Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery.

BACKGROUND: Arthroscopic shoulder surgery is often associated with severe postoperative pain. The results concerning subacromial bursa blockade (SUB) as a method of pain relief have been contradictory. We hypothesized that a SUB and interscalene brachial plexus block (ISB) would similarly reduce early postoperative pain and the need for oxycodone as compared to placebo (PLA). METHODS: Forty-five patients scheduled for arthroscopic shoulder surgery were enrolled in this randomised, prospective study. The ISB and SUB blockades were performed with 15 ml of ropivacaine (5 mg/ml). In the PLA group, 15 ml of 0.9% saline was injected into the subacromial bursa. All patients received general anaesthesia. RESULTS: The mean intravenously patient-controlled delivered oxycodone consumption during the first 6 h was significantly lower in the ISB group (6 mg) than in the SUB group (24.1 mg; P=0.001) or in the PLA group (27 mg; P<0.001). No significant differences were detected between the SUB and PLA groups (P=0.791). The postoperative pain scores during the first 4 h at rest and during the first 6 h on movement were significantly lower in the ISB group than in the SUB and PLA groups. CONCLUSION: After arthroscopic shoulder surgery SUB has a minor effect only on postoperative analgesia, whereas an ISB with low-dose ropivacaine effectively relieves early postoperative pain and reduces the need for opioids.

Two percent lidocaine spinal anaesthesia compared with sevoflurane anaesthesia in ambulatory knee surgery - cost-effectiveness, home readiness and recovery profiles.

A total of 60 patients scheduled for elective knee arthroscopy were randomized to receive spinal anaesthesia (SA) with 2% lidocaine (n=30) or general anaesthesia with sevoflurane (SE) (n=30). SA and SE were compared in terms of the total costs of anaesthesia. The time to reach home readiness and the total time spent in the recovery unit (RU) were assessed. The early postoperative period and recovery at 24 h and 1 week were evaluated in terms of the incidence of pain, sedation, nausea and general satisfaction with the method of anaesthesia and postoperative instructions. The total costs of anaesthetic materials in the operation theatre (OT) and anaesthetic materials and personnel costs until home readiness was achieved in the RU were 160.7 FIM (1 FIM=0.17 EUR) for SA and 171.0 FIM for SE (not significant). The corresponding sums were 197.2 FIM for SA and 224.4 FIM for SE (P=0.001) when the total stay in RU was considered. The time to reach home readiness was 140.8 min (S.D. 52) in the SA group and 96.4 min (S.D. 62) in the SE group (P=0.02). There were no differences in the total RU time (224.0 min (S.D. 67) for SA and 218.0 min (S.D. 59) for SE). The level of postoperative pain was generally low, as all the SA patients and 86.7% of the SE patients had VAS<4 2 h postoperatively. Six SA patients (20.0%) had postoperative headache and two of them also had headache in the supine position. There were no headaches in the SE group (P=0.024). None of the patients in the SA group and six SE patients (20.0%) had nausea (needed treatment) in the RU (P=0.024). Four patients (13.3%) in the SE group and 1 patient (3.3%) in the SA group had nausea during the first 24 h postoperatively. All the patients were alert 60 min postoperatively with no difference between the groups and they were very satisfied during the first 24 h. All patients would have liked to have a similar operation done on an ambulatory basis. 93.3% said they would choose the same kind of anaesthesia. 91.7% were satisfied with the first week.General anaesthesia with SE is more cost-effective than SA with 2% lidocaine in ambulatory knee surgery if a short RU time is needed. The patients do generally well, but the incidence of postspinal headache with SA, adequate postoperative pain treatment and the possibility to have nausea with SE must be kept in mind.

One-week recovery profiles after spinal, propofol, isoflurane and desflurane anaesthesia in ambulatory knee arthroscopy.

There are comprehensive findings on the immediate recovery of patients from different types of anaesthesia, but more information is needed on how patients manage at home after ambulatory surgery. One hundred and seventy-three elective knee arthroscopy patients were randomised into four different anaesthesia groups to receive either spinal anaesthesia (SA) with 5% lidocaine or general anaesthesia (GA) with propofol infusion, isoflurane inhalation or desflurane inhalation. The patients were interviewed over the phone on the next day and asked to complete a questionnaire after 1 week. One hundred and sixty-eight patients (97%) were reached by phone. The questionnaire was returned by 163 patients (94%). After 24 h, all the patients were satisfied with the type of anaesthesia they had received, but 2% of the SA patients would have chosen GA and 4.3% of the GA patients would have chosen SA for the next operation. Based on the questionnaires returned after 1 week, 8.3% of the SA patients would have wanted to have GA, and 4.7% of the GA patients would have wanted to have SA in the future. The incidence of nausea (4.2%) and vomiting (1.8%) was very low in the whole series, with no differences between the anaesthesia groups. Headache after 24 h was experienced by 15.7% of the SA and 10.3% of the GA patients. After 1 week, SA patients reported headache upon standing in 13.5% of the cases, backache in 36.5% and lower leg pain in 59.6%. The corresponding figures for GA patients were 4.5, 9.9 and 39.6% (P<0.05). In spite of the good immediate recovery profile in the all anaesthesia groups, the fact that SA patients reported a higher incidence of headache, backache and lower leg pain after 1 week may be signs of post spinal headache and transient neurologic symptoms (TNS). For overall patient comfort, GA might be a better anaesthetic choice in ambulatory surgery.

Two instances of central nervous system toxicity in the same patient following repeated ropivacaine-induced brachial plexus block.

We describe two instances of central nervous system (CNS) toxicity in the same patient following repeated brachial plexus blocks induced by high doses of ropivacaine (6 mg x kg(-1) and 4.5 mg x kg(-1), respectively). Although very high total and free plasma concentrations of ropivacaine were found up to 98 min after induction of the blocks, no signs of cardiovascular toxicity apart from hypertension and sinus tachycardia were observed. The measured plasma concentrations are the highest so far reported in the literature. We conclude that this case demonstrates the high cardiovascular safety level of ropivacaine. These high doses, however, resulted in severe toxic CNS symptoms. Therefore, it is stressed that the dose in relation to the weight of the patient must be calculated when administering a large volume of local anesthetic.