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Cardiovascular Effects of Intrathecal Hyperbaric Prilocaine or Bupivacaine in Surgery Under Spinal Anesthesia

Primary Purpose

Spinal Anesthesia, Cardiac Toxicity

Status
Recruiting
Phase
Not Applicable
Locations
Belgium
Study Type
Interventional
Intervention
Hyperbaric bupivacaïne
Hyperbaric prilocaïne
Sponsored by
Centre Hospitalier Universitaire Saint Pierre
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional diagnostic trial for Spinal Anesthesia focused on measuring Hyperbaric Bupivacaine, Hyperbaric Prilocaine, Non-Invasive Hemodynamic Assessment, Clear Sight Edwards, Cardiac Ultrasound, Cardiac Output, Stroke Volume Variation

Eligibility Criteria

18 Years - 65 Years (Adult, Older Adult)MaleDoes not accept healthy volunteers

Inclusion Criteria: Male 165 cm < x < 180 cm Aged of 18 or more and less than 65 Elective surgery under spinal anesthesia American Society of Anesthesiology (ASA) I or II Exclusion Criteria: History of heart disease: ischemic or valvular Atrial fibrillation Cardiotropic medication Cardiovascular disease history Norepinephrine uptake medication Urgent surgery History of narrow spinal canal Hemostasis abnormalities or local skin infection Hypersensitivity to local anesthetics Failure of spinal anesthesia leading to plan change during surgery Patient's refusal

Sites / Locations

  • Saint Pierre University HospitalRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Active Comparator

Active Comparator

Arm Label

Group 1: Hyperbaric Bupivacaine

Group 2: Hyperbaric Prilocaine

Arm Description

Outcomes

Primary Outcome Measures

Change in cardiac output assessed by Clear Sight device
Cardiac output (liters per minute) will be assessed by the Clear Sight non-invasive hemodynamic system before spinal anesthesia (baseline), 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Change in cardiac output assessed by transthoracic Ultrasound
Cardiac output (liters per minute) will be assessed by ultrasound assessment before spinal anesthesia (baseline), 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Stroke Volume Variation assessed by the Clear Sight device
Stroke volume variation (%) will be assessed by the Clear Sight non-invasive hemodynamic system before spinal anesthesia, 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Stroke Volume Variation assessed by transthoracic Ultrasound
Stroke volume variation (%)will be assessed by ultrasound assessment before spinal anesthesia, 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).

Secondary Outcome Measures

Highest dermatome level
Highest dermatome level is assessed by the loss of sensitivity to cold at 20 minutes after spinal anesthesia.
Motor block
Maximal intensity is assessed by the use of Bromage score at 20 minutes after spinal anesthesia. Bromage Score is a validated score which assesses patient's capacity to move lower limbs. It goes from 0 = free movement of legs and feet to 3 = unable to move legs or feet.
Adrenocorticotropic Hormone (ACTH)
Adrenocorticotropic Hormone (ACTH) in pg/mL will be measured in blood samples before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Cortisol
Cortisol in microgram/dL will be measured in blood samples before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Dosage of Neuro-Inflammatory Markers
Interleukine-1, Interleukine-6, and Interleukine-10 will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Angiotensine
Angiotensine in microgram/L will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Pro-BNP
Pro-BNP ng/L will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Total Vasopressor Dose
Total Vasopressor Dose used throughout the intervention to maintain Arterial Pressure within a pre-defined individualized ranges ( >= 65 mmHg).
Bradycardia episodes
Bradycardia episodes are counted as single events when patient's heart rate drops below 20% of basal heart rate in beats per minute. These episodes are treated at the physicians discrepancy with 0,5 mg of atropine.
Surgeon's Satisfaction
Surgeon's satisfaction will be assessed using an arbitrary scale: 1 - Satisfied, 2 - Some discomfort, 3 - Fully unsatisfied
Patient's satisfaction
Patient's satisfaction will be assessed using an arbitrary scale: 1 - Satisfied, 2 - Some discomfort, 3 - Fully unsatisfied

Full Information

First Posted
January 22, 2023
Last Updated
March 23, 2023
Sponsor
Centre Hospitalier Universitaire Saint Pierre
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1. Study Identification

