European Journal of Cardiovascular Medicine

Laparoscopic surgery is the one of the most commonly performed spine surgery now a days. Traditionally general anaesthesia (GA) is preferred and widely used anaesthesia technique for lumbar spine surgery due to a variety of factors, including greater patient acceptance, able to extend duration for long surgeries and secured airway in the prone position.[1][2] But in GA, along with the increased stress response of laryngoscopy and intubation, there is also increase blood loss, duration of surgery and requirement for blood transfusion [3].

Among regional anaesthesia, spinal anaesthesia (SA) and epidural anaesthesia are the alternative anaesthesia techniques for lumbar spine surgeries. Spinal anaesthesia has several benefits noted in the literature, including rapid onset, decreased operative and anaesthesia time, less intra-operative blood loss etc. [4][5][6] The shorter duration of anaesthesia and lesser required assistance for positioning the patients are other advantages of SA. There are several studies comparing various perioperative outcome parameters in spinal and general anaesthesia in lumbar spine surgeries

India is still a developing nation with an overall lack of health care that necessitates the use of anaesthesia techniques that are not only safe and cost-effective but also cause less peri-operative morbidity and early discharge from the PACU. Spinal anaesthesia can prove to be such a reliable technique that may reduce the burden not only on the health care system but also on cost-effectiveness for patients. Keeping this aspect in our mind, we planned a study with a aim to compare various perioperative outcome variable between SA and GA in cases of single or double-level elective lumbar laminectomy surgeries.

AIMS&OBJECTIVES

1. The primary objective was to compare anaesthesia duration between both the groups.
2. Secondary objectives were to compare blood loss, hemodynamic stability, operative time, surgeon satisfaction, patient satisfaction, PACU time, total analgesic dose given in first 24 hours and duration of hospital stay between both the groups.

The randomized prospective comparative study was conducted in the Department of Anaesthesiology, IIMSAR Haldia from January 2023 to January 2024 after taking approval of institutional ethics committee approval. In this study we enrolled the patients undergoing Lower abdominal surgery. In the study total 100 patients with American Society of Anaesthesiologists physical status (ASA PS) 1-2, and aged 18-60 years were included. Patients with an anticipated difficult airway, contra-indications of spinal anaesthesia, diagnosed herniated lumbar disc of level >2 for elective surgery, long term history of neuropathic pain at the operation site etc were excluded.

The patients were randomly categorized into Group G and Group S in the order of admission. We use random sampling method to select the cases. Patients were randomized into two groups, Group S and Group G; with 50 patients in each group. In group S, patients were given spinal anaesthesia and in group G, patients were given general anaesthesia. 

Pre-anaesthetic evaluation for all the Participants was done which included general condition, history, physical examination, and ASA- PS grading. All the kinds of investigations including CBP, RFT, coagulation profile, serum electrolytes, urine analysis, HIV, HBsAg, Chest X-ray PA view, and ECG were done before surgery. All subjects were given orally omeprazole 20 mg and alprazolam 0.25 mg and advised to remain nil by mouth (NBM) as per fasting guidelines one night before surgery.

In the pre-operative time Period, the patient was identified and reviewed, consent was checked Properly and NBM status was confirmed. All vital parameters were attached and baseline vitals including HR, BP and SpO2 were recorded. Intravenous (IV) line with 18G cannula was secured. Then, randomization of Participants was done and patients were allocated to either of spinal or general anaesthesia group.

In the group G, once the patient was in operating room (OR) all vitals’ parameters were attached, and iv premedication i.e., inj. midazolam 2 mg, inj. ondansetron 4mg and inj. glycopyrrolate 0.2mg was given. Patients were pre-oxygenated with 100% oxygen on bag and mask and inj. lidocaine (1.5 mg/kg), and inj. fentanyl (2 μg/kg) were given. Patients were induced with inj. propofol (2 mg/kg), and after giving inj. atracurium (0.5 mg/kg), patients were intubated with a cuffed endotracheal tube. Balanced anaesthesia was maintained with sevoflurane and intermittently inj. atracurium 0.1mg/kg. After the completion of surgery, the anaesthetic drugs were discontinued and neuromuscular blockade was reversed. After adequate spontaneous respiration, extubation done and shifted to PACU.

