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Kashanian K, Garceau SP, Kim PR, Dervin GF, Pysyk CL, Bryson GL, Beaulé PE. Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints. J Arthroplasty 2023:S0883-5403(23)00202-4. [PMID: 36889528 DOI: 10.1016/j.arth.2023.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room (OR) to physiotherapy (PT) assessment, and from OR to discharge were recorded. These were referred to as ambulation time and discharge time respectively. RESULTS The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), 227 minutes (range, 77 to 387) respectively-p<0.0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), 371 minutes (range, 217 to 570) respectively-(p<0.0001). No cases of transient neurologic symptoms were reported. CONCLUSIONS Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is quick and efficacious.
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Ruparel D, Thomas S, Pawar D, Sedani S. Randomized controlled study comparing 2-chloroprocaine and bupivacaine for spinal anesthesia in gynecological surgeries. Anesth Essays Res 2022; 16:12-16. [PMID: 36249147 PMCID: PMC9558674 DOI: 10.4103/aer.aer_20_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/10/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Riquelme I, Reina MA, Boezaart AP, Tubbs RS, Carrera A, Reina F. Spinal arachnoid sleeves and their possible causative role in cauda equina syndrome and transient radicular irritation syndrome. Clin Anat 2021; 34:748-756. [PMID: 33449372 DOI: 10.1002/ca.23721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION We have previously described arachnoid sleeves around cauda equina nerve roots, but at that time we did not determine whether injections could be performed within those sleeves. The purpose of this observational study was to establish whether the entire distal orifice of a spinal needle can be accommodated within an arachnoid sleeve. MATERIALS AND METHODS We carefully dissected the entire dural sacs off four fresh cadavers, opened them by longitudinal incision, and immersed them in saline. Under direct vision, we penetrated the cauda equina roots nerves traveling almost vertically downward at 30 locations each with a 27- and a 25-G pencil-point needle (60 punctures total). We captured the images with a stereoscopic camera. RESULTS The nerve root offered no noticeable resistance to needle entry. Although the arachnoid sleeves could not be identified with the naked eye, they were translucent but visible under microscopy. In 21 of 30 attempts with a 27-gauge needle, and in 20 of 30 attempts with a 25-gauge needle, the distal orifice of the spinal needle was completely within the arachnoid sleeve. CONCLUSION It seems possible to accommodate the distal orifice of a 25- or a 27-gauge pencil-point spinal needle completely within the space of the arachnoid sleeve. An injection within this sleeve could potentially lead to a neurological syndrome, as we have previously proposed.
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Affiliation(s)
- Irene Riquelme
- Pain Clinic, Hospital Universitario Sanitas La Moraleja, Madrid, Spain
| | - Miguel A Reina
- CEU-San-Pablo University School of Medicine, Madrid, Spain.,Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain.,Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - André P Boezaart
- Division of Acute and Perioperative Pain Medicine, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA.,Alon P. Winnie Research Institute, Still Bay, Western Province, South Africa
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.,Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Anna Carrera
- Neuroscience, Embryology, Molecular Oncology and Clinical Anatomy Group (NEOMA), School of Medicine, University of Girona, Girona, Spain
| | - Francisco Reina
- Neuroscience, Embryology, Molecular Oncology and Clinical Anatomy Group (NEOMA), School of Medicine, University of Girona, Girona, Spain
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Yang Z, Li D, Zhang K, Yang F, Li M, Wang L. Comparison of epidural anesthesia with chloroprocaine and lidocaine for outpatient knee arthroscopy. J Orthop Surg (Hong Kong) 2020; 27:2309499019865534. [PMID: 31370751 DOI: 10.1177/2309499019865534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aimed to compare clinical efficacy and safety of chloroprocaine and lidocaine in epidural anesthesia for outpatient knee arthroscopy. Eighty patients undergoing knee arthroscopy were randomly allocated to receive 3% 2-chloroprocaine (group C, n = 40) or 2% lidocaine (group L, n = 40) for epidural block. Latency to anesthesia onset, highest block level, time to achieve peak effect, time to complete sensory and motor block regression, vital signs including respiration and hemodynamics, and complications during follow-up were recorded. No significant differences were found in the latency to anesthesia onset and peak effect, duration of anesthesia efficacy, and the time for recovery of sensory function between the two groups. However, the latency to maximal block of pain sensation and the time needed to recover motor function were significantly shorter in group C than in group L (p < 0.05). No adverse effects or neurologic complications were found in both groups. In conclusion, epidural chloroprocaine elicits rapid anesthetic effects, fast sensor and motor block, and faster recovery of motor function compared to lidocaine. These characteristics make chloroprocaine better than lidocaine as the choice of epidural anesthesia in short clinical operations such as knee arthroscopy.
