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37]

Original Article

Comparison between Position Change after Low‑Dose Spinal

Anesthesia and Higher dose with Sitting Position in Elderly Patients:
Block Characteristics, Hemodynamic Changes, and Complications
Mohammed A. Alsaeid, Atef M. Sayed
Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt

Abstract
Background: Large numbers of patients are presenting for surgeries with aging-related pre-existing conditions that make them at higher
risks of adverse outcomes. Hemodynamic instability due to high sympathetic nerve block largely limits the use of conventional dose spinal
anesthesia in high risk elderly patients. Aims and Objectives: We aimed to compare the hemodynamic stability and the block characteristics
in low dose spinal anesthesia (5 mg) with immediate position change into supine position versus higher dose of spinal anesthesia (10 mg)
with maintaining patient position in sitting position for 3 minutes after the block in elderly high risk population. Settings and Design: This
study was a prospective randomized controlled double‑blinded clinical study. Materials and Methods: This study was carried on 70
patients of American Society of Anesthesiologists physical status classes I, II, and III aged 50 years old and above, who were scheduled
for elective knee and below knee orthopedic surgeries expected to last for 40-60 minutes under spinal anesthesia. Patients were randomly
allocated into two groups: group (A) Sitting group n = 35 patients that received 10 mg hyperbaric bupivacaine 0.5% in 2 mL volume
intrathecal at level lumbar (L4-5) in sitting position and remained in this position for 3 minutes before turning supine. And, group (B) Supine
group n = 35 patients received 5 mg (low dose) intrathecal hyperbaric bupivacaine in 2 mL volume (1 mL hyperbaric bupivacaine 0.5%
diluted with 1 ml sterile distilled water) at L4-5 in sitting position then turned supine immediately. The injection will be in the midline over
30 seconds by 25 gauge(G) Quincke needle. We measured the changes of mean arterial blood pressure, heart rate, O2 saturation and the
incidence of hypotension and bradycardia intraoperatively as a primary outcome. Also, we measured the characteristics and the duration
of the sensory and motor blocks, the duration required till return of bladder function and the satisfaction levels of both the patients and the
surgeons as secondary outcomes. Statistical Analysis Used: Student’s t‑test and Chi‑square test were used for analysis. Results: As regards
hemodynamics, mean arterial blood pressure and heart rate were significantly lower in group A compared to group B; P-value <0.05, during
the intraoperative period, while MABP and HR were significantly decreasing in group A during the initial intraoperative period at 5 min,
10 min, 15 min, 20 min, 25 min, 30 min and 35 min, but in group B these parameters were statistically insignificant throughout the whole
procedure P-value >0.05. As regards oxygen saturation, there were no significant differences between both groups or within the same group
during the whole intraoperative period. Comparing sensory and motor blocks, sensory block was significantly higher and motor block was
significantly dense in group A compared to group B during the first intraoperative period at 5 min, 10 min, 15 min, 20 min and 25 minutes.
The recovery times from sensory and motor blocks were significantly longer in group A compared to group B (P-value <0.001). Also, the
void recovery time was significantly longer in group A (129.29 ± 5.87 min) compared to group B (114.77 ± 8.24 min). In group B, patient
satisfaction was significantly better (25 excellent/ 10 good) compared to group A (10 excellent/25 good). Also, surgeon satisfaction was
statistically significantly better in group B (23 excellent/12 good) compared to group A (14 excellent/21 good). As regards side effects, in
group A, 3 patients had to receive ephedrine due to significant reduction in MABP while no patients in group B had significant hypotension
or bradycardia throughout the intra operative period. Conclusion: We concluded that the use of small dose of heavy bupivacaine 0.5%
(5 mg) with immediate patient position changing to supine position provided good spinal block characteristics in elderly population without
any hemodynamic side effects, also with better patient and surgeon satisfaction levels compared to higher doses of heavy bupivacaine
(10 mg) even if we maintained patient position in the sitting position
for 3 min after the block.
Address for correspondence: Dr. Mohammed A. Alsaeid,
Faculty of Medicine, Fayoum University, Fayoum, Egypt.
Keywords: Hemodynamic changes, high‑risk elderly population, E‑mail: drm.awad2008@yahoo.com
low‑dose spinal anesthesia, position change

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How to cite this article: Alsaeid MA, Sayed AM. Comparison between
DOI: position change after low-dose spinal anesthesia and higher dose with sitting
10.4103/aer.AER_101_19 position in elderly patients: Block characteristics, hemodynamic changes,
and complications. Anesth Essays Res 2019;13:476-80.

