Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial.

OBJECTIVE: Assess patients submitted to elective cesarean section under spinal anesthesia, and the efficacy of different doses of fentanyl associated with bupivacaine. METHODS: The study included 124 pregnant women randomly distributed into 4 groups (n = 31) according to different doses of fentanyl (15 µg, 10 µg, 7.5 µg), Groups I, II, and III, respectively, and control group IV, associated with 0.5% hyperbaric bupivacaine (10 mg). An epidural catheter was inserted in case epidural top-up was required. We assessed the anesthetic blockage characteristics, negative maternal and neonatal outcomes, and maternal side effects. Statistical analysis was performed using Kruskal-Wallis, Fisher's exact and chi-square tests. The level of significance was 5% (p < 0.05). RESULTS: The quality of analgesia, time for the first complaint of pain and motor block recovery time were significantly better for groups that received fentanyl in comparison to controls (p < 0.001). None of the groups had negative maternal-fetal outcomes. Nausea was significantly more frequent in patients in Groups II (10 µg) and III (7.5 µg) when compared to Groups I (15 µg) and IV (no fentanyl). Vomiting was more frequent in Group III than in Group I (p = 0.006). The incidence of pruritus was significantly higher in the groups receiving fentanyl (p = 0.012). CONCLUSIONS: Among the solutions studied, the spinal anesthesia technique using 15 µg of fentanyl associated with 10 mg of hyperbaric bupivacaine provided satisfactory analgesia and very low incidence of adverse effects for patients submitted to cesarean section. TRIAL REGISTRATION NUMBER: UTN U1111-1199-0285. REBEC: RBR-5XWT6T.

Effect of programmed intermittent epidural boluses and continuous epidural infusion on labor analgesia and obstetric outcomes: a randomized controlled trial.

PURPOSE: Continuous epidural infusion and programmed intermittent epidural boluses are analgesic techniques routinely used for pain relief in laboring women. We aimed to assess both techniques and compare them with respect to labor analgesia and obstetric outcomes. METHODS: After Institutional Review Board approval, 132 laboring women aged between 18 and 45 years were randomized to epidural analgesia of 10 mL of a mixture of 0.1% bupivacaine plus 2 µg/mL of fentanyl either by programmed intermittent boluses or continuous infusion (66 per group). Primary outcome was quality of analgesia. Secondary outcomes were duration of labor, total drug dose used, maternal satisfaction, sensory level, motor block level, presence of unilateral motor block, hemodynamics, side effects, mode of delivery, and newborn outcome. RESULTS: Patients in the programmed intermittent epidural boluses group received statistically less drug dose than those with continuous epidural infusion (24.9 vs 34.4 mL bupivacaine; P = 0.01). There was no difference between groups regarding pain control, characteristics of block, hemodynamics, side effects, and Apgar scores. CONCLUSIONS: Our study evidenced a lower anesthetic consumption in the programmed intermittent boluses group with similar labor analgesic control, and obstetric and newborn outcomes in both groups.

Sufentanil in combination with low-dose hyperbaric bupivacaine in spinal anesthesia for cesarean section: a randomized clinical trial / Associação de sufentanil a dose reduzida de bupivacaína hiperbárica em raquianestesia para cesariana: ensaio clínico randomizado

Abstract A double blind randomized clinical trial of sufentanil as an adjunct in spinal anesthesia for cesarean section and, thereby, be able to reduce the dose of bupivacaine, a local anesthetic, with the same result of an anesthetic block with higher doses but with fewer perioperative side effects, such as hypotension.

Resumo Ensaio clínico randomizado duplamente encoberto sobre o uso do sufentanil como adjuvante em raquianestesia para cesariana e, possibilitando a redução da dose do anestésico local, a bupivacaína, com o mesmo resultado de bloqueio anestésico com doses mais elevadas, mas com menos efeitos colaterais no perioperatório, como hipotensão.