Unique Protocol Identification Number
NCT05751148
Brief Title
Cardiovascular Effects of Intrathecal Hyperbaric Prilocaine or Bupivacaine in Surgery Under Spinal Anesthesia
Official Title
Cardiovascular Effects of Intrathecal Hyperbaric Prilocaine or Bupivacaine in Surgery Under Spinal Anesthesia: A Multicenter Prospective Pilot Study Based on Non- Invasive Haemodynamic Monitoring
Study Type
Interventional

2. Study Status

Record Verification Date
March 2023
Overall Recruitment Status
Recruiting
Study Start Date
March 22, 2023 (Actual)
Primary Completion Date
September 30, 2023 (Anticipated)
Study Completion Date
September 30, 2023 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Centre Hospitalier Universitaire Saint Pierre

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Spinal anesthesia remains a mainstay in lower limbs- as in day-case surgeries as well. It consists in injecting a local anesthetic drug into the intrathecal space of a patient's spinal canal. To achieve a suitable sensory and motor block for elective or emergent surgery, the anesthetist must adapt his choice of local anesthetic to the surgery's requirements and the patient's comorbidities, too. Spinal anesthesia is often associated with adverse cardiovascular events, notably hypotension which is a major concern in current anesthetic practice, especially in specific patient populations. Spinal induced hypotension is reported to be commonly related to the sympathetic block level and may be linked to perioperative cardiac and renal complications. Several mechanisms might play a role in the incidence of perioperative hypotension after spinal puncture. A decrease in peripheric systemic vascular resistance from arterial vasodilatation, a reduction of cardiac output due to a decrease in preload from a redistribution of venous blood into lower limbs or even an occurrence or increment of cardiac dysfunction, might compound proper blood flow towards noble organs such as brain, heart and kidneys. Spinal induced hypotension may also be related to a direct reduction of cardiac contractibility by the local anesthetic injection. Compensating mechanisms might be inhibited depending on the level of sympathetic blockade, usually related to the dose of the local anesthetic. Former studies found that intrinsic left ventricular depression might occur during spinal anesthesia as left ventricular volumes per se remain stable. One noticed that diastolic and systolic function (i.e., ventricular outflow tract velocity) decreased significantly after intrathecal levobupivacaine plus fentanyl injection based on transthoracic ultrasound assessment. Other authors use Pro-Brain Natriuretic Peptide to assess myocardial stress induced by surgery and anesthetic management. Other serum markers such as Cortisol, Adreno Cortico-Trope Hormone, Angiotensin are identified to screen and monitor myocardial stress as for instance acute myocardial dysfunction. Hyperbaric prilocaine is an intermediate-acting local anesthetic, whereas bupivacaine may be intermediate- or long-acting depending on the employed dose. Both drugs provide comparable sensory and motor block that meet the anesthesia level requirements in various surgical procedures. In regard to the hemodynamic effects, hypotension has been largely reported following hyperbaric bupivacaine in a dose-dependent way. However, discrepancy exists between the rare studies having investigated prilocaine's effects, probably related to the methodology and the employed doses. Moreover, the hemodynamics effects of these local anesthetics have been barely specifically investigated in a non-cesarean section context. The aim of this study is to compare the cardiovascular effects inflicted by hyperbaric prilocaine and bupivacaine under spinal anesthesia. Cardiovascular response will be assessed by non-invasive hemodynamic monitoring whereas metabolic stress will be evaluated using serum stress markers.
Detailed Description
