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LETTERS TO THE EDITOR

Use of Small-Dose Bupivacaine (3 mg vs 4 mg) for Unilateral Spinal Anesthesia in the Outpatient Setting

Department of Anesthesia and Critical Care, Post Graduate Institute of Medical Sciences, Rohtak, India

To the Editor:

The use of lidocaine in outpatient anesthesia, especially in lithotomy and knee arthroscopy positions, increases the risk of transient neurological symptoms (1), whereas bupivacaine might delay the recovery of motor functions and cause urinary retention, leading to delayed discharge of the patient (2). This has increased the interest in small doses of bupivacaine and techniques to produce unilateral spinal anesthesia (3,4). Small-dose intrathecal local anesthetic-opioid combinations increase nausea and vomiting as well as pruritus (5,6).

We designed a study to assess the efficacy of two different doses (3 mg and 4 mg) of 0.5% hyperbaric bupivacaine in patients undergoing outpatient knee arthroscopy under spinal anesthesia. After approval of hospital ethics committee, this study was conducted on 40 adult patients presenting for elective knee arthroscopy. Patients with contraindications to regional anesthesia, diabetes, or peripheral neuropathy were excluded. Informed consent was obtained from all the patients. Patients were randomized using a coded envelope technique to receive one of the two subarachnoid doses of 0.5% hyperbaric bupivacaine: 3 mg (0.6 mL) or 4 mg (0.8 mL). With the operative side dependent, a 25-gauge Yale® spinal BD needle with beveled tip was inserted in midline of L3–4 interspace. After ensuring free flow of CSF, the needle level was turned towards the dependent side and the dose was given over 30 s. Patients were kept in the lateral position for 10 min and then made supine. Highest dermatome level of sensory blockade, time taken to reach this level, modified Bromage scale at the time of peak sensory level, maximum degree of motor block, time taken for regression of block to S₂ dermatome, time to void, and time to discharge of patient were noted.

Demographic characteristics, level of spinal block and recovery variables were similar in both bupivacaine groups (Table 1). The 3 mg (vs 4 mg) dose of 0.5% hyperbaric bupivacaine was associated with a higher incidence of unilateral spinal anesthesia (84 vs 11%, P < 0.05). One patient in the 3-mg group experienced urinary retention requiring catheterization. None of the patients had hemodynamic instability, nausea, or vomiting. Overall, all patients were satisfied with the anesthesia technique.

References

1. Pollock JE, Neal JM, Stephenson CA, Wiley CE. Prospective study of the incidence of transient radicular irritation in patients undergoing spinal anesthesia. Anesthesiology 1996; 84: 1361–7.[Web of Science][Medline]
2. Vaghadia H. Spinal anaesthesia for outpatients: controversies and new techniques. Can J Anaesth 1998; 45: R64–70.[Web of Science][Medline]
3. Tarkkila P, Huhtala J, Tuominen M. Home readiness after spinal anaesthesia with small doses of hyperbaric 0.5% bupivacaine. Anaesthesia 1997; 52: 1157–60.[Web of Science][Medline]
4. Kuusniemi KS, Pihlajamaki KK, Pitkanen MT, Korkeila JE. A low dose hypobaric bupivacaine spinal anesthesia for knee arthroscopies. Reg Anesth 1997; 22: 534–8.[Web of Science][Medline]
5. 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.[Abstract/Free Full Text]
6. Korhonen AM, Valanne JV, Jokela RM, et al. Intrathecal hyperbaric bupivacaine 3 mg + fentanyl 10 µg for outpatient knee arthroscopy with tourniquet. Acta Anesthesiol Scan 2003; 47: 342–6.

This article has been cited by other articles:

				G. S. Nair, A. Abrishami, J. Lermitte, and F. Chung Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy Br. J. Anaesth., March 1, 2009; 102(3): 307 - 315. [Abstract] [Full Text] [PDF]

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