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Safety and Efficacy of Spinal Vs General Anaesthesia in Bone Marrow Harvesting

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Safety and Efficacy of Spinal Vs General Anaesthesia in Bone Marrow Harvesting Bone Marrow Transplantation, (1998) 21, 1145–1148 1998 Stockton Press All rights reserved 0268–3369/98 $12.00 http://www.stockton-press.co.uk/bmt Safety and efficacy of spinal vs general anaesthesia in bone marrow harvesting ¨ M-A Burmeister1, T Standl1, P Brauer1, K Ramsperger1, N Kroger2, A Zander2 and J Schulte am Esch1 1Department of Anaesthesiology, Bone Marrow Transplantation Unit, and 2Department of Oncology and Haematology, University Hospital Hamburg, Germany Summary: gesia requirement have been demonstrated with RA.4 SPA may also be of interest for economical reasons. Bone marrow harvesting (BMH) can be performed with Nevertheless, SPA with the patient in the prone position either general (GA) or spinal anaesthesia (SPA). Whether is still controversial. One of the main arguments against SPA is advantageous in BMH and if this technique is safe SPA in the prone position is the difficulty in adequately for procedures performed in the prone position is still con- ventilating the patient in the event of respiratory insuf- troversial. To evaluate the safety and efficacy of both ficiency. Several reports have presented cases with cardio- anaesthetic techniques in BMH, 37 allogeneic donors (nine pulmonary arrest and resuscitation during SPA.5–7 female, 28 male; 34.3 ؎ 9 years; ASA class 1–2) received The present prospective study was designed to evaluate either spinal (group 1, n = 20) or general anaesthesia the safety and efficacy of the two different anaesthetic tech- (group 2, n = 17) according to their personal wishes. niques in healthy allogeneic donors undergoing BMH. Under standardised harvesting conditions, haematology parameters, cell counts (MNC, CD34+), haemodynamic parameters, adverse reactions and patient satisfaction Patients and methods were registered. No differences were seen between groups with respect to demographic data, harvesting time Following approval from the local ethics committee and vs 60 ؎ 16 min) and bone marrow cell counts written consent, 37 healthy (ASA class 1–2) allogeneic 17 ؎ 55) (MNC: 6.68 ؎ 2.1 vs 5.7 ؎ 1.7 ml/106). The incidence of donors (Table 1) received either spinal (group 1, n = 20) hypotension was higher in group 1 (45 vs 10.8%; or general anaesthesia (group 2, n = 17) according to their P = 0.042). Postoperative analgesic requirement and personal wishes. Randomisation of the anaesthetic tech- emesis were increased in group 2 (P Ͻ 0.04) in comparison nique was not allowed for ethical reasons in healthy allo- to group 1. In conclusion, the present study failed to show geneic bone marrow donors. All patients predonated one superiority of spinal over general anaesthesia with regard unit of autologous RBCs 4 weeks prior to the bone mar- to the quality of the harvested bone marrow. However, row harvest. the lower incidence of complaints after spinal anaesthesia On the day of BMH, patients were orally premedicated appears to offer an advantage over GA in healthy allo- with 7.5 mg midazolam 1 h before arriving at the anaes- geneic bone marrow donors. Keywords: bone marrow harvesting; anaesthesia, spinal- general; prone-position Table 1 Demographic characteristics of 37 healthy donors Characteristics Group 1 Group 2 P Bone marrow harvesting (BMH) is generally performed (spinal (general under general anaesthesia (GA).1 However, regional anaes- anaesthesia) anaesthesia) n = 20 n = 17 thesia (RA) such as epidural or spinal anaesthesia (SPA) can also be used and may even have some advantages in Age (years)a 34.8 ± 8.2 33.8 ± 8.3 0.715 terms of outcome of BMH. Sex Some retrospective studies have shown a shorter har- Female 5 4 0.718 vesting time with an increased yield of nucleated cells in Male 15 13 b the harvested marrow using SPA.2,3 In addition, a reduction ASA class I 16 13 0.553 of allogeneic blood transfusions and postoperative anal- II 4 4 Height (cm)a 179.5 ± 9.0 178.2 ± 10.3 0.751 Body weight (kg)a 81.5 ± 12.0 81.6 ± 13.8 0.981 Broca index (%)a 103.1 ± 15.0 104.6 ± 13.7 0.521 Correspondence: Dr M-A Burmeister, Department of Anaesthesiology, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, aMean Ϯ s.d. Germany bPreoperative risk score according to the American Society of Anesthesiol- Received 15 August 1997; accepted 9 January 1998 ogists. Spinal and general anaesthesia in bone marrow harvesting M-A Burmeister et al 1146 thetic room where they were monitored by ECG, non-invas- pared between groups. In cases of postoperative pain, ive measurement of blood pressure, pulse oximetry and a patients in both groups received a 500 mg paracetamol sup- rectal temperature probe. Patients received 500 ml of pository with a maximum of 3 g paracetamol within 24 h. Ringer’s lactate solution via a peripheral venous