Chloroprocaine 10 mg/ml for low-dose spinal anaesthesia in perianal surgery - a randomised dose finding study

Intrathecal 1% 2-chlorprocaine for short gynecological day care procedures: Prospective, randomized, dose finding study

Background and Aims

Establishing the optimum dose of intrathecal 1% 2-chlorprocaine may reduce the discharge time and encourage more widespread use of spinal anesthesia for day care procedures. The aim of this study was to compare the efficacy and recovery characteristics of three different doses of intrathecal 1% 2-chlorprocaine for short gynecological day care procedures.

Material and Methods

Fifty-one patients scheduled for elective day care gynecological procedures lasting less than 60 min and were randomly divided into three groups of 17 each to receive 35 mg, 40 mg, or 45 mg intrathecal 1% 2-chlorprocaine. Demographic data, time required to achieve readiness for surgery, time required to attain discharge criteria, maximum block height achieved, and adverse effects were recorded in each group.

Results

The time required to achieve readiness for surgery was similar between the three groups (P = 0.306). However, 35 mg group required the shortest time to ambulate and there was a significant difference as compared with both 40 mg (P = 0.012) and 45 mg (P = 0.001). Voiding and the fulfillment of the discharge parameters were also attained more rapidly in the 35 mg group [133 (120,155) min] as compared with both 40 mg [164 (145,175) min, P = 0.000] and 45 mg [160 (150,175) min, P = 0.000]. None of the patients reported neurological symptoms during the follow-up.

Conclusion

The 35 mg intrathecal 1% 2-chlorprocaine not only provides reliable anesthesia for short gynecological procedures but also facilitates faster achievement of the discharge parameters as compared with the 40 mg and 45 mg doses.

Saddle block anesthetic technique for benign outpatient anorectal surgery

BACKGROUND

Current American Society of Colorectal Surgery Clinical Practice Guidelines for Ambulatory Anorectal Surgery endorse use of monitored anesthesia care, general anesthesia, or spinal anesthesia based on physician and patient preference. Although several studies support the use of monitored anesthesia care over general anesthesia, the literature regarding spinal anesthesia is limited and heterogenous due to small sample sizes and disparate spinal anesthesia techniques. Saddle block anesthesia is a form of spinal anesthesia that localizes to the lowermost sacral spinal segments allowing for preservation of lower extremity motor function and faster recovery. We accrued one of the largest reported cohort of anorectal procedures using saddle block anesthesia, as such, we sought to evaluate our institutional 12-year experience.

METHODS

Patients who underwent a benign anorectal procedure at our outpatient surgery center between July 2008-2020 were retrospectively reviewed. Demographics, surgical factors, perioperative times, and adverse events were collected from the electronic medical records. Saddle block anesthesia was generally performed in the preoperative area using a spinal needle (25-27 gauge) and a single injection technique of a 1:1 ratio local anesthetic mixed with 10% dextrose solution. Between 2.5-5 mg of hyperbaric anesthetic was injected intrathecally in the sitting position and the patient remained upright for 3-10 minutes. This technique of saddle block anesthesia provides analgesia for approximately 1-3 hours.

RESULTS

In the study, 859 saddle block anesthesia patients were identified, with a mean age of 44.6 years and American Society of Anesthesia score of 1.9; 609 (70.9%) were male. Surgical indications included lesion removal (27.1%), anal fistula (25.8%), hemorrhoidectomy (24.7%), pilonidal disease (6.3%), anal fissure (5.8%), and a combination of prior (10.2%). Prone jackknife positioning was used in 91.6% of procedures. Saddle block anesthesia most often was performed with bupivacaine (48.9%) or ropivacaine (41.7%). The median procedural saddle block anesthesia time was 11 minutes, surgery time was 17 minutes, anesthesia time was 42 minutes, and recovery time was 91 minutes. Patients spent a median of 3 hours and 53 minutes in the facility. Adverse events included urinary retention (1.9%), conversion to general anesthesia (1.8%), spinal headache (1.5%), hemodynamic instability (0.9%), and injection site reaction (0.3%).

CONCLUSION

Demonstrated using the largest known cohort of anorectal patients with saddle block anesthesia, saddle block anesthesia provides an effective method of analgesia to avoid general anesthesia with a low rate of adverse events.

A Study to Evaluate Intrathecal 1% Chloroprocaine and 0.5% Levobupivacaine in Perianal Surgeries: A Prospective Randomized Study

Background:

With increasing focus on outpatient care, there has been an increased demand for short-acting spinal anesthetics, facilitating early recovery and mobilization of the patient.

Aims:

The aim of the study was to compare 1% chloroprocaine, characterized by short latency and short duration with 0.5% levobupivacaine, which has shown to preserve motor function at low concentrations, with recovery from motor block as the primary objective and recovery from sensory block and hemodynamic stability as secondary objectives.

Settings and Design:

A prospective study to evaluate newer isobaric chloroprocaine and levobupivacaine intrathecally in a cohort of patients using randomization and double blinding.

Materials and Methods:

Sixty American Society of Anesthesiologist physical status Classes I and II patients undergoing perianal surgeries were randomly divided into Group C (n = 30) receiving intrathecal 1% chloroprocaine 3 mL and Group L (n = 30) receiving 0.5% levobupivacaine 1.5 mL. Patients were assessed for sensory and motor block characteristics, hemodynamic changes, period of analgesia, time for ambulation, and urination.

Statistical Analysis:

Qualitative data were analyzed using Chi-square test and quantitative data using Independent t-test.