The investigators will conduct a double blinded pilot study in adult patients scheduled for elective surgery under spinal anesthesia. Selected interventions with few hemodynamic variations and minimal liquid shifts are knee arthroscopy, orthopedic lower limb surgery using a tourniquet, uni- or bilateral saphenectomy, ureteric stent insertion, inguinal hernia repair, vasectomy and penile circumcision. Population Patients will be included in the study, after reading, understanding, and signing the consent documents explaining the goals and the procedure of the study protocol. The study will take place in the departments of Anesthesiology and Pain Medicine of the Saint-Pierre University Hospital and Edith Cavell Interregional Hospital Group - Site Braine l'Alleud, in collaboration with their respective departments of surgery. Considering that the present study is a pilot study, the number of patients to be included has been determined to be 30 in each study group for a total of 60 patients. The trial will end when the whole enrolled population will be subjected to the current protocol on elective surgery under spinal anesthesia. The primary goal is to assess patients' cardiac output variation between the pre-spinal period and 20 minutes after intrathecal anesthesia. Following ethics committee approval and informed signed consent, enrolled patients will be assigned after randomization into 2 groups Group 1 : Spinal anesthesia using 10 mg of hyperbaric bupivacaine 0,5% Group 2 : Spinal anesthesia using 50 mg of hyperbaric prilocaine 2% In both groups, spinal anesthesia will be performed by an attending anesthetist different than the one doing the ultrasound assessment to assure double blindness of this study. To preserve double blindness, 0,5 ml of NaCl 0,9% is added to the bupivacaine solution. Anesthetic management i. Pre-procedural Pre-operative patient consultation Aim: evaluate overall perioperative risks and to assess patient's eligibility for the current study. Usual biological screening comprising blood count, coagulation tests and kidney function will be prescribed at the attending's discretion. Patient will be given information about the study protocol and, if eligible, an informed consent will be signed. Anxiolysis To reduce the impact of psychological stress on the day of surgery, patients are premedicated with 0,5 mg alprazolam. ii. Intra-procedural Setup After admission in the day-care department, the patient is correctly installed, undressed and prepared for surgery. Before carried to the operating theater, a blood sample is obtained to measure basal values of serum markers reflecting cardiac stress i.e.: • Cortisol • ACTH Pro-BNP Angiotensin IL-1 - IL - 6 IL-10 After the blood sample is obtained, vital parameters are collected such as heart rate, arterial pressure and oxygen saturation. Pre-loading A peripheral intravenous line is threaded, and a crystalloid solution perfused at a flow rate determined by the Holliday - Segar 4-2-1 - rule using a Dial-A-Flow device (Wolf Medical Supply, Sunrise, Florida, United States). Pre-operative hypovolemia may increase spinal anesthesia induced hypotension. Inferior vena cava collapsibility during respiratory cycles, measured with an ultrasound device, has shown interest in prediction fluid responsiveness in critical ill patients with septic shock. Preau et al. showed a positive correlation between higher valued of IVCc and fluid responsiveness in patients with spontaneous breathing. Patients whom IVCc exceeds 40% during basal measuring prior to spinal puncture, are pre-loaded with a fluid challenge of 100 ml of a colloid solution for 5 minutes. This procedure is repeated till obtaining a normovolemic state. Another measurement of the patient's IVCc is done after the 5-minute fluid challenge. If the value of IVCc is less than 48%, the investigators then proceed to transthoracic echocardiographic assessment. First cardiac ultrasound assessment Before spinal anesthesia, an extended cardiac ultrasound assessment is realized by the same operator for the entire study duration. Following values are either measured or derived from previous ones: • Left ventricular ejection fraction (LVEF) • Left ventricular outflow tract velocity integral (VTI) • Stroke volume (SV) • Cardiac output (CO) • Fractional shortening of the left ventricle (FR) • Systemic vascular resistance (SVR) (calculated) (PAM - PVC / CO x 80) • Diastolic inflow: E and A peak velocities • E/A ratio & E/E' • Tissue Doppler imaging (TDI) for septal and lateral mitral annulus motion (E') • TDI for systolic velocity of the tricuspid