The Effect of Lithotomy Position on Arterial Blood by zva18483


									REGIONAL ANESTHESIA                    AND    PAIN MANAGEMENT

The Effect of Lithotomy                                              Position                   on Arterial                 Blood Pressure
After Spinal Anesthesia
Masayuki            Miyabe,            MD*,   Hajime        Sonoda,         MD*,     and Akiyoshi          Namiki,            MDt
*Department  of Anesthesia, Kushiro General City Hospital,                           Kushiro,    Japan, and I-Department            of Anesthesiology,              Sapporo
Medical University, School of Medicine, Sapporo, Japan.

        We compared the effect of the lithotomy position on the                          16% at 5 min and continued to decrease to 21%. The
        systolic blood pressure (SBP) with the horizontal   posi-                        extent of the cephalad spread of analgesia 20 min after
        tion after spinal block. The lithotomy position was per-                         spinal block was same between the two groups (T-5 ? 2
        formed 5 min after spinal block. The change in SBP was                           vs T-5 -C 2, respectively).  From these results we con-
        expressed as percent of depression from the baseline                             clude that the lithotomy position after spinal anesthesia
        value. The SBP increased by the lithotomy position (n =                          attenuates the decrease in arterial blood pressure and
        14) from a 16% decrease to an 8% decrease. On the con-                           does not affect the cephalad spread of analgesia.
        trary, in the horizontal  group (n = 14), SBP decreased                                                      (Anesth Analg 1995;81:96-8)

     light head-down tilt is one of the treatments of                                    the right lateral position on a horizontal table. Based

S    hypotension after spinal anesthesia to increase
     venous return and cardiac output (1,2). Similar to
head-down tilt, the lithotomy position may also in-
                                                                                         on the patient’s height (5155 cm, 2.5 mL; ~155 cm,
                                                                                         3 mL), 0.5% tetracaine dissolved in 10% glucose was
                                                                                         injected at a rate of 0.2 mL/s. After subarachnoid
crease venous return and cardiac output after spinal                                     injection, patients were immediately turned to the su-
block. The purpose of this study is to investigate                                       pine position. All patients received an infusion of
whether the lithotomy position affects the systemic                                      lactated Ringer’s solution at a rate of 10 mL/min
blood pressure (SBP) and analgesic level after spinal                                    started before lumbar puncture and continued during
block.                                                                                   the study.
                                                                                            The SBP was measured before the patient was po-
Methods                                                                                  sitioned for lumbar puncture and every 1 min after
                                                                                         injection of the anesthetic with an automated nonin-
The protocol of this study, which was approved by                                        vasive blood pressure device (BP-380 ET; Nippon Co-
our ethics committee, was explained and each pa-                                         lin Co., Ltd., Tokyo, Japan). Cephalad extent of anal-
tient’s consent was obtained. The study was con-                                         gesia was assessedat 5-min intervals for 20 min after
ducted on 28 female patients, ASA physical status I,                                     injection. Analgesia was defined as the inability to
aged 28 - 61 yr, undergoing major elective gynecologic                                   sense pinprick.
surgery (abdominal hysterectomy in the horizontal                                           Fourteen patients were placed in the lithotomy po-
group and transvaginal hysterectomy in the lithotomy                                     sition 5 min after injection of local anesthetic (lithoto-
group). Patients being treated for high or low blood                                     my group). The other 14 patients were maintained in
pressure or receiving any other medications that could                                   the horizontal position (horizontal group). The trends
affect arterial blood pressure or heart rate were ex-                                    of change in the SBP and cephalad spread of analgesia
cluded from this study.                                                                  were compared between the two groups. The change
   One hour before operation the patients were given                                     in SBP was expressed as percent of depression from
2.5-5 mg of midazolam and 0.5 mg of atropine intra-                                      the baseline value.
muscularly. A standard midline lumbar puncture was
                                                                                            Data were expressed as mean + SD. The patient
performed using a 25-gauge needle through the L3-4                                       characteristics between the groups were compared by
interspace. All lumbar punctures were performed in
                                                                                         Student’s t-test. The differences in SBP with or without
                                                                                         the lithotomy position were compared by repeated-
   Accepted    for publication   February     10, 1995.                                  measures analysis variance (two-way analysis of vari-
   Address     correspondence      and reprint        requests       to Masayuki
Miyabe,    MD, The Department         of Anesthesiology,       Institute  of Clin-       ance). As post hoc test the SBP changes from value of
ical Medicine,    University   of Tsukuba,     Tsukuaba      305, Japan.                 5 min after spinal block were compared with Fisher’s

                                                                                                            01995   by the International    Anesthesia       Research       Society
96     Anesth   Analg   1995;81:96-8                                                                                                                     0003.2999/95/$5.00
ANESTH ANALG                                                             REGIONAL       ANESTHESIA                 AND PAIN MANAGEMENT      MIYABE ET AL.                                97
1995;81:96-8                                                             LITHOTOMY,       ARTERIAL                BLOOD PRESSURE, AND SPINAL ANESTHESIA

