Urinary bladder scanning after day-case arthroscopy under spinal anaesthesia: comparison between lidocaine, ropivacaine, and levobupivacaine

M. B. Breebaart, M. P. Vercauteren*, V. L. Hoffmann and H. A. Adriaensen

Department of Anaesthesia, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium

Corresponding author. E-mail: marcel.vercauteren@uza.be

Accepted for publication: October 9, 2002


    Abstract
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background. Micturition problems after spinal anaesthesia may delay hospital discharge. The use of lidocaine has raised concerns because of the occurrence of transient neurological symptoms (TNS). This randomized double-blind study was designed to compare the newer local anaesthetics with lidocaine regarding block characteristics, micturition problems, and discharge times in day-case spinals for arthroscopy.

Methods. Ninety patients received either isobaric lidocaine 60 mg, ropivacaine 15 mg, or levobupivacaine 10 mg intrathecally. Urinary bladder volumes were measured by ultrasound imaging at regular time intervals until a post-voiding residual volume (PVRV) less than 100 ml was obtained. Micturition problems were classified in five groups ranging from no problems to those requiring catheterization.

Results. Times to regain a Bromage-1 and -0 motor block were similar in the three groups but sensory block regression to L2 occurred at 145 (30) min in the lidocaine group, 25–30 min (P<0.05) faster than the other groups. Lidocaine allowed voiding after 245 (65) min and hospital discharge 265 (70) min after spinal injection, 40 min faster than in the two other groups. The incidence or degree of micturition problems were not different between after discharge, three patients (10%) receiving lidocaine complained of symptoms compatible with TNS.

Conclusions. Our study suggested that the three local anaesthetics behave similar regarding quality of anaesthesia and motor block but voiding and discharge occurred significantly earlier with lidocaine although the 40 min difference was not impressive considering a spinal discharge time interval of 4–5 h.

Br J Anaesth 2003; 90: 309–13

Keywords: anaesthetic techniques, subarachnoid; anaesthetics local, levobupivacaine; anaesthetics local, lidocaine; anaesthetics local, ropivacaine; complications, micturition; surgery, orthopaedic


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
An important reason to withhold regional anaesthesia in day-case surgery is the risk of urinary retention as this may delay hospital discharge. Nowadays it is possible to measure the bladder volume by bedside imaging and this may influence the decision to catheterize the bladder.13

Bupivacaine causes a long-lasting motor block, which eliminates it as best choice for day-case surgery. Lidocaine has a shorter duration of action but the occurrence of transient neurological symptoms (TNS) has raised concerns.4 There is uncertainty about other short-acting local anaesthetics with respect to these side effects.5 6

Despite little intrathecal experience with the newer local anaesthetics, it was found that for arthroscopic procedures at least a 50% greater dose of ropivacaine is required when compared with bupivacaine7 and clinical studies using levobupivacaine for spinal anaesthesia found similar potency and block characteristics compared with the racemic component.8 While it is commonly accepted that ropivacaine may induce less motor impairment than racemic bupivacaine, studies have found a similar trend for levobupivacaine.9

The aim of the present study was to evaluate if urinary retention, based upon bedside ultrasound bladder scanning, is a real problem after spinal anaesthesia in day-case procedures, and whether the choice of the local anaesthetic affects micturition and the time to discharge home. For this purpose lidocaine has been compared with the newer local anaesthetics, which possibly have different sensory and/or motor effects.


    Methods
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The protocol was approved by the hospital ethics committee and written informed consent was obtained from each patient. Ninety patients undergoing knee arthroscopy under spinal anaesthesia as a day-case procedure were included in this prospective, randomized (by a computer-generated randomization sequence), double-blind study. All patients were classified as American Society of Anesthesiologists physical status 1 and were aged between 18–60 yr. Patients with a history of renal or urinary tract disorders, neurological disease, or previous lower abdominal surgery were not considered for entrance into the study.

The patients were asked to void before surgery and the bladder volume was measured after micturition using a DxU type BVI 3000-Bladderscan© (Redmond, WA, USA). Patients with a post-voiding residual volume (PVRV) exceeding 50 ml were excluded from the study. During and after the procedure, hydration was limited to 500 ml i.v. and 250 ml orally until the first voiding.

The intrathecal injections were performed with a 27 Gauge Whitacre needle at the L3–L4 or L4–L5 interspace. The puncture was performed in the lateral decubitus position with the operative side uppermost. Patients were randomly assigned to three groups, receiving either lidocaine 60 mg (3 ml isobaric 2%), levobupivacaine 10 mg (2 ml isobaric 0.5% + 1 ml 0.9% NaCl), or ropivacaine 15 mg (2 ml isobaric 0.75% + 1 ml 0.9% NaCl). Densities measured at 37°C by refractometry (T2-NE, Atago Co. Ltd, Japan) were 1.009, 1.006, and 1.007, respectively, being similar to the value measured for cerebrospinal fluid, 1.007. All 3-ml solutions were prepared in an adjacent space by a supervisor not involved in the subsequent evaluation of the study-patient.

