feasibility of spinal anesthesia with sedation for laparoscopic general abdominal procedures in moderate risk patients

One of the major advantages of laparoscopic surgery is minimizing postoperative morbidity. The previous limitations to the use of spinal anesthesia in laparoscopic surgery were the limited work space, high failure rate, more intra-operative morbidity and significant arterial blood gas alterations. However, the addition of a small-dose Ketamine infusion to propofol might provide a suitable sedative combination to be used with high spinal anesthesia, producing titerable sedation, increased hemodynamic stability, and minimal respiratory depression. At KFSH and RC Hospital, after Ethical Committee approval and informed written consent, 18 ASA III patients scheduled for various laparoscopic abdominal procedures were enrolled. Exclusion criteria consisted of ejection fraction below 45% and or peak expiratory flow rate and forced vital capacity of less than 65% of predicted values. Following oral premedication with midazolam 7.5-10 mg 30 min preoperatively, spinal anesthesia was conducted by bupivicaine 0.75% 3-3.5 ml at L3-4, in the lateral position to reach a sensory level at T4. Sedation was started by intravenous injection of 0.4 mg/kg propofol and 0.1 mg/kg ketamine prior to spinal anesthesia. This was followed by infusion of 1.0-1.5 mg/kg/h and 0.3-1.0 mg/kg/h. of the same drugs respectively. The sedation requirements were adjusted to keep the patient sleepy with conservation of airway reflexes at level 3 on a 5 point sedation score. Heart rate, respiratory rate and SpO[2] were monitored, together with direct arterial blood pressure monitoring and arterial blood gas analysis through arterial cannulation. Postoperative first time call for analgesia, total morphine consumption during the first hour and incidence of complications were recorded. Twenty Four hours later, surgeons' and patients' satisfaction were obtained and recorded. Heart rate and mean arterial blood pressure were significantly decreased after spinal anesthesia and intra-peritoneal insufflations of CO[2], with significant increase in arterial carbon dioxide tension accompanied by increase in the respiratory rate. The increase in respiratory rate led to gradual decrease of CO[2] level down to near the pre-operative PaCO[2] values. However, there was insignificant decrease in oxygen saturation throughout the intra-operative time. Postoperatively there were excellent surgeon and patient's satisfaction. Only one patient regained sensation before completion of surgery and sedation was deepened to level 5 sedation score. The mean surgical time was 98.5 +/- 21.4 min while the mean anesthesia time was 117.7 +/- 20.1 min. First mean time call for analgesia was 50 +/- 8 min. 7/18 patients required single dose of morphine of 4 mg during the 1[st] hour postoperatively. The addition of a sedative combination of ketamine and propofol to spinal anesthesia was found to be safe and efficient from both the anesthetic and surgical point of view, especially for sick patients with intermediate clinical predictors

Intra-peritoneal bupivacaine alone or in combination with morphine patients undergoing vertical bypass gastroplasty

Intra-peritoneal instillation of local anesthesia and morphine has been used to alleviate post-operative pain in laparoscopic surgery. Controversy exists about the efficacy of this technique. We studied 48 patients scheduled for Vertical Bypass Gastroplasy [VBG]. All of them received the same technique of general anesthesia [GA]. Patients were randomly allocated into four equal groups. They received equal volumes of the test drug instilled in the peritoneal cavity at the end of laparoscopy, 50 ml of normal saline [Group S]: 50 ml of bupivacaine 0.25% [Group B], 50 ml of bupivacaine 0.25%, plus morphine 40 mcg.kg-1 [maximum of 5 rug] Group M or [Group D] patients received the same regimen as Group M in addition, they received 75 mg intra-muscular diclophenac after induction of general anesthesia. Wound edges were infiltrated with 10 ml bupivacaine 0.25% in all patients. Morphine 25-50 mcg.kg-1 was given intravenously every 10 mm as a rescue analgesic to control postoperative pain in Post Anesthesia Care Unit [PACU]. Post operative pain was evaluated using Visual Analogue Scale [VAS]. vital signs and morphine consumption, and time to receive rescue analgesia were measured at different intervals. The incidence of post-operative complications [respiratory depression. oxygen de-saturation. arid nausea and vomiting] was recorded as well as hospital stay. There was significant decrease in VAS, HR. MBP and morphine consumption in Groups M and D when compared to Groups S and B on admission and on discharge from PACU. There were significant decrease in time to receive rescue analgesia as well as significant reduction in hospital study in Groups M and D when compared to Groups S and B. However, there was no significant difference between group S and B regarding the same parameters. The presented technique is safe and easy to use with good postoperative morphine sparing analgesia, excellent patient satisfaction and short hospital stay