cannula. Patients were interviewed by an anaesthetist on days 1 In group 1, spinal anaesthesia (SPA) was administered and 4 after the harvesting procedure about problems such with the patient in the sitting position, at the L 3/4 inter- as sore throat, headache, lower backpain, shivering, nausea space. After infiltration of the skin with 5 ml lidocaine 2%, or vomiting and urinary dysfunction, using a standardized a 20-G introducer needle (Spinocan, B Braun, Melsungen, questionnaire. Germany) was inserted using the midline approach. A 26- For statistical analyses, quantitative parameters were G Quincke needle was placed in the subarachnoidal space compared with the unpaired t-test. Qualitative data were with the needle bevel parallel to the dural fibers. When free analysed using Fisher’s exact test. A P value Ͻ0.05 was flow of cerebrospinal fluid was obtained, 2.5–4.0 ml of a considered to be significant. mixture of plain bupivacaine 0.5% and hyperbaric mepiva- caine 4% (Astra Chemicals, Wedel, Germany) was injected and patients were placed supine to reach a minimal anal- Results gesic level of T 12. In group 2, general anaesthesia (GA) was induced with Groups were comparable with respect to harvesting time, 0.3 mg/kg etomidate (B Braun), 0.5 ␮g/kg sufentanil total harvested volume and harvested volume per minute. (Janssen, Neuss, Germany) and 0.5 mg/kg atracurium The mononucleated cell content was slightly higher in the (Wellcome, Hamburg, Germany). Following endotracheal harvested marrow of the SPA group but the difference did intubation with a flexible spiral tube (Woodbridge, Mal- not reach significance. Total cell numbers and content of linckrodt, Ireland) and mechanical ventilation, anaesthesia CD34+ cells were virtually equal in both groups (Table 2). was maintained with 0.8–1.2 vol% isoflurane (Abbott, The perioperative decrease in haemoglobin concentration Wiesbaden, Germany) and 30% oxygen in nitrous oxide. was higher in patients receiving SPA when compared to Bradycardia (heart rate Ͻ50/min) was treated by i.v. GA (1.68 Ϯ 0.5 vs 1.1 Ϯ 0.6 g/dl; P = 0.003). However, administration of atropine 0.5–1.0 mg, hypotension (mean none of the patients required allogeneic blood transfusion. arterial blood pressure Ͼ30% below baseline) was treated Two patients of each group received their predonated auto- by i.v. injection of 1–2 ml of a mixture of 100 mg of theo- logous blood within the first 24 h because Hb levels were phylline and 5 mg of theoadrenaline (Asta Medica, Darm- below 10 g/dl. SPA patients received a mean dose of stadt, Germany). 3.15 Ϯ 0.3 ml of LA. The mean level of sensomotory For evaluation of safety, the incidence of adverse reac- blockade was at T 8 Ϯ 2 (Range: T 12–T 5). No patient tions and side-effects such as severe bradycardia (HR experienced major side-effects such as a high level of sen- Ͻ45/min) or hypotension (MAP Ͻ60 mmHg) and inadver- somotory blockade ϾT 4 or an increasing level while in tently ascending spinal anaesthesia (ϾT 4), were analysed. the prone position. Twenty minutes after subarachnoid injection of the LA Baseline values of blood pressure, heart rate, oxygen or after induction of GA, patients were moved from the saturation and rectal temperature did not differ between supine to the prone position. The level of analgesia in group groups. In the SPA group the incidence of hypotension and 1 was controlled every 5 min by pinprick. To avoid hypo- bradycardia was higher when compared to GA (45 vs thermia patients were warmed in an air warming system 10.8%, P = 0.042 and 40 vs 5.8%, P = 0.023). In the SPA (Warm Touch) to the upper body. Patients received 7 ml/kg group these episodes of haemodynamic depression had a Ringer’s lactate and 7 ml/kg hydroxyethyl starch duration of 1–3 min and were seen only 50–80 min after 70 000/0.5 (Rheohes, B. Braun, Germany) before the start subarachnoidal injection of local anaesthetics. No severe of the harvesting procedure. Equal volumes were infused bradycardia or hypotension was seen over time in both intraoperatively in both groups. SPA patients received an intranasal insufflation of 2 l oxygen per minute. The bone marrow was harvested under standardised con- Table 2 Bone marrow harvest characteristics ditions with respect to the staff and material used. Multiple punctures were made to both posterior iliac crests with a 3 Characteristics Group 1 Group 2 P mm needle followed by aspirations to a limit of 10 ml per (spinal (general aspiration. The harvesting time, total harvested volume, anaesthesia) anaesthesia) = = harvested volume per minute, total nucleated and CD34+ n 20 n 17 cell content, were evaluated. Harvest time (min)a,b 55 ± 17 61 ± 16 0.279 To estimate the percentage of mononucleated cells visual BM volume harvested (ml)a 1301.9 ± 85.9 1336.0 ± 117.8 0.315 counting of a sample of unmanipulated marrow was perfor- BM volume harvested per min 26.4 ± 11.3 23.6 ± 6.8 0.370 med.
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