Spinal anaesthesia with chloroprocaine 1% versus total intravenous anaesthesia for outpatient knee arthroscopy: A randomised controlled trial

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Effect of general anaesthesia with remimazolam versus propofol on postoperative quality of recovery in patients undergoing ambulatory arthroscopic meniscus repair: a randomised clinical trial

Background

The type of anaesthesia and choice of anaesthetic drugs may affect the quality of recovery after surgery. Remimazolam is a new benzodiazepine with rapid onset and offset, specifically antagonised by flumazenil. This study aimed to compare remimazolam with propofol on the quality of recovery in patients undergoing ambulatory arthroscopic surgery.

Methods

Patients aged 18-65 yr and scheduled for ambulatory arthroscopic meniscus repair were recruited and randomly assigned to receive either continuous i.v. infusion of remimazolam or plasma target-controlled infusion of propofol. The quality of recovery-15 (QoR-15) scale was administered on postoperative day 1 (POD1) as the primary outcome. Secondary outcomes included the Athens Insomnia Scale (AIS) scores and cardiovascular variables.

Results

In total, 120 patients were randomly assigned to the remimazolam or propofol groups and 114 patients were included in the analysis. The remimazolam group had higher total QoR-15 scores on POD1 (125 [120-127.5] vs 121.5 [119-124], with a median difference of 3 (95% confidence interval: 1-5; P=0.002). Physical independence and psychological support were higher in the remimazolam group (8.5 [8-10] vs 8 [7-9], P=0.043; 17 [13-17] vs 12.5 [12-14], P<0.001). Remimazolam lowered the number of awakenings during the first postoperative night (P=0.042) and the incidence of hypotension (P=0.04).

Conclusions

Remimazolam-based total i.v. anaesthesia was associated with small improvements in the quality of recovery; however, the improvement was less than the minimally clinically important difference.

Clinical trial registration

ChiCTR2100053014.

Spinal anesthesia in ambulatory surgery

Spinal anesthesia is a safe alternative to general anesthesia but remains underrepresented in the ambulatory setting. Most concerns relate to low flexibility of spinal anesthesia duration and the management of urinary retention in the outpatient setting. This review focuses on the characterization and safety of the local anesthetics that are available to adapt spinal anesthesia very flexibly to the needs of ambulatory surgery. Furthermore, recent studies on the management of postoperative urinary retention provide evidence for safe, but report wider discharge criteria and much lower hospital admission rates. With the local anesthetics that have current approval for usage in spinal anesthesia, most requirements for ambulatory surgeries can be met. The reported evidence on local anesthetics without approval supports clinically established off-label use and can improve the results even further.

Randomized controlled study comparing 2-chloroprocaine and bupivacaine for spinal anesthesia in gynecological surgeries

Background:

Ambulatory surgeries are increasing all over. While searching for an ideal anesthetic, the use of lidocaine was linked to a greater rate of transitory neurological symptoms and bupivacaine delays discharge due to a longer duration of motor blockade. 2-chloroprocaine (2CP) with a shorter duration of action is gaining popularity. We aimed to compare intrathecal bupivacaine and 2CP for the subarachnoid block for elective ambulatory gynecological surgeries.

Methods:

A single-blind study was conducted on 90 patients comparing 40 mg 2CP and 10 mg 0.5% bupivacaine heavy measuring pinprick sensation, motor block, time to ambulation, and voiding of urine so as to get ready for discharge.

Results:

In both groups, the beginning of sensory blockage occurred at a similar time, while motor blockade achieved was faster in the 2CP group. The resolution of motor blockade was 1.7 times faster in the 2CP group than in the bupivacaine group. Time taken for ambulation was delayed significantly in the bupivacaine group, i.e., 263.04 ± 29.08 min compared to the 2CP group, i.e., 225.44 ± 29.48 min which was a delay of almost 38 min. Voiding of urine was also delayed in the bupivacaine group by 60 min compared to the 2CP group and was significant finding leading to delay of discharge of patients. Adverse effects were comparable in both groups.