In the group S, once the patients in the OR, vitals’ parameters were attached and the patients were coloaded with 7 ml/kg Lactated Ringer's solution over 10-15 minutes. The patients were placed into a sitting position, prepared and draped. Spinal anaesthesia was performed using a 25-gauge Quincke spinal needle at one or two levels of interspace above the surgical site. After observing spinal fluid, with 3ml 0.5% heavy bupivacaine combined with 25 μg fentanyl were administered into the intrathecal space and patients were placed in the supine position. Once the level of the spinal block (sensory block up to T6 and motor block as per modified Bromage score 1) was established in next five to ten minutes, patients were placed in the prone position. If even after 15 minutes of spinal anaesthesia, adequate level of sensory and motor block was not established then it was considered as spinal block failure and had to be converted into GA and excluded from the study. Oxygen at 4L/min via face mask was administered afterward. During surgery, patient was sedated with intravenous propofol infusion at the rate of 25 to 50 μg/kg/min .The vital parameters i.e., HR, SBP, DBP, MBP, and SpO2 were monitored. If the patients had bradycardia (HR less than 50 per minute) inj. atropine 0.6mg iv or if hypotension (SBP less than 90 mmHg) inj. ephedrine 5mg was administered. If any patient had nausea or vomiting, inj. metoclopramide 0.1mg/kg iv, if headache inj. paracetamol 15 mg/kg iv infusion and if pain (VAS score >4) then inj. tramadol 2 mg/ kg iv (after giving inj. ondansetron 0.15 mg/kg iv) were given respectively.

Observations assessed were the following:

Anaesthesia duration.

Operative time.

Haemodynamic parameters- HR, SBP, DBP, MAP and SpO2 for every 5 minutes for the first half an hour (beginning from the spinal block), then every 15 minutes till 240 minutes (4 hours), then every 30 minutes till 360 minutes (6 hours) and then every 60 minutes till 480 minutes (8 hours).

Blood loss as well as total operative fluid requirements (including fluid given immediately before induction of anaesthesia).

Surgeon’s and patient satisfaction using the Likert scale [7] (a uni-dimensional psychometric scale that measures respondent’s attitude, score ranging from 1-4) where 1=Excellent, 2=Good, 3=Fair and 4=Poor

Perioperative side effects– Bradycardia, hypotension, nausea or vomiting, headache, pain, urinary retention, and shivering were noted.

PACU time

Total analgesia dose given in first 24 hours.

The primary objective was to compare anaesthesia duration between both the groups. Secondary objectives were to compare blood loss, hemodynamic stability, operative time, surgeon satisfaction, patient satisfaction, PACU time, total analgesic dose given in first 24 hours and duration of hospital stay between both the groups.

Statistics and analysis of data

Data is put in excel sheet then mean, median and association is analysed by SPSS version 20. Chi-square test was used as test of significance for qualitative data. Continuous data was represented as mean and SD. MS Excel and MS word was used to obtain various types of graphs such as bar diagram. P value (Probability that the result is true)    of P Value <0.05 was considered as statistically significant after assuming all the rules of statistical tests. Statistical software: MS Excel, SPSS version 22 (IBM SPSS Statistics, Somers NY, USA) was used to analyse data. Sample size is calculated by N master statistical software.

The Demographic characteristics of are comparable between the groups. Out of 100 patients in this study, 60% were scheduled for appendicectomies, 16% for laparoscopic ovarian cystectomies 20% for laparoscopic tubal ligations, and 24% for diagnostic laparoscopies. Appendicectomy (40%), laparoscopic ovarian cystectomy (12%), lap tubal ligation (20%) and diagnostic laparoscopy (8%) were performed in group A in a similar manner to those also performed in group B with a p valve of 1 that was statistically insignificant. A total no of patients were included in this study is 100, out of which Dropout rate is Zero. Theres is no spinal failure occurred.