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Affiliation(s)
- Zhengchao Yang
- 1 Department of Anesthesiology, Wuhan No. 1 Hospital, Wuhan, Hubei, China
| | - Dezhan Li
- 2 Department of Anesthesiology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, China
| | - Kun Zhang
- 2 Department of Anesthesiology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, China
| | - Fang Yang
- 3 Department of Clinical Oncology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Man Li
- 4 Department of Oncology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, China
| | - Lishen Wang
- 2 Department of Anesthesiology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, China
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van Zuylen ML, ten Hoope W, Bos EME, Hermanides J, Stevens MF, Hollmann MW. Safety of epidural drugs: a narrative review. Expert Opin Drug Saf 2019; 18:591-601. [DOI: 10.1080/14740338.2019.1617271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- ML van Zuylen
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W ten Hoope
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - EME Bos
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hermanides
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MF Stevens
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MW Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Samra T, Bala I, Chopra K, Podder S. Effect of Intravenous Ondansetron on Sensory and Motor Block after Spinal Anaesthesia with Hyperbaric Bupivacaine. Anaesth Intensive Care 2019; 39:65-8. [DOI: 10.1177/0310057x1103900110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- T. Samra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - I. Bala
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K. Chopra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S. Podder
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Nagaraj P, Thalamkandathil N, Sadique H. ROPIVACAINE VERSUS LIDOCAINE FOR EPISIOTOMY-A RANDOMISED DOUBLE BLIND STUDY. ACTA ACUST UNITED AC 2017. [DOI: 10.18410/jebmh/2017/382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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Piao LH, Fujita T, Yu T, Kumamoto E. Presynaptic facilitation by tetracaine of glutamatergic spontaneous excitatory transmission in the rat spinal substantia gelatinosa – Involvement of TRPA1 channels. Brain Res 2017; 1657:245-252. [DOI: 10.1016/j.brainres.2016.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/07/2016] [Accepted: 12/21/2016] [Indexed: 11/29/2022]
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10
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Spinal Anesthesia. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Yaksh TL, Fisher CJ, Hockman TM, Wiese AJ. Current and Future Issues in the Development of Spinal Agents for the Management of Pain. Curr Neuropharmacol 2017; 15:232-259. [PMID: 26861470 PMCID: PMC5412694 DOI: 10.2174/1570159x14666160307145542] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/02/2015] [Accepted: 02/05/2016] [Indexed: 11/22/2022] Open
Abstract
Targeting analgesic drugs for spinal delivery reflects the fact that while the conscious experience of pain is mediated supraspinally, input initiated by high intensity stimuli, tissue injury and/or nerve injury is encoded at the level of the spinal dorsal horn and this output informs the brain as to the peripheral environment. This encoding process is subject to strong upregulation resulting in hyperesthetic states and downregulation reducing the ongoing processing of nociceptive stimuli reversing the hyperesthesia and pain processing. The present review addresses the biology of spinal nociceptive processing as relevant to the effects of intrathecally-delivered drugs in altering pain processing following acute stimulation, tissue inflammation/injury and nerve injury. The review covers i) the major classes of spinal agents currently employed as intrathecal analgesics (opioid agonists, alpha 2 agonists; sodium channel blockers; calcium channel blockers; NMDA blockers; GABA A/B agonists; COX inhibitors; ii) ongoing developments in the pharmacology of spinal therapeutics focusing on less studied agents/targets (cholinesterase inhibition; Adenosine agonists; iii) novel intrathecal targeting methodologies including gene-based approaches (viral vectors, plasmids, interfering RNAs); antisense, and toxins (botulinum toxins; resniferatoxin, substance P Saporin); and iv) issues relevant to intrathecal drug delivery (neuraxial drug distribution), infusate delivery profile, drug dosing, formulation and principals involved in the preclinical evaluation of intrathecal drug safety.
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Affiliation(s)
- Tony L. Yaksh
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Casey J. Fisher
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Tyler M. Hockman
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Ashley J. Wiese
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
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Okamoto A, Tanaka M, Sumi C, Oku K, Kusunoki M, Nishi K, Matsuo Y, Takenaga K, Shingu K, Hirota K. The antioxidant N-acetyl cysteine suppresses lidocaine-induced intracellular reactive oxygen species production and cell death in neuronal SH-SY5Y cells. BMC Anesthesiol 2016; 16:104. [PMID: 27776485 PMCID: PMC5078905 DOI: 10.1186/s12871-016-0273-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The local anesthetic lidocaine can affect intra- and extra-cellular signaling pathways in both neuronal and non-neuronal cells, resulting in long-term modulation of biological functions, including cell growth and death. Indeed, lidocaine was shown to induce necrosis and apoptosis in vitro. While several studies have suggested that lidocaine-induced apoptosis is mitochondrial pathway-dependent, it remains unclear whether reactive oxygen species (ROS) are involved in this process and whether the observed cell death can be prevented by antioxidant treatment. METHODS The effects of lidocaine and antioxidants on cell viability and death were evaluated using SH-SY5Y cells, HeLa cells, and HeLa cell derivatives. Cell viability was examined via MTS/PES ([3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt]/phenazine ethosulfate) assay. Meanwhile, cell apoptosis and necrosis were evaluated using a cell death detection assay with Annexin V-FITC and PI staining, as well as by assaying for caspase-3/7 and caspase-9 activity, and by measuring the release of lactate dehydrogenase, respectively. Mitochondrial transmembrane potential (ΔΨm) was assessed using the fluorescent probe tetramethylrhodamine ethyl ester. RESULTS Lidocaine treatment resulted in suppression of the mitochondrial electron transport chain and subsequent attenuation of mitochondrial membrane potential, as well as enhanced ROS production, activation of caspase-3/7 and caspase-9, and induction of apoptosis and necrosis in SH-SY5Y cells in a dose- and time-dependent manner. Likewise, the anesthetics mepivacaine and bupivacaine also induced apoptosis in SH-SY5Y cells. Notably, the antioxidants N-acetyl cysteine (NAC) and Trolox successfully scavenged the mitochondria-derived ROS and suppressed local lidocaine-induced cell death. CONCLUSIONS Our findings demonstrate that the local anesthetics lidocaine, mepivacaine, and bupivacaine inhibited the activity of mitochondria and induced apoptosis and necrosis in a dose-dependent manner. Furthermore, they demonstrate that treatment with the antioxidants NAC, Trolox, and GGA resulted in preservation of mitochondrial voltage and inhibition of apoptosis via suppression of caspase activation.
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Affiliation(s)
- Akihisa Okamoto
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Masahiro Tanaka
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Chisato Sumi
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Kanako Oku
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Munenori Kusunoki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Kenichiro Nishi
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yoshiyuki Matsuo
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Keizo Takenaga
- Department of Life Science, Shimane University School of Medicine, Izumo, Japan
| | - Koh Shingu
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Kiichi Hirota
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan.
