Spinal Anaesthesia for Appendectomy: Experience at the University of Benin Teaching Hospital (UBTH), Benin-city, Edo State, Nigeria

M. O. OSAZUWA , J. M. AFOLAYAN, N. P. EDOMWONYI

Department of Anaesthesiology, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Edo State, Nigeria.

ABSTRACT Background: Appendectomy is the commonest surgical emergency in our hospital. Spinal anaesthesia is one of the anaesthetic techniques for appendectomy; it is simple and safe in experienced hands. We determined the use of spinal anaesthesia for appendectomy and outcome in our centre. Patients and Methods: This was a retrospective study of all cases of appendectomy performed from April 2007 to September 2009 (thirty months), cases that had spinal anaesthesia were further analysed. Information such as patients age, gender, ASA physical health status, PCV, urinalysis, anaesthetic technique, surgery duration, supplemental analgesics, intra-operative complications, and outcome, were obtained from anaesthetic and theatre records. Results: Five hundred and thirty-three cases of appendectomy were performed, of which 105 (19.7%) patients received spinal anaesthesia while majority (80.1%) of the cases were done under general anaesthesia and 1 (0.2%) patient had epidural anaesthesia. Eighty-four (80%) of the patients who had spinal anaesthesia had intrathecal administration of a combination of 0.5% hyperbaric bupivacaine and an opioid (25g Fentanyl or 10mg Pethidine), while 21 (20%) had intrathecal administration of 0.5% hyperbaric bupivacaine without opioid. Of the patients who received spinal anaesthesia, 72 (68.6%) had adequate anaesthesia intra-operatively, 25 (23.8%) patients required supplemental analgesics, while 7.6% cases were converted to general anaesthesia. Complications in the intra-operative period such as hypotension, shivering, high block and itching were managed effectively. Conclusion: The study revealed that use of a combination of 0.5% hyperbaric bupivacaine and an opioid provided effective anaesthesia for appendectomy. We recommend an increasing use of spinal anaesthesia for appendectomy. Keywords: Spinal anaesthesia; Appendectomy; Complications; Outcome INTRODUCTION The incidence of appendicitis in Accra and Lagos is 3 per 10,000 while in England and Wales it is 13 per 10,000.1 Though there is a higher incidence of appendicitis in Europe and America, there is currently a steady increase in the incidence of appendicitis in developing countries with a decrease in western countries.1,2 Acute appendicitis accounts for 30% of surgical emergencies in urban areas of Ghana and Nigeria.1 The incidence of appendicitis in 2008 almost doubled that of 2003 at LAUTECH Teaching Hospital, Osogbo, Nigeria.2 Change to a western lifestyle including change from a high to a low-residue diet has been largely blamed for the rising incidence in the developing countries.3, 4 Appendectomy is a common surgical emergency in the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria. General anaesthesia
*Correspondence: Dr. Osazuwa M. O ., Department of Anaesthesiology, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Edo State, Nigeria. E-mail: maryroseag@yahoo.com