Table 1. Clinical Characteristics         of the Horizontal     and                                                                  time after spinal block (min)
Lithotomy  Groups                                                                 -2        baseline         1             5            10              15                          20
                                                                                                           1 I              I             I               I                          I
                                  Horizontal              Lithotomy               jj+lO              -
                                                                                                                                                  +           horizontal
                                                                                  2                                    lithotomy
                                                                                                                                                  -A-         lithotomy
   No.                              14                           14
                                  39 -c 6                     45 ? 5*              If           o-
   Age (yr)                                                                       z
                                 (2849)                        (41-61)            n
   Weight (kg)                    53 -c 7                      56 t 5             ii      -10        -
                                 (43-67)                      (47-65)             z
   Height (cm)                  155 t 5                      155 -c 7
                              (149-165)                     (146-166)                 c -20          -
   Tetracaine (mg)             13.4 + 1.2                   13.4 ? 1.3
                                                                                  z                                                                                         511
                             (12.5-15)                     (12.5-15)                                                                   ;s     i                                   55 5
                                                                                  8       -30        -
   Analgesic level after spinal block
       5 min                    T-9 I- 2                    T-9 -c 2            Figure    1. The time sequence          of systolic  blood pressure (SBP)
                                                                                change after spinal block with (n = 14) or without               (n = 14) the
                              (Tll-6)                      (T12-5)
                                                                                lithotomy    position.   The lithotomy     position   was performed     5 min
      10 min                    T-7 t 2                     T-7 +- 1            after spinal block. Data are mean f SD. +P < 0.01, *SrP < 0.05
                              (Tll-5)                        (T9-5)             compared     with the value of the horizontal       group. “P < 0.05, **P <
      15 min                    T-6 t 2                     T-7 k 1             0.01 compared       with the 5 min value of the lithotomy        group.  §P <
                                (T9-4)                       (T7-2)             0.01, @P < 0.05 compared           with the 5 min value of the horizontal
      20 min                    T-5 -c 2                    T-5 ‘-’ 2           group.
                                (T9-3)                       (T8-2)
   Values are mean t SD, with the range given in parentheses.                   normal persons (4-6) as well as in spinal-anesthetized
   * P < 0.01 vs horizontal group.                                              patients (4,7), blood pressure response after head-
                                                                                down tilt varies. Compared to head-down tilt, the
                                                                                effect of the lithotomy position in this study seems to
protected least significant difference test. Nonpara-
                                                                                be greater and consistent. Several factors may be re-
metric analysis (Mann-Whitney U-test) was used to                               sponsible for the differences.
compare the analgesic levels. A P value of less than                               First, the autotransfusion effect may be greater in
0.05 was considered to be significant.                                          the lithotomy than in the head-down tilt position. The
                                                                                reason blood pressure increases after placing the pa-
Results                                                                          tient into the Trendelenburg                           or the lithotomy position
                                                                                 is explained  by the return                         of the pooled venous blood
The mean age in the lithotomy group was higher than                              from the lower extremities (500-1000 mL) to the heart
in the horizontal group (Table 1). There were no sta-                            (autotransfusion effect) (1). In this study, the standard
tistically significant differences in mean weight,                               lithotomy position was used; both thighs were lifted
height, and cephalad spread of analgesia between the                             90” toward the trunk and the lower legs were hung on
lithotomy and the horizontal groups.                                             poles with ties. In this position the highest point
    The total volume of lactated Ringer’s solution in-                           (knees) may be approximately 40 cm above the heart
fused during study was 50 mL before spinal block and                             (depending on the individual thigh length), whereas
200 mL after block in both groups. In both groups the                            in a 10” head-down tilt position the highest point is at
average SBP, 5 min after spinal block, decreased 16%                             the feet and which is only approximately 15-20 cm
from baseline. In the lithotomy group, SBP increased                             above the heart (depending on the individual height).
to 8% depression level and maintained at 8%-13%                                  Therefore it is likely that the increase in venous return
depression level for the entire study period (Fig. 1).                           was greater in the lithotomy than in head-down tilt
On the contrary in the horizontal group, SBP contin-                             position.
ued to decrease to 21% depression level by 10 min                                    Second, it is also possible that the beneficial effects
after the block and maintained at this depressed level                           of the lithotomy position on systemic blood pressure
for the entire study period.                                                     after spinal anesthesia may be related to increased
                                                                                 afterload due to the elevation of the lower extremities.
                                                                                 Again,                  this    effect is greater     in the lithotomy                    position
                                                                                 than in the head-down tilt position, because the high-
This study has shown that the lithotomy position after                           est point above the heart is higher in the lithotomy
spinal anesthesia is effective in increasing blood pres-                         position than in the head-down tilt position, as men-
sure. We previously reported that the effect of head-                            tioned before. Compression of the lower extremity
down tilt alone on the arterial blood pressure after                             arterial vasculature is not great in this study because
spinal anesthesia was limited to severe hypotensive                              only the feet were tied to lift the legs.
cases, and that the effect was small and was not                                    The third factor involves the cephalad spread of
necessarily consistent (3). Others have reported that in                         analgesic levels. The analgesic level of spinal block is
98    REGIONAL     ANESTHESIA    AND PAIN MANAGEMENT             MIYABE    ET AL.                                                                         ANESTH         ANALG
      LITHOTOMY,     ARTERIAL   BLOOD  PRESSURE, AND    SPINAL      ANESTHESIA                                                                                     1995;81:96-8

