Spinal lidocaine vs bupivacaine for short duration operative gynecological laparoscopy

Background: The concept that general anesthesia is the only suitable technique for laparoscopic procedures has been changed. Regional anesthesia, including epidural and spinal techniques, combined with the head down position can he used for gynecological laparoscopy without major impairment of ventilation

Aim of the work: This study was designed to compare between lidocaine-fentanyl and bupivacaine-fentanyl spinal anesthesia for operative gynecological laparoscopy regarding the efficacy of the two spinal techniques, patients and surgeons comfort, intra- and postoperative characteristics and complications

Patients and Methods: This is a double blinded randomized prospective study which was conducted at Assuit University Hospital after approval from local ethics committee and informed consent from all patients. The study included 60 women who were scheduled for gynecologic laparoscopy, ASA physical status I and II. Patients were randomly assigned to one of two groups: group I, patients received 2.5 ml 2% plain lidocaine [50 mg] made up to 3 ml solution by addition of 0.5 ml fentanyl [25 microg]. In group II: patients received 2.5 ml 0.5% plain bupivacaine [12.5 mg] made up to 3 ml solution by addition of 0.5 ml fentanyl [25microg]. All patients received 30 mg ketorolac in 500 ml of normal saline, preoperatively, routine monitors were applied [ECG, non invasive blood pressure, pulse oximeter]. The subarachnoid block was performed using a standardized technique. A standardized surgical technique was used for laparoscopy. Shoulder tip pain was recorded and the intensity of pain was measured on a 10-cm visual analog scale [VAS]. Pain >/= 3 on VAS was treated with fentanyl [50microg] and midazolam [1.5 mg] intravenously. Surgical condition, hemodynamic data [non invasive blood pressure [NIBP], heart rate [HR], respiratory rate [RR], O[2] saturation [SpO[2]], arterial blood gas [ABG], intra-operative, and post operative side effects were recorded as nausea, pain and transient neurological symptoms [TNS] in addition to recovery profile including time to full motor and sensory recovery, time to ambulate and time to discharge

Results: There were no significant differences between both groups as regard age, weight, height, body mass index, CO[2] volume and pressure, and pneumoperitonium time. There were no significant differences between the two groups as regard to NIBP, HR, RR, SpO[2], ABG and intra operative complications. Arterial CO[2] tension showed significant increase at 10 min after insufflations in both groups. Surgical condition was rated by surgeons as good to excellent in most patients in both groups with no significant difference between both groups. In the lidocaine group, two patients were excluded from data collection and analysis due to intractable shoulder pain and they required general anesthesia, otherwise shoulder pain >/= 3 on VAS was easily managed in patients in both groups with fentanyl 50microg and midazolam 1.5 mg intravenously. The time to onset of motor block and the time to reach sensory level to T12 and T6 were significantly shorter in the lidocaine group patients in comparison to the bupivacaine group patients. Patients in the lidocaine group showed significantly faster recovery than patients in the bupivacaine group, but unfortunately, they showed significantly higher incidence in TNS than patients in the bupivacaine group. There were no significant differences between both groups regarding postoperative complications

Conclusion: Spinal anesthesia could be a suitable and safe technique for gynecological laparoscopy with a reasonable acceptance from both patients and surgeons. Additionally it possesses the advantage of pain free recovery and low incidence of post operative complications. Even though spinal lidocaine provided faster recovery profile after gynecological laparoscopy than spinal bupivacaine, but it has the disadvantage of higher incidence of TNS

Evaluation of efficacy and side effects of different doses of intrathecal morphine for postoperative analgesia after anorectal surgery

