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Pascarella G, Poloni J, Coculo G, Costa F, Strumia A, Schiavoni L, Mattei A, Cataldo R, Agrò FE, Carassiti M. Spinal anesthesia with chlorprocaine as an effective and safe option for ambulatory gynecological surgery in patients with predicted difficult airway. Minerva Anestesiol 2023; 89:1147-1148. [PMID: 37526469 DOI: 10.23736/s0375-9393.23.17507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Giuseppe Pascarella
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Jessica Poloni
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Greta Coculo
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy -
| | - Fabio Costa
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Alessandro Strumia
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Lorenzo Schiavoni
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Alessia Mattei
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Rita Cataldo
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Felice E Agrò
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia and Intensive Care, Campus Bio-Medico University Hospital, Rome, Italy
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Ambrosoli AL, Di Carlo S, Crespi A, Severgnini P, Fedele LL, Cofini V, Necozione S, Musella G. Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:40. [PMID: 37864260 PMCID: PMC10589922 DOI: 10.1186/s44158-023-00122-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/04/2023] [Indexed: 10/22/2023]
Abstract
Spinal anesthesia is considered safe and reliable for most surgical procedures involving the lower part of the body, but its use in the ambulatory setting requires drugs with rapid onset and regression of the motor and sensory block-like prilocaine.The purpose of this study is to retrospectively analyze data from 3291 procedures recorded in our institutional database, to better define the safety profile of spinal prilocaine and the incidence of complications and side effects.All clinical data, prospectively collected from 2011 to 2019 in an Italian tertiary hospital, of patients treated with spinal anesthesia performed with 40 mg of hyperbaric 2% prilocaine, according to our internal protocol of day surgery, were analyzed.Surgical procedures included saphenectomy (28.5%, n = 937), knee arthroscopy (26.8%, n = 882), proctologic surgery (15.16%, n = 499), and inguinal canal surgery (14.9%, n = 491).Anesthesia-related complication was represented by urinary retention (1.09%, n = 36), lipotimia (0.75%, n = 25), and postoperative nausea (0.33%, n = 11); arrhythmic events were uncommon (0.18%, n = 6). One case of persistent hypotension and 2 cases of persistent hypertension were reported.Persistent motor or sensory block (lasting more than 5 h) was experienced by 7 patients. One patient (0.03%), who underwent knee arthroscopy, experienced pelvic pain lasting for 6 h, compatible with a transient neurological symptom.Proctologic surgery was a factor associated with unplanned admission due to anesthesia-related complications (OR = 4.9; 95% CI: 2-14%).The number of complications related to the method was low as well as the need for hospitalization. This drug is valid and safe for the most performed day surgery procedures; however, further trials are needed to investigate the incidence of complications in the days following the procedure.
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Affiliation(s)
- Andrea Luigi Ambrosoli
- Azienda Ospedaliera Di Varese: Aziende Socio Sanitarie Territoriale Dei Sette Laghi, Varese, Italy.
| | | | - Andrea Crespi
- Azienda Ospedaliera Di Varese: Aziende Socio Sanitarie Territoriale Dei Sette Laghi, Varese, Italy
| | - Paolo Severgnini
- University of Insubria Faculty of Medicine and Surgery: Università Degli Studi Dell'Insubria, Varese, Italy
| | - Luisa Luciana Fedele
- Azienda Ospedaliera Di Varese: Aziende Socio Sanitarie Territoriale Dei Sette Laghi, Varese, Italy
| | - Vincenza Cofini
- University of Aquila: Università Degli Studi Dell'Aquila, L'Aquila, Italy
| | - Stefano Necozione
- University of Aquila: Università Degli Studi Dell'Aquila, L'Aquila, Italy
| | - Giuseppe Musella
- Azienda Ospedaliera Di Varese: Aziende Socio Sanitarie Territoriale Dei Sette Laghi, Varese, Italy
