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      Frequent Spinal Anesthesia in a Patient with Traumatic Lower Extremity Injury: A Case Report

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          Abstract

          Introduction

          Spinal anesthesia is a commonly used anesthetic technique for lower extremity surgery. Despite its widespread use, the acceptable frequency of repeated spinal anesthesia for a patient is unclear. Therefore, herein, we report a patient who frequently received spinal anesthesia.

          Case Presentation

          A 21-year-old man with severe head and leg injury was admitted to the hospital after a motorcycle accident. On admission, he had a tracheal tube and GCS score of six. After emergency vascular and orthopedic surgeries under general anesthesia, he was transported to the ICU. Within 12 days of admission to the ICU, he was extubated with full awareness. After consultation with a neurosurgeon for spinal anesthesia, the patient received seven spinal anesthesia procedures for his lower extremity injury in a period of 15 days. Spinal anesthesia was performed at the L3 - L4 or L4 - L5 interspace with 24 or 25-gauge Quincke needles in the sitting position (12 - 15 mg of 0.5% hyperbaric bupivacaine) by four anesthesiologists. Despite performing several spinal anesthesia procedures, no neurologic sequelae were observed. Finally, he was discharged in a good overall condition. At a four-month follow-up, the patient was in a stable situation without any neurological complications.

          Conclusions

          This report emphasizes that spinal anesthesia with hypertonic bupivacaine could be used several times for a patient in some situation.

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          Most cited references10

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          Comparative addition of dexmedetomidine and fentanyl to intrathecal bupivacaine in orthopedic procedure in lower limbs

          Background Spinal block is a common procedure for lower limbs surgery. Fentanyl, a synthetic opioid and dexmedetomidine, a selective α2 agonist have been used as adjuvants in spinal anesthesia to prolong intraoperative and postoperative analgesia. The aim of current study is to compare the efficacy of dexmedetomidine and fentanyl added to intrathecal bupivacaine in orthopedic procedures in lower limbs. Methods In this randomized clinical trial, 90 patients undergoing elective lower limb surgeries were randomly allocated to three groups. Via intrathecal approach, the patients received 2.5 ml hyperbaric bupivacaine 0.5% plus 5 micrograms dexmedetomidine (BD group), 25 micrograms fentanyl (BF group) or 0.5 ml normal saline (BN group), respectively. Time to reach the complete motor block, the highest sensory level, regression from block, analgesic request and duration of the drug effect, hemodynamic changes and side effects were compared between the groups. Results There was no significant difference between the groups regrading time to reach complete motor block, but time to reach the highest sensory level was shorter in group BD than group BF (6.28 ± 1.75 vs. 7.17 ± 1.45, p = 0.03). Group BD had significantly lower mean of NRS 6 h after operation (1.90 ± 0.84 vs. 6.16 ± 1.44 vs. 6.30 ± 1.17, p < 0.001) and longer duration to regress to Bromage 0 (331.60 ± 73.96 vs. 185.56 ± 35.87 vs. 147.03 ± 33.05 min, p < 0.001), to analgesic request (496.63 ± 70.19 vs. 296.33 ± 44.83 vs. 221.83 ± 22.26 min, p < 0.001), to regress two sensory levels (149.00 ± 23.17 vs. 88.90 ± 12.85 vs. 69.33 ± 6.67 min, p < 0.001) and to regress to S1 (560.53 ± 81.86 vs. 329.83 ± 44.10 vs. 241.83 ± 22.26 min, p < 0.001). Serial changes in SBP (p = 0.006), DBP (p = 0.03) and HR (p = 0.002) in group BF were significantly higher than the other two groups. The three groups had comparable side effects. Conclusions Using dexmedetomidine as an adjuvant to bupivacaine for spinal anesthesia in lower limb surgeries has longer duration of sensory and motor block and longer postoperative analgesia. Trial registration IRCT registration number: IRCT2017041010599N15, 24 May 2017.
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            The centennial of spinal anesthesia.

            H Wulf (1998)
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              Comparison of Adding Sufentanil and Low-Dose Epinephrine to Bupivacaine in Spinal Anesthesia: A Randomized, Double-Blind, Clinical Trial

              Background Spinal anesthesia, as an effective approach, is widely performed in various surgeries with possible complications. To reduce the side effects, many adjuvants are used to maintain desirable sensory and motor blockades and increase the quality and prolong the analgesia. Methods In the current double-blind, randomized clinical trial, 105 participants aged 18 - 60 years with ASA class I or II who were candidate for lower limb surgery were randomly allocated to patients receiving bupivacaine 15 mg + normal saline 1 mL (B group), bupivacaine 15 mg + epinephrine 10 µg (BE group), and bupivacaine 15 mg + sufentanyl 5 µg (BS group). Onset of sensory blockade was determined bilaterally with the pinprick test. The maximum Bromage scale was assessed for the onset of motor blockage. Recovery from sensory and motor blockades was also evaluated. Pain score (visual analogue scale; VAS) was determined for all participants. Results Onset of sensory and motor blockades was statistically different among the groups. Intrathecal bupivacaine (the placebo group) had the lowest onset of sensory blockage, whereas the onset of motor blockade was significantly shorter with the administration of sufentanil + epinephrine (P = 0.001) (BS and BE groups). However, epinephrine (BE group) did not significantly prolong sensory and motor blockade. Recovery time from sensory and motor blockade was significantly lower with the bupivacaine alone (the placebo group). Conclusions The current study results suggested that the combination of 10 µg epinephrine and 5 µg sufentanil + bupivacaine did not prolong the sensory and motor blockades in spinal anesthesia for lower limb surgery, compared with bupivacaine alone.
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                Author and article information

                Contributors
                Journal
                Anesth Pain Med
                Anesth Pain Med
                10.5812/aapm
                Kowsar
                Anesthesiology and Pain Medicine
                Kowsar
                2228-7523
                2228-7531
                12 March 2019
                April 2019
                : 9
                : 2
                : e88595
                Affiliations
                [1 ]Department of Anesthesiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
                [2 ]Department of Orthopedic Surgery, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
                Author notes
                [* ]Corresponding Author: Department of Anesthesiology, Basat Hospital, Hamadan University of Medical Sciences, Shahid Fahmedeh St., Postal Code: 6514845411, Hamadan, Iran. Tel: +98-9181110366, Email: manuchehriann@ 123456gmail.com
                Author information
                https://orcid.org/0000-0002-0025-9771
                https://orcid.org/0000-0002-0151-5888
                https://orcid.org/0000-0003-1063-8537
                Article
                10.5812/aapm.88595
                6614781
                ff886f5c-4e79-4aab-a436-f121085f7066
                Copyright © 2019, Author(s)

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

                History
                : 01 January 2019
                : 14 February 2019
                : 27 February 2019
                Categories
                Case Report

                anesthesia,spinal,bupivacaine,lower extremity
                anesthesia, spinal, bupivacaine, lower extremity

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