected through the epidural catheter and observed for any motor block or rise in the heart rate  . Next, the L 4th- 5 th interspace was identified, a 25 G spinal needle was introduced and 0.5% bupivacaine heavy, 2.5 ml was injected intrathecally. After positioning the patients, surgeons were allowed to proceed with the operation once the desired level of block was achieved. The height of sensory block at 20 minutes after spinal anaesthesia was noted and recorded.
Bolus epidural drugs were administered postoperatively at "two segment sensory regression" time. All the parameters were recorded at 15 min, 30 min, 1 hr, 2 hr, 4 hr, 8 hr, 12 hr, 18 hr & 24 hrs postoperatively. The duration of postoperative analgesia was measured from the time of injection of the epidural bolus to a VAS (Visual Analogue Scale) score of 4  . Top-up doses of drugs were administered whenever the VAS score became 4. Rescue analgesic (diclofenac sodium, 75 mg) was injected deep intramuscularly, when patients complained of inadequate analgesia even after 3 successive top-up doses given 20 minutes apart  and after receiving a total morphine dose of 6mg  and total tramadol dose of 200 mg  .
Observed data were compiled and analyzed statistically using paired and independent sample't' test to assess the variance between the preoperative and postoperative value, and to assess the statistical significance between the groups. A P-value of < 0.05 was considered just significant, < 0.01 as highly significant and < 0.001 as very highly significant.
| Results|| |
The groups were comparable with regard to age, sex, height, weight and ASA physical status.
VAS Score [Table 1]: All the patients in the three groups had VAS = 0, in the immediate postoperative period and at two segment sensory regression. Group BM had least VAS score throughout observation. Group BT had intermediate VAS scores [Figure 1].
VRS Score [Table 2]: All the patients in the three groups had excellent analgesia in the immediate postoperative period and at 2 segment sensory regression. Group BM had longest duration of excellent analgesia, while Group BT was intermediate [Figure 2].
The duration of analgesia [Table 3] or the time to first top-up was longest in Group BM (P < 0.001) and intermediate in Group BT [Figure 3].
The no. of top-up doses given in the postoperative period, was highest in Group BM, intermediate in Group BT and least in Group B (P < 0.001).
The dose of bupivacaine received by the patients in Group BM was 17.5 ± 6.23 mg, in Group BT 25.2 ± 4.78 mg and in Group B, it was 37.7 ± 5.56 mg (P < 0.001).
The average morphine dose (in mg) received by patients of Group BM was 3.9± 0.49 and that of tramadol in Group BT was 135.5 ± 11.47. In Group B, 5 patients required rescue analgesic postoperatively, unlike the other two groups.
Urinary retention was noted in maximum12 (40%) patients in Group BM, followed by 5 (16.6 %) and 4 (13.3 %) patients in Group BT and B respectively. Nausea and vomiting was seen in 7 (23.3%) patients in Group BM, followed by 6 (20 %) and 2 (6.67 %) patients in Group BT and B respectively. Pruritus was observed in 1 patient in Group BM. Only 3 patients (10%) in Group BM had sedation score of 1 at 2 hour observation time.
Traumatic epidural puncture was observed in 1 patient each in Group B& BM, and in 2 patients in Group BT (Total of 4.44 % in the three groups). Backache was noted in 1 patient each in Group B, BM and BT. One patient in Group B had unilateral spinal anaesthesia.
Pulse rate, mean arterial pressure, respiratory rate, Bromage scale & SpO 2 did not differ significantly among the patients of the three groups (P > 0.05).
In 4 patients, the study could not be carried out due to inadvertent dural puncture (1 patient - 1.11%), failure of epidural catheterization (1 patient - 1.11%) and failure to give spinal anaesthesia (2 patients - 2.22%).
| Discussion|| |
Any method of postoperative analgesia must meet three basic criteria; it must be effective, safe and feasible. The majority of the patients after surgery managed with parenteral drugs are left with unrelieved pain  . The discovery of opioid receptors in the brain and spinal cord started a new era in the field of postoperative analgesia  .
