Intrathecal ropivacaine and clonidine for ambulatory knee arthroscopy: a dose-response study.

BACKGROUND: The aim of this study was to evaluate the association of a small dose of intrathecal ropivacaine with small doses of intrathecal clonidine for ambulatory surgery. METHODS: One hundred twenty patients, classified as American Society of Anesthesiologists physical status I and scheduled for knee arthroscopy, were studied. Patients were randomly assigned to receive 4 ml of one of the following double-blinded isobaric intrathecal solutions: 8 mg of ropivacaine (group 1; n =30); 8 mg ropivacaine plus 15 microg clonidine (group 2; n =30); 8 mg ropivacaine plus 45 microg clonidine (group 3; n =30); and 8 mg ropivacaine plus 75 microg clonidine (group 4; n =30). The level and duration of sensory anesthesia were recorded, along with the intensity and duration of motor block. Patient and surgeon were interviewed to evaluate the quality of anesthesia. RESULTS: Intrathecal ropivacaine (8 mg alone) produced short sensory anesthesia and motor blockade (132 +/- 38 min and 110 +/- 35 min; mean +/- SD). However, the quality of anesthesia was significantly lower than in any other group (P < 0.05). Ropivacaine (8 mg) plus 75 microg clonidine produced significantly longer sensory and motor anesthesia (195 +/- 40 min and 164 +/- 38 min; P < 0.05). However, this was associated with systemic effects, such as sedation and reduction of arterial blood pressure. Ropivacaine (8 mg) plus 15 microg clonidine did not prolong sensory or motor blockade, afforded high quality anesthesia, and was not associated with detectable systemic effects. CONCLUSION: Small-dose intrathecal clonidine (15 microg) plus 8 mg intrathecal ropivacaine produces adequate and short-lasting anesthesia for knee arthroscopy.

Preoperative cardiopulmonary assessment in the child with neuromuscular scoliosis.

Preoperative cardiopulmonary assessment in the child with neuromuscular scoliosis comprises two successive steps. The first is the exclusion of any preoperative factor which could make the surgery too dangerous or unacceptable, unless corrected (e.g. clotting problems, decompensated cardiomyopathy, respiratory insufficiency, etc). The second is more functional, and consists of detecting potentially higher risks of postoperative alveolar hypoventilation and secretion removal insufficiency. The authors propose a logical decision-making tree, which can identify the most essential items. Preoperative assessment is a progressive evaluation of an acceptable or unacceptable cost-benefit ratio, which can best be achieved by spending time and discussing all aspects with the patient and family.

Intrathecal ropivacaine for ambulatory surgery.

BACKGROUND: The rationale of this study was to evaluate intrathecal ropivacaine for ambulatory surgery. METHODS: One hundred fifty patients with American Society of Anesthesiologists physical status 1 scheduled for knee arthroscopy were studied. Patients were randomly assigned to receive 4 ml of one of five isobaric intrathecal solutions: Patients in group 1 (n = 30) received 8 mg of bupivacaine; patients in group 2 (n = 30) received 8 mg ropivacaine; patients in group 3 (n = 30) received 10 mg ropivacaine; patients in group 4 (n = 30) received 12 mg ropivacaine; and patients in group 5 (n = 30) received 14 mg ropivacaine. The level and duration of sensory anesthesia were recorded along with the intensity and duration of motor block. Patients were interviewed to identify transient neurologic symptoms. RESULTS: Intrathecal ropivacaine 10 mg produced shorter sensory anesthesia and motor blockade than bupivacaine 8mg (152 +/- 44 min and 135 +/- 41 min vs. 181 +/- 44 min and 169 +/- 52 min, mean +/- SD; P < 0.05). However, the quality of intraoperative analgesia was significantly lower in the 10-mg ropivacaine group (P < 0.05). Ropivacaine 12 mg produced sensory and motor block almost comparable to bupivacaine 8 mg. Ropivacaine 14 mg produced sensory and motor block comparable to ropivacaine 12 mg but significantly increased the time to void. No sign of transient radicular irritation were noted. CONCLUSION: Intrathecal ropivacaine 12 mg is approximately equivalent to bupivacaine 8 mg. At this dose, ropivacaine offers no significant advantage compared with bupivacaine.

A double-blind comparison of 0.125% ropivacaine with sufentanil and 0.125% bupivacaine with sufentanil for epidural labor analgesia.

BACKGROUND: This study intends to evaluate the benefits of the administration of intermittent bolus doses of ropivacaine (0.125%) compared with bupivacaine (0.125%) after addition of sufentanil for analgesia during labor. METHODS: One hundred thirty American Society of Anesthesiologists physical status 1 or 2 parturients were studied. The 90 initial patients were assigned randomly to receive 10 ml bupivacaine, 0.125%, plus 7.5 microg sufentanil (initial bupivacaine 0.125% group) or ropivacaine, 0.125%, plus 7.5 microg sufentanil (ropivacaine 0.125% group). Forty additional patients were recruited and received 0.125% bupivacaine plus 7.5 microg sufentanil (additional bupivacaine 0.125% group) or 0.100% bupivacaine plus 7.5 microg sufentanil (additional bupivacaine 0.100% group). The duration of analgesia, visual analogue scores for pain, motor blockade (using a six-point modified Bromage scale), patient satisfaction scores, nausea, pruritus, heart rate, and blood pressure were recorded. RESULTS: Bupivacaine 0.125% and ropivacaine 0.125% coadministered with sufentanil provided rapid and complete analgesia. Onset of analgesia occurred after +/-15 min and lasted +/-90 min. After the third epidural injection, patients in the ropivacaine group experienced significantly less severe motor blockade than patients in the initial bupivacaine 0.125% group. At this point, 93% of the patients in the ropivacaine group were free from motor impairment versus 66% in the bupivacaine group (P<0.05). Comparable levels of motor blockade were obtained in both additional groups. Patients' evaluation of their analgesia was worst in the bupivacaine 0.100% group. CONCLUSIONS: Ropivacaine 0.125% with sufentanil affords reliable analgesia with minimal motor blockade.

