Spinal 2-Chloroprocaine: A Comparison with Lidocaine
in Volunteers
Mary E. Kouri, MD, and Dan J. Kopacz, MD
From the Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington
Subarachnoid lidocaine has been the anesthetic of choice
for outpatient spinal anesthesia. However, its use is asso-
ciated with transient neurologic symptoms (TNS).
Preservative-free formulations of 2-chloroprocaine are
now available and may compare favorably with lidocaine
for spinal anesthesia. In this double-blinded, randomized,
crossover study, we compared spinal chloroprocaine and
lidocaine in 8 volunteers, each receiving 2 spinal anesthet-
ics: 1 with 40 mg 2% lidocaine and the other with 40 mg 2%
preservative-free 2-chloroprocaine. Pinprick anesthesia,
tolerance to transcutaneous electrical stimulation and
thigh tourniquet, motor strength, and a simulated dis-
charge pathway were assessed. Chloroprocaine pro-
duced anesthetic efficacy similar to lidocaine, including
peak block height (T8 [T511] versus T8 [T6 12], P
W
hen 2-chloroprocaine was first introduced in
1951, Foldes and McNall (1) described its use in
214 spinal anesthetics and reported no cases of
neurotoxicity. It was never used extensively for spinal
anesthesia, possibly because of the concurrent availabil-
ity and widespread acceptance of lidocaine. Further-
more, by 1954, the only solutions of 2- chloroprocaine
commercially available contained methylparaben, a pre-
servative, or sodium bisulfite, an antioxidant, making
them inappropriate for intrathecal injection (2). It has
Supported, in part, by the Department of Anesthesiology, Vir-
ginia Mason Medical Center, Seattle, Washington.
Presented, in part, at the 41st Annual Western Anesthesia Resi-
dents Conference, Palo Alto, California, April, 2003.
Disclaimer: Although 2-chloroprocaine has been approved by the
FDA, it is not specifically indicated for use in spinal anesthesia. Its
use for spinal anesthesia is thus considered off-label. All current
manufacturers of 2-chloroprocaine distinctly label the product Not
for Spinal Anesthesia. All subjects in this study were made aware
of this information, which was also included within their written
informed consent.
Accepted for publication August 14, 2003.
Address correspondence to Dr. Kopacz, Department of Anesthe-
siology, Virginia Mason Clinic, 1100 Ninth Avenue, B2-AN, PO Box
900, Seattle, WA 98111. Address email to anedjk@vmmc.org.
DOI: 10.1213/01.ANE.0000093228.61443.EE
2003 by the International Anesthesia Research Society
0003-2999/03
0.8183) and tourniquet tolerance (46 6 min versus 38
24 min, P 0.4897). Chloroprocaine anesthesia resulted in
faster resolution of sensory (103 13 min versus 126
16 min, P 0.0045) and more rapid attainment of simu-
lated discharge criteria (104 12 min versus 134 14 min,
P 0.0007). Lidocaine was associated with mild to mod-
erate TNS in 7 of 8 subjects; no subject complained of TNS
with chloroprocaine (P 0.0004). We conclude that the
anesthetic profile of chloroprocaine compares favorably
with lidocaine. Reliable sensory and motor blockade with
predictable duration and minimal side effects make chlo-
roprocaine an attractive choice for outpatient spinal
anesthesia.