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Alsaeid and Sayed: Low‑dose spinal anesthesia with position change versus higher dose in elderly population as regards hemodynamic changes
Introduction
Rationale and background
As the average life expectancy has been recently increased due
to advancement in medical service practice and the upsurge
of consideration on health conditions, the aging population
started to rapidly increase. It is required to properly consider
rewards and drawbacks between general and regional
anesthesia, and to provide an understanding of anatomy,
pharmacological changes of medicine, and physiological
changes of old age in order to reduce the frequency of
complications or after effects of surgery or anesthesia, since
an increase of aging population obliges as a major risk factor
for increasing the number of patients suffering from chronic
diseases and perioperative mortality.[1] Spinal anesthesia uses
only a small amount of local anesthetics related to the one
needed for epidural anesthesia and requires relatively simple
procedures and fast anesthetic onset effect. In addition, the
rate of occurrence of thromboembolism and cardiovascular
complications after surgery is reduced during spinal compared
to general anesthesia and the amount of blood transfusion
and hemorrhage in the perioperative period, leading to a
decrease in the rate of pneumonia and respiratory failure
in cases of patients suffering from chronic lung diseases.[2]
Therefore, in general cases, spinal anesthesia is most likely
selected for orthopedic surgery of lower limb for elderly
patients. In addition, this frequently causes hypotension and
bradycardia,[3] such cardiovascular changes serve as a major
reason for increasing the rate of morbidity and mortality.
Therefore, it is required to consider a safe method for
esthesia that can maintain perioperative and postoperative
hemodynamic stability.[4]
Aim of the study
The primary outcome of this study was to compare the
hemodynamic changes of elderly patients who remain in
sitting position for 3 min after 10 mg intrathecal hyperbaric
bupivacaine compared to patients who were placed in
supine position immediately after giving a low dose of
bupivacaine (5 mg). The secondary outcomes were to compare
the level of sensory and motor blocks, Bromage scale,
patient and surgeon satisfaction as well as the occurrence of
complications between the two groups.
Materials and Methods
After Ethical Committee approval of the Fayoum University
Hospitals and written informed consents from the patients
were taken, 70  patients of the American Society of
Anesthesiologists physical status classes I, II, and III aged
50 years old and above, who were scheduled for elective
knee and below knee orthopedic surgeries expected to
the last for 40–60  min under spinal anesthesia, were
included in this prospective double‑blinded study which
was conducted between March 2018 and April 2019.
Exclusion criteria were patients with other neurological
diseases, spine abnormalities, absolute, and relative
Anesthesia: Essays and Researches  ¦  Volume 13  ¦  Issue 3  ¦  July-September 2019
contraindications to spinal anesthesia as patients suffering
