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ORIGINAL ARTICLE
Ahead of print publication  

Safety and efficacy of low-dose selective spinal anesthesia with bupivacaine and fentanyl as compared to intravenous sedation and port-site infiltration for outpatient laparoscopic tubal ligation: A randomized controlled trial


 Department of Anesthesiology, Pain medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission24-Sep-2021
Date of Acceptance21-Dec-2021
Date of Web Publication07-Feb-2022

Correspondence Address:
Shailendra Kumar,
Department of Anesthesiology, Pain Medicine and Critical Care, Room Number 5011, Teaching Block, Anesthesia Office, Ansari Nagar East, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.aer_121_21

   Abstract 

Background: Selective spinal anesthesia has been safely applied for short-duration outpatient gynecological laparoscopic procedure. However, this anesthesia technique is often inadequate and not tolerated by awake patients due to pneumoperitoneum and visceral manipulation. Aims: We aimed to conduct a study to compare spinal anesthesia with bupivacaine, fentanyl, and i.v. sedation with i.v. sedation and laparoscopic port-site infiltration with local anaesthetic in outpatient laparoscopic tubal ligation procedures. Settings and Design: 100 female patients posted for elective surgeries were recruited for a prospective single blind randomised control trial in a tertiary care center in two groups. Materials and Methods: In Group S, patients receive intrathecal 3 mg hyperbaric bupivacaine 0.5% plus 20 microgram fentanyl along with intravenous (i.v.) fentanyl at 1μg.kg-1.h-1 and in Group C i.v. fentanyl at 1μg.kg-1.h-1 along with laparoscopic port site infiltration with 0.5% bupivacaine. Postoperatively, overall patient satisfaction, visual analog score (VAS) score, duration of motor blockade, sensory blockade, and time to attain discharge criteria and any adverse. Statistical Analysis: Continuous variables between the groups were compared by the independent t-test and Wilcoxon rank sum. Chi-square and Fisher exact test used for the categorical value. Results: Overall VAS was significantly lower and patient satisfaction was higher in Group S than Group C. Time to oral intake was significantly prolonged in Group C 126.33 (±29.54) compared to group S 110.81 (±29.54). The requirement of total rescue analgesia (fentanyl) was significantly higher in Group C 2.0 (±0.6) μg.kg-1 compared to group S 0.79 (±0.53) μg.kg-1. Incidence of postoperative nausea vomiting (PONV) was significantly greater in Group C while incidence of pruritus was significantly greater in Group S. Conclusion: Low-dose intrathecal anesthesia with 3 mg bupivacaine and 20 μg fentanyl provided better analgesia, patient satisfaction and with less opioids consumption.

Keywords: Early ambulation, laparoscopic surgery, outpatient procedure, spinal anesthesia



How to cite this URL:
Sarkar P, Singh Y, Patel N, Kumar S, Khanna P, Kashyap L, Subramaniam R. Safety and efficacy of low-dose selective spinal anesthesia with bupivacaine and fentanyl as compared to intravenous sedation and port-site infiltration for outpatient laparoscopic tubal ligation: A randomized controlled trial. Anesth Essays Res [Epub ahead of print] [cited 2022 Jul 1]. Available from: https://www.aeronline.org/preprintarticle.asp?id=337401


   Introduction Top


Laparoscopic tubal sterilization is increasingly performed in outpatient setting as an ambulatory surgical procedure due to reduced health-care costs, early recovery, and remarkable safety profile. However, it involves creating pneumoperitoneum and visceral manipulation and is frequently performed using port-site infiltration of local anesthetic and intravenous (i.v.) sedation with the patient in the extended lithotomy position. This anesthesia technique is often highly inadequate and not tolerated by awake patients. There is also excessive intra-and postoperative nausea and vomiting which may delay discharge. Chances of visceral injury are higher because of patient movement caused by discomfort. General anesthesia with endotracheal intubation though effective may be unsafe in a resource poor country where ideal condition and expertise for general anesthesia might be lacking.

