Satisfactory spinal anesthesia with a total of 1.5 mg of bupivacaine for transurethral resection of bladder tumor in an elderly patient
© The Author(s) 2016
Received: 24 December 2015
Accepted: 27 January 2016
Published: 2 April 2016
Spinal anesthesia is popular for endoscopic urological surgery. Many patients undergoing urological surgery are elderly. It is important to limit the dose to reduce any resultant hemodynamic effect. We present a case in which incremental administration of 0.1 % bupivacaine up to 1.5 mg was sufficient to produce satisfactory spinal anesthesia for transurethral resection of bladder tumor (TURBT).
KeywordsSpinal anesthesia Elderly patient Dilution and incremental administration of local anesthetic
Spinal anesthesia produces hypotension more often in elderly patients than in younger patients. Limiting the dose (and thus, extent of anesthetic spread) to the necessary dermatomes reduces the likelihood of side effects [1, 2]. We attempted to reduce the necessary amount of bupivacaine by dilution and incremental administration.
A 95-year-old man (158 cm, 35 kg) was diagnosed with bladder tumor following macrohematuria and scheduled to undergo transurethral resection of bladder tumor (TURBT). His echocardiogram showed aortic (II/IV), tricuspid (II/IV), mitral (mild) and pulmonic (mild) regurgitation. The left ventricular ejection fraction was 54 %. Pulmonary function testing was impossible due to the inability of the patient to cooperate. The family understood the risk of anesthesia and surgery, accepted the anesthesia and surgery.
Four ml of 0.5 % hyperbaric bupivacaine solution was diluted with 16 ml of normal saline to produce an approximately isobaric 0.1 % solution. A T10 dermatomal level of sensory block was targeted to proceed to surgery. The level of sensory denervation was determined by loss of sensation to pin-prick testing. A combined spinal-epidural needle was inserted at the L4–5 interspace and initially 0.5 ml of 0.1 % bupivacaine solution was intrathecally injected through the spinal needle three times resulted in T10 level of spinal anesthesia, then an epidural catheter was inserted. Midazolam 1 mg was administered against anxiety.
An intra-arterial catheter was placed for continuous monitoring of blood pressure. Dopamine was continuously infused at 1.4–7.1 μg/kg/min to maintain an arterial blood pressure around 140/90 mmHg during surgery. Oxygen was supplemented at 3–5 L/min via face mask in the operating room. The operation was finished uneventfully in 1 h. His leg was paralyzed at the end of surgery but could be moved 2 h after the surgery. Both oxygen and dopamine could also be discontinued 2 h after surgery. The postoperative course was uneventful.
Spinal anesthesia is the most frequently used anesthetic technique for endoscopic urological surgery because the signs and symptoms of water intoxication with fluid overload can be recognized earlier. However, many patients undergoing urological surgery are elderly and have coexisting cardiac and pulmonary disease. It is therefore important to limit the distribution of spinal block to reduce adverse hemodynamic and pulmonary effects in such patients [3, 4].
Baydilek et al.  compared continuous spinal anesthesia (CSA) with single-dose spinal anesthesia (SDSA) in geriatric patients undergoing transurethral resection of prostate. In their group SDSA, 2.5 ml of 0.5 % levobupivacaine (12.5 mg) was injected through the spinal needle and in their Group CSA, initially 2 ml of 0.25 % levobupivacaine (5 mg) was injected through the intrathecal catheter. If the level of sensory block had not reached T10, an extra 1 ml of 0.25 % levobupivacaine (2.5 mg) was given through the catheter, this was repeated until T10 block level was reached. The mean effective dose in Group CSA was (8.70 ± 1.63) mg. They found that CSA provided better hemodynamic stability, shorter recovery period and equal anesthetic quality. Similar findings to the study of Baydilek et al. were reported by others with spinal anesthesia for orthopedic lower extremity surgery [6–11], but none of them diluted the local anesthetic solution.
Concentration of local anesthetic in cerebrospinal fluid (CSF) is one of the factors affecting uptake of local anesthetic into neural tissue [1, 2]. We diluted local anesthetic solution to attenuate the intensity of neural blockade.
