INTRODUCTION The aim of our study was to compare the effects of isobaric and hyperbaric bupivacaine combined with morphine or fentanyl in patients undergoing caesarean section. We assessed quality and spread of analgesia and anaesthesia, postoperative analgesic requirement and side effects. MATERIAL AND METHODS Hundred patients with American Society of Anesthesiologists physical status (ASA) I-II, age 18 to 40 years, were randomized to 4 groups. The intrathecal solutions were isobaric bupivacaine + morphine (group A), isobaric bupivacaine + fentanyl (group B), heavy bupivacaine ++ morphine (group C) and heavy bupivacaine + fentanyl (group D). Mean arterial pressure, heart rate, oxygen saturation, ephedrine consumption, analgesic requirement time and additional analgesic needs were recorded. RESULTS The 1(st) min value of mean arterial pressure was the lowest one in all groups. Heart rate decreased significantly in group A at the 10(th) min but not in the other groups. The decrease of visual analogue scale (VAS) pain scores began in the groups after the 4(th) postoperative h (p < 0.05) and the VAS value of group B at the 8(th) h was significantly higher than the other groups. The first analgesic requirement time in the postoperative period was longer in patients who had intrathecal morphine than those who had fentanyl. The duration of analgesia with isobaric bupivacaine and morphine was the longest one. CONCLUSIONS We concluded that intrathecal morphine provides a long duration of postoperative analgesia but the duration gets longer when it is combined with plain bupivacaine instead of heavy bupivacaine.

Background: There is an interest in finding a safe, short-acting spinal anaesthetic, suitable for ambulatory surgery. In this prospective study, we evaluated the effective dose of plain 2-chloroprocaine (2-CP) for lower limb surgery, including knee arthroscopy and saphenectomy. Methods: Sixty-four ASA physical status I-III patients undergoing elective lower limb surgery were randomly allocated to one of the four local anaesthetic groups for spinal anaesthesia in a double-blind manner. The patients (n=16 patients in each group) received 35, 40, 45 or 50 mg of 10 mg/ml isobaric 2-CP. Results: In all patients, anaesthesia was sufficient for the planned surgery. The median peak block height (T9) was similar in all four groups (P=0.66). Time to complete sensory block regression was faster in the 35 mg group (111 min, mean) and in the 40 mg group (108 min) than in the 50 mg group (134 min, P=0.005). No differences in time to complete motor block regression were observed (P=0.3). Home discharge time was faster in the 35 mg group (123 min) and in the 40 mg group (122 min) than in the 50 mg group (165 min, P=0.001). No complications related to spinal anaesthesia were observed and no transient neurologic symptoms (TNS) were reported at the 3-day follow-up. Conclusion: Spinal 2-CP, 10 mg/ml 35, 40, 45 and 50 mg provide reliable sensory and motor block for ambulatory surgery, while reducing the dose of 2-CP to 35 and 40 mg resulted in a spinal block of faster ambulation.

BACKGROUND Continuous spinal anaesthesia with spinal catheters allows incremental dosing of local anaesthetic and, consequently, less haemodynamic changes. However, little is known about the required doses. Therefore, we designed a study to assess the minimum effective local anaesthetic dose (MLAD) of levobupivacaine and ropivacaine in this context. METHODS Forty-one patients undergoing hip replacement surgery were randomly allocated to one of the two local anaesthetic groups in a double-blind manner. The initial dose of local anaesthetic was determined by the response of the previous patient: the effective dose resulted in a 1 mg decrease in the dose of levobupivacaine or ropivacaine, and an ineffective dose resulted in a 1 mg increase. The MLAD was calculated by the Dixon up-and-down method. RESULTS The MLAD of levobupivacaine was 11.7 mg (95% CI, 11.1-12.4) and that of ropivacaine 12.8 mg (95% CI, 12.2-13.4). CONCLUSIONS These doses are significantly smaller than doses reported before for single-shot spinal anaesthesia. Continuous spinal anaesthesia allows the use of relatively small doses of local anaesthetic.