In our study the double space technique was preferred to the single space CSE technique, since one can perform the epidural test dosing in this technique, with almost no chance of the catheter being pushed intrathecally  and it is quite economical to the patients.
The analgesic mixture was administered when the patients were still under the influence of spinal anaesthesia, as poor analgesic response has been reported with epidural morphine when the drug was administered after the onset of pain  . The concentration of bupivacaine exceeding 0.125% may be associated with excessive motor blockade when used in epidural infusions in the lumbar region  .
Post-operative analgesia using relatively small doses (2 - 4 mg intermittent boluses) of epidural morphine was safe on post-surgical wards  . We used a tramadol dose of 75 mg because, the analgesic efficacy of tramadol via the epidural route, was equipotent to morphine in a dose ratio of about 30:1  .
The total 24 hour morphine dose was kept at or below 6 mg and that of tramadol at or below 200 mg, as epidural morphine dose of more than 6 mg is a risk factor for developing respiratory depression  and epidural tramadol in a dose of 200 mg can be administered for the relief of postoperative pain  .
Maximum duration of analgesia was with morphine bupivacaine (507.3 min), while it was 399.3 min with tramadol-bupivacaine and 206.8 min with bupivacaine alone. Using continuous infusion of analgesic regime and maintaining a sustained plasma level of the drugs and consequently a longer duration of analgesia (10.9 hours with epidural morphine and 16.0 hours with epidural morphine-levobupivacaine combination) was observed in patients undergoing major abdominal surgeries  . Kotur et al using 75 mg of tramadol with lidocaine-adrenaline reported a duration of analgesia of 327.6 ± 58.8 min  .
In our study, none of the patients in the study groups had respiratory depression. Absence of clinically relevant respiratory depression and safety for postoperative pain relief was reported with epidural tramadol  . Yaddanapudi et al using 3 mg of morphine and 50mg of tramadol for postoperative analgesia in patients undergoing laminectomy did not find any occurrence of respiratory depression in their patients  .
3 (10%) of the patients in morphine-bupivacaine group had sedation score of 1 at 2 hour observation period and subsequently during the entire observation period, they had "no sedation".
Due to the very low concentration of bupivacaine none of the patients in the present study demonstrated motor block after 2 hours of observation period.
The incidence of nausea and vomiting, and that of urinary retention were comparable to previous studies , . Magora et al explained epidural opioid-induced urinary retention on the basis of increased tone of detrusor muscle and vesical sphincter  .
Opioid-related pruritus is usually limited to the face and torso  . Its mechanism is not known but it appears to be centrally mediated. Release of histamine has also been considered to be a causative factor  and antihistamines often provide symptomatic relief  .
None of our patients reported other side effects like hypotension, bradycardia, shivering, dizziness, PDPH, convulsions etc.
Incidence of inadvertent dural puncture also, correlates well with the study by Giebler et al  .
| Conclusion|| |
Tramadol is an atypical opioid which acts as a weak agonist for all types of opioid receptors. In addition, it has non-opioid mechanisms of analgesia by inhibition of noradrenaline uptake and stimulation of serotonin release, which probably account for its potent analgesia and negligible opioid-related side effects, especially respiratory depression (high benefit-risk ratio). Epidural administration of tramadol hydrochloride is a simple, effective and safe method to provide moderately prolonged postoperative analgesia, but epidural morphine is a better option in terms of providing excellent postoperative analgesia in lower limb orthopaedic surgeries.
