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From the Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA.
Address correspondence to: Dr. Beverly Waxler, Division of Postanesthesia Care, Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, 1901 West Harrison Street, Chicago, IL 60612, USA. Phone: 312-864-2140; Fax: 312-864-9544; E-mail: 74731.463{at}compuserve.com
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Abstract |
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Methods: Forty-nine patients (ASA I–III, age 20–69 yr) underwent spinal anesthesia for rectal surgery. The patients were randomized into two groups. One group (n = 28) received low-dose IT lidocaine (15 mg) and sufentanil (10 µg) and the other group (n = 21) received IT lidocaine (50 mg). The time to ambulation, the incidence of pruritus, and other variables were recorded. Statistical difference was assumed if P < 0.05.
Results: Our results show a significantly shorter ambulation time (120 ± 26 min) after IT low-dose lidocaine (15 mg) and 10 µg sufentanil vs 50 mg IT lidocaine (162 ± 32 min, P < 0.0001). Patients who received IT lidocaine and sufentanil recovered faster. Fifty percent of the patients who received IT sufentanil suffered from pruritus.
Conclusion: IT lidocaine (15 mg) and sufentanil resulted in a shorter time to ambulation compared to IT lidocaine (50 mg) alone and provided excellent anesthesia despite its disadvantage of pruritus.
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Introduction |
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Many anesthesiologists are using conventional doses of IT lidocaine ranging between 30 to 75 mg for rectal surgery. When these doses are used, the patients may experience intraoperative hypotension and high sensory and motor blocks resulting in a longer stay in the PACU than patients with a lower dose of lidocaine.4 Also, larger doses of IT lidocaine4–6 have been associated with transient neurological symptoms (TNS). Previous investigators4,7–9 have demonstrated the benefits of IT low-dose local anesthetics and opiates for ambulatory surgery including arthroscopy8 and laparoscopy.9 However, many patients suffer from pruritus induced by IT opiate.10–12 The frequency of pruritus associated with IT opioids ranges between 20 and 80%.7,10
We hypothesized that low-dose IT lidocaine (15 mg) and sufentanil (10 µg) would shorten the time to ambulation when compared to IT lidocaine, at the conventional dose of 50 mg, for spinal anesthesia in patients undergoing short rectal surgery.
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Methods |
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Forty-nine ASA physical status I to III patients, 20 to 69 yr old, were scheduled for rectal ambulatory surgery (including hemorrhoidectomy, fistulotomy, excision of pilonidal cyst, fulguration of condylomata) under spinal anesthesia. Patients were randomized into two groups (with Statmate software, Graph Pad, San Diego, CA, USA) to receive low-dose IT 1.5% lidocaine (15 mg) in 7.5% dextrose (in water) and 10 µg sufentanil (n = 28) or IT 5% lidocaine (50 mg) in 7.5% dextrose in water (n = 21). The motor and sensory blocks were assessed at three, six, nine, and 15 min after the IT injection.
Spinal anesthesia was administered in the sitting position using a 25-gauge pencil point needle at the L3–4 intervertebral space with a sterile technique. After free flow of clear cerebrospinal fluid, the anesthetic mixture was injected at the rate of 1 mL per five seconds. Immediately after, the patient was placed in the prone position. Three minutes later, each patient was assisted into the jackknife position. Patients were monitored for the onset and level of sympathetic, motor and sensory blockade. The operation proceeded when adequate sensory and motor blocks were obtained.
In the OR, doses of 1 to 2 mg of midazolam were titrated intravenously to relieve anxiety. No iv narcotic was used in the OR unless the patient complained that he/she was uncomfortable [in which case, incremental doses of fentanyl (50 µg) were given until the patient felt comfortable]. No other iv sedation medications were used. No ketorolac was used in the OR.
Specific variables were evaluated at regular intervals in each patient. Evaluations were performed every three minutes for the first 15 min. The evaluations continued every 15 min in the OR or PACU (for the first 90 min) and then every 30 min. The following variables were evaluated: sympathetic, motor and sensory blockade, time to ambulation, pruritus, postoperative pain, nausea, or any other problems. Pain and pruritus scores were obtained with verbal analogue scores with 0 meaning none and 10 the worst pain or itching that the patient could imagine. Pruritus was treated with diphenhydramine first and then a serotonin inhibitor or naloxone (if necessary) if the patient wanted medication to relieve the itching.
From the OR, all patients went to the PACU. Another anesthesiologist (blinded about the IT injection the patient had received in the OR) evaluated each patient in the PACU. This anesthesiologist evaluated the patient at regular intervals (as described above) and measured the sympathetic level, sensory level, motor blockade (1 = no blockade, full flexion/extension, 2 = partial blockade, just able to move knees, 3 = almost complete blockade, able to move feet only, 4 = complete blockade, unable to move feet or knees), pruritus and pain scores, and any other problems. Once a motor blockade score of 1 was achieved, the patient was assessed at regular intervals to see whether he/she could stand and walk. "Time to ambulation" was the difference between the time the patient was able to stand and walk and the time of the IT injection.
