Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures

Study ObjectiveTo compare isobaric lidocaine and mepivacaine in outpatient arthroscopic surgery.DesignProspective, randomized, double-blinded study.SettingAmbulatory surgery center affiliated with an academic tertiary-care hospital.Patients84 adult, ASA physical status 1, 2, and 3 ambulatory patients, age 18-70 years, undergoing arthroscopic knee surgery.InterventionPatients were randomized to receive a combination spinal-epidural anesthetic using 80 mg of either isobaric 2% mepivacaine or isobaric 2% lidocaine. Patients also received a femoral 3-in-1 block with 0.5% bupivacaine applied to the affected extremity.MeasurementsDemographic data and level and duration of the block were recorded. The use of supplemental epidural anesthesia was noted along with frequency of bradycardia, hypotension, and episodes of nausea and vomiting. Duration of block and times to ambulation and voiding were recorded. Delayed variables, including fatigue, difficulty urinating, back pain, and transient neurologic symptoms (TNS) were obtained.Main ResultsNo demographic differences were noted between groups, and surgical duration was similar. Satisfactory anesthesia was achieved in all cases, with no differences noted in hypotension, bradycardia, nausea, or vomiting. Onset of sensory and motor block was similar. Duration of block before epidural supplementation was 94 ± 21 minutes with lidocaine versus 122 ± 23 minutes for mepivacaine (P < 0.011). Times to ambulation and voiding were longer in patients receiving mepivacaine but did not affect PACU stay. Twenty-four and 48-hour recovery was similar with no TNS symptoms reported.ConclusionNo major differences were noted between lidocaine and mepivacaine spinal anesthesia. Time to ambulation and voiding were longer in patients who received mepivacaine as was time to first dose of epidural catheter. Neither group had TNS symptoms. Lidocaine and mepivacaine are both appropriate spinal anesthetics for ambulatory orthopedic lower extremity procedures.     

Levobupivacaine vs racemic bupivacaine in spinal anesthesia for sequential bilateral total knee arthroplasty: a retrospective cohort study

Study objectivesTo compare the anesthetic potency and safety of spinal anesthesia with higher dosages of levobupivacaine and bupivacaine in patients for bilateral sequential for total knee arthroplasty (TKA).DesignRetrospective cohort study.SettingOperation theater with postoperative inpatient follow-up.PatientsThe medical records of 315 patients who underwent sequential bilateral TKA were reviewed.InterventionsPatients who received intrathecal levobupicavaine 0.5% were compared with patients who received hyperbaric bupivacaine 0.5% with fentanyl 25 μg for spinal anesthesia.MeasurementsThe primary outcome was the use of rescue analgesia (systemic opioids, conversion to general anesthesia) during surgery for both groups. Secondary outcomes included adverse effects of local anesthetics (hypotension and bradycardia) during surgery and morbidity related to spinal anesthesia (postoperative nausea, vomiting, and bleeding) during hospital stay.Main resultsOne hundred fifty patients who received intrathecal levobupivacaine 0.5% (group L) were compared with 90 patients given hyperbaric bupivacaine 0.5% with fentanyl 25 μg (group B). The mean volume of levobupivacaine administered was 5.8 mL (range, 5.0-6.0 mL), and that of bupivacaine was 3.8 mL (range, 3.5-4.0 mL). Both groups achieved similar maximal sensory level of block (T6). The time to maximal height of sensory block was significantly shorter in group B than group L, 18.2 ± 4.5 vs 23.9 ± 3.8 minutes (P< .001). The time to motor block of Bromage 3 was also shorter in group B (8.7 ± 4.1 minutes) than group L (16.0 ± 4.5 minutes) (P< .001). Patients in group B required more anesthetic supplement than group L (P< .001). Hypotension and postoperative bleeding were significantly less common in group L than group B.ConclusionLevobupivacaine at a higher dosage provided longer duration of spinal anesthesia with better safety profile in sequential bilateral TKA.     

