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Departments of *Anesthesia, Health Care and Epidemiology, and Gynecology, Vancouver General Hospital, University of British Columbia, Vancouver BC, Canada
Address correspondence and reprint requests to Dr. Himat Vaghadia, Department of Anesthesia, JPP 2449, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC, Canada V5Z 1M9. Address e-mail to hvaghadi{at}vanhosp.bc.ca
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Abstract |
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IMPLICATIONS: This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.
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Introduction |
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Conventional dose spinal anesthesia is associated with a longer recovery time compared with propofol anesthesia (6). SSA can compete with newer anesthetics such as propofol in terms of recovery and discharge times (1). However, SSA has not been compared with newer volatile anesthetics such as desflurane (DES). We hypothesized that using SSA would provide recovery characteristics comparable to those obtained with short-acting volatile anesthetics such as DES. The purpose of this study was to compare recovery after SSA versus DES in outpatients undergoing short duration gynecological laparoscopy.
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Methods |
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Twenty ASA grade I women scheduled for an outpatient gynecological laparoscopic procedure and amenable to either spinal or GA were enrolled in the study. Patients were randomized into two groups (DES and SSA) by means of computer-generated table of random numbers blocked after every 10. In the preoperative area, an IV cannula was inserted and an infusion of normal saline was commenced. No sedative premedication was given. Patients received acetaminophen 975 mg orally 30 min preoperatively. Each patient walked into the OR, and the routine monitors were then applied.
Anesthesia was administered as described below. All patients received a diclofenac sodium 100 mg suppository and perphenazine 1 mg IV at the end of the procedure as prophylactic analgesic and antiemetic respectively. All surgical sites were infiltrated with bupivacaine 0.25% to reduce incisional pain.
DES Group
A Bispectral index (BIS) electroencephalogram value was obtained preinduction using a BIS monitor. Anesthesia was induced with propofol 2 mg/kg IV and fentanyl 2 µg/kg IV. Tracheal intubation was facilitated by mivacurium 0.15 mg/kg IV and 4% lidocaine 160 mg administered intratracheally immediately before endotracheal intubation. Anesthesia was maintained with DES 2%–6% in combination with 65% N2O in O2 titrated to keep BIS values between 45 and 65. The lungs were ventilated mechanically to maintain an end-tidal carbon dioxide (CO2) concentration between 32 and 36 mm Hg. Supplemental doses of fentanyl 25–50 µg/kg IV were given to treat increases in heart rate or mean blood pressure of more than 15% above preinduction baseline values. Mivacurium 0.04 mg/kg IV boluses were administered if required to maintain adequate muscle relaxation. DES and N2O were discontinued at the time of the last suture. The average values for BIS and total MAC of end-tidal DES and N2O were recorded for a 2-min period immediately before discontinuing the anesthetics. Neostigmine and glycopyrrolate were used to reverse mivacurium as required.
SSA Group
The spinal anesthetic technique used was as described previously by Stewart et al. (1). Spinal anesthesia was administered in the sitting position with a midline approach at the L3-4 or L4-5 level using a 27-gauge Whitacre spinal needle. After aspiration of cerebrospinal fluid, a solution of 1% lidocaine 10 mg mixed with sufentanil 10 µg and made up to a total volume of 3 mL with sterile water was injected as rapidly as possible in a single shot with the needle orifice cephalad. After sitting for 1 min, the patient was placed in 20–30° reverse Trendelenburg position while lithotomy positioning and skin preparation occurred. Patients were placed in steep Trendelenburg position during CO2 insufflation into the peritoneum to minimize diaphragmatic irritation from CO2 and consequent shoulder tip pain. Anxiety and abdominal or shoulder discomfort were treated with increments of midazolam 1 mg and fentanyl 25–50 µg IV, respectively. Surgical conditions were graded by the surgeon as poor, fair, good, or excellent.
Recovery times were determined at 1-min intervals from the discontinuation of maintenance anesthesia to eye opening, tracheal extubation, and orientation. Subsequently, recovery variables including time to straight leg raising and time to ambulation were determined at 15-min intervals until the patient was judged to be discharge ready (having achieved the Day Care Center’s standardized discharge criteria). Aldrete scores were determined on leaving the OR and at 1, 3, 5, 7, and 10 min in the postanesthesia care unit PACU (Table 1).