Total hip arthroplasty (THA) is frequently performed under spinal anesthesia using either isobaric or hypobaric anesthetic solution. However, these two solutions have never been compared under similar surgical conditions. In the present study, we compared the anesthetic and hemodynamic effects of isobaric and hypobaric bupivacaine in 40 ASA physical status I-II patients undergoing THA in the lateral decubitus position under spinal anesthesia. With operative side up, patients randomly received, in a double-blinded manner, a spinal injection of 3.5 mL (17.5 mg) of plain bupivacaine mixed with either 1.5 mL of normal saline (isobaric group) or 1.5 mL of distilled water (hypobaric group). Sensory level and degree of motor block were evaluated on the nondependent and dependent sides until regression to L2 and total motor recovery. Hemodynamic changes during the first 45 min after spinal injection, and the time between spinal administration and first analgesic for a pain score >3 (on a 0-10 scale) were noted. Demographic characteristics of both groups were comparable. Upper sensory level and maximal degree of motor block were comparable between the operative and nonoperative sides in each group and between corresponding sides in both groups. Compared with the isobaric group, in the hypobaric group there was a prolonged time to sensory regression to L2 on the operative side (287 +/- 51 versus 242 +/- 36 min, P < 0.004) and a prolonged time to first analgesic (290 +/- 46 versus 237 +/- 39 min, P < 0.001). No difference in quality of motor block was noted at the end of surgery. Hemodynamic changes were comparable. We conclude that for THA in the lateral position, spinal hypobaric bupivacaine seems to be superior to isobaric in that it prolongs the sensory block on the operative side and delays the use of analgesics after surgery without further compromising hemodynamic stability. IMPLICATIONS: For total hip arthroplasty in the lateral position, spinal hypobaric bupivacaine compared with isobaric prolonged sensory block at the operative side and delayed the time to first analgesic.

BACKGROUND AND OBJECTIVES The clinical impact of patient positioning on motor block during unilateral spinal anesthesia was the focus of our study. It was assumed that a 45 degrees rotation toward the prone position would minimize blocking the ventral motor roots compared with using the conventional lateral decubitus position. METHODS Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine via a 27-gauge Whitacre needle was administered to 70 patients undergoing knee arthroscopy. The patients were kept either in a lateral decubitus position (group I) or rotated approximately 45 degrees toward the prone position (group II). No prophylactic vasopressors or infusions were used. The intensity of motor block (modified Bromage scale) was assessed for both the operative and the contralateral side. RESULTS The patients in group I had a slightly more pronounced motor block, but statistical significance could be shown only 20 minutes following the block. There was no statistical difference between the groups in the need of additional analgesics during the operation. None of the patients needed general anesthesia. The hemodynamics were stable and none of the patients developed postspinal headache or backache. CONCLUSIONS The position of the patient affects the spread of the spinal anesthesia when clearly hypobaric agents are used. However, this small modification in positioning of the patient did not lead to a clinically meaningful difference in the spread of the motor block.

BACKGROUND AND OBJECTIVES Unilateral spinal anesthesia may be advantageous, especially in the outpatient setting. A low dose of anesthetic solution, pencil-point needle, low speed of intrathecal injection, and a lateral position have been reported to facilitate the production of unilateral distribution of spinal anesthesia. We compared the effects of plain and hyperbaric bupivacaine in attempting to obtain a unilateral spinal anesthesia for patients undergoing outpatient knee arthroscopy. METHODS Sixty patients were randomly allocated to 2 groups to receive either 1.2 mL (6 mg) of plain 0.5% bupivacaine (group 1; n = 30) or 1.2 mL (6 mg) of hyperbaric 0.5% bupivacaine in 8% glucose (group 2; n = 30). Drugs were administered at the L2-3 interspace with the patient in the lateral position. Patients remained in this position for 20 minutes before being turned supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale and compared between the operated and nonoperated sides. RESULTS There was a significant difference between the operated and nonoperated side in both groups at all testing times, but a more unilateral spinal block was achieved with hyperbaric bupivacaine. Unilateral motor and sensory block was observed in 25 patients in group 2 (83%) and in 11 patients in group 1 (37%)(P <.01). The hemodynamic changes were minimal, since hypotension occurred only in 5.0% and bradycardia in 1.7% of all patients. CONCLUSION In conclusion, the spinal anesthesia in both groups are suitable alternatives for adult outpatient knee arthroscopies, but hyperbaric bupivacaine provides us with a more unilateral spinal block.