Role of repeated epidural injections in preventing post-spinal hearing loss

Study ObjectiveTo determine if epidural volume extension and continued postoperative epidural injections prevent hearing loss associated with a 23-gauge (G) Quincke spinal needle.DesignProspective, double blinded trial.SettingOperating rooms.Patients30 adult patients scheduled for lower abdominal or perineal surgery during spinal anesthesia.InterventionsPatients were divided into two groups of 15 each. All patients received subarachnoid injection with a 23-G Quincke needle. While patients in Group S received a single-shot spinal, Group E patients underwent epidural catheter placement one intervertebral space above. The epidural catheter was bolused with 10 mL of normal saline followed by postoperative epidural boluses of local anesthetic for analgesia as needed.MeasurementsPatients’ auditory function was evaluated by pure tone audiometry (frequencies of 250-8,000 Hz) on the day before and two days after receiving the spinal anesthesia.Main ResultsUnilateral low-frequency hearing loss (500 Hz) was seen in Group S (P < 0.05). It was prevented by the repeated epidural injections as used in Group E.ConclusionFollowing spinal anesthesia, epidural volume extension with 10 mL of normal saline followed by epidural local anesthetic boluses titrated to adequate postoperative analgesia (6-8 mL each time) prevents post-spinal hearing loss.     

The efficacy of thoracic epidural neostigmine infusion after thoracotomy

Few anesthesia studies have explored perioperative continuous epidural infusion of neostigmine. We examined such a regimen in thoracotomy patients. Ninety patients were randomized to one of three groups in this double-blind trial. Before anesthesia induction, an epidural catheter was inserted in all patients at T5-8 levels under local anesthesia. Pre-neo patients received bolus 500-microg epidural neostigmine before anesthesia induction followed by infusion of 125 microg/h until the end of surgery. Post-neo patients received epidural saline during the same time periods plus bolus 500-microg epidural neostigmine at end of surgery. Patients in the control group received saline placebo during all three periods. Patients in the neostigmine groups postoperatively received patient-controlled epidural analgesia with morphine 0.02 mg/mL, bupivacaine 0.08 mg/mL, and neostigmine 7 microg/mL. Control patient-controlled epidural analgesia excluded neostigmine. Data were recorded for 6 postoperative days. Daily patient-controlled epidural analgesia consumption (mL) for Pre-neo patients was significantly less than that of post-neo and control group patients for postoperative days 1-6 (at least 10% and 16% less, respectively; P < 0.05). There was a modest decrease in pain intensity on postoperative days 3-6 for pre-neo patients versus other groups (P < 0.05). These results suggest that continuous thoracic epidural neostigmine started before anesthesia provided preemptive, preventive analgesia and an analgesic-sparing effect that improved postoperative analgesia for these patients without increasing the incidence of adverse effects.     

Epidural fentanyl speeds the onset of sensory block during epidural lidocaine anesthesia

BACKGROUND AND OBJECTIVES: Shortening the onset time of sensory block is a practical goal to improve the quality of epidural anesthesia. The addition of fentanyl to a local anesthetic solution is widely used during epidural anesthesia. This randomized double-blind study examined the onset time of sensory block during epidural lidocaine anesthesia with and without added fentanyl to the epidural solution. METHODS: Thirty-six young male patients undergoing knee arthroscopy were randomly allocated into 3 groups of 12 patients each: epidural fentanyl (EF, epidural administration of 17 mL of 2% lidocaine plus 100 microg fentanyl and followed by intravenous (IV) injection of 2 mL of normal saline); IV fentanyl (IF, epidural administration of 17 mL of 2% lidocaine plus 2 mL of normal saline and followed by IV injection of 100 microg of fentanyl); and control (C, epidural administration of 17 mL of 2% lidocaine plus 2 mL of normal saline and followed by IV injection of 2 mL of normal saline). The sensory block was assessed by pinprick method. The hemodynamic changes, postepidural shivering, and side effects of epidural fentanyl were also recorded. RESULTS: There was no difference in the distribution of age, weight, and height among the 3 groups. The onset time of sensory block up to T(10) dermatome was significantly more rapid in the EF group (8.3 +/- 3.7 minutes) than that of the IF group (13.1 +/- 4.2 minutes, P <.05) or C group (14.2 +/- 5.4 minutes, P <.05). The upper level of sensory block was also significantly higher in the EF group. Although the incidence of shivering was lower in the EF group, this did not reach statistical significance. Postepidural arterial blood pressures and heart rates were no different among the 3 groups. No nausea, vomiting, pruritus, respiratory depression, urinary retention, or hypotension were observed in any patients. CONCLUSION: Epidural injection of the mixture of 100 microg fentanyl and 2% lidocaine solution accelerated the onset of sensory block during epidural lidocaine anesthesia without increased side effects.     

