Rawal Medical Journal

An official publication of Pakistan Medical Association Rawalpindi Islamabad branch

Established 1975
Volume 36

Number 2

March- June

2011

Original Article

Low-dose Bupivacaine with fentanyl spinal anesthesia to prevent

spinal-induced hypotension in adults
Mohammed Shawagfeh, Ahmad S Sbaihat, Essa A Mayyas, Ala D Alomari, Safwan
G Fawaris
Department of anesthesia and surgery, Prince Rashid Hospital, Amman, Jordan
ABSTRACT
Objectives
To assess the usefulness and efficacy of low-dose Bupivacaine with Fentanyl spinal
anesthesia for prevention of hypotension while maintaining good anesthetic
conditions.
Patients and Methods
At Prince Rashid Hospital, 100 adult patients were randomized into two groups. The
study group (F) comprised of 50 patients who received spinal anesthesia with
Bupivacaine 7.5-9mg and fentanyl 25 g, while in control group (B), 50 patients
received Bupivacaine 12.5-15mg only. The homodynamic stability of the patients and
the quality of the blocks were compared.
Results
All patients had adequate duration of reliable blocks. More control group patients than
study group patients required ephedrine due to hypotension.

Conclusion
A reduced dose of Bupivacaine in combination with fentanyl provided reliable spinal
anesthesia with few events of hypotension and little need for vasopressor support for
blood pressure. (Rawal Med J 2011;36:116-119).
Key words
Bupivacaine, fentanyl, spinal anesthesia.
INTRODUCTION
The ideal spinal anesthesia for ambulatory surgery should provide good surgical
anesthesia with rapid recovery from sensory and motor block.1 Lignocaine has been
widely advocated for ambulatory anesthesia but many studies have questioned the use
of hyperbaric 5% lignocaine for spinal anesthesia and recommended consideration of
bupivacaine as a substitute.2 Bupivacaine, an amide type of local anesthetic, has high
potency, slow onset (58 minutes) and long duration of action (1.52 hours).
Although spinal anesthesia is safe but it is not devoid of complication, hypotension
and sinus bradycardia are the most complication and are attributed to the imbalance
between sympathetic and parasympathetic control of the heart rate. Stimulation of the
sympathetic system may induce myocardial ischemia by causing coronary
vasoconstriction3 and may be related to the genesis of ventricular tachyarrhythmia.4
Hypotension after spinal anesthesia is often treated with vasopressors and intravenous
fluids. This regime is controversial for the geriatric population with coronary disease5
may increase risk of pulmonary oedema in high-risk pregnant patients and has been
associated with fetal acidosis.6 Bupivicaine has other side effects like increased motor
block and bladder dysfunction leading to delayed discharge.7
There has been controversy concerning the relationship between volume,
concentration and total dose of spinally administered drugs. Most of the studies
suggest that the total dosage is more important than the volume.8 These concerns have
increased interest in the use of small doses of bupivacaine.9 Intrathecal opioids have
been shown to enhance analgesia from sub therapeutic doses of local anesthetics and
make it possible to achieve spinal anesthesia using otherwise inadequate doses of
local anesthetic.10,11 In this study, we focused on the usefulness and efficacy of lowdose bupivacaine with fentanyl spinal anesthesia to prevent hypotension and other
complications while maintaining good anesthetic conditions.
PATIENTS AND METHODS
This prospective study included 100 patients who underwent lower abdominal,
anorectal, orthopedic and obstetric surgery under spinal anesthesia technique from
February 2008 to December 2008 at Prince Rashid Hospital. Patients with a history of

previous back surgery, infection at the injection site, uncontrolled hypertension,

hypersensitivity to amide local anesthetics or fentanyl, mental disturbance, or
neurologic disease coagulation disorders were excluded from the study as well as
patients who required conversion to general anesthesia. The approval of the
Institutional Ethical Studies Committee was given for the study
Patients were divided into two group each group with fifty patients. In the first group
(F), 7.5-9 mg of 0.5 percent heavy bupivcaine was injected intrathecaly plus 25 mu
fentanyl. In the second group (B), 12.5-15 mg of 0.5 percent heavy bupivcaine only
was injected intrathecaly. The study was randomized and double-blind regarding the
anesthesia solution, with the subjects being assigned to a study group or a control
group using a sealed-envelope technique.
No premedication was given. ECG, non-invasive blood pressure, heart rate and
peripheral oxygen saturation were monitored. After an intravenous access was
established the patients were received 500 ml of sodium chloride 0.9% solution over
30 min. The intravenous infusion was maintained at (8 ml/kg/1.h) during the intraoperative period. Oxygen was continuously given via a face mask. Systolic arterial
pressure (SAP) and heart rate (HR) were recorded at 5 minute interval at the onset of
block, then at 15 minute intervals until the resolution of the block. Hypotension (SAP
<90 or 30% decrease from the baseline) was treated with intravenous bolus of
ephedrine 3-6 mg, trendelenberg position by 15 degrees and administration of IV fluid
500-1000 ml of lactated range and bradycardia (HR <45) was treated with atropine
0.5 mg intravenously.
Sensory block was determined with a 22-gauge needle in the dermatome levels tested
every two minutes from injection until the level established for four consecutive tests
Testing was then conducted every 10 minutes until two segment regression. Further
testing was then performed at 20 minute intervals in the recovery room until recovery
of the S2 dermatome. Motor block was assessed with the Bromage scale (0 no motor
block; 1 hip blocked; 2 hip and knee blocked; and 3 hip, knee and foot blocked).
Duration of motor block was considered as the time when Bromage score returned to
(0). Motor blockade was assessed at the time of reaching peak sensory level and this
was considered the maximum motor blockade. Pain was assessed every 10 minutes
from the beginning of surgery till discharge from recovery room using a 10-cm visual
analogue pain scale, intra and postoperative analgesia consumption. It was treated
with pethidine (1mg/kg) intramuscularly every 6 h when needed in the 1st 24 hours
postoperatively. Adverse effects such as nausea, vomiting, shivering, pruritus,
respiratory depression, and transient neurological symptoms were recorded.
RESULTS
There were 81 male and 19 female patients in this study; there ages ranged from 23 to
95 year (mean 56). Inguinal herniorrhaphy was the commonest surgery performed
(Table 1).