Intrathecal opioids are frequently used in the management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use. Aim of this study was to compare between six different doses of IT morphine [0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg and 1 mg] as regarding postoperative analgesia and the side effects of IT morphine, and to determine the optimal dose of IT morphine that provides satisfactory analgesia to the patient with minimal side effects. This study was conducted in Anesthesiology Department, Assiut university hospital, after approval of the local ethics committee. Our study was performed on 95 patients of ASA physical status I and II aged from 20 to 40 scheduled for anorectal surgeries. Spinal anesthesia was performed, with the patient in the sitting position, at L4, 5. Each patient received 5 mg of hyperbaric bupivacaine with different doses of IT morphine in a total volume of 2 ml. Patients were kept in the sitting position for five minutes to get sacral block. Intraoperative monitoring: Heart rate, O2 saturation, and non-invasive blood pressure were monitored. Postoperative monitoring: Patients were evaluated for any pain or side effect of IT morphine [Pruritus, PONV, urinary retention, and respiratory depression] during the first 24 hours. Supplemental analgesia in the form of I. V. tenoxicam was available on patient request, and the doses needed for each patient were recorded. Antipruritic and antiemetic therapy was available on patient request. Increasing the dose of IT morphine decreases the incidence of pain during the first 24 hours and subsequently decreases the need for supplemental analgesia. The doses of 0.1 mg and 0.2 mg are comparable with each other as regard to pain relief. 100% of the patients receiving 0.1 mg and 75% of the patients receiving 0.2 mg of IT morphine experienced pain during the first 24 hours and subsequently required supplemental analgesia and even with 40 mg of I. V. tenoxicam, some patient complained of postoperative pain. The doses of 0.3 mg, 0.4 mg or 0.5 mg are comparable with each other. Theses doses are enough to provide 24-hours analgesia in more than 50% of patients. This percentage increases to 100% with the use of 20-40 mg of tenoxicam intravenously. The dose of 1 mg provides 24-hours analgesia in 87% of patients. Increasing the dose of IT morphine causes significant increase in the incidence and severity of pruritus. Postoperative nausea and vomiting occurred in 30% of the patients in the control group. There is a non-significant increase in both the incidence and severity of PONV by increasing the dose of IT morphine. Urinary retention occurred in 20% of the patients in the control group. Increasing the dose of IT morphine causes significant increase in the incidence of urinary retention. Respiratory depression was not detected in any patient. Our study clearly demonstrated that the use of IT morphine in a dose of 0.3 mg in adjuvant with intravenous tenoxicam in a dose of 20-40 mg provides excellent pain relief for 24 hours after anorectal surgeries with minimal side effects of IT morphine

Ropivaciane versus lidocaine for intravenous regional anaesthesia

A longer acting local anaesthetic agent, such as ropivacaine may offer advantages over lidocaine for intravenous regional anaesthesia [IVRA,. The aim of this study was to compare the effectiveness and safety of ropivacaine and lidocaine for IVRA. Patients and methods: this study included 40 adults healthy patients with ASA physical status I or II who were scheduled to undergo hand surgery. They were randomly assigned to the administration of 40 ml of either 0.5% lidocaine or 0.187% ropivacaine for IVRA. The onset and recovery of sensory [pinprick and touch] and motor block, visual analogue score [VAS,] and time of 1st analgesic requirement were determined. Evidence of CNS side effects as well as cardiac arrhythmia were evaluated and treated as necessary. IVRA with 0.187% ropivacaine and 0.5% lidocaine provided equivalent levels of surgical anaesthesia. After tourniquet release recovery to sensation [pinprick and touch] and motor function was significantly longer in the ropivacaine group than in the lidocaine group. VAS was significantly lower at the time of admission to the recovery room in the ropivacaine group [2.3 +/- 0.15] in comparison to the lidocaine group [21.85 +/- 0.21, P<0.001], whereas at the time of discharge the difference in VAS was no longer statistically significant. The time of analgesic requirement was significantly longer in the ropivacaine group [5.32 +/- 1.22 hr] in comparison to the lidocaine group [0.42 +/- 0.12 hr, P<0. 001]. There was no cardiac arrhythmia in both groups. The CNS side effects were significantly less in the ropivacaine group. Ropivacaine 0.187% may be an alternative to 0 5% lidocaine for IVRA in the outpatient surgical setting. Longer lasting analgesia in the immediate postoperative period and less CNS side effects may be due to a more profound and prolonged tissue binding effect of ropivacaine

Preeclampsia: the effect of intravenous fluid preload on vasoactive peptide secretion during caesarean section under spinal anaesthesia

We followed the haemodynamic parameters and determined the peripheral venous levels of ANF, ET-1 and NO before and after, intravenous volume preload of I litre Ringer's solution, followed by a further load of the same volume under spinal anaesthesia in 15 healthy and I5pre-eelamptic women. Blood pressure was decreased significantly in both groups after spinal anaesthesia and such decrease was less in the preeclamptic group. The baseline concentration of ANP was higher in preeclamptic women than in normal pregnancy women. It increased significantly in both groups after the JSI infusion, the.2 nd infusion and after delivery. The CVP increased more during the preload period in the preeclamptic group than in healthy women. The increase in the concentrations of ANP correlated significantly with the increase in CVP in total study group. The baseline concentration of ET-1 was higher in preeclamptic women than in healthy women, it decreased significantly in both groups after the first and second infusions. The plasma concentrations of ET-1 increased significantly in the cord sample both groups. NO increased more in the preeclamptic group during the preload period in healthy women while the same increase was noted after the second infusion in groups. After delivery NO concentration in the cord sample was higher in the preeclamptic group than in healthy women. There was no significant difference in the number of neonates with Apgar score < 7, NACS and the parameters of arterial blood gas between the two groups. We conclude from this study that the release of ANP increases in response to a rapid intravenous infusion of a crystalloid solution during elective Caesarean delivery which is exaggerated in women with preeclampsia. This may help in the vasculatory adaptation to the volume load by increasing its capacity. The increase ANP release was not sufficient to decrease maternal arterial blood pressure, but may counteract vasospasm locally in the maternal and uteroplacental circulation