C. Marchetti

Spinal anesthesia with hyperbaric levobupivacaine and ropivacaine for outpatient knee arthroscopy: a prospective, randomized, double-blind study.

To compare unilateral spinal block produced with small doses of hyperbaric ropivacaine with that produced by 2 doses of hyperbaric levobupivacaine, we randomly allocated 91 ASA physical status I–II outpatients undergoing knee arthroscopy to receive unilateral spinal anesthesia with 7.5 mg of hyperbaric ropivacaine 0.5% (group Ropi-7.5, n = 31) or either 7.5 mg (group Levo-7.5, n = 30) or 5 mg (group Levo-5, n = 30) of hyperbaric levobupivacaine 0.5%. Spinal anesthesia was performed at the L3-4 interspace using a 25-gauge Whitacre spinal needle. The lateral decubitus position was maintained for 15 min after injection. Strictly unilateral sensory block was present in 73%, 50%, and 61% of cases in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively, 30 min after injection (P = 0.40), and unilateral motor block was observed in 94%, 93%, and 83% in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively (P = 0.31). One patient of group Ropi-7.5 required general anesthesia to complete surgery, and fentanyl supplementation was required in one patient of group Ropi-7.5 (3%) and one patient of group Levo-5 (3%) (P = 0.42). The median (range) time for spinal block resolution was shorter in group Ropi-7.5 (135 [126–154] min] than in group Levo-7.5 (162 [148–201] min) (P = 0.04); whereas home discharge was shorter in groups Ropi-7.5 (197 [177–218] min) and Levo-5 (197 [187–251] min) as compared with group Levo-7.5 (238 [219–277] min) (P = 0.02 and P = 0.04, respectively). We conclude that 7.5 mg of 0.5% hyperbaric ropivacaine and 5 mg of 0.5% hyperbaric levobupivacaine provide adequate spinal block for outpatient knee arthroscopy, with a faster home discharge as compared with 7.5 mg of 0.5% hyperbaric levobupivacaine.

A prospective, randomized, double-blind comparison of unilateral spinal anesthesia with hyperbaric bupivacaine, ropivacaine, or levobupivacaine for inguinal herniorrhaphy.

In 60 patients undergoing inguinal hernia repair, we compared the clinical profile of unilateral spinal anesthesia produced with either 8 mg of hyperbaric bupivacaine 0.5% (n = 20), 8 mg of hyperbaric levobupivacaine 0.5% (n = 20), or 12 mg of hyperbaric ropivacaine 0.5% (n = 20). The study drug was injected slowly through a 25-gauge Whitacre directional needle and patients maintained the lateral decubitus position for 15 min. The onset time and intraoperative efficacy were similar in the three groups. The maximal level of sensory block on the operative and nonoperative sides was T6 (T12–5) and L3 (/[no sensory level detectable]–T4) with bupivacaine, T8 (T12–5) and L3 (/–T3) with levobupivacaine, T5 (T10–2) and T11 (/–T3) with ropivacaine (P = 0.11, P = 0.23, respectively). Complete regression of spinal anesthesia occurred after 166 ± 42 min with ropivacaine, 210 ± 63 min with levobupivacaine, and 190 ± 51 min with bupivacaine (P = 0.03 and P = 0.04, respectively); however, no differences were observed in time for home discharge (329 ± 89 min with bupivacaine, 261 ± 112 min with levobupivacaine, and 332 ± 57 min with ropivacaine [P = 0.28]). We conclude that 8 mg of levobupivacaine or 12 mg of ropivacaine are acceptable alternatives to 8 mg of bupivacaine when limiting spinal block at the operative side for inguinal hernia repair.

Intracranial Hypotension: A Case of Spontaneous Arachnoid Rupture in a Parturient

INTRACRANIAL hypotension is an important cause of new daily persistent postural headaches. Among the causes of intracranial hypotension, many cases are due to spontaneous cerebrospinal fluid (CSF) leak, often associated with an underlying generalized connective tissue disorder. Intracranial hypotension may also be due to dural puncture after epidural catheter positioning. Most cases of intracranial hypotension are believed to be self-limiting, and initial treatment is based on antiinflammatory drugs, bed rest, and hydration. In some patients, persistent symptoms are present; for them, available treatment options include epidural blood patching, percutaneous fibrin sealant placement, and surgical repair of the underlying CSF leak. We report a case of intracranial hypotension due to spontaneous arachnoid rupture in a parturient woman during the effort of delivery.

Cardiac protection by volatile anaesthetics in high risk cardiac surgery patients: a randomized controlled study: O-15

with ischaemic heart disease (IHD). Alpha-2 agonists have beneficial effects on heart rate and provide adequate sedation in the perioperative period [1]. We investigated the effects of dexmedetomidine added to epidural anaesthesia on myocardial ischaemia and postoperative analgesic requirements in peripheral vascular surgery. Method: Twenty-eight patients with IHD undergoing peripheral vascular surgery were included in the study. Lumber epidural anaesthesia was initiated in all patients. In the first group (GD n 14) sedation was achieved with dexmedetomidine infusion, while the second (GM n 14) was sedated with midazolam. In the peroperative period we collected haemodynamic data and sedation scale. Holter ECG was performed during the first postoperative 24 hours. Dexmedetomidine infusion continued during 24 hours postoperatively. Troponin-T levels were determined preoperatively, and at postoperative 4th, 8th, 24th, 36th, 48th hours. Postoperative analgesic requirements according to patient-controlled analgesic pumps and visual analogue scale (VAS) were registered. Results: Demographic and operative data were similar between the two groups. There was no cardiac event in any group. Although heart rate was similar at the beginning of the study, it was slower at all times after dexmedetomidine infusion in GD. VAS were higher during postoperative 48 hours followup in GD. Analgesic requirements were higher in GM. Troponin-T levels decreased in GD during the study and were significatly lower at 8th, 24th, 36th hours in GD (0.036 vs. 0.15; 0.02 vs. 0.1 and 0.01 vs. 0.09 ng/mL respectively). Conclusion: Peripheral vascular surgery constitues a major risk for patients with IHD. Dexmedetomidine provides adequate sedation, decreases heart rate and also maintains haemodynamic stability. Dexmedetomidine is a safe alternative for peroperative sedation in ischaemic heart disease. Reference: 1 Talke P, Chen R, Thomas B, et al. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg 2000; 90: 834–839.