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Departments of *Anesthesia and
Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Address correspondence and reprint request to Dr. Anil Agarwal, Type IV/48, SGPGIMS, Lucknow 226 014, India. Address e-mail to aagarwal{at}sgpgi.ac.in
The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple’s pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 µg/kg and propofol titrated to achieve BIS between 40–50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient’s lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40–50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 µg/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student’s t-test and P 
0.05 was considered significant. The requirement of propofol for induction and maintenance of anesthesia in the bupivacaine group was 1.3 ± 0.3 mg/kg and 2.4 ± 0.9 mg · kg–1 · h–1, respectively, compared with 2.4 ± 0.6 mg/kg and 4.4 ± 1.6 mg · kg–1 · h–1 observed in the control group (P < 0.05). Significant reduction was also observed in the requirement of vecuronium and fentanyl during maintenance in the bupivacaine group (P < 0.05). We conclude that epidural bupivacaine given before induction of anesthesia reduces the requirement of propofol, fentanyl, and vecuronium during general anesthesia.
IMPLICATIONS: Epidural local anesthetics reduce the requirement of hypnotics, analgesics, and muscle relaxants. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation, in the clinical setting. We observed that epidural bupivacaine significantly reduces the requirement of all three during general anesthesia.
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