Neuraxial anesthesia has not been routinely used as a sole method of anesthesia in laparoscopic procedures. Spinal anesthesia is a simple and quick procedure which provides rapid induction with excellent operating conditions with a short turn over time. The availability of fine-gauge pencil-point spinal needles has reduced the incidence of significant postdural puncture headache (PDPH) to 0.5%–1%.[1] However, conventional spinal anesthesia may cause prolonged motor blockade or urinary retention, thereby delaying discharge.[2] Selective spinal anesthesia (SSA) which is defined as “the practice of employing minimal doses of intrathecal agents so that only the nerve roots supplying a specific area and only the modalities that require to be anesthetized are affected” circumvents this problem.[1] So this may be an appropriate technique in this setting. A variety of SSA regimens have been described which typically permit discharge within a little over 3 h after surgery.[1]

Various studies have used SSA with lidocaine, bupivacaine, or levobupivacaine with or without fentanyl in ambulatory setting safely and effectively. However, the possibility of transient neurologic symptoms (TNS) though a theoretical risk limits the use of lidocaine SSA, especially in ambulatory setting. Intrathecal fentanyl added to low dose, low concentration local anesthetics produces synergistic effect without increasing sympathetic block or delaying discharge.[3],[4] We conducted this study to compare SSA with bupivacaine, fentanyl, and i.v. sedation with i.v. sedation and laparoscopic port site infiltration with local anesthetic in outpatient laparoscopic bilateral tubal ligation procedures.

The aim of this open-label, prospective, randomized controlled study is to evaluate overall patient satisfaction and visual analog score (VAS) during the procedure and to assess the impact on discharge criteria, i.e., time to oral intake, time to ambulate, time to void, and incidence of adverse effects if any.


   Materials and Methods Top


After approval from Institute Ethics Committee, (IEC PG-624/31.01.2018), the study was conducted at a tertiary care hospital and registered under CTRI (CTRI/2019/03/017929). 100 female patients, American society of anesthesiologist (ASA) physical classes I and II, aged 20–35 years scheduled to undergo elective outpatient laparoscopic tubal ligation were recruited and randomly allocated into two groups – Group C (Control) and Group S (Spinal) using computer generated random number table. Allocation concealment ensured by enclosing assignments in sealed envelopes, sequentially numbered, picked up by patient and opened thereafter by one of the investigators. Exclusion criteria included refusal to participate, body mass index ≥35, ASA PS classes III and IV, allergy to any of the study drugs, pregnancy, any contraindication for spinal anesthesia, history of chronic painful abdomino-pelvic conditions, patients already on long-term analgesics (opioids or nonopioid), and inability to comprehend VAS pain assessment score. After the recruitment of the patients, written informed consent was obtained and a thorough routine preanesthetic assessment of each patient was conducted. Subarachnoid block, i.v. sedation, and VAS were individually explained to each patient. The contact mobile telephone number of the patient and/or spouse was recorded. Adequate NPO status 8 h for solids and 2 h for clear fluids was ensured. A 20G i.v. cannula was secured in each patient. All patients were premedicated with midazolam 1 mg and ranitidine 50 mg i.v. 10 min before the procedure. The recruited patients were randomly allocated into two groups – Group C or Group S before entering the operation theatre by sealed envelope method. After transferring the patient inside the operating room, standard ASA monitors (pulse oximeter [SpO2], noninvasive blood pressure monitoring [NIBP], electrocardiogram and capnometry [EtCO2]) were attached to each patient and baseline hemodynamic data recorded. All the patients in Group S were administered fentanyl 1 ug.kg−1 i.v. and positioned in sitting position on the edge of the operating table and feet supported on a stool. After painting and draping, the site of insertion of spinal needle was infiltrated with 5 mL of 2% plain lignocaine. A 27G Whitacre needle was inserted at L2–L3/L3–L4 intervertebral space and after ensuring free CSF flow 3 mg 0.5% hyperbaric bupivacaine with 20 μg fentanyl diluted up to a total volume of 2 mL with normal saline (0.9%) was slowly injected at 0.2 mL.s−1. All patients were coloaded with 10 mL.kg−1 of Ringer Lactate solution. The patient was placed in supine position immediately after the procedure. The level of sensory block was assessed using loss of pinprick sensation with a 18G needle along the anterior median line after the procedure and a sensory block level of at least up to T10 was ensured before the beginning of procedure. If a sensory block up to the desired level was not achieved, the patient was placed in Trendelenberg position with a downward head tilt of 10 degrees for a maximum of 10 min. If sensory block level of at least up to T10 was still not achieved, spinal anesthesia was regarded as a failure and the procedure was undertaken under general anesthesia. Fentanyl infusion was started in each patient at 1 μg.kg−1.h−1 and continued throughout the procedure. Ondansetron (100 μg.kg−1) i.v. was administered 10 min before the end of the procedure. All patients in Group C received fentanyl 1 μg.kg−1 i.v., following which i.v. infusion of fentanyl was started at 1 μg.kg−1.h−1 and continued throughout the procedure. After cleaning and draping the operative site, infiltration of local anesthetic at the port site was done with 10 mL of 0.5% plain bupivacaine 5 min before trocar insertion. All patients were coloaded with 10 mL.kg−1 of Ringer Lactate solution. Ondansetron (100 μg.kg−1) i.v. was administered 10 min prior to the end of the procedure. In both groups the operating room table was kept in horizontal position before trocar insertion. Pneumoperitoneum was created using a 10 mm trocar inserted through a small infraumbilical incision and intra abdominal pressure was maintained in a range of 10–12 mmHg with a flow of CO2 (Carbon dioxide) at 4–6 l.min−1. After creating pneumoperitoneum, patients were immediately placed in steep Trendelenberg position to minimize shoulder tip pain caused by diaphragmatic irritation by CO2. Hypotension and bradycardia at any time during or after the procedure was defined as ≥20% decrease in NIBP and pulse rate. Hypotension was treated with i.v. fluids and ephedrine in 6 mg i.v. boluses. Bradycardia was treated with atropine 0.6 mg i.v. bolus. Breakthrough pain during the procedure was treated with fentanyl 0.5 μg.kg−1 i.v., repeated if necessary. Postoperatively all patients were transferred to the Post-Anaesthesia Care Unit (PACU), where they were monitored till discharge. The overall pain that was experienced during the procedure was assessed as a single VAS score which was recorded at the end of the procedure, denoted as the overall VAS score. Postoperative VAS score, Modified Bromage Scale score, pulse rate, NIBP were assessed immediately after transfer to PACU and every half hourly up to 4 h, and at discharge. VAS score >3 was treated with fentanyl 0.5 μg.kg−1 i.v. Duration of sensory block was assessed as time from block till first need for analgesia. Duration of motor blockade was assessed as time from block till return to Modified Bromage Scale score 0–1.Time to first oral intake was assessed as the time from block till when the patient was able to take first sips of water. Time to void was assessed as the time period from the block till the patient was able to void urine for the first time. Time to ambulate was determined as the time from the block till the patient was first able to walk unassisted. All these parameters were assessed every every 30 minutes after the end of procedure till the patient was discharged. The patient was only discharged when they were awake, conscious, hemodynamically stable, able to ambulate, has taken oral fluids, has voided and was free of any side effects.