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KANG XH, BAO FP, XIONG XX, LI M, JIN TT, SHAO J, ZHU SM. Major complications of epidural anesthesia: a prospective study of 5083 cases at a single hospital. Acta Anaesthesiol Scand 2014; 58:858-66. [PMID: 24961586 DOI: 10.1111/aas.12360] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND We undertook a prospective study of non-obstetric epidurals placed in surgical inpatients at a single teaching hospital to evaluate the incidence of and potential risk factors for major complications of continuous epidural anesthesia. METHODS Demographic information, details of the epidural procedure, and complications (from the pre-anesthetic period through resolution) were recorded for more than 5000 surgical inpatients who underwent continuous epidural anesthesia in our institution between March 2009 and April 2011. The incidence of and risk factors for major complications were evaluated. RESULTS During the study period, 5083 patients were interviewed and their details were recorded (98% capture rate). Sixty-nine (1.36%) experienced major complications: epidural hematoma in 1 patient (0.02%), post-operative neurologic deficits in 57 patients (1.12%), post-dural puncture headache in 7 patients (0.14%), and systemic local anesthetic toxicity in 4 patients (0.08%). Only one patient had permanent sequelae: unilateral lower limb paresthesia. Identified risk factors for neurologic deficits were as follows: American Society of Anesthesiologists status II-III, siting in the lumbar region, orthopedic and urologic surgery, multiple attempts to site an epidural, paresthesia during insertion, a history of neuraxial anesthesia, and use of patient-controlled epidural analgesia. CONCLUSIONS Serious complications were very rare; only one patient had permanent sequelae, and a single epidural hematoma was diagnosed. Post-operative neurologic deficits were more common, but most complications resolved spontaneously within 3 months and they rarely required intervention.
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Affiliation(s)
- X.-H. KANG
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
| | - F.-P. BAO
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
| | - X.-X. XIONG
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
| | - M. LI
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
| | - T.-T. JIN
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
| | - J. SHAO
- Department of Statistics; University of Wisconsin - Madison; Madison WI USA
| | - S.-M. ZHU
- Department of Anesthesiology; the First Affiliated Hospital; School of Medicine; Zhejiang University; Hangzhou China
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Abstract
Neuraxial anesthesia for outpatient surgery can provide excellent anesthesia for certain patients. The short-acting local anesthetic 2-chloroprocaine has an appropriate length of action for short outpatient procedures with a very low risk of transient neurologic symptoms. Epidural anesthesia with short-acting agents can provide good outpatient anesthesia for procedures lasting 90 minutes or longer.
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Affiliation(s)
- Elizabeth A Alley
- Department of Anesthesia, Virginia Mason Medical Center, B2-AN, 1100 Ninth Avenue, Post Box 900, Seattle, WA 98101, USA.
| | - Michael F Mulory
- Department of Anesthesia, Virginia Mason Medical Center, B2-AN, 1100 Ninth Avenue, Post Box 900, Seattle, WA 98101, USA
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Kulkarni KR, Deshpande S, Namazi I, Singh SK, Kondilya K. A comparative evaluation of hyperbaric ropivacaine versus hyperbaric bupivacaine for elective surgery under spinal anesthesia. J Anaesthesiol Clin Pharmacol 2014; 30:238-42. [PMID: 24803765 PMCID: PMC4009647 DOI: 10.4103/0970-9185.130031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Recently introduced ropivacaine is 40% less potent than bupivacaine. Ropivacaine made hyperbaric by the addition of dextrose is known to provide reliable spinal anesthesia (SA). This study was designed to compare the clinical efficacy of equal doses of hyperbaric 0.5% ropivacaine with 0.5% bupivacaine for SA. Materials and Methods: Eighty American Society of Anesthesiologists grade I-II patients undergoing elective infraumbilical surgeries under SA were recruited and randomized to receive 3ml of hyperbaric ropivacaine 5mg/ml containing dextrose 83 mg/ml (by the addition of desired dose of 25% dextrose) in Group R or 3ml of hyperbaric bupivacaine 5mg/ml containing dextrose 80 mg/ml in Group B. Monitoring of vitals and observation for the block parameters were carried out. The data were presented as mean with a standard deviation and frequency with percentage. Statistical analysis was performed using InStat computer software with appropriate tests and P < 0.05 was considered to be significant. Results: Ropivacaine produced a slower onset of sensory block (ropivacaine 4.5 min; bupivacaine 3.2 min; P < 0.05) and the mean total duration of sensory block was significantly lesser (ropivacaine155 min; bupivacaine 190.5 min; P < 0.05). Patients in the ropivacaine Group R had significantly more rapid recovery from the motor blockade (ropivacaine120 min; bupivacaine 190 min; P < 0.05) and passed urine sooner than the patients in bupivacaine Group B (ropivacaine 257 min; bupivacaine 358 min; P < 0.05). Conclusion: Ropivacaine 15 mg in dextrose 8.3% provides reliable SA of shorter duration than bupivacaine 15 mg in 8% dextrose.
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Affiliation(s)
- Kalpana R Kulkarni
- Department of Anaesthesiology, D. Y. Patil Medical College & University, Kolhapur, Maharashtra, India
| | - Sunetra Deshpande
- Department of Anaesthesiology, D. Y. Patil Medical College & University, Kolhapur, Maharashtra, India
| | - Ismail Namazi
- Department of Anaesthesiology, D. Y. Patil Medical College & University, Kolhapur, Maharashtra, India
| | - Sunil Kumar Singh
- Department of Anaesthesiology, D. Y. Patil Medical College & University, Kolhapur, Maharashtra, India
| | - Konark Kondilya
- Department of Anaesthesiology, D. Y. Patil Medical College & University, Kolhapur, Maharashtra, India
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Li H, Xu J, Wang X, Yuan G. Protective effect of ginsenoside Rg1 on lidocaine-induced apoptosis. Mol Med Rep 2013; 9:395-400. [PMID: 24270314 PMCID: PMC3896509 DOI: 10.3892/mmr.2013.1822] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 10/31/2013] [Indexed: 01/03/2023] Open
Abstract
Lidocaine, as an anesthetic substance, is often used for surface and spinal anesthesia. However, studies have shown that lidocaine may induce transient neurological symptoms and cauda equina syndrome. In the present study the effects of the ginsenoside Rg1 (Rg1) on lidocaine-induced apoptosis were assessed in Jurkat cells using flow cytometry and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL). The data showed that incubation with Rg1 provides protection against lidocaine-induced apoptosis in cultured Jurkat cells. In order to investigate the effect of Rg1 on the apoptosis pathway, caspase 3 gene expression was determined. The results suggested that the protective effect of Rg1 on lidocaine-induced apoptosis is mediated by altering the level of B-cell lymphoma-2 (BCL-2) family proteins and downregulating caspase-3 expression. In conclusion, the present study demonstrated that incubation with Rg1 provides protection against lidocaine-induced apoptosis in cultured Jurkat cells. In addition, the study demonstrated that Rg1 is a notable antiapoptotic molecule that is capable of blocking the caspase-dependent signaling cascade in Jurkat cells, and that the protective effect of Rg1 on lidocaine-induced apoptosis is mediated by altering levels of BCL-2 family proteins and downregulating caspase-3 expression. The present study provides the basis for understanding and evaluating the effect of Rg1 in the in vivo treatment of lidocaine-induced transient neurological symptoms and cauda equina syndrome by lidocaine.