(Anesth Analg 2004;98:7580)
been used extensively for epidural anesthesia, particu-
larly in obstetrics. In fact, 2- chloroprocaine was advo-
cated as the epidural drug of choice for obstetrics be-
cause of its small potential for systemic toxicity to
mother or fetus (3). In the 1980s, 8 patients were reported
to have persistent neurological deficits after epidural
anesthesia with 2-chloroprocaine. Four of these eight
patients are known to have received unintentional sub-
arachnoid injection of large volumes of bisulfite-
containing 2-chloroprocaine (Nesacaine CE, Astra USA,
Wilmington, DE) resulting in total spinals (4 6). Sub-
sequent laboratory studies have shown that persistent
neurologic deficits are associated with sodium bisulfite
at low pH (5.0) and that 2-chloroprocaine alone at pH
3.2 or with bisulfite at pH 7.2 did not produce
irreversible neurologic deficits (7,8). Preservative-free so-
lutions of 2-chloroprocaine appropriate for intrathecal
injection are now available in 2% and 3% concentrations
(Nesacaine-MPF, Astra USA; 2-chloroprocaine, Bedford
Laboratories, Bedford OH).
Subarachnoid lidocaine is popular for spinal anes-
thesia because of its predictable duration and dense
sensory and motor blockade. However, its use is as-
sociated with a syndrome of musculoskeletal pain
radiating to the buttocks or lower extremities, com-
monly known as transient neurologic symptoms
(TNS). Symptoms usually begin 6- 36 h after the spinal
Anesth Analg 2004;98:7580 75
76 AMBULATORY ANESTHESIA KOURI AND KOPACZ ANESTH ANALG
SPINAL CHLOROPROCAINE VERSUS LIDOCAINE 2004;98:7580

Table 1. Clinical Data

2-chloroprocaine Lidocaine P value
Sensory block
Peak block height T8 (T5T11) T8 (T612) 0.8183
Time until 2-dermatome regression (min) 57 14 73 23 0.0417*
Regression to L1 68 10 84 35 0.2823
Tourniquet tolerance 46 6 38 24 0.4897
TES (60mA)
T10 63 14 61 40 0.8602
T12 79 17 79 36 0.9598
RL3 97 16 113 16 0.0096*
LL3 97 14 112 17 0.0198*
RS1 95 16 108 24 0.1740
LS1 101 15 109 24 0.3205
Motor Block
Time (min) until 90% recovery at:
Abdomen 71 18 60 53 0.5581
Quadriceps 51 10 54 17 0.5955
Gastrocnemius 50 7 50 15 0.9701
Bromage 79 15 90 14 0.1612
Discharge criteria
Time (min) until:
Resolution of sensory block at S2 103 13 126 16 0.0045*
Ambulation 104 12 134 14 0.0009*
Micturition 104 12 134 14 0.0007*
TES transcutaneous electrical stimulation.
* P 0.05.

anesthetic and last 17 days. Pain is often described as

cramping, aching, or lancinating and in some cases is
quite severe (9). There are no persistent neurologic
deficits. It is generally self-limited and responds well
to nonsteroidal antiinflammatory drugs (NSAIDS). Al-
though not life-threatening, TNS is an undesirable
side effect that can negatively impact a patients func-
tional status after surgery as well as their satisfaction
with regional anesthesia. TNS occurs more frequently
with lidocaine spinal anesthesia than with other local
anesthetics, and has led many practitioners to aban-
don the use of lidocaine for spinal anesthesia (10).
We speculate that preservative-free 2-chloroprocaine
may compare favorably with lidocaine for use in outpa- Figure 1. Resolution of sensory block determined by pinprick anes-
thesia, 2-chloroprocaine versus lidocaine. Repeated-measures anal-
tient spinal anesthesia. This randomized, double-blinded ysis of variance, P 0.05.
crossover study was designed to compare spinal
2-chloroprocaine and lidocaine in volunteers using end-
within their written informed consent. Prior studies sug-
points of interest in outpatient anesthesia.
