Intrathecal chloroprocaine vs. lidocaine in day-case surgery: recovery, discharge and effect of pre-hydration on micturition.

BACKGROUND: This randomised, double blind prospective study compares intrathecal lidocaine with chloroprocaine in day-case surgery and the influence of a 500 ml pre-load intravenously. We tested the hypothesis that chloroprocaine provides faster recovery and discharge in day-case surgery. Secondary we studied the influence of a preload compared with fluid restriction on discharge time and micturition problems. METHODS: One hundred patients undergoing day-case arthroscopy were randomised to receive either lidocaine (L) 60 mg or chloroprocaine (CP) 40 mg intrathecally and this with (L+, CP+) or without (L−, CP−) a 500 ml pre-load of crystalloid. Block characteristics, micturition and discharge times were registered. Bladder volumes were monitored by ultrasound. Micturition problems received a micturition score. RESULTS: Onset and quality of the block were comparable between groups. Time to regain Bromage 1 and L2 regression were shorter for the CP group compared with the L group. Voiding (168 ± 44 min) and discharge (178 ± 52 min) were approximately 40 min faster for the CP group compared with the L group. Pre-load provided faster bladder filling but there were no differences in voiding time within the CP or L group. The CP+ group (166 ± 36 min) was discharged faster than both L groups (226 ± 57 min, 227 ± 59 min). More serious micturition problems occurred in the L+ group compared with both CP groups. CONCLUSION: Chloroprocaine is suitable for day-case surgery because of faster block regression and discharge than lidocaine. A 500 ml pre-load may not affect discharge but did not increase micturition problems for chloroprocaine.

Post-delivery postural headache: not always a classical post-dural puncture headache.

We report a parturient complaining of headache after spinal and epidural labour analgesia with neurological deterioration following an epidural blood patch. Further investigation revealed a medulloblastoma within the fourth ventricle. The patient underwent an operation 4 days after the diagnosis, but died 2 years later. The consequences of the use of neuraxial analgesia and epidural blood patch in the treatment of post-dural puncture headache in this kind of pathology are discussed.

Low-dose combined spinal-epidural anesthesia for cesarean delivery: a comparison of three plain local anesthetics.

The new local anesthetics have been poorly studied for intrathecal use during Cesarean section surely in low doses and in combination with an opioid substance. The purpose of the present study was to compare bupivacaine and the newer local anesthetics in equipotent doses. During the induction of combined spinal-epidural anesthesia, 91 elective Cesarean section patients were randomly assigned to receive a spinal injection of either 10 mg ropivacaine or 6.6 mg bupivacaine or levobupivacaine both combined with sufentanil 3.3 microg. After securing the epidural catheter patients were turned to the supine position respecting a 15 degrees left lateral tilt. The three local anesthetics were compared with respect to sensory and motor block, the need for epidural supplementation, the severity of hypotension and neonatal outcome. More patients in bupivacaine had a Bromage-3 motor block at incision. The ropivacaine group required additional local anesthetics by the epidural route in 23% of the cases versus 10% in the bupivacaine group and 9% with levobupivacaine. This caused the interval between the spinal injection and the end of surgery to be longer in the ropivacaine group. Hemodynamic values were comparable between the three groups although a trend towards better systolic blood pressures and a lower incidence of severe hypotension were noticed in favor of levobupivacaine. Apgar scores and umbilical pH values did not differ. When performing a low-dose combined spinal-epidural technique for Cesarean section, the present study confirms that the new local anesthetics can be used successfully, induce less motor block but that ropivacaine requires at least a 50% larger dose than bupivacaine or levobupivacaine.

Urinary bladder scanning after day-case arthroscopy under spinal anaesthesia: comparison between lidocaine, ropivacaine, and levobupivacaine.