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Affiliation(s)
- Hui Li
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
| | - Junmei Xu
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
| | - Xin Wang
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
| | - Guixiu Yuan
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
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Ilfeld BM. Liposome bupivacaine in peripheral nerve blocks and epidural injections to manage postoperative pain. Expert Opin Pharmacother 2013; 14:2421-31. [DOI: 10.1517/14656566.2013.844791] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Spinal and epidural anesthesia and analgesia, and the combination of the two techniques, have been excellent choices for the management of certain surgical procedures and continue to grow in popularity. The demand for increased patient mobility and quicker discharge for both inpatients and outpatients lends itself to the benefits of regional anesthesia. A neuraxial block is indicated for any surgical procedure in which the appropriate sensory level can be accomplished without any adverse outcome. This article outlines the indications and contraindications for these techniques.
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Sagadai S, Panchagnula U, Sundararajan R, Quraishi T. Residual neurological deficit after central neuraxial blocks. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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El-Adawy S, Abd-El Alim A, El-Hamamsy M. Effect of intrathecal Bupivacaine–Lidocaine combination on motor block and analgesia period. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.bfopcu.2012.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Intrathecally administered ropivacaine is less neurotoxic than procaine, bupivacaine, and levobupivacaine in a rat spinal model. Can J Anaesth 2012; 59:456-65. [PMID: 22383086 DOI: 10.1007/s12630-012-9685-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 02/15/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of this study was to compare the neurotoxicity of intrathecal procaine, bupivacaine, levobupivacaine, and ropivacaine in an animal model. METHODS The study comprised two experiments. In the concentration experiment, rats (n = 78) were administered 0.12 μL·g(-1) body weight (BW) of 2% or 20% procaine, 0.5% or 5% bupivacaine, 0.5% or 5% levobupivacaine, or 0.5% or 5% ropivacaine. Based on the findings, the doses were increased by volume in the subsequent volume experiment using 0.12, 0.24, or 0.48 μL·g(-1) BW of 6% procaine, 6% levobupivacaine, or 6% ropivacaine (n = 79). Walking behaviour and sensory threshold were analyzed, and a histological examination of the spinal cord, posterior and anterior roots, and cauda equina was performed. RESULTS The concentration experiment showed abnormalities only in the 5% bupivacaine group, and these abnormal findings were in the posterior root (PR) and posterior column (PC). The volume experiment revealed that procaine 0.24 μL·g(-1) was neurotoxic, mainly affecting the PR. At 0.48 μL·g(-1), severe injury was observed in the PR and PC in all six procaine rats and four of six levobupivacaine rats, while milder injury was limited to the PR in one of six ropivacaine rats, which differed significantly from the former two groups (P = 0.006 and P = 0.014, respectively). Electron microscopy showed axonal degeneration. CONCLUSION All four local anesthetics seemed to cause identical neurotoxic lesions commencing in the PR and extending to the PC by axonal degeneration. Bupivacaine appeared to be the most neurotoxic of the four drugs, and the neurotoxicity at higher doses increased by volume with procaine > levobupivacaine > ropivacaine.
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Lacasse MA, Roy JD, Forget J, Vandenbroucke F, Seal RF, Beaulieu D, McCormack M, Massicotte L. Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial. Can J Anaesth 2011; 58:384-91. [PMID: 21203878 DOI: 10.1007/s12630-010-9450-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 12/20/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We have always been searching for the ideal local anesthetic for outpatient spinal anesthesia. Lidocaine has been associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks of long duration. Preservative-free 2-chloroprocaine (2-CP) seems to be a promising alternative, being a short-acting agent of increasing popularity in recent years. This study was designed to compare 2-CP with bupivacaine for spinal anesthesia in an elective ambulatory setting. METHODS A total of 106 patients were enrolled in this randomized double-blind study. Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine 7.5 mg (n = 53) or 2% preservative-free 2-CP 40 mg (n = 53). The primary endpoint for the study was the time until reaching eligibility for discharge. Secondary outcomes included the duration of the sensory and motor blocks, the length of stay in the postanesthesia care unit, the time until ambulation, and the time until micturition. RESULTS The average time to discharge readiness was 277 min in the 2-CP group and 353 min in the bupivacaine group, a difference of 76 min (95% confidence interval [CI]: 40 to 112 min; P < 0.001). The average time for complete regression of the sensory block was 146 min in the 2-CP group and 329 min in the bupivacaine group, a difference of 185 min (95% CI: 159 to 212 min; P < 0.001). Times to ambulation and micturition were also significantly lower in the 2-CP group. CONCLUSION Spinal 2-chloroprocaine 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 bupivacaine. (ClinicalTrials.gov number, NCT00845962).