Low-dose spinal bupivacaine for total knee arthroplasty facilitates recovery room discharge: a randomized controlled trial

Purpose

Regional anesthesia is the preferred technique for total knee arthroplasty to provide a bridge for early postoperative analgesia, reduce opioid consumption, and improve mobility and rehabilitation. Multiple patient and process factors must be weighed when choosing the appropriate technique to reduce morbidity and facilitate discharge. We hypothesized that a low-dose of intrathecal bupivicaine combined with regional block would facilitate discharge from the postanesthesia care unit (PACU) and reduce postoperative morbidity.

Methods

Patients undergoing total knee arthroplasty under spinal anesthesia received either 5 mg (low-dose group) or 10 mg (standard-dose group) isobaric bupivacaine in a double-blind randomized controlled trial. The primary outcome measure was time to achieve eligibility for PACU discharge. Secondary outcome measures included time to recovery of S2 dermatome sensation, time to voiding, rate of bladder catheterization, and time required for nursing intervention in the PACU and after discharge to the surgical ward.

Results

Forty-five of the 49 recruited patients completed the study. Patients receiving low-dose spinal anesthesia were eligible for PACU discharge earlier than those receiving the standard dose (P = 0.0036). Patients receiving the standard dose had significantly delayed recovery of S2 dermatome sensation (P = 0.0035). There was no difference between groups in the amount of time required for nursing intervention in the PACU, but patients receiving low-dose spinal anesthesia required more time for nursing intervention within the first four hours of their arrival on the ward (P = 0.009). None of the patients required intraoperative analgesic supplementation.

Conclusions

In patients undergoing total knee arthroplasty, low-dose intrathecal bupivacaine (5 mg) combined with regional block is associated with a reduced time to achieve eligibility for discharge from the PACU.     

Reversal of prilocaine epidural anesthesia using epidural saline or ringer's lactate washout

BACKGROUND AND OBJECTIVES: Several investigators have described the phenomena of epidural saline washout using bolus injections. This study was designed to determine whether epidural block could be reversed more effectively by infusion of crystalloid solutions via the epidural catheter. METHODS: One hundred male patients scheduled for outpatient surgery were enrolled in this study. After 30 min of 2% prilocaine epidural anesthesia, patients were randomly assigned to receive 45 mL of study solution as follows: (1) normal saline bolus (group NSB); (2) Ringer's lactate bolus (group RLB); (3) normal saline infusion (group NSI); (4) Ringer's lactate infusion (group RLI). Patients in the control group received no washout fluid. Motor, sensory blockade and side effects were compared among 5 groups. Ambulation time is defined as the recovery time. RESULTS: In the control group, ambulation time (139 +/- 15 min) was significantly longer than in the washout groups (NSB 90 +/- 10, RLB 88 +/- 10, NSI 85 +/- 8, RLI 91 +/- 6 minutes) (P < .001). Two-segment sensory regression time in the control group (86 +/- 15 min) was significantly longer than in groups NSB, RLB, NSI and RLI (55 +/- 8, 51 +/- 4, 58 +/- 8, and 53 +/- 10 minutes, respectively) (P < .001). CONCLUSIONS: We concluded that a more rapid recovery of motor and sensory blockade in patients undergoing epidural anesthesia may be achieved by the use of an epidural washout with either bolus or infusion of 45 mL normal saline or Ringer's lactate.     

A randomized comparison of onset of anesthesia between spinal bupivacaine 5 mg with immediate epidural 2% lidocaine 5 mL and bupivacaine 10 mg for cesarean delivery

BackgroundPrevious studies using low-dose spinal anesthesia for cesarean delivery have focused on hypotension and efficacy. This study evaluated whether, using a combined spinal–epidural technique, there was a difference in onset of anesthesia for cesarean delivery between low-dose spinal with an immediate epidural local anesthetic bolus, and conventional-dose spinal anesthesia.MethodsForty healthy term nulliparous women undergoing elective cesarean delivery with a combined spinal–epidural technique were enrolled into this prospective, randomized, double-blind study. Patients were randomly allocated to the low-dose (Group L) or conventional-dose group (Group C). Patients in Group L received intrathecal isobaric bupivacaine 5 mg with sufentanil 2.5 μg followed by epidural 2% lidocaine 5 mL; patients in Group C received intrathecal isobaric bupivacaine 10 mg with sufentanil 2.5 μg followed by epidural saline 5 mL. The onset of anesthesia (defined as the time from spinal injection to a block to T6), incidence of hypotension, maximal sensory block, epidural supplementation and side effects were recorded.ResultsAll blocks reached T6 within 11 min except for one patient in Group L. There were no differences in onset of anesthesia (9.9 ± 3.2 min in Group L vs. 8.5 ± 1.2 min in Group C, P = 0.08), maximal block level and the number of patients who required epidural supplementation in both groups. Hypotension occurred in 8 patients (40%) in Group L and 15 patients (75%) in Group C (P = 0.02).ConclusionsIntrathecal bupivacaine 5 mg with immediate 2% epidural lidocaine 5 mL provided comparable onset and efficacy of anesthesia as bupivacaine 10 mg with immediate epidural normal saline 5 mL for cesarean delivery.     

