[Combined spinal epidural and general anesthesia in abdominal surgery]

Abstract

Almost ten years has past since Eldor described combined spinal-epidural-general anaesthesia (CSEOGA) as a new concept in anaesthesia in which all of these components can be used, with sub-anaesthetic doses of drugs, due to its sinergist effect. The clinics studies has not demonstrated crucial advantages CSEGA comparing with combined epidural-general anaesthesia (CEDGA), in sense of analgesia, pulmonary function and neuro-hormomal inhibition. However we have been routinely practising our technique CSEGA in big abdominal and thoraco-abdominal surgery, since 1997. This study is a retrospective analysis of our technique and clinic observations, during 4.5 years, which include 293 patients. Their demographic characteristics can be seen in table 2. We perform combined spinal-epidural anaesthesia (CSE) in one or two interspinal spaces, depending on the type of surgery, but always before induction in general anaesthesia (GA). For preemptive and intraoperative analgesia we use 0.25% plain bupivacaine (B), both for spinal (SA) and epidural (ED) blockade. The most important detail in our technique, despite precise order to administrate drugs, is analgesic solution (AS) which contain B 4.5 mg, fentanyl (Fe) 50 mcg and morphine hydrochloride (Mo) 0.2 mg, in total volume of 3 ml, in SA. After the ED test dose with 2% lidocaine 60 mg (3 ml), before the induction in GA, we inject more 10 ml B, but intraoperative analgesia is almost performed with B 3 to 5 ml in intermittent bolus doses. This ED bolus dosis is particularly important, partly to sufficiently cephalic migration of the SA somatosensorieblock, as well as for intraoperative analgesia. For very light GA only artificial ventilation with 66% N2O in O2 and muscle relaxation with paneuronium is needed. Co analgesia with intravenous (i.v.) Fe, was exceptionally seldom needed, except for induction. Intraoperative drugs consumption was very small as we see in table 5. With adequate liquid compensation, this technique achieve exceptionally intraoperative homodynamic stability in patients, despite to long and big operations. Postoperative analgesia are supplied by SA the first 24 hours, but the next 72 ours is performed with intermittent ED bolus doses of 0.12% B with 2 mg Mo in total volume of 15 ml and 10 ml, depending on the epidural catheter (EDK) position in lumbar or thoracic part of spine. The break through of postoperative pain was between 20% to 34%, which was suppressed with metamisol. According to the verbal rating scale (VRS < 1) 90% patients were satisfied with this analgesia, which gave possibilities to mobilization and rehabilitation even the first postoperative day. All clinical sings show that thanks to inhibition of spinal and supraspinal sensitization, all principles of the preemptive analgesia (PA), inhibition of neuro-hormonal stress reaction are met and postoperative outcome is improved and satisfied. The complications we had were insignificant, in time observed and without any consequences.