Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery

Abstract

Background Limited studies have applied thoracic continuous spinal anesthesia in abdominal surgery, relying exclusively on opioids. This retrospective study analyzes 2 different schemes of thoracic continuous spinal anesthesia and postoperative analgesia in elderly patients undergoing major abdominal surgery. Methods A total of 98 patients aged ≥ 75 years were divided into 2 groups. The control group (60 patients) received bupivacaine plus fentanyl, whereas the study group (38 patients) received bupivacaine plus ketamine and midazolam. Both received analogous postoperative continuous intrathecal analgesia. Several perioperative variables were evaluated. Results Spinal anesthesia was performed without complications in all patients. Doses of noradrenaline administered, incidence of respiratory depression, need for intraoperative sedation, and time to first flatus were significantly reduced in the bupivacaine plus ketamine and midazolam group. Conclusion In a population of frail, elderly patients, thoracic continuous spinal anesthesia with local anesthetic plus midazolam and ketamine was superior to local anesthetic plus fentanyl. In the group receiving local anesthetic plus midazolam and ketamine, the incidence of respiratory depression was reduced, and doses of norepinephrine and intraoperative sedating medications were lower. Intraoperative anesthesia and postoperative analgesia were similar in both groups.

Opioid-Free Segmental Thoracic Spinal Anesthesia with Intrathecal Sedation for Breast and Axillary Surgery: Report of Four Cases

“…Therefore, as reported in our previous work on TCSA, we developed a technique that allows sparing of the neuraxial opioid, replacing it with other adjuvants, specifically midazolam and ketamine, 13 whose benefits consist in improved duration and quality of spinal anesthesia, with reduced onset time of the sensory-motor blockade and delayed recovery time of the sensory block leading to enhanced perioperative analgesia, together with a mild intraoperative sedation and a decreased incidence of PONV without negative effects on perioperative hemodynamics, significant side effects and neurotoxicity, though only limited evidences exist in literature. 24–26 …”

“…Lastly, the delivery of the anesthetic directly at the required level of the body allows to perform a highly selective neuraxial blockade, with a rapid onset of action, a reduced dose of local anesthetic required and a limited caudal spread with concomitant minor vasodilation and risk of hypotension, representing all described benefits of this method compared to lumbar anesthesia. 12 , 13 , 29 …”

Double neuraxial catheter (Subarachnoid and epidural) in obese patient cancer surgery: A case report

“…For some time, it has been seen that the single Continuous Thoracic Spinal or Peridural Anesthesia without resorting to tracheal intubation, therefore subjected to simple light sedation, is a valid alternative to general anesthesia in high-risk older patients undergoing major abdominal surgery [ 19 ]. But the idea of the double neuraxial catheter is linked to the intra and perioperative management of obese pregnant women who are candidates for caesarean section.…”

Awake Major Abdominal Surgeries in the COVID-19 Era

“…Unfortunately, only a few case reports and even fewer case series deepening the influence of RA on the outcomes after acute care surgery are available [ 15 – 18 ]. As known, RA techniques slightly differ from institution to institution [ 19 , 20 ]. This impedes the standardization of the technique and limits the comparison between different studies.…”