Abstract
When it is indicated for surgical procedures below the umbilicus in our low-resource countries, spinal anaesthesia has many advantages: it is simple, cheap, safe and easy to learn and carry out. It reduces nursing load and the risk of aspiration pneumonitis as well as overall postoperative mortality and morbidity. We prospectively carried out a study of 419 patients operated under spinal anaesthesia during our normal surgical activities. Despite the materials and conditions that were not always those recommended in the published literature, we had very satisfactory results with: (1) a high patient acceptance rate (93.9%); (2) relatively rare adverse effects – the most frequent being hypotension and vomiting each observed in seven (1.67%) patients. We had two cases (0.48%) of the rare cauda equina syndrome. In poor-resource countries, the culture of spinal anaesthesia should be better developed and encouraged by the training institutions.
Introduction
Spinal anaesthesia is a simple, cheap, easily accessible and safe method of providing anaesthesia for surgical operations below the umbilicus. However, it is not as widely used as it should be. It seems to be used more often than general anaesthesia by visiting overseas colleagues than by the African surgeons. 1
We report on a prospective study of the use of spinal anaesthesia in referral hospitals in the Côte d'Ivoire and stress the necessity of popularizing this regional anaesthetic method for surgery below the umbilicus in developing countries with poor resources.
Materials and methods
Study population
Our study concerns a series of consecutive surgical procedures (not including obstetrical and gynaecological cases) below the umbilicus carried out under spinal anaesthesia in 419 patients between February 1997 and March 2005 mainly by two referral hospitals in the Côte d'Ivoire (the regional referral hospital at Daloa and the general hospital of Abobo North on the outskirts of Abidjan). Some cases came from two private clinics in Daloa and Abidjan. Abidjan is the largest city and Daloa the third largest city in the Côte d'Ivoire.
Administration of spinal anaesthesia
The recommended standard method of administration of spinal anaesthesia usually starts with a preoperative visit. At this visit, the technique is explained to the patient (for example, spinal anaesthesia removes the pain but the patient may be aware of some feeling in the operation site, weak legs, etc.). The patient is psychologically prepared for this and consent is obtained.
Spinal anaesthesia is carried out in the induction room or on the operating table. It can be done with the patient in either the lateral or the sitting position. In either case, the back must be well flexed, eventually with the help of an assistant especially in the sitting position when the body should neither be twisted nor bent to one side. The patient's vital signs (blood pressure, pulse and respiratory frequency) are recorded, a reliable intravenous access with a large intravenous cannula is secured and an intravenous preloading with normal saline is carried out. Resuscitation equipment should be available. The operator should scrub up and be gloved as for any other aseptic procedure. The patient's back is correctly cleansed with an antiseptic solution, a suitable interspace between L3 and S1 is located and the area is preferably infiltrated with the local anaesthetic using a hypodermic needle. The lumbar puncture is performed with a 24–27-gauge, pencil tip spinal needle and the correct amount of anaesthetic solution is injected. After the removal of the needle, the lumbar puncture site is dressed and the patient is positioned in the position for the surgical procedure.
The local anaesthetic of choice is bupivacaine, however lidocaine can be used. Fentanyl can be advantageously added to the anaesthetic for the spinal injection.
The assessment of the block is made either by assessing the patient's inability to lift the legs from the table or the bed (the method we used), by a loss of temperature sensation using a swab soaked in either ether or alcohol or by assessing any loss of sensation by pricking the skin with a needle.
In this series
In this series, the standard method of administering spinal anaesthesia was not strictly adhered to because of a lack of materials and a heavy workload as will be explained later.
Each patient's opinion on the spinal anaesthesia was sought either during the operation and/or at the end of surgery or, much more rarely, during the postoperative follow-up visits.
Results
The large majority of our patients were men (395 or 94.3%) with only 24 women (5.7%), giving a male:female ratio of 16.5:1. The age of the patients (n = 418) was from 18 to 87 years with an average of 49.0 years. Their physical status was either ASA I (381, 90.9%) or II (38, 9.1%). They were operated for a variety of procedures below the umbilicus with herniorrhaphy (65.4%) being the most predominant (Table 1).
The operations carried out (55 patients underwent two procedures each)
*Includes 31 strangulated cases which were reduced in emergency and operated electively
†Others are: cyst of the cord (2); extraction of a mesh used earlier for the repair of a recurrent inguinal hernia; resection of intestinal bands (obstruction); rectal prolapse (2); and knee arthrotomy
Lidocaine alone or, much more rarely, associated with adrenaline was used in 249 cases (76.9%) and bupivacaine in only 75 cases (23.1%). The time taken to prepare the local anaesthetic and inject it through a lumbar puncture was from 2–36 min (n = 341) with an average of 6.8 min. The motor block (n = 327) set in 1–30 min (average 5.3 min) after the injection of the anaesthetic and lasted from 50–1260 min (n = 217), with an average of 235.3 min. For lidocaine and bupivacaine the motor block set in, on the average, after 4.1 and 5.7 min (ranges 1–8 and 3–30 min), respectively. The block lasted for an average of 151.9 and 507.4 min, respectively (ranges 50–354 and 130–1260 min, respectively). The time to prepare a patient for surgery with spinal anaesthesia was on average 12.1 min (6.8 + 5.3 min). During the period of this study the time to prepare 30 randomly chosen control patients for surgery under general anaesthesia was 4–15 min (average 9.1 min) without intubation (15 patients) and 6–20 min (average 12.8 min) with intubation (15 more patients).
