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Spa vid dagkirurgi rdquonedan navelnrdquoen alternativ anestesiteknik
Jan JakobssonAnestesi amp Intensivvaringrd
Institutionen foumlr Fysiologi amp Farmakologi
Karolinska Institutet
Walking Spinal ndashselektiv unilateral spinal ndashMini dos spinal
Ambulatory anaesthesia
+ N itrous oxide
D esflurane
+ N itrous oxide
Sevoflurane
Inhaled anaesthesia
+ N itrous oxide
Propofol
In travenous anaesthesia
G eneral anaesthesia
M AC sedation
Local anaesthesia
SpinalW alking spinal
low dose B upi + fent
Am bulatory anaesthesia
plusmnFentanylAlfentanil
Remifentanil
Anestesi foumlr nedre extrimitetens ortopediska kirurgi
bull Houmlftproteskirurgi ndash Spa + LIAbull Knaumlproteskirurgi ndash Spa + LIAbull Akillessena - Spabull Korsband ndash Spabull Fotledskirurgi - Spabull Mellanfot - bull Framfot -
Lokalbedoumlvning
bull Marcain tungbull Marcain spinal
ndash Chirocaine 5 mgmlndash Narop 5 mgml
Spinalbedoumlvning
bull Marcain tung 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp till
exempel urologiska operationer och operationer i nedre extremiteterna som varar 2ndash3 timmar samt operationer i buken som varar 45ndash60 minuter
Indikation Dosml
Dos mg
Tillslagstidminuter (ca)
Durationtimmar (ca)
Urologisk kirurgi 15-3 ml 75-15 mg 5-8 min 2-3 timmar
Ingrepp i nedre extremiteter inklusive houmlftkirurgi
2-4 ml 10-20 mg 5-8 min 2-3 timmar
Bukkirurgi (inklusive kejsarsnitt)
2-4 ml 10-20 mg 5-8 min 45-60 min
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Ambulatory anaesthesia
+ N itrous oxide
D esflurane
+ N itrous oxide
Sevoflurane
Inhaled anaesthesia
+ N itrous oxide
Propofol
In travenous anaesthesia
G eneral anaesthesia
M AC sedation
Local anaesthesia
SpinalW alking spinal
low dose B upi + fent
Am bulatory anaesthesia
plusmnFentanylAlfentanil
Remifentanil
Anestesi foumlr nedre extrimitetens ortopediska kirurgi
bull Houmlftproteskirurgi ndash Spa + LIAbull Knaumlproteskirurgi ndash Spa + LIAbull Akillessena - Spabull Korsband ndash Spabull Fotledskirurgi - Spabull Mellanfot - bull Framfot -
Lokalbedoumlvning
bull Marcain tungbull Marcain spinal
ndash Chirocaine 5 mgmlndash Narop 5 mgml
Spinalbedoumlvning
bull Marcain tung 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp till
exempel urologiska operationer och operationer i nedre extremiteterna som varar 2ndash3 timmar samt operationer i buken som varar 45ndash60 minuter
Indikation Dosml
Dos mg
Tillslagstidminuter (ca)
Durationtimmar (ca)
Urologisk kirurgi 15-3 ml 75-15 mg 5-8 min 2-3 timmar
Ingrepp i nedre extremiteter inklusive houmlftkirurgi
2-4 ml 10-20 mg 5-8 min 2-3 timmar
Bukkirurgi (inklusive kejsarsnitt)
2-4 ml 10-20 mg 5-8 min 45-60 min
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Anestesi foumlr nedre extrimitetens ortopediska kirurgi
bull Houmlftproteskirurgi ndash Spa + LIAbull Knaumlproteskirurgi ndash Spa + LIAbull Akillessena - Spabull Korsband ndash Spabull Fotledskirurgi - Spabull Mellanfot - bull Framfot -
Lokalbedoumlvning
bull Marcain tungbull Marcain spinal
ndash Chirocaine 5 mgmlndash Narop 5 mgml
Spinalbedoumlvning
bull Marcain tung 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp till
exempel urologiska operationer och operationer i nedre extremiteterna som varar 2ndash3 timmar samt operationer i buken som varar 45ndash60 minuter
Indikation Dosml
Dos mg
Tillslagstidminuter (ca)
Durationtimmar (ca)
Urologisk kirurgi 15-3 ml 75-15 mg 5-8 min 2-3 timmar
Ingrepp i nedre extremiteter inklusive houmlftkirurgi
2-4 ml 10-20 mg 5-8 min 2-3 timmar
Bukkirurgi (inklusive kejsarsnitt)
2-4 ml 10-20 mg 5-8 min 45-60 min
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Lokalbedoumlvning
bull Marcain tungbull Marcain spinal
ndash Chirocaine 5 mgmlndash Narop 5 mgml
Spinalbedoumlvning
bull Marcain tung 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp till
exempel urologiska operationer och operationer i nedre extremiteterna som varar 2ndash3 timmar samt operationer i buken som varar 45ndash60 minuter
Indikation Dosml
Dos mg
Tillslagstidminuter (ca)
Durationtimmar (ca)