(GA) has been the most popular anaesthetic technique used for appendectomy. Spinal anaesthesia is a simple and effective anaesthetic technique which also can be used for appendectomy. 5 The advantages of spinal anaesthesia for appendectomy include minimal airway manipulation, reduced risk of aspiration, extension of analgesia into the post-operative period, early ambulation and feeding.6 Spinal anaesthesia is also cheaper than general anaesthesia.5,7 The disadvantages of spinal anaesthesia for appendectomy are pain from peritoneal irritation if the block is not high enough, risk of high spinal, chance of anaesthesia wearing off if surgery is prolonged, hypotension and post-dural puncture headache.7,8 Furthermore, some patients may not tolerate surgery while awake, even when sedated.7 The aim of this study was to determine the use of spinal anaesthesia for appendectomy, complications and outcome. This will help to guide the administration of spinal anaesthesia for appendectomy. PATIENTSAND METHODS This was a retrospective study of cases of
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appendectomy done from April 2007 to September 2009 (period of thirty months). All the cases of appendectomy performed during this period were included in the study. The cases who received spinal anaesthesia were further analysed. Information was derived from anaesthetic paper records and theatre records. Information derived include patients age, gender, American Society of Anesthesiologists (ASA) physical health status, packed cell volume (PCV), urinalysis, type of appendicitis, dose of hyperbaric bupicavaine + opioid used, supplemental analgesic such as intravenous ketamine 10-20mg aliquots, IV fentanyl 25g, IV tramadol 100mg, IV pentazocine 30mg; duration of surgery, intra-operative complications and outcome of management whether it was effective or not. Based on intraoperative events after spinal anaesthesia was established, the patients were categorized into three groups: i) cases that had adequate anaesthesia defined as patients who did not require additional analgesia in the intraoperative period; ii)cases that had supplemental analgesic defined as patients who required additional analgesics to spinal anaesthesia intraoperatively; iii) cases converted to GA defined as patients who had intense pain during surgery that was not relieved by supplemental analgesics. Statistical analysis was carried out using GraphPad Instat version 3. RESULTS Five hundred and thirty three patients had appendectomy from April 2007 to September 2009. One hundred and five (19.7%) patients received spinal anaesthesia, 427(80.1%) were done under general anaesthesia and 1(0.2%) patient had epidural anaesthesia. The age range of patients who had spinal anaesthesia was 14-52years. Seventy four (70.5%) were females while 31(29.5%) were males (p<0.0001 considered extremely significant using Fisher exact test. 95% CI 1.733 to 3.289 using the approximation of Katz) (Table 1). Male: female ratio 0.42. Table 2 shows that most of the patients (70.5%) were classified ASA IE. Twenty (19%) cases were elective while 85(81%) were emergency cases (p<0.0001 considered extremely significant using Fisher exact test. 95% CI 0.1569 to 0.3528 using the approximation of Katz). Spinal anaesthesia was used for 11% of appendectomies done in 2007 and by 2009 the use of spinal anaesthesia had risen to 48% of appendectomies (Figure 1). One hundred and forty appendectomies were done in

2007, 235 in 2008 and 158 were performed in 2009 within the period studied (April 2007-September 2009). Out of the 105 patients that had spinal anaesthesia, 84 (80%) patients were administered a mean dose of 2.7ml (2.5 to 3.5ml based on patients heights by the attending anaesthetist) of 0.5% hyperbaric bupivacaine and 25g of fentanyl or 10mg of pethidine. Twenty one (20%) patients received a mean dose of 2.8ml (2.5 to 3.5 ml based on patients heights) of 0.5% hyperbaric bupivacaine without opioid. A 25 gauge pencil point spinal needle was used in each case at L3/L4 or L4/L5 interspace.
Table 1: Age and sex distribution of patients who had appendectomy under spinal anaesthesia Age range (yr) range (yr) 11-20 21-30 31-40 41-50 >50 Total Female No (%) 23 (82.1) 41 (71.9) 7 (53.8) 2 (33.3) 1 (100) 74 (70.5) Male No (%) 5 (17.9) 16 (28.1) 6 (46.2) 4 (66.7) 31 (29.5) Total No (%) 28 (100) 57 (100) 13 (100) 6 (100) 1 (100) 105 (100)

Table 2: American Society of Anesthesiologists Physical Health Status ASA Number of cases (%) I 18 (17.0) II 2 (2.0) IE 74 (70.5) IIE 9 (8.6) IIIE 1 (0.95) IVE 1 (0.95) TOTAL 105(100)
100 90 80 70 60 50 40 30 20 10 0
SPINAL ANAESTHESIA GENERAL ANAESTHESIA

2007

2008

2009

Figure 1: Type of Anaesthesia for Appendectomy (Spinal versus General Anaesthesia)

Table 3: Analgesic profile of intrathecal bupivacaine + opioid for appendectomy Bupivacaine + opioid (%) Cases who had adequate anaesthesia Cases who had supplemental analgesics Cases converted to GA Total (NS - non significant) 61 (72.6) 18 (21.4) 5 (6) 84 (100) Bupivacaine alone (%) 11 (52.4) 7 (33.3) 3 (14.3) 21 (100) p-value 0.1129 0.2628 0.1963 Level of significance NS NS NS