Table 1: Surgical procedures

The age Distribution, gender, weight, height, BMI, ASA- PS grading and diagnosis between the two groups were being compared. Along with the above mentioned parameters, the surgeries was performed on one level and two levels were also comparable in group S and group G.  The L4-5 was the most common level involved in both Group [Table 2] . In Table 1 Outcome of different variable of two group are showed.

Table 2:  demographic variables.

The Aims and objective of this study was anaesthesia duration. The mean anaesthesia duration was 102.3±11.4 mins in group S as compared to 143.2±11.2 mins in group G with P value of <0.02 the difference is statistically highly significant. The operative time 72.61±14.7 in S group and in G group it was 91.8±14.2 Where P value is 0.002 (<0.05) So it is statistically significant, Other Outcome variable like mean time from entering OR to incision, and mean time from placement of surgical dressing until patient exits from the OR were also found to be statistically significant Because their P value is less than 0.05 (P <0.001).

Table 3: Comparison Of Variables Between Both the Groups

The Mean surgical blood loss calculated in group S was 68.25±13.35 ml whereas in group G it was 125.35±31.62 ml with P-value <0.01. The hospital stay time duration (Days) in S group is 1.51±0.32 where in G group it is 2.59±0.31 days here P value is <0.03 so it is significant. So it revealed that   S group anaesthesia is better as compared to G group anaesthesia in term of hospital stay in RRP surgery.

In my study Requirement of total time’s analgesic dose in S group is 2.41±0.2 where as in G group it is 2.59±0.11 and here P value is 0.03 which is less than 0.05 so we can say that S group anaesthesia is better for patient in compare of G group anaesthesia in term of RRP surgery.

Time Duration of stay in PACU (min) in S group anaesthesia is 190.6±12.06 where in G group Anaesthesia it is 290.5±18.6 Here P value is <0.04 . so it is significant. so we can that S group anaesthesia is better choice in terms of recovery of patient in PACU.

Table 4: VAS scoring.

In the current global scenario, lower abdominal surgeries are the most common surgeries performed among all surgeries. Although both GA and SA are reliable and safe techniques, they can be used interchangeably for performing less extensive lumbar spine surgeries. Both have their advantages and disadvantages that may exert distinctive effects on peri-operative outcomes. [1]

The Demographic characteristics of are comparable between the groups. Out of 100 patients in this study, 60% were scheduled for appendicectomies, 16% for laparoscopic ovarian cystectomies 20% for laparoscopic tubal ligations, and 24% for diagnostic laparoscopies. Appendicectomy (40%), laparoscopic ovarian cystectomy (12%), lap tubal ligation (20%) and diagnostic laparoscopy (8%) were performed in group A in a similar manner to those also performed in group B with a p valve of 1 that was statistically insignificant.

Because pneumoperitoneum causes a variety of physiological changes, laparoscopic surgeries provide extra difficulties to the anesthesiologists. General anesthesia provides total analgesia throughout the surgery while keeping the patient entirely unconscious and oblivious of what is happening, however, it has drawbacks like decreasing functional residual capacity and total lung capacity, causing basal atelectasis, raising airway pressures, building CO2 and rising PETCO2, postoperative course of patients with a higher incidence of pain, PONV and prolonged hospital stay leading to higher hospital costs, which raises the question of whether the widely accepted anesthesia modality, general anesthesia, is actually beneficial. Over the years, several additional techniques have been studied as a result of the necessity for an alternative technique of anesthesia. Spinal anesthesia is one of the most well studied and successfully applied alternatives.

