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AMBULATORY ANESTHESIA

A Comparison of Minidose Lidocaine-Fentanyl Spinal Anesthesia and Local Anesthesia/Propofol Infusion for Outpatient Knee Arthroscopy

Bruce Ben-David, MD^*, Patrick J. DeMeo, MD, Christen Lucyk, RN, ADN^*, and David Solosko, MD^*

Departments of *Anesthesiology and Orthopedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

Address correspondence and reprint requests to Bruce Ben-David, MD, Department of Anesthesia, Allegheny General Hospital, 320 East North Ave., Pittsburgh, PA 15212. Address e-mail to bbendavid{at}mindspring.com

	Abstract

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Traditional methods of spinal anesthesia have proven problematic in the outpatient setting. Minidose lidocaine-fentanyl spinal anesthesia (SAB_MLF) may be the adaptation necessary to reestablish spinal anesthesia in this venue. One hundred patients scheduled for outpatient knee arthroscopy were randomized to receive either local anesthesia plus a titrated IV propofol infusion (LA/PI) or SAB_MLF using 20 mg lidocaine 0.5% + 20 µg fentanyl. Patients received midazolam 0.02–0.03 mg/kg IV and fentanyl 0.75–1.0 µg/kg IV upon arrival in the operating room before lumbar puncture or propofol infusion. The propofol infusion was begun at 50–75 µg · kg^-1 · min^-1 and titrated to maintain patient comfort. Boluses (200–400 µg/kg) were given as needed. Local anesthesia included 30 mL lidocaine 1% with epinephrine 1:200,000 intraarticularly plus 10 mL at the portal sites. Three patients (6%) in the LA/PI group versus none in the SAB_MLF group required general anesthesia. Airway support was required in 54% of the LA/PI patients and in none of the SAB_MLF patients. Total operating room time (43 vs 45 min), time to home readiness (43 vs 45 min), actual discharge times (73.5 min in both groups), and the incidence of discharge >90 min (22% vs 24%) were the same for both LA/PI and SAB_MLF groups. LA/PI and SAB_MLF groups differed in terms of postoperative pruritus (8% vs 68%), pain (44% vs 20%), nausea (8% vs 22%), and ability to void before discharge (56% vs 32%). One patient in each group had mild difficulty initiating voiding at home, but neither required medical attention. In both groups, 90% of patients were either "satisfied" or "very satisfied" with their anesthetic. The two techniques provided comparable patient satisfaction and efficiencies both intraoperatively and in postoperative recovery and discharge. The efficiencies of these techniques were not dependent on special provisions of the physical plant or the practice model.

IMPLICATIONS: Both local anesthesia supplemented by a titrated IV propofol infusion and minidose lidocaine-fentanyl spinal anesthesia for outpatient knee arthroscopy provide high patient satisfaction with equally rapid recovery and discharge.

	Introduction

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The shift in much of surgical practice from an inpatient to an outpatient paradigm has impelled us to adapt our anesthetic techniques to the ambulatory setting. Traditional methods of spinal anesthesia have proven problematic in outpatient surgery. Though widespread availability of small-gauge pencil-point needles has largely quelled concerns of spinal headache, spinal anesthesia for ambulatory surgery has nevertheless fallen into disfavor because of concerns of transient neurologic symptoms (TNS) after intrathecal lidocaine (1–3), issues of delayed recovery and discharge (4–7), and the lack of success in finding an alternative local anesthetic to lidocaine (8).

A few reports in recent years have demonstrated both the feasibility and the benefits of spinal anesthesia using small-dose local anesthetic in combination with an opioid (9–12). Minidose spinal lidocaine-fentanyl (SAB_MLF) for arthroscopic surgery provides reliable anesthesia with an infrequent incidence of TNS and a much faster recovery than after spinal anesthesia with a conventional dose of lidocaine (13). One reason for delayed discharge after spinal anesthesia is that patients have traditionally been required to void before discharge. This practice, however, may not be necessary after lidocaine spinal anesthesia (14,15). A change in this policy in combination with the SAB_MLF technique may make it possible to conduct spinal anesthesia and yet achieve the sort of rapid discharge times that are desirable in the ambulatory setting.