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Affiliation(s)
- Marie-Andrée Lacasse
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM), Hôpital St-Luc, 1058 Saint-Denis, Montreal, QC, H2X 3J4, Canada
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Heavner JE. Topical and Systemic Local Anesthetics. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00126-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
PURPOSE OF REVIEW Local anesthetics are not only used as drugs to block the sodium channel to provide analgesia and antiarrhythmic action. The purpose of this review is to highlight the new indications and limitations of this class of drugs. RECENT FINDINGS Recent research has focused on the use of intravenous local anesthetics to improve bowel function after surgery or trauma, to protect the central nervous system, to find new clues about local anesthetic effects in chronic neuropathic pain, and to investigate the long-term effect of anesthesia/analgesia provided by local anesthetics on cancer recurrence. Recent facts dealing with myotoxicity and chondrotoxicity are presented. SUMMARY There is growing evidence that local anesthetics have a broad spectrum of indications in addition to analgesia and antiarrhythmic effect. Most of them are still insufficiently known and investigated. These new indications will no doubt be intensively studied in the coming years.
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Panni MK, George RB, Allen TK, Olufolabi AJ, Schultz JR, Okumura M, Columb MO, Habib AS. Minimum effective dose of spinal ropivacaine with and without fentanyl for postpartum tubal ligation. Int J Obstet Anesth 2010; 19:390-4. [PMID: 20832280 DOI: 10.1016/j.ijoa.2010.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 11/30/2009] [Accepted: 06/28/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ropivacaine may be the ideal spinal anesthetic for postpartum tubal ligation due to its medium duration of action, low incidence of side effects and possibly reduced post-anesthetic care unit (PACU) stay. METHODS Two prospective up-down sequential allocation studies were performed using hyperbaric spinal ropivacaine via a combined spinal-epidural anesthetic technique for patients undergoing postpartum tubal ligation. The first study was performed using an initial dose of 12.5 mg hyperbaric ropivacaine, which was adjusted in testing intervals of 0.5 mg. The second study used an initial dose of 16 mg hyperbaric ropivacaine, a testing interval of 1.0mg, and a fixed dose of fentanyl 10 μg. The need to supplement the block with intravenous or epidural agents was defined as a failure. Failures were treated with epidural lidocaine. RESULTS The first and second studies recruited 24 and 17 patients, respectively. The median effective dose (ED50) for hyperbaric spinal ropivacaine was 16.4 mg (95% CI 13.7-19) with an ED95 estimate of 21.9 mg. The median effective dose of spinal ropivacaine with fentanyl 10 μg was 17.0 mg (95% CI 15.4-18.7) with an ED95 estimate of 21.3 mg. When data were combined, the overall ED50 for ropivacaine was 16.7 mg (95% CI 15.1-18.4) with an ED95 estimate of 22.5 mg (95% CI 16.3-28.8). A T8 block was not achieved in 4 patients receiving spinal ropivacaine alone, and 1 patient receiving spinal ropivacaine with fentanyl. The majority (82%) of patients who did not receive epidural local anesthetic supplementation had recovery of motor block within 60 min following PACU admission. CONCLUSION Spinal hyperbaric ropivacaine 22 mg with or without fentanyl 10 μg could be used for postpartum tubal ligation surgery.
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Affiliation(s)
- M K Panni
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
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Fuyuta M, Takasugi Y, Morimoto M, Shirai T, Morimoto M, Koga Y. Transient lower limb pain following accidental thoracic subarachnoid insertion of an epidural catheter. J Anesth 2009; 23:601-4. [DOI: 10.1007/s00540-009-0804-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 06/01/2009] [Indexed: 10/20/2022]
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O'Donnell D, Manickam B, Perlas A, Karkhanis R, Chan VWS, Syed K, Brull R. Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial. Can J Anaesth 2009; 57:32-8. [PMID: 19856040 DOI: 10.1007/s12630-009-9207-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 10/13/2009] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The foremost limitation of local anesthetic solutions for spinal anesthesia in the outpatient setting is prolonged motor blockade and delayed ambulation. The purpose of this study was to determine if the addition of intrathecal fentanyl to low-dose spinal mepivacaine provides adequate anesthesia with shorter duration of functional motor blockade for ambulatory knee surgery compared with spinal mepivacaine alone. METHODS Following institutional review board approval and informed consent, 34 patients undergoing unilateral knee arthroscopy were enrolled in this study. The patients were randomly assigned to receive either 30 mg of isobaric mepivacaine 1.5% plus fentanyl 10 microg (M + F group) or 45 mg of isobaric mepivacaine 1.5% alone (M group) intrathecally. Postoperatively, the times to achieve sensory block regression to the S1 dermatome and to attain functional motor block recovery enabling ambulation were recorded. All assessments were blinded. RESULTS The time to completion of Phase I recovery was shorter in the M + F group (104.6 +/- 28.4 min) than in the M group (129.1 +/- 30.4 min; P = 0.023). Regression of sensory blockade to S1 was earlier in the M + F group (118.4 +/- 53.5 min) than in the M group (169.7 +/- 38.9 min; P = 0.003). Patients in the M + F group (176.4 +/- 40.3 min) were able to ambulate significantly earlier than those in the M group (205.6 +/- 31.4 min; P = 0.025). No cases of transient or persistent neurological dysfunction were noted. CONCLUSIONS When compared with 45 mg isobaric mepivacaine 1.5%, an intrathecal dose of 30 mg isobaric mepivacaine 1.5% plus 10 microg fentanyl produces reliable anesthesia, hastens block regression, shortens stay in Phase I recovery, and enables earlier ambulation for patients undergoing unilateral knee arthroscopy (Registration no. NCT00803725).
