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Chloroprocaine vs. prilocaine for spinal anaesthesia in day-case knee arthroscopy: a double-blind randomized trial
Session: MP-02b
Thur, April 11, 10:00am-12:00pm
Tribune

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Chloroprocaine vs. Prilocaine for Spinal Anesthesia in day-case Knee Arthroscopy: a Double-blind Randomized Trial


Authors

Elsbeth Wesselink

Department of Clinical Pharmacy 

Zaans Medisch Centrum Zaandam

The Netherlands

 

Marcel de Leeuw

Department of Anesthesiology 

VUmc medical centers Amsterdam

The Netherlands

 

Rien van der Vegt

Department of Anesthesiology 

Zaans Medisch Centrum Zaandam

The Netherlands

 

Jan van der Aa

Department of Orthopaedic Surgery 

Zaans Medisch Centrum Zaandam

The Netherlands

 

Cor Slagt

Department of Anesthesia

Radboud University Medical Center Nijmegen

The Netherlands

 

Godelief van den Hurk

Department of Clinical Pharmacy 

Zaans Medisch Centrum Zaandam

The Netherlands

 

Christa Boer

School of Medical Sciences 

VUmc medical centers Amsterdam

The Netherlands


Background

A short acting spinal anesthetic facilitates a smooth patient flow: quick recovery of motor function will facilitate unassisted ambulation. For this purpose lidocaine has been the drug of choice for decades. Spinal lidocaine, however, has been associated with a high incidence  (20–30%) of unwanted Transient Neurologic symptoms (TNSs). In recent years, both chloroprocaine and prilocaine have gained interest as short-acting spinal anesthetics seemingly without the issue of urinary retention needing catheterization or TNSs. This study was undertaken to compare the effects of spinal chloroprocaine and spinal prilocaine on motor blockade in patients undergoing knee arthroscopy.

Hypotheses

The null hypothesis is that there is no significant intergroup difference in time to complete recovery from motor blockade. A difference of 15 minutes was considered clinically relevant for the primary outcome time to full recovery of motor block (Tmb0). Secondary outcome parameters included time to full regression of sensory block, peak sensory block level, urine retention needing catheterisation, time until hospital discharge, TNS and patient satisfaction.

Methodes

Patients scheduled for knee arthroscopy with spinal anesthesia and >18yr of age with an ASA physical status I-II were eligible for participation in the study. Patients with allergy to one of the study drugs, a contraindication to neuraxial anesthesia, previous neuropathy to the lower extremities, previous participation to the study for the other knee as well as pregnant patients were excluded. Using block randomisation (block size of 4 patients, computer-generated sequence) patients were randomly allocated to receive a spinal injection of 40 mg of either preservative-free plain 2-chloroprocaine 1% (Ampres®, Sintetica, Switzerland) or hyperbaric prilocaine 2% (Prilotecal®, Nordic Group BV, Netherlands). A blinded observer recorded the evolution of spinal block until achievement of hospital discharge criteria. Motor block was assessed using a 4-point Bromage scale. Sensory block was assessed using loss of cold sensation (ice cubes) until full regression was observed. Both sensory and motor block were assessed bilaterally. Thirty minutes after surgery, the urinary bladder was scanned by ultrasound. The time of first spontaneous voiding (Tv) was registered. The time to hospital discharge (Thd) was defined as the time between spinal injection and the moment the subject met the discharge criteria for this study. On the first and seventh postoperative day, patients were interviewed following a standardized checklist.  

Results

Chloroprocaine resulted in a shorter time to complete recovery from motor blockade compared with prilocaine (median: 60 min; interquartile range (IQR) 60 – 82.5 compared to median: 75 min; IQR 60 – 90; p = 0.004). Chloroprocaine also showed faster onsets of sensory block (median: 2 min; IQR 2 – 4 compared to median: 4 min; IQR 2 – 6; p = 0.010), full regression of sensory block (median: 120 min; IQR: 90 – 135 compared to 165 min; IQR: 135-190, p < 0.001) and hospital discharge (mean difference: 57 minutes (3.7 vs 4.7 h); 95% confidence interval: 38 - 77, p<0.001). Peak sensory block was higher in the chloroprocaine group (median: T9; IQR: T6 – T12: compared to median: T10;  IQR: T8 – T12, p<0.008). The arterial blood pressure (MAP) at 20 min was lower and the use of vasopressor drugs was higher (22.7% vs 10%) in chloroprocaine group compared with prilocaine. No TNSs were found in both groups. Patient satisfaction did not differ between the groups. Urine retention needing catheterisation was the same in both groups (C 8.0% vs P 1.3%; p=0.12).

Conclusion

The results of this study confirm earlier observations that both short acting spinal anaesthetics chloroprocaine and prilocaine, using 40 mg dosages, result in adequate anesthesia with quick recovery of sensory/motor functions for knee arthroscopy in the ambulatory setting. However, certain findings of this study may favour the use of chloroprocaine over prilocaine. Chloroprocaine resulted in a shorter offset time from motor blockade, onset of sensory block and full regression of sensory block compared with prilocaine. As a consequence of a faster offset, the time to spontaneous voiding was shorter in patients undergoing spinal anesthesia with chloroprocaine than with prilocaine. As voiding is required for hospital discharge after spinal anesthesia, chloroprocaine has the advantage of a shorter length of stay. Although patient satisfaction was the same in both groups, a faster recovery facilitates a quick patient flow with less delay on the PACU or the general ward and can therefore be judged as clinically and economically relevant for high patient volumes.

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