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Seventy two (68.6%) of the patients had adequate anaesthesia, 25(23.8%) required supplemental analgesics, 8(7.6%) cases were converted to GA. (Table 3). Reasons for conversion to GA include prolonged surgery (1 patient), others are failed spinal and inadequate block height. In the group that received bupivacaine and opioid, 61 (72.62%) patients had adequate anaesthesia, 18 (21.43%) patients required supplemental analgesic, while 5 (5.95%) cases were converted to GA. In the group that received bupivacaine alone, 11 (52.38%) patients had adequate anaesthesia, 7 (33.33%) patients required supplemental analgesic, while 3 (14.29%) patients were converted to GA. The percentage of patients who required supplemental analgesics was less in the group that had intrathecal opioid. (p= 0.2628, considered not significant using Fisher exact test). The percentage of patients who were converted to GA was also less in the group who had intrathecal opioid. (p= 0.1963, considered not significant using Fisher exact test). A higher occurrence of use of supplemental analgesics or conversion to general anaesthesia was recorded with patients who had lower doses of bupivacaine (less than 3ml) compared with those who had >3ml of bupivacaine. (Table 4). Supplemental analgesics given were intravenous ketamine 10-20mg aliquots, IV fentanyl 25g, IV tramadol 100mg, IV pentazocine 30mg. Complications which resulted from the anaesthetic technique were hypotension (n=2), respiratory difficulty due to high block (n=1), shivering (n=4) and itching (n=2). (Table 5). Occurrence of post-dural puncture headache was difficult to ascertain as only the anaesthetic charts and theatre records were analysed. Hypotension was managed with ephedrine and IV fluids, respiratory difficulty was managed with administration of oxygen by face mask, shivering was treated with warm IV fluids and by covering the patient with blankets. Chlorpheniramine was used to treat itching. Outcome of management of complications was satisfactory.
Table 4: Dose of intrathecal bupivacaine versus use of supplemental analgesics/conversion to general anaesthesia <3ml of >3ml of bupivacaine bupivacaine Number of patients who had adequate anaesthesia (%) 42 (61.8) Number of patients who required supplemental analgesics or conversion to GA (%) 26 (38.2) Total (%) 68 (100) 30 (81.1)

7 (18.9) 37 (100)

Table 5: Complications arising from the use of spinal anaesthesia for appendectomy Complications Hypotension Respiratory difficulty Shivering Itching Total Number of patients (%) 2 (1.90) 1 (0.95) 4 (3.81) 2 (1.90) 9 (8.56)