Intravenous vs Oral Acetaminophen as an Adjunct to Multimodal Analgesia After Total Knee Arthroplasty: A Prospective,Randomized, Double-Blind Clinical Trial

Background

The efficacy of intravenous (IV) acetaminophen compared with its oral formulation for postoperative analgesia is unknown. We hypothesized that the addition of acetaminophen to a multimodal analgesia regimen would provide improved pain management in patients after total knee arthroplasty (TKA) and that the effect of acetaminophen would be variable based on the route of delivery.

Laparo-endoscopic single-site (LESS) cholecystectomy with epidural vs. general anesthesia

Background

Laparo-endoscopic single-site (LESS) surgery involves a single umbilical incision, lending itself to epidural anesthesia. This prospective, randomized study was undertaken to evaluate epidural anesthesia for patients undergoing LESS cholecystectomy, to assess the feasibility, and to analyze all intraoperative and postoperative complications. The secondary objectives were to determine differences in postoperative pain and time until PACU discharge-to-home readiness between patients.

Methods

With institutional review board approval, 20 patients with chronic cholecystitis, cholelithiasis, and/or biliary dyskinesia were randomized to receive spinal epidural anesthesia (n = 10) or general anesthesia (n = 10). Postoperative pain at rest was recorded in the PACU every 10 min, and at rest and walking at discharge using the visual analog scale (VAS). Operative time and time until PACU discharge-to-home readiness were recorded. Results are expressed as mean ± SD.

Results

Patient age, American Society of Anesthesiologists class, and body mass index were similar. There were no additional ports/incisions, conversions to “open” operations, or conversions to general anesthesia. There were no differences in operative duration. Time until postanesthesia care unit discharge-to-home ready was not significantly different. The most common postoperative adverse event was urinary retention (1 epidural and 3 general anesthesia patients). Resting postoperative VAS pain score at discharge was 4.7 ± 2.5 vs. 2.2 ± 1.6 (p = 0.02, general versus epidural anesthesia respectively); the stressed VAS pain score at discharge was 6.1 ± 2.3 vs. 3.1 ± 2.8 (p = 0.02, general versus epidural anesthesia respectively).

Conclusions

LESS cholecystectomy with epidural anesthesia was completed with no operative or anesthetic conversions, and less postoperative pain at discharge. Epidural anesthesia appears to be a preferable alternative to general anesthesia for patients undergoing LESS cholecystectomy.     

Reversal of lidocaine with epinephrine epidural anesthesia using epidural saline washout

