Fluid challenge in patients submitted to spinal block.

AIM: The practice of routinely prehydrating patients by infusing a colloid solution for prevention of spinal anesthesia-induced hypotension has been challenged recently. The aim of the study was to evaluate the influence of a 15 mL/kg pre-emptive bolus of colloids (6% hydroxyhethyl starch) on heart rate (HR), mean arterial blood pressure (MAP), cardiac index (CI) in patients submitted to subarachnoid block with hyperbaric bupivacaine 0.5%, 0.2 mg/kg for orthopedic surgery of the lower limb. METHODS: Patients were monitored by a Model Flow method. Forty patients (ASA I-II) scheduled to undergo to spinal anesthesia for elective orthopedic surgery of the lower limb were enrolled in the study. The 20 patients in Group A were treated with a preanesthetic infusion of 15 mL/kg of hydroxyhaethyl starch 6%, Group B (20 untreated patients) was the control group. HR, MAP, CI were collected at T0 (first relevation); T1 (after 5 min from the spinal block); T2 (after 10 min); T3 (after 15 min); T4 (after 20 min); T5 (after 25 min); T6 (after 30 min); T7 (after 35 min). RESULTS: Our data show that MAP value is higher in treated patients than in control group (ANOVA: P<0.001) and at T1 in Group B MAP was lower than at T0 (P<0.05). HR and CI trend appear similar in the 2 groups. Our results show that heart rate is not affected by colloid infusion. This may be due to the substantial cardiovascular stability of the selective spinal anesthesia, which does not activate a clinical relevant compensatory vagal effect. Fluid prehydration would expand the vascular space and hence compensate for the reduction in systemic vascular resistance, although MAP reduction following the induction of spinal anesthesia is present in both treated and control groups. CONCLUSION: Our data show that despite to fluid challenge, we could not prevent MAP decrease in Group A, even if it is more marked in Group B.

Haemodynamic modifications after unilateral subarachnoid anaesthesia evaluated with transthoracic echocardiography.

AIM: The aim of the study is the evaluation through transthoracic echocardiography of the haemodynamic modifications due to unilateral subarachnoid anaesthesia with bupivacaine 0.5% given for orthopaedic surgery. METHODS: In this prospective study, at the University Hospital Orthopedics surgical theater, 20 patients underwent orthopaedic surgery on the lower limbs. Unilateral spinal block was performed with hyperbaric bupivacaine 0.5%, 8 mg after a fluid challenge with saline solution 0.9%. Transthoracic echocardiography was performed and cardiac output was calculated from the left ventricular outflow tract (LVOT) with a recently validated technique. Cardiac output, stroke volume, ejection fraction, heart rate, mean arterial pressure were evaluated. These parameters were obtained before anaesthesia (t1), 5 minutes after anaesthesia (t2) and 16 minutes after anaesthesia (t3). RESULTS: Systolic, mean and diastolic arterial pressures after 5 min and 16 min from anaesthesia significantly decreased if compared to basal time (p<0.05 and p<0.001 respectively) while cardiac index (p<0.001) and ejection fraction (p<0.05) decreased only after 16 min from subarachnoid anaesthesia. CONCLUSION: Despite the fluid challenge we can not prevent a significant fall in the blood pressure and a decrease of the left ventricular function calculated with the decrease of cardiac output and of the left ventricular ejection fraction.

[Epidural vs general anaesthesia]. / Anestesia epidurale vs generale.

BACKGROUND: Aim of this study is to determine if and how the anaesthesia technique can significantly influence the outcome in patients after major orthopaedic surgery in terms of: patrimony of red blood cells (blood loss and erythropoiesis), incidence of intra and postoperative complications, postoperative pain control and hospital stay. METHODS: 210 patients, ASA physical status I-III, undergoing elective primary total hip replacement were randomly allocated in three groups of 70 patients to receive either epidural anaesthesia (Group EA), general anaesthesia (GA), or epidural anaesthesia integrated with mild general anaesthesia (IA). RESULTS: Data show a significant difference between the amount of pain measured by VRS immediately after surgery: prevalently absent in groups IA (84.3%) and EA (85.7%) and prevalently severe and moderate in group AG (34.3%). The measurement of the basic circulating erythrocyte mass in the first, third and fifth postoperative day, calculated by the Mercuriali formula, which considers blood loss, autologous and homologous transfusions and erythropoiesis, showed that general anaesthesia leads to a significant delay in the resumption of haemopoiesis. This result was attenuated by its combination with epidural anaesthesia. CONCLUSIONS: On the basis of the literature and the results of our study, epidural anaesthesia seems to be the most appropriate technique for patients scheduled for total hip replacement: due to its simpler analgesic cover, its tendency to be associated with a lower incidence of complications in the first 24 hours after surgery. The incidence of relevant hypotension is minor compared to integrated anaesthesia. General anaesthesia produced a significant decrease in postoperative erythropoiesis.