Actu anaesth. scand. 1977, 21, 368-373
Anaesthesia for Short-stay Varicose Vein Surgery ULLAAROMAA Department of Anaesthesia, Helsinki University Central Hospital, Meilahti, Helsinki, Finland
The study was undertaken in order to elucidate the suitability of four different types of general anaesthesia and of epidural block in short-stay varicose vein surgery. Special consideration was given to recovery after anaesthesia. The series consisted of 230 female patients subjected to varicose vein surgery of one lower extremity. The patients' recovery after surgery was observed through tests measuring visual-motor coordination and through questionnaires. The general anaesthesias used were halothane-nitrous oxide-oxygen anaesthesia with spontaneous respiration (Ha), relaxant-dominated combined anaesthesia (Re), analgesicdominated combined anaesthesia (An), and analgesic-dominated combined anaesthesia with hyperventilation (Hy). Of the general anaesthesia, halothane nitrous-oxide inhalation anaesthesia gave the fastest recovery, although there were no major differences between it and analgesic-dominated combined anaesthesia. In contrast, immediate recovery was prolonged after hyperventilation and after relaxant-dominated anaesthesia. Epidural blockade provided a good alternative to general anaesthesia.
Received 18 October 1976, accepted for publication 13 Januarv 1977
Continuous increases in hospital costs are an incentive to find ways of reducing the period of hospitalization. This can be done by treating diseases of veins of the lower extremities on an outpatient basis. Anaesthetic techniques used in connection with varicose vein surgery on an out-patient basis have not received as much attention as surgical procedures, which have been extensively reported in numerous publications. Only a few reports (SUTHERLAND & HORSFALL 1961, THOMPSON et al. 1973) have considered the anaesthesia employed. In this study, four different types of general anaesthesia and epidural block were compared, in order to evaluate their suitability in shortstay surgery.
MATERIAL AND METHODS The present series of patients consisted of 230 female patients who were subjected to varicose vein surgery of one lower extremity at the out-patient department
of the Meilahti Clinic, Helsinki University Central Hospital. All patients belonged to cla5s ASA I. (DRIPPS et al. 1972), and their age range was 18-60 years. In every instance, stripping of the vena saphena magna and local excisions of secondary branches were performed. In 45% of operations, one or several perforant veins were ligated extrafascially, and in 23% the vena saphena parva was also removed. The anaesthetics were all administered by the author. After the operation, the patients were observed in the hospital for a period of less than 24 hours. The four general anaesthesia groups were first chosen at random from the patients, and then the epidural group was selected. The same criteria were used in the epidural as in the general anaesthesia groups, except that patients with spine anomalies or neurological symptoms were excluded
::[El Age, years
20
30
40
50
Weight, kg
50
60
70
80
Lengt h,cm 155 160 185 170
An "Y EP
Fig. I. Mean age, Wright and height in the different groups.
ANAESTHESIA AND VARICOSE VEINS
from the epidural group. The mean ages, heights and weights of the patients in the various groups, with standard deviations, are shown in Figure 1. There were no statistically significant differences between the groups. The patients' blood group, haemoglobin, and urinary protein and sugar were determined, and screen X-ray and an ECG were taken. All patients presented with normal laboratory examination results. No statistically significant differences were present between the groups with regard to any one of the parameters mentioned. The patients were also informed of the study in progress and its purpose, and their consent was obtained.
