Anesthesia; Adverse Effect, Spinal and Epidural Clinical Trial
Official title:
Comparative Study Between Continuous Epidural Anesthesia Using Standard Epidural Catheter And Continuous Spinal Anesthesia Using Wiley™ Spinal Catheter In Geriatric Patients Undergoing TURP
Geriatric patients have a significantly higher incidence of morbidity and morality during surgery compared with younger age group. Transurethral resection of the prostate (TURP) is the gold standard treatment for elderly patients with bladder outlet obstruction. Thus Regional techniques may be better tolerated in the elderly patients undergoing TURP having the advantages of minimizing blood loss and thromboembolic events. The Wiley Spinal™ (Epimed; Johnstown, NY) catheter is an innovative flexible cannula over needle designed for convenient intrathecal access that reduces PDPH. We hypothesized that using less anesthetics during continuous spinal anesthesia with the Wiley spinal catheter would offer more hemodynamic stability with less side effects when compared with continuous epidural anesthesia in patients undergoing TURP
Geriatric patients have a significantly higher incidence of morbidity and morality during
surgery compared with younger age group as they commonly have respiratory, circulatory and
renal problems [1]. Transurethral resection of the prostate (TURP) is the gold standard
treatment for elderly patients with bladder outlet obstruction. TURP procedure has been
associated with high morbidity rate including bleeding, TURP syndrome, bladder perforation,
hypothermia and disseminated intravascular coagulation during intraoperative and early
postoperative period. Therefore, it becomes very important to keep a stable anesthesia that
minimizes these side effects. Detection of such complications is quite difficult under
general anesthesia as compared to regional anesthesia. Thus Regional techniques may be
better tolerated in the elderly patients undergoing TURP having the advantages of minimizing
blood loss and thromboembolic events [2].
Subarachnoid single dose injection provides a potent blockade of fast onset while its
extension and duration are difficult to predict [3]. Continuous epidural anesthesia with a
catheter placement offers flexibility to extend, intensify, and maintain the block as well
as providing postoperative analgesia [4]. Continuous spinal anesthesia consists of
introducing a catheter in the subarachnoid space and maintaining blockade by repeated
anesthetic injections. The possibility of fractionating local anesthetics dosage along time
allows a fast onset with better blockade quality and less hemodynamic changes [5]. Recent
study [6] reported that pain scores in patients received continuous spinal anesthesia were
significantly lower than those received continuous femoral nerve block.
Advantages of continuous spinal anesthesia include the following: (a) Prior placement of the
catheter in the induction area facilitates the surgical schedule. (b) Spinal anesthesia may
be induced through the catheter after the patient has been positioned for surgery, thereby
lessening the potential for hypotension. (c) The low doses of local anesthetic
intermittently injected eliminate the possibility of systemic toxic reactions. (d) Repeated
injection of small doses of local anesthetic solution facilitates obtaining the right level
of anesthesia and decreases the cardiovascular instability during induction. (e) Employing a
low dose of local anesthetic shortens the recovery period. (f) Anesthesia can be prolonged
when the duration of surgery is uncertain. (g) A definite end point (aspiration of
cerebrospinal fluid) assures that the catheter is in the right place and so enhances the
likelihood of successful anesthesia. (h) Subarachnoid narcotics may be administered during a
surgical procedure or continued into the recovery period to provide long-lasting
postoperative analgesia [7].
The disadvantages of continuous spinal anesthesia are as follows: (a) Additional time is
required to place the catheter in the right place, which may occasionally prove difficult.
(b) Spinal headache is possible. (c) There is a potential for catheter breakage, infection,
nerve trauma, and hemorrhage (these potential complications have, however, rarely been
documented in previous clinical settings). The primary factor that has limited use of
continuous spinal anesthesia is the belief that the large size of available spinal catheters
requiring insertion through large spinal needles will result in an incidence of post dural
puncture headache (PDPH) in young patients that is unacceptable [7].
The Wiley Spinal™ (Epimed; Johnstown, NY) catheter is an innovative flexible cannula over
needle designed for convenient intrathecal access that reduces PDPH [8]. We hypothesized
that using less anesthetics during continuous spinal anesthesia with the Wiley spinal
catheter would offer more hemodynamic stability with less side effects when compared with
continuous epidural anesthesia in patients undergoing TURP. The primary outcome of this
study is the hemodynamic variability between both techniques. Secondary outcomes of interest
are detection of adverse events including early and late neurological complications. Thus
the aim of this prospective randomized study is to compare the efficacy of the continuous
spinal anesthesia using the Wiley spinal catheter and continuous epidural anesthesia in
geriatric patients undergoing TURP.
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Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Treatment
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