Laura Bertini

Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy

Purpose: To compare unilateral and conventional bilateral bupivacaine spinal block in outpatients undergoing knee arthroscopy.Methods: One hundred healthy, premedicated patients randomly received conventional bilateral (n=50) or unilateral (n=50) spinal anesthesia with 8 mg hyperbaric bupivacaine 0.5%. A lateral decubitus position after spinal injection was maintained in unilateral group for 15 min. Times from spinal injection to readiness for surgery, block resolution, and home discharge were recorded.Results: Three patients in each group were excluded due to failed block. Readiness for surgery required 13 min (5 – 25 min) with bilateral and 16 min (15 – 30) with unilateral spinal block (P=0.0005). Sensory and motor blocks on the operated limb were T9 (T12 – T2) with a Bromage score 0/1/2/3: 0/2/0/45 in the unilateral group and T7 (T12 – T1) with Bromage score 0/1/2/3: 4/1/6/36 with bilateral block (P=0.026 andP=0.016, respectively). Vasopressor was required only in five bilateral patients (P=0.02). Two segment regression of sensory level and home discharge required 81±25 min and 281±83 min with bilateral block, and 99±28 min and 264±95 min with unilateral block (P=0.002 andP=0.90, respectively).Conclusion: Seeking unilateral distribution of spinal anesthesia provided more profound and longer lasting block in the operated limb, less cardiovascular effects, and similar home discharge compared with bilateral spinal anesthesia, with only a slight delay in preparation time.RésuméObjectif: Comparer le bloc rachidien unilatéral au bloc bilatéral traditionnel chez des patients ambulatoires qui subissent une arthroscopie du genou.Méthode: Cent patients sains ont reçu une prémédication et, de façon aléatoire, une rachianesthésie bilatérale traditionnelle (n=50) ou unilatérale (n=50) avec 8 mg de bupivacaïne hyperbare à 0,5 %. Après l’injection, les patients du groupe unilatéral ont été maintenus en décubitus latéral pendant 15 min. On a enregistré: le temps écoulé entre l’injection et le début de l’opération, le temps écoulé entre l’injection et le début de l’opération, le temps nécessaire à la résolution du bloc et le moment de la sortie du service.Résultats: Trois patients ont été exclus dans chaque groupe à cause de l’échec du bloc. II a fallu 13 min (5 – 25 min) de préparation à l’opération avec le bloc bilatéral et 16 min (15 – 30) avec le bloc unilatéral (P=0,0005). Les blocs sensitif et moteur sur le membre opéré ont été de T9 (T12 – T2) avec des scores de 0/1/2/3: 0/2/0/45 à l’échelle de Bromage dans le groupe unilatéral et de T7 (T12 – T1) et des scores de Bromage de 0/1/2/3: 4/1/6/36 avec le bloc bilatéral (P=0,026 et P=0,016, respectivement). Des vasopressures ont été nécessaires chez cinq patients seulement du groupe bilatéral (P=0,02). Le temps nécessaire à la régression de deux segments du bloc sensitif et au congé a été de 81±25 min et de 281±83 min avec le bloc bilatéral, et de 99±28 min et 264 ±95 min avec le bloc unilatéral (P=0,002 et P=0,90, respectivement).Conclusion: La rachianesthésie unilatérale, comparée à la rachianesthésie bilatérale, produit un bloc plus profond et plus long dans le membre opéré, moins d’effets cardiovasculaires, un séjour hospitalier de durée similaire et seulement un léger délai de préparation à l’intervention.

A new posterior approach to the sciatic nerve block : A prospective, randomized comparison with the classic posterior approach

