The impact of seasonal changes on spinal anesthesia-related complications: a prospective observational longitudinal study

Abstract

AimIn this tudy, it was aimed to investigate the complications that may develop during and after the anesthesia in patients undergoing spinal anesthesia, and the seasonal relationships of the monitored parameters in this study.MethodsA total of 190 patients with ASA I-II group, aged between 18-65 years, who were scheduled for lower extremity operation, were included in the study after obtaining the ethics committee approval and the consent of the patients. The patients were divided into four groups: Group Su, Group Au, Group Wi, and Group Sp. Patient heart rate, blood pressure, peripheral oxygen saturation values were recorded. A subarachnoid puncture was performed with a 25G Quincke spinal needle and the number of attempts required for successful puncture was recorded. For spinal anesthesia, standard dose of 3 ml (15 mg) of 0.5% levobupivacaine was administered to all groups. All patients were visited on 6-12-24-48-72nd postoperative hours and on the 7th postoperative day, and the discharged patients were asked about complications via telephone.ResultsThe number of atropine injections due to complications of intraoperative bradycardia was significantly higher in Group Su than in the other groups (p = 0.010). Although there was no statistical difference between groups in terms of headache complications (p=0.394), it was quantitatively higher in Group Su. The low back pain incidence was significantly higher in Group Su (37.7%, p=0.01).ConclusionIn this study, we concluded that intraoperative and postoperative complications were more common in the summer period in patients who underwent spinal anesthesia.

Keywords

Introduction

Spinal anesthesia is commonly preferred as a regional anesthesia technique that is applied by local anesthetic injection into the subarachnoid area and leads to transient sensory, motor, and sympathetic block. The spinal anesthesia procedure, widely used in lower extremity operations, was performed for the first time with cocaine by August Bier in 1898.¹
The most important advantages of spinal anesthesia include the ability of the patient to remain conscious during the surgery, the presence of spontaneous respiration, preservation of cough and swallowing reflexes, low incidence of postoperative nausea and vomiting, postoperative analgesia, rapid mobilization, and early initiation of feeding.² However, although spinal anesthesia is an easy, inexpensive, and safe method of anesthesia, it can cause a series of complications ranging from limited back pain to disability and even death.^3-4
For centuries, the effect of weather on people has been considered a general health problem. In the past, researchers have shown that extreme hot and cold temperature periods increase mortality, and the relationship between heat and mortality was demonstrated in the analysis of current time series. These studies have shown that an increase from ideal temperature values towards heat or cold increases mortality. An increase in deaths due to coronary and cerebral thrombosis is recorded during heat waves.⁵ In addition, in a recent study on postoperative intensive care patients, it was found that the length of hospital stay was longer in summer than in winter.⁶
The hypothesis of this study is that changes in human body physiology caused by seasonally changing atmospheric temperature differences may be related to the incidence of spinal anesthesia-related complications. The primary aim of this study was to evaluate the effect of seasons on postspinal headache in patients who underwent spinal anesthesia in spring, summer, autumn, and winter periods. Investigating other complications, which may develop during and after anesthesia, and the seasonal relations of the differences between the monitored parameters were the second aim of the study.

