Spinal anaesthesia for ambulatory surgery

Abstract

Explain the historical context of spinal anaesthesia in the ambulatory setting. Describe the ideal characteristics of an ambulatory spinal anaesthetic. Recognise the central role of prilocaine and 2chloroprocaine in the ambulatory setting. Select the right drug for the right patient and the right procedure. Ambulatory surgery places high demands on anaesthetic technique. In this setting, rapid onset and offset of anaesthesia, rapid recovery of protective reflexes, mobility and micturition, and good control of postoperative pain and nausea are required. Since the inception of ambulatory surgery, the favoured anaesthetic technique has been general anaesthesia with short-acting drugs. Concerns about the time to perform spinal anaesthesia and the risks of prolonged motor block and urinary retention have limited its use. Whilst in the UK, 'ambulatory surgery' refers solely to patients being discharged from the hospital shortly after surgery, in the USA this term may also apply to admissions for up to 23 h. In this article, we will consider ambulatory surgery to mean that the patient is discharged home before midnight on the day of surgery. Spinal anaesthesia has become increasingly popular for inpatient surgery, but, until recently, its use has been limited in ambulatory surgery by the lack of a safe, licensed short-acting local anaesthetic agent. An ideal intrathecal agent for ambulatory surgery should have a rapid onset of motor and sensory blockade, predictable regression within an acceptable time frame, and a low incidence of adverse effects. Historically, lidocaine was the preferred agent in this setting, providing a dense block with rapid recovery, but the identification of a high incidence of transient neurologic symptoms (TNS) has effectively excluded it from use. 1,2 Until recently, the only local anaesthetic preparations licensed for intrathecal use have been hyperbaric William Rattenberry FRCA is a specialty trainee in anaesthesia whose interests include quality improvement and regional anaesthesia.

Determination of the ED95 of intrathecal hyperbaric prilocaine with sufentanil for scheduled cesarean delivery: a dose-finding study based on the continual reassessment method

“…Several studies the last past years have shown its efficacy when applied for spinal anesthesia and have determined the appropriate doses for various ambulatory surgery procedures lasting up to 90 min [14][15][16].…”

Fluid management: An update for perioperative practitioners

“…Over recent years, goal-directed fluid therapy (GDT) has been the gold standard of treatment for cardiovascular optimisation. Randomised control trials investigating GDT report not only improvements in morbidity and mortality but also reduced length of intensive care stay and hospital admission (Jin et al 2018, Rollins & Lobo 2016).…”

“…Delivery of warmed fluids throughout the perioperative period by practitioners is essential to prevent hypothermia. Perioperative hypothermia is associated with a range of complications; increased intraoperative blood loss, prolonged recovery with increased duration of inpatient stay, impaired wound healing and cardiovascular complications (Frank et al 1997, Lenhardt et al 1997, Marik & Lemson 2014, Rollins & Lobo 2016). One litre of room temperature crystalloid fluid decreases core temperature by 0.25°C.…”

Determination of the ED95 of intrathecal hyperbaric prilocaine with sufentanil for scheduled cesarean delivery: A dose-finding study based on the continual reassessment method

“…Several studies the last past years have shown its efficacy when applied for spinal anesthesia and have determined the appropriate doses for various ambulatory surgery procedures lasting up to 90 minutes. [14][15][16] First introduced for intrathecal use in 1965, 17 the former presentation of prilocaine was assessed in obstetrics for vaginal or cesarean delivery under continuous epidural anesthesia in 1968. 18,19 Good quality of anesthesia was reported with 1%-2% formulations with no clinically relevant blood accumulation of prilocaine, although considerable doses had been administered via the continuous epidural mode.…”