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4COMPARATIVE EVALUATION OF THE HEMODYNAMIC EFFECTS OF SPINAL ANESTHESIA DEPENDING ON THE POSITION OF THE PATIENT AFTER THE ADMINISTRATION OF A HYPERBARIC SOLUTION OF BUPIVACAINE TO PATIENTS WITH ESSENTIAL
HYPERTENSION Matlubov M. M.1, Nematulloev T. K.2
1Matlubov Mansur Muratovich - Doctor of Medical Sciences, Associate Professor,
Head of the Department of Anesthesiology, Nematulloev Tukhtasin Komiljonovich - free of applicants,
DEPARTMENT OF ANESTHESIOLOGY, RESUSCITATION AND EMERGENCY
MEDICINE, SAMARKAND STATE MEDICAL UNIVERSITY, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: relevance of the topic: Arterial hypotension is one of the frequent complications during spinal anesthesia. In this regard, the position of the patient may influence the incidence of arterial hypotension. In this study, we assessed the effect of 1- and 2-minute sitting and immediate laying down after local anesthetic administration on the incidence of hypotension. For examination, 72 patients with concomitant hypertension at stages 1 and 2 were selected, who underwent a planned operation in the colo-proctological area due to chronic expansion of hemorrhoids. Patients were divided into 3 groups randomly, 24 in each group. Groups A1 and A2 remained in a sitting position for 1 and 2 minutes after spinal anesthesia, respectively, and group B was immediately placed in a horizontal position. Systolic, diastolic and mean arterial pressure, as well as heart rate, were recorded 1, 2, 3 and 5 minutes after spinal anesthesia, every 5 minutes during the first 30 minutes of the operation and every 10 minutes until its end. A P value < 0.05 was considered statistically significant. Results: the incidence of arterial hypotension was 50 (69%) of the total number of patients. Of these, 40 (55%) cases of hypotension occurred in group B compared with groups A1 and A2 in the first 5 minutes after spinal anesthesia. Conclusions: The study showed that a 1-2-minute sitting position after spinal anesthesia with hyperbaric bupivacaine solution during elective colo -proctological operations leads to greater hemodynamic stability compared with the immediate transfer of the patient to a horizontal position.
Keywords : spinal anesthesia, hypertension, arterial hypotension, hyperbaric solution of bupivacaine.
Introduction
Spinal anesthesia has been considered an effective method of anesthesia for colo-proctological operations for over 100 years. The advantage of this method is the absence of complications from the respiratory system and the patient's wakefulness during the operation (1,2,3,4). This method is simple and fast to use and is considered a reliable and economical option, especially when compared to epidural anesthesia (3,4). However, patients have more severe hypotension due to a wider distribution of
the local anesthetic in the subarachnoid space, decreased sympathetic tone may exacerbate hypotension (1,3). There are many different methods to prevent arterial hypotension, including the introduction of fluids, vasopressors, compresses of the lower extremities. Although the incidence of hypotension is reduced by these strategies, it is still a common side effect of spinal anesthesia (5-7). Some studies have shown that the position of the patient during or after spinal anesthesia may affect the incidence of hypotension (8, 9, 10). Spinal anesthesia can be administered to the patient in a sitting or supine position (left, right or Oxford). However, turning patients into a lateral position after anesthesia can be difficult, especially among women with a high body mass index; as a result, a change in position may pose a danger to the patient's condition. In addition, it is technically easier to insert the needle while the patient is seated (10, 11); therefore, the sitting position may be preferred by many anesthesiologists (9, 10, 11, 12).
According to the literature, laying the patient in the supine position after anesthesia can direct the local anesthetic to the head and increase the blockade of the thoracic dermatome . Therefore, allowing the patient to remain seated instead of lying down immediately can delay the onset of anesthesia and reduce the incidence of hypotension (11,15,16,17,18).
Objective: In this clinical study, we compared the incidence of hypotension after spinal anesthesia with 12.5 mg hyperbaric bupivacaine 0.5% plus 5 ^g fentanyl in 3 groups. Groups A1 and A2 were in a sitting position for 1 and 2 minutes after the administration of spinal anesthesia, respectively, and group B was immediately placed in a horizontal position after administration of local anesthetic.
Methods
For the study, 72 patients were selected who underwent spinal anesthesia (January 2019 - February 2020; SamMI Clinic No. 1) for operations in the colo-proctological zone (for chronic hemorrhoids of 2-3 degrees). All patients were classified according to the ASA scale into II and III risk groups at the age of 45-60 years. Patients with complicated forms of hypertension (grade 2-3 arterial hypertension, cardiac arrhythmia, hyperthyroidism, diabetes mellitus, history of allergic reactions, heart failure) were excluded from the study. Premedication of patients was carried out according to the scheme: on the night before - diazepam 2.5 mg, in the morning on the day of surgery - 2-3 hours before the operation, diazepam - 5 mg, 30 minutes before the operation - atropine 0.1% 1 ml / m and diphenhydramine 1% 1 ml / m.
Spinal anesthesia was performed with a 25-gauge Quincke needle in the interval L3 - L4, along the midline in the sitting position. 12.5 mg hyperbaric bupivacaine plus 5 ^g (0.1 ml) fentanyl administered over 10-12 seconds was used.
