A randomised controlled trial of perineural vs intravenous dexamethasone for foot surgery.

We used 20 ml ropivacaine 0.75% for ankle blocks before foot surgery in 90 participants who we allocated in equal numbers to: perineural dexamethasone 8 mg and intravenous saline 0.9%; perineural saline 0.9% and intravenous dexamethasone 8 mg; or perineural and intravenous saline 0.9%. Dexamethasone increased the median (IQR [range]) time for the return of some sensation or movement, from 14.6 (10.8-18.8 [5.5-38.0]) h with saline to 24.1 (19.3-29.3 [5.0-44.0]) h when given perineurally, p = 0.00098, and to 20.9 (18.3-27.8 [8.8-31.3]) h when given intravenously, p = 0.0067. Dexamethasone increased the median (IQR [range]) time for the return of normal neurology, from 17.6 (14.0-21.0 [9.5-40.5]) h with saline to 27.5 (22.0-36.3 [7.0-53.0]) h when given perineurally, p = 0.00016, and to 24.0 (20.5-32.3 [13.0-42.5]) h when given intravenously, p = 0.0022. Dexamethasone did not affect the rates of block success, postoperative pain scores, analgesic use, or nausea and vomiting. The route of dexamethasone administration did not alter its effects.

Spinal anaesthesia for ambulatory arthroscopic surgery of the knee: a comparison of low-dose prilocaine and fentanyl with bupivacaine and fentanyl.

BACKGROUND: Prospective data on the use of prilocaine for ambulatory spinal anaesthesia remain limited. We compared the behaviour and characteristics of subarachnoid block using prilocaine and fentanyl with that of bupivacaine and fentanyl. METHODS: In a prospective, double-blind, randomized controlled trial, 50 patients undergoing elective ambulatory arthroscopic knee surgery received subarachnoid anaesthesia, with either prilocaine 20 mg and fentanyl 20 µg (Group P) or plain bupivacaine 7.5 mg and fentanyl 20 µg (Group B). Primary endpoints included times for onset of maximum sensory block level and regression of sensory block to L4, and also motor block at 1 and 2 h, and levels of haemodynamic stability. Comparisons between the groups were made by χ² test for proportions and the Mann-Whitney test for ordinal data. Time-to-event data were analysed by the Mann-Whitney test for uncensored data or the logrank test for censored data. RESULTS: At 2 h, motor block in Group P had fully resolved in 86% of patients, compared with 27% in Group B (P<0.001). Median time to regression of sensory block to L4 was significantly shorter in Group P (97 min) than in Group B (280 min) (P<0.001). A clinically significant decrease in arterial pressure was more common in Group B (73%) than in Group P (32%) (P=0.004). Two patients in Group P required conversion to general anaesthesia, but for reasons unrelated to prilocaine itself. CONCLUSIONS: The combination of prilocaine and fentanyl is a better alternative to that of low-dose bupivacaine and fentanyl, for spinal anaesthesia in ambulatory arthroscopic knee surgery.

Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy. I. A randomized comparison with conventional dose hyperbaric lidocaine.

A randomized, single-blind trial of two spinal anesthetic solutions for outpatient laparoscopy was conducted to compare intraoperative conditions and postoperative recovery. Thirty women (ASA physical status I and II) were assigned to one of two groups. Group I patients received a small-dose hypobaric solution of 1% lidocaine 25 mg made up to 3 mL by the addition of fentanyl 25 micrograms. Group II patients received a conventional-dose hyperbaric solution of 5% lidocaine 75 mg (in 7.5% dextrose) made up to 3 mL by the addition of 1.5 mL 10% dextrose. All patients received 500 mL of crystalloid preloading. Spinal anesthesia was performed at L2-3 or L3-4 with a 27-gauge Quincke point needle. Surgery commenced when the level of sensory anesthesia reached T-6. Intraoperative hypotension requiring treatment with ephedrine occurred in 54% of Group II patients but not in any Group I patients. Median (range) time for full motor recovery was 50 (0-95) min in Group I patients compared to 90 (50-120) min in Group II patients (P = 0.0005). Sensory recovery also occurred faster in Group I patients (100 +/- 22 min) compared with Group II patients (140 +/- 27 min, P = 0.0001). Postoperative headache occurred in 38% of all patients and 70% of these were postural in nature. Oral analgesia was the only treatment required. Spinal anesthesia did not result in a significant incidence of postoperative backache. On follow-up, 96% said they found spinal needle insertion acceptable, 93% found surgery comfortable, and 90% said they would request spinal anesthesia for laparoscopy in future. Overall, this study found spinal anesthesia for outpatient laparoscopy to have high patient acceptance and a comparable complication rate to other studies. The small-dose hypobaric lidocaine-fentanyl technique has advantages over conventional-dose hyperbaric lidocaine of no hypotension and faster recovery.

Lateral popliteal sciatic nerve block compared with ankle block for analgesia following foot surgery.

The purpose of this study was to compare postoperative analgesia after foot surgery in patients anaesthetised either with popliteal sciatic nerve block or ankle block. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups. Following induction of general anaesthesia, Group PS (n = 21) received a lateral popliteal sciatic nerve block and Group AB (n = 19) received an ankle block. Both groups received 20 ml bupivacaine 0.5% plain. In group PS 43% required morphine analgesia in the Post Anaesthetic Recovery Room (PAR) compared with 16% in group AB. Postoperative analgesia was assessed using VAS and a pain scale in the PAR and a questionnaire by telephone follow-up on the day after surgery. The ankle block appeared to be more reliable, providing more consistent analgesia in the PAR. Postoperative analgesia in Group PS lasted a median of 18.0 hr and in Group AB lasted 11.5 hr (P < 0.05). Both techniques provided effective analgesia after discharge home and high levels of patient satisfaction.

Lateral popliteal sciatic nerve block compared with subcutaneous infiltration for analgesia following foot surgery.

A new lateral approach to blocking the sciatic nerve in the popliteal fossa is described. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups following induction of general anaesthesia: group PS (n = 21) received a lateral popliteal sciatic nerve block and group SC (n = 19) received subcutaneous infiltration of the wound. Both groups received 20 ml bupivacaine 0.5% plain. The lateral approach to the popliteal sciatic nerve was found to be an effective, quick, and easy to perform, block. Postoperative analgesia in groups PS lasted a median of 18.0 hr and in group SC lasted 6.3 hr (P < 0.05). The lateral popliteal sciatic nerve block provided effective analgesia following foot surgery and had a high level of patient satisfaction.