Spinal injection of local anesthetic during cervical facet joint injection / Injeção espinhal de anestésico local durante injeção em facetas articulares cervicais

Abstract Introduction: Facet joint pain is a common source of non-radicular back pain worldwide. Non-surgical interventional modalities remain the mainstay in the treatment of facetogenic back pain and comprise the second most commonly performed interventional pain procedures in the USA. Case: A 36 year-old man with chronic cervical pain secondary to C6-C7 facet arthrosis radiographically, underwent diagnostic local anesthetic bilateral facet joint injection under fluoroscopic guidance. The left side was injected uneventfully; however, 1-2 min following injection of the right side the patient complained of unwellness and became very anxious. He referred paresthesias of the bilateral upper extremities, chest and upper abdomen. Physical examination showed sensory deficits roughly from C5 to T7 without motor deficits; resuscitation measures were not warranted. The deficits were completely resolved by 35-40 min in the recovery area. Discussion: Facet joint injections are a common and safe method of treating back pain secondary to facet arthropathy. Despite excellent safety profiles, rare and sometimes, life-threatening complications can occur. Our case hypothesizes intrathecal injection of local anesthetic during facet joint injection. Few reports have described similar situations. We hypothesize a mechanism of entry through the facet joint, given the proximity of the ligamentum flavum, and the intrathecal space to the anterior aspect of the facet joint. This report reinforces the need for resuscitation and airway management equipment to be readily available where interventional procedures are performed, as well as the need for adequate proficiency in airway management and resuscitation techniques in Pain Medicine training.

Resumo Introdução: A dor nas articulações facetárias é uma fonte mundialmente comum de dores nas costas não radiculares. As modalidades de intervenções não cirúrgicas continuam sendo os pilares no tratamento da dorsalgia facetária e ocupam o segundo lugar entre os procedimentos mais comumente feitos nos EUA para o manejo da dor. Relato de caso: Paciente do sexo masculino, 36 anos, com dor cervical crônica secundária à artrose facetária em C6-C7 (confirmada por radiografia), submetido a exame diagnóstico bilateral das facetas com injeção de anestésico local sob orientação fluoroscópica. O lado esquerdo foi injetado sem intercorrências; porém, um-dois minutos após a injeção do lado direito, o paciente queixou-se de mal-estar e ficou muito ansioso. Mencionou parestesia nos braços, no tórax e no abdome superior. O exame físico revelou déficits sensoriais de, aproximadamente, C5 a T7, sem déficit motor; medidas de reanimação não eram justificáveis. Os déficits foram completamente resolvidos em 35-40 minutos na área de recuperação. Discussão: A aplicação de injeções nas articulações facetárias é um método comum e seguro de tratar a dor nas costas secundária à artropatia facetária. Apesar dos excelentes perfis de segurança, complicações raras e, às vezes, com risco de morte podem ocorrer. Nosso caso relata a injeção intratecal de anestésico local durante injeção nas facetas articulares. Poucos relatos descreveram situações semelhantes. Levantamos a hipótese de um mecanismo de entrada através da faceta articular, por causa da proximidade do ligamento amarelo e do espaço intratecal com o aspecto anterior da faceta articular. Esse relato reforça a necessidade de reanimação e de equipamentos para o manejo das vias aéreas estarem prontamente disponíveis quando procedimentos intervencionistas são feitos, bem como a necessidade de estabelecer o domínio do conhecimento no manejo das vias aéreas e das técnicas de reanimação e treinamento em medicina da dor.

Sufentanil in combination with low-dose hyperbaric bupivacaine in spinal anesthesia for cesarean section: a randomized clinical trial.

A double blind randomized clinical trial of sufentanil as an adjunct in spinal anesthesia for cesarean section and, thereby, be able to reduce the dose of bupivacaine, a local anesthetic, with the same result of an anesthetic block with higher doses but with fewer perioperative side effects, such as hypotension.

Spinal injection of local anesthetic during cervical facet joint injection.

