Pharmacoeconomics of intravenous regional anaesthesiavs general anaesthesia for outpatient hand surgery

Purpose

To compare the cost and effectiveness of intravenous regional anaesthesia (IVRA) with general anaesthesia (GA) for outpatient hand surgery.

Method

A retrospective record analysis of 121 patients who received IVRA were compared with 64 patients who received GA in our Daycare centre. The costs of anaesthesia and recovery were calculated from an institutional perspective using 1995 Canadian Dollar values. Effectiveness was measured in terms of time for anaesthesia, recovery and discharge, % with unsatisfactory anaesthesia and complications.

Results

Both groups were well matched in terms of weight, sex and ASA class. Patients in the IVRA group were older (45 ± 16 vs 38 ± 13 yr) and had a lower frequency of two types of operation. The median total cost for the IVRA group of $24.60 (15.76–55.29) was less than that for the GA group of $48.66 (35.59–73.11). (P < 0.00001). Anaesthesia was unsatisfactory in 11% of the IVRA group, but in none having GA, (P < 0.01). Recovery was faster in the IVRA group with a median time to discharge of 70 (35–180) min compared with 118 (45–320) min in the GA group. (P < 0.00001) Vomiting requinng treatment occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). Dizziness which delayed discharge also occurred in 5% of the GA group, but in none having IVRA. (P < 0.05).

Conclusion

The cost of anaesthesia and recovery using IVRA for outpatient hand surgery was half that of GA. Intravenous regional anaesthesia was less effective than GA in achieving satisfactory anaesthesia, equally effective in time to administer anaesthesia, and more effective in speeding recovery and minimising postoperative complications.     

Non-alkalinized and alkalinized 2-chloroprocainevs lidocaine for intravenous regional anesthesia during outpatient hand surgery

PURPOSE: Chloroprocaine should be an ideal agent for intravenous regional anesthesia (IVRA) because of its rapid onset and ester hydrolysis. Raising the pH of local anesthetics may increase the speed of onset and the intensity of nerve blocks. We compared plain and alkalinized 2-chloroprocaine 0.5% with lidocaine for IVRA. METHODS: In two separate double-blind studies, 78 patients scheduled for daycare hand surgery were randomized to receive 40 mL plain 2-chloroprocaine 0.5%, alkalinized 2-chloroprocaine 0.5% or lidocaine 0.5% for IVRA. Time to sensory and motor block, need for supplemental analgesia, and side effects were compared. RESULTS: There was no difference in time to sensory or motor block in either group. Patients who received plain chloroprocaine required more supplemental opioid and had a higher incidence of metallic taste and of hives than patients who received lidocaine (P < 0.05). Comparing alkalinized chloroprocaine with lidocaine, there was no difference found with respect to opioid supplementation, CNS side effects, or incidence of hives. CONCLUSION: In conclusion, alkalinized chloroprocaine was found to be an effective agent for IVRA but no benefit over lidocaine was detected. Plain chloroprocaine for IVRA produced more minor side effects than lidocaine.     

Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time

BACKGROUND: The performance of anesthetic procedures before operating room entry (e.g., with either general or regional anesthesia [RA] induction rooms) should decrease anesthesia-controlled time in the operating room. The authors retrospectively studied the associations between anesthesia techniques and anesthesia-controlled time, evaluating one surgeon performing a single procedure over a 3-yr period. The authors hypothesized that, using the anesthesia care team model, RA would be associated with reduced anesthesia-controlled time compared with general anesthesia (GA) alone or combined general-regional anesthesia (GA-RA). METHODS: The authors queried an institutional database for 369 consecutive patients undergoing the same procedure (anterior cruciate ligament reconstruction) performed by one surgeon over a 3-yr period (July 1995 through June 1998). Throughout the period of study, anesthesia staffing consisted of an attending anesthesiologist medically directing two nurse anesthetists in two operating rooms. Anesthesia-controlled time values were compared based on anesthesia techniques (GA, RA, or GA-RA) using one-way analysis of variance, general linear modeling using time-series and seasonal adjustments, and chi-square tests when appropriate. P < 0. 05 was considered significant. RESULTS: RA was associated with the lowest anesthesia-controlled time (11.4 +/- 1.3 min, mean +/- 2 SEM). GA-RA (15.7 +/- 1.0 min) was associated with lower anesthesia-controlled time than GA used alone (20.3 +/- 1.2 min). CONCLUSIONS: When compared with GA without an induction room for outpatients undergoing anterior cruciate ligament reconstruction, RA with an induction room was associated with the lowest anesthesia- controlled time. Managers must weigh the costs and time required for anesthesiologists and additional personnel to place nerve blocks or induce GA preoperatively in such a staffing model.     

Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery

BACKGROUND: In the last few years infraclavicular plexus block has become a method of increasing interest. However, this block has been associated with high complication incidences and without advantage in the quality of blockade over the axillary approach. We prospectively studied 40 patients (ASA I-III) undergoing surgery of the forearm and hand, and investigated the performance of the lateral infraclavicular plexus block against an axillary paravascular block to evaluate the success rate as well as the extent and quality of blockade. METHODS: Patients were randomized into two groups: group I (lateral infraclavicular approach; n=20) and group A (axillary approach; n=20). The lateral infraclavicular approach is a technique with the coracoid process (CP) as landmark. Alone the sagittal plane, the needle is inserted until contact with the CP. The needle is then withdrawn 2-3 mm and reinserted directly under the CP, until it contacts the brachial plexus sheath. Plexus blockade was performed using 40 ml of mepivacaine 1%. Quality of sensory and motor block was recorded selectively for each nerve distribution at close intervals for 6 h. RESULTS: Successful block according to Vester-Andersen's criteria was achieved in 100% of group I and 85% of group A. In group I, a pronounced sensory and motor blockade of the musculocutaneous nerve was observed, while patients of group A had a weak block of this nerve. In group I, an additional spectrum of nerves (thoracodorsal, axillary and medial brachial cutaneous nerves) was involved compared to group A. There was no difference among groups in onset and duration of block. CONCLUSION: Based on the safe landmark and feasibility of this procedure and the additional spectrum of nerve block achieved, the application of lateral infraclavicular technique has to be reconsidered in clinical practice.     

Improved intravenous regional anesthesia for surgery of the hand, wrist, and forearm. The second wrap technique

In 330 consecutive anesthetics administered over a period of 24 months, an improved method of upper extremity intravenous regional anesthesia, entitled "the second wrap technique," included wrapping the extremity a second time with a Martin rubber bandage after the extremity was prepared and draped. In addition, a Penrose drain tourniquet often was applied during injection of the 0.5% lidocaine. No complications occurred. The technique provides a nearly bloodless operative field, improves the anesthesia, diminishes tourniquet pain, lessens the contraindications, and requires no premedication. The only contraindications are allergy to lidocaine, infection, operating time over 2 hours, and severe hypertension.     

Ropivacaine 0.2% and lidocaine 0.5% for intravenous regional anesthesia in outpatient surgery

BACKGROUND: A longer-acting local anesthetic agent, such as ropivacaine, may offer advantages over lidocaine for intravenous regional anesthesia. The objectives of this study were to evaluate whether the findings of volunteer investigations with intravenous regional anesthesia with ropivacaine (which have shown prolonged analgesia after release of the tourniquet) translates into improved pain control after surgery. METHODS: With Human Investigation Committee approval and a double-blind study design, 20 healthy patients with American Society of Anesthesiologists physical status I or II classification who were scheduled to undergo forearm and hand surgery were randomly assigned to administration of 40 ml of either 0.2% ropivacaine or 0.5% lidocaine for intravenous regional anesthesia. Evidence of central nervous system side effects, such as lightheadedness, tinnitus, and metallic taste, as well as cardiac arrhythmias, were evaluated and treated (if necessary) after local anesthetic administration, before and during surgery, and after release of the tourniquet until discharge from the postanesthesia care unit. Regression of sensory anesthesia in the nerve distributions of the forearm and hand was recorded. Verbal numerical pain scores were monitored and quantified until the patients were discharged to home from the postanesthesia care unit. Patient pain scores, side effect profiles, time to first oral intake, and total amount of oral analgesics were recorded 24 h postoperatively. RESULTS: Intravenous regional anesthesia with 0.2% ropivacaine and 0.5% lidocaine provided equivalent levels of surgical anesthesia. After release of the tourniquet, the first evidence for return of sensation in the distribution of the five peripheral nerves occurred later in the ropivacaine group (median, 20 min; range, 15-40 min) than in the lidocaine group (median, 1 min; range, 1-25 min). Verbal numerical pain scores were significantly lower at the time of admission, whereas during the remainder of the postanesthesia care unit stay and later at home, the difference in verbal numerical pain scores between the two groups was no longer statistically significant. CONCLUSIONS: Ropivacaine 0.2% may be an alternative to 0.5% lidocaine for intravenous regional anesthesia in the outpatient surgical setting. Longer-lasting analgesia in the immediate postoperative period may be due to a more profound and prolonged tissue binding effect of ropivacaine.     

