A randomised controlled trial of intrathecal blockade versus peripheral nerve blockade for day-case knee arthroscopy

Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients

Spinal anesthesia is considered safe and reliable for most surgical procedures involving the lower part of the body, but its use in the ambulatory setting requires drugs with rapid onset and regression of the motor and sensory block-like prilocaine.The purpose of this study is to retrospectively analyze data from 3291 procedures recorded in our institutional database, to better define the safety profile of spinal prilocaine and the incidence of complications and side effects.All clinical data, prospectively collected from 2011 to 2019 in an Italian tertiary hospital, of patients treated with spinal anesthesia performed with 40 mg of hyperbaric 2% prilocaine, according to our internal protocol of day surgery, were analyzed.Surgical procedures included saphenectomy (28.5%, n = 937), knee arthroscopy (26.8%, n = 882), proctologic surgery (15.16%, n = 499), and inguinal canal surgery (14.9%, n = 491).Anesthesia-related complication was represented by urinary retention (1.09%, n = 36), lipotimia (0.75%, n = 25), and postoperative nausea (0.33%, n = 11); arrhythmic events were uncommon (0.18%, n = 6). One case of persistent hypotension and 2 cases of persistent hypertension were reported.Persistent motor or sensory block (lasting more than 5 h) was experienced by 7 patients. One patient (0.03%), who underwent knee arthroscopy, experienced pelvic pain lasting for 6 h, compatible with a transient neurological symptom.Proctologic surgery was a factor associated with unplanned admission due to anesthesia-related complications (OR = 4.9; 95% CI: 2-14%).The number of complications related to the method was low as well as the need for hospitalization. This drug is valid and safe for the most performed day surgery procedures; however, further trials are needed to investigate the incidence of complications in the days following the procedure.

Selective spinal anesthesia with hyperbaric prilocaine provides better perioperative pain control than local anesthesia for ambulatory inguinal hernia repair without affecting discharging time: a randomized controlled trial

PURPOSE

Local anesthesia is the most used anesthetic technique for inguinal hernia repair, despite its unpredictability. Selective spinal anesthesia with a short-term local anesthetic guarantees rapid recovery, predictable duration and low incidence of side effects. We tried to assess the efficacy of this neuraxial technique in ambulatory setting.

METHODS

One hundred thirty-two ASA I-III, aged > 18 patients scheduled for inguinal hernia repair have been randomized into two groups receiving unilateral spinal anesthesia with 40 mg of hyperbaric prilocaine (group A) or local anesthesia with mepivacaine (group B).

PRIMARY ENDPOINT

intraoperative and post-operative NRS. Other outcomes: sensory block onset, need for opiates and deep sedation, surgery duration, and time to discharge.

RESULTS

Group A: intraoperative NRS was 0 in 100% of patients; post-operative maximum NRS was > 3 in 12.12% of patients. Group B: mean intraoperative NRS was 4; mean post-operative NRS was 2.5. Spinal anesthesia resulted superior in controlling both intraoperative and post-operative pain (p < 0.00001; p = 0.008). Mean time of the motor block resolution in group A was 98 ± 2 min. Mean time to discharge was not significantly different between groups. Surgical time was significantly different between the two groups (mean time of 37 ± 3.2 min group A; 54 ± 6 min group B-p < 0.00001).

CONCLUSION

Spinal anesthesia group patients had significantly less pain than local anesthesia group, both intraoperatively and post-operatively, without differences in time to discharge, incidence of complications and with improvement of surgical time. More randomized controlled trials are needed to confirm this hypothesis.

TRIAL REGISTRATION

NCT05136534 . Registered November 29, 2021-Retrospectively registered.

Intrathecal chloroprocaine or hyperbaric prilocaine for ambulatory knee surgery? A prospective randomized study

Purpose

The aim of this study was to compare intrathecal 1% chloroprocaine with 2% hyperbaric prilocaine in the setting of ambulatory knee arthroscopy. We hypothesized that complete resolution of the sensory block was faster with chloroprocaine.

Methods

Eighty patients scheduled for knee arthroscopy were included in this prospective randomized double-blind study. Spinal anesthesia was performed with either chloroprocaine (50 mg) or hyperbaric prilocaine (50 mg). Characteristics of sensory and motor blocks and side effects were recorded.