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Affiliation(s)
- Dermot O'Donnell
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Mc Laughlin Pavilion 2-405, 399 Bathurst Street, Toronto, ON, M5T-2S8, Canada
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Lima JE, Bianchin MM, Marques W. Permanent asymmetric neurologic deficits after spinal anesthesia with bupivacaine. Anesth Analg 2009; 109:686. [PMID: 19608852 DOI: 10.1213/ane.0b013e3181abcdf4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Spinal Procaine Is Less Neurotoxic Than Mepivacaine, Prilocaine and Bupivacaine in Rats. Reg Anesth Pain Med 2009; 34:189-95. [DOI: 10.1097/aap.0b013e31819a27bd] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Umbrain V, Lauwers MH, Shi L, Smolders I, Michotte Y, Poelaert J. Comparison of the effects of intrathecal administration of levobupivacaine and lidocaine on the prostaglandin E 2 and glutamate increases in cerebrospinal fluid: a microdialysis study in freely moving rats. Br J Anaesth 2009; 102:540-5. [DOI: 10.1093/bja/aep035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nair GS, Abrishami A, Lermitte J, Chung F. Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy. Br J Anaesth 2009; 102:307-15. [PMID: 19193651 DOI: 10.1093/bja/aen389] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The use of lidocaine in spinal anaesthesia is associated with transient neurological syndrome (TNS). Bupivacaine has a lower incidence of TNS as an alternative but it may have a prolonged action. This study systematically reviews the literature about the recovery profile of patients undergoing spinal anaesthesia, using bupivacaine for arthroscopic knee surgery. We identified 17 eligible randomized clinical trials (RCTs) (1268 patients). All the articles in this review, except one, used hyperbaric bupivacaine. Five trials compared different doses of bupivacaine (range 3-15 mg). Large doses of bupivacaine (10 and 15 mg) were associated with delayed recovery, and supine positioning was associated with a high incidence of failure. With unilateral positioning, a dose as low as 4-5 mg seems to be sufficient. Five trials comparing bupivacaine or levobupivacaine with ropivacaine showed no significant difference in the time to home discharge. When bupivacaine was combined with fentanyl in two trials, marginal delay in recovery was found [time to discharge (min); weighted mean difference (WMD) 14.1, 95% CI 11.9-40.1] and increased nausea and pruritus but had reduced postoperative pain. Unilateral and bilateral spinal anaesthesia were assessed in two trials, and the latter group was associated with early recovery and discharge [time to discharge (min); WMD -41.6, 95% CI -63.6 to -19.6). The results of our systematic review suggest that 4-5 mg of hyperbaric bupivacaine can effectively produce spinal anaesthesia for knee arthroscopy with unilateral positioning. Ropivacaine or the addition of adjuvants did not improve the recovery time. There is a need for tighter RCTs with more consistent endpoints.
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Affiliation(s)
- G S Nair
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, McL 2-405, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8
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Gil MJL, Gómez AE, Vargas DB, Garcia EM, Daros FN, Tugas EI, Paises AA, Pi-Siques F. Factors associated with delayed postsurgical voiding interval in ambulatory spinal anesthesia patients: a prospective cohort study in 3 types of surgery. Am J Surg 2009; 197:182-8. [DOI: 10.1016/j.amjsurg.2007.12.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 12/31/2007] [Accepted: 12/31/2007] [Indexed: 11/30/2022]
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Umbrain V, Shi L, Lauwers MH, Smolders I, Michotte Y, Camu F. Intrathecal lidocaine elevates prostaglandin E 2 levels in cerebrospinal fluid: a microdialysis study in freely moving rats † †This work was partly presented as an oral abstract at the Annual Neuroscience Meeting of Washington on November 14, 2005. Br J Anaesth 2008; 101:716-22. [DOI: 10.1093/bja/aen243] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Luck JF, Fettes PDW, Wildsmith JAW. Spinal anaesthesia for elective surgery: a comparison of hyperbaric solutions of racemic bupivacaine, levobupivacaine, and ropivacaine. Br J Anaesth 2008; 101:705-10. [PMID: 18765643 DOI: 10.1093/bja/aen250] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of this study was to compare the clinical effects of 'hyperbaric' bupivacaine for spinal anaesthesia with those of similar preparations of levobupivacaine and ropivacaine. METHODS Sixty ASA grade I-II patients undergoing elective surgery under spinal anaesthesia were randomized to receive 3 ml of bupivacaine, levobupivacaine, or ropivacaine, each at 5 mg ml(-1) and made hyperbaric by the addition of glucose 30 mg ml(-1). A standard protocol was followed after which a blinded observer assessed the sensory and motor blocks. The level and duration of sensory (pinprick) block, intensity and duration of motor block, and time to mobilize and to micturate were also recorded. RESULTS One patient (ropivacaine group) required general anaesthesia because of technical failure, but all the other blocks were adequate. There were no significant differences between the groups with regard to the mean time to onset of sensory block at T10, the extent of spread, or mean time to maximum spread. Regression of sensory block in the ropivacaine group was more rapid as demonstrated by duration at T10 (P<0.0167) and total duration of sensory block (P<0.0167). Patients in the ropivacaine group had more rapid recovery from motor block (P<0.0167) and shorter times to independent mobilization (P<0.0167). There were no significant differences between the bupivacaine and the levobupivacaine groups. CONCLUSIONS 'Hyperbaric' ropivacaine provides reliable spinal anaesthesia of shorter duration than bupivacaine or levobupivacaine, both of which are clinically indistinguishable. The recovery profile of ropivacaine may be useful where prompt mobilization is required.
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Affiliation(s)
- J F Luck
- University Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee DD19SY, UK.
