Kathleen McGinn, MD

Abstract

Suprascapular nerve block (SSNB) reportedly improves analgesia and 24-h outcomes after arthroscopic shoulder surgery performed under general anesthesia. In this study, we assessed the analgesic and clinical outcome efficacy of SSNB as an adjunct to interscalene brachial plexus block (ISB) for ambulatory nonarthroscopic shoulder surgery. Fifty patients were randomized to receive either a SSNB or sham injection as part of a standardized ISB-general anesthesia regimen. Time to first significant pain (the primary outcome measure) was significantly delayed in the SSNB group (594 +/- 369 min versus 375 +/- 273 min, respectively; P = 0.02). There were no other differences between groups with regard to postanesthesia recovery unit measures, 24-h assessment of pain, supplemental analgesic use, or quality of life outcomes. We conclude that adjunctive SSNB adds minimal value to a primary ISB anesthetic for nonarthroscopic shoulder surgery.When used as an adjunct to an interscalene block combined with general anesthesia, suprascapular nerve block with bupivacaine moderately prolongs analgesia without improving other outcome measures after ambulatory nonarthroscopic shoulder surgery.

View details for DOI 10.1213/01.ANE.0000052380.69541.D4

View details for Web of Science ID 000181808300014

View details for PubMedID 12651646

Abstract

Voiding before discharge is usually required after outpatient epidural or spinal anesthesia because of concern about bladder overdistention and dysfunction. Shorter duration spinal and epidural anesthesia may allow return of bladder function before overdistention occurs in low-risk patients (those younger than age 70, not having hernia, rectal, or urologic surgery, and without a history of voiding difficulty), and predischarge voiding may not be necessary.After institutional review board approval and informed consent, 201 low-risk ambulatory patients were prospectively studied in either a standard or accelerated pathway after undergoing spinal or epidural anesthesia with procaine, lidocaine, 2-chloroprocaine, or less than 7 mg bupivacaine; epinephrine was not used in any anesthetic. Standard pathway patients (n = 70) were required to void before discharge. Accelerated pathway (n = 131) patients were not required to void. (After randomization of an initial 163 patients to one of the two tracks, 38 additional patients were assigned to the accelerated pathway.) If accelerated pathway patients voided, they were discharged when all other discharge criteria were met. If they did not spontaneously void after block resolution, a bladder ultrasound (BUS) was performed. If the BUS indicated a urine volume of less than 400 ml, the patients were discharged and instructed to return to the emergency department if they were unable to void within 8 h of discharge. If the BUS indicated a urine volume of greater than 400 ml, the patients were reassessed in 1 h and were discharged if they could void spontaneously. If they could not void spontaneously, they were catheterized to facilitate discharge. All patients were contacted the next day to assess the return of normal bladder function.All standard pathway patients voided without difficulty, and were discharged in 153 +/- 49 (SD) min. 62 patients in the accelerated pathway voided spontaneously after resolution of their block and were discharged in 127 +/- 41 min. 46 patients were discharged with a BUS less than 400 ml in 120 +/- 42 min. 23 patients had a BUS greater than 400 ml: of these, 20 patients voided within an hour and were discharged in 162 +/- 45 min. Three were catheterized after 1 h, and were discharged in 186 +/- 61 min. Mean discharge time for all patients in the accelerated pathway was 22 min shorter than the standard pathway (P = 0.002). No patients had difficulty voiding or returned to the hospital for urinary problems. None reported new urologic symptoms.Delay of discharge after outpatient spinal or epidural anesthesia with short-duration drugs for low-risk procedures is not necessary, and may result in prolonged discharge times.

View details for Web of Science ID 000177282400004

View details for PubMedID 12151918

Abstract

Fentanyl is used as an additive to prolong intrathecal anesthesia with both lidocaine and low-dose bupivacaine in the outpatient setting to minimize voiding or discharge delays. Pruritus is the most common side effect. When using procaine as a substitute for lidocaine, we perceived an increased frequency and severity of pruritus. We compared prospectively the frequency and severity of itching with combinations of fentanyl with lidocaine, bupivacaine, and procaine.After institutional review board approval, 135 patients requesting neuraxial anesthesia were asked to evaluate the presence and severity (using a 100 point verbal pruritus score [VPS]) of itching 30 minutes after injection of their spinal anesthetic, on arrival to the postanesthesia care unit (PACU), and at the time of resolution of their block. Choice of anesthetic drug and dose and the use of intravenous sedation was left to the discretion of the attending and resident anesthesiologist.Thirty-three patients received lidocaine and fentanyl, 47 received bupivacaine and fentanyl, and 55 received procaine and fentanyl. In the lidocaine group, 21% of patients experienced pruritus compared with 55% of the bupivacaine group and 55% of the procaine group (P =.003). The average VPS at 30 minutes postblock was 18.4 in the procaine group compared with 0 and 5.5 in the lidocaine and bupivacaine groups (P =.06). On admission to the PACU, it was 37 compared with 16 and 20 for lidocaine and bupivacaine, respectively (P =.006).Procaine produces a higher frequency of pruritus than that seen with lidocaine-fentanyl combinations and a greater severity of pruritus than seen with lidocaine-fentanyl and bupivacaine-fentanyl spinal anesthesia. Reg Anesth Pain Med 2001;26:252-256.