The increasing use of ambulatory surgery requires methods of anaesthesia that allow patients to be discharged soon after the operation is completed. Spinal anaesthesia is usually simple and quick, and the incidence of post-spinal headache has been reduced by using non-cutting small-gauge needles. Limiting the spread of spinal anaesthesia, as long as it still provides analgesia for surgery, should reduce the haemodynamic effects and speed recovery. Restricted spinal anaesthesia, intended to be unilateral using 0.18% hypobaric bupivacaine via a 25G or 27G Whitacre unidirectional needle, was compared with epidural anaesthesia (using a mixture of lignocaine and prilocaine) in 64 matched-pair patients undergoing ambulatory arthroscopy. Motor blockade, assessed for the specific myotomes L2 to S1, was significantly more unilateral in the spinal group. Two patients in the spinal group and nine patients in the epidural group were treated for hypotension (P < 0.05). One patient in the spinal group developed a post-spinal headache. One patient in the epidural group rated the anaesthesia poor.

BACKGROUND AND OBJECTIVES Ambulatory surgery requires anesthesia methods that allow rapid recovery and safe discharge of the patient. Spinal anesthesia is easy and quick to perform, and the use of noncutting small gauge needles reduces the occurrence of postdural puncture headache. For minimal hemodynamic consequences and faster recovery and discharge it would be optimal to limit the spread of spinal anesthesia only to the area which is necessary for surgery. In this study, the possibility in achieving unilateral spinal anesthesia with 0.18% hypobaric bupivacaine was studied. METHODS Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine (6.12 mg), without any intravenous infusion or prophylactic vasopressors, was administered with 27-gauge Whitacre unidirectional needle to 70 ASA I and II patients undergoing knee arthroscopies. The patients were allocated randomly to be kept either 20 (group I) or 30 (group II) minutes in the lateral position operation side uppermost. Sensory and motor block (pinprick/modified Bromage scale) were compared between the operation and the contralateral side. RESULTS The motor and sensory block between operation and contralateral sides were significantly different at all testing times in both groups (P <.001, Mann-Whitney U test). The motor block was completely unilateral in 14 patients (39%) in group I and in 22 patients (65%) in group II. The hemodynamics were stable in all 70 patients. CONCLUSIONS Approximately three and a half milliliters hypobaric 0.18% bupivacaine (6.12 mg) provides a predominantly unilateral spinal block. Thirty minutes spent in the lateral position does not provide benefits over 20 minutes. The main advantages of our method are the hemodynamic stability and the patient satisfaction.

BACKGROUND AND OBJECTIVES The clinical impact of patient positioning on motor block during unilateral spinal anesthesia was the focus of our study. It was assumed that a 45 degrees rotation toward the prone position would minimize blocking the ventral motor roots compared with using the conventional lateral decubitus position. METHODS Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine via a 27-gauge Whitacre needle was administered to 70 patients undergoing knee arthroscopy. The patients were kept either in a lateral decubitus position (group I) or rotated approximately 45 degrees toward the prone position (group II). No prophylactic vasopressors or infusions were used. The intensity of motor block (modified Bromage scale) was assessed for both the operative and the contralateral side. RESULTS The patients in group I had a slightly more pronounced motor block, but statistical significance could be shown only 20 minutes following the block. There was no statistical difference between the groups in the need of additional analgesics during the operation. None of the patients needed general anesthesia. The hemodynamics were stable and none of the patients developed postspinal headache or backache. CONCLUSIONS The position of the patient affects the spread of the spinal anesthesia when clearly hypobaric agents are used. However, this small modification in positioning of the patient did not lead to a clinically meaningful difference in the spread of the motor block.

BACKGROUND AND OBJECTIVES Unilateral spinal anesthesia may be advantageous, especially in the outpatient setting. A low dose of anesthetic solution, pencil-point needle, low speed of intrathecal injection, and a lateral position have been reported to facilitate the production of unilateral distribution of spinal anesthesia. We compared the effects of plain and hyperbaric bupivacaine in attempting to obtain a unilateral spinal anesthesia for patients undergoing outpatient knee arthroscopy. METHODS Sixty patients were randomly allocated to 2 groups to receive either 1.2 mL (6 mg) of plain 0.5% bupivacaine (group 1; n = 30) or 1.2 mL (6 mg) of hyperbaric 0.5% bupivacaine in 8% glucose (group 2; n = 30). Drugs were administered at the L2-3 interspace with the patient in the lateral position. Patients remained in this position for 20 minutes before being turned supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale and compared between the operated and nonoperated sides. RESULTS There was a significant difference between the operated and nonoperated side in both groups at all testing times, but a more unilateral spinal block was achieved with hyperbaric bupivacaine. Unilateral motor and sensory block was observed in 25 patients in group 2 (83%) and in 11 patients in group 1 (37%)(P <.01). The hemodynamic changes were minimal, since hypotension occurred only in 5.0% and bradycardia in 1.7% of all patients. CONCLUSION In conclusion, the spinal anesthesia in both groups are suitable alternatives for adult outpatient knee arthroscopies, but hyperbaric bupivacaine provides us with a more unilateral spinal block.