INTRODUCTION: Facet joint pain is a common source of non-radicular back pain worldwide. Non-surgical interventional modalities remain the mainstay in the treatment of facetogenic back pain and comprise the second most commonly performed interventional pain procedures in the USA. CASE: A 36 year-old man with chronic cervical pain secondary to C6-C7 facet arthrosis radiographically, underwent diagnostic local anesthetic bilateral facet joint injection under fluoroscopic guidance. The left side was injected uneventfully; however, 1-2min following injection of the right side the patient complained of unwellness and became very anxious. He referred paresthesias of the bilateral upper extremities, chest and upper abdomen. Physical examination showed sensory deficits roughly from C5 to T7 without motor deficits; resuscitation measures were not warranted. The deficits were completely resolved by 35-40min in the recovery area. DISCUSSION: Facet joint injections are a common and safe method of treating back pain secondary to facet arthropathy. Despite excellent safety profiles, rare and sometimes, life-threatening complications can occur. Our case hypothesizes intrathecal injection of local anesthetic during facet joint injection. Few reports have described similar situations. We hypothesize a mechanism of entry through the facet joint, given the proximity of the ligamentum flavum, and the intrathecal space to the anterior aspect of the facet joint. This report reinforces the need for resuscitation and airway management equipment to be readily available where interventional procedures are performed, as well as the need for adequate proficiency in airway management and resuscitation techniques in Pain Medicine training.

Levobupivacaine absorption pharmacokinetics with and without epinephrine during TAP block: analysis of doses based on the associated risk of local anaesthetic toxicity.

PURPOSE: Cases of local anaesthetic systemic toxicity (LAST) periodically occur following transversus abdominal plane (TAP) blocks. The aim of this study was to characterize levobupivacaine absorption pharmacokinetics, with and without epinephrine, and estimate the risk of LAST, based on a previously reported toxic threshold. METHODS: Previously reported data from 11 volunteers receiving ultrasound-guided TAP blocks with and without epinephrine on two independent occasions were analysed. Serial venous concentrations were measured for 90 min. A pharmacokinetic analysis was performed using the NONMEM statistical programme. The use of epinephrine in the solution was included in the analysis of covariates. The associated risk of LAST symptoms associated with different levobupivacaine dose schemes with and without epinephrine was estimated in 1000 simulated subjects. RESULTS: A one-compartment first-order input and elimination model adequately fit the levobupivacaine data. Epinephrine prolonged the levobupivacaine absorption half-life {4.22 [95 % confidence interval (CI) 2.53-6.50] vs. 7.02 [95 % CI 3.74-14.1]; p < 0.05} and reduced its relative bioavailability (0.84; 95 % CI 0.72-0.97; p < 0.05) The derived model predicts that levobupivacaine dose schemes should be halved from 3 mg kg(-1) body weight with epinephrine to 1.5 mg kg(-1) without epinephrine to obtain a comparable risk of anaesthetic toxicity symptoms of approximately 0.1 %. CONCLUSIONS: Our results strongly support the addition of epinephrine to the local anaesthetic solution, especially when doses of levobupivacaine of >1.5 mg kg(-1) are required. Recommendations regarding the maximum allowable doses of local anaesthetics should consider population analysis to determine safer dosage ranges.

Neurologic Outcomes After Low-Volume, Ultrasound-Guided Interscalene Block and Ambulatory Shoulder Surgery.

BACKGROUND AND OBJECTIVES: Postoperative neurologic symptoms after interscalene block and shoulder surgery have been reported to be relatively frequent. Reports of such symptoms after ultrasound-guided block have been variable. We evaluated 300 patients for neurologic symptoms after low-volume, ultrasound-guided interscalene block and arthroscopic shoulder surgery. METHODS: Patients underwent ultrasound-guided interscalene block with 16 to 20 mL of 0.5% bupivacaine or a mix of 0.2% bupivacaine/1.2% mepivacaine solution, followed by propofol/ketamine sedation for ambulatory arthroscopic shoulder surgery. Patients were called at 10 days for evaluation of neurologic symptoms, and those with persistent symptoms were called again at 30 days, at which point neurologic evaluation was initiated. Details of patient demographics and block characteristics were collected to assess any association with persistent neurologic symptoms. RESULTS: Six of 300 patients reported symptoms at 10 days (2%), with one of these patients having persistent symptoms at 30 days (0.3%). This was significantly lower than rates of neurologic symptoms reported in preultrasound investigations with focused neurologic follow-up and similar to other studies performed in the ultrasound era. There was a modest correlation between the number of needle redirections during the block procedure and the presence of postoperative neurologic symptoms. CONCLUSIONS: Ultrasound guidance of interscalene block with 16- to 20-mL volumes of local anesthetic solution results in a lower frequency of postoperative neurologic symptoms at 10 and 30 days as compared with investigations in the preultrasound period.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats / Avaliação da lesão do nervo ciático após injeção intraneural de bupivacaína, levobupivacaína e lidocaína em ratos