Conclusion:

Intrathecal preservative-free 2CP provides satisfactory surgical block, and has a considerably faster rate of block regression, resulting in earlier ambulation and voiding, allowing the patient to be discharged from the hospital sooner as compared to intrathecal bupivacaine.

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature

BACKGROUND AND OBJECTIVES

In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting.

METHODS

A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used).

RESULTS

One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result.

CONCLUSIONS

Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.

High turnover for ambulatory orthopedic surgery

PURPOSE OF REVIEW

The trend in the perioperative management of patients having orthopedic surgery in the ambulatory setting emphasizes time-efficiency and rapid turnovers. Anesthetic techniques and management continue to evolve to increase efficiency and decrease time spent in recovery.

RECENT FINDINGS

Minimizing time patients spend in phase 1 recovery or bypassing phase 1 altogether, known as fast-tracking, has become an important goal in containing costs in high turnover, ambulatory settings. Anesthetic techniques, particularly implementation of regional anesthesia and multimodal analgesia, have evolved to maximize efficiency.

SUMMARY

Anesthetic goals in the setting of high-turnover orthopedic surgery include effective multimodal analgesia, decreasing monotherapy with opioids, and patient education. Regional anesthesia as part of a multimodal analgesic regimen is increasingly used in ambulatory surgery fast-tracking protocols.

The Comparison of Intrathecal Ropivacaine with Bupivacaine for Knee Arthroscopy: A Meta-analysis of Randomized Controlled Trials

The comparison of intrathecal ropivacaine with bupivacaine for knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the efficacy of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2019 for randomized controlled trials (RCTs) assessing the effect of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. This meta-analysis is performed using the random effects model. Five RCTs are included in the meta-analysis. Overall, compared with intrathecal bupivacaine for knee arthroscopy, intrathecal ropivacaine is associated with increased onset time of motor block (mean difference [MD] = 2.05, 95% CI: 1.43-2.67, p < 0.00001) and decreased duration of sensory block (MD = -26.82, 95% CI: -31.96 to -21.67, p < 0.00001) but shows no remarkable influence on onset time of sensory block (MD = -0.09; 95% CI: -1.89 to 1.70, p = 0.92), duration of motor block (MD = -59.76; 95% CI: -124.44 to 4.91, p = 0.07), time to maximum block (MD = 2.35; 95% CI: -0.16 to 4.86, p = 0.07), first urination time (MD = -26.42, 95% CI: -57.34 to 4.51, p = 0.09), or first ambulation time (MD = 3.63, 95% CI: -25.20 to 32.47, p = 0.80).Intrathecal ropivacaine can substantially increase onset time of motor block and decrease the duration of sensory block than intrathecal bupivacaine for knee arthroscopy.

A randomised, non-inferiority study of chloroprocaine 2% and ropivacaine 0.75% in ultrasound-guided axillary block

Chloroprocaine is a short-acting local anaesthetic with a rapid onset of action and an anaesthesia duration up to 60 min. In this pivotal study success rates, onset and remission of motor and sensory block and safety of chloroprocaine 2% was compared to ropivacaine 0.75% for short-duration distal upper limb surgery with successful block rates as primary outcome. The study was designed as a prospective, randomised, multi-centre, active-controlled, double-blind, parallel-group, non-inferiority study, performed in 4 European hospitals with 211 patients scheduled for short duration distal upper limb surgery under axillary plexus block anaesthesia. Patients received either ultrasound guided axillary block with 20 ml chloroprocaine 2%, or with 20 ml ropivacaine 0.75%. Successful block was defined as block without any supplementation in the first 45 min calculated from the time of readiness for surgery. 90.8% patients achieved a successful block with chloroprocaine 2% and 92.9% patients with Ropivacaine 0.75%, thus non-inferiority was demonstrated (10% non inferiority margin; 95% CI − 0.097, 0.039; p = 0.02). Time to onset of block was not significantly different between the groups. Median time to motor and sensory block regression was significantly shorter as was time to home discharge (164 [155–170] min for chloroprocaine versus 380 [209–450] for the ropivacaine group, p < 0.001). For short-duration surgical procedures, the short-acting Chloroprocaine 2% may be used, with success rates non-inferior to ropivacaine and a favourable safety profile.