In the operating room and PACU, ECG, and pulse-oximetry were monitored continuously while arterial pressure was measured at 3-min intervals (Datex AS3, Helsinki, Finland). Any hypotension or bradycardia, defined as a 25% decrease of systolic blood pressure from baseline values, was treated with ephedrine 5 mg or atropine 0.5 mg increments.

All interventions were performed with patients in the supine position while only the leg to be operated was hanging down with a tourniquet inflated to 350 mm Hg. None of the interventions was performed in the lithotomy position.

Motor block was scored using a Bromage scale (0–3). The maximum Bromage score reached and duration of the motor block (duration from spinal injection until Bromage-1 and -0 score) were registered. Sensory block was assessed by loss of cold sensation and the highest level, onset time to T12 and duration until regression to L2 dermatomal level was noted. When, after the intervention, motor block returned to a Bromage-1 score, the patient was discharged from the recovery room to the day-case hospital ward.

Upon arrival in the day-case ward, the bladder volume was measured again and this determined the interval for re-evaluation (<100 ml, 2 h; >100 ml, 1 h). If the bladder volume was greater than 400 ml, patients were encouraged to void within the first hour. Volumes greater than 500 ml or complaints at lower volumes necessitated voiding within 15 min. If this was impossible, an ‘in and out’ catheterization was performed. Catheterization was also performed in case of incontinence or a PVRV exceeding 300 ml. Any difficulties with voiding were noted. Voiding problems were classified in five groups ranging from no problems to those requiring a single catheterization (Table 1). Postoperative pain was noted hourly using a VAS (0–10) scale. If the pain score at rest was higher than 3, propacetamol 2 g were given i.v. Patients were discharged from hospital if the PVRV was less than 100 ml and VAS pain score <3.


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Table 1 Classification of micturition problems
 
Two days after discharge, all patients were contacted by phone and asked about the occurrence of back pain, pain, or dysaesthesia radiating to the legs and buttocks, headache or other problems.

Data are presented as means (SD). Patients characteristics, duration of surgery, and spinal block were compared between groups by analysis of variance (with the Fisher post-hoc test). Micturition problems between groups were compared with a Kruskal–Wallis test. A P-value <0.05 was considered as statistically significant.


    Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
There was no difference with respect to age, weight, height, and male/female ratio (Table 2) between the groups. The time of surgery was comparable also. All except two blocks in the lidocaine group and one in the other two groups were excellent but in none of them was general anaesthesia required. Administration of fentanyl, midazolam, or both was sufficient in these four patients.


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Table 2 Patient characteristics. Data are expressed as mean (SD or range). There were no significant differences
 
The onset time to reach a T12 sensory level was identical for the three groups (Table 3). The majority of patients obtained a Bromage-3 motor block. Return to a Bromage-1 and -0 motor block was identical in the three groups. In the majority of patients the upper sensory level reached T10–12 in all groups (Fig. 1). The time to L2 regression was 145 (30) min in the lidocaine group but was 25–30 min (P<0.05) longer in the other two groups. Hypotension within the first 20 min after the spinal injection was not seen in the ropivacaine group but occurred in five lidocaine patients and one levobupivacaine patient (not significant).


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Table 3 Motor and sensory block characteristics. Data are mean (SD) or %. *Significantly different from the lidocaine group, P<0.05
 


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Fig 1 Maximal upper sensory level of the block. There were no statistically significant differences.

 
After surgery patients from the lidocaine group voided after 245 (65) min, which was 40 min faster than patients from the other two groups (Table 4). The total i.v. hydration and bladder volume at which the patients voided was not significantly different between the groups. Despite faster voiding with lidocaine, there were no significant differences in micturition problems (Fig. 2). The longer intervals until first voiding resulted in a similar prolongation in discharge times for the levobupivacaine and ropivacaine groups. Although 33 out of 90 patients were females, moderate to serious micturition problems were registered in two patients only, which is significantly less (P<0.05) than the 16 out of 57 males. Two of the patients who required a single catheterization were seen by an urologist after discharge but no causal or residual problems were found.


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Table 4 Micturition characteristics. Data are mean (SD). *Significantly different from the lidocaine group, P<0.05
 


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Fig 2 Degree of micturition problems. L=lidocaine, LB=levobupivacaine, R=ropivacaine. There were no statistically significant differences.

 
No differences were noted with respect to postoperative pain and analgesic requirements.