ABSTRACT OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350 g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2 mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

RESUMO OBJETIVO: Os anestésicos locais podem causar neurotoxicidade. Nosso objetivo foi comparar o potencial neurotóxico de diferentes anestésicos locais, os danos induzidos aos nervos e as alterações patológicas de um nervo periférico. MÉTODOS: Foram estudados 60 ratos Whistler com 200-350 g. Os ratos foram divididos em três grupos, uma agulha de calibre 26 foi inserida no nervo ciático esquerdo, com o uso de ampliação, e 0,2 mL de bupivacaína a 0,5%, levobupivacaína a 5% e lidocaína a 2% foram injetados por via intraneural. Um colaborador, cego para os conteúdos das injeções, monitorou a função neurológica no primeiro dia de pós-operatório e depois diariamente. O exame neurológico incluiu a avaliação da presença e da gravidade da nocicepção e dos reflexos de agarrar. No sétimo dia, uma amostra do nervo ciático foi colhida para avaliar as alterações histopatológicas. RESULTADOS: Não houve diferença estatística entre os grupos em relação ao reflexo de agarrar e à avaliação histopatológica. Dois casos no grupo bupivacaína, um no grupo levobupivacaína e dois no grupo lidocaína apresentaram um leve reflexo de agarrar; também no grupo lidocaína, um caso não apresentou reflexo de agarrar no sétimo dia. Degeneração axonal grave foi observada em todos os grupos: quatro casos no grupo bupivacaína (20%), três no grupo levobupivacaína 3 (15%) e seis no grupo lidocaína (30%). CONCLUSÃO: Em todos os grupos, a frequência de dano histopatológico e de gravidade foi maior do que a deficiência motora.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats.

OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

Myocardial contractility impairment with racemic bupivacaine, non-racemic bupivacaine and ropivacaine. A comparative study

PURPOSE: To study racemic bupivacaine, non-racemic bupivacaine and ropivacaine on myocardial contractility. METHODS: Isolated Wistar papillary muscles were submitted to 50 and 100 mM racemic bupivacaine (B50 and B100), non-racemic bupivacaine (NR50 and NR100) and ropivacaine (R50 and R100) intoxication. Isometric contraction data were obtained in basal condition (0.2 Hz), after increasing the frequency of stimulation to 1.0 Hz and after 5, 10 and 15 min of local anesthetic intoxication. Data were analyzed as relative changes of variation. RESULTS: Developed tension was higher with R100 than B100 at D1 (4.3 ± 41.1 vs -57.9 ± 48.1). Resting tension was altered with B50 (-10.6 ± 23.8 vs -4.7 ± 5.0) and R50 (-14.0 ± 20.5 vs -0.5 ± 7.1) between D1 and D3. Maximum rate of tension development was lower with B100 (-56.6 ± 38.0) than R50 (-6.3 ± 37.9) and R100 (-1.9 ± 37.2) in D1. B50, B100 and NR100 modified the maximum rate of tension decline from D1 through D2. Time to peak tension was changed with NR50 between D1 and D2. CONCLUSIONS: Racemic bupivacaine depressed myocardial contractile force more than non-racemic bupivacaine and ropivacaine. Non-racemic and racemic bupivacaine caused myocardial relaxation impairment more than ropivacaine.(AU)

A Randomized Comparison Between Single- and Triple-Injection Subparaneural Popliteal Sciatic Nerve Block.