BACKGROUND AND OBJECTIVES: Prolonged motor and sensory block following epidural anesthesia can be associated with extended postoperative care unit stays and patient dissatisfaction. Previous studies have demonstrated a more rapid motor recovery following the administration of epidural crystalloids in patients who had received plain bupivacaine and lidocaine epidural anesthesia. However, epinephrine is commonly added to local anesthetics to improve the quality and prolong the duration of the epidural block. The objective of this study was to determine the relationship of 0.9% NaCl epidural catheter flush volume (i.e., washout) to the recovery of motor and sensory block in patients undergoing 2% lidocaine with epinephrine epidural anesthesia. METHODS: A prospective, randomized, double-blind study design was utilized. Thirty-three subjects scheduled for elective gynecologic or obstetrical surgical procedures underwent epidural anesthesia using 2% lidocaine with epinephrine (1:200,000). A T4 dermatome level of analgesia, determined by toothpick prick, was maintained intraoperatively. Following surgery, subjects were randomized to 1 of 3 treatment groups. Group 1 (control, n = 11) received no epidural 0.9% NaCl (normal saline [NS]) postoperatively. Group 2 (15 mL NS x 1, n = 10) received an epidural bolus of 15 mL NS. Group 3 (15 mL NS x 2, n = 12) received an epidural bolus of 15 mL NS postoperatively and a second 15-mL NS bolus 15 minutes later. Assessment of motor and sensory block was performed at 15-minute intervals until complete motor and sensory recovery. RESULTS: Times to partial and full motor and sensory recovery were significantly faster in the epidural NS groups than in the control group. Full motor recovery was more rapid in subjects receiving two 15-mL NS epidural NS boluses (30 mL total) compared with those receiving a single 15-mL NS bolus (108 +/- 9 min v 136 +/- 13 min) and significantly faster than control group subjects (153 +/- 14 min). Both NS x 1 and NS x 2 epidural bolus groups experienced significantly reduced times to complete sensory recovery when compared with the control group (NS x 1 = 154 +/- 13 min, NS x 2 = 153 +/- 9 min, control 195 +/- 14 min). CONCLUSIONS: A more rapid recovery of motor and sensory block in patients undergoing 2% lidocaine with epinephrine epidural anesthesia can be achieved with the use of 30 mL NS epidural washout. Reg Anesth Pain Med 2001;26:246-251.     

Recovery characteristics of three anaesthetic techniques for outpatient orthopaedic surgery

The goals of this study are to observe prospectively the perioperative recovery characteristics associated with general anaesthesia (GA), spinal anaesthesia (SAB), and epidural anaesthesia (EPID) in 200 patients scheduled for outpatient knee arthroscopy. Patients were observed from the time they entered the recovery room until they were discharged. Patients were contacted on postoperative days (POD) 1, 3, and 5. The EPID group had the quickest recovery times (125 ± 37 min, mean ± SD, ANOVA P < 0.01) compared with the GA group (165 ± 57 min) and SAB group (167 ± 51 min). Comparing the side effects of the three anaesthetic techniques, GA was associated with the highest incidence of nausea (27%) and vomiting (16%) on the day of surgery that persisted into the first postoperative day (nausea 41 % and vomiting 22%). There was no difference in the incidence of headache overall; however, SAB was associated with a 13% incidence of postdural puncture (PDP) headache that became apparent on POD 3. All the PDP headaches resolved with conservative therapy by the first postoperative week, except for two patients who required an epidural blood patch. The EPID group followed by the SAB and GA groups, had the highest incidence of backaches on POD 1 (respectively, 63%, 41% and 17%). By POD 3, the incidence of backache was not statistically different between groups. No specific treatment for backache was required. The ideal anaesthetic has not been developed, but our data suggests that an epidural technique is advantageous for knee arthroscopy in terms of a quick recovery and minimal adverse effects.     

Intraoperative infusion of lidocaine reduces postoperative fentanyl requirements in patients undergoing laparoscopic cholecystectomy

Background: Lidocaine has been shown to inhibit neural conduction and to have anti-inflammatory properties. The purpose of this study was to determine whether intraoperative lidocaine infusion reduces opioid consumption in the postanesthesia care unit (PACU). Methods: Fifty patients were enrolled in this prospective, randomized and observer-blinded study. At induction of anesthesia the control group (n=25) received fentanyl 3 µg·kg^?1 while the lidocaine group received fentanyl 1.5 µg·kg^?1 and a bolus of lidocaine 1.5 mg·kg^?1 followed by a continuous infusion of lidocaine 2 mg·kg^?1·hr^?1. General anesthesia included propofol, rocuronium, and desflurane titrated to maintain blood pressure and heart rate within set parameters, and the bispectral index between 35 and 50. No supplemental opioids were given during surgery. All patients received acetaminophen, ketorolac, dexamethasone, droperidol and local anesthetics in the skin incision. Patients received fentanyl and ondansetron in the PACU. The primary outcome variable was the amount of fentanyl required in the PACU to establish and to maintain visual analogue scale pain scores<3. Results: Most patients received fentanyl for pain relief in the PACU, but the cumulative mean dose was lower in the lidocaine group compared to the control group (98±54 µg,vs154±3 99 µg, respectively,P=0.018). Lidocaine infusion reduced by 10% the amount of desflurane required (P=0.012). White-Song scoresτ;12 were attained by all patients in both groups within 30 min of their arrival in the PACU. Median time from arrival to the PACU to discharge home was similar in both groups, 167.5 min in the control groupvs 180 min in the lidocaine group (P=0.649). Conclusion: Intraoperative lidocaine infusion reduces opioid consumption in the PACU and intraoperative requirements of desflurane.     