The anaesthesias used Premedication - All patients were given atropineO.Olmg/ kg b.w. and pethidine 1 mg/kg b.w., 45 min preoperatively, intramuscularly. Anaesthesia Group Ha. - 47 patients. Anaesthesia was induced by injecting propanidid 5 mg/kg b.w. Anaesthesia was continued with an oxygenlnitrous oxide mixture containing 40% oxygen, and with halothane, employing a semi-open system with a Ruben valve. The halothane concentration of the inspired gas mixture varied between 0.5 and 1.5%. The patients breathed spontaneously through a mask. Anaesthesia Group Re. - 46 patients. Induction was by propanidid, as in Group Ha; thereafter, suxamethonium was administered intravenously, 1 mg/kg b.w., and an endotracheal tube was inserted. The patients were ventilated by means of a Manley ventilator, using a semi-open system with oxygen/nitrous oxide mixture, containing about 25% oxygen. The patients were normoventilated. The end-tidal carbon dioxide concentration was monitered with a Uras capnograph (N. V. Godart, de Bilt UTR, Holland), and the CO2 level was kept within 5.5 to 6.0% by volume (pco, 38-43 mmHg=5.05-5.72 kpa). Two neurostimulator needle electrodes were inserted on the ulnar side of the patient's left forearm, and the neuromuscular block was observed throughout the operation. Alcuronium was administered until the fifth consecutive stimulus from the neurostimulator produced no movement, or only a hardly visible movement, of the fingers. If there were reactions suggestive of pain, fentanyl in a single intravenous dose of 0.05-0.1 mg was given. The relaxation was reversed with neostigmine (2 mg) given with atropine (lmg). Anaesthesia Group An. - 47 patients. Anaesthesia was induced as in Group Re, but relaxation was kept a t a lower level. Only that amount of alcuronium which resulted in a just observable fade was given. The patients were normoventilated as in Group Re. Fentanyl was dosed in the same way as in Group Re.
369
Anaesthesia Group H y . - 46 patients. Anaesthesia was identical to that in Group An, except that the patients were hyperventilated so that the end-tidal C 0 2 was 3.3 to 3.5% ( P c o ~20-25 mmHg=2.66-3.32 pKa). Epidural Group Ep. - 44 patients. The epidural puncture was made through the LIII-LIV interspace with a Tuohy needle. The hanging drop technique was used to identify the epidural space, and 30 ml of 1.5% lidocaine-adrenalin was injected to produce the blockade. Thereafter, all patients received Effortil", 3 Ing i.v. If needed during the operation, local infiltration with 0.5% lidocaine or i.v. diazepam or fentanyl was given. The amounts of relaxants and analgesics in groups Re, An and Hy are presented in Table 1.
Table 1 Amounts of relaxants and analgesics in different general anaesthesia POUPS.
Group Re An HY
Alloferin mg Mean 16.4 9.3 10.7
Fentanyl mg Mean 0.10 0.33 0.36
In 42% of the patients, the epidural blockade alone was sufficient. I n 24% of patients, local infiltration with 1% lidocaine was used, mostly in the region of the ankle. Fifteen percent of patients were given diazepam 5-10 mg i.v. and 15% received fentanyl 0.05-0.1 mg, Nineteen percent of the patients received both fentanyl and diazepam. The mean operation time in all the groups was 6 0 k 15 min.
Studies in the immediate postoperative phase The examinations were referred to control values, which had been measured for all patients in the induction room, prior to premedication. All examinations were carried out before premedication and also 30, 60 and 180 min after the patient had awakened. Reaction time. A visual stimulus was used to measure the reaction time. The patient had to react to the stimulus by operating an electric switch connected & ORKIN 1968). to a recorder (WOLLMAN M a d h x Wing test. The extraocular muscular balance was measured using the Maddox Wing test (HANNINGTON-KIPP1970). Bender test. This test consists of a series of dots arranged at I-cm intervals in the outline of a geometric figure.
370
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Ha :EP' 180
0.06
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The paticnt was required to connect the dots with a pencil to complete the figure. The number of dots RESULTS left outside the line drawn by the patients (missed error) and the aggregate length in mm of extraneous Reaction time. A comparison of the findings line (extraneous deviation) were determined (TRIEGERin the different general anaesthesia groups et al. 1970). revealed that the reaction times returned Alert~ess. In the recovery room, the alertness was roughly assessed using a simple scoring scale from 3-1, where 3 indicated a fully awake patient and 1 a drowsy patient . Postoperative ,follow-up. O n the morning or the first postoperative day, prior to their discharge, the patients were interviewed, and particular attention was paid to their subjective sensations. The patients were given a questionnaire to take home.