Urologisk kirurgi 15-3 ml 75-15 mg 5-8 min 2-3 timmar
Ingrepp i nedre extremiteter inklusive houmlftkirurgi
2-4 ml 10-20 mg 5-8 min 2-3 timmar
Bukkirurgi (inklusive kejsarsnitt)
2-4 ml 10-20 mg 5-8 min 45-60 min
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalbedoumlvning
bull Marcain tung 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp till
exempel urologiska operationer och operationer i nedre extremiteterna som varar 2ndash3 timmar samt operationer i buken som varar 45ndash60 minuter
Indikation Dosml
Dos mg
Tillslagstidminuter (ca)
Durationtimmar (ca)
Urologisk kirurgi 15-3 ml 75-15 mg 5-8 min 2-3 timmar
Ingrepp i nedre extremiteter inklusive houmlftkirurgi
2-4 ml 10-20 mg 5-8 min 2-3 timmar
Bukkirurgi (inklusive kejsarsnitt)
2-4 ml 10-20 mg 5-8 min 45-60 min
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalbedoumlvning bull Marcain spinal 5 mgmlbull Indikationerbull Spinalanestesi vid kirurgiska ingrepp i
nedre extremiteter inklusive houmlftkirurgi som varar 3ndash4 timmar och daumlr en uttalad motorblockad behoumlvs
Indikation Dosml
Dos mg
Tillslagstidminuter
(ca)
Durationtimmar (ca)
Ingrepp iNedreExtremiteterInklusivehoumlftkirurgi
2-4 ml 10-20 mg 5-8 min 15-4 timmar
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalbedoumlvning
bull Narop 5 mgmlbull Indikationerbull Kirurgisk anestesi
spinalanestesi
Indikation Styrka mgml
Volym ml
Dos mg
Tillslag minuter
Duration timmar
Spinaladministrering foumlr kirurgi
5 mgml 3-4 ml 15-20 mg 1-5 min 2-6 tim
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalbedoumlvningbull Chirocaine 5 mgmlbull Indikationerbull Kirurgisk anestesi bull intratekal
DOSERINGSTABELL
Koncentrationmgml1
Dos Motorblockad
Kirurgisk anestesi
Intratekal 50 3 ml (15 mg)
Maringttlig till fullstaumlndig
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Vilket medel aumlr baumlstbull Ropivacaine the S-isomer of the propyl homologue of
bupivacaine (Whiteside et al 2001) has approximately 50 of the potency of bupivacaine at equal doses when administered it (Gautier et al 1999 McDonald et al 1999)
bull Levobupivacaine is the S-enantiomer of bupivacaine with a lower degree of cardiotoxicity compared to racemic bupivacaine (Whiteside and Wildsmith 2001)
ndash Cardiotoxicity is not relevant with the bupivacaine doses (up to 20 mg) used in spinal anaesthesia
bull No difference was found between the spinal block after it bupivacaine or levobupivacaine (Alley et al 2002)
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Dos och tid till utskrivning
ndash In a dose-response study of hyperbaric bupivacaine (375 ndash 1125 mg) in volunteers each additional mg of bupivacaine increased the time to home readiness by 21 min (Liu et al 1996)
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Kontraindikation
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Allergi
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Systemtoxiska effekter
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Complications in regional anaesthesia
Moen V Dahlgren N Irestedt LAnesthesiology 2004 Oct101(4)950-9
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
CNSSpinal cord
Central Nervous System
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalkanalen
Intratekalt Epiduralt
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Kroppslaumlgebull Sittandebull Liggandebull Horisontalt
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
PunktionsnivaringL3-L4L2-L3
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Vad paringverkar hur spinalen sprider sig
bull Greene reported 25 factors that could affect the distribution of the local anaesthetic in the cerebrospinal fluid (Greene 1985) but not all of them have clinical relevance
bull These factors can be classified into 4 subgroups characteristics of the patient and of the CSF characteristics of the local anaesthetic agent and the injection technique used (Table 2)
bull Besides the drug dosage the position of the patient at the time of injection and thereafter together with the baricity of the anaesthetic are the most important factors affecting the level of spinal anaesthesia (Stienstra and Greene 1991 Connolly and Wildsmith 1998 Enk 1998)
