Spinal Versus General Anesthesia With Popliteal and Adductor Canal Blocks for Ambulatory Foot and Ankle Surgery.
Condition: Nerve Block; General Anesthesia; Spinal Anesthesia; Pain; Postoperative Nausea and Vomiting
MeSH terms: Nausea; Vomiting; Postoperative Nausea and Vomiting
Intervention: 25 mL of 0.25% bupivacaine plus 2 mg preservative-free (PF) dexamethasone / 30 ml for popliteal nerve block; 10 mL of 0.25% bupivacaine plus 2 mg preservative-free (PF) dexamethasone / 30 ml for adductor canal nerve block; Midazolam, 2-5 mg IV + Glycopyrrolate, 0.1 mg IV + Ketamine, 10-20 mg + propofol as needed; 45-60 mg of 1.5% mepivacaine for spinal anesthesia; LMA insertion + titrated propofol infusion + sevoflurane + ketamine 10 mg/hr for general anesthesia
Intervention MeSH terms: Dexamethasone; Dexamethasone acetate; Midazolam; Glycopyrrolate; Ketamine; Bupivacaine; Mepivacaine; Anesthetics; Propofol; Sevoflurane; BB 1101
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Enrollment: 36.0
Sex: All
Minimum age: 18 Years
Maximum age: 75 Years
Healthy volunteers: No
Keywords: Nerve Block; General Anesthesia; Spinal Anesthesia; Pain; Postoperative Nausea and Vomiting

Summary:

      The purpose of this study is to determine if there is a difference in patient outcomes with
      general anesthesia versus spinal anesthesia when given in addition to popliteal and adductor
      canal nerve blocks for foot and ankle surgery. Popliteal and adductor canal nerve blocks are
      injections of local anesthetic agents near nerves in the back and front of the knee going to
      the foot and ankle that provide numbness during and after surgery. These peripheral nerve
      blocks offer good pain control and reduce the need for opioids (opioids are pain medications
      such as morphine, Dilaudid, and oxycodone). General anesthesia involves the flow of oxygen
      and anesthesia gas through a tube which, along with additional intravenous medications,
      causes unconsciousness and unawareness of sensations during surgery. Spinal anesthesia
      involves an injection of local anesthetic in the lower back, which causes numbness below the
      waist. In addition to spinal anesthesia, a sedative is typically given intravenously to cause
      relaxation and sleepiness throughout surgery.

      General, spinal, and nerve block anesthesia are all routinely used for surgery at the
      Hospital for Special Surgery. General or spinal anesthesia is typically used in addition to
      peripheral nerve blocks during foot and ankle surgery to 1) allow the surgeons to use a thigh
      tourniquet to reduce bleeding, 2) provide anesthesia earlier, and 3) prevent unwanted
      movement. However, it is unclear whether general or spinal anesthesia provides better patient
      outcomes when given with peripheral nerve blocks. Some reports show that on its own, spinal
      anesthesia has advantages over general anesthesia in terms of side effects such as nausea and
      pain. However, these advantages may also be gained from combining peripheral nerve blocks
      with general anesthesia. Spinal anesthesia can be associated with headache and backache,
      although headache and backache can also happen after operations performed with general
      anesthesia. A previous study at the Hospital for Special Surgery showed low rates of nausea
      among patients who received nerve blocks with spinal anesthesia, and no nausea among patients
      who received a nerve block with general anesthesia. Therefore, the primary aim of this study
      is to determine if, as a treatment, either general or spinal anesthesia has advantages over
      the other treatment in terms of readiness for discharge, side effects, pain and patient
      satisfaction in an ambulatory foot and ankle population.
    

Eligibility criteria:

        Inclusion Criteria:

          -  18-75 aged patients

          -  American Society of Anesthesiologists (ASA) Physical Status classification 1-3

          -  Elective foot and ankle day surgery procedures, lasting between 1 and 3 hours as per
             surgeon, performed by 3 co-investigator surgeons.

          -  Planned for combined popliteal and adductor canal block

          -  No contraindications for spinal or LMA general anesthesia

        Exclusion Criteria:

          -  Incapable of providing informed consent

          -  Contraindications for regional or LMA anesthesia (anticoagulation, infection at
             injection site)

          -  Anticipated difficult airway

          -  BMI>40

          -  Anticipated surgical procedure time less than 1 hour or more than 3 hours

          -  Hx of severe postoperative nausea and vomiting

          -  ASA >3

          -  Peripheral neuropathy affecting the operative extremity

          -  Pregnant or nursing women

          -  Chronic opioid use (daily use of opioids one month prior to surgery/ patients
             requiring chronic pain interventions)

          -  Prone position

          -  Obstructive sleep apnea with planned admission overnight to the hospital

          -  Known allergy/sensitivity to any study medications

          -  Planned admission after surgery

          -  Non-English speaking