We evaluated the effect of 25 microg of fentanyl added to bupivacaine on sensory and motor block. By using a double-blinded study design, 80 men undergoing urologic surgery were randomized into the following four groups: Group I, bupivacaine 10 mg; Group II, bupivacaine 10 mg + fentanyl 25 microg; Group III, bupivacaine 7.5 mg + fentanyl 25 microg; Group IV, bupivacaine 5 mg + fentanyl 25 microg. The final volume of intrathecal injectate was adjusted to 2. 5 mL with sterile distilled water. Spinal anesthesia was administered with the 27-gauge Whitacre needle at the L2-3 interspace with the patient in the sitting position. Neural block was assessed by using pinprick and a modified Bromage scale. The degree of motor block was more profound in Group II compared with Group I at the end of operation. In Group IV, there was no motor block at the end of operation in any of the patients. The median level of the upper limit of the sensory block was higher than T(7) in all groups before the start of surgery. The addition of 25 microg of fentanyl to 5 mg of bupivacaine resulted in short-acting motor block. When 25 microg of fentanyl was added to 10 mg of bupivacaine, it increased the intensity and duration of motor block. Only 5 (6. 3%) of the patients needed supplemental analgesia during the operation. ¿abs¿

BACKGROUND Recently, local infiltration analgesia (LIA) has been promoted for pain control after total hip arthroplasty (THA). We hypothesized that LIA would offer equal analgesic efficacy but less adverse effects, e.g., nausea and vomiting, when compared with an established regimen [intrathecal morphine (it-M)] after THA. METHODS This randomized controlled trial comprised 60 patients undergoing THA under spinal anaesthesia. For LIA, the surgeon administered levobupivacaine, ketorolac and epinephrine at the surgical site intraoperatively. LIA patients received a LIA top-up through a wound catheter on the morning of the 1st post-operative day (POD). In group it-M, 0.1 mg morphine was given together with the spinal anaesthetic. Study parameters included pain scores, vital parameters and side effects, e.g., post-operative nausea and vomiting (PONV). Besides, levobupivacaine plasma concentrations were determined in 10 LIA patients. RESULTS The median (25th/75th percentiles) rescue oxycodone demand differed significantly with LIA 15 (10/25) mg vs. 8.5 (1.5/15) mg with it-M (P < 0.006) during the day of surgery, but not anymore on 1st or 2nd POD. The LIA top-up had no effect. However, both analgesic regimens resulted in comparable pain scores and patient satisfaction. PONV incidence and medication did not vary significantly. LIA offered certain advantages regarding early post-operative mobilization. Maximum levobupivacaine plasma concentrations (229-580 ng/ml) remained under the toxic level. CONCLUSIONS While LIA might enable earlier mobilization after THA, it was not associated with less nausea as compared with it-M. Less rescue oxycodone was given early after it-M, but urinary retention was more common in that group.

BACKGROUND The benefits of subacromial local anesthetic infusion are controversial. The aim of this study was to evaluate the efficacy of subacromial bupivacaine infusion after arthroscopic acromionplasty and rotator cuff procedures. METHODS Ninety patients with subacromial impingement disease scheduled for elective shoulder arthroscopy were enrolled in this randomized, prospective and placebo-controlled study. The patients received subacromially either 5.0 mg/ml bupivacaine or 9.0 mg/ml saline at the rate of 2 ml/h post-operatively for 48 h. The primary outcome measure was the use of rescue oxycodone. The consumption of opioids, ibuprofen, paracetamol and codeine, and the intensity of pain were recorded. RESULTS Patients receiving bupivacaine infusion used significantly less oxycodone compared with patients receiving saline [15 vs. 20 mg (median) oxycodone intravenously on the day of surgery, 0 vs. 10 mg (median) perorally on the first post-operative day]. There was no significant difference in the use of ibuprofen, paracetamol and codeine, except that paracetamol was used more in patients receiving saline during the day of surgery (P = 0.009). The pain scores of patients receiving bupivacaine were lower at 18 h (P = 0.008). Average pain scores for the worst pain experienced did not differ between the groups. There were three (4%) premature discontinuations because of technical problems. CONCLUSIONS Considering the low need of opioids, expenses and technical problems in these patients, subacromial 5.0 mg/ml bupivacaine infusion 2 ml/h confers only moderate and probably clinically insignificant efficacy compared with placebo. This efficacy might be overweighed by the disadvantages.

