Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial

Tyagi, Asha; Ramanujam, Mukundan; Sethi, Ashok Kumar; Mohta, Medha

doi:10.1016/j.bjane.2020.12.005

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Brazilian Journal of Anesthesiology

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Sumário

Clinical Research • para Braz. J. Anesthesiol. 71 (1) • Jan-Feb 2021 • https://doi.org/10.1016/j.bjane.2020.12.005 copy

Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial^☆ ☆ This research was conducted at the University College of Medical Science, Delhi India.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background and objectives:

Epidural Volume Extension (EVE) involves instillation of normal saline into the epidural space soon after an intrathecal injection, with the aim to augment the sensory block height. Its clinical relevance lies in the possibility of using reduced intrathecal dose and yet achieving the desired sensory block level. Intrathecal dose is a known determinant of the level of sensory block. Whether EVE is dependent on intrathecal dose is not known.

Methods:

We conducted a randomized, controlled, double-blind study to compare the maximum sensory level (S_max) achieved with or without application of EVE to two different reduced intrathecal doses. Eighty four adult male patients of ASA status I or II with body weight between 50-70 kg and height in the range of 150-180 cm, scheduled for orthopedic lower limb surgery using combined spinal epidural anesthesia were randomized to receive, either intrathecal dose (5 or 8 mg) with or without EVE, in accordance to group allocation.

Results:

S_max was lowered by application of EVE to 5 mg intrathecal bupivacaine (T_8.9±4.3 vs. T_6.4±1.9 with and without EVE respectively; p = 0.030). S_max was similar when EVE was applied to 8 mg intrathecal bupivacaine than without it (T_5.8±1.8 vs. T_6.4±2.2 respectively; p = 0.324).

Conclusion:

EVE should not be applied to 5 mg plain bupivacaine during a combined spinal epidural block in patients undergoing lower limb orthopedic surgery as it may result in a decrease in the maximum sensory level.

KEYWORDS
Epidural volume extension; Combined spinal epidural anesthesia; Orthopedic anesthesia

	Group B5 (n = 20)	Group BE5 (n = 19)	p-value^a a Intergroup comparisons between group B5 and BE5.	Group B8 (n = 20)	Group BE8 (n = 20)	p-value^b b Intergroup comparisons between group B8 and BE8.
Age (years)	35.9 ± 12.4	37.6 ± 12.0	0.593	34.1 ± 14.0	33.6 ± 15.2	0.923
Weight (Kg)	63.8 ± 6.0	65.2 ± 6.5	0.411	60.3 ± 7.0	63.3 ± 6.1	0.160
Height (cm)	164.6 ± 6.5	162.9 ± 7.6	0.572	160.2 ± 7.0	162.2 ± 8.6	0.435
ASA physical status (II:I)	4:16	4:15	0.915	7:13	4:16	0.429
Basal mean arterial pressure (mmHg)	96 ± 9	98 ± 7	0.742	100 ± 14	97 ± 11	0.409
Basal heart rate (min^-1)	85 ± 15	81 ± 17	0.302	90 ± 17	83 ± 14	0.190
Presence of comorbidity	4 (20)	4 (21)	0.915	7 (35)	4 (20)	0.429
Duration of surgery (min)	112.2 ± 40.0	111.3 ± 40.0	0.942	111.5 ± 28.2	131.3 ± 51.4	0.141

	Group B5 (n = 20)	Group BE5 (n = 19)	p-value^a a Intergroup comparisons between group B5 and BE5.	Group B8 (n = 20)	Group BE8 (n = 20)	p-value^b b Intergroup comparisons between groups B8 and BE8.
S_max	T_6.4± 1.9	T_8.9± 4.3	0.030	T_6.4± 2.2	T_5.8± 1.8	0.324
Time to maximum sensory level (min)	8.2 ± 2.7	6.7 ± 3.2	0.108	9.2 ± 3.4	8.7 ± 3.0	0.623
Maximum motor block (Bromage score)	3.6 ± 0.7	3.6 ± 1.5	0.961	3.2 ± 0.7	2.8 ± 0.9	0.170
Time to maximum motor blockade (min)	6.9 ± 2.6	7.0 ± 3.2	0.974	9.0 ± 3.9	9.1 ± 2.9	0.930
Time to position the patient supine (min)	3.4 ± 1.0	4.0 ± 1.4	0.171	3.7 ± 0.9	4.3 ± 1.0	0.029

	Group B5 (n = 20)	Group BE5 (n = 19)	p-value^a a Intergroup comparisons between group B5 and BE5.	Group B8 (n = 20)	Group BE8 (n = 20)	p-value^b b Intergroup comparisons between group B8 and BE8.
Hypotension	5 (25)	8 (42)	0.365	8 (40)	7 (35)	0.799
Nausea and/or vomiting	1 (5)	1 (5)	0.989	0 (0)	1 (5)	0.799
Pruritus	0 (0)	0 (0)	1.000	0 (0)	0 (0)	1.000

	Group B5 (n = 20)	Group BE5 (n = 19)	p-value^a a Intergroup comparisons between group B5 and BE5.	Group B8 (n = 20)	Group BE8 (n = 20)	p-value^b b Intergroup comparisons between group B8 and BE8.
Frequency of intraoperative epidural top-up	17 (85)	18 (95)	0.607	18 (90)	17 (85)	0.799
Indicated due to inadequate intrathecal block	1 (5)	5 (26)	0.247	1 (5)	0 (0)	0.799
Time to first epidural top-up (min)	75.8 ± 29.2	53.9 ± 33.2	0.034	90.0 ± 32.3	104.3 ± 34.2	0.184

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[1] * Corresponding author: E-mail: iammukundan@gmail.com (M. Ramanujam).

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Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial☆ ☆ This research was conducted at the University College of Medical Science, Delhi India.

Abstract

Background and objectives:

Methods:

Results:

Conclusion:

Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial^☆ ☆ This research was conducted at the University College of Medical Science, Delhi India.