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Haemodynamic Effects and Quality of Intrathecal Block in Lateral Decubitus Position using 25GÂ Whitacre versus 25G Quincke Spinal Needles- AÂ Cohort Study
Correspondence Address :
Dr. Shivani Rathee,
Tower-C, Heritage Max, Sector-102, Gurugram, Haryana, India.
E-mail: vp.ratheeclinic@gmail.com
Introduction: Various attempts have been made to manipulate the needle designs to counter the adverse effects (hypotension, postdural puncture headache) of spinal anaesthesia. This includes the modification of the tip, the location of the orifice, the length and material of the needle.
Aim: To access if a whitacre needle is a better substitute than the classical commonly used, Quincke spinal needle along with intraoperative haemodynamic changes and quality of intrathecal block.
Materials and Methods: The present study was a hospital-based cohort study which included 100 patients in the age group of 20-50 years, who belonged to American Society of Anaesthesiologists (ASA) grade of I and II, and were operated for lower abdominal and lower limb surgeries under spinal anaesthesia. They were assigned into two groups A and B, wherein group A, 25G Whitacre and in Group B, 25G Quincke needles were used respectively. The primary outcome measures were the differences in the incidence of hypotension, bradycardia, and quality of sensory and motor blockade in the two groups. The t-test and Chi-square test were used. Statistical calculations were done using Statistical Package for the Social Science (SPSS) 21.0 version.
Results: There was a noteworthy drop in the blood pressures {Systolic blood pressure (SBP), Diastolic blood pressure (DBP), and Mean Arterial Pressure (MAP)}, but the variance between the two needle groups was statistically insignificant (p>0.05). There was no statistically significant difference between the two needles group to the quality of intrathecal block. Sensory block onset in group A (83.08±12.26 seconds), group B (81.42±17.81 seconds) with p-value 0.410. The mean Bromage score in group A (2.90±0.30), group B (2.88±0.33).
Conclusion: Both the needles provided excellent sensory and motor blockade and haemodynamic steadiness.
Haemodynamic, Motor and sensory blockade, Spinal anaesthesia, 25G Whitacre and quincke spinal needle
The selection of the anaesthetic procedure depends upon surgical requirements and the patient’s concerns. There are various anaesthetic techniques which includes general, regional and local anaesthesia (1). Spinal Anaesthesia (SA) is the inoculation of a Local Anaesthetic (LA) into the subarachnoid (or intrathecal) space using a needle, thus after diluting with the Cerebrospinal Fluid (CSF) creating a conduction blockade of the spinal nerves. The resultant nerve block is required for surgical anaesthesia and the level is attained as per the site of surgery. The benefits of this technique are well aware of. It’s economical, simple, and does not require any refined equipment (2).
Different designs and sizes of the needle are available based on the concept of anatomy and physiology of the CNS. This aids us in reducing the problems of spinal anaesthesia. Various efforts have been made to design the needle to counter the adverse effects of the subarachnoid blockade. This includes the alteration of the tip, location of the orifice, length and material of the needle. In various studies, compared cutting and pencil point spinal needle effect on frequency of Post Dural Puncture Headache (PDPH) and on haemodynamics (3),(4). The present study focuses on haemodynamic effect, level of sensory and motor blockade rather than postdural complications. There is less data on different needle shape effect on level of sensory, motor blockade. So, this study attempted to compare the 25G Quincke and 25G Whitacre needles for changes in the haemodynamics, level of sensory and motor blockade after giving spinal anaesthesia.
This was a hospital-based cohort study, done in the Department of Anaesthesiology, MMIMSR, Mullana, Ambala, Haryana, India. The study period was two years, from December 2018 to December 2020. Informed consent was taken from the participants, and the Institutional Ethical Committee (IEC-1199) approval was obtained.
The patients were divided into two groups of 50 cases each- odd number selected in group A and even number in group B. Group A consisted of cases in which a 25G Whitacre needle was introduced. Group B consisted of cases in which a 25G Quincke needle was introduced.