Materials and Methods

A total of 190 patients aged 18 - 65 years with ASA (American Society of Anesthesiologists) classes I - II status and who were planned to undergo lower extremity surgery in Erciyes University Faculty of Medicine, Department of Anesthesiology and Reanimation were included in the study after receiving Erciyes University Clinical Research Ethics Committee approval and the consent of the patients. The presence of systemic diseases such as peripheral neuropathy and diabetes mellitus, motor and sensory loss before the operation, psychiatric problems, bone deformities such as scoliosis and rheumatoid arthritis, any infection and chronic skin disease on the skin surface where the intervention will be performed, previously known local anesthetic allergy and coagulopathy, and refusal of spinal anesthesia were the criteria for exclusion from the study.
The patients were divided into four groups: June, July, August as summer group (Group Su); September, October, November as autumn group (Group Au); December, January, February as winter group (Group Wi); and March, April, May as spring group (Group Sp). Meteorological average daily temperature values were recorded in the groups during the study periods. Serum osmolality was calculated based on biochemical and hematological parameters that were routinely checked before surgery (serum osmolality = 2(Na) + glucose/18 + BUN/1.8).⁷ The normal serum osmolality was accepted as 275 - 295 mOsm/kg.⁸
Intravenous access was established with an 18 Gauge cannula before operation and 10 mL/kg of 0.9% NaCl was administered over 30 minutes. All patients were monitored with non-invasive blood pressure, peripheral oxygen saturation (SpO2), and electrocardiogram (ECG) measurements. Basal heart rate (HR), systolic, diastolic, and mean blood pressures (SBP, DBP, MAP), and SpO2 were recorded. After providing skin asepsis with iodine, the L2 - 3, L3 - 4, or L4 - 5 interspaces were palpated, and the widest interspace was determined in the patient in a sitting position. Before the spinal block, 2 mL of 2% lidocaine infiltration anesthesia was applied intradermally and subcutaneously. A 25G Quincke spinal needle was used for subarachnoid puncture. A standard dose of local anesthetic (3 mL of 0.5% levobupivacaine - 15 mg) was administered for spinal anesthesia in all groups. Levobupivacaine was injected within 30 seconds, and the end of the injection was accepted as minute 0. The patients were immediately placed in a supine position. All patients were given 2 L/min O2 by nasal cannula. Afterwards, the patients’ HR, SBP, DBP, MAP, SpO2 values were noted at 0 - 3 - 5 - 10 - 15 - 20 - 25 - 30 - 45 - 60 minutes.
Sensory block level was controlled with a “pinprick” test after spinal anesthesia, and motor block was evaluated with the “Modified Bromage Scale”.⁹
During the intraoperative patient follow-up, a decrease in SBP below 90 mmHg or more than 30% decrease in MAP regarding the control value was accepted as hypotension and treated with intravenous 5 - 10 mg ephedrine. Bradycardia was treated with intravenous 0.5 mg of atropine when HR decreased below 50 beats/min.^2-3 All patients were visited on 6 - 12 - 24 - 48 - 72nd postoperative hours and on the 7th day in their clinics, and the discharged patients were asked about complications by phone calls. These procedures were performed by a single researcher.
Headache was considered a spinal block-related complication if it occurred within the first 7 days after lumbar puncture, was located in the occipital or frontal region, exacerbated by sitting or standing up, relieved or disappeared after lying down, and was recorded using a Visual Analogue Scale (VAS) scoring (10-scale measure from painlessness to severe pain ¹⁰).^4,10 The same scoring system was used for low back pain.¹¹ Complications such as headache, low back pain, and urinary retention after spinal anesthesia were treated with a standard treatment protocol.Ethical ApprovalEthics Committee approval for the study was obtained.Statistical AnalysisSPSS 15.00 Lead Technologies and PASS 2008 NCSS, LLC, Kaysville, Utah program was used for statistical analysis. The distribution of quantitative data was defined as X ± SD. The Kolmogorov-Smirnov test was used for conformity of the normal distribution of quantitative data. For comparing the normally distributed variables between independent groups, a One-Way ANOVA was used followed by Tukey’s test as the pairwise comparison. Repeated measures ANOVA was used to compare dependent groups, and the Bonferroni test was used to perform pairwise comparisons of repeated measurements. The Kruskal-Wallis analysis was used in the 4 groups for quantitative data that did not comply with the normal distribution. The determination of different groups was made using the Mann-Whitney U test with Bonferroni correction. The distribution of qualitative data was defined as frequency/%. The Chi-square test was used to compare qualitative data. A p-value <0.05 was accepted as statistically significant.
The sample size was determined by G-Power 3.1 software. According to the analysis, the study sample size was calculated as 48 patients (each group: 12 patients) with medium effect size (d = 0.5), 90% strength, and 5% error probability.