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Influence of height on ED95 of intrathecal 2-chloroprocaine for knee arthroscopy: A prospective dose-response clinical trial. Eur J Anaesthesiol 2022; 39:602-610. [PMID: 35695753 DOI: 10.1097/eja.0000000000001692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Plain 2-chloroprocaine , a rapid acting amino-ester-type local anaesthetic, is used in short ambulatory procedures under spinal anaesthesia. The ED 95 of 2-chloroprocaine for lower limb surgery has not yet been defined. Moreover, patients' body height could influence the effects of the administered dose. OBJECTIVES The aim of this study was to determine the ED 95 of plain 2-chloroprocaine based on the height of patients undergoing ambulatory knee arthroscopy under spinal anaesthesia using the continual reassessment statistical method (CRM). DESIGN Prospective, dose-response, double blind, controlled, bi-center, clinical trial. SETTING One university teaching hospital in Brussels and one general teaching hospital, Braine l'Alleud, Belgium. Université libre de Bruxelles. PATIENTS ASA I-III (120 patients) scheduled for day-case knee arthroscopy under spinal anaesthesia. INTERVENTIONS Patients were divided into three groups of 40, each comprising 10 cohorts of 4 patients, according to their respective heights (Group 1: 150-165 cm, Group 2: 166-180 cm, Group 3: 181-195 cm). Each patient enrolled into one of the 3 groups received an intrathecal dose of plain 2-chloroprocaine determined by the CRM. The starting doses for the first cohorts of four were 40 mg in group 1, 45 mg in group 2 and 50 mg in group 3. The doses for subsequent cohorts were determined by CRM of outcomes in all patients in the previous competed cohorts. Anaesthesia was considered successful when there was a lack of pinprick or cold sensation up to T12, the visual analogue scale score for tourniquet pain was < 2 and no pain during surgery. MAIN OUTCOMES The primary outcome was the success or failure of the block. Side effects were also recorded. RESULTS ED 95 of 2-chloroprocaine is 40 mg in group 1, 35 mg in group 2, 45 mg in group 3. Groups were different in terms of height and gender ( P < 0.05) and similar in terms of body mass index and age ( P > 0.05). CONCLUSION The ED95 of intrathecal 2-chloroprocaine for patients undergoing ambulatory knee arthroscopy is between 35 and 45 mg. Height could be a factor involved in the calculation, and patient sex could partly explain the nonlinear relation between height and dose. TRIAL REGISTRY NUMBER Clinicaltrials.gov NCT03882489.
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Costa F, Pascarella G, Luffarelli P, Strumia A, Biondo G, Piliego C, Alloni R, Agrò FE. Selective spinal anesthesia with hyperbaric prilocaine provides better perioperative pain control than local anesthesia for ambulatory inguinal hernia repair without affecting discharging time: a randomized controlled trial. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:6. [PMID: 37386519 DOI: 10.1186/s44158-022-00034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/10/2022] [Indexed: 07/01/2023]
Abstract
PURPOSE Local anesthesia is the most used anesthetic technique for inguinal hernia repair, despite its unpredictability. Selective spinal anesthesia with a short-term local anesthetic guarantees rapid recovery, predictable duration and low incidence of side effects. We tried to assess the efficacy of this neuraxial technique in ambulatory setting. METHODS One hundred thirty-two ASA I-III, aged > 18 patients scheduled for inguinal hernia repair have been randomized into two groups receiving unilateral spinal anesthesia with 40 mg of hyperbaric prilocaine (group A) or local anesthesia with mepivacaine (group B). PRIMARY ENDPOINT intraoperative and post-operative NRS. Other outcomes: sensory block onset, need for opiates and deep sedation, surgery duration, and time to discharge. RESULTS Group A: intraoperative NRS was 0 in 100% of patients; post-operative maximum NRS was > 3 in 12.12% of patients. Group B: mean intraoperative NRS was 4; mean post-operative NRS was 2.5. Spinal anesthesia resulted superior in controlling both intraoperative and post-operative pain (p < 0.00001; p = 0.008). Mean time of the motor block resolution in group A was 98 ± 2 min. Mean time to discharge was not significantly different between groups. Surgical time was significantly different between the two groups (mean time of 37 ± 3.2 min group A; 54 ± 6 min group B-p < 0.00001). CONCLUSION Spinal anesthesia group patients had significantly less pain than local anesthesia group, both intraoperatively and post-operatively, without differences in time to discharge, incidence of complications and with improvement of surgical time. More randomized controlled trials are needed to confirm this hypothesis. TRIAL REGISTRATION NCT05136534 . Registered November 29, 2021-Retrospectively registered.