gest 2-chloroprocaine has a similar anesthetic profile to
lidocaine at a 45-mg dose (3 mL of 3% preservative-free
2-chloroprocaine) (11). All subjects had fasted for 6 h and
Methods received no sedatives during the study. Before subarach-
After IRB approval and written informed consent were noid block, a 20-gauge peripheral IV line was placed
obtained, 8 healthy volunteers were enrolled. Although and an IV bolus of lactated Ringers solution (6 mL/kg)
2-chloroprocaine has been approved by the Food and was administered, followed by an infusion of
Drug Administration, it is not specifically indicated for 8 mL kg1 h1 for the first hour and 2 mL kg1 h1
use in spinal anesthesia. Its use for spinal anesthesia is thereafter. A random number generator was used to
thus considered off-label. All current manufacturers of determine order of drug administration. Each volunteer
2-chloroprocaine distinctly label the product Not for received 2 spinal anesthetics separated by at least 48 h, 1
Spinal Anesthesia. All subjects in this study were made with 2 mL plain, preservative-free 2% 2-chloroprocaine
aware of this information, which was also included (40 mg; Nesacaine MPF, Astra USA) and the other with
ANESTH ANALG AMBULATORY ANESTHESIA KOURI AND KOPACZ 77
2004;98:7580 SPINAL CHLOROPROCAINE VERSUS LIDOCAINE

Figure 2. Duration of tolerance to simulated surgical stimulus (transcutaneous electrical stimulation of 60 mA), by dermatomes. Tolerance
to thigh tourniquet placed 30 min after injection. Time to completion of simulated discharge pathway, independent ambulation and
micturition. All analyses are paired Students t-tests, averaged if bilateral measurements were made. *P 0.05.

2 mL preservative-free 2% lidocaine (40 mg, Abbott Lab-

oratories, North Chicago, IL).
Spinal anesthesia was administered with the volun-
teers in the left lateral decubitus position. Under ster-
ile conditions, and after local infiltration of the skin
with 1% lidocaine, the subarachnoid space was en-
tered at the L23 interspace via the midline approach
using a 20-gauge introducer and a 24-gauge Sprotte
needle. With the spinal needle orifice facing cephalad,
0.2 mL of the cerebrospinal fluid was aspirated, fol-
lowed by injection of the study solution at a rate of
0.25 mL/s. After drug administration, a second 0.2-mL
aspiration and reinjection of cerebrospinal fluid was
used to confirm intrathecal injection. Subjects were
immediately laid supine for the remainder of the
study. Vital signs were monitored with continuous
pulse oximetry, continuous electrocardiogram, and in-
termittent noninvasive blood pressure. Vasoactive
drugs were administered only if symptoms of hypo-
tension or bradycardia developed.
Bilateral sensory block to pinprick was tested by a
blinded assessor in a cephalad to-caudad direction
with a disposable dermatome tester every 5 min after
injection for the first 60 min, then at 10-min intervals
until complete resolution of sensory anesthesia. The
right C5-6 dermatome was used as an unblocked ref- Figure 3. A, resolution of motor block measured by isometric force
erence point. Tolerance to transcutaneous electrical dynamometry of quadriceps muscle, repeated-measures analysis of
variance, P 0.0480. B, resolution of motor block measured by
stimulation (TES) was determined at 6 common sur- isometric force dynamometry of gastrocnemius muscle, repeated-
gical sites: at the lateral ankle (S1) bilaterally, at the measures analysis of variance, P 0.0942.
78 AMBULATORY ANESTHESIA KOURI AND KOPACZ
SPINAL CHLOROPROCAINE VERSUS LIDOCAINE
Figure 4. Hemodynamic changes during spinal anesthesia,
2-chloroprocaine versus lidocaine. Repeated-measures analysis of
variance, P 0.05.
medial knee (L3) bilaterally, at the pubis midline
(T12), and at the umbilicus midline (T10). TES was
performed with a peripheral nerve stimulator (Model
NS252; Fisher & Paykel, Auckland, New Zealand) us-
ing 50 Hz tetanus for 5 s initially at 10 mA and then
with increasing increments of 10 mA to a maximum of
60 mA. This maximum limit was chosen because pre-
vious studies have shown TES at 60 mA to be equiv-
alent to the intensity of stimulation caused by surgical
incision (12). Testing began in a systematic cephalad-
to-caudad order at 4 min after injection and continued
at 10-min intervals until the subject could no longer
tolerate 60 mA on 2 successive tests. If the subject was
never able to tolerate 60 mA, the testing was termi-
nated at 34 min.