Effect of tranexamic acid on reducing postoperative blood loss in combined hypotensive epidural anesthesia and general anesthesia for total hip replacement

Study ObjectiveTo determine whether the use of tranexamic acid in the setting of hypotension induced by hypotensive epidural anesthesia (HEA) has any additional beneficial effects in reducing perioperative blood loss and transfusion requirements in total hip replacement.DesignProspective, randomized, double-blinded trial.SettingUniversity-affiliated hospital.Patients68 adult, ASA physical status 1 and 2 patients undergoing primary unilateral cementless total hip replacement with general anesthesia and HEA.InterventionsThe HEATA group received a bolus dose of 15 mg/kg of tranexamic acid before surgical incision, followed by a continuous 15 mg/kg infusion until skin closure. The HEA group received normal saline instead of tranexamic acid in the same manner.MeasurementsIntraoperative blood loss was measured using the difference between the weights of used gauze and the original unused gauze, in addition to the blood volume accumulated in suction bottles. Postoperative blood loss was considered to be the amount of blood accumulated in drainage bags.Main ResultsThere was no significant difference in intraoperative blood loss between the HEA and HEATA groups (251.8 ± 109.9 mL vs 234.9 ± 93.9 mL), but postoperative blood loss was significantly less in the HEATA group than the HEA group (439.3 ± 171. 6 mL vs 1074.4 ± 287.1 mL), as was total cumulative blood loss (674.2 ± 216.4 mL vs 1326.2 ± 347.8 mL). There was no significant difference in intraoperative transfusion incidences, but postoperative transfusion was greater in the HEA group than the HEATA group.ConclusionsAdministration of tranexamic acid combined with hypotensive epidural anesthesia reduced postoperative and total accumulative blood loss and transfusion requirements more than did hypotensive epidural anesthesia alone.     

A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy

Study ObjectiveTo compare anesthetic management and postoperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) and radical retropubic prostatectomy (RRP) with general anesthesia.DesignRetrospective database study of RALP and RRP patients at Duke University Medical Center from 6/2003 to 6/2006.SettingUniversity teaching hospital.Patients541 ASA physical status I, II, and III men, 280 of whom were RRP patients and 256 RALP patients.MeasurementsPatient demographics, intraoperative fluids and blood products, hemodynamic parameters, pain scores in the Postanesthesia Care Unit (PACU), intraoperative and postoperative analgesic consumption, need for rescue antiemetics in the PACU, and intraoperative use of vasopressors and antihypertensives, were all recorded. Additional data included postoperative transfusion data; clinical status of the patient's cancer preoperatively and postoperatively; hematocrit, platelet count, and creatinine levels; and length of hospital stay.Main ResultsEstimated blood loss (EBL) was higher for RRP than RALP patients (mean ± SD; 1,087 ± 853 mL vs. 287 ± 317 mL; P < 0.0001). Likewise, 24% of RRP patients received red blood cell (RBC) transfusions intraoperatively, compared with 0.4% RALP patients (P < 0.0001). Intraoperatively, RALP patients received more antihypertensive agents (37% vs. 21%; P < 0.0001), and fewer vasopressors (63% vs. 78%; P < 0.0001) than did RRP patients. The two groups had similar morphine-equivalent opioid use intraoperatively, but in the PACU, RALP patients required fewer morphine equivalents (mean ± SD; 11.4 ± 7.7 mg vs. 14.9 ± 9.8 mg; P < 0.0001). The RALP patients had longer surgical times (mean ± SD; 296 ± 76 vs.193 ± 69 min; P < 0.0001) but shorter PACU stays (mean ± SD; 113 ± 55 min vs. 143 ± 58 min; P < 0.0001) and shorter hospital stays (mean ± SD; 44 ± 77 hrs vs. 56 ± 26 hrs; P = 0.009).ConclusionsDuration of surgery was greater with RALP, but it was associated with less EBL, fewer transfusions of blood products, and shorter PACU and hospital stays.     