BACKGROUND AND OBJECTIVES: This prospective randomized trial compared ultrasound-guided single-injection (SI) and triple-injection (TI) subparaneural popliteal sciatic nerve block. We hypothesized that multiple injections are not required when local anesthetic (LA) is deposited under the paraneurium because the latter entraps LA molecules, ensuring circumferential spread around the nerve. Therefore, in addition to comparable success rates, we also expected similar total anesthesia-related times (sum of performance and onset times) and designed this study as an equivalency trial. METHODS: Ultrasound-guided subparaneural posterior popliteal sciatic nerve block was carried out in 100 patients. In the SI group, LA was deposited at a single location between the tibial and peroneal nerves. In the TI group, LA was injected between the tibial and peroneal divisions, medial to the tibial nerve, and lateral to the common peroneal nerve. The total LA volume (15 mL) and mixture (lidocaine 1%-bupivacaine 0.25%-epinephrine 5 µg/mL) were identical in all subjects. The performance time, number of needle passes, and adverse events (paresthesia, neural edema) were recorded by the (nonblinded) investigator supervising the block. A blinded observer evaluated the success rate (sensorimotor composite score ≥6/8 points at 30 minutes) as well as the onset time and contacted patients 7 days after the surgery to inquire about persistent numbness or motor deficit. RESULTS: Both techniques provided comparable success rates (92%) and total anesthesia-related times (17.1-19.7 minutes). Expectedly, the SI group required fewer needle passes (1 vs 3; P < 0.001) and a shorter needling time (3.0 ± 2.3 minutes vs 4.0 ± 2.3 minutes; P = 0.025). The TI group displayed a shorter onset time (12.5 ± 7.9 minutes vs 15.8 ± 7.9 minutes; P = 0.027). The performance time, procedural discomfort, and incidence of paresthesia (14%-20%) were similar between the 2 groups. Sonographic neural swelling was detected in 2 subjects in the SI group. In both cases, the needle was carefully withdrawn and the injection was completed uneventfully. Follow-up of the 100 subjects 1 week after surgery revealed no residual numbness or motor deficit. CONCLUSIONS: Ultrasound-guided SI and TI subparaneural popliteal sciatic nerve blocks result in comparable success rates and total anesthesia-related times. Expectedly, the SI technique requires fewer needle passes.

Infiltración con bupivacaína de la incisión de Pfannenstiel para la analgesia pos cesárea / Bupivacaine infiltration of the Pfannenstiel incision for post-caesarean section analgesia

OBJETIVO: Comparar la efectividad analgésica de la infiltración con Bupivacaína de la incisión de Pfannens-tiel respecto a un placebo para la analgesia posoperatoria de gestantes llevadas a cesárea segmentaria en el Hospital "Dr. Adolfo Pons" de Maracaibo, estado Zulia, Venezuela. MÉTODOS: Investigación comparativa y aplicada, con diseño cuasi-experimental, de casos y controles, contemporáneo y de campo, donde se incluyeron 60 gestantes planificadas para cesárea segmentaria electiva, divididas aleatoriamente en dos grupos pareados para infiltrarles la incisión de Pfannenstiel con 30 mL de Bupivacaína al 0,25% (75 mg) o solución salina. La intensidad del dolor se evaluó mediante la escala visual análoga (EVA). RESULTADOS: En cuanto a la intensidad del dolor, tanto en reposo como en movimiento, se encontraron diferencias altamente significativas a favor del grupo que recibió la infiltración incisional con Bupivacaína durante las primeras seis horas del postoperatorio (p<0,001); posterior a las 8 horas del posoperatorio no hubo diferencias significativas entre los dos grupos evaluados. De igual manera, estas pacientes presentaron un mayor tiempo libre de dolor, que sobrepasaba las 4 horas (251 ± 14 minutos vs. 220 ± 11 minutos; p<0,001), menores requerimientos analgésicos (199,37 ± 0,15 mg vs. 298,04 ± 1,96 mg; p<0,001) y con menos efectos adversos (p<0,05). CONCLUSIÓN: La infiltración de la incisión de Pfannenstiel es efectiva para la analgesia postoperatoria de la cesárea segmentaria, prolongado el tiempo libre de dolor y disminuyendo los requerimientos de analgésicos.