The Aims and objective of this study was anaesthesia duration. In our study  mean anaesthesia duration was 102.3±11.4 mins in group S as compared to 143.2±11.2 mins in group G with P value of <0.02 the difference is statistically highly significant. The operative time 72.61±14.7 in S group and in G group it was 91.8±14.2 Where P value is 0.002 (<0.05) So it is statistically significant, Other Outcome variable like mean time from entering OR to incision, and mean time from placement of surgical dressing until patient exits from the OR were  also found to be statistically significant Because  there P value is less than 0.05 (P <0.001).

Numerous studies have shown that it is a good substitute for GA and in some circumstances is even superior to GA. These studies looked at factors like patient comfort during and after the procedure, recovery from anesthesia, the frequency of postoperative complications, ambulation, hospital stay and cost-effectiveness.[6,7]

In the SA group, the levels of the hormones adrenaline, noradrenaline and all other catecholamines drastically dropped during surgery. While variations in noradrenaline levels indicate activity in the sympathetic nervous system, variations in circulating adrenaline levels indicate action in the adrenal medulla. Therefore, a decrease in both catecholamines may result from total blockage of the adrenal medulla innervation.

In this study, preoperatively, the mean heart rate was statistically insignificant the mean heart rate was greater at various intraoperative time points in spinal anaesthesia group but statistically insignificant at all times. In a study by Pamela et al,[10] who came to the conclusion that SAB offered good intra- operative conditions and muscle relaxation that was comparable to GA. Contrary to GA patients, SAB patients displayed reduced tachycardia during surgery. Bradycardia was discovered in 2 patients (8%) receiving spinal anesthesia, and they were successfully treated with a 0.2 mg intravenous infusion of glycopyrrolate similar to our study.

In their research, Purvi J. Mehta et al,[11] and Gautam B,[12] found no evidence of bradycardia, demonstrating that bradycardia poses little danger. In group GA, no patients had hypotension, while hypotension (defined as a fall in blood pressure of more than 20%) was recorded in 5 (20%) cases treated with mephentermine 6 mg bolus in only 2 cases, while the remaining patients received intravenous fluids as similarly managed in our study.

In 18.21% of the patients, Sinha et al,[13] and Purvi J Mehta et al,[11] reported hypotension and in 30% of the cases. This demonstrates unequivocally that using SAB during open surgery or laparoscopic surgery has no effect on the incidence of hypotension. Hypertension tends to occur more frequently towards the onset of insufflations, when the increasing intra-abdominal pressure which is still below 10 mm Hg increases the venous return by reducing the blood volume in the splanchnic vasculature.[14] Thus showing that compared to GA, spinal anesthesia offers a better overall hemodynamic picture. The reduced surgical bed oozing brought on by hypotension, bradycardia and increased venous drainage brought on by SAB has been mentioned as an additional cardiovascular benefit.[15]

Overall, it is said that in this situation, spontaneous physiological respiration (SA) would always be preferable than aided respiration (GA). When it is compared to SAB, GA has a higher risk of intubation and ventilation- related issues, including an increase in mechanical ventilation to reach an adequate ventilation pressure.[17]

In addition, after laparoscopic surgery with GA, pulmonary function takes 24 hours to restore to normal. Contradictory reports of respiratory parameter changes while patients are under regional and GA are present and the observations are not all consistent.

When the patient was under GA as opposed to when the patient was breathing on their own, Nishio et al,[18] researches from 1980 showed a larger increase in PaCo2 after CO2 pneumoperitoneum. On the other hand, under epidural anesthesia Chiu et al,[19] , documented considerable arterial blood gas abnormalities. Epidural anesthesia for laparoscopy does not result in ventilatory depression, according to Circolo et al.[20]

During the surgery, neither CO2 retention nor hypoxemia were seen in the spinal anesthetic group. While some surgeons maintain lower pressures (< 10 mmHg, others prefer high pressures (14 mmHg). To lessen diaphragmatic discomfort, we selected a low pressure of up to 8 mmHg. Because of the good muscular relaxation brought on by the high level of sensory and motor block, O2 saturation and PET CO2 were normal during the SA group, showing the safety of the approach even without tracheal intubation. Pneumoperitoneum had to be raised above 9 mmHg in the GA group.[21] With the exception of lowering peritoneal pressure to 8 mmHg to prevent vagal reflexes and bradycardia, spinal anesthesia may not result in any changes to surgical technique.