annulus (S') Tricuspid annular plane systolic excursion (TAPSE) Peak tricuspid regurgitation velocity Pulmonary artery systolic pressure (PAPs) All the Doppler variables are determined by averaging the values measured over three consecutive cardiac cycles. Novel non-invasive hemodynamic assessment using Clear Sight Hemodynamic variables such as VVE, SV, SVR and Cardiac Output can be easily obtained with the new Clear Sight device from Edwards Electronics. The latter has been approved and validated for its reliability according to other more invasive cardiac output measuring devices. Moreover, the Clear Sight is used as a guarantor of plausible hemodynamic values obtained by transthoracic ultrasound in this setting. The Clear Sight device has the advantage of being fully handy and ready to use after a fast initial calibration with its Heart-rate-sensor. Spinal anesthesia Spinal anesthesia (SA) is always performed in a sitting position by a different staff anesthetist than the one doing cardiac assessment. To do so, manual palpation and ultrasound spotting identifies L3-L4 intervertebral space. Using a 25-Gauge Withacre needle (BD, Franklin Lakes, NJ, USA) in a midline approach, either 50 mg of hyperbaric prilocaine (2,5 mL) or 10 mg of hyperbaric bupivacaine + 0,5 mL NaCL 0,9% (2,5 mL) are injected into intrathecal space after positive barbotage test. After the procedure, the patient remains immediately in a supine position. HR and NIBP are continually measured at 5-minute intervals until the end of surgery. The dermatome level of the sensory block is obtained with the cold- and the pin-prick test bilaterally. Attainment of an at least Th7 level signifies a good quality block for urological-, gynecological-, lower abdominal- and lower limb surgery, respectively. Second cardiac ultrasound assessment, clear sight assessment and cardiac biomarkers The second cardiac evaluation will be done twenty minutes after intrathecal injection. If the sensory block is found to be insufficient (i.e. below Th7) twenty minutes after spinal puncture, another five minutes are awaited to undergo second echocardiographic assessment. All the mentioned values from the first cardiac assessment are collected. Another blood sample is obtained for cardiac stress markers determination. Surgery Surgery rarely exceeds one hour. If used, tourniquet is inflated to 350 mmHg. Minimal blood loss is expected during all selected interventions. This procedural environment allows to practically characterize our subjects as "healthy" subjects undergoing spinal anesthesia. • Spinal anesthesia failure In case of insufficient sensory block, the anesthetic plan is converted into general anesthesia and the patient is excluded from per procedural analyses. • Hypotension Protocol Hypotension is defined as a Mean BP (MBP) < 65 mmHg. It is treated using intravenous ephedrine: 6-mg boluses every five minutes if necessary. • Bradycardia Protocol Bradycardia is defined as a decrease of 20% of basal heart rate. Symptomatic bradycardia is treated with intravenous atropine: 0,5 mg repeated, if necessary, based on physician's discretion. iii. Postoperative Postoperative analgesia Postoperative analgesia is administrated as soon as the patient returns to ward. A multimodal approach using paracetamol and non-steroidal anti-inflammatory drugs is applied. First NSAID dose is given per os preoperatively. Post-operative analgesic medication consists of paracetamol, NSAID and second stage analgesics such as tramadol if necessary. Third stage analgesics such as morphine and piritramide are barely used but administered if necessary, at the anesthetist's discretion. Third cardiac ultrasound assessment, clear sight assessment and cardiac biomarkers After complete offset of sensory and motor block, patients undergo a last transthoracic ultrasound examination. Variables are compared to those gathered from the Clear Sight non-invasive hemodynamic device. A further blood sample is obtained, and the patient is discharged from PACU.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Spinal Anesthesia, Cardiac Toxicity
Keywords
Hyperbaric Bupivacaine, Hyperbaric Prilocaine, Non-Invasive Hemodynamic Assessment, Clear Sight Edwards, Cardiac Ultrasound, Cardiac Output, Stroke Volume Variation