Inclusion criteria: Patients with age group 20-50 years, of either sex, ASA grade I and II, weight 50-70 kgs. Elective surgeries like lower limb, orthopaedic and lower abdominal surgeries were included in the study.
Exclusion criteria: ASA Grade III and IV, unveiling patients, known case of any drug allergy, disease or deformity of the spine, any signs of infection at the desired site, psychiatric patients were excluded from the study.
A preanaesthetic evaluation was performed one day before the surgery and all required routine investigations were done.
Group A: Intrathecal anaesthesia was given with (0.5%) hyperbaric bupivacaine 10 mg plus inj. fentanyl 25 g using 25G Whitacre needle in left lateral position in the midline.
Group B: Intrathecal anaesthesia was given with (0.5%) hyperbaric bupivacaine 10 mg plus inj. fentanyl 25 g using 25G Quincke needle in left lateral position in the midline.
On arrival in the operating room, non invasive blood pressure, pulse oximetry, and Electrocardiography (ECG) monitoring were applied to the patient. Under all aseptic measures, lumbar puncture was performed either by 25G Quincke or 25G Whitacre spinal needle in the left lateral position in the midline between L3-L4 intervertebral space. All the patients were blinded to the type of needle utilised. An observer blinded to the spinal needle-type recorded the haemodynamic parameters and the level of sensory and motor blocks. The data were recorded at 0 mins (i.e. at the time of subarachnoid block) was considered as the baseline haemodynamic values for each patient.
Primary outcome: Heart Rate (HR), DBP, SBP, and MBP, and Oxygen saturation (SpO2) was documented at every 1 minute for 5 minutes after the intrathecal blockade and then every 5 minutes for 30 minutes.
Secondary outcome: The level of sensory block was judged by needle prick. The time for commencement of action of block and time taken to reach the full sensory blockade level was noted. The level of motor block was assessed by the modified Bromage scale (5).
When the fall in blood pressure was >30% to the baseline reading, it was considered as hypotension and same with heart rate <55 beats/minutes or >100 beats/minute, were considered as bradycardia or tachycardia, respectively (6).
Statistical Analysis
Data was defined in terms of series; mean±Standard Deviation (±SD), median, frequencies (number of cases), and relative frequencies (percentages) as appropriate. Assessment of quantitative variables between the two groups was done using the Student’s t-test and Mann-Whitney U test. For assessing categorical data, Chi-square (χ2) test was performed and the Fisher’s-exact test was used when the expected frequency is less than 5. A probability value (p-value) <0.05 was taken as significant. All statistical calculations were done using SPSS 21.0 version (SPSS Inc., Chicago, IL, USA).
The demographic data like age (20-50 years), weight (50-70 kg), and gender on comparison between two groups, values were not significant (p>0.05) (Table/Fig 1).
The haemodynamic parameters taken into consideration were HR, SBP, DBP, SpO2, MAP and there were no statistically significant (p-value >0.05). The mean baseline SBP in group A was 124.56±10.19 mmHg, and in group B was 124.80±9.19 mmHg. There was no statistically significant difference in SBP between the two groups intraoperatively at 1, 2, 3, 4, 5, 10, 15, 20, 25, 30Â minutes (p-value >0.05).
There was a statistically significant (p-value <0.05) decrease in the systolic blood pressure in both the groups as compared to baseline values. The mean baseline DBP in group A was 75.62±6.87 mmHg and in group B was 75.60±7.31 mmHg. There was no statistically significant difference in the DBP between the two group intraoperatively at 1, 2, 3, 4, 5, 10, 15, 20, 25, 30 minutes (p-value >0.05).
