Spinal anaesthesia for day case surgery

The quality of recovery favours spinal anaesthesia if the incidence of headache can be made sufficiently small. This can be done by excluding young adults who are most at risk. However, those anaesthetists who are prepared to become practised at using fine bore needles can offer day-case patients of all ages spinal blocks. It is suggested that nothing larger than 26-gauge needles are used for day-cases. Pencil and oval pointed needles also appear to confer advantages. Spinal anaesthesia is gaining momentum and need not be denied to day-case patients.     

Epidural anaesthesia for day care surgery.

The records of 682 patients who received epidural anaesthesia for day care surgery were reviewed. The advantages and disadvantages of this form of anaesthesia is discussed. No major complications were recorded.     

Spinal anaesthesia for outpatient surgery

Spinal anaesthesia in the outpatient is characterized by rapid onset and offset, easy administration, minimal expense, and minimal side effects or complications. Spinal anaesthesia offers advantages for outpatient lower extremity, perineal, and many abdominal and gynaecological procedures. Development of small-gauge, pencil-point needles are responsible for the success of outpatient spinal anaesthesia with acceptable rates (0-2%) of postdural puncture headache (PDPH). Compared with peripheral nerve blocks, spinal anaesthesia has a more predictable offset. There are many possible choices of local anaesthetics for outpatient spinal anaesthesia. These include lidocaine, prilocaine, mepivacaine and small doses of bupivacaine. Meperidine has local anaesthetic properties in addition to its opiate properties. It has been used as the sole intrathecal agent for spinal anaesthesia but has no real advantages over lidocaine. Mepivacaine and lidocaine have each been associated with transient neurological symptoms (TNS) following intrathecal administration. This has stimulated development of alternative agents, including combinations of local anaesthetics and opioids. Lidocaine remains the most useful agent for outpatient spinal anaesthesia. For longer procedures, mepivacaine is an excellent spinal anaesthetic agent. Attention to technique, reduction of dose and addition of fentanyl to lidocaine result in effective spinal anaesthesia with rapid recovery and a low incidence of significant side effects or complications.     

Spinal anaesthesia for spinal surgery

Spinal anaesthesia for spinal surgery is becoming increasingly more popular because this anaesthetic technique allows the patient to self-position and avoid neurological injury that may occur with prone positioning under general anaesthesia. Spinal anaesthesia reduces intraoperative surgical blood loss, improves perioperative haemodynamic stability and reduces pain in the immediate postoperative period. This leads to a reduced need for analgesics and a reduction in the incidence of nausea and vomiting in the postoperative setting. Spinal anaesthesia for lumbar spine surgery also decreases the incidence of lower extremity thrombo-embolic complications and does not increase the occurrence of problems with micturition. These benefits increase the patient's satisfaction, and they expedite discharge of the patient from the hospital. Combination anaesthetic techniques, using both subarachnoid and epidural dosing schemes, may be beneficial for improving postoperative pain control and add further to the benefit of spinal anaesthesia for lumbar spine surgical procedures.     

Spinal anaesthesia for outpatient surgery

In a prospective study of 51 young male outpatients given spinal anaesthesia through a 25-gauge needle, we found a 37.2% incidence of postdural puncture headache. In addition, 54.9% complained of backache after surgery. Occurrence of headache significantly prolonged the sick-leave from work. General anaesthesia would be preferred by 31.4% of patients for a similar procedure in the future. These patients had a higher incidence of postoperative backache and pain during lumbar puncture. It is concluded that spinal anaesthesia is not a satisfactory technique for outpatient procedures in young men.     

Spinal anaesthesia for urological surgery

A survey was conducted on 100 consecutive patients who underwent spinal anaesthesia in our urology operating theatres. Details of the spinal technique were recorded in the operating theatre. In 25% of patients, more than one attempt at subarachnoid puncture was required and 16% of this group went on to require general anaesthesia. The patients were visited between 24 and 48 h postoperatively by one of the authors. On questioning, 24% of patients reported a headache, which had the characteristics associated with dural puncture; 62% of these headaches were described as moderate or severe and lasted between 12 and 24 h. Patients were significantly (p < 0.05) more likely to develop a postdural puncture headache if more than one attempt at subarachnoid puncture was made.     

Total intravenous anaesthesia versus inhalational anaesthesia for dental day surgery.