BACKGROUND: Micturition problems after spinal anaesthesia may delay hospital discharge. The use of lidocaine has raised concerns because of the occurrence of transient neurological symptoms (TNS). This randomized double-blind study was designed to compare the newer local anaesthetics with lidocaine regarding block characteristics, micturition problems, and discharge times in day-case spinals for arthroscopy. METHODS: Ninety patients received either isobaric lidocaine 60 mg, ropivacaine 15 mg, or levobupivacaine 10 mg intrathecally. Urinary bladder volumes were measured by ultrasound imaging at regular time intervals until a post-voiding residual volume (PVRV) less than 100 ml was obtained. Micturition problems were classified in five groups ranging from no problems to those requiring catheterization. RESULTS: Times to regain a Bromage-1 and -0 motor block were similar in the three groups but sensory block regression to L2 occurred at 145 (30) min in the lidocaine group, 25-30 min (P<0.05) faster than the other groups. Lidocaine allowed voiding after 245 (65) min and hospital discharge 265 (70) min after spinal injection, 40 min faster than in the two other groups. The incidence or degree of micturition problems were not different between after discharge, three patients (10%) receiving lidocaine complained of symptoms compatible with TNS. CONCLUSIONS: Our study suggested that the three local anaesthetics behave similar regarding quality of anaesthesia and motor block but voiding and discharge occurred significantly earlier with lidocaine although the 40 min difference was not impressive considering a spinal discharge time interval of 4-5 h.

Intrathecal labor analgesia with bupivacaine and sufentanil: the effect of adding 2.25 microg epinephrine.

BACKGROUND AND OBJECTIVES: Epinephrine, 25 microg and 200 microg, has been found to prolong the duration of intrathecal labor analgesia when added to an opioid. In our hospital we use the standard epidural mixture, prepared by the pharmacist, containing epinephrine 1:800,000; i.e., 1.25 microg/mL for both spinal and epidural labor analgesia. We wanted to evaluate whether such a low dose, depending on its effect on duration or quality of analgesia, should be maintained or deleted in future mixtures. METHODS: Forty-five term parturients were randomly assigned to receive 1.8 mL intrathecally of a mixture containing bupivacaine 0.125% and sufentanil 0.75 microg/mL with or without epinephrine 1.25 microg/mL. The quality and duration of analgesia, side effects, and obstetric/neonatal outcome were compared. RESULTS: For both combinations, the onset until the first painless contraction was between 5 and 6 minutes. Most patients were pain free during the second uterine contraction. The duration of complete analgesia was 93.2 +/- 24.2 minutes in the epinephrine group and 79.3 +/- 18.1 minutes for patients not receiving epinephrine (P = .014). The quality of the block, bupivacaine consumption, side effects, and obstetric/neonatal outcome were not different between groups. CONCLUSIONS: It was concluded that epinephrine in a dose as low as 2.25 microg significantly prolonged the duration of intrathecal analgesia of bupivacaine-sufentanil by 15 minutes. No other differences were noticed. Diluting the commercially available bupivacaine 0.5% with epinephrine 1:200,000 may avoid the need of freshly prepared epinephrine solutions.

Levobupivacaine combined with sufentanil and epinephrine for intrathecal labor analgesia: a comparison with racemic bupivacaine.

UNLABELLED: We performed a randomized, double-blinded study to compare levobupivacaine with racemic bupivacaine for labor analgesia. Eighty term parturients received either levobupivacaine 0.125% or racemic bupivacaine 0.125%, to which was added sufentanil 0.75 microg/mL and epinephrine 1.25 microg/mL. As part of a combined spinal-epidural procedure, 2 mL of this mixture was initially injected intrathecally, and the same solutions were subsequently administered epidurally. For both combinations, onset until the first painless contraction was 4 to 5 min. Most patients were pain free during the second contraction. The duration of initial spinal analgesia was 93.5 +/- 20 min and 94.7 +/- 31 min for levobupivacaine and racemic bupivacaine, respectively. The duration of analgesia for the first epidural top-up dose was also similar in the two groups. Total local anesthetic requirements during labor were not different. The only major difference observed was the absence of motor impairment in levobupivacaine-treated parturients as compared with the Racemic Bupivacaine group, in which the incidence of a Bromage-1 motor block was 34%. Other side effects and obstetric or neonatal outcomes were not different between groups. Intrathecal levobupivacaine has a similar clinical profile as racemic bupivacaine, but at equal doses it produced less motor block. IMPLICATIONS: When used intrathecally and epidurally for labor analgesia, levobupivacaine had the same clinical profile as racemic bupivacaine, but at equal doses it produced less motor block.

Prevention of hypotension by a single 5-mg dose of ephedrine during small-dose spinal anesthesia in prehydrated cesarean delivery patients.