from intracranial hypertension, major bleeding disorder,
patients on anticoagulant, local infection, dementia, and
allergic reaction to local anesthetics. Patients received no
preoperative sedation, and they were off oral fluids for 2 h
and for 8 h for solid food preoperatively. On arrival to the
anesthetic room, two large bore intravenous (i.v.) cannulas
were inserted, and ringer lactate 8  mL/kg was given as
a preload over  30  min when appropriate and maintained
intraoperatively with a rate of 8 mL.kg-1.h-1. All patients
received oxygen  (4 L.min -1) using a face mask during
the procedure; standard routine monitoring was applied
including electrocardiogram, noninvasive blood pressure,
and pulse oximetry that will be continued intraoperatively.
Patients were allocated to either study groups using a
randomized central computer‑generated sequence and a
sealed envelope assignment held by an investigator not
involved with the clinical management or data collection,
and they were randomly allocated into two groups as
follows: Group  (A) Sitting group n  =  35  patients who
received 10 mg hyperbaric bupivacaine 0.5% (Marcaine®,
AstraZeneca, Sweden) in 2 mL volume intrathecal at level
lumbar (L4–5) in sitting position and remained in this position
for 3  min before turning supine. Moreover, Group  (B)
supine group n  =  35  patients received 5  mg  (low dose)
intrathecal hyperbaric bupivacaine in 2 mL volume (1 mL
hyperbaric bupivacaine 0.5% diluted with 1  mL sterile
distilled water) at L4–5 in sitting position then turned supine
immediately. The injection will be in the midline over 30
s by 25 gauge (G) Quincke needle. The study solution was
prepared by another investigator and its content blinded to
the anesthetist who administered it, the anesthesiologist
who will collect the data will be unaware about any of the
experimental groups. If adequate surgical anesthesia was
not achieved, general anesthesia was performed, and patient
was excluded from our study. Hypotension was defined
as a systolic blood pressure dropped <90 mmHg or mean
arterial blood pressure  (MABP) was reduced 30% lower
than the base line, and hence, ephedrine was given in 3 mg
incremental doses until improvement. If heart rate  (HR)
was recorded lower than 50 beat/min, it was defined as
bradycardia and 0.5 mg of atropine was given i.v..
Measured parameters
1. The mean arterial pressure, pulse rate, and oxygen
saturation were recorded at 5‑min intervals till the end
of the procedures (primary outcome)
2. The rate of occurrence of hypotension, bradycardia who
required the use of ephedrine and atropine  (primary
outcome)
3. The level of sensory block and motor blocks (secondary
outcome). Five minutes after subarachnoid injection,
patients were evaluated for 25 min, in 5‑min intervals.
Sensory block level was evaluated using the pin‑prick
test for both sides by using a 25G needle. Assessments of
motor block were made immediately after the assessment
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Alsaeid and Sayed: Low‑dose spinal anesthesia with position change versus higher dose in elderly population as regards hemodynamic changes