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Affiliation(s)
- Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy.
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Paolo Luffarelli
- Department of Pelvic Floor Surgery and Proctology, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Gaspare Biondo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Chiara Piliego
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Rossana Alloni
- Department of Specialistic General Surgery, Campus Bio-Medico of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
| | - Felice E Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, via Álvaro del Portillo 21, 00128, Rome, Italy
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Krishna H, Ravi S. Comparison of spinal anaesthesia with isobaric chloroprocaine and general anaesthesia for short duration ambulatory urological procedures. J Anaesthesiol Clin Pharmacol 2022; 38:91-96. [PMID: 35706653 PMCID: PMC9191783 DOI: 10.4103/joacp.joacp_131_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 01/04/2021] [Accepted: 04/09/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Aims: Chloroprocaine is a short-acting local anaesthetic agent for spinal anaesthesia (SA) that has been used in day care surgeries due to its faster recovery characteristics and faster discharge rates compared to other local anaesthetics. This study aimed at finding out its efficacy for the same as compared to general anaesthesia (GA). Material and Methods: This observational study was conducted on 60 patients belonging to the American Society of Anaesthesiologists (ASA) physical status I and II who underwent short elective urological procedures (<60 min) under GA (group GA) as per standard of care in our hospital (n = 30) and SA (group SA) with 50 mg 1% isobaric 2-Chloroprocaine (n = 30). Time taken to meet the discharge criteria, modified Aldrete score and modified post anaesthesia discharge score in each group were noted. The cost of the anaesthetic procedure, anaesthetic procedural time, hemodynamics, supplemental analgesia, complications related to the procedure were noted and compared. Results: Patient characteristics and duration of surgery were comparable. Time taken by group SA was significantly higher than group GA to meet the discharge criteria. Cost of GA [2624.76 (166.16) units] was significantly more than SA [1561.63 (81.32) units, P < 0.05]. There was no requirement of supplemental analgesia in group SA and no hemodynamic instability or complications in either group. Conclusion: GA is significantly better as compared to SA with 50 mg 1% isobaric 2-Chloroprocaine as an anesthetic technique in day care urology surgeries in terms of faster recovery and faster discharge rate but is costlier.
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Wells HL, Lazenbury A, Fairchild L, Harris M. Applying an enhanced recovery approach to endoscopic procedures: Local experience with progression to day-case transurethral resection of bladder tumour. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/2051415820903194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Transurethral resection of bladder tumour (TURBT) is a common urological procedure. With improvements in technology, technique and community support, our unit was able to implement a dedicated day-case pathway for patients undergoing TURBT. The aim of this study was to prove that this has been a safe and cost-effective improvement to our urology service. Patients and methods: A retrospective audit was carried out of 312 elective TURBT cases performed in one centre between 2011 and 2014 (36 excluded for lack of data/emergency status). Data were gathered regarding length of stay, causes of delayed discharge, readmissions and resection quality. Results: In 2011, 11% of TURBTs were performed as day cases, and 66% had an overnight stay. After introduction of the TURBT pathway, by 2014, 68% patients went home the same day, and 21% had an overnight stay. The 30-day readmission rate in 2011 was 7% (mostly following overnight stays), whereas 6% were readmitted in 2014. Resection quality was comparable across the two groups. Conclusion: Our experience suggests that day-case TURBT can be widely implemented without compromising quality or patient safety. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Abigail Lazenbury
- Department of Urology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, UK
| | - Lucy Fairchild
- Department of Urology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, UK
| | - Mark Harris
- Department of Urology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, UK
