Using chloroprocaine for spinal anaesthesia in outpatient knee-arthroscopy results in earlier discharge and improved operating room efficiency compared to mepivacaine and prilocaine

Spinal Anesthesia for Ambulatory Surgery Using Hyperbaric Prilocaine vs Hyperbaric Bupivacaine: A Prospective Study

Background Spinal anesthesia is a suitable technique for ambulatory surgery, offering benefits such as rapid recovery and minimal complications. The choice of local anesthetic is a key factor in achieving a rapid turnover in an ambulatory surgery unit. This study compares the safety and effectiveness of hyperbaric prilocaine and hyperbaric bupivacaine in an ambulatory setting. Methods A total of 114 patients undergoing ambulatory surgery were randomly allocated to receive either hyperbaric prilocaine (20mg/mL) or hyperbaric bupivacaine (5mg/mL). Time to first walk, time to discharge, and perioperative complications were compared. Results Eighty-nine patients were analyzed: the median time to first unassisted ambulation was significantly reduced by 41 minutes in the prilocaine group, and the average discharge time was reduced by 29 minutes. Hypotension was the most frequently observed complication, occurring in 17.4% of the prilocaine group and 16.3% of the bupivacaine group, with no statistically significant difference. There was no statistically significant difference between the two groups in other perioperative complications studied. Conclusion Hyperbaric prilocaine is a safe and effective alternative to hyperbaric bupivacaine for ambulatory surgery, offering a rapid onset and intermediate duration, resulting in earlier patient discharge. Improving the perioperative times can make the ambulatory unit more efficient and contribute to cost reduction.

Total joint replacement in ambulatory surgery

Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.

The Comparison of Intrathecal Ropivacaine with Bupivacaine for Knee Arthroscopy: A Meta-analysis of Randomized Controlled Trials

The comparison of intrathecal ropivacaine with bupivacaine for knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the efficacy of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2019 for randomized controlled trials (RCTs) assessing the effect of intrathecal ropivacaine versus bupivacaine for knee arthroscopy. This meta-analysis is performed using the random effects model. Five RCTs are included in the meta-analysis. Overall, compared with intrathecal bupivacaine for knee arthroscopy, intrathecal ropivacaine is associated with increased onset time of motor block (mean difference [MD] = 2.05, 95% CI: 1.43-2.67, p < 0.00001) and decreased duration of sensory block (MD = -26.82, 95% CI: -31.96 to -21.67, p < 0.00001) but shows no remarkable influence on onset time of sensory block (MD = -0.09; 95% CI: -1.89 to 1.70, p = 0.92), duration of motor block (MD = -59.76; 95% CI: -124.44 to 4.91, p = 0.07), time to maximum block (MD = 2.35; 95% CI: -0.16 to 4.86, p = 0.07), first urination time (MD = -26.42, 95% CI: -57.34 to 4.51, p = 0.09), or first ambulation time (MD = 3.63, 95% CI: -25.20 to 32.47, p = 0.80).Intrathecal ropivacaine can substantially increase onset time of motor block and decrease the duration of sensory block than intrathecal bupivacaine for knee arthroscopy.

A randomised, non-inferiority study of chloroprocaine 2% and ropivacaine 0.75% in ultrasound-guided axillary block

Chloroprocaine is a short-acting local anaesthetic with a rapid onset of action and an anaesthesia duration up to 60 min. In this pivotal study success rates, onset and remission of motor and sensory block and safety of chloroprocaine 2% was compared to ropivacaine 0.75% for short-duration distal upper limb surgery with successful block rates as primary outcome. The study was designed as a prospective, randomised, multi-centre, active-controlled, double-blind, parallel-group, non-inferiority study, performed in 4 European hospitals with 211 patients scheduled for short duration distal upper limb surgery under axillary plexus block anaesthesia. Patients received either ultrasound guided axillary block with 20 ml chloroprocaine 2%, or with 20 ml ropivacaine 0.75%. Successful block was defined as block without any supplementation in the first 45 min calculated from the time of readiness for surgery. 90.8% patients achieved a successful block with chloroprocaine 2% and 92.9% patients with Ropivacaine 0.75%, thus non-inferiority was demonstrated (10% non inferiority margin; 95% CI − 0.097, 0.039; p = 0.02). Time to onset of block was not significantly different between the groups. Median time to motor and sensory block regression was significantly shorter as was time to home discharge (164 [155–170] min for chloroprocaine versus 380 [209–450] for the ropivacaine group, p < 0.001). For short-duration surgical procedures, the short-acting Chloroprocaine 2% may be used, with success rates non-inferior to ropivacaine and a favourable safety profile.