Three patients in the lidocaine group reported symptoms compatible with TNS, which lasted for 24 h, whereas two patients complained of back pain at the puncture site. No such events occurred in the other groups (not significant). One patient in the ropivacaine group complained of severe headache, which lasted for 2 days.


    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The present study demonstrates that ropivacaine and levobupivacaine are acceptable alternatives to lidocaine. They produce a similar quality of spinal anaesthesia but were associated with a slight but significant delay in hospital discharge. Micturition problems were similar in each group.

The 10% incidence of TNS in the lidocaine group was consistent with other studies using the 50–80 mg dose regardless of baricity or concentration although much higher incidences, up to 40%, have been reported.5 6 1019 Despite the lack of significance in comparison with the other groups and the short duration of complaints, a 10% incidence may justify the search for alternative intrathecal local anaesthetics. The results obtained with other short-acting local anaesthetics such as prilocaine and mepivacaine, regardless of baricity, were not very convincing.5 6 14 15

Although bupivacaine does not seem to cause TNS,10 15 its long duration of action is considered to be a major disadvantage for its use in day-case surgery. Little experience exists with the spinal use of the newer local anaesthetics in day-case procedures while also possible potency differences remain a controversial issue. With respect to levobupivacaine, it has been shown in patients undergoing total hip replacement that doses identical to bupivacaine can be used.8 However, comparative studies in labouring patients found weaker motor block properties with levobupivacaine which might accelerate recuperation after spinal anaesthesia.9 16 The shorter duration of motor block with ropivacaine is less debatable than for levobupivacaine. As demonstrated in volunteers and during arthroscopic procedures, the doses of intrathecal ropivacaine should be at least 50% larger than the previously used doses of racemic bupivacaine.7 17 Ropivacaine 10 mg induced a shorter lasting block than bupivacaine 8 mg but the quality of the anaesthesia was significantly less. When increasing the ropivacaine dose to 12 mg, the characteristics and durations of sensory and motor block became identical to bupivacaine 8 mg.7 Similar differences were found in urological procedures during which 15 mg ropivacaine required more i.v. alfentanil supplements than 10 mg bupivacaine.17 18 Although Gautier and colleagues7 recommended the 12 mg dose of ropivacaine for arthroscopic procedures, in a preliminary evaluation, we found this dose to be insufficient. Because of this, we determined the study dose to be 15 mg while consequently for levobupivacaine a 10 mg dose was selected. As the quality of anaesthesia and the degree of motor block did not differ among the three groups, this supports the contention that the selected doses of the three anaesthetics were appropriate. In fact, the return to normal motor function did not differ either but the duration of the sensory block lasted longer (20 min) in patients receiving ropivacaine or levobupivacaine.

A long-lasting sensory block may affect the voiding capability, which requires regression of the sensory block to at least a dermatomal level of S3 in order to obtain normal detrusor function. According to a study by Kamphuis and colleagues,19 the detrusor block lasts 460 min after administration of 10 mg intrathecal bupivacaine, which appears to be longer than in the present study. There may be some debate as to whether patients need to stay in the hospital until they have voided. With excellent home-nursing protocols it seems possible to limit micturition problems to an extremely low incidence. However, this strategy is not recommended following urological procedures and surgery performed under neuraxial techniques.2 20

It is difficult to classify micturition problems as a description does not exist in the literature. The necessity to catheterize the bladder is only the final stage of urinary retention. There is no agreement regarding the bladder volume, which should not be exceeded. According to Kamphuis and colleagues,19 the capacity of the bladder, as measured by preoperative cystometry was 505 ml while Slappendel and others3 catheterized only when this volume exceeded 800 ml. A larger than normal bladder volume may cause over-distension whereas even an ‘in-and-out’ evacuation may cause urinary tract infection.3 In a previous study following ligamental repair and postoperative PCEA, we have tried to use a preliminary classification of voiding problems mostly based upon subjective criteria.21 In the present study we modified this classification because of the availability of an ultrasound bladder scanner. A more exact quantification of the problems may result in better decision-making in a high-risk group but also in establishing better-defined qualitative subclasses.

In patients who are not dehydrated and where return of voiding capability is very important, it may be wise to restrict the administration of fluids. These volumes did not differ among the three groups in our study. The interval between spinal injection and first voiding was 40 min longer for those patients receiving the newer local anaesthetics while the moment at which patients could be discharged was delayed to the same extent. However, considering that in the lidocaine group patients were discharged after 265 (70) min, such a prolongation (15%) is not clinically important. When evaluating the different subclasses of voiding difficulties, there were no differences between the three groups. None to minor problems were noted in the majority of patients (>75%); male subjects were more at risk.


    References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
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