Density of CSF at 37 °C ranges from 0.9998 g/ml to 1.005 g/ml varying with reports [2, 12–16]. Specific gravity of 0.5 % hyperbaric bupivacaine solution at 20 °C is 1.025–1.031 (AstraZeneca Pharmaceutical Company). Density of normal saline at 20 °C is 1.004 g/ml, and that of distilled water at 20 °C is 0.9982 g/ml (Otsuka Pharmaceutical Company). Calculated density of our diluted 0.1 % solution at 20 °C is 1.0078–1.009 mg/ml. Increasing temperature decreases the density of a solution [1, 2]. Our diluted 0.1 % solution would have been warmed up to patient’s CSF temperature and the density would have been less than 1.0078–1.009 mg/ml. In fact, our diluted anesthetic solution worked as an approximately isobaric solution.
One of the most serious complications of spinal anesthesia is cardiac arrest [17–19]. The cardiologist suggested the possibility of cardiac arrest in this case. Unnecessary high level of spinal anesthesia-induced sympathetic blockade should be avoided. The spread of SDSA is reported to be unpredictable . However, our method, incremental administration of diluted local anesthetic solution, made it possible not only to predict but also to control the spread of local anesthetic.
Many articles suggest that the addition of fentanyl or sufentanil can enhance local anesthesia and thereby reduce the dose of local anesthetics with more stable hemodynamics for urological surgery [3, 20, 21] and other surgery [11, 22–26]. Had we added fentanyl to bupivacaine, it might have reduced the dose of bupivacaine and provided more stable hemodynamics and the need for vasopressors.
The dose of intrathecal bupivacaine to produce a T10 level is reported to be 10–15 mg . This case report demonstrates that when diluted bupivacaine was given in incremental doses of 0.5 mg, a total of 1.5 mg could be sufficient to produce satisfactory spinal anesthesia to proceed to TURBT in an elderly patient. This lower dose can minimize the risk of spinal anesthesia. Prolonged surgery and postoperative pain can be controlled by the combined spinal-epidural anesthesia.
Written informed consent was obtained from patient’s daughter.
Transurethral resection of bladder tumor
Continuous spinal anesthesia
Single-dose spinal anesthesia
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Brull R, Macfarlane AJR, Chan VWS. Spinal, Epidural, and Caudal Anesthesia. In: Miller RD, editor. MILLER’S ANESTHESIA. Elsevier: Saunders; 2015. p. 1684–720.Google Scholar
- Pitkanen M. Spinal (Subarachnoid) Blockade. In: Cousins MJ, Carr DB, Horlocker TT, Bridenbaum PO, editors. Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine. Philadelphia: Williams & Willkins; 2009. p. 213–40.Google Scholar
- Kararmaz A, Kaya S, Turhanoglu S, Ozyimaz A. Low-dose bupivacaine-fentanyl spinal anaesthesia for transurethral prostatectomy. Anesthesia. 2003;58:526–30.View ArticleGoogle Scholar
- Labbene I, Lamine K, Gharsallah H, Jebali A, Adhoum A, Ghozzi A, et al. SPINAL ANESTHESIA FOR ENDOSCOPIC UROLOGICAL SURGEY –Low dose vs. Varying dose of Hyperbaric Bupivacaine. MEJ ANESTH. 2007;19:369–84.Google Scholar
- Baydilek Y, Yurtlu BS, Hanci V, Ayoglu H, Okyay RD, Kayhan GE, et al. The comparison of levobupivacaine in continuous or single dose spinal anesthesia for transurethral resection of prostate surgery. Rev Bras Anestesiol. 2014;64:89–97.View ArticleGoogle Scholar
- Klimscha W, Weinstabl C, Ilias W, Mayer N, Kashanipour A, Schneider B, et al. Continuous spinal anesthesia with a microcatheter and Low-dose bupivacaine decreases the hemodynamic effects of centroneuraxis block in elderly patients. Anesth Analg. 1993;77:275–80.View ArticlePubMedGoogle Scholar
- Schnider TW, Mueller-Duysing S, Johr M, Gerber H. Incremental dosing versus single-dose spinal anesthesia and hemodynamic stability. Anesth Analg. 1993;77:1174–8.PubMedGoogle Scholar