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Guntz E, Vasseur C, Ifrim D, Louvard A, Fils JF, Kapessidou Y. Intrathecal chloroprocaine or hyperbaric prilocaine for ambulatory knee surgery? A prospective randomized study. J Exp Orthop 2021; 8:15. [PMID: 33629206 PMCID: PMC7905001 DOI: 10.1186/s40634-021-00332-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022] Open
Abstract
Purpose The aim of this study was to compare intrathecal 1% chloroprocaine with 2% hyperbaric prilocaine in the setting of ambulatory knee arthroscopy. We hypothesized that complete resolution of the sensory block was faster with chloroprocaine. Methods Eighty patients scheduled for knee arthroscopy were included in this prospective randomized double-blind study. Spinal anesthesia was performed with either chloroprocaine (50 mg) or hyperbaric prilocaine (50 mg). Characteristics of sensory and motor blocks and side effects were recorded. Results Mean time to full sensory block recovery was shorter with chloroprocaine (169 (56.1) min vs 248 (59.4)). The characteristics of the sensory blocks were similar at the T12 dermatome level between the two groups. Differences appeared at T10: the percentage of patients with a sensory block was higher, onset quicker and duration longer with hyperbaric prilocaine. The number of patients with a sensory block at T4 dermatome level in both groups was minimal. Times to full motor recovery were identical in both groups (85 (70–99) vs 86 (76–111) min). Time to spontaneous voiding was shorter with chloroprocaine (203 (57.6) min vs 287.3 (47.2) min). Incidence of side effects was low in both groups. Conclusions When considering the characteristics of the sensory block, the use of chloroprocaine may allow an earlier discharge of patients. Cephalic extension was to a higher dermatomal level and the sensory block at T10 level was of prolonged duration with hyperbaric prilocaine, suggesting that the choice between the two drugs should also be performed based on the level of the sensory block requested by the surgery. This study is registered in the US National Clinical Trials Registry, registration number: NCT030389, the first of February 2017, Retrospectively registered.
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Affiliation(s)
- E Guntz
- Department of Anesthesiology, Hôpital Braine L'Alleud Waterloo, Université Libre de Bruxelles (ULB), 35 rue Wayez, 1420, Braine l'Alleud-Waterloo, Belgium.
| | - C Vasseur
- Department of Anesthesiology, Hôpital Braine L'Alleud Waterloo, Université Libre de Bruxelles (ULB), 35 rue Wayez, 1420, Braine l'Alleud-Waterloo, Belgium
| | - D Ifrim
- Department of Anesthesiology, Hôpital Braine L'Alleud Waterloo, Université Libre de Bruxelles (ULB), 35 rue Wayez, 1420, Braine l'Alleud-Waterloo, Belgium
| | - A Louvard
- Department of Anesthesiology, Hôpital Braine L'Alleud Waterloo, Université Libre de Bruxelles (ULB), 35 rue Wayez, 1420, Braine l'Alleud-Waterloo, Belgium
| | - J F Fils
- Independant Biostatistician - Ars Statistica, Nivelles, Belgium
| | - Y Kapessidou
- Department of Anesthesiology, CHU St Pierre, ULB, 322 rue Haute, 1000, Bruxelles, Belgium
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Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers. Curr Pain Headache Rep 2021; 25:1. [PMID: 33443656 DOI: 10.1007/s11916-020-00922-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed. RECENT FINDINGS Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized. This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.
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Spinal anesthesia for ambulatory surgery: current controversies and concerns. Curr Opin Anaesthesiol 2020; 33:746-752. [DOI: 10.1097/aco.0000000000000924] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Some authors have reported that outpatient total knee arthroplasty (TKA) is a successful, safe and cost-effective treatment in the management of advanced osteoarthritis. The success obtained has been attributed to the coordination of the multidisciplinary team, standardized perioperative protocols, optimal hospital discharge planning and careful selection of patients. One study has demonstrated a higher risk of perioperative surgical and medical outcomes in outpatient TKA than inpatient TKA, including component failure, surgical site infection, knee stiffness and deep vein thrombosis. There remains a lack of universal criteria for patient selection. Outpatient TKA has thus far been performed in relatively young patients with few comorbidities. It is not yet clear whether outpatient TKA is worth considering, except in very exceptional cases (young patients without associated comorbidities). Outpatient TKA should not be generally recommended at the present time.