Trial registration: The trial was registered at Clinicaltrials.gov with registration number NCT02385097 (March 11th, 2015) and European Clinical Trial Database with the EudraCT number 2014-002519-40 (July 7th, 2015, Austria—BASG).

Spinal anaesthesia with Chloroprocaine HCl 1% for elective lower limb procedures of short duration: a prospective, randomised, observer-blind study in adult patients

Background

This prospective, randomised, observer-blinded study has been conducted in patients undergoing procedures of the lower extremities to evaluate the time to complete block resolution of 2-chloroprocaine 1% at three intrathecal doses (30, 40 and 50 mg).

Methods

After informed consent, we enrolled 45 male and female patients, aged 18–65 years, ASA score I-II, BMI 18–32 kg/m², undergoing elective lower limb procedures lasting ≤40 min and with a requested dermatomeric level of sensory block ≥ T12.

The patients were randomised in a 1:1:1 ratio to receive Chloroprocaine HCl 1% at one of the three different intrathecal doses (Group 30 = 30 mg, Group 40 = 40 mg or Group 50 = 50 mg). The progression and regression of both sensory and motor blocks were evaluated blindly. Urine and venous blood samples were collected for pharmacokinetic analysis.

Results

Times to regression of spinal blocks were 1.76 ± 0.35 h, 2.13 ± 0.46 h and 2.23 ± 0.38 h, in Group 30, 40 and 50 respectively: the 30 mg dose showed a significantly faster resolution of spinal block than the 40 mg (p = 0.034) and the 50 mg (p = 0.006). Time to readiness for surgery was significantly reduced with the dose of 50 mg when compared to dose of 30 mg (p = 0.0259).

Conclusions

The doses of 50 mg and 40 mg yielded a longer resolution of spinal block than the dose of 30 mg. Nevertheless, the dose of 30 mg resulted in a higher secondary failure rate.

Trial registration

Registration of clinical trial: clinicaltrials.gov (NCT02481505).

Preoperative assessment of expectations, anxiety and preferences for anesthesia in patients undergoing ambulatory knee arthroscopic surgery

Objective : In this observational study, we aimed at measuring preoperative anxiety and preferences for anesthesia in patients undergoing knee arthroscopic surgery. Background : Little is known about preoperative anxieties, expectations and preferences of patients undergoing surgery, for which both spinal or general anesthesia can be provided. Literature shows that spinal anesthesia is associated with lower postoperative co- morbidity and mortality rates as compared to general anesthesia (1-2). Anxiety itself is an important factor influencing patients’ outcome (3). Methods : Every patients >18 years old undergoing an ambulatory arthroscopy of the knee in the surgical day care center of the AZ Nikolaas (in Sint-Niklaas and Beveren), was asked preoperatively to fill in a questionnaire. The questionnaire focused both on the patients’ knowledge about and preference of anesthesia, as well as their preoperative anxieties and worries. Patients were asked to score preoperative anxiety on a 5-point anxiety scale for any of 9 aspects/complications of the anesthetic (placement of the IV cannula, spinal puncture, death, awareness, pain, postoperative nausea and vomiting, cognitive impairment, infection, blood loss). During the study period, from January 11/01/ 2019 to 11/06/2019, a total of 806 patients were asked to fill out the questionnaire. 201 of these patients completed the questionnaire and were consequently enrolled in the study. This work has been approved by the Ethics Committee of the AZ Nikolaas on 11/11/2018 and by the Ethics Committee of the University Hospital in Antwerp (UZA) on 19/11/ 2018. Results : Seventy-five % of patients had a clear preference for their anesthesia technique. Of these, 2/3 opted for general anesthesia. Patients mainly based their preference on a subjective feeling ; a minority had discussed the choice with their surgeon or general practitioner. Rarely, patients indicated the wish to talk to the anesthesiologist about their choice. Fear for a spinal puncture occurred in 40% of patients (median anxiety score 3/5, range 1-5) and was therefore the most prominent anxiety in this patient population. Conclusions : Patients’ greater preference for general over spinal anesthesia was clearly based rather on a subjective than an objective basis. Forty 40% of patients had a substantial fear for spinal puncture. By informing patients about the risks and complications of the different anesthesia techniques, anxiety feelings can probably be alleviated, and a well-judged decision about their anesthesia technique can be made. There is room for improvement in communication and discussion between patients and anesthesiologists about the patients’ choice of anesthesia technique.