AIM: To compare the analgesic effectiveness of Pfannenstiel incision infiltration with bupivacaine over a placebo for post-operative analgesia in cesarean section in pregnants attending at the Hospital "Dr. Adolfo Pons" in Maracaibo, Zulia state, Venezuela. METHODS: A comparative and applied research, with quasi-experimental, case-control, contemporary and field design, which included 60 pregnant women scheduled for elective cesarean section, divided randomly into two groups matched for Pfannestiel incision infiltration with 30 mL Bupivacaine 0.25% (75 mg) or saline solution. Pain intensity was assessed by visual analog scale (VAS). RESULTS: In terms of pain intensity at rest and in motion, were found highly significant differences in favor of the group receiving the incisional infiltration with bupivacaine during the first six hours after surgery (p<0.001); not later than 8 hours after surgery where in all measurements, were found no significant differences between the two tested groups. Similarly, these patients had higher pain free time, surpassing the 4 hours (251 ± 14 minutes vs. 220 ± 11 minutes; p<0.001), lower analgesic requirements (199.37 ± 0.15 mg vs. 298.04 ± 1.96 mg; p<0.001) and fewer adverse effects (p<0.05). CONCLUSION: The infiltration of the Pfannenstiel incision is effective for postoperative analgesia in cesarean section, prolonged pain-free time and decreasing analgesic requirements.

Association of lipophilic opioids and hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. Randomized controlled study.

PURPOSE: To evaluate the efficacy and side-effects of fentanyl and sufentanil combined with hyperbaric spinal bupivacaine in elective cesarean section. METHODS: A prospective, randomized, double-blind study with 64 term parturients, distributed into 2 groups according to the opioid combined with hyperbaric bupivacaine 0.5% (10mg): GF - fentanyl (25 µg) and GS - sufentanil (5.0 µg). The latency and maximum sensory block level; degree and duration of motor block; duration and quality of analgesia; maternal-fetal repercussions were evaluated. This was an intention-to-treat analysis with a 5% significance level. RESULTS: The latency period, maximum sensory block level, motor block degree and perioperative analgesia were similar in both groups. Motor block and analgesia had a longer duration in the sufentanil group. Maternal adverse effects and neonatal repercussions were similar. The incidence of hypotension was higher in the fentanyl group. In both groups, there was a predominance of patients who were awake and either calm or sleepy. CONCLUSIONS: The addition of fentanyl and sufentanil to hyperbaric subarachnoid bupivacaine was shown to be effective for the performance of cesarean section, and safe for the mother and fetus. Analgesia was more prolonged with sufentanil.

Association of lipophilic opioids and hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. Randomized controlled study

PURPOSE: To evaluate the efficacy and side-effects of fentanyl and sufentanil combined with hyperbaric spinal bupivacaine in elective cesarean section. METHODS: A prospective, randomized, double-blind study with 64 term parturients, distributed into 2 groups according to the opioid combined with hyperbaric bupivacaine 0.5% (10mg): GF - fentanyl (25µg) and GS - sufentanil (5.0µg). The latency and maximum sensory block level; degree and duration of motor block; duration and quality of analgesia; maternal-fetal repercussions were evaluated. This was an intention-to-treat analysis with a 5% significance level. RESULTS: The latency period, maximum sensory block level, motor block degree and perioperative analgesia were similar in both groups. Motor block and analgesia had a longer duration in the sufentanil group. Maternal adverse effects and neonatal repercussions were similar. The incidence of hypotension was higher in the fentanyl group. In both groups, there was a predominance of patients who were awake and either calm or sleepy. CONCLUSIONS: The addition of fentanyl and sufentanil to hyperbaric subarachnoid bupivacaine was shown to be effective for the performance of cesarean section, and safe for the mother and fetus. Analgesia was more prolonged with sufentanil. .

Addition of lidocaine to levobupivacaine reduces intrathecal block duration: randomized controlled trial.