Intrathecal clonidine combined with sufentanil for labor analgesia.

BACKGROUND: Intrathecal sufentanil provides rapid-onset and complete analgesia for the first stage of labor. The dose required to produce this effect can be associated with maternal respiratory depression, hypotension, nausea, or pruritus. Because clonidine potentiates the analgesic effects of opioids without increasing their side effects, the authors wanted to determine the efficacy of low doses of intrathecal clonidine (15 and 30 microg) combined with sufentanil. METHODS: Ninety-eight parturient requesting labor analgesia were studied. In a combined spinal-epidural technique, patients were randomly assigned to receive one of the following intrathecal solutions: either 15 microg clonidine (n = 10); 30 microg clonidine (n = 10); 2.5 microg sufentanil (n = 13); 5 microg sufentanil (n = 13); 2.5 microg sufentanil and 15 microg clonidine (n = 13); 2.5 microg sufentanil and 30 microg clonidine (n = 13); 5 microg sufentanil and 15 microg clonidine (n = 13); or 5 microg sufentanil and 30 microg clonidine (n = 13). Visual analog scores for pain, blood pressure, heart rate, sensory levels, incidence of nausea and pruritus, and motor blockade, and maternal and cord blood concentrations of clonidine were recorded. RESULTS: Patients receiving 30 microg intrathecal clonidine with 2.5 or 5 microg intrathecal sufentanil had significantly longer-lasting analgesia (145 +/- 36 and 145 +/- 43 min vs. 104 +/- 35 for those receiving 5 microg intrathecal sufentanil alone). Clonidine levels were undetectable in maternal serum. CONCLUSIONS: Thirty micrograms of intrathecal clonidine combined with 2.5 or 5 microg intrathecal sufentanil significantly increased the duration of analgesia during the first stage of labor without adverse maternal or fetal effects.

Ambulatory combined spinal-epidural analgesia for labor. Influence of epinephrine on bupivacaine-sufentanil combination.

BACKGROUND AND OBJECTIVES: Subarachnoid sufentanil 5 micrograms during labor is known to have variable results. However, subarachnoid sufentanil 5 micrograms plus bupivacaine 1 mg provides good quality labor analgesia of 100 minutes' average duration. The objective of this study was to examine the effects of adding epinephrine 25 micrograms to this mixture. METHODS: Forty-two parturients with less than 5 cm cervical dilation participated in this double-blind, randomized study. A combined spinal-epidural technique was used for subarachnoid administration of sufentanil 5 micrograms and bupivacaine 1 mg with or without epinephrine 25 micrograms. Analgesia was assessed by visual analog scores. Time elapsed until first request for additional analgesia, blood pressure, heart rate, sensory levels, motor block, and incidence of pruritus, nausea, and sedation were noted. RESULTS: Addition of epinephrine prolonged the duration of analgesia from 103.8 +/- 28.2 minutes to 142 +/- 54.3 minutes and lowered the median cephalad level of sensory block from T3 to T6. The incidence of side effects was similar in both groups, as was the motor performance; 19 patients were able to ambulate in each group. CONCLUSIONS: This minimal bupivacaine-sufentanil-epinephrine mixture allows high-quality analgesia of 142 +/- 54.3 minutes' duration, with a low sensory block level and no motor block. However, hypotension can occur as a late side effect.

[Combined epidural and spinal anesthesia for cesarean section]. / Rachi-péri séquentielle pour césarienne.

Combined spinal epidural block has proven its efficacy in skilled hands. This technique allies advantages of spinal anaesthesia, regarding its speed of action and intensity of motor blockade and advantages of postoperative epidural analgesia. This block must be performed with great care and method to reach a success rate of almost 100%. Local anaesthetics and additives are reviewed and commented. The two main complications, hypotension and post dural puncture headache can be contained in very low limits.

Does epidural injection of physiological saline facilitate the advancement of catheters?

Seventy patients (ASA I, ASA II), scheduled for a surgical intervention under epidural or combined spinal-epidural anaesthesia, were randomly allocated to one of two groups. The epidural space was identified by loss of resistance using air, followed by injection in Group A (35 patients) of 10 ml of physiological saline directed cephallad and in Group B (35 patients) by no injection. Thereafter an anaesthetist, different to the one who placed the Tuohy in the epidural space, advanced a catheter up to 10 cm into the epidural space. At each cm of advance the resistance was judged. No significant difference in resistance was found between the groups. The authors conclude that the injection of 10 ml of physiological saline into the epidural space does not facilitate the advancement of an epidural catheter.

[Surgical treatment of spinal deformities in Duchenne muscular dystrophy]. / Traitement chirurgical des déformations rachidiennes de la dystrophie musculaire de Duchenne.

Forty seven Duchenne Muscular Dystrophy patients, operated on for spinal deformity with segmental spinal instrumentation according to Luque's technique, are reviewed with a mean post-operative follow up of 4 years 4 months. The study of the results obviously showed the interest of Luque Galveston technique for the treatment of severe curves with pelvic obliquity, whereas Dove's rectangle is an interesting choice for the early instrumentation. A total spinal arthrodesis can probably be avoided in these patients, which often demonstrate a satisfying spontaneous fusion after instrumentation. The general and mechanical complications are described, according to the consequences they have on the management technique of these patients.