Spinal anaesthesia with 4 mg versus 3 mg of hyperbaric bupivacaine plus 10 µg of fentanyl for adult anorectal surgery: faster recovery with prolonged analgesia

Background: The study was designed to test the hypothesis that fentanyl added to low-dose spinal hyperbaric bupivacaine reduces the effective dose of bupivacaine with faster recovery and similar quality of anaesthesia for anorectal surgery. Methods: 132 adult consecutive American Society of Anaesthesiology (ASA) 1–3 patients were randomized to receive spinal anaesthesia (SA) in the sitting position with hyperbaric bupivacaine (Marcaine Spinal Heavy 0.5%) injected over 2 minutes: Group S4 (n = 66) 0.8 mL, Group S3F (n = 66) 0.6 mL + fentanyl 10 µg to 0.8 mL. After sitting for 10 minutes, surgery was started. The rate of success, level and duration of sensory and motor block, time to voiding, ambulation, complications, consumption of analgesics, quality of anaesthesia according to the patient and medical staff (0–2 score) were assessed. Student’s t, Mann-Whitney, Analysis of variance (ANOVA), Kruskall-Wallis and χ2 tests were used. Characteristics of SA are presented as mean ± standard deviation (SD), no of cases (%), median (range), p < 0.05* regarded as statistically significant. Results: Maximum level of sensory block was 7.7 ± 1.4 vs. 7.0 ± 1.8 dermatomes, Group S3F vs. Group S4. Level of motor block was 0 Bromage score in >85% of cases in both groups. Mean duration of sensory block was 212.7 ± 35.1* vs. 229.5 ± 36.5 minutes, Group S3F vs. Group S4. Median time to urinate was 260 (120–960)* vs. 315 (160–1140) minutes, Group S4 vs. Group S3F. Quality of anaesthesia was comparable among groups. Pruritus was recorded in 4 cases vs. 0, Group S3F vs. Group S4 (p < 0.05). Conclusions: 3 mg of spinal hyperbaric bupivacaine combined with fentanyl produce an adequate level of anaesthesia similar to 4 mg but with faster recovery and prolonged analgesia for adult anorectal surgery. Clinical Trial Registration: The trial was registered retrospectively in ISRCTN registry as ISRCTN84658134 and can be viewed at https://www.isrctn.com/ISRCTN84658134.

Spinal; Bupivacaine; Fentanyl; Anorectal; Anaesthesia

[1] Ahmed Jonayed S, Alam MS, Al Mamun Choudhury A, Akter S, Chakraborty S. Efficacy, safety, and reliability of surgery on the lumbar spine under general versus spinal anesthesia—an analysis of 64 cases. Journal of Clinical Orthopaedics and Trauma. 2021; 16: 176–181.

[2] Kumar S, Santha N. Low dose and the conventional dose of 0.5% hyperbaric bupivacaine produce comparable outcomes in the lower segment caesarean section. An observational study. Annals of African Medicine. 2022; 21: 390–394.

[3] Ferrarezi WPP, Braga ADFDA, Ferreira VB, Mendes SQ, Brandão MJN, Braga FSDS, et al. Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial. Brazilian Journal of Anesthesiology. 2021; 71: 642–648.

[4] Sangadala P, Talawar P, Tripathy DK, Kaushal A, Gupta A, Raj N. Comparison of block characteristics and outcomes in opioid-free and opioid-based thoracic continuous spinal anaesthesia in patients undergoing major abdominal surgery: a double-blinded randomised controlled trial. Indian Journal of Anaesthesia. 2024; 68: 280–286.

[5] Alnaeli GR, Hwisa SA, Ajaj ARI, Alhuwayj KAO, Elmaggoze SAE. The impact of adding fentanyl to bupivacaine on spinal anesthesia for caesarean. Libyan Journal of Medical Research. 2023; 17: 108–117.

[6] Gudaityte J, Marchertiene I, Karbonskiene A, Saladzinskas Z, Tamelis A, Toker I, et al. Low-dose spinal hyperbaric bupivacaine for adult anorectal surgery: a double-blinded, randomized, controlled study. Journal of Clinical Anesthesia. 2009; 21: 474–481.

[7] Shim SM, Park JH, Hyun DM, Jeong EK, Kim SS, Lee HM. The effects of adjuvant intrathecal fentanyl on postoperative pain and rebound pain for anorectal surgery under saddle anesthesia. Korean Journal of Anesthesiology. 2018; 71: 213–219.

[8] Gurbet A, Turker G, Girgin NK, Aksu H, Bahtiyar NH. Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in out-patient anorectal surgery. The Journal of International Medical Research. 2008; 36: 964–970.

[9] Al-Bahar MSIA, Al-Hosainy AM, El-Garhy AMM. Combination of ultra doses bupivacaine plus fentanyl for spinal anesthesia in out-patient anal surgeries. Al-Azhar Medical Journal. 2021; 50: 1599–1612.

[10] Wang H, Peng X, Zhan L, Xiao Y, Zhao B. Effects of intrathecal bupivacaine and bupivacaine plus fentanyl in elderly patients undergoing total hip arthroplasty. Journal of the College of Physicians and Surgeons Pakistan. 2019; 29: 1133–1137.

[11] Honca M, Dareli N, Kose EA, Honda T, Kutuk S, Unal S, et al. Low-dose levobupivacaine plus fentanyl combination for spinal anesthesia in anorectal surgery. Brazilian Journal of Anesthesiology. 2015; 65: 461–465.

[12] Attari MA, Mortazavi Najafabadi F, Talakoob R, Abrishamkar S, Taravati H. Comparison of the effects of 3 methods of intrathecal bupivacaine, bupivacaine-fentanyl, and bupivacaine-fentanyl-magnesium sulfate on sensory motor blocks and postoperative pain in patients undergoing lumbar disk herniation surgery. Journal of Neurosurgical Anesthesiology. 2016; 28: 38–43.

[13] Lawrie CM, OOng AC, Hernandez VH, Rosas S, Post ZD, Orozco FR. Incidence and risk factors for postoperative urinary retention in total hip arthroplasty performed under spinal anesthesia. The Journal of Arthroplasty. 2017; 32: 3748–3751.

[14] Kairaluoma P, Bachmann M, Kallio H, Rosenberg P, Pere P. Hyperbaric articaine with or without fentanyl in spinal anaesthesia: patient and observer blinded comparison. Acta anaesthesiologica Scandinavica. 2013; 57: 118–125.

[15] Fonseca NM, Guimarães GMN, Pontes JPJ, Azi LMTA, de Ávila Oliveira R. Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials. Brazilian Journal of Anesthesiology. 2023; 73: 198–216.

[16] Rhee WJ, Chung CJ, Lim YH, Lee KH, Lee SC. Factors in patient dissatisfaction and refusal regarding spinal anesthesia. Korean Journal of Anesthesiology. 2010; 59: 260–264.

[17] Botea MO, Lungeanu D, Petrica A, Sandor MI, Huniadi AC, Barsac C, et al. Perioperative analgesia and patients’ satisfaction in spinal anesthesia for cesarean section: fentanyl versus morphine. Journal of Clinical Medicine. 2023; 12: 6346.