The mean baseline MAP in group A was 91.93±7.97 mmHg and in group B was 92.35±7.93 mmHg. There was no statistically significant difference in the MAP between the two groups intraoperatively at 1, 2, 3, 4, 5, 10, 15, 20, 25, 30 minutes (p-value >0.05). The mean baseline SpO2 in Group A was 100.00±0.00% and in Group B was 99.94±0.24% (Table/Fig 2). There was no statistically significant difference in the SpO2 between the two groups intraoperatively at 1, 2, 3, 4, 5, 10, 15, 20, 25, 30 minutes (p-value >0.05). (Table/Fig 3) shows comparison of intraoperative blood pressure, (Table/Fig 4) shows comparison of time required to achieve sensory and motor blockade in both groups, (Table/Fig 5) shows comparison of peak sensory block level between the two groups.
This clinical trial suggests that the SBP, DBP and MAP drops after the induction of spinal anaesthesia regardless of the type of needle used as mentioned in (Table/Fig 3). This was similar to the study conducted by Ghanei MM and Mehraban MS. They found that the SBP dropped upto 30 minutes after the induction of SA regardless of the type of needle (7). In a similar study done by Rizwee S et al., there was no significant difference in the SBP between 27G Whitacre and 27G Quincke spinal needle (8). Pal A et al., conducted a study using 25G Whitacre or Quincke spinal needle, and observed that the MAP did not differ between the two groups and there were no significant differences also (9). Casati A et al., and Shutt LE et al., showed similar results (10),(11).
In distinction to the present study, Campbell DC et al., did not witness hypotension and stated that it may be the result of good pre-hydration (12). SpO2 in both the needle groups was comparable (p-value >0.05). This is as per the study conducted by Pal A et al., using 25G Whitacre or Quincke spinal needle, observed that at all the measured time intervals, the SpO2 did not differ between the two needle groups (9). There was no statistically significant difference in the degree of motor blockade between the two needle groups with a p-value of 0.750 (>0.05).
Sensory block in the present study, there was no statistically significant difference in the onset of sensory blockade between the two needle groups. However, there was no statistically significant difference in the height of sensory blockade between the two needle groups. Similar findings were reported by Shutt LE et al., and Tahoor S and Rao R (11),(13). Time for attaining the highest level of sensory blockade was similar between both the groups as described in (Table/Fig 4). Similar results were observed by others also (10),(14),(15). The level of peak sensory block was either T4 (fast group) or T3 (Table/Fig 5). McShane FJ et al., conducted a study to check the influence of 25G Whitacre spinal needle orifice direction on the level of sensory blockade. The maximum sensory block achieved in patients was either T4 (cephalad group) or T5 (caudad group) (16). Hence, the present study findings are similar to the previous studies done by Shutt LE et al., Tahoor S and Rao R, Anderson L et al., and McShane FJ et al., (11),(13),(15),(16).
In the present study, the degree of motor blockade (modified Bromage criteria) was either 2 or 3 in both the needle groups. There was no statistically significant difference to the degree of motor blockade between the two needle groups as shown in (Table/Fig 4). Singla M et al., conducted a study using 25G Whitacre or 25G Quincke spinal needle. The mean Bromage group was 2.90±0.30 and in Quincke group was 2.88±0.33. Both the needles were comparable in terms of the degree of motor block (4). Tahoor S and Rao R conducted a study using 25G Quincke and 25G Whitacre spinal needles. For grading the degree of motor blockade, they used Bromage scores of 1, 2, 3 and 4. A Bromage score of 3 was seen in 7 patients of the Quincke group and 15 patients of the Whitacre group. A score of 4 was seen in 33 patients of the Quincke group and 25 patients of the Whitacre group (14).
Limitation(s)
The main limitation of the present study was the postdural headache was not seen and anaesthesiologist comfort was not assessed.
The pencil point 25G Whitacre spinal needle and cutting-beveled 25G Quincke spinal needle both are comparable in terms of sensory blockade, motor blockade, and haemodynamic changes. Hence, either of the needles can be used for the induction of spinal anaesthesia and smooth conduct of surgery.
DOI: 10.7860/JCDR/2022/55248.16500
Date of Submission: Jan 29, 2022
Date of Peer Review: Mar 03, 2022
Date of Acceptance: May 09, 2022
Date of Publishing: Jun 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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