UNLABELLED: To evaluate the effectiveness of prophylactic ephedrine for the prevention of hypotension associated with spinal anesthesia, 50 parturients undergoing cesarean delivery received either ephedrine 5 mg or saline IV in a double-blinded fashion immediately after the induction of spinal anesthesia. Spinal anesthesia was performed with hyperbaric bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural technique. All patients received 1000 mL of lactated Ringer's solution and 500 mL of hydroxyethylstarch 6% before the spinal injection. Additional ephedrine boluses (5 mg) were administered IV when the systolic blood pressure or heart rate decreased by more than 30% from baseline values, when systolic blood pressure became <100 mm Hg, or when patients complained of nausea or feeling faint. The height of the block was equal in the groups; however, more patients in the placebo group were found to develop hypotension (58% vs 25%, P < 0. 05). Only 2 (8%) patients in the ephedrine group developed hypotension with systolic blood pressure values <90 mm Hg, whereas 10 patients (42%) in the saline group experienced hypotension of this severity (P < 0.05). In addition, there was a higher incidence of nausea in the placebo-treated patients. The total amount of ephedrine administered did not differ between groups. These findings suggest that the incidence and severity of hypotension are significantly reduced by the IV administration of a prophylactic dose of 5 mg ephedrine in patients receiving small-dose spinal anesthesia for cesarean delivery. IMPLICATIONS: Ephedrine is the drug most often used to correct hypotension during spinal anesthesia for cesarean delivery in healthy patients. A single IV dose of 5 mg decreases the occurrence and limits the severity of hypotension in prehydrated subjects receiving a small-dose spinal local anesthetic-opioid combination.

Seven-year review of requests for epidural blood patches for headache after dural puncture: referral patterns and the effectiveness of blood patches.

A review was undertaken of all 190 patients who were referred over 7 years, from 1991 to 1997 inclusive, for an epidural blood patch as a treatment for headache after dural puncture. The patterns of referral and symptoms, the distributions of age and gender and the effectiveness of the blood patch were examined. Most of the referrals (n = 153) were after deliberate diagnostic dural puncture in neurology and neuroradiology, with a minority (n = 28) used for anaesthesia and obstetrics, which were mostly inadvertent. Another nine cases were related to placement of an intrathecal catheter. The numbers of referrals per year reached a maximum in 1995 before falling again, a curious inverse relation to the number of invasive neuro-radiological diagnostic procedures. Most of the patients were between 30 and 50-years-old, with 25 younger than 30 and 14 older than 60. Women accounted for 70% of the referrals for headache, although the gender ratio amongst patients subjected to at risk procedures appeared closer to 50:50. Neckache accompanied the headache in 85% of cases, auditory problems were volunteered by three patients and one patient had diplopia for 6 weeks. Of the 190 patients who were referred, 186 received at least one patch, the symptoms in the remaining four being too mild or atypical to warrant blood patch treatment. This provided initial relief in all but two patients, one of whom received a further epidural blood patch with no effect. There was sustained relief of symptoms in 136 and a partial relapse in 38 patients, which resolved without needing any further blood patch. A second patch was provided for seven patients and a third for three patients, of whom two were cured. Of the patients who needed more than one blood patch, nine were after inadvertent dural puncture with a Tuohy needle and, of these patients, six were in labour. A total of 200 patches were provided in all for the 186 patients and all but three patients had a satisfactory outcome. Epidural blood patches are effective in treating headache after dural puncture, but less successful than is commonly believed, especially after inadvertent dural taps. A relapse after treatment does not always require a second patch. Specialities other than anaesthesia seemed reluctant to accept the benefits in both cost and comfort of using needles of improved design for dural puncture.

Posterior epidural space depth: safety of the loss of resistance and hanging drop techniques.

We have compared skin to epidural space distance (SED) and tip to tip distance (TTD), a measure of posterior epidural space depth (PESD), in 40 patients with a 27-gauge Whitacre needle after identification of the epidural space using the hanging drop (HD) or loss of resistance (LOR) to air technique. After the LOR technique, TTD was found to be 2 mm greater than that after the HD technique, whereas SED was the same. We conclude that identification of the epidural space can be performed successfully with both techniques, but with a diminished risk of dural damage after LOR compared with the HD technique.

Small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section.