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Lite kring faktorerna som paringverkar utbredning och aringterhaumlmtning
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Selektiv unilateral spinalbull The advantages of unilateral or selective versus
conventional SA are ndash better haemodynamic stability (Tanasichuk et al 1961 Pittoni
et al 1995 Vaghadia et al 1997 Fanelli et al 2000) ndash faster motor and sensory recovery (Vaghadia et al 1997
Vaghadia 1998 Fanelli et al 2000) ndash decreased risk of urinary retention (Ben-David et al 1996 Ben-
David et al 1997 Ben-David et al 2000 Kuusniemi et al 2000a Mulroy et al 2002)
ndash The patientsrsquo satisfaction with the unilateral techniques has been high too (Pittoni et al 1995 Kuusniemi et al 1997 Kuusniemi et al 2000a)
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
SSA
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
SSA
Administration
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
SSA
Kranialt SakraltHorisontalt
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
SSA
Kranialt Sakralt
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinalanestesi mix bull rdquosingel shotrdquo
ndash Adrenalinndash Opioid
raquo Sufentaraquo fentanylraquo Morfinraquo kombinationer
ndash Alfa-2agonisterraquo Clonidin
ndash kateter
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Olika blandningar inte helt laumltt
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Men vad aumlr baumlst
bull Recently several studies with low-dose bupivacaine for ambulatory knee arthroscopy have been conducted with varying failure rates and time to home-readiness
bull Maringnga olika tekniker inte helt laumltttolkade resultat
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
METHODS bull One hundred healthy premedicated patients
randomly received conventional bilateral (n = 50) or unilateral (n = 50) spinal anesthesia with 8 mg hyperbaric bupivacaine 05
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group
on Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51RESULTS bull Three patients in each group were excluded due to
failed block bull Readiness for surgery required 13 min (5 - 25 min) with
bilateral and 16 min (15 - 30) with unilateral spinal block (P = 00005)
bull Sensory and motor blocks on the operated limb were T9 (T12 - T2) with a Bromage score 0123 02045 in the unilateral group and T7 (T12 - T1) with Bromage score 0123 41636 with bilateral block(P = 0026 and P = 0016 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull Vasopressor was required only in five bilateral patients (P = 002)
bull 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
bull (P = 0002 and P = 090 respectively)
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral bupivacaine spinal anesthesia for outpatient knee arthroscopy Italian Study Group on
Unilateral Spinal AnesthesiaFanelli G Borghi B Casati A Bertini L Montebugnoli M Torri G
Can J Anaesth 2000 Aug47(8)746-51
bull 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
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6bull To evaluate the onset time success rate and recovery profile of
unilateral spinal anesthesia produced with 4 mg 6 mg and 8 mg of 05 hyperbaric bupivacaine
MEASUREMENTS AND MAIN RESULTS ndash The onset time of surgical block
bull 13 +- 5 minutes in Group 4 bull 10 +- 4 minutes in Group 6 (p = 0006) bull 9 +- 4 minutes in Group 8 (p = 0002)
ndash The maximum level of sensory block on the operative and nonoperative sides wasraquo T(10) (T(12)-T(6)) and (-L(2)) in Group 4 (p = 00005) raquo T(8) (T(12)-T(6)) and (-L(5)) in Group 6 (p = 00005) raquo T(7) (T(12)-T(5)) and (-T(10)) in Group 8 (p = 00005)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash A strictly unilateral sensory block was observed inbull 27 Group 4 patients (90) bull 28 Group 6 patients (93) bull 23 Group 8 patients (77) (p = 028)
ndash Complete unilateral motor block was observed inbull 29 Group 4 patients (97) bull 28 Group 6 patients (93) bull 28 Group 8 patients (93) (p = 080)