Effect of Adductor Canal Block Versus Femoral Nerve Block on Quadriceps Strength, Function, and Postoperative Pain After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level 1 Studies

BACKGROUND

Femoral nerve block (FNB) is a popular technique for reducing postoperative pain in patients with anterior cruciate ligament reconstruction (ACLR), but it is also linked to a number of adverse effects, such as quadriceps weakness, antalgic ambulation, and increased fall risk. Adductor canal block (ACB) has been offered as a motor nerve-sparing alternative to FNB.

PURPOSE

To evaluate available literature that compares the effects of ACB and FNB on functional outcomes after arthroscopic ACLR.

STUDY DESIGN

Systematic review.

METHODS

Following the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search of PubMed (Ovid), CINAHL, Scopus, Cochrane, and Google Scholar databases was conducted. Search terms were designed to capture studies comparing the effects of ACB and FNB in patients undergoing arthroscopic ACLR. Data were evaluated regarding study and patient characteristics, functional measures, opioid consumption, pain scores, and complications.

RESULTS

Eight randomized controlled trials (N = 655 patients) comparing the efficacy of ACB versus FNB in arthroscopic ACLR were included. The heterogeneity of outcome measures precluded meta-analysis. Seven studies reported functional measures, which included isokinetic strength, straight-leg raise, and other various measures. Follow-up periods varied between 1 hour and 6 months. In 3 trials, ACB was found to preserve quadriceps strength as measured using straight-leg raise for the first 12 to 24 hours after surgery, while 3 other trials found no difference between the groups. No differences were reported in isokinetic strength at 6 months. In other functional measures, ACB either outperformed or was equivalent to FNB. The majority of studies reporting opioid consumption, pain scores, and complications found no differences between the blocks.

CONCLUSION

This systematic review suggests that when compared with FNB, ACB preserves quadriceps function in the early postoperative period after ACLR while providing a similar level of analgesia. Limitations of this study include the use of various functional measures and limited long-term follow-up. More research evaluating long-term functional outcomes with standardized measures is needed to draw adequate conclusions regarding the effects of ACB and FNB on function after ACLR.

A comparative study on the effect of addition of intrathecal buprenorphine to 2-chloroprocaine spinal anesthesia in short duration surgeries

Background and Aims

Spinal anesthesia is a safe and reliable technique for surgeries on the lower abdomen and lower limbs. Some of its characteristics like delayed ambulation and pain after block regression may limit its use, especially for short duration surgeries. 2-chloroprocaine is an amino-ester local anesthetic with an approximate duration of action of 40 minutes, which is ideal for short duration surgeries. This study aims to compare the effect of adding intrathecal buprenorphine to 2-chloroprocaine with regard to spinal anesthesia characteristics.

Material and Methods

After obtaining the institutional ethical committee clearance and clinical trial registration, informed consent was taken from 90 patients who were undergoing either lower abdominal or lower limb surgeries of less than 60 minutes duration and were then randomized into two groups. Group C received 40 mg of 1% 2-chloroprocaine and Group B received 40 mg of 1% 2-chloroprocaine with 60 mcg of buprenorphine. Sensory/motor block characteristics, first analgesic requirements, time to void, and unassisted ambulation were assessed. Student t test was used to analyze the metric parameters and Fisher's exact test was used to compare the categorical variables.

