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Re: Spinal anaesthesia for knee arthroscopy - are we getting better?
- Gopakumar Sudhkaran Nair, Amir Abrishami, Frances Chung. (1 April 2009)
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Spinal anaesthesia for knee arthroscopy - are we getting better?
- Ramabhadran Kadayam Sreenivasan, Dr Snehal R Kumbhare CT1 in Anaesthetics - Homerton University Hospitals (7 March 2009)
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Gopakumar Sudhkaran Nair Toronto western hospital, University health Network, University of Toronto, Toronto, Canada, Amir Abrishami, Frances Chung.
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Thank you for the comments and interest in the article. Many of the points that you have raised are genuine and need to be addressed in the real world. Many of our surgical colleagues and nursing staff do lack awareness regarding the benefits of regional anesthesia. According to a survey conducted among orthopedic surgeons , it was found that 48% of surgeons directed their patients regarding the type of anesthesia and the most common reason for not favoring spinal is the delay in induction(43%).1 However,the survey concluded that orthopedic surgeons preferred regional anesthesia. As you have rightly pointed out, the extra few minutes taken for induction can be compensated by the fact that no time is needed to awaken the patient from spinal versus general anesthesia. Gonano et al2 showed this in orthopedic patients, that even though the time to induction is longer with spinal anesthesia, the total anesthetic time is similar in spinal and general anesthesia groups. An induction room is helpful in reducing the delay in spinal anesthesia. Setting up an induction room can be economical in the long term as spinal anesthesia cost less than general anesthesia2. Also, patient education about the benefits of spinal anesthesia is essential. We agree with your opinion on the use of short acting local anesthetics in ambulatory knee arthroscopy. At present, it is difficult to say if there is going to be a change in turn over time in the operating room but it may benefit patients by attaining an early discharge. Fentanyl added to bupivacaine can improve the quality of spinal anesthesia. However, we showed in our review that the incidence of postoperative pruritus was quite high. With the current level of evidence, decision to adding fentanyl should be made on individual patient basis. References 1.A Survey of Orthopedic Surgeons’ Attitudes and Knowledge Regarding Regional. Anesth Analg 2004;98:1486-1490 2.Spinal Versus General Anesthesia for Orthopedic Surgery: Anesthesia Drug and Supply Costs. Anesth Analg 2006;102:524 –9 Conflict of Interest:None declared |
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Ramabhadran Kadayam Sreenivasan, ST4 in Anaesthesia London Chest Hospital, Dr Snehal R Kumbhare CT1 in Anaesthetics - Homerton University Hospitals
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This is a very interesting review about spinal anaesthesia for day case arthroscopy. We as anaesthetists are required to perform two functions in day case scenarios that are difficult to achieve in the best of times – 1.Ensure patient safety and comfort i.e providing best possible care based on best research evidence and 2.Ensure smooth and efficient running of the day case list including optimal utilisation of theatre time i.e rapid turnover of cases followed by early discharge with minimum complications. This debate about regional anaesthesia for day case surgery is academic as far as I am concerned. From a patient perspective there are definite advantages with spinal anaesthesia with regards to reduced pain scores, reduced opioid consumption in the immediate post-operative period and reduced incidence of adverse effects like PONV1. The main disadvantage as suggested by Liu et al2 in their meta- analysis is the longer induction time needed plus the fact that there was a 35 min increase in total ambulatory surgery time. Your review seems to suggest that if used in the appropriate dose unilaterally it does not result in longer discharge times. Could we say that best research evidence supports the use of spinal anaesthesia especially unilateral with or without added fentanyl in the setting of day case knee arthroscopies? I think we can. There are a number of other alternatives as well to bupivacaine for the spinal namely articaine3, chloroprocaine4 which have a shorter duration of action than bupivacaine. But will this ensure the smooth running of the day case list with rapid turnover of patients? Probably not. My own personal experience is that as part of the day care team we (patient & anaesthetist) cannot unilaterally take a decision with regards to the choice of anaesthesia even though technically we can. It is imperative that the surgeons are on board along with para-medical staff and the best via media is found. I have broached this subject with a few orthopaedic surgeons and their biggest worry is the time it takes for the spinal to work. I have tried arguing that this is compensated by the fact that no time is needed to recover the patient at the end of the procedure and also that it has definite advantages for the patient. As with every entrenched idea it will take a lot of time and effort to overturn it. Your review is another weapon in my armamentarium to convince them. I am also aware of units using 4-5 mg of isobaric bupivacaine with 10 mcg of fentanyl as a protocol for all knee arthroscopies. The surgeons have been taken on board in the decision making and they apparently like to explain things to the patient as they are doing it which in turn is liked by a lot of patients. Another advantage of spinal I guess!! References 1.A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy. Anna-Maija Korhonen et al, Anaesth Analg 2004; 99: 1668-1673 2.A comparison of Regional versus General Anaesthesia for Ambulatory Anaesthesia: A meta-analysis of randomised controlled trials. Spencer S. Liu et al, Anaesth Analg 2005; 101: 1634-1642 3.Plain articaine or prilocaine for spinal anaesthesia in day case knee arthroscopy: a double blind randomized control trial. M. P. Hendricks et al Br J Anaesth 2009; 102: 259-263 4.Intrathecal 2-Chloroprocaine for lower limb outpatient surgery: a prospective, randomized, double blind, clinical evaluation. A Casati et al, Anesth Analg. 2006 Jul;103(1):234-8 Conflict of Interest:None declared |
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