Results

There was no difference between the demographic characteristics of the groups (Table 1). The evaluation of some preoperative biochemical parameters and calculated osmolality values (Table 1) revealed that sodium values in Group Su were lower than in other groups (p=0.030), and the osmolality value in Group Wi was significantly higher than in Group Su (p=0.041). A significant difference between the groups in terms of daily temperature averages was determined. Daily average temperature values (°C): Group Su: 21.1, Group Au: 11.6, Group Wi: -0.2, Group Sp: 10.2 (available at: https://mgm.gov.tr/eng/forecast-cities.aspx). The number of lumbar puncture attempts (one and more) was similar between the groups (p=0.575).
No significant difference regarding the mean amount of crystalloid, colloid, and blood used for intraoperative fluid management was determined between the groups (p=0.682, p=0.454, and p=0.136). The number of atropine applications due to intraoperative complications of bradycardia was significantly higher in Group Su than in other groups (p=0.011). A significant decrease in within-group SBP, DBP, MAP, and HR values compared to baseline was noted in all groups (p=0.0001, p=0.001, p=0.0001, and p=0.0001, respectively) (Figure 1).
Figure 1 shows changes in mean arterial pressure of patients during 60 minutes just after administration of spinal anesthesia according to four study groups (Summer (Su), Autumn (Au), Winter (Wi), Spring (Sp)).
The complication of headache was quantitatively higher in Group Su (Figure 2), but this result was not statistically significant (p=0.394, Fig. 2). In within-group comparisons, the highest rate of headache in Group Su was detected at the postoperative 48 - 72 hours (Table 2).
Figure 2 presents the proportion of study participants with headache and low back pain according to four groups (Summer (Su), Autumn (Au), Winter (Wi), Spring (Sp)).
The incidence of low back pain was 15.1% in the Sp Group, 17.0% in the Wi Group, and 30.2% in the Au Group; this rate was 37.7% in the Su Group, which was statistically significant (p=0.010). In the comparison of the groups regarding the number of cases with low back pain at 48 - 72 hours and 72 hours - 7 days after spinal anesthesia, a significant difference was found between the groups (p=0.010 and p=0.004) (Figure 3). The low back pain incidence was higher in the Su Group between 48 - 72 hours (39.3%) and between 72 hours - 7 days (50%). The incidence of low back pain was similar at the other time intervals (Table 2).
Figure 3 shows the percentage of patients with back pain during follow-up according to all study groups (Summer (Su), Autumn (Au), Winter (Wi), Spring (Sp)).
Urinary retention complications were not statistically different between the groups (p=0.235).
In the study, when all complications were evaluated independent of the groups, the frequency of urinary retention after spinal anesthesia was 8.9%, the frequency of headaches was 22.1%, and the frequency of low back pain was 27.9%.

