Spinal Hyperbaric Ropivacaine-Fentanyl for Day-Surgery:

Intrathecal 1% 2-Chloroprocaine with Fentanyl in Comparison with Ropivacaine (0.5%) with Fentanyl in Day Care Perianal Surgery: Prospective Randomized Comparative Study

Background:

Spinal anesthesia is a reliable and safe technique for perianal surgeries; the changing trend of surgical practice from an inpatient to outpatient has urged us to use lower dose of local anesthetic providing segmental block with adjuvants such as opioids. Ropivacaine is a long acting; amide local anesthetic, with greater sensory motor differentiation. Chloroprocaine (CP) is an amino-ester local anesthetic with a very short half-life. This study was designed to compare CP with ropivacaine for spinal anesthesia in an elective ambulatory setting.

Methods:

This prospective, randomized, comparative study included 60 adult patients scheduled to undergo perianal surgeries under subarachnoid block with intrathecal 3.0 mL of 1% CP with 12.5 μg fentanyl (Group C) or 1.5 mL of 0.5% ropivacaine with 12.5 μg fentanyl (Group R).

Statistical Analysis:

Chi-square test used to assess significance for qualitative data, independent t-test for significance of the mean difference between two quantitative variables.

Results:

Meantime of onset of sensory block at T₁₀ in both the groups were comparable (Group C – 4.7 min, Group R – 4.8 min). Maximum upper level of sensory block was at T8 in both the groups, time for regression of sensory level to L₁ was significantly longer with ropivacaine (Group R – 135 min, Group C – 76 min, P < 0.0001), and the duration of motor blockade (Group C – 81 min, Group R – 145 min P < 0.0001) was significantly short in the Group C with early ambulation (160 min).

Conclusion:

CP provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal ropivacaine.

Comparison of intrathecal ropivacaine-fentanyl and bupivacaine-fentanyl for major lower limb orthopaedic surgery: A randomised double-blind study

Background and Aims:

Intrathecal bupivacaine results in complete anaesthetic block of longer duration than ropivacaine. Fentanyl as an adjuvant may improve the quality of spinal block of ropivacaine while maintaining its advantage of early motor recovery. In this study, we proposed to compare the efficacy and safety of intrathecal ropivacaine-fentanyl (RF) with bupivacaine-fentanyl (BF) for major lower limb orthopaedic surgeries.

Methods:

Sixty patients were randomly allocated to receive either intrathecal 15 mg 0.5% ropivacaine with 25 mcg fentanyl (Group RF) or 15 mg 0.5% bupivacaine with 25 mcg fentanyl (Group BF). The onset, duration, spread of sensory and motor block, haemodynamic parameters and side effects were recorded. Statistical Package for Social Sciences 20 software was used for statistical analysis.

Results:

Time to reach highest sensory level and complete motor block were comparable. Sensory regression to L1 dermatome was 226 ± 46.98 min in Group RF and 229.33 ± 50.51 min in Group BF, P = 0.36. The motor recovery to Bromage scale 1 was faster in Group RF (242.8 ± 47.06 min) than Group BF (268 ± 49.9 min) P = 0.023. Time for rescue analgesia was prolonged in Group BF (263.33 ± 63 min) when compared to Group RF (234.44 ± 58.76 min), P = 0.021. The haemodynamic stability was better in Group RF than Group BF.

Conclusion:

Intrathecal RF provided satisfactory anaesthesia with haemodynamic stability for major lower limb orthopaedic surgery. It provided similar sensory but shorter duration of motor block compared to BF which is a desirable feature for early ambulation, voiding and physiotherapy.

Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients

BACKGROUND

Articaine and chloroprocaine have recently gained interest as short-acting spinal anaesthetics. Based on previous work comparing articaine 60 mg with chloroprocaine 40 mg, we hypothesised that articaine 40 mg and chloroprocaine 40 mg would produce similar spinal anaesthesa regarding block onset, maximal spread, and recovery.

METHODS

In this randomised, double-blind study, adult patients (18-70 years, American Society of Anaesthesiologists physical status I-III, BMI < 36 kg/m(2) ) scheduled for day-case knee arthroscopy received either articaine 40 mg (20 mg/ml) (group A40, n = 16) or chloroprocaine 40 mg (20 mg/ml) (group C40, n = 18) intrathecally. Telephone interviews were performed on the first and seventh postoperative day to disclose possible side effects, e.g. transient neurological symptoms (TNS).

RESULTS

The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. Surgery could be performed successfully under spinal anaesthesia except once in A40 (insufficient block) and once in C40 (prolonged surgery). Complete recovery was significantly slower in A40 vs. C40 for both motor block (105 (94/120) vs. 75 (71/90) min) [P < 0.001, Mann-Whitney U-test (MW-U)] and sensory block [135 (109/176) vs. 105 min (90/124)] (P < 0.02, MW-U), respectively [data are median (25th/75th percentiles)]. One patient from A40 showed mild TNS.

CONCLUSION

Both A40 and C40 provided mainly adequate spinal anaesthesia for day-case knee arthroscopy. While onset and maximal spread were comparable, the recovery from motor block was clearly faster with chloroprocaine after equivalent doses of spinal articaine and chloroprocaine.