View details for Web of Science ID 000168843300009

View details for PubMedID 11359225

Abstract

Femoral nerve block is effective in reducing postoperative pain after inpatient knee surgery. We studied its efficacy compared with standard analgesia following outpatient anterior cruciate ligament repair, including the duration of analgesia and the effect of different concentrations of bupivacaine.After Institutional Review Board approval and informed consent, we prospectively randomized patients to receive, in a blinded fashion, either a sham block, a femoral nerve block with 25 mL 0.25% bupivacaine, or with 25 mL 0.5% bupivacaine after anterior cruciate ligament repair under epidural anesthesia. Verbal analog pain scores were evaluated by a blinded observer at 20 and 40 minutes after injection. Patients with pain >4 (out of 10) were assessed for the presence of a block and offered a supplemental block if no anesthesia was present at either evaluation. By prospective agreement, any study group with 6 failures was excluded from further recruitment. After discharge, patients recorded pain scores and analgesic consumption in a diary, and estimated the time at which they perceived that analgesia and sensory block from the femoral nerve block resolved, based on an increase in pain, sensation, and strength in the leg.In the sham block group, 6 of 12 patients reported inadequate analgesia in the postanesthesia care unit (4 at 20 minutes, 2 at 40 minutes; greater than other groups, P <.003) and were excluded from further study. Patients with sham blocks had higher pain scores 20 minutes after the block, and requested intravenous analgesia more often. Bupivacaine 0.25% and 0.5% provided 23.2 +/- 7 and 25.7 +/- 11 hours of analgesia, respectively.Femoral nerve block with 0.25% bupivacaine contributes significantly to multimodal postoperative analgesia in the immediate postoperative period following outpatient anterior cruciate ligament repair. Both doses of bupivacaine studied provided analgesia for the first night after surgery.

View details for Web of Science ID 000166554200006

View details for PubMedID 11172507

Abstract

We compared general, epidural, and spinal anesthesia for outpatient knee arthroscopy (excluding anterior cruciate ligament repairs). Forty-eight patients (ASA physical status I-III) were randomized to receive either propofol-nitrous oxide general anesthesia with a laryngeal mask airway with anesthetic depth titrated to a bispectral index level of 40-60, 15-20 mL of 3% 2-chloroprocaine epidural, or 75 mg of subarachnoid procaine with 20 microg fentanyl. All patients were premedicated with <0.035 mg/kg midazolam and <1 microg/kg fentanyl and received intraarticular bupivacaine and 15-30 mg of IV ketorolac during the procedure. Recovery times, operating room turnover times, and patient satisfaction were recorded by an observer using an objective scale for recovery assessment and a verbal rating scale for satisfaction. Statistical analysis was performed with analysis of variance and chi(2). Postanesthesia care unit discharge times for the general and epidural groups were similar (general = 104+/-31 min, epidural = 92+/-18 min), whereas the spinal group had a longer recovery time (146+/-52 min) (P = 0.0003). Patient satisfaction was equally good in all three groups (P = 0.34). Room turnover times did not differ among groups (P = 0.16). There were no anesthetic failures or serious adverse events in any group. Pruritus was more frequent in the spinal group (7 of 16 required treatment) than in the general or epidural groups (no pruritus) (P<0.001). We conclude that epidural anesthesia with 2-chloroprocaine provides comparable recovery and discharge times to general anesthesia provided with propofol and nitrous oxide. Spinal anesthesia with procaine and fentanyl is an effective alternative and is associated with a longer discharge time and increased side effects. Implications: For outpatient knee arthroscopy, anesthesia can be provided adequately with regional or general anesthesia. Epidural and general anesthesia provide equal recovery times and patient satisfaction, whereas spinal anesthesia may prolong recovery and have increased side effects. The choice of anesthesia may depend primarily on the patient's interest in being alert or asleep during the procedure.

View details for Web of Science ID 000089503700017

View details for PubMedID 11004038