Of the various anesthetic techniques that have been recommended for outpatient arthroscopy, that which appears to provide the shortest time to discharge is the use of local anesthesia (LA) (16–19). LA alone, however, may not reliably provide a comfortable patient experience or optimal operating conditions (16). LA in combination with a propofol infusion may provide excellent anesthesia while still allowing for rapid recovery and patient discharge (5).

The purpose of this prospective, randomized study was to determine the operating room (OR) efficiency and recovery profiles as well as the reliability, complications, side effects, and patient satisfaction levels of the SAB_MLF technique compared with a technique of LA in combination with a titrated IV propofol infusion.

	Methods

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This study was approved by the hospital’s IRB, and all patients gave written informed consent. All patients were between 18 and 75 yr of age and of ASA physical status I–II. Patients were English speaking, agreeable to follow-up telephone interviews, and had no contraindications to either technique (e.g., allergy, coagulopathy, localized infection, or neurologic disease). Patients were randomized by sealed envelope technique to receive one of two anesthetics. The two study groups were as follows: SAB_MLF = spinal anesthesia with 0.5% lidocaine 20 mg + fentanyl 20 µg, and LA/PI = local anesthesia using 30 mL of 1% lidocaine + titrated IV propofol infusion.

A power analysis was initially conducted to determine the necessary sizes of the two groups. We assumed SD of 30 min in time to discharge (taken from a previous study), an error of 0.05, and a ß error of 90%. To show a 20-min difference in discharge times to a power of 90%, the groups would require 48 patients each. Therefore, 100 patients equally divided between groups were enrolled in the study.

Patients received no premedication. An IV infusion of lactated Ringer’s solution was begun upon arrival in the OR, and patients were immediately given midazolam 0.02–0.03 mg/kg IV and fentanyl 0.75–1.0 µg/kg IV. Standard monitoring included continuous electrocardiogram, pulse oximetry, and automated blood pressure at 5-min intervals. All patients received supplemental oxygen via an oxygen mask.

For the patients in the SAB_MLF group, lumbar puncture was performed in the sitting position. The patient was immediately returned to supine on completion of the spinal. Lumbar punctures were made with 25- or 26-gauge pencil-point needles positioned midline at the L2-3 or L3-4 interspace with the orifice directed cephalad. Injections were made over 10 to 15 s. The spinal injectate was prepared by drawing up a mixture of 5 mL of 1% lidocaine (50 mg), 1 mL of fentanyl (50 µg), and 4 mL of dextrose 10%. From this solution, 4 mL was used for the anesthetic. This yielded 20 mg of 0.5% lidocaine + 20 µg of fentanyl in dextrose 4%. All spinals were conducted by the same anesthesiologist (BB-D). Continuing care was provided by a staff certified registered nurse anesthetist who, to avoid investigator bias, made the ongoing determinations of need for further sedation or analgesia or the need to convert to general anesthesia (GA). Further sedation was allowed with midazolam 0.01–0.02 mg/kg IV and further analgesia allowed with fentanyl 0.75–1.0 µg/kg IV. If the patient was still unduly anxious or still in pain, the protocol considered this an "anesthetic failure" and called for conversion to general inhaled anesthesia by using propofol 2 mg/kg IV followed by inhalation of oxygen, nitrous oxide, and isoflurane. The protocol called for the use of either a laryngeal mask airway or endotracheal intubation.

Patients in the LA/PI group received the same initial dose of fentanyl and midazolam IV as patients in the SAB_MLF group. An infusion of propofol was begun at 50–75 µg · kg^-1 · min^-1 and titrated to maintain a stable level of sedation in which the patient was comfortable but, if possible, remained responsive to verbal or light tactile stimulation. Likewise, to avoid investigator bias, a staff certified registered nurse anesthetist made the determination of need for further sedation or analgesia or the need to convert to GA. Additional boluses of propofol (200–400 µg/kg) were allowed as needed. Before application of the tourniquet and surgical preparation, the surgeon (all surgeries were performed by the same surgeon, PJD) injected 30 mL of 1% lidocaine with epinephrine 1:200,000 into the knee. Before incision, an additional 10 mL of the LA was injected at the portal sites. Additional fentanyl 0.75–1.0 µg/kg IV was allowed, as in the spinal group. Airway intervention was undertaken as deemed clinically necessary. If patient comfort and/or the airway could not be maintained, the protocol considered this an "anesthetic failure" and called for conversion to general inhaled anesthesia using propofol 2 mg/kg IV followed by inhalation of oxygen, nitrous oxide, and isoflurane via either a laryngeal mask airway or endotracheal tube. In both study groups, at the conclusion of the procedure, the surgeon injected 20 mL of 0.25% bupivacaine into the knee joint.