ndash No failed blocks were reported
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
ndash Complete regression of spinal anesthesia required
bull 71 +- 20 minutes in Group 4 (range 40 to 110 min) bull 82 +- 25 minutes in Group 6 (range 30 to 160 min) bull 97 +- 37 minutes in Group 8 (range 50 to 120 min)
raquo (p = 0003)
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Unilateral spinal block for outpatient knee
arthroscopy a dose-finding study Borghi B et al A J Clin Anesth 2003 Aug15(5)351-6
CONCLUSIONS Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy with a faster recovery profile than when a 6 mg or 8 mg dose was used
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
SSA
bull Bupivacainbull Chirocainbull Ropivacain
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
A comparison of intrathecal plain solutions containing ropivacaine 20 or 15 mg versus bupivacaine 10 mg
Kallio H Snaumlll EV Kero MP Rosenberg PH Anesth Analg 2004 Sep99(3)713-7
This prospective randomized double-blinded study included 90 ambulatory lower-extremity surgery patients who received 2 mL ofndash ropivacaine 1 20 mgndash ropivacaine 075 15 mgndash bupivacaine 05 10 mg
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Aringterhaumlmtning
Kallio H et al
AampA 2004
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Kraft
Kallio H et al
AampA 2004
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower
limb surgerybull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for
ambulatory surgery of lower-extremities Hypothetically hyperbaric solution could improve and shorten the block
bull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery
of lower extremities They received intrathecally either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS bull All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5
min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION bull In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of
analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery
bull Br J Anaesth 2004 Nov93(5)664-9 Kallio H Snaumlll EV Tuomas CA Rosenberg PHbull BACKGROUND bull Previously plain ropivacaine 15 mg given intrathecally has been shown to be feasible for ambulatory surgery of lower-extremities
Hypothetically hyperbaric solution could improve and shorten the blockbull METHODS bull This prospective randomized double-blind study included 56 patients undergoing surgery of lower extremities They received intrathecally
either 15 ml of ropivacaine 10 mg ml(-1) and 05 ml of glucose 300 mg ml(-1) (HYP) or 2 ml of ropivacaine 75 mg ml(-1) (PL)
bull RESULTS All patients in Group HYP achieved T(10) dermatome analgesia but only 64 (1828) of Group PL T(10) analgesia was reached in 5 min (median range 5-20 min) in the HYP group vs 10 min (5-45 min) in the PL group (P=0022) and full motor block in 10 min (5-45 min) vs 20 min (5-60 min) (P=0003) respectively Group HYP had a longer duration of analgesia at T(10) 83 min (5-145 min) vs 33 min (0-140 min) (P=0004) Duration of sensory block from injection of the anesthetic to complete recovery was shorter in Group HYP than in Group PL 210 min (120-270 min) vs 270 min (210-360 min) (Plt0001) as was duration of motor block 120 min (5-150 min) vs 210 min (120-330 min) (Plt0001) Patients of Group HYP attained discharge criteria earlier than those of Group PL (P=0009)
bull CONCLUSION In comparison with the plain solution 15 mg of intrathecal hyperbaric ropivacaine produced a faster onset greater success rate of analgesia at the level of T(10) dermatome and faster recovery of the block
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia
bull Br J Anaesth 2005 Jan94(1)107-11 Epub 2004 Oct 29 Fettes PD Hocking G Peterson MK Luck JF Wildsmith JA
bull BACKGROUND Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine and may be of particular use in the day-case setting However there are few data comparing the actions of plain and hyperbaric solutions of this drug