Drug therapy for preventing post-dural puncture headache

BACKGROUND

Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for preventing PDPH in adults and children.

SEARCH METHODS

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital.

AUTHORS' CONCLUSIONS

Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

Comparison of intrathecal bupivacaine and ropivacaine with different doses of sufentanil

BACKGROUND

Spinal bupivacaine produces a complete anaesthetic block of a longer duration than ropivacaine, which leads to a potentially increased risk of failure. A combination of sufentanil to ropivacaine may improve the block's reliability.

METHODS

Sixty-four patients, scheduled for varicose vein stripping or the tension-free vaginal tape procedure, were allocated to receive double-blindly, spinal bupivacaine 10 mg (Group 1) or ropivacaine 10 mg without (Group 2) or with sufentanil 2.5 mcg (Group 3), 5 mcg (Group 4). Sensory block was tested with pinprick and motor block was evaluated with the Bromage scale until full recovery. The primary endpoint was to compare the duration of sensory block evaluated by regression to S2.

RESULTS

In comparison with bupivacaine, ropivacaine produced a shorter duration sensory block (median at 68, 90 and 120 min in groups 2, 3 and 4, respectively, vs. 150 min in Group 1) and motor block (median at 90, 98 and 120 min in groups 2, 3 and 4 vs. 180 min in Group 1). Motor blockade was significantly less important in patients receiving spinal ropivacaine (median values for the Bromage scale at 3 in groups 2, 3 and 4, vs. 1 in Group 1). Pruritus was significantly more frequent in patients receiving spinal sufentanil (Groups 3 and 4 vs. Groups 1 and 2).

CONCLUSION

Plain bupivacaine 10 mg has a longer recovery profile than the same dose of ropivacaine with or without sufentanil.

Intrathecal sufentanil decreases the median effective dose (ED50) of intrathecal hyperbaric ropivacaine for caesarean delivery

BACKGROUND

The addition of opioid to local anaesthetics has become a well-accepted practice of spinal anaesthesia for caesarean delivery. Successful caesarean delivery anaesthesia has been reported with the use of a low dose of intrathecal hyperbaric ropivacaine coadministered with sufentanil. This prospective, double-blinded study determined the median effective dose (ED50) of intrathecal hyperbaric ropivacaine with and without sufentanil for caesarean delivery, to quantify the sparing effect of sufentanil on the ED50 of intrathecal hyperbaric ropivacaine.

METHODS

Sixty-four parturients undergoing elective caesarean delivery with combined spinal-epidural anaesthesia were randomized into two groups: Group R (ropivacaine) and Group RS (ropivacaine plus sufentanil 5 microg). The initial dose of ropivacaine was 13 mg in Group R and 10 mg in Group RS. The effective dose was defined as a T(6) level attained within 10 min and no supplemental epidural anaesthetic required during surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the dose of ropivacaine for the next patient using an up-down sequential allocation.

RESULTS

The ED50 of intrathecal ropivacaine was 11.2 mg [confidence interval (CI) 95%: 11.0-11.6] in Group R vs. 8.1 mg (CI 95%: 7.8-8.3) in Group RS. Motor block was markedly more intense in Group R than in Group RS, and the incidence of shivering was lower in Group RS than in Group R. There were no differences in the onset time of sensory block or motor block, in the incidence of hypotension, nausea and vomiting.

CONCLUSION

Intrathecal sufentanil 5 microg produced a 28% reduction of ED50 of intrathecal hyperbaric ropivacaine for caesarean delivery.

Low-dose ropivacaine-sufentanil spinal anaesthesia for caesarean delivery: a randomised trial

BACKGROUND

It is well known that intrathecal opioids have a synergic effect with spinal local anaesthetics. The aim of this study was to evaluate whether low-dose ropivacaine in combination with sufentanil could produce effective spinal anaesthesia with less maternal hypotension and vomiting than ropivacaine alone.

METHODS

80 ASA I and II parturients undergoing elective caesarean delivery under combined spinal-epidural anaesthesia were randomly allocated to two groups. Group R15 received intrathecal hyperbaric ropivacaine 15 mg and group SR10 hyperbaric ropivacaine 10 mg with sufentanil 5 micrograms. Characteristics, efficacy and side effects of spinal anaesthesia in each group were measured.

RESULTS

There was no significant difference in the quality of intraoperative analgesia and muscle relaxation between groups. The incidence of hypotension was significantly higher (55% vs. 20%, P < 0.005) and the need for ephedrine less in group R15 than in group SR10. In group SR10, the onset of motor block was delayed (2.9 +/- 1.1 vs. 4.6 +/- 2.5 min, P < 0.005), the duration was shorter (65.9 +/- 15.1 vs. 125.4 +/- 26.4 min, P < 0.005). The duration of effective analgesia was longer (260 +/- 32.5 vs. 143 +/- 22.1 min, P < 0.005), the incidence of shivering (20% vs. 60%, P < 0.005) and vomiting (5% vs. 30%, P < 0.005) were lower in group SR10.

CONCLUSIONS

The combination of hyperbaric ropivacaine 10 mg with sufentanil 5 lg produced effective spinal anaesthesia for caesarean delivery with significantly less hypotension, vomiting and shivering, shorter duration of motor blockade and longer lasting analgesia than hyperbaric ropivacaine 15 mg.