Results

The time of onset of sensory and motor blocks, peak sensory block, readiness for surgery, and complete regression of both sensory and motor blocks were comparable between the groups. Group B showed significantly prolonged duration of postoperative analgesia (855.82 ± 667.09 vs. 359.07 ± 253.3 minutes). 91.1% patients were able to ambulate within 100 minutes in our study.

Conclusion

We conclude that addition of buprenorphine to 2-chloroprocaine has a significant synergistic effect on prolonging postoperative analgesia.

Using chloroprocaine for spinal anaesthesia in outpatient knee-arthroscopy results in earlier discharge and improved operating room efficiency compared to mepivacaine and prilocaine

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.

Chloroprocaine versus prilocaine for spinal anesthesia in ambulatory knee arthroscopy: a double-blind randomized trial

BACKGROUND

In ambulatory lower limb surgery, spinal anesthesia with rapid onset and a short duration of block is preferable. We hypothesized that the use of 2-chloroprocaine would be associated with a faster motor block recovery compared with prilocaine in knee arthroscopy. A difference of 15 min was considered clinically relevant.

METHODS

150 patients were randomly allocated to receive intrathecally either 40 mg of 2-chloroprocaine or 40 mg of prilocaine. The primary outcome was the time to complete recovery from motor blockade. Secondary outcomes included time to full regression of sensory block, peak sensory block level, urine retention needing catheterization, time until hospital discharge, incidence of transient neurologic symptoms and patient satisfaction.

RESULTS

Time to complete recovery from motor blockade was 15 min shorter for 2-chloroprocaine (median: 60 min; IQR: 60-82.5) than for prilocaine (median: 75 min; IQR: 60-90; p=0.004). 2-Chloroprocaine also resulted in faster full regression of sensory block (median: 120 min; IQR: 90-135 compared with median: 165 min; IQR: 135-190, p<0.001) and faster time to hospital discharge (mean difference: 57 min; 95% CI 38 to 77, p<0.001). Peak sensory block was higher in the 2-chloroprocaine group (median: T9; IQR: T6-T12 compared with median: T10; IQR: T8-T12, p<0.008). Patient satisfaction and urine retention needing catheterization were equal in both groups.

CONCLUSIONS

In knee arthroscopy, spinal anesthesia with 2-chloroprocaine results in a faster recovery of motor and sensory block, leading to quicker hospital discharge compared with prilocaine.

TRIAL REGISTRATION NUMBER

NTR6796.

[Evaluation of spinal anesthesia in urological outpatient surgery, comparison between two local anesthetics (Chloroprocaine/Bupivacaine)]

INTRODUCTION

Spinal anesthesia in outpatient urology is controversial (longer hospital stay, risk of urinary retention). The main goal was to evaluate outpatient spinal anesthesia and to compare 2 local anesthetics secondarily.

MATERIAL

Monocentric retrospective study including all patients undergoing surgery in urological ambulatory surgery under spinal anesthesia between December 2011 and May 2015, split into two groups according to the local anesthetic used: bupivacaine (BP) and chloroprocaine (CP). Quantitative variables were compared by Student's t-test, qualitative variables by χ² test.

RESULTS

Seventy-one (95%) out of the 75 patients included have been discharged the same day. Discharge was impossible in these cases: patient alone at home (1), bladder clot (1), JJ intolerance (1), delayed micturition (1). The mean duration of the procedure was 27±19min, the SSPI's was 55±31min, the stay's was 360±91min. A total of 45 patients (60%) received BP and 30 (40%) received CP. The mean residence time in SSPI was significantly reduced in the CP group (47±24min vs. 61±34min, P=0.04). One patient experienced urination delay in the BP group with no significant difference. No significant difference for the other criteria studied despite the mean age, which is higher in the CP group (P=0.02).

CONCLUSION

Spinal anesthesia is adapted to ambulatory urology, and does not increase the risk of urinary retention, especially with CP that would decrease the length of stay in SSPI compared to BP.

LEVEL OF EVIDENCE

4.