BACKGROUND The applicability of the Visual Analogue Scale (VAS) has been questioned in the assessment of pain in the elderly. We compared VAS with three other pain scales, Verbal Rating Scale (VRS), Red Wedge Scale (RWS) and Box Scale (BS), in hip fracture patients. METHODS VAS, VRS, RWS and BS were compared in 140 analysable patients undergoing surgery, 70 with hip fracture and 70 with other lower limb trauma. Pain scores were recorded once a day, repeated after 10 min, for 4 subsequent days starting pre-operatively. The primary endpoint was the rate of successful pain measurements in hip fracture patients and 90% was chosen as a sufficient level for an applicable pain scale. RESULTS Age was different between the groups (hip fracture 78 ± 11, other trauma 49 ± 11 years, P<0.0001). In hip fracture patients, 67-83% of pain measurements were successful with VAS, 82-100% with VRS, 83-96% with RWS and 79-91% with BS. The success rate with VAS was significantly <90% on 2 days (P<0.0001) and with BS on 1 day (P=0.04). All the other success rates with the four scales in both groups were above or not different from 90%. CONCLUSION VRS and RWS were the most applicable scales, unlike VAS, which appeared to be an unreliable pain scale in perioperative hip fracture patients. In patients with other lower limb trauma, all four scales provided excellent applicability. Our results are in accordance with the accumulating evidence suggesting that VAS is not an ideal tool for pain measurement in the elderly.

Background: In clinical practice, we noticed a greater than expected spread of sensory spinal block in patients with rheumatoid arthritis. We decided to test this impression and compared the spread of standard spinal anaesthesia in rheumatoid and non-rheumatoid control patients. Methods: Spinal anaesthesia with 3.4 ml (17 mg) of plain bupivacaine was administered to 50 patients with seropositive rheumatioid arthritis and to 50 non-rheumatoid control patients. The protocol was standardised for all patients. All the patients were undergoing lower limb surgery and the rheumatoid patients were operated on due to their rheumatoid disease. The spread of sensory block was recorded 30 min from the dural puncture using a pin prick test and a cold ice-filled container. The impact of body mass index (BMI), height and age on the spread were analysed. Results: The spread of sensory block was greater in patients with rheumatoid arthritis (15.6+/-3.1 dermatomes) than in non-rheumatoid patients (14.1+/-3.3 dermatomes)(P<0.05). Increasing BMI was related to cephalad spread of block in the rheumatoid group (P<0.05), but not in the control group. Conclusion: The mean spread of sensory block 30 min after the injection of plain bupivacaine was 1.5 segments cephalad in patients with rheumatoid arthritis than in those without this disease. BMI might be a patient-related factor contributing to the extent of the block in rheumatoid patients. These findings should be considered when performing a spinal block in rheumatoid patients.

AIM: To identify plain radiographic findings that predict segmental lumbar spine instability as shown by functional flexion-extension radiography. MATERIALS AND METHODS: Plain radiographs and flexion-extension radiographs of 215 patients with clinically suspected lumbar spine instability were analysed. Instability was classified into anterior or posterior sliding instability. The registered plain radiographic findings were traction spur, spondylarthrosis, arthrosis of facet joints, disc degeneration, retrolisthesis, degenerative spondylolisthesis, spondylolytic spondylolisthesis and vacuum phenomena. Factors reaching statistical significance in univariate analyses (P < 0.05) were included in stepwise multiple logistic regression analysis. RESULTS: Degenerative spondylolisthesis (P = 0.004 at L3-4 level and P = 0.017 at L4-5 level in univariate analysis and odds ratio 16.92 at L4-5 level in multiple logistic regression analyses) and spondylolytic spondylolisthesis (P = 0.003 at L5-S1 level in univariate analyses) were the strongest independent determinants of anterior sliding instability. Retrolisthesis (odds ratio 10.97), traction spur (odds ratio 4.45) and spondylarthrosis (odds ratio 3.20) at L3-4 level were statistically significant determinants of posterior sliding instability in multivariate analysis. CONCLUSION: Sliding instability is strongly associated with various plain radiographic findings. In mechanical back pain, functional flexion-extension radiographs should be limited to situations when symptoms are not explained by findings of plain radiographs and/or when they are likely to alter therapy.

