Optimal local anesthetic for spinal anesthesia in patients undergoing ambulatory non-arthroplasty surgery: a systematic review and Bayesian network meta-analysis of randomized controlled trials.

Abstract

Purpose: Dosing and types of local anesthetic agents for spinal anesthesia in ambulatory settings vary significantly. We sought to conduct a network meta-analysis to evaluate the effect of the type and dose of local anesthetic on outcomes in patients undergoing ambulatory surgery.

Methods: After PROSPERO registration (CRD42023399356), we searched various databases for randomized controlled trials (RCTs) evaluating adult patients undergoing daycare surgery under spinal anesthesia. Most included trials focused on patients undergoing knee arthroscopy, while other covered procedures were perineal, lower abdominal, and limb surgeries. Unfortunately, we could not include trials on arthroplasty surgery owing to the lack of RCTs in this area. We used Confidence in Network Meta-Analysis (CINeMA) to assess the confidence in the estimates, and we used surface under the cumulative ranking curve (SUCRA) to determine the probability rank order. The primary outcome was the time to discharge. Intraoperative effectiveness of anesthetic, sensory, and motor blockade duration; time to first micturition; time to ambulation; and adverse effects such as urinary retention and transient neurologic symptoms (TNS) were the secondary outcomes.

Results: Overall, this study included 44 trials comprising 3,299 patients, each comprising 11 distinct agents (2-chloroprocaine, articaine, high-dose bupivacaine, low-dose bupivacaine, lidocaine, high-dose levobupivacaine, low-dose levobupivacaine, mepivacaine, prilocaine, high-dose ropivacaine, and low-dose ropivacaine). Low- to moderate-certainty evidence showed that 2-chloroprocaine, lidocaine, and mepivacaine were superior for discharge readiness, while 2-chloroprocaine ranked highest for other outcomes (sensory and motor block duration, time to first ambulation, and spontaneous voiding).

Conclusions: Evidence supports 2-chloroprocaine for short-duration spinal anesthesia in the ambulatory setting.

Study registration: PROSPERO ( CRD42023399356 ); first submitted 13 February 2023.