For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia

BACKGROUND: Both general and nerve block anesthesia are effective for shoulder surgery. For outpatient surgery, it is important to determine which technique provides more efficient recovery. The authors' goal was to compare nerve block with general anesthesia with respect to recovery profile and patient satisfaction after rotator cuff surgery. METHODS: In this clinical trial, 50 consenting outpatients (aged 18-70 yr) were randomly assigned to receive either fast-track general anesthesia followed by bupivacaine (0.25%) wound infiltration or interscalene brachial plexus block (0.75% ropivacaine), each under standardized protocols. Blinded recovery room nurses assessed the need for pain treatment and rated patient eligibility for bypass of the phase 1 postanesthesia care unit and for discharge home. Patients were followed up for 2 weeks postoperatively. The primary outcome measures were postanesthesia care unit bypass and same-day discharge. Other same-day recovery outcomes included severity of and treatment for pain and time to ambulation. Postoperative outcomes at home included satisfaction with the anesthesia technique and absence of complications (at 2 weeks). RESULTS: Patients who received nerve block (vs. general anesthesia) bypassed the postanesthesia care unit more frequently (76 vs. 16%; P < 0.001), reported less pain, ambulated earlier, were ready for home discharge sooner (123 vs. 286 min; P < 0.001), had no unplanned hospital admissions (vs. 4 of 25 patients who underwent general anesthesia; P = 0.05), and were more satisfied with their care. No complications were reported in either treatment group. CONCLUSIONS: Nerve block anesthesia for outpatient rotator cuff surgery provides several same-day recovery advantages over general anesthesia.     

A randomized comparative study between selective walking spinal anesthesia and general anesthesia for anorectal surgeries in outpatient settings

BackgroundSpinal anesthesia is gradually increasing in ambulatory setting. The limiting factor to the more widespread use of spinal anesthesia in the outpatient setting refers to the effect of residual block. Selective spinal anesthesia (SSA) with low dose lidocaine was compared with modern general anesthesia (GA) technique in day care anorectal surgeries.ObjectiveOur objectives in this study was to compare SSA with propofol and fentanyl based modern GA as regard to 1 – operating conditions 2 – patients’ and surgeon’s satisfaction, 3 – intraoperative, postoperative adverse events and 4 – recovery profiles in ambulatory anorectal surgeries.MethodsProspective randomized clinical study was conducted on 60 patients undergoing elective day case anorectal surgery. The patients were randomly allocated into one of two groups (GA and SSA groups) of 30 patients each. In GA group anesthesia was induced with intravenous fentanyl (2 μg/kg) and propofol (2–3 mg/kg). Airway was secured with I-gel supraglottic airway. Anesthesia was maintained by sevoflurane 1.5–2%, nitrous oxide 60% in oxygen mixture. SSA group patients received spinal anesthesia with lidocaine 20 mg and fentanyl 25 μg to a total volume of 3 ml with sterile water for injection. Intraoperative, postoperative and home adverse events, time to ambulate, time to home discharge, patients’ and surgeon’s satisfactions were statistically compared between both groups.ResultsBoth anesthetic techniques showed acceptable operating conditions and high rate of patients’ satisfaction. Low pain intensity, shorter time to ambulate and home discharge in SSA compared to GA with a p value < 0.001. Intraoperative hemodynamic stability was reported in both groups. No major postoperative or home adverse events in both groups.ConclusionsSSA with low dose lidocaine may be suitable alternative and competitive for modern GA in ambulatory anorectal surgery.     

Comparison of total intravenous anesthesia and sevoflurane-fentanyl anesthesia for outpatient otorhinolaryngeal surgery

STUDY OBJECTIVE: To compare the recovery characteristics of two widely used anesthetic techniques: remifentanyl-propofol and sevoflurane-fentanyl in a standardized ambulatory population.DESIGN: Randomized, single-blinded study. SETTING: University-affiliated medical center. PATIENTS: 50 ASA physical status I and II patients undergoing elective ambulatory otorhinolaryngeal surgery. INTERVENTIONS: Patients were randomized two groups to receive total intravenous anesthesia (TIVA group) with remifentanil and propofol or sevoflurane-fentanyl (SF group). TIVA patients received induction with propofol 1.5 mg/kg intravenously (IV) and remifentanil 0.5 microg/kg IV. The anesthesia was continued with a continuous infusion of propofol 100 microg/kg/min and remifentanil 0.0625-0.25 microg/kg/min. The SF group received, at induction, fentanyl 2 microg/kg followed by propofol 1.5 mg/kg IV. Maintenance was obtained with 1 to 1.5 minimum alveolar concentration of sevoflurane and bolus of fentanyl 1 microg/kg IV as needed. MEASUREMENTS AND MAIN RESULTS: Early recovery times (eye opening, response to commands, extubation, orientation, operating room stay after surgery, and Aldrete score > or =9) and patient satisfaction were similar between the two groups. Postanesthetic discharge scoring system (PADSS) > or = 9 was significantly shorter for the TIVA group (135.9 +/- 51 vs. 103 +/- 32 min) (p < 0.01) but this difference was not associated with a shorter postanesthesia care unit (PACU) length of stay. CONCLUSION: Early recovery times are comparable between total intravenous anesthesia and sevoflurane-based anesthesia. Even though patients in the TIVA group achieved home readiness criteria in a significantly shorter time, this technique does not shorten PACU length of stay, which depends instead on multiple nonmedical and administrative issues.     