Objective: To assess the haemodynamic changes in patients receiving unilateral and bilateral spinal anaesthesia with their pre-anaesthesia recordings. Study Design: Quasi-experimental study. Place and Duration of Study: Main Operation Theater, Liaquat National Hospital, Karachi, from May 2006 to February 2007. Methodology: Sixty patients meeting the inclusion criteria were randomly allocated in two groups of 30 patients each. One and a half ml of 0.75% hyperbaric bupivacaine was injected with free flow of cerebrospinal fluid using a 23 gauge quincke needle. Lumbar puncture was performed in the sitting position at 3 - 4 or 4 - 5 lumbar interspace. Patients were then assigned to the supine or lateral decubitus position for 10 minutes. Heart rate, systolic, mean and diastolic blood pressures of patients were recorded with their pre-anaesthesia readings in the 1st, 5th, 15th, 30th and then at every 15th minute till the end of procedure. Recovery room readings were also taken. Results: The systolic, mean and diastolic blood pressure changes were significant in both groups. But from 1st minute to recovery room, statistically significant difference (p < 0.05) was found at each time interval, the unilateral groups (group A) being more stable with respect to pre-anaesthesia readings. The decrease in heart rate was comparable in both groups. Conclusion: Unilateral spinal anaesthesia was associated with a more stable cardiovascular profile, therefore, it is a valuable technique for high risk patients.

BACKGROUND: The rapid and short-acting local anaesthetic articaine is a feasible spinal anaesthetic for day-case open inguinal herniorrhaphy (OIH). We hypothesised that similarly to other spinal local anaesthetics, the addition of fentanyl may prolong articaine spinal analgesia without prolonging motor block. METHODS: We performed a randomised, controlled study in 100 adult patients undergoing OIH. Spinal anaesthesia was induced by injecting hyperbaric articaine 72 mg with (Group A + F) or without (Group A) fentanyl 10 μg with the patient in lateral decubitus position. The distribution of sensory block was tested using pinprick and controlled by tilting the operating table 10 up or down. Motor block testing was based on the patient's ability to flex knees and ankles. Rescue analgesic was intravenous (i.v.) fentanyl. Pain scores were registered, and i.v. paracetamol 1 g was given as the first post-operative analgesic. RESULTS: There were no differences (A + F vs. A) in the maximum median extension of the sensory block (T5 vs. T5), mean duration of sensory block ≥ T10 (76 min vs. 73 min), or total duration of sensory (146 min vs. 146 min) or motor block (99 min vs. 107 min). Fewer patients in Group A + F needed fentanyl (5 vs. 14, P < 0.05) perioperatively or paracetamol (3 vs. 18, P < 0.001) post-operatively. CONCLUSION: Fentanyl 10 μg added to spinal hyperbaric articaine improved analgesia and reduced analgesic consumption during and after OIH. Fentanyl did not prolong motor block or delay recovery.

BACKGROUND To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery. METHODS In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications. RESULTS Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups. CONCLUSION We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.

Needle-through-needle combined spinal-epidural (CSE) may cause significant delay in patient positioning resulting in settling down of spinal anaesthetic and unacceptably low block level. Bilateral hip flexion has been shown to extend the spinal block by flattening lumbar lordosis. However, patients with lower limb fractures cannot flex their injured limb. This study was conducted to find out if unilateral hip flexion could extend the level of spinal anaesthesia following a prolonged CSE technique. Fifty American Society of Anesthesiologists (ASA) I/II males with unilateral femur fracture were randomly allocated to Control or Flexion groups. Needle-through-needle CSE was performed in the sitting position at L2-3 interspace and 2.6 ml 0.5% hyperbaric bupivacaine injected intrathecally. Patients were made supine 4 min after the spinal injection or later if epidural placement took longer. The Control group patients (n=25) lay supine with legs straight, whereas the Flexion group patients (n=25) had their uninjured hip and knee flexed for 5 min. Levels of sensory and motor blocks and time to epidural drug requirement were recorded. There was no significant difference in sensory levels at different time-points; maximum sensory and motor blocks; times to achieve maximum blocks; and time to epidural drug requirement in two groups. However, four patients in the Control group in contrast to none in the Flexion group required epidural drug before start of surgery. Moreover, in the Control group four patients took longer than 30 min to achieve maximum sensory block. To conclude, unilateral hip flexion did not extend the spinal anaesthetic level; however, further studies are required to explore the potential benefits of this technique.