Thermoregulatory effects of spinal and epidural anesthesia during cesarean delivery

Background and Objectives: Hypothermia is likely to develop faster during spinal anesthesia than epidural anesthesia. A natural consequence of the rapid temperature decrease during spinal anesthesia is that the shivering threshold will be reached sooner and that more shivering will be required to prevent further hypothermia. We tested the hypotheses that the onset of hypothermia is more rapid and the onset and intensity of shivering earlier during spinal than epidural anesthesia. Methods: Patients undergoing cesarean delivery were randomly assigned to spinal anesthesia or epidural anesthesia. Spinal anesthesia was induced by injecting 2 mL 0.5% dibucaine into the L4–L5 interspace. Epidural anesthesia was induced with 20 mL 2% mepivacaine injected into the L2–L3 interspace. Thermal comfort and shivering were scored by a blinded observer. Results: Fifteen patients given each type of anesthesia had upper sensory levels ≥T4 dermatome. Sensation was entirely absent from the leg during spinal anesthesia, but lower block levels were near S5 during epidural anesthesia. Tympanic membrane temperatures initially decreased faster during spinal anesthesia, but subsequently decreased at a rate of 0.5°C/h in both groups. The onset and incidence of shivering (detected qualitatively) did not differ significantly between the two groups, but shivering intensity was significantly reduced during spinal anesthesia. Furthermore, the shivering thresholds were 36.4 ± 0.3°C (mean ± SD) during spinal anesthesia versus 37.1 ± 0.4°C in those given epidural anesthesia (P = .006). There were no clinically important differences in thermal comfort with the two kinds of neuraxial anesthesia. Conclusions: We failed to confirm our hypothesis, but for an unexpected reason: Thermoregulation was impaired more by spinal anesthesia than epidural anesthesia. It seems likely that in our patients spinal anesthesia inhibited thermoregulatory control more than epidural anesthesia because it better blocked sensory input from the legs.     

The analgesic effect of interscalene block using clonidine as an analgesic for shoulder arthroscopy

Used as the sole analgesic, clonidine produces analgesia after central neural blockade and intraarticular injection but not after axillary block. In this study, we sought to determine whether interscalene clonidine induces analgesia for shoulder arthroscopy. Forty patients scheduled for shoulder arthroscopy were prospectively included in this double-blinded study. Using a nerve stimulator technique, an interscalene catheter was inserted. The patients were randomly divided into two groups. The interscalene group (n = 20) received clonidine 150 micro g in 15 mL of saline through the catheter and 1 mL of subcutaneous saline, and the systemic group (n = 20) received 15 mL of saline through the catheter and clonidine 150 micro g (1 mL) subcutaneously. All patients underwent general anesthesia for surgery. On completion of arthroscopy, all patients received, via a patient-controlled analgesia, on demand a bolus of 8 mL of ropivacaine 0.2% through the catheter with a 1-h lockout period. Postoperative pain was measured every 4 h using the visual analog scale (VAS) for 24 h. Additional postoperative analgesia was available with parenteral nalbuphine if required until VAS < 3. VAS scores in the recovery room were significantly higher in the systemic group compared with the interscalene group (P < 0.0001). Analgesic duration was significantly longer in the interscalene group (P < 0.00001), and ropivacaine consumption was significantly less than in the systemic group (P < 0.0001). No significant difference was observed between groups for nalbuphine consumption. Side effects were comparable in the two groups. IMPLICATIONS: Clonidine administered via an interscalene catheter enhanced analgesia compared with systemic administration. Nevertheless, the adverse effect of clonidine at this dose limits its use for routine management for postoperative analgesia.     

Sensory block extension during combined spinal and epidural

Background and Objectives. During a combined spinal and epidural technique, extension of sensory block by epidural injection of saline or bupivacaine has been demonstrated and attributed to a volume effect or to the combination of a volume effect with a local anesthetic effect. This two-part study was designed to evaluate the time dependency of the volume effect and the local anesthetic effect on the mechanism of spinal block extension. Methods. We performed two prospective studies. Thirty patients were randomized in each study. A combined spinal and epidural was performed in a sitting position in all groups. The patients in the first study received 15 mg hyperbaric bupivacaine intrathecally and were placed supine 2 minutes after spinal injection. They received 10 mL epidural saline either 5 minutes after spinal (group A) or 20 minutes after spinal (group B) compared to a control group (group C). The patients in the second study received 12.5 mg hyperbaric bupivacaine intrathecally and were placed supine 5 minutes after spinal injection. They then received epidurally either 10 mL saline 7 minutes after spinal (group D) or 10 mL bupivacaine 7 minutes after spinal (group E) or nothing (group F). Sensory block levels were assessed by a loss of sensation to cold using ether. Results. In the first portion of this study, in group A, area under the curve of sensory block levels by time from 10 to 40 minutes after spinal injection, and maximum sensory block levels were significantly higher (P < .05) compared to groups B and C. In the second portion of the study, sensory block levels were comparable at all times in the three groups. Conclusions. During a combined spinal and epidural technique with the use of hyperbaric bupivacaine, the volume effect is time dependent and is seen when epidural top up is done soon after spinal injection. This volume effect is abolished when patients are left seated for 5 minutes after spinal injection. The local anesthetic effect is not demonstrated when high sensory block levels are achieved by spinal injection.     

Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial

Background

The foremost limitation of local anesthetic solutions for spinal anesthesia in the outpatient setting is prolonged motor blockade and delayed ambulation. The purpose of this study was to determine if the addition of intrathecal fentanyl to low-dose spinal mepivacaine provides adequate anesthesia with shorter duration of functional motor blockade for ambulatory knee surgery compared with spinal mepivacaine alone.

Methods

Following institutional review board approval and informed consent, 34 patients undergoing unilateral knee arthroscopy were enrolled in this study. The patients were randomly assigned to receive either 30 mg of isobaric mepivacaine 1.5% plus fentanyl 10 μg (M + F group) or 45 mg of isobaric mepivacaine 1.5% alone (M group) intrathecally. Postoperatively, the times to achieve sensory block regression to the S1 dermatome and to attain functional motor block recovery enabling ambulation were recorded. All assessments were blinded.

Results

The time to completion of Phase I recovery was shorter in the M + F group (104.6 ± 28.4 min) than in the M group (129.1 ± 30.4 min; P = 0.023). Regression of sensory blockade to S1 was earlier in the M + F group (118.4 ± 53.5 min) than in the M group (169.7 ± 38.9 min; P = 0.003). Patients in the M + F group (176.4 ± 40.3 min) were able to ambulate significantly earlier than those in the M group (205.6 ± 31.4 min; P = 0.025). No cases of transient or persistent neurological dysfunction were noted.

Conclusions

When compared with 45 mg isobaric mepivacaine 1.5%, an intrathecal dose of 30 mg isobaric mepivacaine 1.5% plus 10 μg fentanyl produces reliable anesthesia, hastens block regression, shortens stay in Phase I recovery, and enables earlier ambulation for patients undergoing unilateral knee arthroscopy (Registration no. NCT00803725).     

Does epidural versus combined spinal-epidural analgesia prolong labor and increase the risk of instrumental and cesarean delivery in nulliparous women?

Study ObjectiveTo compare duration of labor, mode of delivery, and local anesthetic consumed in women who received labor analgesia with epidural or combined spinal-epidural technique.DesignRetrospective, observational study.SettingDelivery room of a university hospital.Patients788 nulliparous women in labor at term with cervical dilation between three and 5 cm.InterventionsIn Group E (epidural alone), parturients received an epidural solution of 8 mL (levobupivacaine 0.125% with fentanyl 5 μg/mL). In Group CSE (combined spinal-epidural), parturients received a spinal injection of levobupivacaine two mg with fentanyl 15 μg (total volume two mL). Then an epidural catheter was placed in all patients and connected to a patient-controlled analgesia pump (basal infusion rate of 8 mL/hr of 0.1% levobupivacaine and fentanyl two μg/mL, patient-controlled bolus dose of three mL, and lockout time of 30 min).MeasurementsLabor duration, mode of delivery (spontaneous vaginal vs. instrumental delivery vs. cesarean section), and local anesthetic consumed, were recorded.Main ResultsLabor analgesia was performed with an epidural technique in 322 patients (40.9%), and a combined spinal-epidural technique in 466 patients (59.1%), of whom 39 Group E women (12.1%) and 46 Group CSE women (9.9%) required cesarean section (P=ns). No differences in the mode of delivery were observed between the groups. Time from analgesia to delivery (Group E: 217 ± 111 min vs. Group CSE: 213 ± 115 min; P=ns), and epidural local anesthetic consumed (Group E: 35 ± 20 mL vs. Group CSE: 33 ± 20 mL; P=ns), were similar in both groups.ConclusionsNo significant differences were observed between epidural and combined spinal-epidural given for labor analgesia in nulliparous women in duration of labor, mode of delivery, or local anesthetic consumed.