bull METHODS Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1) either in plain solution or with glucose 50 mg ml(-1) The extent and duration of sensory and motor block pulse rate blood pressure and time to mobilization were recorded
bull RESULTS Two patients (one per group) were withdrawn because of total block failure There were significant differences in median time to onset of sensory block at T10 (plain 10 min hyperbaric 5 min Plt001) median maximum extent (plain T8 hyperbaric T4 Plt005) and median duration of sensory block at T10 (plain 25 min hyperbaric 115 min Plt0001) However median times to complete regression of both sensory (270 vs 240 min Plt005) and motor (180 vs 120 min Plt0001) block were longer in the plain group Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17] Plt001) All the hyperbaric blocks were adequate for surgery but three patients receiving plain ropivacaine required general anaesthesia
bull CONCLUSION Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset block reliability duration of useful block for perineal surgery and speed of recovery Plain solutions are less reliable for surgery above a dermatomal level of L1
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
S tu dy flow
b u p iva ca in 4 m gL 3L4
G Ad e sflu ra ne
S tud y V
b u p iva ca in 4 m gL 2L3
b u p iva ca in 4 m gL 3L4
h e ad tilt
S tu dy IV
b u p iva ca in 4 m g
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gro d an se tron 4 m g iv
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
o n da n se tron 8 m g iv
S tu dy III
b u p iva ca in 3 m gfe n tan yl 10 m ic ro gr
S tu dy II
b u p iva ca in 4 m g b u p iva ca in 6 m g
S tud y I
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Erfarenheterna fraringn Finland
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Olika spinaler och tid till utskrivning
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Median upper level operative side
7 min 30 min EO 120 min
B3F IIIII
B4 II
B4 I
B6 I
Th7
Th8
Th9
Th10
Th11
Th12
L1
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Percent having S1 block
0
20
40
60
80
100
7 min EO 80 min 100 min 120 min 140 min 160 min
o
f th
e p
atie
nts
L23 L34T L34H
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Recovery of motor function
0
20
40
60
80
100
80 min 120 min 160 min 200 min
Cu
mu
lati
ve
B4 I
B6 I
B3F II
B4 II
B3F III
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinal anaesthetic technique
bull Low dosebull Low volumebull Low injection speedbull Lateral position for 10 minutesbull L 23bull 27 G Quincke needle
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures
sucess
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Success rate
0
10
20
30
40
50
60
70
80
90
100
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4
failures
opioid suppl
sucess
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Success rate
0
2
4
6
8
10
12
14
No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
failures opioid suppl poor
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Quality aspects
0
5
10
15
20
25
30
35
40
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH spinal pain dysuria pruritus
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Quality aspects
0
5
10
15
20
25
30
35
40No Pat
b4 b6 b3f b4 b3f b3f b3f b4 b4 b4 b4 des
PDPH back pain dysuria pruritus PONV
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
A comparison of selective spinal anesthesia with hyperbaric bupivacaine and general anesthesia with
desflurane for outpatient knee arthroscopybull Anesth Analg 2004 Dec99(6)1668-73 Korhonen AM Valanne JV Jokela RM Ravaska P Korttila KTbull Abstractbull In this randomized and controlled trial 64 adult ambulatory knee arthroscopy patients received either
selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities a shorter stay in the postanesthesia care unit and earlier discharge home compared with GA with desflurane Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group ndash No difference was seen in the fast-tracking possibilities or time in the
postanesthesia care unit between the groups ndash Home readiness was achieved after 114 (31-174) and 129 (28-245) min (NS)