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Lee SJ, Bai SJ, Lee JS, Kim WO, Shin YS, Lee KY. The Duration of Intrathecal Bupivacaine Mixed with Lidocaine. Anesth Analg 2008; 107:824-7. [DOI: 10.1213/ane.0b013e3181806149] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Reina MA, Maches F, López A, De Andrés JA. The ultrastructure of the spinal arachnoid in humans and its impact on spinal anesthesia, cauda equina syndrome, and transient neurological syndrome. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.trap.2008.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Estimation of the minimum motor blocking potency ratio for intrathecal bupivacaine and lidocaine. Int J Obstet Anesth 2008; 17:223-7. [PMID: 18501583 DOI: 10.1016/j.ijoa.2007.05.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 05/01/2007] [Indexed: 01/18/2023]
Abstract
BACKGROUND The up-down sequential allocation model has been adapted to investigate a variety of clinical and pharmacological issues in neuraxial anaesthesia including the estimation of relative potency ratios for analgesia and motor block of the most commonly used epidural and intrathecal local anaesthetics. The aim of this study was to establish the median effective doses (ED50) for motor block with intrathecal lidocaine and bupivacaine and to define the relative motor blocking potency ratio. METHODS In this prospective, randomised, double blind, parallel group, up-down sequential allocation study, we enrolled 71 parturients undergoing elective caesarean section under combined spinal-epidural anaesthesia. The women received either intrathecal lidocaine 2% w/v or bupivacaine 0.5% w/v. The initial dose was 4 mg for bupivacaine and 12 mg for lidocaine. Subsequent doses were determined by the outcome in the previous parturient, according to the up-down sequential allocation technique. The end point was the occurrence of any motor block in either lower limb within 5 min. RESULTS The intrathecal ED50 for motor block was 13.7 mg for lidocaine (95% CI, 13.1 to 14.4) and 3.4 mg for bupivacaine (95% CI, 2.6 to 4.1) (P<0.0001) and the relative motor blocking potency ratio was 4.1 (95% CI 3.3 to 5.2). CONCLUSIONS Intrathecal bupivacaine was 4.1 times more potent than lidocaine for motor block.
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Liedgens H, Hertel N, Gabriel A, Nuijten M, Dakin H, Mitchell S, Nautrup BP. Cost-Effectiveness Analysis of a Lidocaine 5% Medicated Plaster Compared with Gabapentin and Pregabalin for Treating Postherpetic Neuralgia. Clin Drug Investig 2008; 28:583-601. [DOI: 10.2165/00044011-200828090-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
PURPOSE OF REVIEW Local anesthetics are used in a wide range of clinical situations to prevent acute pain and to stop or ameliorate pain produced by cancer or pain associated with chronic painful conditions. Knowledge of the pharmacology of local anesthetics is essential for their safe use and selection of specific agents to achieve intended goals. RECENT FINDINGS Local anesthetics are a group of drugs defined by their ability to prevent sodium entry into axons, thereby preventing the generation of propagated action potentials in axons. They have other actions, however, such as prevention of axonal sprouting and effects on G-protein-coupled receptors, and on conductance of ions in addition to sodium that might be important in the management of pain. The recent literature focuses on the spectrum of pharmacodynamic actions of local anesthetics, on comparison of pharmacodynamic and pharmacokinetic properties of racemic mixtures versus solutions of pure enantiomer, and on formulations to prolong duration of action. There is new evidence that lipid suspension is useful in the treatment of bupivacaine cardiac toxicity. SUMMARY Local anesthetics have similar chemical structure but differing pharmacokinetic properties and spectra of pharmacodynamic effects that influence selection of agents for use in various clinical situations.
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Affiliation(s)
- James E Heavner
- Department of Anesthesiology and Physiology, Texas Technology University Health Sciences Center, Lubbock, TX 79430, USA.
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Dakin H, Nuijten M, Liedgens H, Nautrup BP. Cost-Effectiveness of a Lidocaine 5% Medicated Plaster Relative to Gabapentin for Postherpetic Neuralgia in the United Kingdom. Clin Ther 2007; 29:1491-507. [PMID: 17825701 DOI: 10.1016/j.clinthera.2007.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 01/08/2023]
Abstract
BACKGROUND Approximately 50% of elderly patients develop postherpetic neuralgia (PHN) after herpes zoster infection (shingles). A lidocaine 5% medicated plaster marketed in the United Kingdom in January 2007 has been shown to be an effective topical treatment for PHN with minimal risk of systemic adverse effects. OBJECTIVE This paper assessed the cost-effectiveness of using a lidocaine plaster in place of gabapentin in English primary care practice to treat those PHN patients who had insufficient pain relief with standard analgesics and could not tolerate or had contraindications to tricyclic antidepressants (TCAs). The analysis took the perspective of the National Health Service (NHS). METHODS The costs and benefits of gabapentin and the lidocaine plaster were calculated over a 6-month time horizon using a Markov model. The model structure allowed for differences in costs, utilities, and transition probabilities between the initial 30-day run-in period and maintenance therapy and also accounted for add-in medications and drugs received by patients who discontinued therapy. Most transition probabilities were based on non-head-to-head clinical trials identified through a systematic review. Data on resource utilization, discontinuation rates, and add-in or switch medications were obtained from a Delphi panel; cost data were from official price tariffs. Published utilities were adjusted for age and were supplemented and validated by the Delphi panel. RESULTS Six months of therapy with the lidocaine plaster cost pound 549 per patient, compared with pound 718 for gabapentin, and generated 0.05 more quality-adjusted life-years (QALYs). The lidocaine plaster therefore dominated gabapentin (95% CI, dominant- pound 2163/QALY gained). Probabilistic sensitivity analysis showed that there was a 90.15% chance that the lidocaine plaster was both less costly and more effective than gabapentin and a 99.99% chance that it cost < pound 20,000/QALY relative to gabapentin. Extensive deterministic sensitivity analyses confirmed the robustness of the conclusions. CONCLUSION This study found that the lidocaine 5% medicated plaster was a cost-effective alternative to gabapentin for PHN patients who were intolerant to TCAs and in whom analgesics were ineffective, from the perspective of the NHS.
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Affiliation(s)
- Helen Dakin
- Abacus International, Bicester, Oxfordshire, United Kingdom.
