Vertebral level of Tuffier's line measured by ultrasonography in parturients in the lateral decubitus position

BACKGROUND

It is known that Tuffier's line intersects the spine at the L4 spinous process or at the L4-L5 intervertebral space. Full term parturient women undergo various physical changes. Therefore, determining the vertebral level with Tuffier's line based on palpation inevitably is not very accurate. The aim of this study was to use ultrasound to verify the difference between vertebral levels for the palpated Tuffier's line in parturient and non-parturient women in the lateral decubitus position.

METHODS

We consecutively enrolled 40 parturient women at 37-41 weeks of gestation and 40 non-parturient women scheduled for regional anesthesia. In the left lateral position, the location of the vertebra was identified using ultrasonography. We marked every intervertebral space from L5 to L2 vertebra, divided each spinous process into two equal parts, and numbered the spaces sequentially from 1 to 9. We drew a Tuffier's line by palpating, recorded the vertebral level that this line intersected.

RESULTS

The mean value of an arbitrary number of vertebral level of Tuffier's line was 6.4 ± 0.9 in the non-pregnant group and this represents L4-lower vertebral level. In the pregnant group, the mean value was 3.0 ± 1.0 which represents L3-lower vertebral level. There was a significant difference between the two groups (P < 0.05).

CONCLUSIONS

We compared using an available ultrasound technique the vertebral levels intersected by the palpated Tuffier's line between parturient and non-parturient women and found that the vertebral levels were more cephalad in the parturient women compared to the non-parturient women.

The comparison of the effects of intravenous ketamine or dexmedetomidine infusion on spinal block with bupivacaine

Background

Ketamine and dexmedetomidine are commonly used for sedation and analgesia in patients. We tried to compare the effects of intravenous ketamine and dexmedetomidine infusion on spinal block with bupivacaine.

Methods

Ninety American Society of Anesthesiologists physical status class I or II patients, who were scheduled to spinal anesthesia were randomly assigned to one of three groups (n = 30). Normal saline 10 ml, 5 ml/hr (loading dose for 10 minutes, infusion) (Group NS), dexmedetomidine 1 µg/kg, 0.5 µg/kg/hr (Group DEX), or ketamine 0.2 mg/kg, 0.5 mg/kg/hr (Group KET) was infused intravenously before spinal anesthesia. We recorded the time to highest sensory block level, sensory and motor regression, and hemodynamic changes.

Results

Patients in Groups KET had a significantly faster onset time of sensory block than patients in Group NS. The highest sensory block levels were not significantly different between groups. Average time of sensory regression and knee flexion, was significantly longer in the Group KET and Group DEX than the Group NS.

Conclusions

Intravenous dexmedetomidine and ketamine were found to have a similar synergistic effect with intrathecal bupivacaine. Hemodynamic stability showed better results in Group KET.

Laparoscopic Cholecystectomy Under Spinal Anaesthesia vs. General Anaesthesia: A Prospective Randomised Study

INTRODUCTION

Laparoscopic cholecystectomy (LC) is conventionally performed under general anaesthesia (GA) in our institution. There are multiple studies which have found spinal anaesthesia as a safe alternative. We have conducted this study of LC, performed under spinal anesthesia to assess its safety and feasibility in comparison with GA.

MATERIALS AND METHODS

Fifty patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomised to have LC under spinal (n = 25) or general (n = 25) anesthesia. Intraoperative vitals, postoperative pain, complications, recovery, and surgeon satisfaction were compared between the 2 groups.

RESULTS

In the SA group six patients (24%) complained of shoulder pain, two patients required conversion to GA (8%) as the pain did not subside with Fentanyl. None of the patients in the SA group had immediate postoperative pain at operated site. Only two (8%) patients had pain score of 4 at the operative site within eight hours requiring rescue analgesic. One patient had nausea but no vomiting (4%). All the patients (100%) in the GA group had pain at operated site immediately after surgery and their pain score ranged from 4-7, all patients received rescue analgesic before shifting to the ward. In the first 24h tramadol required as rescue in the GA group was 82±24 mg which was significantly higher than the SA group requiring only 30±33.16 mg. Although, the GA group had more patients experiencing postoperative nausea & vomiting it was not statistically significant.

