Continuous spinal anaesthesia or continuous epidural anaesthesia for post-operative pain control after hip replacement?

Both continuous spinal anaesthesia and continuous epidural anaesthesia are supposed to provide adequate post-operative pain relief. The purpose of this randomized, prospective study was to compare the quality of analgesia, occurrence of side effects and patient satisfaction between spinal and epidural administration of bupivacaine during the first post-operative 72 h. One hundred and two patients scheduled for hip arthroplasty were randomly assigned to one of two groups: Group 1 received continuous spinal anaesthesia for intra-operative and post-operative management, Group 2 received continuous epidural anaesthesia. Immediately after surgery, the continuous spinal anaesthesia-group received a 1-mL bolus (bupivacaine 0.25%), followed by a continuous infusion of 10 mL over 24 h. The continuous epidural anaesthesia-group received a 10-mL bolus (bupivacaine 0.25%), followed by 2 mL h-1. The level of pain was gauged from a verbal rating score and from a visual analogue scale; the degree of motor blockade was recorded using the Bromage score. In the continuous spinal anaesthesia-group 90.2% reported complete analgesia on the verbal rating scale, but only 21.6% of the continuous epidural anaesthesia-group did. The visual analogue scale scores given by the continuous spinal anaesthesia-group were significantly lower than those of the continuous epidural anaesthesia-group. The percentage of patients with a motor block was significantly higher in the continuous spinal anaesthesia-group on the day of surgery and at the first post-operative day. During the first 24 h, nausea and vomiting occurred more often in the continuous epidural anaesthesia-group. The satisfaction was considered excellent in 92.2% of the continuous spinal anaesthesia-group and in 70.6% of the continuous epidural anaesthesia-group. It is concluded that continuous spinal anaesthesia and continuous epidural anaesthesia are effective and safe for post-operative pain relief after hip replacement. Compared with continuous epidural anaesthesia, continuous spinal anaesthesia provides faster onset of pain relief, ensures better analgesia and results in more satisfied patients.     

Warm or cold saline for volume preload before spinal anaesthesia for caesarean section?

In this study, we compared the effect of prophylactic administration of warm and cold saline against spinal anaesthesia induced hypotension in parturients undergoing elective caesarean section. One hundred and thirteen parturients with singleton pregnancies received an i.v. infusion of isotonic saline 20 mL x kg(- 1)during the 15 min before spinal injection followed by 10 mL x kg(- 1)during the 20 min after spinal injection. Fifty-seven patients were allocated to the warm saline group (37 degrees C) and 56 to the cold saline group (21 degrees C). Discomfort in the infusion arm was less in the warm saline group (P<0.01), whereas the incidence of shivering was similar in the two groups. Following induction of spinal anaesthesia, blood pressures were significantly higher in the cold saline infusion group compared to the warm saline group (P<0.05). However, the group mean difference in mean arterial pressure was only about 5 mmHg, and the amount of ephedrine administered and the incidence of clinical significant hypotension did not differ between groups. In conclusion, the temperature of the fluid used for i.v. preload and maintenance at caesarean section under spinal anaesthesia is not clinically important.     

Cost-effective anaesthesia for outpatient arthroscopic knee surgery: spinal,desflurane, isoflurane or propofol anaesthesia?

Spinal anaesthesia (SA) is widely used in day surgery because it is easy and cheap. But how cheap is SA really, when compared to modern general anaesthesia with short-acting agents? The aim of this study was to compare SA to three modes of general anaesthesia in terms of the total costs of anaesthesia during outpatient knee arthroscopy (KA). There were 173 patients scheduled for elective KA randomised to receive SA with lidocaine, propofol infusion (PA), isoflurane (IA) or desflurane (DA) inhalation anaesthesia. The time spent in the operation theatre (OT) and the time to reach home readiness after postoperative care in the recovery unit (RU) were measured. The material and salary costs for the different anaesthesias were calculated. The total costs for IA and DA were significantly lower (P<0.05) than those for SA or PA. Inhalation anaesthesia, with either isoflurane or desflurane, is more cost-effective than SA or PA in elective ambulatory KA.     

Unilateral spinal anaesthesia: gadget or tool?

The results of different studies investigating the use of unilateral spinal anaesthesia are confusing and partly inconsistent. Some authors doubt whether it is possible to create a strictly unilateral block (i.e. motor, sensory and sympathetic) at all, while others claim that such a procedure is standard, especially for ambulatory anaesthesia. This review considers those factors which are relevant, plausible and proven.     

Intrathecal diamorphine or intrathecal fentanyl to supplement spinal anaesthesia for Caesarean section?

Editor—I was interested to read the paper by Cowan andcolleagues.¹ The study compared post-Caesarean section analgesiawhen i.v. morphine patient-controlled analgesia (PCA) was used,after supplementation of spinal anaesthesia from bupivacainewith intrathecal diamorphine, fentanyl or saline. There wereonly marginal benefits from using intrathecal diamorphine comparedwith intrathecal fentanyl. Intrathecal diamorphine was associated     

Job satisfaction, stress and burnout in anaesthesia: relevant topics for anaesthesiologists and healthcare managers?