Incidence of any complications like hypotension, bradycardia, postoperative nausea vomiting (PONV), pruritus, respiratory depression, PDPH, and TNS (Transient Neurologic Syndrome) was recorded. Hypotension was treated with i.v. fluid bolus followed by boluses of ephedrine 6 mg i.v. if needed. Bradycardia was treated with atropine 0.6 mg i.v. bolus. PONV was treated if there was persistent nausea or more than 1 episode of vomiting, with ondansetron 4 mg i.v. boluses up to a maximum of 0.2 mg.kg−1. Pruritus defined as the sensation that provokes the desire to scratch was treated initially with reassurance, then antihistaminic (pheniramine 25 mg i.v.). Persistent pruritus was planned to be treated with dexamethasone 8 mg i.v., followed by ondansetron 4 mg i.v., if still not controlled, by propofol 10–20 mg i.v. or i.v. naloxone 0.25–1 μg.kg−1 as last resort. PDPH and TNS were planned to be treated by overnight admission of the patient and treated according to standard institutional practice. Respiratory depression, defined as <8 breaths/min during PACU stay with/without desaturation of SpO2 <92% was treated with 100% oxygen through facemask @ 4–6 l.min−1 and naloxone 0.25–1 μg.kg−1 i.v. till saturation improved to >96%. Retention of urine was assessed before discharge. In case of retention the patient was admitted and then treated initially with reassurance, then by intermittent bladder catheterization. At the time of discharge overall patient satisfaction was assessed on a scale of 0–2 where “0” stands for very uncomfortable, “1” stands for partially comfortable or noncommittal and “2” stands for comfortable. Patients were followed up by three telephonic calls on the day after the procedure and twice on the day thereafter. In case of any adverse events at home patients were asked to report at the hospital immediately.