CONCLUSION

SA as the sole anaesthesia technique is feasible, safe and cost effective for elective LC.

The effects on Apgar scores and neonatal outcomes of switching from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic vasopressor during spinal anesthesia for cesarean section

Background

Ephedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthesia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section.

Methods

In obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combination of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (2011-2012, two years).

Results

There were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal seizure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002).

Conclusions

Conversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a significant decrease in the incidence of 1 min Apgar < 7.

Effects of general and spinal anesthetic techniques on endothelial adhesion molecules in cesarean section

Background

The aim of this study was to investigate the effects of anesthetic techniques used during general anesthesia (GA) and spinal anesthesia (SA) on endothelial adhesion molecules in the fetal circulation of healthy parturients undergoing elective cesarean section.

Methods

Patients were randomly assigned to either the general anesthesia (n = 20) or spinal anesthesia (n = 20) group. Maternal and cord blood neopterin, sE-selectin, and sL-selectin levels were measured in both groups.

Results

Cord blood neopterin concentrations in the SA group were not different from those in the GA group, but maternal neopterin levels in the SA group were different from those in the GA group. Maternal blood levels of sE-selectin and sL-selectin were not different between the two groups. Similarly, the cord blood levels of sE-selectin and sL-selectin were not different between the two groups. We found an increased inflammatory process in the fetal circulation depending on the anesthetic method used.

Conclusions

These results indicate the effects of general and spinal anesthetic techniques on serum sL-selectin, sE-selectin, and neopterin levels in neonates and parturients undergoing elective cesarean section. sE-selectin and neopterin concentrations and leukocyte counts were higher in the fetal circulation than in the maternal circulation during both GA and SA.

Addition of lidocaine to levobupivacaine reduces intrathecal block duration: randomized controlled trial

BACKGROUND

The duration of the spinal block is a concern for anesthetists. Low dose intrathecal lidocaine has vasodilatory effects and increases the local anesthetic clearance from the intrathecal space. The aim was to investigate whether this effect of lidocaine can be used to increase the resolution of levobupivacaine spinal anesthesia.

METHOD

After obtaining ethical approval and informed patient consent, 40 patients underwent transurethral prostate resection were studied. Patients were randomized into two groups and patients received either levobupivacaine 6.75 mg + 0.3 mL 2% lidocaine (Group L) or levobupivacaine 6.75 mg + saline (Group C). The main outcome measures were the difference between groups regarding the duration of the spinal block and PACU stay. Secondary outcome measures were the difference between groups in onset and resolution of the spinal block, adverse events and treatments were also investigated.

RESULTS

Spinal block resolved faster in Group L than Group C; 162.43±39.4 min vs 219.73 ± 37.3 min (p = 0.000). PACU time was shorter in Group L (109 ± 49.9 min in Group L vs 148 ± 56.8 min in Group C) (p = 0.036). There was no difference between groups with respect to the incidence of adverse events and treatments. Groups were also similar regarding complications. PDPH and TNS were not observed in any group.

CONCLUSION

Addition of low dose lidocaine to hyperbaric levobupivacaine reduces the duration of the intrathecal block provided by hyperbaric levobupivacaine. This technique can be used to reduce the spinal block duration for relatively short procedures like TUR-P.

Neuraxial anesthesia for outpatients

Neuraxial anesthesia for outpatient surgery can provide excellent anesthesia for certain patients. The short-acting local anesthetic 2-chloroprocaine has an appropriate length of action for short outpatient procedures with a very low risk of transient neurologic symptoms. Epidural anesthesia with short-acting agents can provide good outpatient anesthesia for procedures lasting 90 minutes or longer.

Comparison of two dosing schedules of intravenous dexmedetomidine in elderly patients during spinal anesthesia

Background

As the number of elder patients grows, spinal anesthesia for such patients are increasing significantly. Any effort is needed to use the least anesthetic drug for maintaining the anesthesia while avoiding hazards of cardio-pulmonary complications.