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All anesthetics were administered by two of the investigators (PL and HV), and all assessments were performed by one of the investigators (PL).
Data were entered into a spreadsheet program (Microsoft Excel) and analyzed. Continuous data that were normally distributed were expressed as mean ± SD and analyzed for between-group differences using unpaired Student’s t-tests. When these data were measured over time, two factor repeated-measures analysis of variance was used, with the Student-Newman-Keuls test post hoc. Nonparametric data were analyzed by using the 
2 test. A P value of <0.05 was considered significant.
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Results |
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Discussion |
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Spinal anesthesia competes with the newer GA in ambulatory anesthesia but discharge times are significantly longer after conventional dose spinal anesthesia compared with GA (6,7). Discharge times reported with conventional dose spinal anesthesia using procaine or lidocaine range from 145 to 185 min (6,8), whereas discharge times after newer GA range from 100 to 140 min (6,9). In an effort to make spinal anesthesia more efficient for outpatient use, investigators have examined the feasibility of using smaller doses of local anesthetics because complete return of sensation to pinprick remains the rate-limiting step to early discharge (10). The addition of a small dose of intrathecal opioid overcomes the potential risk of inadequate block associated with small-dose lidocaine spinal anesthesia (8,10). Intrathecal opioids act synergistically with intrathecal local anesthetics to enhance subtherapeutic doses of local anesthetics that, as a sole drug, may not provide an adequate block (11,12). The dose of spinal lidocaine can be reduced from 75 mg to 10 mg without compromising intraoperative conditions (2,10). As the dose of lidocaine is progressively reduced, there are beneficial effects in terms of a more stable hemodynamic profile, as well as preservation of spinal cord function with a selective blockade of the spinothalamic columns (2,3,10). With selective spinal anesthesia, modalities such as light touch, proprioception, vibration sense, and motor function are essentially preserved. With a reduction in intrathecal lidocaine dose from 75 mg to 10 mg, the time to achieve discharge criteria decreased from 162 min to 75–91 min (2,3,10,13).
Comparison of SSA to propofol-based anesthesia demonstrated that times to straight leg raising and ambulation were faster in the SSA group (1). However, the propofol-based anesthetic group lacked an objective measure of depth of anesthesia such as BIS monitoring. In the present study, a BIS monitor was used to provide a more objective measure of anesthetic depth in the DES group and to avoid an excessive administration of anesthesia. Recovery times (Phase I and II) for the DES group were comparable to those reported in the literature by other investigators (14). Recovery times (Phase I and II) in the SSA group were not significantly shorter than the DES group even though patients in the DES group had significantly longer times to perform straight leg raises and ambulate. One explanation for this discrepancy may be that all patients in the SSA group were required to demonstrate complete recovery of sensory block (i.e., pinprick) before being transferred to Phase II.
Regrettably, two of the SSA patients with a history of severe PONV after previous GA experienced moderate PONV after SSA. Perhaps a better choice of prophylactic antiemetic in this group would have been a multimodal approach. The overall incidence of PONV in the SSA group in this study was comparable to that reported with spinal anesthesia in previous studies (13). Pruritus, a common side effect of SSA related to the use of intrathecal opioids (10,13), occurred in 40% of patients in the SSA group but resolved spontaneously without the need for pharmacological intervention. In keeping with our previously reported experience, voiding was not a problem in the SSA group (13).
When comparing a spinal technique with an awake patient to a GA technique, it is impossible to blind the patient, the surgeon, and the attending anesthesiologist to the technique of anesthesia. The anesthesiologist performing the assessments was not blinded with respect to anesthetic type; however, a single investigator performed all the assessments to avoid interobserver variability. These assessments were done using a strict assessment protocol in an effort to minimize bias. In addition, there may be concerns that the Aldrete score was designed for assessment of recovery of GA only and cannot be used for spinal anesthesia. On the contrary, the Aldrete score was designed to evaluate recovery after both general and neuraxial anesthesia (15). Some patients who receive regional anesthesia also require sedative/analgesic adjuvants that can impair the recovery process. The Aldrete score also allows objective assessment of recovery from such adjuvant therapy.
In conclusion, SSA provided satisfactory surgical conditions with Phase I and II recovery times that were comparable to DES-based GA for short duration outpatient gynecological laparoscopy. Patients receiving SSA were awake and oriented at the end of the procedure, had less postoperative pain, and were able to ambulate earlier than DES patients.
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