of the analgesia, motor block level was assessed using the the satisfaction of the surgeons immediately after the
Bromage scale,[5] (0 = no motor block; 1 = hip blocked; surgery and of the patients right before coming to the
2 = hip, and knee blocked; and 3 = hip, knee, and foot ward (secondary outcome).
blocked)
4. The durations of recovery from sensory and motor blocks
Statistical analysis and sample size
Using PASS 11 and based on data from Mehta S et al. study,[6]
were measured (secondary outcome). Duration of sensory
it was calculated that group sample size of 23 patients per
block was defined as the time when the sensory blockage
group achieved 81% power to detect a difference between the
reached highest dermatomal level till recovery of S2
group proportions of 40% in the incidence of hypotension, The
dermatome. Duration of motor block was defined as the
test statistic used is the two‑sided Z test with pooled variance.
time at which the Bromage scale was declined from score
The significance level of the test was targeted at 0.0500. The
3 to score 0
significance level actually achieved by this design is 0.0497.
5. The duration required till the return of bladder function
(ability to void urine without difficulty) was recorded and
compared (secondary outcome) Table 3: Heart rate (beat/min)
6. The degree of satisfaction of the patients and the surgeons
Group A (n=35) Group B (n=35) P
was compared between the two groups. Four grades will
Preoperative 107.85±15.25 109.97±13.9 0.548
be classified: Excellent, good, fair, and poor. We evaluated
5 min 100.5±12.8 107.11±13.82 0.045*
P 0.001** 0.292
Table 1: Demographic data 10 min 96.62±11.35 106.63±13.23 0.032*
P 0.02** 0.224
Group A (n=35) Group B (n=35) P 15 min 93.15±11.16 106±10.225 <0.001*
Age (years) 55.18±10.9 56.76±8.69 0.501 P 0.03** 0.292
Sex (male/female) 17/18 19/16 0.54 20 min 90.12±7.1 104.4±11 <0.001*
Height (cm) 165.12±10.3 169.57±8.6 0.2 P 0.021** 0.234
Weight (kg) 69.59±9.9 69.14±9.36 0.847 25 min 87.88±10.98 102.37±11.1 <0.001*
Duration of surgery 49.12±6.45 52.43±5.74 0.27 P 0.04** 0.142
(min) 30 min 84.35±13.66 101.28±8.2 0.014*
Data are presented as mean±SD or ratio of patients. P>0.05 is considered
P 0.041** 0.31
statistically nonsignificant. SD=Standard deviation
35 min 80.1±10.69 101.22±6.97 <0.001*
P 0.04** 0.96
40 min 82.58±10.2 103.3±10.13 <0.001*
Table 2: Mean arterial blood pressure (mmHg)
P 0.212 0.155
Group A (n=35) Group B (n=35) P 45 min 84.47±7.24 104.3±7.23 0.012*
Preoperative 99.56±11.95 106.11±11.4 0.2 P 0.210 0.495
5 min 97.82±9.52 105.2±12.1 0.011* 50 min 86.3±10.37 107.83±9.86 0.014*
P <0.001** 0.185 P 0.204 0.21
10 min 95.6±8.7 103.5±10 0.001* Data are presented as mean±SD. *P<0.05 is considered statistically
P <0.001** 0.181 significant between the two groups, **P<0.05 is considered statistically
15 min 92.9±9.66 102.9±11.2 0.001* significant compared to the data before in the same group. SD=Standard
deviation
P <0.001** 0.84
20 min 89.47±11.08 102±6.86 <0.001*
P <0.001** 0.377 Table 4: O2 saturation(%)
25 min 87.65±10.4 100.6±12.48 <0.001*
P <0.001** 0.187 Group A (n=35) Group B (n=35) P
30 min 84.12±8.63 100.86±18.3 <0.001⃰ Preoperative 98.4±2.16 98.7±0.4 0.142
P 0.004** 0.2 5m 97.86±1.99 98.49±051 0.153
35 min 81.9±10.84 101.36±9.85 <0.001* 10 m 98.2±0.77 98.4±0.5 0.158
P <0.001** 0.04 15 m 97.74±0.83 98.1±0.56 0.43
40 min 82.3±17.1 102.2±8 <0.001* 20 m 97.9±0.75 98.2±0.58 0.08
P 0.04 0.186 25 m 97.6±0.82 98.26±0.66 0.07
45 min 84.9±9.97 103.9±9 <0.001* 30 m 98±0.43 97.94±2.1 0.883
P 0.211 0.3 35 m 98.2±0.79 98.3±0.789 0.569
50 min 86.8±11.39 104.3±9.2 0.001* 40 m 97.88±1.6 99±1 0.149
P 0.3 0.66 45 m 98.2±0.68 98.4±0.6 0.158
Data are presented as mean±SD. *P<0.05 is considered statistically 50 m 98.35±0.85 98.3±0.67 0.835
significant between the two groups, **P<0.05 is considered statistically Data are presented as mean±SD. P>0.05 is considered statistically not
significant compared to the data before in the same group. SD=Standard significant between the two groups. SD=Standard deviation. SD=Standard
deviation deviation