Table 1. Type of surgical procedures.

Procedure

Number

Inguinal hernia

39

Anorectal surgery

27

orthopedic surgery

27

Obstetric surgery

High ligation of varicose vein

Total

100

The sensory and motor block in the two groups is shown in Table 2.
Table 2. Sensory and motor block variables.
Variable

Group F

Group B

Numberof dermatomes
blocked( mean)

13

11

Upper limit of sensory

block

T12

T11

Time to reach peak of

sensory block(minute)

8.6

9.1

110.6

134.4

Time of sensory regression

(minute)

174

191.2

Two segment
regression(minute)

55.4

64.4

Maximum motor block

(Bromage scale 0-3) mean
Duration of motor block
(minute)

The number of dermatomes blocked was relatively comparable in both groups as well
as the median upper limit of the sensory block. Recovery of motor function took place
significantly earlier in Group F compared with Group B (110.6 minute vs 134.4
minute).

Table 3. Pain variables.

Group

Number of patients needing intra-operative

245

267

VAS (intra operative 0-10)

2.7

2.8

VAS (post operative 0-10)

5.1

4.9

analgesia (intravenous fentanyl)

Average pethidine dose post operatively
(mg) per patient

Time to reach of peak sensory lose was earlier in group F, however did not differ
significantly. Although the two-segment regression was slower in Group B compared
with Group F but did not seemed to be significant, but time for sensory recovery was
earlier in group F than group B, (174.3 minute vs 191.2 minute).
No differences were found between the groups in the total analgesic consumption
(Table 3), or the number of patients who required postoperative analgesics in the
recovery room.
Table 4. Adverse effects.
Group

F
(number)

Hypotension

B
(number)

13

97.5

20.0

Bradycardia

Nausea and vomiting

Shivering

Pruritus

Respiratory depression

Transient
neurological
manifestation

Total of ephedrine doses

(mg)

Lowest SAP (<30%) occurred in Group B (13 patients) and was significantly higher
than those of Group F (3 patients), while incidence of bradycardia was comparable in
both groups (Table 4). Total amount of the ephedrine used for treatment of
hypotension was higher in Group B than Group F (97.5 mg vs 20mg respectively).
Other adverse effects seem to be comparable in both groups except for pruritus that is
higher in group F (Table 4).
DISCUSSION
Although spinal anesthesia is significantly safer than general anesthesia, morbidity
and mortality still can occurred with spinal anesthesia. Deaths in regional anesthesia
are primarily related to excessive high regional blocks and toxicity of local
anesthetics. Reduction in doses and improvement in technique to avoid higher block
levels and heightened awareness to the toxicity of local anesthetics have contributed
to the reduction of complications related with regional anesthesia.12 As bupivacaine is
used commonly for spinal and epidural anesthesia, we decided to combine it with
intrathecal fentanyl for various surgical procedures to provide adequate depth of
anesthesia with lesser doses of bupivacaine13 with better maintainance of the
hemodynamic stability of these patients.
Our results are comparable with those studies that proved the improvement of
intrathecal opioids without altering the degree of sympathetic blockade when added to
sub therapeutic doses of local anesthetics.14,15 It potentiates sensory anesthesia
without prolonging recovery from spinal anesthesia.16 However, motor recovery was
not significantly affected by the addition of intrathecal fentanyl.
Bradycardia results from the blockade of sympathetic cardio accelerator fibers and
decreased venous return to the heart. In our study, bradycardia overall occurrence was
4 % (in F group) with no significant inter group variation, while incidence of
hypotension was markedly reduced by lowering the anesthetic drug and adding
intrathecal fentanyl. We should admit that the variation in our included surgical
procedures limit us to specify our results for specific procedure but our results are
comparable with various studies for single procedure.
CONCLUSIONS
A reduced dose of bupivacaine in combination with fentanyl provided reliable spinal
anesthesia in adults for variable kinds of surgical procedures with few events of
hypotension and little need for vasopressor support of blood pressure. It offers a
reliable block, good post-operative analgesia and satisfactory for the patient and
surgeon.

Correspondence: Dr Issa mayyas, Department of Surger

Email:issamayyas@yahoo.com Tel: 00962777314092
Received: January 2, 2011 Accepted: February 2, 2011
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