DISCUSSION The incidence of spinal anaesthesia for appendectomy in our centre is 197 per 1000 appendectomies. Our study showed an increasing use of spinal anaesthesia for appendectomy, from 110 per 1000 appendectomies in 2007, to 480 per 1000 appendectomies in 2009. This can be attributed to improved skill in the use of spinal anaesthesia by the anaesthetists in our hospital, and to the availability of opioids. The decrease in use of spinal anaesthesia in 2008 was due to irregular supply of opioids during that period. Our results showed that the patients who present for appendectomy are healthy young adults as evidenced by their ages and ASA physical health status. A significant proportion of the patients in our study were female. Mangete et al9 in Port Harcourt, Nigeria, also found a significantly higher incidence of appendicitis in females. Appendicitis though, is generally reported to be more common in males.2 The appendix arises from the posteromedial aspect of the caecum about 2.5cm below the ileocaecal valve; its innervation is derived from sympathetic elements contributed by the superior mesenteric plexus (T10-L1) and afferents from parasympathetic elements via the vagus nerve.10 A spinal block height of T4 is considered adequate for appendectomy in order to prevent pain from manipulation of the peritoneum.7 Spinal anaesthesia is simpler, cheaper and safer than it used to be in the past.11, 12 This may be attributed partly to more standardized doses of local anaesthetics, improved skill and prompt management of complications. It is associated with reduced risk of aspiration, decreased airway manipulation, extension of analgesia into the postoperative period, early ambulation & feeding.6 Opioid receptors have been identified in the substantia gelatinosa of the spinal cord, hence the administration of opioids intrathecally.13 Intrathecal local anaesthetics or opioids are known to block visceral pain.14, 15 A study by Tejwani and colleagues16 has revealed that on intrathecal injection, the antinociceptive effects of morphine, when combined with bupivacaine, were significantly greater than when morphine or bupivacaine was injected alone. They also demonstrated a direct effect of bupivacaine on the binding of opioids to and spinal receptors. Furthermore, a synergistic inhibitory action of local anaesthetics and opioids on A-gamma (I) and C nerve fibres conduction has been demonstrated by Wang et al17; they arrived at the conclusion that the effectiveness of spinal analgesia with bupivacaine can be enhanced if it is supplemented with fentanyl. Intrathecal administration of a local anaesthetic or, an opioid + local anaesthetic combination has been shown to provide effective anaesthesia for appendectomy by Techanivate et al.8; in their randomized double-blind study, they assessed the effectiveness of the administration of fentanyl in spinal anesthesia for appendectomy. Forty patients were recruited to receive either 4 ml of 0.5%
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hyperbaric bupivacaine + 20g of fentanyl (Group F) or 4 ml of 0.5 % hyperbaric bupivacaine + 0.4 ml normal saline (Group S). Their study revealed that intrathecal 20 g fentanyl significantly improved the quality of analgesia; it prolonged the duration of bupivacaine in spinal anaesthesia and delayed the analgesic requirement in the early postoperative period. In our study, 72.62% of patients had adequate anaesthesia in the group that received bupivacaine with opioid compared with 52.38% in the group that received bupivacaine alone, thus the percentage of patients who required supplemental analgesics or conversion to GA was less in the group who had intrathecal opioid. Hunt and colleagues15 have also demonstrated that the addition of fentanyl to hyperbaric bupivacaine intrathecally reduces intraoperative opioid supplement as was observed in our study. Seventy two (68.6%) of the total cases in our study had adequate intra-operative analgesia. This is also comparable with Techanivate et al8, in their study, 82.5% of patients had good intraoperative analgesia without supplemental analgesic. Sule and colleagues5 in Jos University Teaching Hospital, Nigeria have as well successfully used spinal anaesthesia for appendectomy, using 0.5% hyperbaric Bupivacaine, in similar doses with our study. Our study revealed a low incidence of side effects of 8.6%. This buttresses the finding by Sudarshan and colleagues18 that intrathecal fentanyl is usually not associated with troublesome side effects, when they investigated the efficacy of intermittent doses of intrathecal fentanyl in 30 patients undergiong thoracotomy. Our study further demonstrated that intrathecal fentanyl or intrathecal pethidine with bupivacaine 0.5% provides excellent surgical anaesthesia with few side effects. This agrees with the findings of Belzarena et al.19 It is recommended that high dose of 0.5% bupivacaine (>3ml) is used when administering spinal anaesthesia for appendectomy, in order to achieve a high enough block.7 Our study revealed a higher occurrence of use of supplemental analgesics or conversion to general anaesthesia in patients who had lower doses of bupivacaine (less than 3ml) compared with those who had >3ml of bupivacaine. Techanivate et al8 reported complications such as nausea & vomiting, hypotension, shivering, high block. In our study, similar complications such as hypotension, shivering, respiratory difficulty and itching occurred and were managed with good outcome. Davies and colleagues20 have also reported respiratory depression following the use of intrathecal opioid. The respiratory difficulty in our study may have been due to high block observed in the patient or the effect of intrathecal opioid. CONCLUSION Our study revealed an increasing use of spinal anaesthesia for appendectomy in our centre. Addition of an opioid to 0.5% hyperbaric bupivacaine intrathecally
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was more effective than bupivacaine alone for appendectomy. The high incidence of pain that is felt in the intraoperative period from peritoneal irritation during appendectomy can be overcome with the addition of opioid to local anaesthetic intrathecally. We therefore recommend an increasing use of spinal anaesthesia for appendectomy. REFERENCES
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