Spinal anesthesia

Which of the following agents for spinal anesthesia has the best pharmacokinetic profile for outpatient surgery?

A. Advance the needle
B. Retract the needle
C. Turn up the current on the peripheral nerve stimulator
D. Perform the nerve block in the current needle location

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Correct Answer: B

Explanation:

It is difficult to utilize spinal anesthesia in the ambulatory setting due to inconsistency in the onset and duration of spinal anesthesia, leading to prolonged recovery room stays. Occasionally, there may be patients that would benefit from spinal anesthesia in the outpatient setting, such as those individuals with significant reactive airway disease. While duration is influenced by dose and block height, of the drugs listed, chloroprocaine has the quickest onset with the shortest time to recovery of motor and sensory function. A new formulation without preservatives was introduced back into clinical care in 2004 due to initial concerns of neurotoxicity from bisulfite and EDTA preservatives. A 40mg dose of intrathecal chloroprocaine has a recovery time of approximately 2 to 3 hours. The other three local anesthetics (lidocaine, bupivacaine, tetracaine) have much more prolonged time to recovery of motor and sensory function, and therefore, will result in less efficient outpatient surgical times. Lidocaine has been implicated in higher rates of transient neurologic symptoms (TNS), while bupivacaine and tetracaine would result in excessive duration of action for the outpatient setting, resulting in extensive stays in the recovery unit, not only for resolution of motor/sensory changes, but also due to delayed need for management of postoperative pain with resolution of the spinal unless a regional anesthetic had been done for postoperative analgesia. The use of chloroprocaine for spinal anesthesia, however, is not FDA-approved.

References:

Teunkens A, Vermeulen K, Gerven EV, Fieuws S, Velde MV, Rex S. “Comparison of 2-chloroprocaine, bupivacaine, and lidocaine for spinal anesthesia in patients undergoing knee arthroscopy in an outpatient setting: A double-blind, randomized controlled trial.” Reg Anesth Pain Med 2016;41:576-83.

Barash PG, Cullen BF, Stoelting RK. “Chapter 26: Epidural and Spinal Anesthesi.” Clinical Anesthesia: 4th Ed; 2001, Lippincott Williams & Wilkins, pages 689-713.

Goldblum E, Atchabahian A. “The use of 2-chloroprocaine for spinal anaesthesia.” Acta Anaesthesiol Scand 2013;57:545-552.

Zaric D, Pace NL. “Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anesthetics.” Cochrane Database Syst Rev 2009;15(2):CD003006

Nair GS, Abrishami A, Lermitte J, Chung F. “Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy.” Brit J Anaesthesia 2009;102(3):307-15.

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