Trial registration: The trial was registered at Clinicaltrials.gov with registration number NCT02385097 (March 11th, 2015) and European Clinical Trial Database with the EudraCT number 2014-002519-40 (July 7th, 2015, Austria—BASG).

Preoperative assessment of expectations, anxiety and preferences for anesthesia in patients undergoing ambulatory knee arthroscopic surgery

Objective : In this observational study, we aimed at measuring preoperative anxiety and preferences for anesthesia in patients undergoing knee arthroscopic surgery. Background : Little is known about preoperative anxieties, expectations and preferences of patients undergoing surgery, for which both spinal or general anesthesia can be provided. Literature shows that spinal anesthesia is associated with lower postoperative co- morbidity and mortality rates as compared to general anesthesia (1-2). Anxiety itself is an important factor influencing patients’ outcome (3). Methods : Every patients >18 years old undergoing an ambulatory arthroscopy of the knee in the surgical day care center of the AZ Nikolaas (in Sint-Niklaas and Beveren), was asked preoperatively to fill in a questionnaire. The questionnaire focused both on the patients’ knowledge about and preference of anesthesia, as well as their preoperative anxieties and worries. Patients were asked to score preoperative anxiety on a 5-point anxiety scale for any of 9 aspects/complications of the anesthetic (placement of the IV cannula, spinal puncture, death, awareness, pain, postoperative nausea and vomiting, cognitive impairment, infection, blood loss). During the study period, from January 11/01/ 2019 to 11/06/2019, a total of 806 patients were asked to fill out the questionnaire. 201 of these patients completed the questionnaire and were consequently enrolled in the study. This work has been approved by the Ethics Committee of the AZ Nikolaas on 11/11/2018 and by the Ethics Committee of the University Hospital in Antwerp (UZA) on 19/11/ 2018. Results : Seventy-five % of patients had a clear preference for their anesthesia technique. Of these, 2/3 opted for general anesthesia. Patients mainly based their preference on a subjective feeling ; a minority had discussed the choice with their surgeon or general practitioner. Rarely, patients indicated the wish to talk to the anesthesiologist about their choice. Fear for a spinal puncture occurred in 40% of patients (median anxiety score 3/5, range 1-5) and was therefore the most prominent anxiety in this patient population. Conclusions : Patients’ greater preference for general over spinal anesthesia was clearly based rather on a subjective than an objective basis. Forty 40% of patients had a substantial fear for spinal puncture. By informing patients about the risks and complications of the different anesthesia techniques, anxiety feelings can probably be alleviated, and a well-judged decision about their anesthesia technique can be made. There is room for improvement in communication and discussion between patients and anesthesiologists about the patients’ choice of anesthesia technique.

Chloroprocaine Provides Safe, Effective, Short-Acting Spinal Anesthesia Ideal for Ambulatory Surgeries: A Retrospective Review

BACKGROUND

The ideal local anesthetic for use in ambulatory spinal anesthesia is safe, with minimal adverse effects, and of a duration that does not impede post-anesthesia care unit (PACU) discharge. Since its approval for use in spinal anesthesia in Europe in 2012, chloroprocaine has seen a resurgence. Recent studies have investigated the safety and efficacy of preservative-free chloroprocaine for use in spinal anesthesia, but few provide the incidence of adverse events such as urinary retention and transient neurologic symptoms.

QUESTIONS/PURPOSES

We sought to assess the safety of chloroprocaine for spinal anesthesia, including the incidence of adverse events and the duration and quality of its use, in the initial 6 months of its use at our institution. We hypothesized that chloroprocaine would provide effective spinal anesthesia for orthopedic cases of short duration, with a low rate of complications.

METHODS

We conducted a retrospective chart review of all patients from June to December 2016 at our institution who had ambulatory knee arthroscopy or foot procedures in which chloroprocaine spinal anesthesia was used. For all 445 charts analyzed, data were collected on anesthesia characteristics, office visits, nursing PACU assessment, and nursing post-operative day 1 follow-up phone calls.

RESULTS

The median chloroprocaine dosage was 44 mg (interquartile range [IQR], 40 to 50). The median duration of sensory block was 156 min (IQR, 128 to 189) and of motor block was 148 min (IQR, 123 to 181). Time to ambulation was 186 min (IQR, 158 to 218) and time to meeting of discharge criteria was 218 min (IQR, 189 to 250). The most common adverse events in the PACU were bradycardia and hypotension. No patients had urinary retention or transient neurologic symptoms.