Intraoperative time intervals were recorded for the following: 1) time of entry in the OR until the time the surgeon began surgical skin preparation, 2) time of entry in the OR until the time of incision, and 3) time of entry in the OR until the time of exiting the OR.

All patients bypassed the postanesthesia care unit (PACU) (Phase I recovery) and were transferred directly from the OR to the Phase II recovery area. On arrival in Phase II recovery, vital signs were recorded and the patient was scored according to the fast track scoring system of White and Song (20). Patients were checked at 15-min intervals for home readiness. The criteria used to determine home readiness were the following: 1) vital signs within 20% of preoperative value, 2) fully awake and oriented, 3) able to stand up and remain standing for >1 min, 4) minimal nausea, 5) minimal to moderate pain, 6) minimal bleeding, and 7) having had, and tolerated, per os fluids. Voiding was not a requirement for determination of home readiness and was not required before discharge. Intervals were recorded from the time of Phase II recovery arrival until first oral intake, until home readiness, and until actual discharge. When a patient’s recovery time exceeded 90 min, a specific explanation was sought for the delayed discharge.

Pain in the recovery unit was treated with ketorolac 30 mg IV. Additional analgesia was provided with hydrocodone 5–10 mg per os with acetaminophen 500–1000 mg per os. Nausea was treated with droperidol 0.625 mg IV, and if further treatment was necessary, then with dolasetron 12.5 mg IV. Pruritus was treated with nalbuphine 2.5 mg IV, and if further treatment was necessary, then with diphenhydramine 12.5 mg IV. All medication requirements were recorded. At the time of discharge, patients were queried about their postoperative experience of pain, nausea, pruritus, headache, or dizziness. Patients were asked to score positive responses on a verbal analog scale of 0 (none) to 10 (worst imaginable). Before discharge, it was recorded whether or not the patient had been able to void.

A telephone interview was conducted the evening of surgery. Patients were asked whether they had had any difficulty with voiding at home and, if so, the degree of difficulty and whether it had continued or been only on the first void. Patients were queried about their at-home postoperative experience of pain, nausea, pruritus, headache, or dizziness. Patients were asked to score positive responses on a verbal analog scale of 0 (none) to 10 (worst imaginable).

A second telephone interview was conducted the evening of the second postoperative day or in several cases when patients could not be reached, on the third postoperative day. Patients were asked whether they had had any headache or backache since the surgery. Positive responses were further investigated as to the degree and nature of the complaint; specifically, in the case of headaches, whether the headache was positional in nature and, in the case of backache, whether there was associated radiation of pain. Patients were asked for their general comments and whether they had other complaints or concerns. They were asked to rate their anesthetic experience as poor, moderately satisfied, satisfied, or very satisfied. Finally, they were asked, "If you were coming for surgery on the other knee, would you want the same anesthesia?"

Statistical analysis was conducted using StatView 5 (SAS Institute, Cary, NC). Data analysis was on an "intent-to-treat" basis, where data from patients who required general anesthesia were included in the analysis. Data were analyzed using analysis of variance, the Mann-Whitney U-test, ², or expanded contingency table analysis as appropriate. Results were considered significant at a P value of 0.05.

	Results

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The two groups were similar with regard to age, height, weight, and gender (Table 1). There were no major anesthetic or surgical complications (Table 2).

OR times did not differ between the groups (Table 1). All patients, including those three requiring GA, bypassed PACU and went directly to Phase II recovery. On arrival there, the SAB_MLF patients were more likely to achieve a maximal fast track score of 14 (90% versus 72%). Only one patient, who was from the LA/PI group, had a fast track score <12 (the recommended cutoff for PACU bypass eligibility). The SAB_MLF patients also began oral intake sooner (5 vs 9 min). Nevertheless, the two groups both achieved readiness for discharge at the same time and both groups were equally delayed approximately 30 min until actual discharge. A similar number of patients in both groups had discharge delayed beyond either 75 or 90 min. The reasons for patient discharge delay beyond 90 min were as follows: nausea (eight patients), surgeon logistics (five patients) (patients waiting to meet with the surgeon before discharge), patient logistics (three patients) (waiting for a ride home), sedation (three patients), pruritus (or sedation after its treatment) (two patients), and nursing logistics (one patient). In the SAB_MLF group, 6 of the 12 patients with delayed discharge were attributed to nausea and 2 were attributed to pruritus.