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Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007; 104:965-74. [PMID: 17377115 DOI: 10.1213/01.ane.0000258740.17193.ec] [Citation(s) in RCA: 379] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Regional anesthesia (RA) provides excellent anesthesia and analgesia for many surgical procedures. Anesthesiologists and patients must understand the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Many studies that have investigated neurological complications after RA are dated, and do not reflect the increasing indications and applications of RA nor the advances in training and techniques. In this brief narrative review we collate the contemporary investigations of neurological complications after the most common RA techniques. METHODS We reviewed all 32 studies published between January 1, 1995 and December 31, 2005 where the primary intent was to investigate neurological complications of RA. RESULTS The sample size of the studies that investigated neurological complications after central and peripheral (PNB) nerve blockade ranged from 4185 to 1,260,000 and 20 to 10,309 blocks, respectively. The rate of neuropathy after spinal and epidural anesthesia was 3.78:10,000 (95% CI: 1.06-13.50:10,000) and 2.19:10,000 (95% CI: 0.88-5.44:10,000), respectively. For common PNB techniques, the rate of neuropathy after interscalene brachial plexus block, axillary brachial plexus block, and femoral nerve block was 2.84:100 (95% CI 1.33-5.98:100), 1.48:100 (95% CI: 0.52-4.11:100), and 0.34:100 (95% CI: 0.04-2.81:100), respectively. The rate of permanent neurological injury after spinal and epidural anesthesia ranged from 0-4.2:10,000 and 0-7.6:10,000, respectively. Only one case of permanent neuropathy was reported among 16 studies of neurological complications after PNB. CONCLUSIONS Our review suggests that the rate of neurological complications after central nerve blockade is <4:10,000, or 0.04%. The rate of neuropathy after PNB is <3:100, or 3%. However, permanent neurological injury after RA is rare in contemporary anesthetic practice.
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Affiliation(s)
- Richard Brull
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Casati A, Fanelli G, Danelli G, Berti M, Ghisi D, Brivio M, Putzu M, Barbagallo A. Spinal Anesthesia with Lidocaine or Preservative-Free 2-Chlorprocaine for Outpatient Knee Arthroscopy: A Prospective, Randomized, Double-Blind Comparison. Anesth Analg 2007; 104:959-64. [PMID: 17377114 DOI: 10.1213/01.ane.0000258766.73612.d8] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this prospective, randomized, double-blind study we tested the hypothesis that 50 mg of 1% preservative-free 2-chloroprocaine would provide a faster resolution of spinal block than the same dose of 1% plain lidocaine. METHODS After IV midazolam premedication (0.03 mg/kg), 30 ASA physical status I-II outpatients undergoing knee arthroscopy were randomly allocated to receive 50 mg of either 1% plain lidocaine (n = 15) or 1% preservative-free plain chloroprocaine (n = 15). A blinded observer recorded the evolution of sensory (loss of pinprick sensation) and motor (modified Bromage scale) block until complete regression, as well as times to unassisted ambulation and voiding. A telephone call follow-up was performed 24 h and 7 days after surgery. RESULTS Two chloroprocaine patients (13%) and one lidocaine patient (7%) required fentanyl supplementation (100 microg IV) (P = 0.99) intraoperatively, but no patient required general anesthesia to complete surgery. Median (range) times for recovery of sensory and motor function, and unassisted ambulation were faster with 2-chloroprocaine [95 (68-170) min; 60 (45-120) min; and 103 (70-191) min] than lidocaine [120 (80-175) min; 100 (60-140) min; and 152 (100-185) min] (P = 0.019, P = 0.0005, and P = 0.003, respectively). No differences in first voiding were reported between chloroprocaine [180 (100-354) min] and lidocaine patients [190 (148-340) min] (P = 0.191). Transient neurological symptoms were reported in five lidocaine patients (33%) but no chloroprocaine patients (0%) (P = 0.042). CONCLUSION Intrathecal injection of 50 mg of preservative-free 2-chloroprocaine 1% resulted in quicker recovery of sensory/motor function, and unassisted ambulation, and fewer incidences of transient neurologic symptoms than the same dose of 1% lidocaine.
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Affiliation(s)
- Andrea Casati
- University of Parma, Department of Anesthesiology and Pain Therapy, Ospedale Maggiore di Parma, Via Gramsci 14, 43100 Parma, Italy.
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Schug SA, Saunders D, Kurowski I, Paech MJ. Neuraxial drug administration: a review of treatment options for anaesthesia and analgesia. CNS Drugs 2007; 20:917-33. [PMID: 17044729 DOI: 10.2165/00023210-200620110-00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neuraxial drug administration describes techniques that deliver drugs in close proximity to the spinal cord, i.e. intrathecally into the CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion. This approach was initially developed in the form of spinal anaesthesia over 100 years ago. Since then, neuraxial drug administration has evolved and now includes a wide range of techniques to administer a large number of different drugs to provide anaesthesia, but also analgesia and treatment of spasticity in a variety of acute and chronic settings. This review concentrates on the pharmacological agents used and the clinical basis behind currently utilised approaches to neuraxial drug administration. With regard to local anaesthetics, the main focus is on the development of the enantiomer-specific compounds ropivacaine and levobupivacaine, which provide similar efficacy to bupivacaine with a reduced risk of severe cardiotoxicity. Opioids are the other group of drugs widely used neuraxially, in particular to provide analgesia alone or more commonly in combination with other agents. The physicochemical properties of the various opioids explain the main differences in efficacy and safety between these drugs when used intrathecally, of which morphine, fentanyl and sufentanil are most commonly used. Another group of drugs including clonidine, dexmedetomidine and epinephrine (adrenaline) provide neuraxial analgesia via alpha-adrenergic receptors and are used mainly as adjuvants to local anaesthetics and opioids. Furthermore, intrathecal baclofen is in routine clinical use to treat spasticity in a number of neurological conditions. Beside these established approaches, a wide range of other drugs have been assessed for neuraxial administration to provide analgesia; however, most are in various early stages of investigation and are not used routinely. These drugs include neostigmine, ketamine, midazolam and adenosine, and the conotoxin ziconotide. The latter is possibly the most unusual compound here; it has recently gained registration for intrathecal use in specific chronic pain conditions.
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Affiliation(s)
- Stephan A Schug
- Pharmacology Unit, School of Medicine and Pharmacology, UWA Anaesthesia, University of Western Australia, Perth, WA, Australia.
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Heavner JE. Topical and Systemic Local Anesthetics. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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