Since the first spinal fusion by Hibbs 1911, yet anesthesia for correction of scoliosis is challenging due to frequently associated co-morbidities, the extensive nature of surgery and liability for many complications. Among the major concerns for anesthesiologists are the pain and bleeding. Scoliosis correction accounts for massive blood loss that may exceed more than half of blood volume. There are many strategies for blood conservation; however sometimes some of them may not be suitable. For analgesia, the most frequently loco regional analgesic techniques in spine surgery are intrathecal, epidural or local infiltration techniques. infiltration data reviled inconclusive and heterogeneous results. Our purpose is to optimize blood conservation and analgesia through anatomically based modification of the infiltration technique.
The most frequently loco-regional analgesic techniques in scoliosis surgery are intrathecal, epidural, caudal morphine, or local infiltrations techniques including ultrasound guided thoracolumbar interfascial plane block. however these techniques possess some limitations in scoliosis surgery. Local anesthetic infiltration was first applied over 35 years ago in lumbar spine surgery as a reliable technique for pain relief. However meta-analysis of data reviled inconclusive and heterogeneous efficacy results.This conflict arise from the differences in the technique and drugs.There are three levels of infiltration; subcutaneous, muscular and perineural. Its timing either pre-incision or post-surgery. Generally the preemptive and deep infiltration offer better analgesia when compared with post-surgical and superficial forms. Different drugs including local anesthetics, epinephrine and adjuvants can be given as a single injection or infusion. Doses and volumes are also different, usually ranging from 10 to 30 ml at a concentration of 0.25% Bupivacaine. the use of epinephrine helps bleeding control Concomitantly, unlike the other techniques, bupivacaine infiltration was combined at three levels in this study; subcutaneous, muscular and neural paravertebral to provide sensory, motor and sympathetic blockade all together. In addition, this drug combination may help to maintain spinal cord perfusion by avoiding deliberate hypotension. The high volume sufficient for proper tissue infiltration combined at three anatomically guided levels for three types of nerves has not been described so far. This research may benefit all spine surgery patients.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
QUADRUPLE
Enrollment
52
* Bupivacaine 0.5% (Astra Zeneca) 2 mg/Kg. * Lidocaine 5 mg/Kg. * Epinephrine 5 mcg/ml of the total volume. * Add normal saline to a total volume of 100 ml/10 cm of the wound length.
normal saline 100 ml/10 cm of the wound length
Mansoura University Hospital and Delta Hospital
Al Mansurah, Dakahlya, Egypt
Estimated blood loss
milliliter
Time frame: Intraoperative
Total Morphine consumption.
milligram
Time frame: during first 24 hours postoperatively.
The surgical field visualization for subcutaneous incision
measured by Fromme's operative visibility scale (0-5) ,5: Massive uncontrollable bleeding, Surgery impossible. 4: Heavy but controllable. 3: Moderate bleeding , 2: Moderate bleeding but without interference with accurate dissection. 1: Bleeding, so mild, No suctioning. 0: No bleeding,
Time frame: Intraoperative, 10 minutes after skin incision.
The surgical field visualization for muscular dissection
measured by Fromme's operative visibility scale (0-5) ,5: Massive uncontrollable bleeding, Surgery impossible. 4: Heavy but controllable. 3: Moderate bleeding , 2: Moderate bleeding but without interference with accurate dissection. 1: Bleeding, so mild, No suctioning. 0: No bleeding,
Time frame: Intraoperative, 30 minutes after the thoracolumbar fascia incision,
The surgical field visualization for nails insertion
measured by Fromme's operative visibility scale (0-5) ,5: Massive uncontrollable bleeding, Surgery impossible. 4: Heavy but controllable. 3: Moderate bleeding , 2: Moderate bleeding but without interference with accurate dissection. 1: Bleeding, so mild, No suctioning. 0: No bleeding,
Time frame: Intraoperative, 30 minutes after the first nail insertion.
The surgical field visualization for osteotomy
measured by Fromme's operative visibility scale (0-5) ,5: Massive uncontrollable bleeding, Surgery impossible. 4: Heavy but controllable. 3: Moderate bleeding , 2: Moderate bleeding but without interference with accurate dissection. 1: Bleeding, so mild, No suctioning. 0: No bleeding,
Time frame: Intraoperative, 20 minutes after the first osteotomy
The operative duration
minutes, from the start of anesthesia induction to extubation times
Time frame: Intraoperative
The number of blood transfusion unites.
unites of packed red blood cells
Time frame: intraoperative
Nitroglycerin consumption
milligram
Time frame: Intraoperative
Fentanyl consumption
microgram
Time frame: intraoperative
Atracurium consumption
milligram
Time frame: intraoperative
Propranolol consumption
milligram
Time frame: intraoperative
Mean blood pressure (MBP)
millimeter mercury
Time frame: basal, 5 minutes after the onsite of infiltration, 3 minutes after the onsite of skin incision, then after 30, 60, 90, 120, 150, 180, 210, 240, 270, 300 minutes from the start of anesthesia.
Mean heart rate (HR)
beats per minute
Time frame: basal, 5 minutes after the onsite of infiltration, 3 minutes after the onsite of skin incision, then after 30, 60, 90, 120, 150, 180, 210, 240, 270, 300 minutes from the start of anesthesia.
Inhalational isoflurane concentration
percent
Time frame: intraoperative: at 30, 60, 90, 120, 150, 180, 210, 240, 270, 300 minutes from the start of anesthesia induction.
The number of hypertensive episodes
defined as more than 25% rise of MBP than the basal, provided as total number
Time frame: intraoperative
The number of tachycardic episodes
defined as more than 25% rise of HR than the basal, provided as total number
Time frame: intraoperative
Ephedrine consumption
milligram
Time frame: intraoperative
The total amount of fluid utilization.
milliliter
Time frame: intraoperative
Visual analog score
scale (0-10), 0= no pain
Time frame: postoperative at 1,4,8,12,16, 20, 24 hours
the time to first analgesic request
minutes
Time frame: postoperative for 24 hours
Opioid request episodes
number
Time frame: postoperative for 24 hours
Ambulation time
hours to the time of first standing alone after the operation.
Time frame: postoperative, the first test after 12 hours, then every 8 hours, up to 72 hours.
Hospital stay
days until the discharge time with the ability to walk, eat, controlled pain.
Time frame: postoperative, till the time of signed discharge order. up to 10 days
the Incidence of wound complications.
infection, dehiscence, seroma, hematoma, bleeding
Time frame: postoperative till 2 weeks
Surgeon satisfaction with the operative filed
score (0-10), 10 is the best
Time frame: within 2 hours from the end of operation
Patient satisfaction with analgesia
score (0-10), 10 is the best
Time frame: 24 hours after the end of surgery
Urine output
milliliter
Time frame: intraoperative
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