Preservatives

A 56 year old male with a history of hematuria and non-invasive bladder cancer is scheduled for a 70 minute cystoscopy and laser ablation. The patient requests a spinal anesthetic. An uncomplicated spinal using 60 mg of preservative free hyperbaric 2-chloroprocaine was administered. To prolong the spinal 100 mcg of epinephrine was added to the spinal. However, epinephrine is not added to chloroprocaine spinal solutions due to the risk of:

A. Epidural hematoma
B. Spinal cord ischemia
C. Fever, malaise, and myalgias
D. High spinal

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Correct answer: C

Explanation:
In a study evaluating the spinal dosing using 2-chloroprocaine and epinephrine, investigators found a 100% incidence of flu-like symptoms, malaise and myalgias in patients who received the epinephrine additive. Symptoms resolved in 6 to 48 hours. Some patients also reported non-radiating back stiffness, backache, and lower extremity pain. Spinal dosing of lidocaine is not as commonly used due to transient neurologic symptoms while bupivacaine spinals last too long for ambulatory procedures. The etiology of the association of epinephrine and chloroprocaine is unclear as epinephrine is commonly used in bupivacaine spinals with no such symptoms. Possible explanations include a small amount of bisulfate preservative in the epinephrine.

References
Smith KN, Kopacz DJ, McDonald SB. Spinal 2-Chloroprocaine: A dose-ranging study and the effect of added epinephrine. Anesth Analg 2004;98:81-8.

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