Statistical analysis

Data were analyzed with STATA 12.0( STATA Corp LP College Station, Tx77845, USA) and presented in frequency (%) and median (range)/mean (standard deviation [SD]). Continuous variables were compared by Independent t-test (following normal distribution) and Wilcoxon rank sum (not following normal distribution) between the two groups. Categorical variable compared by Chi-square/Fischer exact test. A P < 0.05 was considered statistically significant.


   Results Top


A total of 102 patients were enrolled in this study. Two patients declined to participate, hence the rest 100 were randomly allocated into either of the two groups [Figure 1]. There was no significant difference between groups with respect to age, sex, height, weight, and ASA physical status [Table 1].
Figure 1: “CONSORT” flow diagram

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Table 1: Demographic variables

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Intraoperative hemodynamic outcomes

The mean intraoperative heart rate and mean arterial pressure (MAP) was significantly lower in Group S as compared to Group C. There was one episode of hypotension in one patient in Group S with NIBP 70/40 mmHg (MAP 51) which responded to bolus of crystalloids and single bolus of ephedrine 6 mg. One episode of bradycardia noted while creating pneumoperitoneum in one patient in group S with heart rate dropping to 46.min−1 which responded to deflation of pneumoperitoneum and Atropine 0.6 mg i.v. One patient in Group S was converted to GA after failure to reach sensory block level of T10 even after 10 min of Trendelenberg position. One patient in Group C was converted to GA after repeated failed attempts to create pneumoperitoneum and a persistent VAS score of 8 even after repeated fentanyl bolus.

Postoperative outcomes

The mean VAS score during the procedure was significantly lower in Group S (3.42 [±0.98]) than in Group C (5.79 [±0.98], P = 0.00). Patient satisfaction was scored on a scale of 0–2, “0” denoting very uncomfortable, “1” as partially comfortable/noncommittal, and “2” as comfortable. The majority of patients in Group S (41/49, 83.67%) rated their satisfaction as 2 (comfortable) compared to (6/50, 12.24%) in Group C. A comparable number of patients (2/49, 4.08%) in Group C and (1/49, 2.04%) in Group S had a score of “0” (very uncomfortable). The majority of patients in Group C (41/49, 83.67%) compared to (7/49, 14.29%) in Group S rated their satisfaction as “1” (partially comfortable/noncommittal).The P value for overall patient satisfaction was significant with P = 0.00 [Figure 2].
Figure 2: Overall patient satisfaction

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Only one patient in Group S had a motor blockade with Modified Bromage Scale score of 2 at the end of procedure, with duration of motor blockade of 30 min. The mean duration of sensory blockade in Group S (minutes: mean [±SD]/median [range]) was 117.88 (±42.58)/120 (1–210). There was statistically significant difference in postoperative VAS scores at four different time points in the postoperative period. The VAS score at the end of procedure was 4.36 ± 0.78 in Group C and 2.81 ± 0.48 in Group S with P = 0.00.The VAS score at the end of 30 min in the postoperative period was 3.63 ± 0.88 in Group C and 2.63 ± 0.72 in Group S with P = 0.00.The VAS score at the end of 60 min in the postoperative period was 3.08 ± 0.34 in Group C and 2.73 ± 0.93 in Group S with P = 0.00.The VAS score at the end of 150 min in the postoperative period was 2.93 ± 0.24 in Group C and 3.57 ± 1.25 in Group S with P = 0.01 [Figure 3]. The requirement of total rescue analgesia in the form of i.v. fentanyl boluses [μg. kg-1: mean (±SD)] was significantly higher in Group C [2.0(±0.6)] than in Group S [0.79(±0.53)] with P = 0.00.The time to oral intake [min: mean (±SD)] in group S was 110.81(±29.91) which was significantly lower compared to that in Group C 126.33(±29.54) with P = 0.01.The time to void [min: mean (±SD)] in both the group were comparable with 151.73 ± 32.66 in Group C and 156.71 ± 31.32 in Group S, respectively, (P = 0.4).The time to ambulate (min: mean [±SD]) in Group C was 123.26 ± 26.78 which was comparable with that in group S 119.67 ± 30.03, (P = 0.53) [Table 2].
Figure 3: Postoperative visual analog score

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Table 2: Postoperative outcome variables

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The mean postoperative heart rate (beats per minute: mean [±SD]) and the mean postoperative MAP (mmHg: mean [±SD]) were comparable in both groups. The mean postoperative heart rate in Group C was 81.30 ± 0.57 and that in Group S was 80.85 ± 0.57 with a P value of 0.57. The mean postoperative MAP in Group C was 80.97 ± 0.6 and that in Group S was 80.09 ± 0.72 mmHg with a statistically nonsignificant P value of 0.36.