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Alsaeid and Sayed: Low‑dose spinal anesthesia with position change versus higher dose in elderly population as regards hemodynamic changes

after inclusion to the study. As regards hemodynamics, MABP

Table 5: Bromage score
and HR were significantly lower in Group A compared to that
Group A (n=35) Group B (n=35) P of Group  B  [Tables  2 and 3]; value of P <  0.05, during the
5 min 2 (2-3) 1 (1-2) 0.01* intraoperative period, whereas MABP and HR were significantly
10 min 3 (2-3) 2 (2-3) 0.021* decreasing in Group A during the initial intraoperative period
15 min 3 (2-3) 2 (2-3) 0.0018* at 5, 10, 15, 20, 25, 30 , and 35 min, but in Group B, these
20 min 3 (3-3) 3 (2-3) 0.0068* parameters were statistically insignificant throughout the whole
25 min 3 (3-3) 3 (2-3) 0.006* procedure P > 0.05. As regards oxygen saturation, there were
Data are presented as median (IQR). *P<0.05 is considered statistically
significant between the two groups. IQR=Interquartile range
no significant differences between both groups or within the
same group during the whole intraoperative period [Table 4].
Comparing sensory and motor blocks  [Tables  5 and 6],
Table 6: Level of sensory block sensory block was significantly higher and motor block
Group A (n=35) Group B (n=35) P was significantly dense in Group A compared to Group  B
5 min T10 (T10-T12) T11 (T11-L1) <0.001* during the first intraoperative period at 5, 10, 15, 20 , and
10 min T9 (T9-T11) T10 (T10-12) <0.001* 25  min. The recovery times from sensory and motor blocks
15 min T8 (T8-T11) T10 (T10-T11) <0.001* were significantly longer in Group A compared to Group  B
20 min T8 (T8-T10) T9 (T9- T11) <0.001* (P < 0.001) [Table 7]. Furthermore, the void recovery time was
25 min T8 (T8-T11) T9 (T9-T12) <0.001* significantly longer in Group A (129.29 ± 5.87 min) compared
Data are presented as median (IQR). *P<0.05 is considered statistically to Group B (114.77 ± 8.24 min) [Table 7]. In Group B, patient
significant between the two groups. IQR=Interquartile range satisfaction was significantly better (25 excellent/10 good)
compared to Group A  (10 excellent/25 good). Furthermore,
Table 7: SB recovery time, MB recovery time, void surgeon satisfaction was statistically significantly better in
recovery time, patient satisfaction level, surgeon Group  B  (23 excellent/12 good) compared to Group A (14
satisfaction level excellent/21 good)  [Table  7]. As regards side effects, in
Group A, 3 patients had to receive ephedrine due to a significant
Group A (n=35) Group B (n=35) P reduction in MABP while no patients in Group B had significant
SB recovery time 111.88±5.24 103.2±6.1 <0.001* hypotension or bradycardia throughout the intraoperative period.
(min)
MB recovery time 94.4±4.16 86.37±12.92 0.001*
(min) Discussion
Void recovery time 129.29±5.87 114.77±8.24 <0.001*
(min)
Surgeries done with spinal anesthesia have distinct
Patient satisfaction
advantages of decreased blood loss, minimal perioperative
Excellent 10 25 0.001* cardiac ischemic incidents, postoperative hypoxic episodes,
Good 25 10 arterial venous thrombosis, and better postoperative pain
Surgeon satisfaction control.[7] A change in cardiovascular physiology associated
Excellent 14 23 <0.001* with aging decreases cardiovascular reserve and may
Good 21 12 predispose elderly patients to hemodynamic instability
Data are presented as mean±SD or number of patients. *P<0.05 is more over the high incidence of coronary artery diseases
considered statistically significant between the two groups. SD=Standard that render those patients more liable to cardiac ischemia
deviation, SB=Sensory block, MB=Motor block
due to hypotension.[8] This cardiovascular risk increases
with the use of spinal anesthesia, especially in the elderly
We choose our sample size to replace any missing data. The population. There is considerable controversy over the use
statistical analysis was performed using the standard SPSS
of vasopressors to treat the hypotension of spinal anesthesia;
software package version 21 (Chicago, IL, USA). Normally
furthermore, ephedrine treatment of hypotension increases
distributed numerical data are presented as a mean ± standard
HR.[9,10] Furthermore, excessive fluid loading may lead to
deviation and differences between groups were compared using
more complications such as fluid overload and is, therefore,
the independent Student’s t‑test, and categorical variables were
better to be avoided.[9] The increase of the age and the high
analyzed using the Chi‑square test or Fisher’s exact test and are
level of the sensory block are the main reasons for hypotension
presented as number (%). All P values are two‑sided. Value of
after spinal anesthesia. Hypotension occurred due to the
P < 0.05 is considered as statistically significant.
sympathetic nerve block that is 2–4 segments higher than the
level of sensory block. According to Lee et al.,[11] the ratio of
Results occurrence of hypotension on the elderly patients aged more
The demographic data of the two studied groups are summarized than 70 were 48%, which turned out to be significantly higher
in Table 1, statistical analysis revealed nonsignificant differences than the patients aged <60 by 4.2% after using 7 mg of 0.5%
between the two groups as regards age, sex distribution, height, heavy bupivacaine. Therefore, the level of the sympathetic
weight, and duration of surgery. No patients were excluded block is important in our practice and it is important not