Results

Mean time to full sensory block recovery was shorter with chloroprocaine (169 (56.1) min vs 248 (59.4)). The characteristics of the sensory blocks were similar at the T12 dermatome level between the two groups. Differences appeared at T10: the percentage of patients with a sensory block was higher, onset quicker and duration longer with hyperbaric prilocaine. The number of patients with a sensory block at T4 dermatome level in both groups was minimal. Times to full motor recovery were identical in both groups (85 (70–99) vs 86 (76–111) min). Time to spontaneous voiding was shorter with chloroprocaine (203 (57.6) min vs 287.3 (47.2) min). Incidence of side effects was low in both groups.

Conclusions

When considering the characteristics of the sensory block, the use of chloroprocaine may allow an earlier discharge of patients. Cephalic extension was to a higher dermatomal level and the sensory block at T10 level was of prolonged duration with hyperbaric prilocaine, suggesting that the choice between the two drugs should also be performed based on the level of the sensory block requested by the surgery.

This study is registered in the US National Clinical Trials Registry, registration number: NCT030389, the first of February 2017, Retrospectively registered.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

The effect of midazolam on pain control after knee arthroscopy: a systematic review and meta-analysis

BACKGROUND

Midazolam has some potential in pain control of patients undergoing knee arthroscopy. However, the results remain controversial. We conduct a systematic review and meta-analysis to explore the effect of midazolam on pain control after knee arthroscopy.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched. Randomized controlled trials (RCTs) assessing the effect of midazolam on pain management after knee arthroscopy are included. Two investigators have independently searched articles, extracted the data, and assessed the quality of the included studies. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs are included in this meta-analysis. Compared with control intervention after knee arthroscopy, midazolam intervention can significantly reduce the pain scores (standard mean difference (Std. MD) = - 3.70; 95% confidence interval (CI) = - 6.81 to - 0.60; P = 0.02), the number of patients requiring analgesics (risk ratio (RR) = 0.66; 95% CI = 0.49 to 0.88; P = 0.005), and analgesic consumption (Std. MD = -1.62; 95% CI = - 3.04 to - 0.19; P = 0.03), as well as increase the time to first analgesic requirement (Std. MD = 1.58; 95% CI = 0.17 to 2.99; P = 0.03). In addition, midazolam intervention results in no increase in adverse events following knee arthroscopy (RR = 0.74; 95% CI = 0.18 to 2.98; P = 0.67).

CONCLUSIONS

Midazolam intervention is revealed to substantially reduce the pain scores, the number of patients requiring analgesics, and analgesic consumption, as well as improve the time to first analgesic requirement after knee arthroscopy.

Prilocaine hydrochloride 2% hyperbaric solution for intrathecal injection: a clinical review

Prilocaine is a local anesthetic characterized by intermediate potency and duration and fast onset of action. As hyperbaric formulation of 5% solution, it was introduced and has been successfully used for spinal anesthesia since 1960. A new formulation of 2% plain and hyperbaric solution is currently available in Europe. Because of its lower incidence of transient neurological symptoms, prilocaine is suggested as substitute to lidocaine and mepivacaine in spinal anesthesia for ambulatory surgery, as well as a suitable alternative to low doses of long-acting local anesthetics. The National Library of Medicine database, the Excerpta Medica database, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials database, were searched for the period 1970 to September 2016, with the aim to identify studies evaluating the intrathecal use of 2% prilocaine. A total of 13 randomized clinical trials (RCTs), 1 observational study, 2 dose finding, and 4 systematic reviews has been used for this review. The studies evaluated showed that 2% hyperbaric prilocaine due to a favorable anesthetic and safety profile is an alternative drug to lidocaine and mepivacaine for spinal anesthesia of intermediate or short duration. In comparison with plain solutions, hyperbaricity remarkably accelerates the onset and offset times of intrathecal 2% prilocaine. Literature suggests a dose ranging between 40 and 60 mg of prilocaine for lower extremities and lower abdominal procedures lasting up to 90 min, whereas a dose ranging from 10 to 30 mg is appropriate for perineal surgery. Readiness for discharge occurs in ~4 h from spinal administration.