Spinal or Intravenous Dexmedetomidine for Spinal Anesthesia with Chloroprocaine in Ambulatory Knee Arthroscopies: A Double-Blind Randomized Trial

Purpose

Chloroprocaine provides spinal anesthesia for day-case surgery lasting up to 40 minutes. Intravenous and spinal dexmedetomidine can prolong spinal anesthesia, but no data are available for the combination with chloroprocaine. This double-blind randomized controlled trial compares chloroprocaine with spinal or intravenous dexmedetomidine regarding block characteristics, micturition, and discharge times.

Patients and Methods

After ethical approval and informed consent, 135 patients scheduled for knee arthroscopy were randomized to receive either 40mg spinal chloroprocaine (Chloro-group), 40mg chloroprocaine with 5 mcg spinal dexmedetomidine (Spinal Dex-group) or 40mg chloroprocaine with 0.5 mcg/kg IV dexmedetomidine (IV DEXgroup). Block characteristics, hemodynamic variables and the use of analgesics were registered. Voiding and discharge times were noted. A scoring system was used for micturition problems and sedation. Transient neurological symptoms (TNS) and other late side effects were evaluated after one week.

Results

Demographic data were similar between groups. Block onset times and intensity of motor block were comparable between groups. The time to L2 and Bromage 1 regression was prolonged in the SpinalDEx-group by approximately 30 minutes compared to the other groups (p < 0.01). First voiding as well as discharge from the hospital was prolonged in the Spinal Dex-group by approximately 40 minutes p < 0.01. There was no significant difference between groups regarding treatment of hypotension, sedation, micturition problems or the use of postoperative analgesics (P > 0.8). One patient experienced TNS.

Conclusion

Intrathecal but not intravenous (0.5 mcg/kg) dexmedetomidine can prolong chloroprocaine (40mg) spinal anesthesia when surgery is expected to last over 40 minutes. Despite a similar incidence of adverse effects, this also led to a postponed hospital discharge time.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.