To evaluate the efficacy and acceptance of a new posterior subgluteus approach to the sciatic nerve, as compared with the classic posterior approach, 128 patients undergoing foot orthopedic procedures were randomly allocated to receive either the classic posterior sciatic nerve block (Group Labat, n = 64) or a modified subgluteus posterior approach (Group subgluteus, n = 64). All blocks were performed with the use of a nerve stimulator (stimulation frequency, 2 Hz; intensity, 1–0.5 mA). In Group subgluteus, a line was drawn from the greater trochanter to the ischial tuberosity; then, from the midpoint of this line, a second line was drawn perpendicularly and extended caudally for 4 cm. The end of this line represented the needle entry. In both groups, a proper sciatic stimulation was elicited at 0.5 mA; then 20 mL of 0.75% ropivacaine was injected. The time from needle insertion to successful sciatic nerve stimulation was 60 s (range, 10–180 s) with the Labat’s approach and 32 s (range, 5–120 s) with the new subgluteus approach (P = 0.0005). The depth of appropriate sciatic stimulation was 45 ± 13 mm (mean ± sd) after 2 (range, 1–7) needle redirections in Group subgluteus and 67 ± 12 mm after 4 (range, 1–10) needle redirections in Group Labat (P = 0.0001 and P = 0.00001, respectively). The failure rate was similar in both groups. Severe discomfort during the procedure was less frequent and acceptance better in Group subgluteus (5 patients [8%] and 60 patients [94%], respectively) than in Group Labat (20 patients [31%] and 49 patients [77%], respectively) (P = 0.0005 and P = 0.005, respectively). We conclude that this new subgluteus posterior approach to the sciatic nerve is an easy and reliable technique and can be considered an effective alternative to the more traditional Labat’s approach.

Postoperative Analgesia with Continuous Sciatic Nerve Block After Foot Surgery: A Prospective, Randomized Comparison Between the Popliteal and Subgluteal Approaches

To compare the posterior popliteal and subgluteal continuous sciatic nerve block for anesthesia and acute postoperative pain management after foot surgery, 60 ASA physical status I and II patients undergoing elective orthopedic foot surgery were randomly assigned to either a Subgluteal group (n = 30) or Popliteal group (n = 30). Before surgery and after performing a femoral nerve block with 15 mL of 2% mepivacaine, we performed the sciatic nerve block with 20 mL of 0.75% ropivacaine using either a subgluteal or posterior popliteal approach, and the placement of a catheter came afterward. In the recovery room, the catheter was connected to a patient-controlled analgesia pump to infuse 0.2% ropivacaine (basal infusion rate of 5 mL/h, incremental bolus of 10 mL, and a lockout time of 60 min). There were no technical problems in catheter placement. Intraoperative efficacy of nerve block was similar in the two groups. Postoperative catheter displacement and occlusion were recorded in four patients in the Popliteal group and two patients in the Subgluteal group (P = 0.67). Both approaches provided similar postoperative analgesia. We conclude that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach for continuous sciatic block and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures.

Perioperative care for the older outpatient undergoing ambulatory surgery.

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

Continuous subgluteus sciatic nerve block after orthopedic foot and ankle surgery: comparison of two infusion techniques.

Background and Objective To compare continuous infusion or a patient-controlled technique for postoperative analgesia after foot surgery, using a new subgluteus approach for continuous sciatic nerve block. Methods Fifty healthy patients, undergoing orthopedic foot surgery, received a continuous sciatic nerve block using a new subgluteus approach. All blocks were placed with the aid of a nerve stimulator using a 10-cm, 18-gauge insulated Tuohy needle. After either plantar flexion or dorsiflexion of the operated foot was elicited at ≤ 0.5 mA, 20 mL of 0.75% ropivacaine was injected incrementally using repeated aspiration tests, then followed by the introduction of a 20-gauge epidural catheter. Postoperatively, 0.2% ropivacaine was infused with either a 10 mL/h continuous infusion (group Continuous, n = 25) or with a 5 mL/h basal rate with 5 mL bolus every 60 minutes (group patient-controlled analgesia [PCA], n = 25). Intraoperative analgesic supplementation, as well as postoperative pain relief, morphine consumption, incidence of complication, and patient satisfaction were recorded by an observer unaware of group assignment. Results The sciatic catheter was successfully placed in all patients. Intravenous fentanyl supplementation (dose range, 50 to 150 μg) was required in 4 patients in each group, but no patient required general anesthesia. Catheter dislocation was reported in 2 patients (4%). The quality of pain relief was good in both groups, and none experienced complications. Nine patients of the Continuous group (37%) and 7 patients of the PCA group (29%) required rescue morphine analgesia because of pain in the femoral dermatomes (P = .76). Ropivacaine consumption was 240 mL in the Continuous group (range, 200 to 240 mL) and 140 mL in the PCA group (range, 120 to 290 mL) (P = .0005). Patient acceptance was good in both groups. Conclusions The continuous subgluteus sciatic nerve block represents an easy and reliable option for postoperative analgesia after foot surgery; using a patient controlled rather than a continuous infusion technique reduces the consumption of local anesthetic solution without affecting the quality of pain relief.