7. Study Design

Primary Purpose
Diagnostic
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
ParticipantOutcomes Assessor
Allocation
Randomized
Enrollment
60 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Group 1: Hyperbaric Bupivacaine
Arm Type
Active Comparator
Arm Title
Group 2: Hyperbaric Prilocaine
Arm Type
Active Comparator
Intervention Type
Drug
Intervention Name(s)
Hyperbaric bupivacaïne
Other Intervention Name(s)
Hyperbaric Marcaïne
Intervention Description
Spinal anesthesia with 10mg of hyperbaric bupivacaïne. A syringe filled with 2 mL of hyperbaric bupivacaïne + 0,5 ml of saline solution
Intervention Type
Drug
Intervention Name(s)
Hyperbaric prilocaïne
Other Intervention Name(s)
Tachipri
Intervention Description
Spinal anesthesia with 50mg of hyperbaric prilocaïne. A syringe filled with 2,5 mL of hyperbaric prilocaïne
Primary Outcome Measure Information:
Title
Change in cardiac output assessed by Clear Sight device
Description
Cardiac output (liters per minute) will be assessed by the Clear Sight non-invasive hemodynamic system before spinal anesthesia (baseline), 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Time Frame
Up to two hours post surgery
Title
Change in cardiac output assessed by transthoracic Ultrasound
Description
Cardiac output (liters per minute) will be assessed by ultrasound assessment before spinal anesthesia (baseline), 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Time Frame
Up to two hours post surgery
Title
Stroke Volume Variation assessed by the Clear Sight device
Description
Stroke volume variation (%) will be assessed by the Clear Sight non-invasive hemodynamic system before spinal anesthesia, 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Time Frame
Up to two hours post surgery
Title
Stroke Volume Variation assessed by transthoracic Ultrasound
Description
Stroke volume variation (%)will be assessed by ultrasound assessment before spinal anesthesia, 20 minutes after spinal anesthesia and before discharge from the post anesthesia care unit (PACU).
Time Frame
Up to two hours post surgery
Secondary Outcome Measure Information:
Title
Highest dermatome level
Description
Highest dermatome level is assessed by the loss of sensitivity to cold at 20 minutes after spinal anesthesia.
Time Frame
20 minutes after spinal anesthesia
Title
Motor block
Description
Maximal intensity is assessed by the use of Bromage score at 20 minutes after spinal anesthesia. Bromage Score is a validated score which assesses patient's capacity to move lower limbs. It goes from 0 = free movement of legs and feet to 3 = unable to move legs or feet.
Time Frame
20 minutes after spinal anesthesia
Title
Adrenocorticotropic Hormone (ACTH)
Description
Adrenocorticotropic Hormone (ACTH) in pg/mL will be measured in blood samples before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Time Frame
Up to two hours post surgery
Title
Cortisol
Description
Cortisol in microgram/dL will be measured in blood samples before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Time Frame
Up to two hours post surgery
Title
Dosage of Neuro-Inflammatory Markers
Description
Interleukine-1, Interleukine-6, and Interleukine-10 will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Time Frame
Up to two hours post surgery
Title
Angiotensine
Description
Angiotensine in microgram/L will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Time Frame
Up to two hours post surgery
Title
Pro-BNP
Description
Pro-BNP ng/L will be measured in blood samples before before spinal anesthesia, 20 minutes after spinal anesthesia and just before discharging from PACU.
Time Frame
Up to two hours post surgery
Title
Total Vasopressor Dose
Description
Total Vasopressor Dose used throughout the intervention to maintain Arterial Pressure within a pre-defined individualized ranges ( >= 65 mmHg).
Time Frame
Up to two hours post surgery
Title
Bradycardia episodes
Description
Bradycardia episodes are counted as single events when patient's heart rate drops below 20% of basal heart rate in beats per minute. These episodes are treated at the physicians discrepancy with 0,5 mg of atropine.
Time Frame
Up to two hours post surgery
Title
Surgeon's Satisfaction
Description
Surgeon's satisfaction will be assessed using an arbitrary scale: 1 - Satisfied, 2 - Some discomfort, 3 - Fully unsatisfied
Time Frame
Through surgery completion, an average of one hour after spinal anesthesia
Title
Patient's satisfaction
Description
Patient's satisfaction will be assessed using an arbitrary scale: 1 - Satisfied, 2 - Some discomfort, 3 - Fully unsatisfied
Time Frame
Up to two hours post surgery

10. Eligibility

Sex
Male
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
65 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Male 165 cm < x < 180 cm Aged of 18 or more and less than 65 Elective surgery under spinal anesthesia American Society of Anesthesiology (ASA) I or II Exclusion Criteria: History of heart disease: ischemic or valvular Atrial fibrillation Cardiotropic medication Cardiovascular disease history Norepinephrine uptake medication Urgent surgery History of narrow spinal canal Hemostasis abnormalities or local skin infection Hypersensitivity to local anesthetics Failure of spinal anesthesia leading to plan change during surgery Patient's refusal
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Daniel Patricio, MD.
Phone
025354286
Ext
+32
Email
daniel.patricio@stpierre-bru.be
First Name & Middle Initial & Last Name or Official Title & Degree
Panayota Kapessidou, MD. PhD.
Phone
025353750
Ext
+32
Email
panayota.kapessidou@stpierre-bru.be
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Panayota Kapessidou, MD. PhD.
Organizational Affiliation
Centre Hospitalier Universitaire Saint Pierre
Official's Role
Study Director
Facility Information:
Facility Name
Saint Pierre University Hospital
City
Brussels
ZIP/Postal Code
1000
Country
Belgium
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Daniel Patricio, MD.
Phone
02 535 42 86
Ext
+32
Email
daniel.patricio@stpierre-bru.be
First Name & Middle Initial & Last Name & Degree
Panayota Kapessidou, MD. PhD
Phone
02 535 37 50
Ext
+ 32
Email
panayota.kapessidou@stpierre-bru.be
First Name & Middle Initial & Last Name & Degree
Daniel Patricio, MD.

12. IPD Sharing Statement

Plan to Share IPD
No

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Cardiovascular Effects of Intrathecal Hyperbaric Prilocaine or Bupivacaine in Surgery Under Spinal Anesthesia

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