to the preoperative values fastest in Groups Ha and Re. The reaction time at 180 min in Group Hy was longer at a statistically significant level (P
Anaesthesia for Short-stay Varicose Vein Surgery ULLAAROMAA Department of Anaesthesia, Helsinki University Central Hospital, Meilahti, Helsinki, Finland
The study was undertaken in order to elucidate the suitability of four different types of general anaesthesia and of epidural block in short-stay varicose vein surgery. Special consideration was given to recovery after anaesthesia. The series consisted of 230 female patients subjected to varicose vein surgery of one lower extremity. The patients' recovery after surgery was observed through tests measuring visual-motor coordination and through questionnaires. The general anaesthesias used were halothane-nitrous oxide-oxygen anaesthesia with spontaneous respiration (Ha), relaxant-dominated combined anaesthesia (Re), analgesicdominated combined anaesthesia (An), and analgesic-dominated combined anaesthesia with hyperventilation (Hy). Of the general anaesthesia, halothane nitrous-oxide inhalation anaesthesia gave the fastest recovery, although there were no major differences between it and analgesic-dominated combined anaesthesia. In contrast, immediate recovery was prolonged after hyperventilation and after relaxant-dominated anaesthesia. Epidural blockade provided a good alternative to general anaesthesia.
Received 18 October 1976, accepted for publication 13 Januarv 1977
Continuous increases in hospital costs are an incentive to find ways of reducing the period of hospitalization. This can be done by treating diseases of veins of the lower extremities on an outpatient basis. Anaesthetic techniques used in connection with varicose vein surgery on an out-patient basis have not received as much attention as surgical procedures, which have been extensively reported in numerous publications. Only a few reports (SUTHERLAND & HORSFALL 1961, THOMPSON et al. 1973) have considered the anaesthesia employed. In this study, four different types of general anaesthesia and epidural block were compared, in order to evaluate their suitability in shortstay surgery.
MATERIAL AND METHODS The present series of patients consisted of 230 female patients who were subjected to varicose vein surgery of one lower extremity at the out-patient department
of the Meilahti Clinic, Helsinki University Central Hospital. All patients belonged to cla5s ASA I. (DRIPPS et al. 1972), and their age range was 18-60 years. In every instance, stripping of the vena saphena magna and local excisions of secondary branches were performed. In 45% of operations, one or several perforant veins were ligated extrafascially, and in 23% the vena saphena parva was also removed. The anaesthetics were all administered by the author. After the operation, the patients were observed in the hospital for a period of less than 24 hours. The four general anaesthesia groups were first chosen at random from the patients, and then the epidural group was selected. The same criteria were used in the epidural as in the general anaesthesia groups, except that patients with spine anomalies or neurological symptoms were excluded
::[El Age, years
20
30
40
50
Weight, kg
50
60
70
80
Lengt h,cm 155 160 185 170
An "Y EP
Fig. I. Mean age, Wright and height in the different groups.
ANAESTHESIA AND VARICOSE VEINS
from the epidural group. The mean ages, heights and weights of the patients in the various groups, with standard deviations, are shown in Figure 1. There were no statistically significant differences between the groups. The patients' blood group, haemoglobin, and urinary protein and sugar were determined, and screen X-ray and an ECG were taken. All patients presented with normal laboratory examination results. No statistically significant differences were present between the groups with regard to any one of the parameters mentioned. The patients were also informed of the study in progress and its purpose, and their consent was obtained.
The anaesthesias used Premedication - All patients were given atropineO.Olmg/ kg b.w. and pethidine 1 mg/kg b.w., 45 min preoperatively, intramuscularly. Anaesthesia Group Ha. - 47 patients. Anaesthesia was induced by injecting propanidid 5 mg/kg b.w. Anaesthesia was continued with an oxygenlnitrous oxide mixture containing 40% oxygen, and with halothane, employing a semi-open system with a Ruben valve. The halothane concentration of the inspired gas mixture varied between 0.5 and 1.5%. The patients breathed spontaneously through a mask. Anaesthesia Group Re. - 46 patients. Induction was by propanidid, as in Group Ha; thereafter, suxamethonium was administered intravenously, 1 mg/kg b.w., and an endotracheal tube was inserted. The patients were ventilated by means of a Manley ventilator, using a semi-open system with oxygen/nitrous oxide mixture, containing about 25% oxygen. The patients were normoventilated. The end-tidal carbon dioxide concentration was monitered with a Uras capnograph (N. V. Godart, de Bilt UTR, Holland), and the CO2 level was kept within 5.5 to 6.0% by volume (pco, 38-43 mmHg=5.05-5.72 kpa). Two neurostimulator needle electrodes were inserted on the ulnar side of the patient's left forearm, and the neuromuscular block was observed throughout the operation. Alcuronium was administered until the fifth consecutive stimulus from the neurostimulator produced no movement, or only a hardly visible movement, of the fingers. If there were reactions suggestive of pain, fentanyl in a single intravenous dose of 0.05-0.1 mg was given. The relaxation was reversed with neostigmine (2 mg) given with atropine (lmg). Anaesthesia Group An. - 47 patients. Anaesthesia was induced as in Group Re, but relaxation was kept a t a lower level. Only that amount of alcuronium which resulted in a just observable fade was given. The patients were normoventilated as in Group Re. Fentanyl was dosed in the same way as in Group Re.