For a follow-up of up to four years (for about 45%) the side-effects and complications were relatively rare in this series given our conditions of work (Table 2).
Adverse events
*Three deaths: at day1 (a 74-year-old ASA II prostatectomy for BPH); day 9 (a 40-year-old inguinal herniorrhaphy with appendicectomy); and day 16 (a 43-year-old inguino-scrotal herniorrhaphy who died of enterocutaneous fistula) – the last two apparently did not die as a result of the spinal anaesthesia
Of the 359 patients whose opinion was recorded, 337 (93.9%) preferred spinal anaesthesia to general anaesthesia and only 22 (6.1%) opted for the latter.
Fifty-four had already undergone one or more surgical procedures under general anaesthesia. Fifty-two (96.3%) of these preferred the use of spinal anaesthesia to general anaesthesia.
Discussion
This paper does not aim to compare general anaesthesia with spinal anaesthesia or replace the former with the latter. Each has its own indications and general anaesthesia remains more widely used than any other form of anaesthesia because of its adaptability. Our aim is to encourage the greater use of spinal anaesthesia when it is indicated for surgery below the umbilicus, particularly in developing countries with poor resources. In such a setting spinal anaesthesia has many advantages: it is cheap, simple, easy to learn and easy to carry out. 2–9 There are fewer problems with respiratory function and airway management as long as unduly high blocks are avoided. 3,5 It also leaves the patient conscious and the airway open, thereby decreasing the risk of aspiration pneumonitis 2–4 and reducing the nursing load and the need for postoperative observation. 5,9 In addition, it also allows an immediate return to oral intake, particularly for diabetic patients. 3,9
Postoperatively, it better preserves lung volumes (measured by spirometry) in patients, especially the obese. 10 It also avoids cross-infection and the contamination of inhalation anaesthetic circuits when dealing with patients with respiratory infections such as pulmonary TB and bronchiectasis. 5 In addition, there are high patient satisfaction rates. 3,4,8 Perhaps most important of all, it reduces the overall postoperative mortality and morbidity with relatively few adverse effects which are generally not life-threatening 11 and are the source of case reports or reports on series involving small numbers. 2,12–14
Spinal anaesthesia has these advantages without apparently increasing the stress response of patients compared to general anaesthesia 15 and seemingly without unduly prolonging the time taken to prepare them for surgery. In our study, on average the time for spinal anaesthesia was 12.1 min and for general anaesthesia 9.1 min without intubation and 12.8 min with intubation. Published literature for spinal anaesthesia report times of 10–15 min 4,16 and for general anaesthesia without intubation an average of 8.5 min. 4
The ideal conditions for spinal anaesthesia are now better understood. 3–5 Even allowing for a lack of all these ‘ideal’ conditions we still had very few adverse effects (Table 2) and a high patient acceptance rate (93.9%). Only 22 (6.1%) of the 359 patients preferred general to spinal anaesthesia. These figures are in the range of the high patient satisfactory rates found in the literature (90–100%). 4,8 Fifty-two (96.3%) of our 54 patients who had already gone through surgery preferred spinal to general anaesthesia.
The main problems encountered can be divided into lack of materials and a heavy workload. The lack of materials included an absence of: sterile gloves; ‘atraumatic spinal’, pencil point type needles for the lumbar puncture; the use of lignocaine alone or with adrenaline; and an absence of fentanyl. A heavy workload also caused problems such as: an absence of an adequate prior psychological preparation for the patients; a failure to fill in all the data for a ‘prospective’ work; a dependence in some cases on the patients and relations for indications of when the spinal anaesthesia effect had ended; and the fact that we could only use one of the teams of the different surgery departments in the hospitals involved.
In the light of these setbacks, it would be interesting to carry out similar observations on a wider scale and on a more exhaustive level (more data determined and investigated) in order to arrive at more reliable conclusions. These conclusions could help the academic authorities to ensure that spinal (and other local) anaesthesia techniques are included in the training curriculums. They could also be used to convince the administrative and political authorities to make the products for spinal anaesthesia more readily available. In turn, it will reduce costs and reduce the nursing load of our presently overworked and understaffed personnel.
Deaths from anaesthesia are understandably more frequent in developing countries than in the developed world. 2,6 Meo et al. state that ‘in developing countries the anaesthesia is as dangerous as the surgery’. 6 All these stress the urgent necessity of reducing such deaths by, among other measures, a wider use of spinal anaesthesia when it is indicated for surgery below the umbilicus. In our poorly developed countries where conditions of health services can sometimes be amazingly far away from the ‘ideal’ situations of the developed world, 2,6,7 every effort should be made in the training institutions and programmes so as to guide nurse anaesthetists and paramedics (who perform most of the anaesthesia) 1,7 and surgeons into the culture of spinal anaesthesia as well as render them capable of performing it.
Conclusion
When it is indicated for surgery below the umbilicus, particularly in resource-poor developing countries, spinal anaesthesia has many advantages and very few adverse effects. In these circumstances, spinal anaesthesia can be said to be tailored to the situation in developing countries where conditions of the health services can sometimes be amazingly far away from the ‘ideal’ situations in the developed world.
Even without having all the ideal conditions required for spinal anaesthesia, we were able to obtain reassuring and gratifying results. Our results, together with those of similar series from developing countries, should encourage practitioners from such places to popularize spinal anaesthesia when it is indicated for surgery below the umbilicus.