in the SSA and GA groups respectively ndash In the hospital the pain scores were significantly (P lt 0001) lower in the SSA
group compared with the GA group and the need for postoperative opioids was significantly (P = 0008) larger after GA
ndash The incidence of postoperative nausea and vomiting was 0 versus 19 in the SSA and GA groups (P = 0024) respectively
bull We conclude that for outpatients undergoing knee arthroscopy SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Artroskopi av knaumlt
bull Locally applied anaesthesiabull Number of ports
ndash SURGERYbull Meniscus resectionbull Shavingbull rdquoother majorrdquo
bull Irrigating fluidbull Fluid pressurebull Tourniquet
ndash Time ndash Pressure
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Foumlrsoumlk till sammanfattning
bull Unilateral rdquoselektivrdquo walking spinal foumlr operation nedre extremitetenndash L3-4 rdquolaumlttrdquo
ndash saumlnkt huvudaumlnda vid knauml op
ndash 4 mg Marcain tung ndash Baumlttre kvalitet men mer klaringda med 10 microgr fentanyl
ndash Laringngsam injektionndash Beharingll sidolaumlge ca 10 minuter
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Men saring kom det studier fraringn Spainhellip
bull Group I received 5 mg (1 mL) levobupivacaine 05 (Chirocane 05 Abbott Laboratories Madrid Spain) with 10 g fentanyl (02 mL)
bull Group II received 4 mg (08 mL) levobupivacaine 05with 10 g fentanyl bull Group III received 3 mg (06 mL) levobupivacaine 05 with 10 g fentanyl bull All solutions were prepared to a total volume of 3 mL with sterile water bull The solutions had a specific gravity of 0999510 0998945 and 0998470
mgmL at 25degC respectively (Anton Paar Graz Austria)ndash Spinal anesthesia was performed by one of the authors who was not involved in further patient
evaluation
bull The spinal technique was performed in the sitting position with a midline approach at the L3-4 intervertebral space using a 27-gauge Whitacre spinal needle (Becton Dickinson Medical Systems Madrid Spain)
bull After sitting for 2 minutes patients were placed in the supine position with the back section of the surgical table elevated to 20deg to 30deg for 5 to 10 minutes
bull3 mg avbroumlts foumlr mycket failures
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
bull The patient was placed in the sitting position
bull Combined spinalndashepidural anesthesia (CSEA) was instituted in the sitting position with a midline approach at the L2ndashL3 level in all
bull subjects
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
bull Ropivacaine 05 5 mg (Naropin AstraZeneca USA) was mixed with 25 μg fentanyl and sterile water
bull The specific gravity of this mixture was 1002 as the specific gravity of cerebrospinal fluid is 1003ndash1008 at 378C this mixture would be hypobaric in this fluid
ndash Specific gravity was determined with a refractometer (American Optical Company Chicago IL USA) measured at 378C
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
bull Levobupivacaine 075 375 mg (Chirocaine Abbott Laboratories North Chicago IL USA) was mixed with 25 μg fentanyl and sterile water
bull the specific gravity of this mixture was 1001
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
bull Each of the solutions was diluted to a total volume of 3 ml with distilled water
bull The solution was injected over 150ndash180 s after free cerebrospinal fluid leakage was obtained through the needle
bull The tip of the needle was pointed in the cephalad direction during this process
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle
fracturesbull J Bone Joint Surg Am 2010 Feb92(2)368-74 Jordan C Davidovitch RI Walsh M Tejwani N Rosenberg A Egol KAbull bull BACKGROUND To our knowledge no study to date has compared the use of spinal and general anesthesia in patients
undergoing operative fixation of an unstable ankle fracture The purpose of this study was to assess the effects of anesthesia type on postoperative pain and function in a large cohort of patients