Discussion

Our findings revealed that postspinal headaches and low back pain were more common in summer than in other seasons.
For thousands of years, the average seasonal climatic conditions have been relatively stable, but they have gained a rapid acceleration of change in the last 50 years.¹² According to the IPCC AR4, 6 IPCC Emissions Scenarios Special Report, global average temperature is predicted to increase between 1.1 °C and 6.4 °C from 1990 to 2100.^12-13 It is strongly believed by experts on climate that climate changes will affect the earth and cause extreme weather events such as increasingly frequent and severe heat waves and rising sea levels.¹⁴ It is normal for these seasonal and climatic changes to cause changes in human physiology and affect human health. In particular, it has been reported that there is a relationship between climatic conditions and the clinical manifestations of cardiopulmonary disorders, and acute coronary syndromes, myocardial infarction, and related morbidity and mortality rates show seasonal variations in patients.¹⁵ During the period of this research, seasonal average daily temperature measurements were different in accordance with the purpose of the study.
During the hypothesis generation of this study, it was supposed that seasonal temperature changes may affect spinal anesthesia-related complications by considering its possible effects on human physiology. However, as a result of the detailed literature review, no information was obtained about the effect of seasonal changes on the incidence of postspinal headache and other complications that may occur during and after spinal anesthesia. For this reason, our study has an original quality that will make a significant contribution to the literature. The similarity of patient demographics in the study groups indicates that the study is standardized. The purpose of measuring preoperative sodium and osmolality values is to exclude dehydration. According to the analysis of our findings, sodium levels were found to be statistically lower in summer than in winter. The reason for these low values can be due to the fact that people consume more water in the summer period.
Spinal anesthesia is an anesthesia technique that has many complications during or after the procedure. The frequently encountered complications during spinal anesthesia are hypotension and bradycardia; and postspinal headache, low back pain, and urinary retention are seen after spinal anesthesia.² When the seasonal variations of complications were evaluated in detail in this study, bradycardia, headache, and low back pain were found to be more common in summer than in other seasons. Here, it is thought that acute venodilation is the reason why headaches are more common in summer. Cerebrospinal fluid hypotension due to leakage as a result of spinal anesthesia results in headache caused by acute venous distension and compensatory meningeal venodilation (available at: https://www.uptodate.com/contents/post-dural-puncture-headache). This mechanism has been demonstrated in several reported cases of PDPH (Post-dural puncture headache), consistent with magnetic resonance imaging (MRI).^13,16 Similarly, complications of hypotension and bradycardia are more common in the summer and this may be attributed to the synergy formation of vasodilatation due to the temperature of summer season with the vasodilation associated with the spinal anesthesia procedure. In addition, the decrease in mean blood pressure compared to baseline in-group comparisons in this study is another indicator that supports the vasodilation effect of spinal anesthesia.
Nearly 90% of PDPHs occur within 72 hours after dural puncture; however, its onset up to two weeks has been rarely reported.¹⁷ In our study, in accordance with the literature, PDPH was determined at postspinal 48 - 72 hours in summer.
Low back pain after dural puncture has not received much attention as it is not as debilitating as postdural puncture headache. Low back pain has been attributed to local bleeding into the local tissue such as fascia, bone, or ligament, paraspinal muscle relaxation and immobility of spine, elimination of normal lumbar convexity, stretching of joint capsules, and the lumbosacral ligaments.¹⁸ Low back pain after dural puncture has a higher incidence than postspinal headache, with an incidence varying between 13 - 30%.^19-20 In this study, low back pain complications were found to be significantly higher with a rate of 39.3% between the postspinal 48 - 72 hours and 50% between the 72 hours and the 7th day in the summer period.
Spinal block affects the bladder by the afferent and efferent nerve signals, especially from S2 - 4. Thus, detrusor functions are blocked and the sense of urgency resulting from a full bladder.²¹ Frenkel et al. found an incidence of urinary retention of 2.5% in the study conducted with 202 young male patients aged 20 - 30 years.²² In this study, the overall rate of urinary retention was 8.9%, and no difference was found in the incidence between seasons.
In our study, when the groups were not considered, the PDPH rate was found to be 22.1%, which is a high rate. We think that the reason for this is that we used a 25G Quincke (sharp-tipped) needle, and also the fact that the axis of the needle is placed perpendicular to the long axis of the spine in our technique.²³ In a study of 218 patients, a 27-gauge Quincke needle was used that was randomly placed parallel or transverse to the long axis of the spine, and PDPH incidence was determined as 4% in patients in the parallel group and 23% in patients in the transverse group.²⁴ This result is similar to our study.
The limitation of our study is that the number of patients is limited to the number of patients who come to our hospital for surgery during these seasons.

Conclusion

Our findings indicate that complications developing during and after spinal anesthesia are more common in the summer period. We recommend that patients who will undergo spinal anesthesia be operated on by correcting their electrolytes. For further evaluation, studies with larger samples are needed in locations with different climates.

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