Thirty minutes after injection, duration of the toler-
ance to left thigh tourniquet was assessed using a
34-inch pneumatic cuff that was inflated to 300 mm
Hg after exsanguination by gravity. This is similar to
the tourniquet application used in lower extremity
orthopedic procedures at our institution. The subjects
were instructed to request deflation of the tourniquet
when the discomfort level reached a pain score of 5 on
a 10-point scale or at a maximum time limit of
120 min.
Motor block of the abdominal and lower extremity
muscles was assessed using electromyography (EMG),
isometric force dynamometry, and modified Bromage
scale. To test abdominal muscle strength, an EMG lead
was placed over the body of the rectus abdominus
muscle to the left of the umbilicus. A restraining strap
was placed across the body at the level of the xiphoid,
and an isometric maximal contraction of abdominal
muscle flexion against the strap was conducted. Using
a commercially available surface EMG (MyoTrac2;
Thought Technology Ltd., Montreal, PQ), an aver-
aged, rectified measurement was taken during the
middle 2 s of a 6-s maximal effort. Muscle strength of
ANESTH ANALG
2004;98:7580
the right lower extremity was measured using a com-
mercially available isometric force dynamometer (Mi-
cro FET; Hoggan Health Industries, Draper, UT), dur-
ing a 5-s maximal force contraction of the right
quadriceps muscle (straight leg lift against resistance)
and right gastrocnemius (plantar flexion against resis-
tance). Measurements for both tests were performed
in triplicate and averaged at baseline and at 10-min
intervals after injection until 90% of baseline
strength returned. Modified Bromage scores (0 no
block, 1 able to bend the knee, 2 able to dorsiflex
the foot, and 3 complete motor block) were re-
corded every 10 min after injection until the resolution
of the motor block or until 40 min if no motor block
was achieved.
Each subject underwent a simulated clinical dis-
charge pathway. On recovery of the S2 dermatome to
pinprick, the subjects attempted ambulation without
assistance. If ambulation was successful, they then
attempted to void. If either ambulation or voiding was
unsuccessful, then the attempts were repeated at 10-
min intervals until these end-points were achieved.
Volunteers were questioned daily for 72 h regarding
the presence of headache, backache, or other
symptoms.
Bilateral measurements were averaged for each sub-
ject. Paired Students t-tests were used to determine
differences between anesthetics in each subject.
Repeated-measures analysis of variance was used for
continuous variables, and 2 analysis was used for
incidence data. Unless otherwise specified, data are
mean sd, with significance defined as P 0.05.
Results
Successful spinal anesthesia was obtained in all subjects
(3 female, 5 male; age, 35 6 yr; weight, 79 19 kg;
height, 173 7 cm). Subjects received 400 222 mL of
IV lactated Ringers solution. 2-chloroprocaine was sim-
ilar to lidocaine in pertinent measures of surgical efficacy
including peak block height, tourniquet tolerance, and
tolerance of TES equivalent to surgical incision (Table 1,
Fig. 1). 2-chloroprocaine was associated with faster res-
olution of sensory anesthesia and earlier attainment of
commonly used discharge criteria, including time to
complete regression and voiding (Table 1, Fig. 2). Al-
though there was a tendency for 2-chloroprocaine to
produce a shorter duration of motor blockade (Fig. 3),
this did not reach statistical significance (Table 1). Sacral
sparing was noted in two subjects, one after a lidocaine
spinal anesthetic and one after a 2-chloroprocaine spinal
anesthetic. Three subjects had tourniquet tolerance of
30 min with lidocaine spinals; all subjects had tourni-
quet tolerance of 30 min with 2-chloroprocaine spinal
anesthesia.