bull METHODS Between October 2000 and November 2006 501 patients who underwent surgical fixation of an unstable ankle fracture were followed prospectively Patients receiving spinal anesthesia were compared with a cohort who received general anesthesia All patients were evaluated at three six and twelve months postoperatively with use of standardized validated general and limb-specific outcome instruments Standard and multivariable analyses comparing outcomes at these intervals were performed
bull RESULTS Four hundred and sixty-six patients (93) who had been followed for a minimum of one year met the inclusion criteria
bull Compared with the general anesthesia group the spinal anesthesia group had a greater mean age (p = 0005) higher classification on the American Society of Anesthesiologists system (p = 003) and a greater number of patients with diabetes (p = 002)
bull There was no difference in sex distribution between the groups bull At three months patients who received spinal anesthesia had significantly better pain scores (p = 003) and total
scores on the American Orthopaedic Foot and Ankle Society outcome instrument (p = 002) At six months patients in the spinal anesthesia group continued to have better pain scores (p = 004) but there was no longer a difference in total scores (p = 006)
bull At twelve months no difference was detected between the groups in terms of functional or pain scores There was no difference in complication rates between the groups
bull CONCLUSIONS Patients who undergo fixation of an ankle fracture under spinal anesthesia seem to experience less pain and have better function in the early postoperative period We recommend that unless there is a specific contraindication patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
Svensk praxis ndash Knee arthroscopy routines and practice
bull Knee Surg Sports Traumatol Arthrosc 2010 Dec18(12)1656-60 Epub 2010 Sep 21bull Brattwall M Jacobson E Forssblad M Jakobsson Jbull Sourcebull Department of Anaesthesia Institute for Clinical Sciences at Sahlgrenska Academy Sahlgrenska University Hospital Moumllndal SE 431 80
Gothenburg Sweden methabrattwallvgregionsebull Knee arthroscopy is one of most commonly performed day-case orthopaedic procedures thus consuming huge medical resources The aim of the
present questionnaire survey was to study knee arthroscopy routines and practicebull METHODS bull An electronic web-based survey including questions around pre- per- and postoperative routines for elective knee arthroscopy was send to all
orthopaedic units associated to the Swedish Arthroscopic Society (n = 60)bull RESULTS bull Responses covering 37 centres out of 60 (response rate 62) were returned Preoperative radiograph routines varied considerable between
centres conventional radiograph varied between 5 and 100 and preoperative MRI between 5 and 80 of patients bull General anaesthesia was the preferred intra-operative technique used in all centres (median 79 of
patients) local anaesthesia with or without light sedation was used in all 28 out of the 37 centres responding (median 10 of cases) and spinal anaesthesia was used in 15 centres (median 5 of cases)
bull Intra-articular local anaesthesia was provided in all but one of centres Perioperative administration of oral NSAIDs was common (31 out 37) 6 centres (all teaching hospitals) did not routinely give pre- or postoperative NSAID
bull Analgesic prescription was provided on a regular base in 18 (49) of centres an NSAID being the most commonly prescribed All but one centre provided written information and instruction at discharge Referral to physiotherapy prescribed sick leave and scheduled follow-up in the outpatient clinic diverged considerably
bull CONCLUSION bull Routines and practice associated to elective knee arthroscopy differed however no clear differences in practice were seen between teaching
centres general or local hospitals apart from a lower usage of NSAID for perioperative analgesia There is an obvious room for further standardisation in the routine handling of patients undergoing elective arthroscopy of the knee
bull helliptack
bull helliptack