Whereas LA/PI patients were more likely to have pain requiring analgesic medication before discharge (44% vs 20%), the SAB_MLF patients were more likely to suffer nausea (8% vs 22%) or pruritus (8% vs 68%). There were no differences between groups in the incidence of other postoperative symptoms. More LA/PI patients were able to void before discharge (56% vs 32%), but this did not affect discharge times because voiding was not a criterion for discharge.

Follow-up phone interviews the evening of surgery revealed that one patient in each group had had mild difficulty in initiating micturition, but in both cases, the problem had resolved itself without medical intervention. The incidence of pain and nausea at home after surgery (Table 3) and the severity of these were not different for the two groups. With the exception of an increased incidence of pruritus in the spinal group, there were no differences between groups in their postoperative complaints. Typically, the pruritus in the spinal patients subsided within several hours after discharge.

	Discussion

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The need to adapt to the ambulatory setting has led to significant changes in anesthetic techniques and choice of technique. It has focused attention on the dual, and sometimes dueling, imperatives of the patient (maximize safety, comfort, and satisfaction) and the provider (maximize efficiency, minimize costs). Although spinal anesthesia is appealing for reasons of speed, simplicity, and reliability, it has proven problematic for ambulatory surgery. The results of recent studies using minidose lidocaine-opiate spinal anesthesia raise the possibility that this technique might be the adaptation necessary to reestablish spinal anesthesia in the outpatient setting (9,11,13). This study shows that the technique can be used efficiently and reliably in the OR while allowing for recovery and discharge times comparable to the technique of LA plus propofol infusion.

Some authors have reported a high degree of success and efficiency performing arthroscopy of the knee under LA alone (16) or with minimal sedation (17–19). Our experience has been that LA alone is frequently insufficient to provide the patient with a comfortable operative experience. LA in combination with an IV propofol infusion enhances patient comfort without compromising rapid recovery. Li et al. (5) compared a similar technique of LA plus propofol infusion to spinal anesthesia and to sevoflurane/nitrous oxide GA for ambulatory anorectal surgery. Their results with LA/PI were nearly identical to our own—an average time to discharge of 76 minutes versus our 73.5 minutes.

The 20% incidence of arterial desaturation and the 54% need for some sort of airway intervention in the LA/PI group might suggest overdosing of propofol. Whereas this may be so in some cases, our observation is that propofol is often needed as an anesthetic more than as a sedative. Many patients have substantial pain with the LA technique and require titration of the propofol to levels of anesthesia that are something more than "sedation" (total IV anesthesia, TIVA, with spontaneous ventilation?). We believe that these observations are more a reflection of the depth of anesthesia required and not of careless dosing of propofol. Thus, we have intentionally avoided use of the term "monitored anesthesia care" (MAC). Perhaps a hybrid term such as MAC/TIVA would be more appropriate.

Although our results with LA/PI are the same as those of Li et al. (5), our results with spinal anesthesia differ radically. We found no difference in intraoperative times between groups, whereas they found that spinal anesthesia added 32 minutes to OR time. The similar OR times in our study may be because our practice is to begin patient positioning, tourniquet application (not inflation), and surgical preparation immediately on completion of the spinal anesthetic without waiting for block onset. Additionally, we found the time to oral intake to be 5 minutes versus their 59 minutes and an average time to discharge of 73.5 minutes versus their 193 minutes. Although the studies differed in lidocaine dose (20 vs 30 mg), surgical model (knee arthroscopy versus anorectal surgery), and the requirement to void before discharge, it is very possible that other unspecified "management" issues accounted for the vastly different results.

In another such comparison, Song et al. (21) compared bupivacaine-fentanyl spinal anesthesia with a technique of ilioinguinal-hypogastric nerve block plus propofol infusion for inguinal hernia repair. Their Block Plus Propofol Infusion group had far more expedient home-readiness and discharge times and decreased total costs. However, it is misleading to compare the delayed discharge of their Spinal group, who received conventional doses of long-acting bupivacaine, with the recovery after SAB_MLF. However, the surgical procedure used by Song et al. averaged 90 minutes, and SAB_MLF would not have provided adequate duration of surgical anesthesia. This highlights a limitation of SAB_MLF’s usefulness to predictable, relatively short cases.