Hemodynamic changes were mild, and did not vary
significantly between groups (Fig. 4). No vasoactive
ANESTH ANALG
2004;98:7580
Table 2. Side Effects
2-CP Lidocaine
Subject TNS TNS Site
1 No Yes Bilat. posterior thighs to knees
2 No Yes Low back pain
3 No Yes Bilat. mid-posterior calves
4 No Yes Low back to bilat. anterior/lateral thighs
5 No No
6 No Yes Bilat. anterior thighs
7 No Yes Bilat. hips and buttocks
8 No Yes Bilat. anterior and posterior thighs
TNS transient neurologic symptoms; VAS visual analog scale; NSAIDS nonsteroidal antiinflammatory drugs.
drugs were required.
No subjects complained of headache after either
anesthetic. Of note were complaints of low back pain
with radiation to the hips, buttocks, or lower extrem-
ities consistent with TNS in 7 of 8 subjects after receiv-
ing lidocaine spinal anesthesia. These symptoms
started 0 36 h after the resolution of spinal anesthesia,
lasted for 24 72 h, and were rated by subjects as
having a mean visual analog score of 4.7, with a range
of 2 8. No subject reported symptoms of TNS after
receiving 2-chloroprocaine spinal anesthesia (2, P
0.004) (Table 2). One subject complained of ab-
dominal pain and constipation for 2 days after the
2-chloroprocaine spinal; otherwise, there were no
complaints of side effects after 2-chloroprocaine spinal
anesthesia.
Discussion
This study demonstrates that spinal anesthesia with
40 mg of preservative-free 2-chloroprocaine produces
an equivalent quality of surgical anesthesia compared
to 40 mg lidocaine. Onset and peak block height were
similar in both groups. Tourniquet tolerance was sim-
ilar in both groups, though we must note that tourni-
quet times were unacceptably short during lidocaine
spinals for 3 subjects, suggesting that 40 mg plain
lidocaine may not be sufficient for procedures where
prolonged tourniquet use is anticipated. Sedation with
benzodiazepines or propofol, as is common with
many regional anesthetics, may extend the duration of
tourniquet tolerance during surgical procedures. Pre-
vious studies have shown TES to 60 mA to be an
equivalent stimulus to surgical incision during general
anesthesia, and tolerance of TES stimulation likely
represents a reasonable facsimile to surgical condi-
tions under regional anesthesia (11,12). We found the
duration of both sensory and motor block is shorter
with 2-chloroprocaine, resulting in an earlier time to
void and ambulate.
Some clinicians have advocated use of small-dose
bupivacaine in lieu of lidocaine, as the incidence of
AMBULATORY ANESTHESIA KOURI AND KOPACZ 79
SPINAL CHLOROPROCAINE VERSUS LIDOCAINE
Onset VAS Duration Treatment
4h 2/10 48 h NSAIDS
36 h 4/10 24 h NSAIDS
2h 2/10 72 h NSAIDS
Immediate 8/10 48 h NSAIDS
2h 8/10 36 h NSAIDS
36 h 2/10 24 h NSAIDS
4h 7/10 48 h NSAIDS
TNS is significantly less (13). Small-dose spinal bupiv-
acaine does not reliably provide motor block (14), and
larger doses may delay discharge because of pro-
longed sensory blockade and failure to void, making it
less attractive for outpatient procedures. Unlike small-
dose bupivacaine, 2-chloroprocaine spinal anesthesia
reliably produces profound lower extremity motor
block, which is desirable for many surgical proce-
dures. 2-chloroprocaine also produces a more predict-
able duration of sensory anesthesia, with standard
deviations of 20 min for all measurements. In con-
trast, small-dose spinal bupivacaine has been shown
to be quite variable in duration, with a 3.75-mg dose of
bupivacaine resulting in 73 43 min of TES tolerance
at S2 (15).