In the PACU, 30 mg of ketorolac iv were given if the patient complained of pain and there were no contraindications. Also, incremental doses of fentanyl were given to patients with pain scores greater than 4. Another iv narcotic (morphine or meperidine) was used if the patient’s pain was not relieved by ketorolac and fentanyl. After outpatient surgery with spinal anesthesia, the patient was discharged (from the PACU) when the patient met our standard criteria: 1) the oxygen saturation (by pulse oximetry) on room air was greater than 92%; 2) the patient was able to breathe and cough freely; 3) the systolic blood pressure was 20% of the preanesthetic level; 4) the patient was fully awake; 5) the patient was able to stand and walk [to go to the same day surgery (SDS) unit, and home]; 6) the patient was free of itching (or pain) or did not request further medication for mild itching (or discomfort). "Time to discharge" was the difference between the time of discharge from the PACU and the time of the IT injection. After discharge from the PACU, all patients (except for one) went to the SDS unit (and then home).
Power analysis was performed with Statmate software (GraphPad) to calculate the minimum number of patients in each group. A power analysis calculated that the minimum number of patients to achieve 80% power was 16 per group (assuming 30 min as the minimum significant difference for the time of ambulation between the groups, and a standard deviation of 30 min per group). To accommodate for patient "drop out," at least 20 patients in each group were studied. Values are reported as mean ± SD or as percentage. Nonparametric data were analyzed with Fisher’s exact test or Mann-Whitney U test as appropriate. Parametric data were analyzed with an unpaired Student’s t test. All tests were two tailed. Statistical difference was assumed if P < 0.05.
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Results |
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) were similar. Patients who received a lower dose of IT lidocaine with sufentanil had a significantly shorter time to ambulation than patients who received a higher dose of IT lidocaine only (P < 0.0001, Table I). All the criteria for discharge from the PACU were met at the same time that the patient was able to walk and stand in 89% of patients with IT lidocaine with sufentanil and in 62% of patients with IT lidocaine alone. Also, the mean time to discharge from the PACU was shorter in patients who received IT lidocaine and sufentanil compared to patients who received IT lidocaine alone (P < 0.0001, Table I).
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) did not differ statistically in the two groups. Respiratory depression was not observed in either group. The use of iv narcotics for pain (in the PACU) was not statistically different in the two groups.
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Discussion |
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Our study demonstrates that the addition of 10 µg sufentanil to a small dose of lidocaine (15 mg) produces similarly adequate surgical conditions compared to 50 mg lidocaine for ambulatory rectal cases. Only one patient needed additional iv fentanyl in the OR. Sufentanil is a useful additive to local anesthetics.14,15 Our results are consistent with the experimental effects of IT opioids, which show that combinations of opioids and local anesthetics are synergistic for somatic analgesia in animal models.16 Subtherapeutic IT doses of local anesthetics produce marked analgesia when mixed with narcotics.17
Our study focused on the time to ambulation (as a marker for recovery time). A short recovery time for ambulatory surgery is important to the patient and to the hospital. In our study, time to ambulation was a reliable marker of recovery time. Patients, usually, were discharged soon after they could stand and walk. The shorter stay in the PACU of the patients who received low-dose IT lidocaine and sufentanil was due to the shorter time to ambulation. Other studies have also observed faster recovery after spinal anesthesia with lower doses of a local anesthetic agent and IT opioid.4,7–9 In addition, the time to discharge from the PACU1 can be influenced by many factors (including waiting for transportation to the SDS unit from the PACU). Discharge time from the SDS unit can also be influenced by the arrival time of the patient’s family or friend to take the patient home.1
Itching, unfortunately, is a well-known side effect of IT narcotics.10–12 IT lidocaine and sufentanil caused pruritus in 50% of patients in our study but did not delay discharge from the PACU. No other adverse events differed between the two groups. We did not see any respiratory depression18 in our patients (less than 75 yr old). Most studies have reported such complications in special populations:18,19 obstetrical or older patients (in their 80s).
In the medical literature, TNS has been associated with IT lidocaine.4–6,20 TNS may be related to the total dose of IT lidocaine. Ben-David et al.4 reports that TNS was seen in 32.7% of patients who received 50 mg of IT lidocaine vs 3.6% of patients who received 20 mg IT lidocaine and 20 µg fentanyl. However, none of our patients showed any sign or symptom compatible with TNS.
Difficulty in voiding has been reported with spinal anesthesia especially in patients with the following risk factors: 1) over 70 yr old; 2) hernia, rectal, or urological surgery; or 3) previous history of difficulty urinating.21 The use of IT low-dose local anesthetics and opioid may reduce the incidence of urinary retention especially in patients with a lower risk of difficulty in voiding.8,21 However, in our study, there was no difference in the incidence of difficulty in voiding between the two groups. Two patients (one from each group) required catherization.