In a study by Yuksek et al,[25] 16 patients (55.2%) complained intraoperative right shoulder discomfort recorded, necessitating the administration of fentanyl or requiring anesthetic conversion. Three patients required anesthetic conversion due to the severity of the pain, while five others required further 2% lidocaine solution spraying on the diaphragm to relieve the discomfort. According to Tzovaras et al65 right shoulder pain occurs in 13% of cases and requires intravenous fentanyl in 20% of cases.

In the current study, pain scores at 2, 4, 6, 8 and 12 hrs after surgery were significantly lower in the SA group than in the GA group. This difference is attributable to the local anesthetic continued analgesic effects in the subarachnoid space as well as a reduction in discomfort from the lack of a tracheal tube and its complications with avoiding GA.[26] After SAB, there was no postoperative restlessness that is typically observed after GA and the patient is always receptive and more compliant towards instructions. It appears that SA has the ability to reduce the need for postoperative analgesia. When GA was utilized, the injectable analgesic was typically needed soon after extubation in the postoperative phase and it can be difficult to effectively manage immediate postoperative pain.

In the first 4-6 postoperative hours following lower elective abdominal surgery, this study found that SA with hyperbaric bupivacaine 0.5% is superior than GA for reducing pain intensity, the need for further analgesia and the frequency of opioid requests. Mean variations in heart rate and blood pressure were statistically lower during the surgery and the first six postoperative hours, which may indicate less pain during that time. But after that period until

24 h there were no statistically significant differences between the two groups regarding postoperative pain scores. In a recent study, Kessous et al. found that postoperative meperidine requirements in the first 24 hours were considerably higher in the GA than SAB.

The surgeon was questioned about the surgical circumstances and muscular relaxation following each procedure and asked to rate them as bad, good or extraordinary. The surgeons claim of good abdominal muscle relaxation in comparison to general anesthesia may be explained by the high amount of sensory, motor and sympathetic block in both spinal methods. Similar assessments of the surgical circumstances were made by Pamela et al10, who came to the conclusion that SAB offered

The percentage can range from 60% to 70% when they are present. Antiemetics may be necessary in as many as 50% of patients with PONV and in 7% of patients, they may cause a delay in hospital discharge89. Even with more modern drugs like Propofol and Isoflurane, the incidence can reach 30%, which significantly raises anesthesia expenses.[27] In comparison to SA patients, our GA patients had a 20% incidence of PONV, which was significantly greater. 16% of the GA group reported having a sore throat. Our initial reports with laparoscopic spinal anesthetic surgery are encouraging.

In our study,. it is found that after giving SA it is easier and faster to prone an awake patient as the patient can move freely and adjust according to the position but during GA more time is taken to orally intubate, then prone the paralyzed patient carefully and also supine the patient at the end of surgery all while avoiding pressure necrosis and nerve injuries and finally extubate. The lesser anaesthesia duration leads to less time for the patient to stay inside the OR thus decreasing morbidity, and peri-operative complications, hence reducing the burden on our healthcare system in terms of both time and cost. These results are also consistent with a study conducted by Sharif Ahmed Jonayed et al., [9] who conducted a cross-sectional analytical study on 64 patients and discussed that in GA more time is required to intubate, extubate, and transfer the patient to the post-operative room which is not required in SA.

Based on the findings of this study, it is evident that Different variable and outcome of Spinal Anaesthesia in terms of surgery are more significant as compared to General Anaesthesia.  So we concluded that we can safely and reliably use spinal anaesthesia as an anaesthetic technique in cases of Lower abdominal surgery.

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