increased by the head-down              tilt (3). Since sensory                 be interesting   to know whether     the blood pressure
levels of spinal anesthesia to T-3 are associated with                          difference was maintained or if spinal anesthesia con-
total sympathetic      denervation     (l), increase of analge-                 tinued to advance cephalad after 20 min. However,
 sic levels up to T-3 may cause further decrease of the                         since there were several factors, such as the difference
blood pressure. We have shown in this study that the                            of operation between two groups and the effect of
analgesic level is not affected by placing patients in the                      sedation, it was difficult to assess the effect of the
lithotomy position. Therefore, unlike head-down                   tilt,         lithotomy position on blood pressure after starting the
the lithotomy position does not cause further decrease                          operation. Analgesic level after 20 min of spinal block
of blood pressure due to a higher level of block. This                          is almost at plateau if the position is not changed (7).
may have also contributed         to the greater effectiveness                  In this study, analgesic level was not measured during
in lithotomy than head-down           tilt position.                            operation, but after the end of operation (1-1.5 h) it
     Fourth, Moriyama      (8) reported that when only the
                                                                                decreased one to two segments.
head was tilted down while the body was kept hori-
                                                                                    We conclude that the lithotomy position after spinal
zontal, systemic blood pressure decreased. They at-
                                                                                anesthesia reduces the decrease in blood pressure and
 tributed this to carotid baroreflex, which also may be
                                                                                does not affect the analgesic level. Taken together with
activated during the head-down               tilt. Although      this
lasts only a short time (30 heart beats), it is completely                      our previous study (3), these results indicate that the
opposite to the effect of head-down               tilt which is be-             lithotomy position is apparently superior to the head-
lieved to increase blood pressure (1). In head-down                             down tilt position.
tilt, carotid baroreflex probably occurs first, followed
by increase of venous return. On the contrary, in the                           The authors          gratefully     thank    Dr. T. J. K. Toung,    Department   of
lithotomy position, head position is not changed and                            Anesthesiology           and Critical       Care Medicine,     The Johns Hopkins
baroreflex does not occur. This explains the consistent                         Medical     Institutions,       for helping     us to revise this manuscript.
result from lithotomy position.
     Gaffney et al. (9,10), reported that passive leg rais-
ing (60”) or application of antishock trousers does not
produce a significant or sustained autotransfusion                  ef-         References
 fect in healthy volunteer. They attributed the reason to
                                                                                     1. Greene NM. Physiology                of spinal anesthesia.     3rd ed. Baltimore:
 the fact that, in a healthy person, intravascular           volume
                                                                                        Williams        & Wilkins,      1981.
 in the leg is relatively small (loo-250 mL) and is only                             2. Greene         NM.   Preganglionic         sympathetic     blockade       in man: a
partly displaceable. Therefore, the effects of transloca-                               study of spinal anesthesia.               The Torston     Gordh     Lecture,    1980.
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                                                                                        blood pressure          after spinal anesthesia.         Anesth Analg 1993;76:
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     Age in horizontal    group was lower than in lithot-                               spinal anesthesia.          Anesth Analg 1991;73:385-90.
 omy group in this study (Table 1). To evaluate the                                  5. Pricolo VE, Burchard              K, Singh A. Trendelenburg           versus PASG
 effect of age on outcome in this study, we separated                                   ;yi!i;;.tion-hemodynamic                response     in man. J Trauma        1986;26:
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 group (age ~39 yr; mean, 33 +- 4 yr; y1 = 6) and an                                    Trendelenburg          position:     hemodynamic        effects in hypotensive
 older group (age 240 yr; mean, 43 ? 3 yr, n = B), and                                  and normotensive           patients.    Crit Care Med 1979;7:218-24.
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 sure after spinal anesthesia. As a result, mean values                                 position    on spinal anaesthesia           with hyperbaric       bupivacaine.         Br
                                                                                        J Anaesth      1982;54:497-500.
 in the older group were always slightly lower than in                               8. Moriyama         K. Cardiovascular          response   to cerebral       circulatory
 the younger group, but there was no statistically               sig-                   regulation      during    shifts in head position.       Nichiidai-shi        1989;56:
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 the age of the horizontal group was higher, the result                              9. Gaffney    FA, Thal ER, Traylor WF, et al. Hemodynamic                      effects of
                                                                                        medical anti-shock          trousers (MAST garment).           J Trauma 1981;21:
 must be the same, or even more obvious, in compar-
 ison to this study.                                                                10. Gaffney    FA, Bastian BC, Thal ER, et al. Passive leg raising does
     The effect of the lithotomy       position was observed                            not produce         a significant      or sustained     autotransfusion          effect.
 only 20 min after spinal block in this study. It would                                 J Trauma      1982;22:190-3.

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