Objective: The aim of this study was to compare the haemodynamic and anaesthetic effects of 12 mg ropivacaine and 8 mg bupivacaine, both with 20 mug fentanyl, in spinal anaesthesia for major orthopaedic surgery in geriatric patients. Subjects and Methods: Sixty American Society of Anesthesiologists (ASA) II-III patients scheduled for hip arthroplasty were randomly assigned to receive an intrathecal injection of either 12 mg ropivacaine with 20 mug fentanyl (group R, aged 70 +/- 7 years, range 67-89) or 8 mg hyperbaric bupivacaine with 20 mug fentanyl (group B, aged 69 +/- 6 years, range 66-92). Motor and sensory block, haemodynamics and side effects were recorded. Results: Mean levels of sensory block were similar, but the onset time of sensory block in group B (2.52 +/- 0.69 min) was shorter than that in group R (3.17-0.72 min); the difference was statistically significant (p < 0.01), and the number of patients who had motor Bromage scale 3 in group B (24) was greater than in group R (16). The difference was also statistically significant (p < 0.05). Systolic and diastolic arterial pressures (SAP, DAP) and heart rate (HR) decreased after the block in both groups. SAP (after the 60th and 120th min of block), DAP (all measurement times), and HR (after the 20th, 25th and 30th min of block) were lower in group B than in group R. Conclusions: The data showed that 12 mg of ropivacaine and 8 mg of bupivacaine with 20 mug fentanyl in spinal anaesthesia can provide sufficient motor and sensory block for major orthopaedic surgery in geriatric patients. However, ropivacaine caused less motor block and haemodynamic side effects than bupivacaine during the procedure.

This study was designed to evaluate different doses of hypobaric 0.15% bupivacaine administered to achieve unilateral orthopaedic surgery under subarachnoid block. Using a randomised, double-blinded protocol, 150 ASA I to II patients scheduled for elective unilateral orthopaedic surgery were allocated to received a subarachnoid block with hypobaric bupivacaine 0.15% 4.5 mg (3 ml)(Group 1), 6.0 mg (4 ml)(Group 2) or 7.5 mg (5 ml)(Group 3). Measurements included cardiovascular and haemodynamic stability, incidence of unilateral anaesthesia, time to recover from motor block, postoperative urinary retention, transitory neurological symptoms and postdural puncture headache. There was a dose-dependent increase in the duration of the block, from 1:55 +/- 00:20 hours (4.5 mg) to 2:15 +/- 00:22 hours (6.0 mg) and 3:15 +/- 00:31 hours (7.5 mg). The sensory block in the operated limb was significantly higher than that in the non-operated limb at all times. The increasing dose resulted in an increase of the motor block score. Seventy percent of patients had unilateral block. It was concluded that the spinal anaesthesia in all groups was suitable for single limb orthopaedic surgery. The smallest dose (4.5 mg) of hypobaric 0.15% bupivacaine resulted in more unilateral blocks, with narrower distribution and shorter duration.

Backround: Low-dose hyperbaric bupivacaine has been used to produce unilateral spinal anaesthesia for outpatient surgery. Unilateral spinal anaesthesia is associated with reduction of hypotension, faster recovery and increased patient satisfaction. Small doses of clonidine have shown effectiveness in intensifying spinal anaesthesia. We investigated the effect of adding 15 mug of clonidine to 5 mg hyperbaric bupivacaine on unilaterality. Methods: Sixty patients undergoing outpatient knee arthroscopy were randomly allocated to receive either 1.2 ml (6 mg) of hyperbaric bupivacaine or a 1.2 ml solution containing 1.0 ml (5 mg) hyperbaric bupivacaine, 0.1 ml (75 mug) clonidine and 0.1 ml sterile water. The motor block was assessed by a modified Bromage scale and the sensory block by a pinprick. Results: There was a significant difference in the spread of anaesthesia between the operated and contralateral sides in both groups. Seventy-seven per cent of the blocks were unilateral in group B and 73% in group B-C. There was no significant difference between the groups, in unilaterality. The motor block was prolonged in group B-C but it did not affect home-readiness. Patients receiving clonidine needed more vasopressors. There was a significant difference in blood pressures between the groups, being lower in group B-C after 1 h 45 min. Conclusion: Using 5 mg hyperbaric bupivacaine with 15 mug of clonidine, the unilaterality can be achieved and spinal anaesthesia intensified without affecting home-readiness. More vasopressors are needed in the beginning, but after the surgery patients experienced less pain.