- Favarel-Garrigues JF, Sztark F, Petitjean ME. Hemodynamic effects of spinal anesthesia in the elderly: single dose versus titration through a catheter. Anesth Analg. 1996;82:312–16.PubMedGoogle Scholar
- Goy RW-L, Chee-Seng Y, Sia AT-H, Choo-Kok K, Liang S. The median effective dose of intrathecal hyperbaric bupivacaine is larger in the single-shot spinal as compared with the combined spinal-epidural technique. Anesth Analg. 2005;100:1499–502.View ArticlePubMedGoogle Scholar
- Minville V, Fourcade O, Grousset D, Chassery C, Nguyen L, Asehnoune K, et al. Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of Hip fracture in elderly patients. Aneth Analg. 2006;102:1559–63.View ArticleGoogle Scholar
- Saber R, Metainy SE: Saber R, Metainy SE. Continuous spinal anesthesia versus single small dose bupivacaine-fentanyl spinal anesthesia in high risk elderly patients: a randomized controlled trial. Egyptian Journal of Anaesthesia. 2015;31:233–8.View ArticleGoogle Scholar
- Davis H. CORRESPONDENCE: specific gravity and density. Anesthesiology. 1976;44:270–1.PubMedGoogle Scholar
- Horlocker TT, Wedel JD. Density, specific gravity, and baricity of spinal anesthetic solution at body temperature. Aneth Analg. 1993;76:1015–108.View ArticleGoogle Scholar
- Gaiser RR. Spinal, epidural, and caudal anesthesia. In: Longnecker DE, Murphy FL, editors. INTRODUCTION TO ANESTHESIA. Philadelpha: W. B. SAUNDERS COMPANY; 1997. p. 216–31.Google Scholar
- Lui ACP, Polis TZ, Cicutti NJ. Repotrs of Investigation/ Densities of cerebrospinal fluid and spinal anaesthetic solutions in surgical patients at body temperature. Can J Anaesth. 1998;45:297–303.View ArticlePubMedGoogle Scholar
- Heller AR, Zimmermann K, Seele K, Rossel T, Koch T, Litz RJ. Modifying the baricity of local anesthetics for spinal anesthesiology by temperature adjustment. Anesthesiology. 2006;105:346–53.View ArticlePubMedGoogle Scholar
- Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg. 2001;92:252–6.View ArticlePubMedGoogle Scholar
- Ishiyama T, Shibuya K, Terada Y, Iwashita H, Masamune T, Kotoda M, et al. Cardiac arrest after spinal anesthesia in a patient with neutrally mediated syncope. J Anesth. 2012;26:103–6.View ArticlePubMedGoogle Scholar
- Kumari A, Gupta R, Bajwa SJS, Singh A. Unanticipated cardiac arrest under spinal anesthesia: an unavoidable mystery with review of current literature. Anesth Essays Res. 2014;8:99–102.View ArticlePubMedPubMed CentralGoogle Scholar
- Kim SY, Cho JE, Hong JY, Koo BN, Kim JM, Kil HK. Comparison of intrathecal fentanyl and sufentanyl in lowdose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy. Br J Anaesth. 2009;103:750–4.View ArticlePubMedGoogle Scholar
- Chaudhay A, Bogra J, Singh PK, Saxena S, Chandra G, Verma R. Efficacy of spinal ropivacaine versus ropivacaine with fentanyl in transurethral resection operations. Saudi J Anesth. 2014;8:89–91.View ArticleGoogle Scholar
- Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med. 2000;25:235–9.View ArticlePubMedGoogle Scholar
- Olofsson C, Nygards EB, Bjersten AB, Hessling A. Low-dose bupivacaine with sufentanil prevents hypotention after spinal anesthesia for hip repair in elderly patients. Acta Anaesthesiol Sand. 2004;48:1240–4.View ArticleGoogle Scholar
- Gurbet A, Turker G, Girgin NK, Aksu H, Bahtiyar NH. Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in Out-patient anorectal surgery. J Int Med Res. 2008;36:964–70.View ArticlePubMedGoogle Scholar
- Ozyilkan NB, Kocum A, Sener M, Galiskan E, Tarim E, Ergenoglu P, et al. Comparison of intrathecal levobupivacaine combined with sufentanil, fentanyl, or placebo for elective caesarean section: a prospective, randomized, double-blind, controlled study. Curr Ther Res. 2013;75:64–70.View ArticleGoogle Scholar
- Venkata HG, Pasupuleti S, Pabba UG, Porika S, Talari G. A randomized controlled prospective study comparing a low dose bupivacaine for cesarean section. Saudi J Anaesth. 2014;8:88–91.View ArticleGoogle Scholar