Cite this article: EFORT Open Rev 2020;5:172-179. DOI: 10.1302/2058-5241.5.180101
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Palumbo P, Usai S, Amatucci C, Cerasari S, Perotti B, Ruggeri L, Cirocchi R, Tellan G. Tailored Surgery in Inguinal Hernia Repair. The Role of Subarachnoid Anesthesia: A Retrospective Study. Open Med (Wars) 2019; 14:639-646. [PMID: 31667353 PMCID: PMC6818077 DOI: 10.1515/med-2019-0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/16/2019] [Indexed: 01/16/2023] Open
Abstract
Safety and effectiveness evaluation of subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose (30mg) in combination with Fentanyl (20mcg), for the purpose of ensuring an optimal analgesia in open inguinal hernia repair. Although the local anesthesia is the first line treatment for open inguinal hernia repair, a minority of patients is not eligible because of obesity or big groin hernia, requiring a high dose of local anesthetic. Subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose in combination with Fentanyl may be a good alternative. Thirty patients were treated with intrathecal association of Prilocaine 30 mg and Fentanyl 20 mcg (group PF); they were compared to a group of fifty three ones, previously treated with a classic procedure with intrathecal Prilocaine 60 mg (group P). The sensitive blockage remained within an higher limit at T12 level in the patients of PF group, and a lower limit at S1 level 50 minutes after the anesthesia, while in the P group the anesthetic tended to migrate (p<0.0001). In PF group 70 minutes after the anesthesia 21 patients had a Bromage score equal to 0 and 9 patients equal to 9 (in P group, 19 patients had a score equal to 3, 8 to 2 and 3 to 1, p<0.0001). Subarachnoid anesthesia using Prilocaine 30 mg + Fentanyl 20 mcg could be stated as a viable alternative to local anesthesia in selected patients.
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Affiliation(s)
| | - Sofia Usai
- Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Chiara Amatucci
- Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Saverio Cerasari
- Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Bruno Perotti
- Department of Surgical Sciences, “Sapienza” University of Rome, Rome, Italy
| | - Luca Ruggeri
- Department of Emergency, Anesthesia and Critical Care, “Sapienza” University of Rome, Rome, Italy
| | - Roberto Cirocchi
- Department of Surgical Sciences, University of Perugia, Perugia, Italy
| | - Guglielmo Tellan
- Department of Emergency, Anesthesia and Critical Care, “Sapienza” University of Rome, Rome, Italy
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Gebhardt V, Hausen S, Weiss C, Schmittner MD. Using chloroprocaine for spinal anaesthesia in outpatient knee-arthroscopy results in earlier discharge and improved operating room efficiency compared to mepivacaine and prilocaine. Knee Surg Sports Traumatol Arthrosc 2019; 27:3032-3040. [PMID: 30552467 DOI: 10.1007/s00167-018-5327-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Knee arthroscopies are regularly carried out in an outpatient setting. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics for spinal anaesthesia on operating room efficiency (perioperative process times) and postoperative recovery. This study aims to determine the optimal LA for SPA in patients undergoing knee arthroscopy at a day-surgery centre. METHODS Anaesthesia records of all patients undergoing knee arthroscopy under spinal anaesthesia from 2010 until 2017 were analysed. Patients were categorised as having received spinal anaesthesia with prilocaine, mepivacaine or chloroprocaine. RESULTS Three-hundred and nine patients were included. Postoperative recovery was significantly faster for chloroprocaine 1% compared with both other local anaesthetics regarding all stages of recovery until discharge. Perioperative processes and surgery time were significantly shorter when chloroprocaine was used. Early postoperative pain occurred more frequently and earlier after spinal anaesthesia with chloroprocaine. Nevertheless, pain intensity did not differ between groups. CONCLUSION Spinal anaesthesia provides reliable blocks for outpatient knee arthroscopy. Considerations on the choice of local anaesthetic for spinal anaesthesia must include not only the recovery profile, but also the impact on operating room efficiency. Due to a superior recovery profile, low incidences of adverse side effects and raised operating room efficiency, chloroprocaine is the recommendable local anaesthetic for spinal anaesthesia in patients undergoing knee arthroscopy in an ambulatory setting. Since the frequency of SPA in patients undergoing outpatient knee arthroscopy is rising yearly, the results of this study are of high clinical relevance. The use of chloroprocaine leads to improved recovery, optimized perioperative processes and consecutively to a raised OR efficiency. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Volker Gebhardt
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Centre Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Sebastian Hausen
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Centre Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, University Medical Centre Mannheim, Ruprecht-Karls-University Heidelberg, Heinrich-Lanz-Zentrum, 68135, Mannheim, Germany
| | - Marc D Schmittner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Medical Faculty Mannheim of Heidelberg University, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Saporito A, Ceppi M, Perren A, La Regina D, Cafarotti S, Borgeat A, Aguirre J, Van De Velde M, Teunkens A. Does spinal chloroprocaine pharmacokinetic profile actually translate into a clinical advantage in terms of clinical outcomes when compared to low-dose spinal bupivacaine? A systematic review and meta-analysis. J Clin Anesth 2019; 52:99-104. [DOI: 10.1016/j.jclinane.2018.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/15/2018] [Accepted: 09/08/2018] [Indexed: 10/28/2022]
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Backstein D, Thiagarajah S, Halawi MJ, Mont MA. Outpatient Total Knee Arthroplasty-The New Reality and How Can It Be Achieved? J Arthroplasty 2018; 33:3595-3598. [PMID: 30318253 DOI: 10.1016/j.arth.2018.09.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- David Backstein
- Granovsky Gluskin Division of Orthopaedics, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Shankar Thiagarajah
- Granovsky Gluskin Division of Orthopaedics, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Michael A Mont
- Lenox Hill Hospital, Northwell Health, New York, New York
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Abstract
The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.