Job satisfaction is defined as an employee's positive reaction towards his/her work. Changes in health policies, which are seen as a threat to the autonomy of health workers, are associated with a decrease in satisfaction levels, increase burnout among physicians, and may impair the quality and safety of care. The work environment of anaesthesiologists include stressful areas such as the operating theatre, the ICU, and the emergency setting, and this has been linked to higher levels of stress and lower satisfaction. We frequently lack feedback from patients and even our colleagues despite usually working within a team. Nevertheless, job satisfaction and burnout rates in anaesthesia are similar to other specialties. The most relevant factors in job satisfaction are worker autonomy, control of the working environment, recognition of our value, professional relationships, leadership and organisational justice. Although these can be manipulated for good or otherwise, there are additional, less malleable factors such as personality, expectations and motivation of the employee, that play a part. Within organisations there needs to be the will to evaluate employees' satisfaction, to improve their work environment and to develop strategies and coping mechanisms for professional stress. Personal wellness should also be nurtured, as a satisfactory work-life balance and an adequate social support network might act as a buffer for dissatisfaction and burnout. Improvement in satisfaction might create a positive work climate that would benefit both the safety of our patients and our profession.     

Is transient lumbar pain after spinal anaesthesia with lidocaine influenced by early mobilisation?

BACKGROUND: The aetiology of transient lumbar pain (TLP) after spinal anaesthesia has generated much interest. Many theories have been discussed. Early ambulation has been suggested as one plausible theory for developing TLP. METHODS: A total of 107 patients scheduled for inguinal hernial repair under spinal anaesthesia (20 mg/ml hyperbaric lidocaine) were randomised to either early or late ambulation: the early ambulation (group A), as early as possible after total regression of spinal block or the late mobilisation (group B) bedridden for more than 12 h. The clinical course and duration of operation were monitored. Assessments 4, 8 and 12 h after spinal anaesthesia were performed with respect to wound pain, nausea, tiredness and eventual symptoms of TLP were recorded. The patients also kept a diary about any symptoms once daily day 1-3 at home. A telephone follow-up was performed at day 5-7. RESULTS: Our results showed an incidence of TLP of 23% in all patients. No difference was recorded between early and late mobilisation patients, 12 and 13 patients, respectively. CONCLUSION: Early ambulation does not seem to increase the risk of developing TLP.     

Meningitis following spinal anaesthesia - a coincidental infection?

We report a case of meningitis developing a number of days after a subarachnoid block for caesarean section. No organisms were grown but the clinical picture was suggestive of bacterial meningitis, the clinical course of which had been modified by the administration of antibiotics for presumed wound infection. The possible aetiology is discussed.     

Desflurane or sevoflurane for gynaecological day-case anaesthesia with spontaneous respiration?

Sixty gynaecological day-case patients were anaesthetised with either desflurane or sevoflurane in oxygen/nitrous oxide, following intravenous induction. Mean end-tidal desflurane was 4.5% at 5 and 10 min post induction, whereas mean end-tidal sevoflurane was 1.7%. There were five untoward airway events (coughing, hiccoughs) in the desflurane group and three in the sevoflurane group, including one laryngospasm. Time to eye opening and orientation following anaesthesia were significantly faster in the desflurane group (2.8 min/4.8 min) than in the sevoflurane group (7.0 min/9.8 min; p < 0.0001). Time to being ready for discharge home was also significantly earlier in the desflurane group (3 h compared with 3.5 h). Telephone interview on the first postoperative day showed that in the desflurane group 29 of 31 were fully returned to normal activity compared with only 15 out of 29 in the sevoflurane group (p < 0.01).     

What height of block is needed for manual removal of placenta under spinal anaesthesia?

The technique of spinal anaesthesia for manual removal of placenta was examined prospectively in 101 women. Factors associated with maternal discomfort during surgery were the height of the block (P = 0.007) and the force applied by the surgeon in removing the placenta (P = 0.04). A sensory block to cold to T9 or T10 resulted in discomfort for six out of 27 women (22%). Only two women out of 38 experienced discomfort with a block to T6 or above. A block to cold to T6 or above is therefore recommended for manual removal of placenta under subarachnoid block. Factors not affecting maternal comfort were grade of the obstetrician, (P = 0.61), grade of the anaesthetist (P = 0.88), position of the mother during spinal injection (P = 0.32), volume of hyperbaric bupivacaine injected (P = 0.75), time from spinal injection to the start of surgery (P = 1.0), and duration of surgery (P = 0.77). Intraoperative hypotension was more common in those women with greater blood loss, (P = 0.002), but not with higher sensory levels (P = 0.31).