Postoperative analgesia by combined continuous infusion and patient-controlled epidural analgesia (PCEA) following hip replacement: ropivacaine versus bupivacaine

Background: Ropivacaine is a new local anaesthetic, which compared to bupivacaine is less toxic and shows greater sensory and motor block dissociation. We hypothesised that treatment of postoperative pain with a combined regimen of continuous epidural infusion and Patient‐Controlled Epidural Analgesia (PCEA) using ropivacaine could have given better results compared with those we had obtained using bupivacaine.

Posterior subgluteal approach to block the sciatic nerve: description of the technique and initial clinical experiences

Background and objective: A new posterior approach to the sciatic nerve in the subgluteal region was developed. We describe our clinical experiences on 135 consecutive patients. Methods: All blocks were performed with a nerve stimulator (stimulation frequency 2 Hz; intensity from 1 reduced to ⩽0.5 mA before application). A line was drawn from the greater trochanter to the ischial tuberosity of the femur; then, from the mid-point of this line, a second line was drawn perpendicularly and extended caudally for 4 cm: the end of this line represented the entry point of the needle. Sciatic stimulation was elicited at ⩽0.5 mA; then ropivacaine 0.75% 20 mL was injected. An independent observer recorded the time from needle insertion to successful sciatic nerve stimulation (performance time), the depth of appropriate sciatic stimulation and the number of needle redirections, as well as the quality of nerve block, the discomfort during the procedure and patient acceptance. Results: The performance time was 41 ± 25 s (mean ± SD) and the mean (SD) depth at which the sciatic nerve stimulation was found was 45 ± 10 mm. The median (range) number of needle redirections required to find the proper sciatic stimulation was 2 (1-5). The tibial response was observed in 77 patients (57%), while the common peroneal response was observed in 58 patients (43%). The degree of discomfort reported was very low and only 16 patients (12%) reported severe pain during placement of the block. The onset time (mean ± SD) of sensory and motor block was 7 ± 4 and 17 ± 13 min respectively, and the surgical procedure was completed with only the peripheral nerve block in 127 patients (94%). The same anaesthesia procedure was acceptable by 127 patients (94%) and only eight patients (6%) would prefer a different anaesthesia technique in the future. Conclusions: The study demonstrated that the sciatic nerve can be easily blocked using this new posterior subgluteal approach, suggesting that it represents a safe and effective alternative to block the sciatic nerve at a proximal level, with the potential for reducing the discomfort experienced by the patient during block placement.

Does local anesthetic dilution influence the clinical effectiveness of multiple-injection axillary brachial plexus block?: a prospective, double-blind, randomized clinical trial in patients undergoing upper limb surgery.

Objectives: The relationship between the dose, volume, and concentration of local anesthetic and the quality and success of regional anesthesia remains unclear. Our aim was to test whether using 3 different volumes of the same local anesthetic dose influences the success rate of an axillary brachial plexus block with a multiple-injection technique in patients undergoing upper limb surgery. Methods: One hundred sixty-five patients were prospectively randomized to 1 of 3 groups. Each group received an axillary block with mepivacaine 400 mg, diluted in 3 different volumes (20, 30, and 40 mL). Outcome measures recorded were the block success rate at 30 mins, sensory and motor onset times, and length of postoperative sensory and motor blockade. Results: No difference was found in the rate of successful axillary plexus blocks determined when the 30-min follow-up ended among the 3 groups: 94% for 20-mL volume, 94% for 30-mL volume, and 98% for 40-mL volume. The median sensory and motor onset times of anesthesia did not differ. However, postoperative motor blockade and sensory analgesia lasted significantly longer in the patients receiving mepivacaine 400 mg diluted in a volume of 30 mL than in the other groups. Conclusions: An axillary brachial plexus block induced with a multiple-injection technique with mepivacaine 400 mg yields a high success rate regardless of the volume of anesthetic injected.