There was a significantly increased incidence of PONV on the day of the procedure (D0) in Group C (20 [40.82%]) compared to (8 [16.33%]) in Group S with P = 0.007. The incidence of pruritus on the day of the procedure (D0) was significantly enhanced in Group S 10 (20.41%) compared to Group C (0 [0%]), (P = 0.01). There was no incidence of PONV or pruritus on D1 or D2 of follow-up in any of the groups. There was no incidence of postoperative hemodynamic instability or urinary retention in any of the two groups.

There was one incidence of PDPH in one patient of group S. The patient developed headache with nausea on postoperative day 1. The PDPH was resolved on postoperative day 4 after plenty of oral fluids, bed rest, NSAIDS, and caffeine.


   Discussion Top


In our study, SSA with i.v. sedation demonstrated better overall patient satisfaction compared to i.v. sedation alone. SSA also showed better postoperative pain management with lower VAS scores reducing total opioid consumption as rescue analgesia. This indirectly led to reduced incidence of PONV in Group S patients promoting early oral intake with comparable time to ambulate and time to void.

Significantly lower overall VAS scores and higher overall patient satisfaction in our study demonstrated the superiority of low dose SSA over sedation alone in providing adequate levels of analgesia and patient comfort in outpatient ambulatory procedures similar to the findings of other authors like Lennox et al.,[5] De Santiago et al.[6],[7]

Ultra low-dose spinal solutions have been reported in literature to produce SSA block.[8],[9] Lidocaine though effective in this ambulatory setting has the disadvantage of causing Transient Neurologic Syndrome (TNS) even at low concentrations.[10] Bupivacaine on the other hand has the advantage of producing differential neuraxial block, preserving motor function when used in low concentrations. In our study, we have used 3 mg bupivacaine at a concentration of 0.15% along with 20 microgram of fentanyl achieving reliable surgical anesthesia and analgesia with preservation of motor function. In a similar prospective randomized double-blind study by de Santiago et al.[6] comparing two different local anesthetic solutions in 52 healthy women undergoing laparoscopic tubal sterilization found that low-dose spinal anesthesia with hypobaric (0.1%) levobupivacaine 3 mg plus 10 μg fentanyl was a suitable alternative to 10 mg lidocaine with 10 μg fentanyl with clinically equivalent time for resolution of sensory block, similar intraoperative conditions, and comparable patient satisfaction. Time to ambulation was not significantly prolonged and no differences were observed in time for home discharge.

In our study, we observed that after performing the spinal anesthesia in the sitting position with the low-dose bupivacaine solution and placing the patient in supine position the initial sensory block height reached was T12. Therefore, we had to place all the patients in Trendelenberg position with 10 degrees of downward head tilt for a minimum of 5 min for the block height to reach the required level of T10. In a similar study by de Santiago et al. after performing low dose spinal anesthesia at L3–L4 or L4–L5 level with 3 mg levobupivacaine and 10 μg fentanyl with a total volume of 3 mL, the authors made the patients to sit for 2 min, following which they were placed in 20°–30° Trendelenberg position for approximately 5–8 min until a sensory level of T4 was reached.[6] Vaghadia et al.[11] in a similar study, while performing SSA in gynecological laparoscopy with hypobaric low dose of lidocaine and sufentanyl made the patients sit for 1 min followed by Trendelenberg position for 6–8 min to facilitate cephalad spread of local anesthetic.

The mean duration of sensory block assessed by the first need of rescue analgesia in the Group S was found to be 120 (1–210) minutes similar to that observed by de Santiago et al.[6] which is around 105 (78–150) minutes and 90 min by Beilin et al.[12] Hence it can be hypothesized that the prolonged sensory blockade and intrathecal fentanyl added to low dose bupivacaine might have contributed to better perioperative analgesia and lower total opioid consumption in SSA group compared to the control similar to the findings of Unal et al.,[13] Korhonen et al.[8],[14] Increased postoperative opioid consumption lead to higher incidence of PONV in Group C which in turn leads to increased time to oral intake in the former.

