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.

Summary

In a network meta-analysis of 44 RCTs (3,299 patients), 2-chloroprocaine, lidocaine, and mepivacaine shortened discharge readiness, with 2-chloroprocaine ranking best across recovery metrics (shorter sensory/motor block, earlier ambulation and voiding) for ambulatory spinal anesthesia.

Key Findings

• Across 44 RCTs (n=3,299), 2-chloroprocaine, lidocaine, and mepivacaine improved time to discharge versus longer-acting comparators.
• 2-chloroprocaine ranked highest for shorter sensory/motor block durations, earlier ambulation, and spontaneous voiding (SUCRA-based).
• Evidence was low-to-moderate certainty; most trials involved knee arthroscopy, with limited data for arthroplasty.

Clinical Implications

For short-duration ambulatory procedures, preferentially consider 2-chloroprocaine to expedite discharge readiness and recovery milestones, while balancing local availability and TNS/urinary retention risks compared with alternatives.

Limitations

• Heterogeneity in procedures and dosing; many trials focused on knee arthroscopy, limiting generalizability to other surgeries
• Low-to-moderate certainty; insufficient RCTs for arthroplasty restricted scope

Future Directions

Head-to-head RCTs of short-acting agents in diverse ambulatory procedures, standardized dosing, and patient-centered outcomes (PONV, TNS, urinary retention, satisfaction) to refine recommendations.