In summary, our important findings are as follows: 1) the use of a low dose of IT lidocaine (15 mg) in combination with sufentanil (10 µg) provided anesthesia equally effective as a higher dose of IT lidocaine (50 mg) for short rectal ambulatory surgical cases; 2) this low dose of lidocaine (with sufentanil) allowed a shorter time of ambulation (and recovery time) compared to lidocaine (50 mg) alone; 3) IT lidocaine and sufentanil is an effective and inexpensive anesthetic mixture for these types of cases but, unfortunately, this technique caused mild to moderate pruritus.
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Acknowledgments |
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Footnotes |
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Accepted for publication January 21, 2003. Revision accepted April 14, 2004.
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References |
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2 Li S, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000; 93: 1225–30.[Medline]
3 Stewart AV, Vaghadia H, Collins L, Mitchell GW. Small-dose selective spinal anaesthesia for short-duration outpatient gynaecological laparoscopy: recovery characteristics compared with propofol anaesthesia. Br J Anaesth 2001; 86: 570–2.
4 Ben-David B, Maryanovsky M, Gurevitch A, et al. A comparison of minidose lidocaine-fentanyl and conventional-dose lidocaine spinal anesthesia. Anesth Analg 2000; 91: 865–70.
5 Eberhart LH, Morin AM, Kranke P, Geldner G, Wulf H. Transient neurologic symptoms after spinal anesthesia. A quantitative systematic overview (meta-analysis) of randomized controlled studies (German). Anaesthesist 2002; 51: 539–46.[Medline]
6 Tong D, Wong J, Chung F, et al. Prospective study on incidence and functional impact of transient neurologic symptoms associated with 1% versus 5% hyperbaric lidocaine in short urologic procedures. Anesthesiology 2003; 98: 485–94.[Medline]
7 Ben-David B, DeMeo PJ, Lucyk C, Solosko D. Minidose lidocaine-fentanyl spinal anesthesia in ambulatory surgery: prophylactic nalbuphine versus nalbuphine plus droperidol. Anesth Analg 2002; 95: 1596–600.
8 Ben-David B, DeMeo PJ, Lucyk C, Solosko D. A comparison of minidose lidocaine-fentanyl spinal anesthesia and local anesthesia/propofol infusion for outpatient knee arthroscopy. Anesth Analg 2001; 93: 319–25.
9 Vaghadia H, McLeod DH, Mitchell GW, Merrick PM, Chilvers CR. Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy. I. A randomized comparison with conventional dose hyperbaric lidocaine. Anesth Analg 1997; 84: 59–64.[Abstract]
10 Kam PC, Tan KH. Pruritus-itching for a cause and relief? Anaesthesia 1996; 51: 1133–8.[Medline]
11 Szarvas S, Harmon D, Murphy D. Neuraxial opioid-induced pruritus: a review. J Clin Anesth 2003; 15: 234–9.[Medline]
12 Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth 1995; 42: 891–903.
13 Henderson CL, Schmid J, Vaghadia H, Fowler C, Mitchell GW. Selective spinal anesthesia for outpatient laparoscopy. III: sufentanil vs lidocaine-sufentanil. Can J Anesth 2001; 48: 267–72.
14 Dunn SM, Connelly NR, Steinberg RB, et al. Intrathecal sufentanil versus epidural lidocaine with epinephrine and sufentanil for early labor analgesia. Anesth Analg 1998; 87: 331–5.
15 Lau WC, Green CR, Faerber GJ, Tait AR, Golembiewski JA. Intrathecal sufentanil for extracorporeal shock wave lithotripsy provides earlier discharge of the outpatient than intrathecal lidocaine. Anesth Analg 1997; 84: 1227–31.[Abstract]
16 Saito Y, Kaneko M, Kirihara Y, Sakura S, Kosaka Y. Interaction of intrathecally infused morphine and lidocaine in rats (part I): synergistic antinociceptive effects. Anesthesiology 1998; 89: 1455–63.[Medline]
17 Chilvers CR, Goodwin A, Vaghadia H, Mitchell GW. Selective spinal anesthesia for outpatient laparoscopy. V: pharmacoeconomic comparison vs general anesthesia. Can J Anesth 2001; 48: 279–83.
18 Ferouz F, Norris MC, Leighton BL. Risk of respiratory arrest after intrathecal sufentanil. Anesth Analg 1997; 85: 1088–90.[Medline]
19 Fournier R, Gamulin Z, Van Gessel E. Respiratory depression after 5 µg of intrathecal sufentanil. Anesth Analg 1998; 87: 1377–8.
20 Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anesthesia. An epidemiologic study of 1,863 patients. Anesthesiology 1998; 89: 633–41.[Medline]
21 Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology 2002; 97: 315–9.[Medline]
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