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Manassero A, Fanelli A. Prilocaine hydrochloride 2% hyperbaric solution for intrathecal injection: a clinical review. Local Reg Anesth 2017; 10:15-24. [PMID: 28408851 PMCID: PMC5383067 DOI: 10.2147/lra.s112756] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Prilocaine is a local anesthetic characterized by intermediate potency and duration and fast onset of action. As hyperbaric formulation of 5% solution, it was introduced and has been successfully used for spinal anesthesia since 1960. A new formulation of 2% plain and hyperbaric solution is currently available in Europe. Because of its lower incidence of transient neurological symptoms, prilocaine is suggested as substitute to lidocaine and mepivacaine in spinal anesthesia for ambulatory surgery, as well as a suitable alternative to low doses of long-acting local anesthetics. The National Library of Medicine database, the Excerpta Medica database, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials database, were searched for the period 1970 to September 2016, with the aim to identify studies evaluating the intrathecal use of 2% prilocaine. A total of 13 randomized clinical trials (RCTs), 1 observational study, 2 dose finding, and 4 systematic reviews has been used for this review. The studies evaluated showed that 2% hyperbaric prilocaine due to a favorable anesthetic and safety profile is an alternative drug to lidocaine and mepivacaine for spinal anesthesia of intermediate or short duration. In comparison with plain solutions, hyperbaricity remarkably accelerates the onset and offset times of intrathecal 2% prilocaine. Literature suggests a dose ranging between 40 and 60 mg of prilocaine for lower extremities and lower abdominal procedures lasting up to 90 min, whereas a dose ranging from 10 to 30 mg is appropriate for perineal surgery. Readiness for discharge occurs in ~4 h from spinal administration.
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Affiliation(s)
- Alberto Manassero
- Department of Emergency and Critical Care, Anesthesia and Intensive Care Unit, S. Croce e Carle Hospital, Cuneo
| | - Andrea Fanelli
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Unit, Policlinico S. Orsola-Malpighi, Bologna, Italy
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17
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An update on pain management for elderly patients undergoing ambulatory surgery. Curr Opin Anaesthesiol 2017; 29:674-682. [PMID: 27820738 DOI: 10.1097/aco.0000000000000396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting. RECENT FINDINGS Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h. SUMMARY The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.