UNLABELLED: In a double-blind, randomized trial, 98 parturients undergoing cesarean section received either hyperbaric or plain bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural procedure. To prevent hypotension, 1000 mL of lactated Ringer's solution, 500 mL of hydroxyethyl starch 6%, and ephedrine 5 mg were administered i.v. The height of the block was equal in both groups, but more patients in the plain group had blocks that were either too high or too low (P < 0.01). The number of patients requiring epidural supplementation was equal in both groups. Strict criteria were used to treat hypotension. The overall incidence of systolic blood pressure (<90 mm Hg) was 13%, whereas it was more pronounced in the plain group (21% vs 6% in the hyperbaric group, P < 0.05), which required more ephedrine (P < 0.05) and in which a greater incidence of nausea was noticed (P < 0.05). We conclude that the use of a small dose of intrathecal bupivacaine combined with sufentanil plus our described preloading regimen resulted in a lower incidence of hypotension. Further, we conclude that the use of hyperbaric bupivacaine in this manner provides a more reliable block and a lower incidence of hypotension than plain bupivacaine. IMPLICATIONS: A small dose of hyperbaric bupivacaine 0.5% combined with sufentanil used intrathecally during cesarean section offered a more reliable cephalad spread of the spinal block than the glucose-free combination, which was reflected in a lower incidence of hypotension and nausea.

Addition of bupivacaine to sufentanil in patient-controlled epidural analgesia after lower limb surgery in young adults: effect on analgesia and micturition.

BACKGROUND AND OBJECTIVES: The usefulness of adding bupivacaine to an opioid administered by the epidural route is controversial. This study examines both the quality of pain relief and side effects, in particular urinary retention, during patient-controlled epidural analgesia (PCEA) with sufentanil alone or in combination with two different concentrations of bupivacaine. METHODS: In a double-blind randomized study, 60 healthy young adults undergoing open knee or ankle surgery with combined spinal-epidural anesthesia received postoperative analgesia via PCEA with sufentanil alone or with 0.06% or 0.12% bupivacaine. In addition to pain scores at rest and during mobilization, bladder function was evaluated. Strict criteria were respected in scoring the occurrence of problems suggestive of urinary retention. The 24-hour analgesic consumption and the incidence of other side effects were also recorded. RESULTS: Patients receiving bupivacaine had better pain relief than those receiving only the opioid, but this difference was more pronounced when measuring dynamic pain scores. The consumption of sufentanil was significantly higher in the group receiving the opioid alone than in the group receiving 0.06% bupivacaine. The bupivacaine dose requirements were twice as high with the 0.12% concentration. Bladder problems occurred significantly more frequently in patients treated with the highest bupivacaine concentration. Motor impairment was not a major problem. CONCLUSIONS: A 0.06% bupivacaine-sufentanil combination offered the best results in terms of analgesic quality and lower side effects, mainly micturition problems, which may be explained by the higher consumption of local anesthetic at the higher bupivacaine concentration. Analgesic quality could not be improved by increasing the bupivacaine concentration.

Postoperative intrathecal patient-controlled analgesia with bupivacaine, sufentanil or a mixture of both.

In a randomised double-blind study, 45 patients, scheduled for major orthopaedic surgery under continuous spinal anaesthesia, received for relief of postoperative pain patient-controlled analgesia with either sufentanil 2 micrograms.ml-1, bupivacaine 0.0625% or a mixture of both by the intrathecal route. The mean (SD) consumption of sufentanil and bupivacaine during the first 12 h was 65.5 (27.1) micrograms and 18.2 (4.8) mg, respectively. Combining bupivacaine and sufentanil reduced the consumption of both to approximately 40% as compared to the administration of each component separately. Pain relief was very good in all subjects, although this was obtained faster with the combined regimen. Moreover, more patients in this group remained completely painfree during the entire observation period (p < 0.05). The incidence of hypotension was low and not significantly different when the plain bupivacaine group was compared with the two other groups. Nausea and vomiting were significantly more frequently observed in both groups treated with sufentanil. Motor block was not a major problem and was noticed during the first 2 h of treatment only. Tachyphylaxis did not occur. It was concluded that the groups receiving plain bupivacaine and sufentanil alone experienced pain relief of good quality. The use of a mixture, however, accelerated the onset of analgesia, improved the analgesic quality and reduced the doses for both components by 60% but at the expense of a higher incidence of nausea and vomiting.