Only one among the 49 patients in Group S showed motor blockade with Modified Bromage Scale 2, for a duration of 30 min in the postoperative period which is consistent with findings by other author like Lennox et al.[5] and Korhonen et al.[15] The lack of motor blockade in the SSA group with low opioid consumption lead to comparable time to ambulate in both the groups. Although majority of the patients in the Group S could actually shift themselves from the operating table to the shifting trolley but they needed extra time before they could walk unassisted. The most probable cause behind this finding was possibly that the recovery of the proprioceptive fibers was delayed beyond that of the motor fibers. Although not statistically or clinically significant a slightly increased average time to ambulate was noted in the Group C. Postoperative sedation and a high incidence of PONV secondary to increased overall opioid consumption perhaps served as the most probable causative factor behind delayed ambulation in this group.

Hydrophilic opioids like morphine are known to cause increased incidence of urinary retention compared to lipophilic opioids like fentanyl.[4] Local anesthetic blockade of S2, S3 and S4 nerve roots inhibit urinary function as detrusor muscle is weakened.[16] In this study, intrathecal bupivacaine and fentanyl did not contribute to any incidence of urinary retention. The risk of postoperative urinary retention is low with SSA except in elderly population or when bupivacaine more than 7 mg is used.[1] As suggested by a report by Mulroy et al.[17] patients with short-acting neuraxial blocks can be discharged home without an increased incidence of urinary retention. However, voiding before home discharge is a routine practice at our institution and was also a necessary criteria of home discharge according to our study protocol. Time to void observed in this study was 90 min (150–230) which is less compared to that demonstrated by de Santiago et al.,[6] Korhonen et al.,[15] Ben-David et al.[4] No significant difference in time to void was noted in between the two groups in this study.

We found an increased incidence of pruritus (20.41%) in the Group S in comparison to the Group C (0%), which was mostly secondary to the administration of intrathecal opioids.[18] However, the occurrence of pruritus was merely transient, resolved spontaneously after reassurance none requiring pharmacological intervention for its remission.

The use of fine gauge pencil point needles has reduced the incidence of PDPH to 0.5%–1%[1],[19] which has facilitated the use of spinal anesthesia, especially in the ambulatory setting. None of the authors commented on any incidence of PDPH with SSA in ambulatory day-care surgery with 27G Whitacre spinal needle.[6],[5],[20] In our study, only one incidence of PDPH was noted in one patient in the Group S. The patient complained of occipital headache with nausea on postoperative day 1 aggravating with upright or sitting position and relieving on lying down. The patient was immediately asked to report at our institution and was subsequently admitted and observed. She was advised plenty of oral fluids and bed rest along with oral paracetamol ibuprofen combinations and oral caffeine tablets 300 mg twice per day. The pain resolved spontaneously on postoperative day 4 following which she was discharged.

Limitations

Blinding could not be performed in our study. We did not measure the baricity of the spinal anesthetic solution used in the study. We did not perform any test to ascertain the return of proprioceptive function in patients in Group S which might have affected the time to ambulate in our study.


   Conclusion Top


To conclude, low-dose intrathecal anesthesia with 3 mg bupivacaine and 20 μg fentanyl provided better analgesia with less opioid consumption and overall patient satisfaction with no adverse impact on discharge criteria compared to i.v. sedation and local anesthesia. In addition, decreased incidence of PONV without any incidence of prolonged motor block or urinary retention renders SSA a safe, effective, and a lucrative alternative to conventional modes of anesthesia in the ambulatory setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Ronald MD, Neal CH, Lars EI, Lee FA, Wiener-Kronish PJ, Young WL, editors. Miller's Anesthesia. 8th ed., Vol. 2. Philadelphia, Canada: Elsevier, Saunders; 2015. p. 2612-47.  Back to cited text no. 1
    
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Korhonen AM, Valanne JV, Jokela RM, Ravaska P, Korttila KT. A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with desflurane for outpatient knee arthroscopy. Anesth Analg 2004;99:1668-73.  Back to cited text no. 14
    
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Korhonen AM, Valanne JV, Jokela RM, Ravaska P, Korttila K. Intrathecal hyperbaric bupivacaine 3 mg+fentanyl 10 microg for outpatient knee arthroscopy with tourniquet. Acta Anaesthesiol Scand 2003;47:342-6.  Back to cited text no. 15
    
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[PUBMED]  [Full text]  
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De Santiago J, Santos-Yglesias J, Giron J, Jimenez A, Errando CL. Low-dose, low-concentration levobupivacaine plus fentanyl selective spinal anesthesia for knee arthroscopy: A dose finding study. Anesth Analg 2011;112:477-80.  Back to cited text no. 20
    


    Figures

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