The search for an alternative to spinal lidocaine was initially motivated by reports of a frequent incidence of TNS after its use (1–3). Small-dose bupivacaine-fentanyl spinal anesthesia yielded discharge times comparable to those of conventional doses of spinal lidocaine (22), but these discharge times have come to be seen as unduly long. SAB_MLF (lidocaine 25 mg + fentanyl 25 µg; L25/F25) provided surgical anesthesia with a recovery so rapid that patients achieved discharge criteria within 122 minutes from the time of placement of the spinal (9). SAB_MLF (L20/F25) also yielded a 10-fold reduction in the incidence of TNS compared with lidocaine 50 mg, with the added benefit of a speedier recovery (13). The present study further shows that SAB_MLF (L20/F20) allows rapid recovery and patient discharge in times nearly identical to the LA/propofol infusion technique while also providing the same high patient satisfaction rate.

Ambulatory patients have traditionally, especially after spinal anesthesia, been required to void before discharge. This may not be necessary after lidocaine spinal anesthesia (14,15) with the possible exception of those cases in which there may be an increased risk for urinary retention (hernia repair, urogenital or perirectal surgery, history of retention) (4,23). Chilvers et al. (24) did not require voiding before discharge after SAB_MLF (L20/F25) for outpatient laparoscopy. Forty percent of their patients went home without voiding and, as in our study, no patient required treatment in order to void. Based on a comparison with SAB_MLF (L20/F25) in which voiding was required before discharge (13), we estimate that this policy reduced discharge time by 25–30 minutes. Larkin et al. (25) suggest using ultrasound evaluation of bladder volume in patients who have not voided as a useful way to identify high-risk patients who should not be discharged before voiding or catheterization. Regardless, it would appear prudent to advise patients about the potential for urinary retention and to provide them with a mechanism for medical intervention should this be necessary.

It is noteworthy that both of the anesthetic techniques used in this study provided discharge times much shorter than other commonly used anesthetics for knee arthroscopy. Luttropp et al. (7) used propofol/nitrous oxide GA to provide for rapid recovery and early patient discharge (116 minutes). Mulroy et al. (6) compared GA with propofol infusion and nitrous oxide to 3% 2-chloroprocaine epidural anesthesia and to spinal anesthesia with procaine-fentanyl. They found the times to meet discharge criteria (not actual discharge times) to be, respectively, 104, 92, and 146 minutes, with the spinal anesthesia group being significantly delayed compared with the other two groups. These compare to our actual discharge times of 73.5 minutes for both groups.

Peripheral nerve block has been suggested as a means to provide satisfactory anesthesia and rapid discharge after knee arthroscopy (26). Because OR time is costly, it is not unimportant that a nerve block is likely to require more time than spinal anesthesia. Performing an epidural or peripheral regional block preoperatively in an induction area will preserve OR efficiency (27), but this solution may not be applicable to all physical plants, and it requires an anesthesia practice model in which an anesthesiologist is available to perform the block while the previous surgery is still underway.

In the recovery unit, the SAB_MLF group experienced more nausea (22% vs 8%) and pruritus (68% vs 8%) but a decreased incidence of early postoperative pain (20% vs 44%). The pruritus and postoperative analgesia are typical for intrathecal fentanyl, but the 20% incidence of nausea in the spinal group was surprising and is not paralleled by such findings in other studies. These two complaints were responsible for two-thirds of the delayed discharges in the SAB_MLF group. The 4% incidence of TNS in this study corroborates the 3.6% incidence reported with SAB_MLF (L20/F25) spinal (13). The infrequent incidence, the mild to moderate severity, and the limited duration of the TNS lend support to the continued use of small-dose spinal lidocaine.

In conclusion, we have conducted a randomized prospective comparison of two anesthetic techniques for outpatient knee arthroscopy—LA/PI and SAB_MLF (L20/F20). Although there appear to be particular advantages or disadvantages to either technique, both techniques provided a high degree of patient satisfaction with comparable efficiencies both intraoperatively and postoperatively. These efficiencies are superior to those reported with other techniques and, moreover, are not dependent on special provisions of the physical plant or the practice model.

	References

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