Fifty young healthy and unpremedicated patients scheduled for removal of impacted teeth were randomly allocated to receive either total intravenous anaesthesia with propofol or conventional thiopentone/isoflurane/nitrous oxide anaesthesia. A double-blind postoperative assessment showed the former group to have a shorter reversal time and faster recovery of faculties, i.e. speech, memory as well as ability to sit up and walk without assistance (P < 0.01). There was no incidence of hypotension and of awareness in either group. The incidence of headache, nausea and vomiting was higher in the thiopentone/isoflurane/nitrous oxide group.     

Spinal anesthesia for day surgery

The unique characteristics of spinal anesthesia recommend it for outpatient surgical procedures. The technique is easily and safely performed on patients in the lateral, sitting, or jacknife position with a variety of agent preparations tailored to the surgical requirements. New needle technologies have made postdural puncture headache uncommon ( ̃1%). Sedation is often provided to minimize patient anxiety, both preoperatively and intraoperatively, usually to the satisfaction of patients who expected to “go to sleep” for their operation. The distribution of spinal anesthesia can be targeted to a specific patient population and procedure, although interindividual variability limits predictability. Vigilance is paramount to managing spinal anesthesia, because minor side effects as well as severe bradyarrythmias and cardiac arrest may occur. Lidocaine has the optimal onset and duration profile for most outpatient anesthesia. However, transient neurologic symptoms (TNS) occurring after lidocaine spinal anesthesia have recently been documented. TNS can be markedly uncomfortable and occur to some degree in approximately 20% of outpatients receiving lidocaine. Mepivacaine does not appear to offer any advantage over lidocaine, whereas procaine may cause a lower incidence of TNS. Bupivacaine has the lowest associated incidence of TNS, and has been adapted for ambulatory surgery by using small doses in the 5 to 10 mg range. Adjuncts such as fentanyl can improve the success rate of small-dose spinal anesthesia without prolonging discharge time. Overall, factors that encourage early voiding will minimize time to home readiness. Anticoagulated patients need special consideration in light of new therapies and indications. Copyright © 2000 by W.B. Saunders Company     

Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery

BACKGROUND AND OBJECTIVE: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. METHODS: Patients in Group 1 (n = 20) received alfentanil 20 microg kg(-1) followed by 2 microg kg(-1) min(-1) intravenously; patients in Group 2 (n = 20) received remifentanil 1 microg kg(-1) followed by 0.5 microg kg(-1) min(-1) intravenously. Both groups then received propofol 2 mg kg(-1) followed by 9 mg kg(-1) h(-1) intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). RESULTS: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score > or = 9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores > or = 9 were similar. CONCLUSIONS: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.     

Spinal anaesthesia for minor paediatric surgery

Our recent experience using spinal anaesthesia for paediatric surgical procedures is reviewed. In 1984, 30 patients aged seven weeks to 13 years were anaesthetised in this manner. Lumbar puncture failed in four of 34 patients, 12 required sedation during the operative course and 11 required light general anaesthesia to complete these procedures. Tetracaine one per cent or bupivacaine 0.75 per cent were the drugs used. During the procedure and depending on their age, the patients were either sedated or were distracted with the use of Disney cartoons played on a video cassette recorder. There were no significant intraoperative or postoperative complications.     

Spinal bupivacain anaesthesia in traumatological surgery.

Two-hundred forty spinal cases of bupivacain anaesthesia are reported. One third of the patients was over 60 years of age and one quarter in a poor condition. No serious or lasting complications were observed. In the overwhelming majority anaesthesia during operation was satisfactory, thus the drug was found suitable for use in traumatological surgery. Due to its protracted effect, bupivacain ensures analgesia in the early postoperative period.     

Inhalation versus intravenous anaesthesia for day surgery

Opinion is often fiercely divided over the relative merits of intravenous or inhaled anaesthesia for day case procedures. Advocates of intravenous anaesthesia claim superior recovery and minimal side effects, yet inhalational agents remain popular and are widely used for their excellent operative conditions and low costs. This review will consider the recent evolution in both inhalation and intravenous anaesthesia and will describe what are probably the optimal techniques for the delivery of each. Possible advantages and disadvantages of these approaches will be discussed and the outcomes examined. In reality, recovery characteristics are very similar with either of the two techniques and where differences do exist, they are of minimal importance. Costs may differ, but again the differences are small and frequently absorbed within the far greater overall costs of the procedure. Postoperative nausea and vomiting (PONV) is the most contentious outcome and this will be examined in some detail. While most evidence would favour intravenous anaesthesia in this respect, the magnitude of the advantage may be overestimated and strategies for reducing side effects after inhalation anaesthesia to acceptable levels will be presented. Finally, the future of day case anaesthesia will be considered, with the unfortunate conclusion that the supply of exciting new anaesthetic agents appears to be exhausted, at least for the present.