PURPOSE Intrathecal morphine is administered to provide profound and prolonged analgesia, and to treat acute postoperative pain. We compared the effectiveness of hyperbaric bupivacaine alone and in combination with morphine for unilateral spinal anesthesia in patients undergoing knee arthroscopy. METHODS Sixty patients were randomly allocated to two groups to receive either 1.2 ml (6 mg) of 0.5% hyperbaric bupivacaine (group B; n = 30) or 1.2 ml of 0.5% hyperbaric bupivacaine containing 0.16 mg of morphine (group BM; n = 30). Spinal block was assessed by pinprick and a modified Bromage scale and compared between the operated and nonoperated sides. Visual analog scale (VAS) values, duration of analgesia, and total analgesic requirement of patients were recorded. RESULTS Patients in group BM had significantly lower VAS values on movement at 30 min and at 2, 4, 6, and 12 h postoperatively (P < 0.05 and P < 0.001, P < 0.001, P < 0.001, and P < 0.05, respectively). The total analgesic requirement in the first 24 h after surgery was significantly higher in group B (P < 0.001). Patients in group BM had a significantly longer duration of analgesia in the first 24 h postoperatively (P < 0.001). Motor blockade of the operated limb in group BM was similar to that in group B (P > 0.05), and motor blockade of the nonoperated limb in group BM was also similar to that in group B (P > 0.05). CONCLUSION We conclude that unilateral spinal anesthesia with hyperbaric bupivacaine plus 0.16 mg morphine is preferable to hyperbaric bupivacaine alone with respect to analgesic requirement, duration of analgesia, and VAS values.

STUDY OBJECTIVE: To compare spinal anesthesia and combined sciatic-femoral nerve block for outpatient knee arthroscopy. DESIGN: Prospective, randomized, controlled study. SETTING: Postoperative recovery area at a university-affiliated medical center. PATIENTS: 50 ASA physical status I and II adult outpatients undergoing arthroscopic knee surgery. INTERVENTIONS: Study subjects were equally divided (n = 25 each) into spinal and sciatic-femoral groups. Spinal group patients received spinal anesthesia with 7.5 mg of 0.5% hyperbaric bupivacaine. Sciatic-femoral group patients received combined sciatic-femoral nerve blocks using a mixture of 20 mL of lidocaine 2% plus 20 mL of bupivacaine 0.5%. MEASUREMENTS: Times including that from arrival in the operating room to readiness for surgery, duration of surgery, recovery time, and patient satisfaction were recorded. Analgesia and occurrence of adverse events also were recorded. MAIN RESULTS: No significant differences between the two groups were found for any of the study measurements of recovery. After discharge, postoperative pain differed significantly between groups only at 6 hours (P < 0.002). Patient satisfaction was high with both techniques. CONCLUSIONS: Combined sciatic-femoral nerve block for outpatient arthroscopic knee surgery offers satisfactory anesthesia, with a clinical profile similar to that of low-dose spinal anesthesia. Sciatic-femoral nerve blocks are associated with significantly lower pain scores during the first 6 postoperative hours.

BACKGROUND Fast onset and short duration are prominent properties of the amide-type local anaesthetic articaine. Similar to bupivacaine, a hyperbaric solution of articaine may produce faster onset and shorter duration of spinal anaesthesia than a plain solution. METHODS Patients undergoing open inguinal hernia repair received in random order articaine 84 mg in either hyperbaric (HyperA, n=49) or plain solution (PlainA, n=48) intrathecally. A blinded observer tested the dermatomal spread (pinprick) and motor block (Bromage scale). RESULTS Median (range) onset time to the T(10) dermatome was 2 (2-8)(n=46) and 6 (2-30) min (n=39)(P<0.001), and the duration of the sensory block at (or above) the T(10) dermatome was 86 (39-148) and 69 (15-118) min (P=0.007), in Groups HyperA and PlainA, respectively. Peak sensory block was greater in Group HyperA T(4)(L(2)-C(2)) than in Group PlainA T(8)-T(7)(L(3)-T(3)) dermatome, median (range), P<0.001. Spread of the block to the cervical dermatomes associated with hypotension occurred in three patients of Group HyperA (one patient C(2) and two C(4)). The sensory block resolved to the S(2) dermatome significantly faster in Group HyperA, 2.5 (1.5-4.5) h, than in Group PlainA, 3.5 (2.0-4.5) h (P<0.001). Median duration of the motor block was significantly shorter in Group HyperA, 2.0 (1.3-3.5) vs 3.0 (1.5-4.0) h (P<0.001). CONCLUSIONS Hyperbaric articaine 84 mg had a faster onset and shorter duration of spinal anaesthesia than the plain solution.