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Gebhardt V, Mueller-Hansen L, Schwarz A, Bussen D, Weiss C, Schmittner MD. Chloroprocaine 10 mg/ml for low-dose spinal anaesthesia in perianal surgery - a randomised dose finding study. Acta Anaesthesiol Scand 2017; 61:241-249. [PMID: 27892594 DOI: 10.1111/aas.12839] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/20/2016] [Accepted: 11/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Low-dose spinal anaesthesia is a safe and reliable anaesthesia technique in outpatient perianal surgery. Regarding its short duration of action and its trend to hyperbaric characteristics, plain chloroprocaine 10 mg/ml seems to be ideal to perform low-dose spinal anaesthesia. The aim of this trial was to determine the optimal dosage of chloroprocaine for this indication. METHODS Hundred and twenty patients undergoing perianal surgery were enrolled and randomly allocated to receive 10, 20 or 30 mg of chloroprocaine 10 mg/ml intrathecally. Patients had to sit upright for at least 10 min after injection. We measured the expansion of sensory and motor block and the times until voiding, walking without assistance and home discharge. RESULTS The expansion of the sensory (P ≤ 0.0059) and the motor block (P ≤ 0.0086) gained with increasing doses. At a dose of 30 mg the incidence of a profound, clinically relevant motor block was significantly higher compared to 10 and 20 mg (P ≤ 0.0004). In the 10 mg group two patients suffered from nociceptive pain due to an incomplete block and five patients announced discomfort during procedure. Doses of 10 and 20 mg led to a significantly earlier discharge compared to 30 mg (P = 0.0003; P = 0.0406). CONCLUSION Plain chloroprocaine 10 mg/ml can successfully be used for low-dose spinal anaesthesia in perianal outpatient surgery. Regarding the unfavourable motor block and later discharge-times in the 30 mg group on the one hand and the block-failures in the 10 mg group on the other, 20 mg can be recommended as the optimal dose.
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Affiliation(s)
- V. Gebhardt
- Department of Anaesthesiology and Surgical Intensive Care Medicine; University Medical Centre Mannheim; Mannheim Germany
| | - L. Mueller-Hansen
- Department of Anaesthesiology and Surgical Intensive Care Medicine; University Medical Centre Mannheim; Mannheim Germany
| | - A. Schwarz
- Department of Anaesthesiology and Surgical Intensive Care Medicine; University Medical Centre Mannheim; Mannheim Germany
| | - D. Bussen
- Centre of Colo-proctology; Mannheim Germany
| | - C. Weiss
- Department of Medical Statistics; University Medical Centre Mannheim; Mannheim Germany
| | - M. D. Schmittner
- Department of Anaesthesiology and Surgical Intensive Care Medicine; University Medical Centre Mannheim; Mannheim Germany
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Spinal anaesthesia in outpatient and conventional surgery: A point of view from experienced French anaesthetists. Anaesth Crit Care Pain Med 2016; 37:239-244. [PMID: 28007520 DOI: 10.1016/j.accpm.2016.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/01/2016] [Accepted: 12/05/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The objective of this investigation was to evaluate the practice of spinal anaesthesia among French anaesthetists in inpatient and outpatient settings. METHODS AND MATERIALS A questionnaire was sent to members of the French Association of Anaesthetists involved in regional anaesthesia during the first 4months of 2015. The questionnaire included items on the practice of spinal anaesthesia (type of needle, local anaesthetic available, puncture and disinfection techniques, etc.) and on the anaesthetic techniques usually used in 5 surgical situations eligible for outpatient surgery (knee arthroscopy, inguinal hernia, transobturator tape, haemorrhoids, varicose veins in the lower limbs). RESULTS Responses from 703 anaesthesiologists were analysed. Spinal anaesthesia was usually performed in a sitting position (76%) using a Whitacre needle (60%) with a 25 G (57%) diameter. Ultrasound before puncture was reported in 26% of cases due to obesity or spinal abnormalities. Among the 5 surgical situations eligible for outpatient spinal anaesthesia, the technique was typically proposed in 29-49% of cases. Bupivacaine was the most used local anaesthetic. Concerns over delays in attaining readiness for hospital discharge, urine retention, operation length, and surgeon's preference were the main reasons for choosing another anaesthetic technique in these situations. DISCUSSION New local anaesthetics are beginning to be used for outpatient spinal anaesthesia due to their interesting pharmacodynamic profile in this context. This study will provide a basis for evaluating future changes in practice.