Results:

There was no significant difference in highest sensory level, onset of motor block, maximum Bromage scale achieved, and hemodynamic changes between the two groups. There was a significant difference in mean Time for Maximum Bromage scale, Time for Sensory regression (Lumbar-L₁), Duration of Motor Block (Group C 50.7 ± 5.7 min and Group L 181 ± 27.8 min), Time for rescue Analgesia, Time for 1^st void, and Time for ambulation (Group C 88.3 ± 9.1 min and Group L₂ 06.7 ± 27.2 min) between chloroprocaine and levobupivacaine group. The above duration was shorter in chloroprocaine group than in levobupivacaine group.

Conclusion:

Thus, chloroprocaine provides good surgical anesthesia and early motor recovery than levobupivacaine and is well suited for day care surgeries.

Optimal local anesthetic regimen for saddle block in ambulatory anorectal surgery: an evidence-based systematic review

BACKGROUND

Ambulatory anorectal surgery requires an anesthetic of short duration but profound depth. Saddle block anesthesia (SBA) can provide dense sacral anesthesia with minimal motor blockade, but the ideal local anesthetic agent remains undefined. This systematic review aims to identify the optimal SBA regimen for ambulatory anorectal surgery.

METHODS

We sought randomized trials examining SBA for ambulatory anorectal surgery and stratified patients into four subgroups according to local anesthetic type and dose: (1) longer acting, higher dose; (2) longer acting, lower dose; (3) shorter acting, higher dose; and (4) shorter acting, lower dose. Longer acting agents included bupivacaine and levobupivacaine; shorter acting agents included chloroprocaine, mepivacaine, and prilocaine. Lower dose was defined as ≤5 mg and ≤20 mg for longer and shorter acting local anesthetics, respectively. The primary outcome was time to discharge; secondary outcomes included times to sensory and motor block regression, urine voiding, and ambulation, as well as block success.

RESULTS

A total of 11 trials (1063 patients) were included. Overall study quality and reporting consistency was poor. Doses ranged from 1.5-7.5 mg to 3-30 mg of longer and shorter acting local anesthetics, respectively. Hyperbaric local anesthetics were used in eight trials (953 patients, 86%). The median time to discharge appeared similar across all subgroups with an overall time of 182 (IQR 102) min. The use of long-acting, lower dose regimens was associated with a faster median time to motor block regression. Block success approached 99% among all trials.

CONCLUSIONS

There is presently insufficient qualitative and quantitative evidence to identify an optimal SBA regimen for ambulatory anorectal surgery. Nonetheless, we found that doses as low as 1.5 and 3 mg of longer and shorter acting hyperbaric local anesthetics, respectively, can achieve effective and reliable SBA with timely hospital discharge. Despite similar discharge times, longer acting, lower dose local anesthetics may produce faster motor block regression following SBA for ambulatory anorectal surgery.

[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.

Influence of anxiolytic premedication on vasovagal reactions and home readiness following outpatient intrathecal anaesthesia-A retrospective analysis

BACKGROUND

Vasovagal reactions during application of intrathecal anaesthesia (IA) are associated with high anxiety levels. A high percentage of patients undergoing outpatient surgery suffer from anxiety. Anxiolytic premedication in day-surgery is suspected to delay recovery and discharge and is, therefore, not routinely used. The aim of this retrospective analysis was to detect the influence of anxiolytic premedication on the incidence of vasovagal reactions and time until discharge home.

METHODS

Anaesthesia records of all patients undergoing outpatient surgery under low-dose IA from January 2008 to June 2017 were analysed. Incidences of vasovagal reactions with a decrease in blood pressure and/or heart rate and need for cardiovascular activating medications were documented. Patients were categorised as having received an anxiolytic premedication or not. The time from intrathecal injection of the local anaesthetic until readiness for discharge was recorded.

RESULTS

The records of 2747 patients were analysed. One thousand two hundred and ninety-one of them received an anxiolytic premedication of 1-2 mg midazolam intravenously. Three hundred and fourteen patients had vasovagal incidents during application of IA (no premedication n = 217 [15.0%], premedication n = 97 [7.5%], P < 0.0001). Premedication did not prolong time to achieve readiness for discharge (mepivacaine: P = 0.5886, chloroprocaine: P = 0.1555). However, in the prilocaine group, premedication led to a significantly earlier achievement of readiness for discharge (P = 0.0002).

CONCLUSION

Anxiolytic premedication significantly reduces the incidence of vasovagal reactions during the application of IA and does not affect time until readiness for discharge.

Retrospective analysis of mepivacaine, prilocaine and chloroprocaine for low-dose spinal anaesthesia in outpatient perianal procedures

PURPOSE

Perianal procedures are carried out in an outpatient setting regularly. The purpose of this retrospective analysis was to investigate the impact of different local anaesthetics (LA) for spinal anaesthesia (SPA) on operating room (OR) efficiency (perioperative process times, turnaround times) and postoperative recovery. This study aims on the determination of the optimal LA for low-dose SPA in the specific setting of a high-volume day-surgery centre.

METHODS

Anaesthesia records of all patients undergoing perianal outpatient surgery under saddle-block SPA at the Mannheim University Medical Centre from 2008 until 2017 were analysed. Patients were categorized as having received prilocaine, mepivacaine or chloroprocaine.

RESULTS

Two thousand seven hundred forty-six patients were included. Postoperative recovery was faster for chloroprocaine 1% compared with both other LAs. Preoperative processes but not process times in the OR were shorter for chloroprocaine. In contrary, turnaround times were significantly prolonged when chloroprocaine had been used, leading to reduction of OR efficiency.

CONCLUSION

Low-dose SPA provides reliable blocks for perianal surgery. Considerations on the choice of LA for SPA must include not only the recovery profile, but also the impact on OR efficiency. Due to shorter turnaround times and a manageable prolonged duration of stay, prilocaine is the preferable LA for low-dose SPA in perianal outpatient surgery at a high-volume day-surgery centre.