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Alsaeid and Sayed: Low‑dose spinal anesthesia with position change versus higher dose in elderly population as regards hemodynamic changes
to unnecessarily increase the height of the block during
spinal anesthesia in those elderly patients. The advantage of
using hyperbaric local anesthetic solutions is the flexibility
of controlling the level with posture. However, it is still
controversial in terms of period needed for seating position
to restrict the level of sympathetic block. For the purpose of
minimizing the degree of the sympathetic block, especially
in those high‑risk elderly patients, many studies tried to use
different techniques and even injecting different intrathecal
drugs to achieve this. In 2014, Singh et al. studied the use of
unilateral intrathecal block with low‑dose heavy bupivacaine
0.5% (7.5 mg) in lower limb orthopedic surgeries, but they
found that the unilateral block was obtained only in 75% of the
patients which became only 65% on turning the patients into
supine position which led to hypotension in some patients.[12]
In 2015, in the study done by Saber and El Metainy,[13] they
concluded the efficiency and better hemodynamic stability
with the use of continuous intrathecal block (CSA) in lower
limb orthopedic surgeries compared to low‑dose intrathecal
heavy bupivacaine 0.5% (7.5 mg), but still CSA carries the
risk of significant postoperative dural puncture headache as
well as infection due to the presence of intrathecal catheter,
especially in those high‑risk elderly patients. The study
demonstrates that the use of small dose  (5  mg) of heavy
bupivacaine 0.5% in spinal anesthesia with immediate position
changing (supine) provides hemodynamic stability without
episodes of severe hypotension or bradycardia and provides
also sufficient anesthesia for lower limb fractures repair in the
elderly compared to higher intrathecal doses (10 mg) even if
we maintain the sitting position for 3 min. In concordance
with our results, Kararmaz et  al.[14] studied the effect of
low‑dose bupivacaine  (only 4  mg) in spinal anesthesia for
trans‑urethral resection of the prostate and they concluded
that it provided sufficient block for the surgery without any
hemodynamic complications, but they had to add 25 µg of
fentanyl intrathecally that caused some adverse effects in the
form of pruritis, nausea, and vomiting which we did not use
in our study as we used larger bupivacaine dose (5 mg) with
immediate patient’s position change (supine). Kim et al.,[15]
who compared the effect of low‑dose intrathecal heavy
bupivacaine given in lateral decubitus position then turning the
patients immediately to supine position compared to the effect
of the same dose given in sitting position with maintaining
this sitting position for 2  min after block, and they found
that the sensory block and the episodes of hypotension and
bradycardia were significantly higher in the supine position
group compared to the sitting group which is in contrast to our
findings. This may be attributed to the fact that in our study;
in the sitting group, we injected larger heavy bupivacaine
dose (10 mg) while Kim et al. injected only 6.5 mg heavy
bupivacaine in their sitting group so this caused higher sensory
block level and more episodes of hypotension and bradycardia
in our setting group than those of the sitting group of Kim et al.
Also, we gave smaller intrathecal bupivacaine dose (5 mg) in
our supine position group than the dose that Kim et al. used
in their supine position group (6.5 mg) so in our supine group
480 Anesthesia: Essays and Researches  ¦  Volume 13  ¦  Issue 3  ¦  July-September 2019
the episodes of hypotension and bradycardia were less than
those of the supine group of Kim et al.
Conclusion
We believe that the use of small dose of heavy bupivacaine
0.5%  (5  mg) with immediate patient position changing to
supine position provides good spinal block characteristics in
elderly population without any hemodynamic side effects, also
with better patient and surgeon satisfaction levels compared to
higher doses of heavy bupivacaine (10 mg) even if we maintain
patient position in the sitting position for 3 min after the block.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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