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20
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Abstract
Unilateral spinal anesthesia is a cost-effective and rapidly performed anesthetic technique. An exclusively unilateral block only affects the sensory, motor and sympathetic functions on one side of the body and offers the advantages of a spinal block without the typical adverse side effects seen with a bilateral block. The lack of hypotension, in particular, makes unilateral spinal anesthesia suitable for patients with cardiovascular risk factors e. g. aortic valve stenosis or coronary artery disease. Increasing numbers of surgical procedures are now being performed on an outpatient basis. Until now, spinal anesthesia has been considered unsuitable for this, not only because of the high incidence of intraoperative hypotension and postoperative urinary retention but also because of the prolonged postoperative stay before home discharge. This is not the case with unilateral spinal anesthesia: motor function returns rapidly, the incidence of urinary retention is extremely low, and patients are usually eligible for home discharge sooner than after bilateral spinal anesthesia or general anesthesia. The success of the technique depends on a number of factors. In addition to the local anesthetic, its concentration and dose, and the baricity of the injected solution, the shape of the spinal needle, the injection speed, the patient's position during injection, and the time the patient remains in this position after injection are equally important parameters. A number of intrathecally applied adjuvant drugs are used to give a more intense and/or longer-lasting block. For this review, we collated the published data on unilateral spinal anesthesia from journals with an impact factor greater than 1.0 and defined an optimized method for performing the technique. In order to achieve an exclusively unilateral block one should use 0.5 % hyperbaric bupivacaine injected at a rate of 0.33 ml/min or slower. During the injection and the following 20 min the patient should lie in the lateral decubitus position on the side intended for surgery with knees drawn to the chest. An injection of 5 mg (1 ml) hyperbaric bupivacaine 0.5 % provides an hour-long block to T 12, and a dose of 7.5 to 10 mg (1.5-2.0 ml) extends the block to T 6. Adding clonidine (0.5 to 1.0 µg/kg BW) to the injection prolongs the duration of the block to approximately two to three hours. During the 20-minute fixation period, the cephalad spread of the block can be influenced to a certain extent by raising or lowering the head of the table.
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Ambrosoli AL, Guzzetti L, Cappelleri G. Intrathecal anaesthesia for day-case knee arthroscopy - a reply. Anaesthesia 2016; 71:860-1. [PMID: 27291617 DOI: 10.1111/anae.13552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - L Guzzetti
- Ospedale di Circolo di Varese, Varese, Italy
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22
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Prin M, Guglielminotti J, Moitra V, Li G. Prophylactic Ondansetron for the Prevention of Intrathecal Fentanyl- or Sufentanil-Mediated Pruritus: A Meta-Analysis of Randomized Trials. Anesth Analg 2016; 122:402-9. [PMID: 26505578 DOI: 10.1213/ane.0000000000001046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pruritus is a common side effect of intrathecal fentanyl or sufentanil that decreases patient satisfaction and may delay hospital discharge. There are conflicting reports about the efficacy of prophylactic ondansetron in reducing the incidence of pruritus. This meta-analysis aimed to assess the effect of prophylactic ondansetron on the incidence of intrathecal fentanyl- or sufentanil-mediated pruritus and the need for rescue treatment. METHODS A systematic search on PubMed, Medline, and the Cochrane Central Register of Controlled Trials from January 1, 1994, to January 1, 2014, was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Randomized controlled trials evaluating the efficacy of prophylactic ondansetron on pruritus associated with intrathecal fentanyl or sufentanil were included. The primary outcome was the incidence of pruritus, and the secondary outcome was patients' need for rescue therapy. Sensitivity analyses were conducted to assess the outcomes in obstetric and nonobstetric patients and in patients who received ondansetron before or after intrathecal opioid injection. Analyses used random-effect models. RESULTS Six randomized controlled trials involving 555 patients were included. In the overall analysis, prophylactic ondansetron did not significantly decrease the incidence of pruritus, but there was a trend toward reduced rescue medication use (risk ratio [RR], 0.57; 95% confidence interval [CI], 0.35-0.91; I = 0%; P = 0.02). Exploratory subgroups, including nonobstetric surgery patients and patients who received ondansetron before spinal opioid administration, also suggest a trend toward less rescue medication use (RR, 0.47; 95% CI, 0.26-0.85; P = 0.01; and RR, 0.62; 95% CI, 0.38-1.00; P = 0.05). CONCLUSIONS IV 8 mg prophylactic ondansetron does not decrease the incidence of fentanyl- or sufentanil-mediated pruritus but may decrease the need for pruritus rescue medication, particularly in specific subgroups. Randomized trials are needed to confirm these results.
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Affiliation(s)
- Meghan Prin
- From the *Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York; †Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France; ‡INSERM, UMR 1137, IAME, Paris, France; and §Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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