| References|| |
|1.||Ferrante FM, VadeBoncouer TR. Epidural analgesia with combinations of localanaesthetics and opioids. In:Editors - Ferrante FM, VadeBoncouer TR; 1st Edition, Postoperative Pain Management. USA: Churchill Livingstone Inc 1993;305-334. |
|2.||Seymour RA. The use of pain scales in assessing the efficacy of analysis in postoperative dental pain. Eur J Clin Pharmacol 1982; 23:441. |
|3.||David LB. Miller's Anesthesia, 6th Edition. USA: Churchill Livingstone 2005;1653-1683. |
|4.||Ready LB. Regional analgesia with intraspinal opioids. In: Editors - JohnD. Loeser, Stephen H. Butler, C. Richard Chapman; 3rd edition, Bonica's management of pain. Lippincott Williams& Wilkins 2001;1953-1966. |
|5.||Baraka A, S Jabbour, M Ghabash, A Nader, G Khoury and A Sibai. A comparison of epidural tramadol and epidural morphine for postoperative analgesia. Can JAnaesth 1993; 40:308313. |
|6.||Bromage PR. Philadelphia: WB Saunders; 1978: 144. |
|7.||Armitage EN. Principles and Practice of RegionalAnaesthesia, 3 rd edition. UK: Churchill Livingstone Inc. 2003: 139-167. |
|8.||Browne RA, Politi VL. Knotting of an epidural catheter: a case report. Can Anaesth Soc J 1979; 26:142-144. |
|9.||Poblete B, Van Gessel EF, Gaggero G, Gamulin Z. Efficacy of three test doses to detect epidural catheter misplacement. Can J Anaesth 1999; 46:34-39. |
|10.||P Malik, et al. Comparative evaluation of epidural tramadol and morphine for postoperative analgesia. Eg J Anaesth 2005; 21: 135 - 40. |
|11.||Baraka A, Siddik-Sayyid, Aouad-Maroun M, Sleiman D, Sfeir M. Epidural tramadol for postoperative pain after Cesarean section. Can J Anaesth 1999; 46:731-5. |
|12.||Moote C Technique for postoperative pain management in the adult. Can J Anaesth 1993; 63:189-195. |
|13.||Gilbert PE, Martin WR. The effects of morphine and nalorphine-like drugs inthe nondependent, morphine-dependent and cyclazocine-dependent chronic spinal dog. Journal of Pharmacology and Experimental Therapeutics 1976; 198: 66-82. |
|14.||Eldor J, Guedj P, Levine S. Delayed respiratory arrest in combined spinal-epidural anesthesia. Reg Anaesth 1994; 19:418-422. |
|15.||Chambers WA, Sinclair CJ, Scott DB. Extradural morphine for pain after surgery. Br J Anaesth 1981; 53:921-925. |
|16.||James C. Crews,AllenH. Hord, Donald D. Denson, and Carmen Schatzman. A Comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0.005% morphine alone for the management of postoperative pain in patients undergoing major abdominal surgery. Anesth Analg 1999; 89:1504. |
|17.||Glass PSM, Estok P, Ginsberg B, et al. Use of patient-controlled analgesia to compare the efficacy of epidural to intravenous fentanyl administration. Anesth Analg 1992; 74:345-351. |
|18.||Chrubasik J, Warth L, Wust H, et al. Pain 1988; 9:12-18. |
|19.||Kotur PF, Suresh SN, Anupama L: www.jnmc.edu (accessed on 18/01/06). |
|20.||Houmes RJ, Voets MA, VerkaaikA, ErdmannW and Lachmann B. Efficacy and safety of tramadol versus morphine for moderate and severe postoperative pain with special regard to respiratory depression. Anesthesia& Analgesia 1992; 74:510-514. |
|21.||Yaddanapudi LN, Wig J, Singh B, Tewari MK. Comparison of efficacy and side effects of epidural tramadol and morphine in patients undergoing laminectomy : a repeated dose study. Neurol India 2000;48:398-400. [PUBMED] |
|22.||Delilkan AE, Vijayan R: Epidural tramadol for postoperative pain relief. Anaesthesia 1993; 48: 328-331. |
|23.||Stenseth R, Sellevold O, Breivik. Epidural morphine for postoperative pain relief: Experience with 1085 patients. Acta Anaesthesiol Scand 1985; 29:148-156. |
|24.||Magora F, Olshwang D, Eimerl D, et al. Observations on extradural morphineanalgesiain various painconditions. Br JAnaesth 1980; 52:247-251. |
|25.||Benedetti C. Intraspinal analgesia: a historical overview. Acta Anaesthesiol Scand 1987; 31 (Suppl 85):17-24. |
|26.||Greaves MW, Wall PD. Pathophysiology of itching. Lancet 1996; 348:938-940. |
|27.||Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization. Anesthesiology 1997; 86: 55-63. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]