Procaine, another short-acting ester anesthetic, has an
infrequent incidence of TNS (16) but has been associated
with a 14%17% incidence of clinical block failure (16,17)
and prolonged discharge from outpatient procedures
because of nausea, vomiting, and other side effects
(16,18). Ester anesthetics such as procaine and
2-chloroprocaine can provoke allergic reactions in pa-
tients sensitive to p-aminobenzoic acid. Skin sensitivity
is relatively common, but serious allergic reactions are
rare. We are unaware of any clinical studies directly
comparing spinal 2-chloroprocaine with either bupiva-
caine or procaine.
The incidence of TNS with spinal lidocaine in our
study was surprisingly frequent, occurring in 7 of 8
subjects. Surgical patients taking NSAIDS or narcotics
after surgery may be less likely to have symptoms of
TNS. Concurrent use of sedatives, hypnotics, or analge-
sics commonly given to surgical patients during block
placement or the surgical procedure may also reduce the
incidence of TNS. We speculate that the study design
itself, with frequent use of low back (sit-ups) and lower
extremitiy (leg lifts) muscles may also have contributed
to an increased incidence of these symptoms. However,
the randomized, double-blinded crossover study design
included these same maneuvers in each subject for each
spinal anesthetic. There were no complaints of TNS after
2-chloroprocaine spinal anesthesia. Therefore, despite a
small number of subjects and an unusually frequent
80 AMBULATORY ANESTHESIA KOURI AND KOPACZ
SPINAL CHLOROPROCAINE VERSUS LIDOCAINE
incidence of TNS with lidocaine, the intraindividual dif-
ference clearly suggests that subarachnoid block with
2-chloroprocaine is less likely to be associated with TNS.
Reliable achievement of discharge criteria is of great
interest in an outpatient setting. We evaluated several
commonly used discharge criteria in our unsedated vol-
unteers, including resolution of sensory anesthesia, in-
dependent ambulation, and voiding. 2-chloroprocaine
spinal anesthesia produced earlier attainment of all dis-
charge criteria. This may not predict actual discharge
times in surgical patients, who frequently receive seda-
tion and narcotics during the perioperative period. Other
side effects such as nausea, vomiting, and urinary reten-
tion can also delay discharge in surgical patients but
were not seen in this small sample.
Reports of persistent neurotoxicity after intrathecal
injection of large volumes of preservative-containing
2-chloroprocaine intended for the epidural space have
been well reviewed in the anesthesia literature (2). In
short, it has been shown that sodium bisulfate and
metabisulfite, used as preservatives, are neurotoxic
when combined with acidic formulations of local an-
esthetics. Although the literature is somewhat di-
vided, most clinicians have concluded that the injuries
reported from injection of large doses of Nescaine-CE
in the intrathecal space were most likely caused by
neurotoxicity from this preservative. No convincing
evidence exists to suggest that preservative free
2-chloroprocaine is neurotoxic in doses appropriate
for spinal anesthesia.
A second preservative, EDTA, has been implicated
as a possible cause of back pain after epidural injection
of 2-chloroprocaine; this formulation is no longer com-
mercially available. The pain syndrome experienced
after epidural anesthesia with 2-chloroprocaine is dis-
tinctly different from TNS. It consists of localized low
back pain without radiation or radicular symptoms,
with onset immediately after the resolution of anes-
thesia (19). It is thought to be dose-related and occurs
most frequently with doses of 400 mg or more of
2-chloroprocaine.
Intrathecal injection of preservative-free 2-
chloroprocaine compares favorably with lidocaine for
ambulatory anesthesia, providing equivalent surgical
anesthesia with earlier block resolution, more rapid
attainment of commonly used discharge criteria, and
ANESTH ANALG
2004;98:7580
no evidence of TNS. Larger clinical trials are under-
way to further address questions of safety and efficacy
of 2-chloroprocaine for ambulatory spinal anesthesia.
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