CONCLUSIONS

In 6 months of use at our institution, chloroprocaine provided safe and effective spinal anesthesia for short orthopedic procedures, with no incidence of transient neurologic symptoms, neuropraxia, or urinary retention.

Spinal Anesthesia Using Chloroprocaine is Safe, Effective, and Facilitates Earlier Discharge in Selected Fast-track Total Hip Arthroplasty

BACKGROUND

Spinal anesthetic choice plays an underappreciated role in total hip arthroplasty (THA). Chloroprocaine, a short-acting local anesthetic, has been limited to short-duration ambulatory procedures and has not been studied in THA. We compare perioperative outcomes of patients undergoing fast-track THA using chloroprocaine spinal anesthesia with those who have surgery with a longer-acting agent (bupivacaine).

METHODS

A total of 143 THAs performed under spinal anesthesia by 3 arthroplasty surgeons between November 2018 and July 2019 were retrospectively reviewed. Patients receiving chloroprocaine were matched 1:1 by demographics to patients receiving bupivacaine. Ultimately, 74 patients were included (37 chloroprocaine and 37 bupivacaine). The primary outcome was hospital length of stay (LOS). Other perioperative outcomes were also evaluated.

RESULTS

A total of 37 patients (50%) received chloroprocaine (60 mg), whereas 37 (50%) received bupivacaine (median 10 mg, range 8-15 mg). Among the matched groups, chloroprocaine use was associated with shorter hospital LOS (0.9 vs 1.2 days; P = .03), shorter operative time (68.2 vs 83.6 minutes, P = .03), lower estimated blood loss (184.7 vs 218.9 mL, P = .02), shorter postanesthesia care unit LOS (139.4 vs 194.9 minutes; P = .04), and less intraoperative hypotension (59.5% vs 83.8%, P = .02). Patients receiving chloroprocaine were also more commonly discharged home (100% vs 89.2%; P = .04).

CONCLUSION

Chloroprocaine is a safe and reliable option for patients to mobilize rapidly and leave the hospital sooner after THA. Compared with bupivacaine, it is associated with shorter hospital LOS and higher likelihood for discharge to home.

Impact of Chloroprocaine on the Eligibility for Hospital Discharge in Patients Requiring Ambulatory Surgery Under Spinal Anesthesia: An Observational Multicenter Prospective Study

Introduction

This observational study was designed to assess the use of spinal anesthesia with chloroprocaine in the context of ambulatory surgery.

Methods

A prospective, multicenter, observational study was carried out among 33 private or public centers between May 2014 and January 2015 and adult patients, scheduled for a short ambulatory surgery under spinal anesthesia with chloroprocaine. The primary outcomes were anesthetic effectiveness, defined as performance of the whole surgical procedure without any additional anesthetic agent, and the time to achieve eligibility for hospital discharge. Secondary outcomes were the effect of chloroprocaine on motor and sensory blocks, patients’ satisfaction, and the use of analgesics in the first 24 h after surgery.

Results

Among the 615 enrolled patients, 56% were male, the mean age was 47.2 ± 15.2 years, and most patients had an ASA (American Society of Anesthesiologists) status of 1 (63.7%). Main surgical procedures performed were orthopedic (62.6%) and gynecologic (16.1%), and the mean duration of surgery was 26.7 ± 16.7 min. The overall anesthetic success rate was 93.8% (95% CI [91.5%; 95.6%]) for the 580 patients with available data for primary criteria. The failure rate was lower than 7% for all surgical procedures, except for gynecologic surgery (14.8%; 95% CI [8.1%; 23.9%]). The average times of eligibility for hospital discharge and effective discharge were 252.7 ± 82.7 min and 313.8 ± 109.9 min, respectively. The time of eligibility for hospital discharge is defined as the recovery of the patient’s normal clinical parameters and the time of effective discharge is defined as the time for the patient to leave the hospital after surgery. Eligibility for patient’s discharge was achieved more rapidly in private than public hospitals (236.3 ± 77.2 min vs. 280.9 ± 80.7 min, respectively, p < 0.001).

Conclusions

This study showed positive results on the effectiveness of chloroprocaine as a short-duration anesthetic and could be used to reduce the time to achieve eligibility for hospital discharge.

Trial Registration

ClinicalTrials.gov identifier, NCT02152293. Registered on May 6, 2014. Date of enrollment of the first participant in the trial May 7, 2014.