Combined spinal epiduralfor hip surgery in asaiii iv pts.
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This document discusses the use of combined spinal-epidural analgesia for hip surgeries in ASA III-IV patients, outlining the advantages over general anesthesia, including better pain management and fewer complications. It presents a study involving 60 adults that compares the efficacy of epidural and intramuscular administration of butorphanol as an adjuvant analgesic. The findings suggest that epidural administration provides quicker onset and better maximum pain relief, while maintaining stable vital parameters.
Combined spinal epiduralfor hip surgery in asaiii iv pts.
- 1. COMBINED SPINAL-EPIDURAL ANALGESIA FOR HIP SURGERY In ASA III- IV patients for both planned & emergency orthopedic procedures
- 2. Dr.Mridul M. Panditrao CONSULTANT Public Hospital Authority‟s RAND MEMORIAL HOSPITAL FREEPORT GRAND BAHAMA COMMONWEALTH OF THE BAHAMAS
- 3. FOMERLY: Professor /Head & I/C ICU Department of Anaesthesiology & Critical Care & Dean of Medical Faculty Pad. Dr. D.Y. Patil Medical College & Research Centre, Dr. D.Y. Patil University, Pimpri, Pune.
- 4. INTRODUCTION FOR ALL THE HAPPINESS Mankind can gain. Is not in pleasure But in rest from “pain” JOHN DRYDEN
- 5. INTRODUCTION (Contd.) Nociception: Transduction Transmission Modulation Perception “Gate control theory of Melzac & Wall” 1965 “Reynolds Theory of „Supra-Spinal Descending Control in Modulation in Dorsal Horn‟ ” 1969 “Woolf C.J” 1989 :- “ Supra spinal inhibition of nociception”
- 6. Hip surgeries/Lower limb orthopaedic surgeries.
- 7. Problems in a ASA III-IV Patients Elderly, Cachexic, Bedridden patients Associated systemic problems Rapid onset is required Prolonged time required GA is a relative contra indication Post operative complications of GA: May Require ventilator & associated problems Cost & Economy of GA Theatre pollution
- 8. Why Combined Spinal & Epidural? No sedation, drowsiness & grogginess Early ambulation is possible No respiratory depression Minimal Cardio vascular interference Low incidence of PONV Avoidance of autonomic stress response Pre emptive analgesia Superior quality of analgesia Cost effective
- 9. Adjuvants to Neuraxial Blockade: Why needed? Problems of LAAS So alternatives to LAAs were tried If duration of action is to be prolonged? Motor blockade causing interference with the mobility of the patient Sympathetic blockade leading to bradycardia and hypotension.
- 10. ALTERNATIVES TO LAAs: Problems: Side effects of Opioids Difficulty in procuring/licensing Minimal muscle relaxation Other agents viz. Clonidine, Neostigmine, Ketamine, Midazolam and their side effects
- 11. Advantages of Adjuvants Improvement of quality of block Onset of analgesic effect of LAAs is enhanced Duration of action of LAAs is prolonged Dose requirement of each drug is reduced Lower incidence of side effects
- 12. Routes of Administration In epidural space through epidural catheter when combined spinal epidural Analgesia is given In sub-arachnoid space when only SA is given
- 13. Various drugs used as Adjuvants Opioids agonists: Morphine, Fentanyl etc. Agonist /antagonist: Butorphanol, Buprenorphine Clonidine Neostigmine Ketamine Midazolam Tramadol Newer drugs like: Dexmedetomidine/Clonidine
- 14. Our Study: 60 adults of either sex Inclusion criteria Age range 35 – 80 yrs ASA l & ll Elective hip surgeries No or controlled systemic disorders Consent Exclusion criteria Age below 35 or above 80 yrs Uncontrolled systemic disorders Acute infection Spinal deformities Coagulopathies Opioid dependence