全麻复合硬膜外阻滞在老年病人上腹部手术的应用

目的　评价全麻复合硬膜外阻滞对老年上腹部手术病人循环及应激反应状态的影响。方法　 30例ASAⅠ～Ⅱ级、择期上腹部手术老年病人 ,随机分为单纯全麻组 (对照组 )和全麻复合硬膜外阻滞组 (研究组 )。两组全麻诱导和维持方法相同 ,全麻诱导用咪唑安定 0 0 5mg/kg、芬太尼4 μg/kg、丙泊酚 1 5mg/kg、阿曲库铵 0 2mg/kg、琥珀胆碱 1 5mg/kg。研究组于诱导前取T9～ 10 椎间隙行硬膜外穿刺置管 ,注入 2 %利多卡因 3～ 4ml,测定麻醉平面后给追加量 ,麻醉平面控制在T4平面以下。间断静注咪唑安定、芬太尼和阿曲库铵并吸入 0 5 %～ 1%异氟醚维持麻醉。于麻醉前、切皮后 10分钟、切皮后 1小时、术毕时采外周静脉血测定血清皮质醇、血管紧张素 Ⅱ (A Ⅱ )、白细胞介素 6 (IL 6 )的浓度 ;记录循环指标、全麻药用量及术中知晓、术后躁动情况。结果　研究组血清皮质醇、A Ⅱ浓度在手术 1小时、术毕时明显低于对照组 (P <0 0 5 ) ;两组间血清IL 6水平无显著性差异。研究组术毕时HR明显低于对照组 (P <0 0 5 ) ,术中SBP、DBP明显低于对照组 (P <0 0 5和P<0 0 1)。 30例病人术毕血清IL 6浓度与手术时间呈正相关 (r =0 5 7,P <0 0 5 )。研究组全麻药用量和术后躁动例数低于对照组 ,而术中知晓例数高于对照组     

Total intravenous anesthesia, spinal anesthesia or combined sciatic-femoral nerve block for outpatient knee arthroscopy

AIM: The aim of this study was to compare efficacy, efficiency and surgeon's satisfaction of total intravenous anesthesia with propofol and remifentanil with those of spinal or peripheral nerve blocks for outpatient knee arthroscopy. METHODS: One hundred and twenty patients undergoing elective outpatient knee arthroscopy were randomly allocated to receive total intravenous anesthesia with propofol and remifentanil (40), combined sciatic-femoral nerve block (40), or spinal anesthesia (40). Preparation times, surgeon's satisfaction, and discharge times with the 3 anesthesia techniques were measured. Anesthesia-related costs were also compared based on costs of drugs, disposable materials, and anesthesia and nurse staff. RESULTS: Preparation time was 13 min (8-22 min) with general anesthesia, 15 min (5-30 min) with spinal anesthesia and 15 min (5-25 min) with sciatic-femoral blocks (p=0.006). Surgeon's satisfaction was similar in the 3 groups, but 17 patients receiving peripheral nerve block (42%) and 12 receiving spinal anesthesia (30%) by-passed the postanesthesia care unit after surgery as compared with only 2 general anesthesia patients (5%) (p=0.01). Discharge from the postanesthesia care unit required 5 min (5-20 min) after peripheral block as compared with 15 min (5-25 min) with spinal and 15 min (5-80 min) with general anesthesia (p=0.005); however, stay in the Day-Surgery Unit was shorter after general anesthesia [170 (100-400) min] than peripheral [265 (110-485) min] or spinal blocks [230 (95-800) min] (p=0.026). Urinary retention was reported in 3 spinal patients only (8%) (p=0.03). CONCLUSION: Regional anesthesia techniques reduce the rate of admission and the duration of stay in the postanesthesia care unit as compared with general anesthesia. Peripheral rather than spinal nerve blocks should be preferred to minimise the risk for urinary retention.