369
Anaesthesia Group H y . - 46 patients. Anaesthesia was identical to that in Group An, except that the patients were hyperventilated so that the end-tidal C 0 2 was 3.3 to 3.5% ( P c o ~20-25 mmHg=2.66-3.32 pKa). Epidural Group Ep. - 44 patients. The epidural puncture was made through the LIII-LIV interspace with a Tuohy needle. The hanging drop technique was used to identify the epidural space, and 30 ml of 1.5% lidocaine-adrenalin was injected to produce the blockade. Thereafter, all patients received Effortil", 3 Ing i.v. If needed during the operation, local infiltration with 0.5% lidocaine or i.v. diazepam or fentanyl was given. The amounts of relaxants and analgesics in groups Re, An and Hy are presented in Table 1.
Table 1 Amounts of relaxants and analgesics in different general anaesthesia POUPS.
Group Re An HY
Alloferin mg Mean 16.4 9.3 10.7
Fentanyl mg Mean 0.10 0.33 0.36
In 42% of the patients, the epidural blockade alone was sufficient. I n 24% of patients, local infiltration with 1% lidocaine was used, mostly in the region of the ankle. Fifteen percent of patients were given diazepam 5-10 mg i.v. and 15% received fentanyl 0.05-0.1 mg, Nineteen percent of the patients received both fentanyl and diazepam. The mean operation time in all the groups was 6 0 k 15 min.
Studies in the immediate postoperative phase The examinations were referred to control values, which had been measured for all patients in the induction room, prior to premedication. All examinations were carried out before premedication and also 30, 60 and 180 min after the patient had awakened. Reaction time. A visual stimulus was used to measure the reaction time. The patient had to react to the stimulus by operating an electric switch connected & ORKIN 1968). to a recorder (WOLLMAN M a d h x Wing test. The extraocular muscular balance was measured using the Maddox Wing test (HANNINGTON-KIPP1970). Bender test. This test consists of a series of dots arranged at I-cm intervals in the outline of a geometric figure.
370
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AROMAA
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; zS
'HY
40 K
BENDER TEST
IL Y
K W
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u) W
d u
K
-20 K
MADDOX WING
0 Y
s 0
S
0 Y
y1 u)
Ha EP
* I
30 N
2
An
60 min.
Ha :EP' 180
0.06
40
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An
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s 0.04
Ha
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m
r
:: 0.02
u)
w
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K
REACTION
TIME
LL U
0
U z
0
3b
6'0
2 K
Ha
sac.
r
0 min.
180 -0.02
Ep\.
EP
- 0.04 Fig. 2. The results of the postoperative tests.
The paticnt was required to connect the dots with a pencil to complete the figure. The number of dots RESULTS left outside the line drawn by the patients (missed error) and the aggregate length in mm of extraneous Reaction time. A comparison of the findings line (extraneous deviation) were determined (TRIEGERin the different general anaesthesia groups et al. 1970). revealed that the reaction times returned Alert~ess. In the recovery room, the alertness was roughly assessed using a simple scoring scale from 3-1, where 3 indicated a fully awake patient and 1 a drowsy patient . Postoperative ,follow-up. O n the morning or the first postoperative day, prior to their discharge, the patients were interviewed, and particular attention was paid to their subjective sensations. The patients were given a questionnaire to take home.
to the preoperative values fastest in Groups Ha and Re. The reaction time at 180 min in Group Hy was longer at a statistically significant level (P