- 15. Methodology Randomization, NBM status No sedatives/ hypnotics pre or intra operatively IV infusion & monitoring devices 16 G Touhy’s needle, L2-3 level 16 G Epidural Catheter in situ. 26 G Quincke/ 27G Whitacre spinal needle 0.5% Bupivacaine (heavy) 3.5 ml Top ups of LAAs as required Intra-operative monitoring
- 16. Methodology (contd) Post-op :- As spinal wore off: VAS: VAS ≥ 5 Group A: Inj. Butorphanol 1mg with 4 ml of Normal Saline Epidurally Group B: Inj. Butorphanol 1mg IM VAS monitoring every 10 minutes VAS ≤ 3 – Onset Duration calculated VAS ≤ 7 - Released from study Analgesia of surgeon’s choice Side effects noted
- 17. Combined Spinal Epidural in the Same Intervertebral Space Using Combipack
- 33. Combined Spinal & Epidural in two different Intervertebral Spaces
- 41. Results
- 43. 93 92.4 17.66 17.75 96.88 98.62 8.92 9.03 0 20 40 60 80 100 MEANVALUE PULSE RR MAP VAS COMPARISION OF MEAN BASELINE PARAMETERS GROUP A GROUP B
- 44. Comparison of Parameters at regular time intervals In group A Significant decrease in: Mean pulse from base line to at 20 minutes Mean respiratory rate from baseline to at 10 min, 20min, 30min, 1 hr &11/2 hr In group B Significant decrease in: Mean pulse from base line to at 11/2 hr Mean respiratory rate from baseline to at 11/2 hr There was no difference of Systolic/Diastolic/ MAP in any of the groups from baseline at any time
- 45. COMPARISON OF MEAN PULSE RATE AT REGULAR INTERVALS 84.23 90 88.3 86 85.56 85.36 87.36 93 87 85.25 81 86.1 88 92.4 84.25 90 80 82 84 86 88 90 92 94 BASE 10M 20 M 30M 1 HR 11/2 HR 2 HR W'ring off MEANPULSERATE GROUP A GROUP B
- 48. COMPARISION OF MEAN ONSET, PEAK, DURATION 54.83 87.5 266.3 17.83 268.3 23.5 0 25 50 75 100 125 150 175 200 225 250 275 300 ONSET PEAK DURATION MEANVALUES GROUP A GROUP B
- 50. 11 0 10 3 5 16 4 9 0 1 0 1 0 3 6 9 12 15 18 NO.OFPATIENTS 0 1 2 3 4 5 V-MAX MAXIMUM PAIN RELIEF COMPARISION GROUP A GROUP B
- 51. 1.13 2.35 0 0.5 1 1.5 2 2.5 MEANSCORE COMARISON OF MEAN VAS COMPARSION OF MEAN V-MAX GROUP A GROUP B
- 52. Discussion Celsus (Circa AD 14-37) Wang H, Nauss L, Thomas J Anaesthesiology 1979, 50:149 Pain relief by Intrathecal use of Morphine in man Murkin JM J. Cardiothorac. Vasc. Anesth 1991, 85,655 - 74 Central analgesic mechanisms : Review of opioid receptors physio-pharmacology and related anti- nociceptive system
- 53. Discussion (contd) Dobkin AB et al Clini. Pharmacol. Ther. 1975 Butorphanol & Pentazocine intra-Muscularly in patients with severe post operative pain Dutta S et al Anesthesiology 1992 Double-blind epidural vs. intravenous Butorphanol Palacios QT et al Can. J. Anaesth.1991 Post LSCS analgesia: epidural Butorphanol vs. Morphine
- 54. Conclusion C S E is an ideal & suitable alternative to GA Especially in patients for hip surgeries Use of adjuvants to LAAs is beneficial Opioids are the most suitable adjuvants Pure agonists have their own problems Butorphanol (agonist-antagonist) by two routes viz. IM verses Epidural was tried
- 55. Conclusion (contd) Duration of analgesia was comparable Onset of analgesia was quicker in epidural group Peak of analgesia achieved faster in epidural group No significant difference observed in vital parameters of both the groups Maximum pain relief in epidural was better Incidence of all the side effects was more in the intra muscular group
- 56. Conclusion (contd) Considering the quality of pain relief EPIDURAL route has distinct advantage over the intramuscular route* . *Incidentally this is the first study of it’s kind.