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Is the cremasteric reflex an indicator of successful spinal anaesthesia with bupivicaine and meperidine (pethidine)? |
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Nazim DOGAN, Fikret SILBIR, Ali Fuat ERDEM
Department of Anaesthesiology, Atatürk University School of Medicine, Erzurum - Turkey
Background:
Methods: The study was performed on 62 adult male patients, average age 51±11 years, ASA I and II, with positive bilateral cremasteric reflexes before spinal anaesthesia. Hyperbaric bupivicaine, 3ml of 5% solution, was administered intrathecally to group B (n=30) and 3 ml of meperidine, diluted with saline to 0.50 mg.kg-1, was given to group M (n=32). At 1, 2, 3, 4 and 5 minutes after administration of spinal drugs, the presence of the bilateral cremasteric reflex was sought, and pin-prick tests performed simultaneously.
Results: The cremasteric reflex disappeared when both drugs, more rapidly with bupivicaine. Meperidine caused more side effects such as nausea, vomiting and pruritis than bupivicaine.
Conclusion: We conclude that the reflex can be used as an indicator of the onset of spinal anaesthesia with bupivicaine and meperidine.
Key words: Spinal anaesthesia, cremasteric reflex, bupivicaine, meperidine
Introduction
Spinal anaesthesia is widely used. In patients who can co-operate, the progress of spinal anaesthesia can be followed by pinching, pin-prick, cold stimuli, blowing a gas jet and application of pressure (1-3). Okuda et al showed that the abolition of the cremaster reflex might be a useful indicator of spinal anaesthesia in patients who can not cooperate (4). We hypothesised that, in patients who can be cooperated, the if abolition of the cremaster reflex might be an indicator of sufficient spinal anaesthesia with local anaesthetics (bupivicaine) or opioids (meperidine). When the upper part of the inner thigh is stimulated by slight stretching, the cremaster muscle contracts. The cremaster forms the middle layer of the spermatic cord and is an extension of the internal oblique muscle. Contraction of the cremaster shortens the spermatic cord and elevates the ipsilateral testes. The afferent impulse is conveyed by the femoral branch of the genitofemoral nerve, the efferent via the genital branch of the same nerve (5).
This study was conducted in order to investigate the effects of bupivicaine or meperidine, used in spinal anaesthesia, on the cremasteric reflex, and to determine whether the reflex is an indicator for sufficient spinal with bupivicaine or meperidine anaesthesia in adult male patients.
Method
Sixty-two adult male patients, ASA I-II, aged between 21-62 years, mean (standard deviation) 51±11 years, were included in this study. Permission of Faculty Ethics Committee and written informed consent from each participating patients for spinal anaesthesia were obtained. This study was planned as prospective randomized double-blind method. There were 23 orthopedic patients, 29 urological, and 10 general surgerical. All patients had positive right and left cremasteric reflexes, and had no hepatic, renal or and coagulation problems, and no allergy to opioid and local anaesthetics. The patients were randomly divided into two groups: Group B (n=30) received bupivicaine, and group M (n=32) received meperidine. Before anaesthesia, all the patients were given 500 ml Ringer Lactate solution via an intravenous 16 Gauge catheter placed in the antecubital vein. Non-invasive blood pressure, oxygen saturation (SpO2) and ECG monitoring were performed.
Following skin preparation in a seated position, the intrathecal space was entered via a 27-Gauge (Spinocan®, B.Braun Melsungen AG, Germany) spinal needle between the third and fourth lumbar vertebrae. After observing spinal fluid, 3 mL hyperbaric bupivicaine (Marcaine® Spinal Heavy 0.5%, Eczac?bas?, Istanbul-Turkey) and 0.5 mg.kg-1 meperidine (Aldolan®, Gerot Pharmazeutika GmbH, Vienna-Austria), diluted with saline in 3 ml were injected intrathecally to group B and group M, respectively. All patients were then placed head up in the supine position.
An anaesthetist performed the block and an other one assessed the cremasteric reflex. Both of them were blinded to which drug had been administered. The presence of the bilateral cremasteric reflex was assessed at 1, 2, 3, 4 and 5 minutes after the spinal injection, with negative results being recorded if it was absent. The extent of the spinal anaesthesia was checked simultaneously by pin-prick. Side effects developing up to 24 hours were recorded. Absence of the cremasteric reflex was compared within and between groups, employing chi-square test. Values of p<0.05 were considered as significant, and p<0.001 as very significant.
Results
No patient required general anaesthesia. Cremasteric reflex results following spinal anaesthesia are shown in Table 1.
|
1 Minute |
2 Minute |
3 Minute |
4 Minute |
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|
Right |
Left |
Right |
Left |
Right |
Left |
Right |
Left |
Group B |
32 |
32 |
5 |
6 |
0 |
0 |
0 |
0 |
Group M |
30 |
30 |
17 |
17 |
7 |
6 |
1 |
0 |
Table 1. Positive right and left cremasteric reflexes according to time after spinal anaesthesia.
The reflex was positive in all patients at 1 minute. There were more negative tests in group B at 2 minutes than at 1 min (p<0.001); by 3 minutes, all tests in group B were negative. In group M, the number of negative reflexes increased at 2 and again at 3 minutes (p<0.001). At 2 and 3 minutes, there were more negative reflexes in group B than in group M (p<0.001), the differences disappearing at 4 minutes. Similar findings were obtained on pin-prick testing (p>0.05). In group B, two patients (6.6%) developed hypotension, one requiring ephedrine. In group M, five patients (15.6%) developed hypotension, three requiring ephedrine. Four patients (12.5%) in group M complained of nausea and vomiting, which did not require treatment, and a further seven (21.8%) developed pruritis during the 24-hour follow-up period. There was no respiratory depression.
Discussion
The cremaster reflex may be used as an indicator of spinal anaesthesia, provided it is bilaterally positive before the block. The reflex, which is present to a variable extent in newborns and during infancy (6), and is thus not useful in children (7,8), is clearly an easy and objective indicator for spinal anaesthesia with local anaesthetics in male adults (4).
Intrathecal meperidine and opioids are used (9,10). Meperidine alone or added to intrathecal local anaesthetics increases the incidence of side effects such as nausea, vomiting and pruritis (11-13). Increasing the dose also increases the risk of respiratory depression (14). We used only low doses in our study, and thus the frequency and intensity of side effects was acceptable. The addition of meperidine or other opioids to intrathecal local anaesthetics allows prolonged post-operative analgesia (15-17).
In the meperidine group, the cremasteric reflex disappeared 1-2 minutes later than in the hyperbaric bupivicaine group, in parallel with the loss of sensation to the pin-prick test. However, given the innervation of the cremasteric reflex, the test may not be useful for upper abdominal surgery (5).
In conclusion, we think that the cremaster reflex may be used as an indicator of sufficient spinal anaesthesia with meperidine for lower abdominal, perineal and lower limb surgery, in adult males. We believe, however, that further comparisons with other conventional tests are required in order to clarify the issue.
References
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