BACKGROUND: The duration of the spinal block is a concern for anesthetists. Low dose intrathecal lidocaine has vasodilatory effects and increases the local anesthetic clearance from the intrathecal space. The aim was to investigate whether this effect of lidocaine can be used to increase the resolution of levobupivacaine spinal anesthesia. METHOD: After obtaining ethical approval and informed patient consent, 40 patients underwent transurethral prostate resection were studied. Patients were randomized into two groups and patients received either levobupivacaine 6.75 mg + 0.3 mL 2% lidocaine (Group L) or levobupivacaine 6.75 mg + saline (Group C). The main outcome measures were the difference between groups regarding the duration of the spinal block and PACU stay. Secondary outcome measures were the difference between groups in onset and resolution of the spinal block, adverse events and treatments were also investigated. RESULTS: Spinal block resolved faster in Group L than Group C; 162.43±39.4 min vs 219.73 ± 37.3 min (p = 0.000). PACU time was shorter in Group L (109 ± 49.9 min in Group L vs 148 ± 56.8 min in Group C) (p = 0.036). There was no difference between groups with respect to the incidence of adverse events and treatments. Groups were also similar regarding complications. PDPH and TNS were not observed in any group. CONCLUSION: Addition of low dose lidocaine to hyperbaric levobupivacaine reduces the duration of the intrathecal block provided by hyperbaric levobupivacaine. This technique can be used to reduce the spinal block duration for relatively short procedures like TUR-P.

Comparison of the effects and complications of unilateral spinal anesthesia versus standard spinal anesthesia in lower-limb orthopedic surgery.

INTRODUCTION: A restricted sympathetic block during spinal anesthesia may minimize hemodynamic changes. This prospective randomized study compared unilateral and bilateral spinal anesthesia with respect to the intra- and postoperative advantages and complications of each technique. MATERIAL AND METHODS: Spinal anesthesia was induced with 0.5% hyperbaric bupivacaine and a 25-G Quincke needle (Dr. J) in two groups of patients with physical status ASA I-II who had been admitted for orthopedic surgeries. In group A, dural puncture was performed with the patient in a seated position using 2.5 cm(3) of hyperbaric bupivacaine. Each patient was then placed in the supine position. In group B, dural puncture was performed with the patient in the lateral decubitus position with 1.5 cm(3) of hyperbaric bupivacaine. The lower limb was the target limb. The speed of injection was 1 mL/30s, and the duration of time spent in the lateral decubitus position was 20 min. RESULTS: The demographic data were similar in both groups. The time to the onset of the sensory and motor block was significantly shorter in group A (p=0.00). The duration of motor and sensory block was shorter in group B (p<0.05). The success rate for unilateral spinal anesthesia in group B was 94.45%. In two patients, the spinal block spread to the non-dependent side. The incidence of complications (nausea, headache, and hypotension) was lower in group B (p=0.02). CONCLUSION: When unilateral spinal anesthesia was performed using a low-dose, low-volume and low-flow injection technique, it provides adequate sensory-motor block and helps to achieve stable hemodynamic parameters during orthopedic surgery on a lower limb. Patients were more satisfied with this technique as opposed to the conventional approach. Furthermore, this technique avoids unnecessary paralysis on the non-operated side.

Efficiency of levobupivacaine and bupivacaine for supraclavicular block: a randomized double-blind comparative study.

BACKGROUND AND OBJECTIVES: Success rate of catheter applications is low in supraclavicular block. Thus, bupivacaine and levobupivacaine become important with their long effect time in single injection practices. In this study, we aimed to compare the effectiveness, side effects and complications of bupivacaine and levobupivacaine in supraclavicular block. METHODS: Sixty patients aged between 20 and 65, with body weight between 50 and 100 kg, in the ASA I-II-III group who were scheduled for hand, forearm and arm surgery using supraclavicular block were randomized into two groups of 30. The patients received 30 ml 0.5% bupivacaine (Group B) or 30 ml 0.5% levobupivacaine (Group L). Motor and sensory blocks were evaluated. Motor and sensory block onset times, total block durations, postoperative pain, amount of postoperative analgesic used and patient satisfaction were recorded. RESULTS: Demographic data, distribution of surgical area and hemodynamic data were similar between the two groups. Surgery, motor and sensory block durations of Group B and L patients did not vary statistically significantly. However, motor and sensory block onset times in Group B were significantly shorter than Group L (p<0.05). The mean time for first postoperative analgesic demand were 16.6 ± 8.0 h in Group B and 14.4 ± 7.3h in Group L (p>0.05). CONCLUSION: 30 ml 0.5% bupivacaine and levobupivacaine provide similar block characteristics for supraclavicular block. Bupivacaine leads to faster motor and sensory block onset compared to levobupivacaine however similar duration of postoperative analgesia.