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BackgroundIn ambulatory lower limb surgery, spinal anesthesia with rapid onset and a short duration of block is preferable. We hypothesized that the use of 2-chloroprocaine would be associated with a faster motor block recovery compared with prilocaine in knee arthroscopy. A difference of 15 min was considered clinically relevant.Methods150 patients were randomly allocated to receive intrathecally either 40 mg of 2-chloroprocaine or 40 mg of prilocaine. The primary outcome was the time to complete recovery from motor blockade. Secondary outcomes included time to full regression of sensory block, peak sensory block level, urine retention needing catheterization, time until hospital discharge, incidence of transient neurologic symptoms and patient satisfaction.ResultsTime to complete recovery from motor blockade was 15 min shorter for 2-chloroprocaine (median: 60 min; IQR: 60–82.5) than for prilocaine (median: 75 min; IQR: 60–90; p=0.004). 2-Chloroprocaine also resulted in faster full regression of sensory block (median: 120 min; IQR: 90–135 compared with median: 165 min; IQR: 135–190, p<0.001) and faster time to hospital discharge (mean difference: 57 min; 95% CI 38 to 77, p<0.001). Peak sensory block was higher in the 2-chloroprocaine group (median: T9; IQR: T6–T12 compared with median: T10; IQR: T8–T12, p<0.008). Patient satisfaction and urine retention needing catheterization were equal in both groups.ConclusionsIn knee arthroscopy, spinal anesthesia with 2-chloroprocaine results in a faster recovery of motor and sensory block, leading to quicker hospital discharge compared with prilocaine.Trial registration numberNTR6796.

In one-third of preoperatively screened patients, an MEA was found. The number of medications and respiratory comorbidities are risk factors for MEA in preoperatively screened patients.

BackgroundA short acting spinal anesthetic facilitates smooth flow since quick recovery of motor function will facilitate unassisted ambulation. The aim of this study was to estimate the effective dose (ED90) of intrathecal 2-chloroprocaine 1% in outpatient knee arthroscopy.MethodsTwo cohorts were included in two different hospitals. In cohort I, a randomized biased-coin up-and-down design with 40 patients was used to find the ED90. Four dose-levels of plain 2-chloroprocaine 1% were used: 25, 30, 35 and 40 mg. The identified primary outcome, the ED90, was validated in 50 patients in cohort II with an open label design. Secondary outcomes included time to complete recovery from motor and sensory block with spinal injection as time zero, peak sensory block level, urine retention and time until hospital discharge.ResultsForty patients were included in the final analysis in cohort I. The ED90 was estimated at 27.8 mg, successful spinal anesthesia was obtained in 38 patients (95%). Fifty patients were included in the final analysis in cohort II, 49 patients had successful anesthesia with a fixed round dose of 28 mg. In this Cohort, peak sensory block was T10/T11 (range: (L4–T4)). The median time to full recovery of the motor block was 60 min (45–60) and 90 min (75–105) for the sensory block. The mean time to hospital discharge was 2.9 hours (0.7).ConclusionThe ED90 of 2-chloroprocaine 1% in knee arthroscopy was estimated to be 27.8 mg. In an external population, the ED90 resulted in successful anesthesia in 98% of the patients (95% CI 89% to 100%).Trial registration numberNetherlands Trial Registry (NL6769).

Of 368 included patients, 167 (45.4%) had at least 1 MEA. ROC analysis revealed significant differences in the area under the curve of 0.535 ( P = 0.26; validation cohort) versus 0.752 ( P < 0.0001; derivation cohort). The sensitivity in this validating cohort was 66%, with a specificity of 40%. Conclusion and Relevance: The risk prediction model developed in a general hospital population is not suitable to identify patients at risk for MEA in a university hospital population. However, number of medications is a common risk factor in both patient populations and should, thus, form the basis of an adapted risk prediction model.

Background: Medication reconciliation has become standard care to prevent medication transfer errors. However, this process is time-consuming but could be more efficient when patients are engaged in medication reconciliation via a patient portal. Objectives: To explore whether medication reconciliation by the patient via a patient portal is noninferior to medication reconciliation by a pharmacy technician. Design (including intervention): Open randomized controlled noninferiority trial. Patients were randomized between medication reconciliation via a patient portal (intervention) or medication reconciliation by a pharmacy technician at the preoperative screening (usual care). Setting and Participants: Patients scheduled for elective surgery using at least 1 chronic medication were included. Measures: The primary endpoint was the number of medication discrepancies compared to the electronic nationwide medication record system (NMRS). For the secondary endpoint, time investment of the pharmacy technician for the medication reconciliation interview and patient satisfaction were studied. Noninferiority was analyzed with an independent t test, and the margin was set at 20%. Results: A total of 499 patients were included. The patient portal group contained 241 patients; the usual care group contained 258 patients. The number of medication discrepancies was 2.6 AE 2.5 in the patient portal group and 2.8 AE 2.7 in the usual care group. This was not statistically different and within the predefined noninferiority margin. Patients were satisfied with the use of the patient portal tool. Also, the use of the portal can save on average 6.8 minutes per patient compared with usual care. Conclusions and Implications: Medication reconciliation using a patient portal is noninferior to medication reconciliation by a pharmacy technician with respect to medication discrepancies, and saves time in the medication reconciliation process. Future studies should focus on identifying patient characteristics for successful implementation of patient portal medication reconciliation.

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A patient with Graves' disease was admitted with a thyroid storm. She had severe hypercalcaemia caused by thyrotoxicosis. Treatment was complicated by vomiting and diarrhoea. With intravenous ondansetron, hydration and bisphosphonates, GI symptoms improved and oral thyreostatics could be started. This, combined with bisphosphonate administration, resulted in a mild hungry bone syndrome.