A new combined spinal-epidural apparatus: measurement of the distance to the epidural and subarachnoid spaces.

A new combined spinal-epidural anaesthesia apparatus with a 27G lockable spinal needle was used in 151 patients. Two groups could be created, based on whether dural perforation was felt or not (group 1: with dural click; group 2: no dural click). Measurements of the epidural space depth and of the protrusion of the spinal needle from the epidural needle (tip-to-tip distance) were made. The mean depth of the epidural space was 5.59 cm. Correlations were found with body weight, weight-to-height ratio and body mass index (p < 0.001). The mean tip-to-tip distance measured was 7.0 mm in the patients of group 1, whereas in group 2 a distance of 8.9 mm was found. This difference was statistically significant. Correlations were found between the epidural space width and the patient's height, weight-to-height ratio and body mass index. Four patients felt paraesthesia during placement of the spinal needle and, in another four patients, aspiration was necessary to detect cerebrospinal fluid. Two patients needed epidural top-ups due to insufficient level of anaesthesia. The lockable spinal needle provides safe and stable conditions during injection and a high rate of success in reaching the subarachnoid space.

Potentiation of sufentanil by clonidine in PCEA with or without basal infusion.

Sufentanil or a sufentanil-clonidine combination was evaluated to determine whether the basal rate in patient-controlled epidural analgesia (PCEA) might affect the daily consumption, quality of analgesia or incidence of side effects. Following Caesarean section delivery, 60 patients were randomly assigned to receive one of the four following PCA regimens (15 patients per group) for the relief of post-operative pain by the epidural route: sufentanil 2 micrograms mL-1 in 0.9% NaCl, demand dose 5 micrograms i.e. 2.5 mL, (group S+ with, group S without an infusion at 2.5 mL hr-1) or sufentanil 2 micrograms mL-1 + clonidine 3 micrograms mL-1, demand dose 5 micrograms sufentanil + 7.5 micrograms clonidine i.e. 2.5 mL (group SC+ with and SC without an infusion of 2.5 ml hr-1). The other PCA settings (Bard I PCA pump) were a lock out of interval of 10 min and a 1 h limit of 20 micrograms sufentanil and 30 micrograms clonidine i.e. 10 mL. The parameters measured were the analgesic drug consumption and number of dose demands during the first 24 h, pain scores at 6 h intervals, side effects and quality of sleep. The concurrent infusion increased the dose requirements regardless of the content of the syringe. Consumption of sufentanil was the highest in those patients receiving the plain solution with a basal infusion. Clonidine addition reduced the dose requirements but only significantly in those receiving the background infusion. Patients treated with the mixture tended to reach lower pain scores than those receiving sufentanil only without basal rate. Patients receiving the mixture with basal rate requested significantly fewer additional demands compared with the three other groups, but this did not influence the quality of sleep. Since side effects were more frequently registered in the patients in this group, it was concluded that the optimum regimen was the sufentanil-clonidine combination but with deletion of the basal rate.

Pressure sores as a complication of patient-controlled epidural analgesia after cesarean delivery. Case report.

BACKGROUND AND OBJECTIVES: Postoperative epidural analgesia using mixtures of bupivacaine and opioids has become common practice following abdominal surgery. Side effects such as hypotension, motor block, respiratory depression, pruritus, and urinary retention are well known. Pressure sores occurring within the first 24 hours are extremely rare. METHODS: Three parturients scheduled for cesarean delivery received for postoperative pain relief with a patient-controlled epidural analgesia, consisting of 0.11% bupivacaine, 2 micrograms/mL sufentanil, 3 micrograms/mL clonidine, and 1.25 micrograms/mL epinephrine. RESULTS: Within the first postoperative day pressure sores were observed at one heel. In one patient the coccygeal area was also affected. After discontinuation of the patient-controlled analgesia and local treatment, including application of heel pads, the pressure sores healed uneventfully. CONCLUSIONS: Pressure sores following postoperative epidural analgesia may occur even in young patients. Although bupivacaine may induce a motor block, its combination with other drugs in the analgesic mixture or other contributing factors may explain the occurrence of pressure sores. Prophylaxis and increased alertness should eliminate this complication.