Patients were randomly divided into 3 groups: A1, A2 and B. Groups A1 and A2 were in a sitting position after spinal anesthesia for 1 and 2 minutes, respectively. Patients in group B were immediately transferred to a horizontal position after induction of anesthesia.
Systolic blood pressure (SBP), heart rate, mean arterial pressure ( MAP ), and O2 saturation (SpO2) were recorded 1 minute before (baseline) and 1, 2, 3, and 5 minutes after spinal anesthesia was administered. Thereafter, measurements were taken at 5-minute intervals during the first 30 minutes of the operation and then every 10
minutes until the end of the operation. Side effects (itching, nausea, dizziness, bradycardia) and the need for vasopressors have also been reported.
Motor block was assessed using the Modified Bromage Scale 15 minutes after induction of spinal anesthesia (3, no movement; 2, ability to flex only the ankle and foot; 1, ability to flex the knee; and 0, no block and ability to elevate the limb). Hypotension (SBP < 90 mm Hg or decrease in SBP less than 20% of baseline) was treated with intravenous mezaton solution. When patients complained of pain during the operation, 50 ^g of fentanyl was administered intravenously. Nausea, not associated with arterial hypotension, was stopped by the introduction of 10 mg of metoclopramide bolus .
Statistical processing of the obtained data was carried out by the method of variation statistics using Student's t-test. Data are presented as mean ± standard deviation. A P value of less than 0.05 was considered statistically significant.
Results
The study examined the course of spinal anesthesia in 72 patients. They were divided into 3 groups ( n = 24). Demographic and anesthetic characteristics of the study groups are presented in Table 1.
Table 1. Demographic and anesthetic characteristics of the study
Variables Group B Group A1 Group A2 R
Weight, kg) 75.75±7.85 82.91±1.4 77.17±6.62 0.237
Age (year) 48.6±5.5 48.7±5.1 49.5±5.2 0.55
Height (cm) 157.8±5.4 159±7.1 161.3±2.3 0.51
Duration of operation (min) 40±9.17 45.42±16.9 44±14.16 0.64
Volume of crystalloids (l) 1.5±0.02 1.2±0.3 1.3±0.25 0.62
Need for mezatone (mg) 2.2±0.15 4.1 ± 0.2 3.6±0.3 0.15
Motor blockade on the Bromage scale was assessed 15 minutes after the induction of anesthesia, and in all groups by this time it had reached 3 points on the scale (no movements). For blood pressure maintenance, more mezatone was used in group B compared to groups A1 and A2 (Table 1).
There was a significant difference in the incidence of hypotension in the first 5 minutes of surgery between group B and groups A1 and A2 (P = 0.03 and P = 0.001, respectively) (Table 2).
Table 2. Hemodynamic characteristics ofpatients in stages of the study hypotension Group B ( Group B ( Group B ( General R
n = 24) n = 24) n = 24)
During the 22 (92%) 16 (66%) 12 (50%) 50 (69%) 0.007
operation
Within the first 5 minutes 20 (83%) 12 (50%) 8 (33%) 40 (55%) 0.002
after the
administration of the
anesthetic
Compared to baseline, SBP decreased in all groups after induction of spinal anesthesia, and there was no significant difference in SBP over time between groups (P > 0.05) (Figure 1).
CHANGE SBP DURING SURGERY
160
Fig. 1. Systolic blood pressure in groups of the study
In group B, SBP significantly decreased from baseline after local anesthetic induction during the first 5 minutes: 1 minute (P = 0.02), 2 minutes (P = 0.04), 3 minutes (P = 0.03) and 5 minutes (P = 0.001) as well as in the subsequent minutes of the operation. In group A1, there was no significant difference at 1 minute post-anesthesia compared to baseline SBP. A significant decrease in SBP (P = 0.018) began from 2 minutes after anesthesia and lasted: 3 minutes (P = 0.006) and 5 minutes (P = 0.001), 5-30 minutes (P = 0.001) and in the next 30-60 minutes of surgery (P = 0.001).
In the A2 group, there were no significant changes in SBP compared to baseline at 1 and 2 minutes after anesthesia. A significant decrease from baseline was recorded at 3 minutes (P = 0.001) and 5 minutes (P = 0.001) after spinal anesthesia . As well as 5-30 minutes of surgery (P = 0.00) and last 30-60 minutes of surgery (P = 0.001).
Significant changes in heart rate were found between groups at 1 and 2 minutes after spinal anesthesia. Heart rate was higher in group B compared to groups A1 and A2 (P = 0.02 and P = 0.007).
Discussion
Hypotension is one of the most common complications of spinal anesthesia. The effects of various methods to reduce this complication have been investigated previously (5, 6). A number of studies have examined the effect of patient position
during or after spinal anesthesia, although there have been conflicting results (8-15). The current study showed that the incidence of hypotension in the first 5 minutes after spinal anesthesia was significantly lower in patients who remained in a sitting position for 1 -2 minutes compared to those who were immediately placed in a supine position. The need for vasopressors was lower in patients who were in a sitting position for the first 1-2 minutes after anesthetic administration. Conclusions
The present study showed that the position of the patient is an important factor influencing the incidence of hypotension and the onset of sensory-motor block during elective spinal anesthesia. According to the results of the study, keeping patients in a sitting position for 1 or 2 minutes after spinal anesthesia, compared with immediate transfer to a horizontal position, can reduce the incidence of hypotension and the use of vasopressors in the first 5 minutes after anesthetic administration.
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