Methods

American Society of Anesthesiologists physical status classification I and II, Forty five elderly patients (≥ 60 years) who received transurethral resection of the prostate or transurethral resection of the bladder tumor were allocated randomly into three treatment groups. The DMT 0.5 group was designed as with dexmedetomidine 0.5 µg/kg while the DMT 1.0 group has a 1 µg/kg intravenous injection over 10 min before anesthetic induction. The Control group was designed to get a normal saline. Each group was compared regarding the maximum sensory block level, extension of anesthesia, degree of motor block, level of sedation, VAS score and complications.

Results

There were no significant differences among the 3 treatment groups regarding the maximum level of sensory block and motor block. However, the duration of sensory block was significantly longer in DMT 1.0 group than in the control group (P = 0.045). Both DMT 1.0 group (median = 3, range = 2-6) and DMT 0.5 group (median = 3, range = 1-6) showed a mean value of 3-4 Ramsay sedation score, which resulted in more excessive sedation and significantly greater incidence of bradycardia compared to the control group. No complications such as hypotension, nausea, tremor, and hypoxia were found during this investigation.

Conclusions

In elder patients, the DMT 1.0 group is effective in duration of sensory block and is superior in the aspect of prolonged duration of sensory block compared to the DMT 0.5 group.

Comparison of the efficacy of a forced-air warming system and circulating-water mattress on core temperature and post-anesthesia shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia

Background

In the present study, we compared changes in body temperature and the occurrence of shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia during warming with either a forced-air warming system or a circulating-water mattress.

Methods

Forty-six patients were randomly assigned to either the forced-air warming system (N = 23) or circulating-water mattress (N = 23) group. Core temperature was recorded using measurements at the tympanic membrane and rectum. In addition, the incidence and intensity of post-anesthesia shivering and verbal analogue score for thermal comfort were simultaneously assessed.

Results

Core temperature outcomes did not differ between the groups. The incidence (13.0 vs 43.5%, P < 0.05) and intensity (20/2/1/0/0 vs 13/5/3/2/0, P < 0.05) of post-anesthesia shivering was significantly lower in the forced-air system group than in the circulating-water mattress group.

Conclusions

The circulating-water mattress was as effective as the forced-air warming system for maintaining body temperature. However, the forced-air warming system was superior to the circulating-water mattress in reducing the incidence of post-anesthesia shivering.

Influence of the timing of administration of crystalloid on maternal hypotension during spinal anesthesia for cesarean delivery: preload versus coload

Background

Prophylactic fluid preloading before spinal anesthesia has been a routine procedure to prevent maternal hypotension during cesarean delivery. Unlike colloid, timing of infusion of crystalloid may be important because of its short stay in intravascular space. We hypothesized that crystalloid loading just after intrathecal injection compared to preload would be more effective in preventing maternal hypotension.

Methods

In this prospective controlled study, sixty parturients were randomized to receive 15 ml/kg of crystalloid before (preload group) or after (coload group) intrathecal drug injection for spinal anesthesia. Hypotension was defined if systolic arterial pressure decreased below 80% of baseline and ephedrine was administered to treat hypotension. The incidence of hypotension and the total dose of ephedrine were checked. Blood pressure, heart rate and nausea before childbirth were assessed. Neonatal outcomes were evaluated with Apgar scores and umbilical blood gas analysis.

Results

The incidence of hypotension was lower in the coload group compared to the preload group (53% vs. 83%, P = 0.026). The blood pressure showed the bigger drop during spinal anesthesia in the preload group (34 ± 13 vs. 25 ± 10 mmHg, P = 0.002) and smaller dose of ephedrine was required in the coload group (7.5 [0–30] vs. 15 [0–40] mg, P = 0.015). The incidence of nausea was also lower in the coload group (27% vs. 60%, P = 0.019). Neonatal outcome measures were comparable between two groups.

Conclusions

In case of using crystalloids for cesarean delivery, coload is more effective than preload for the prevention of maternal hypotension after spinal anesthesia.

Trial registration

Clinical Research Information Service KCT0000324 (Jan 12^th, 2012)

[Comparison of metaraminol, phenylephrine and ephedrine in prophylaxis and treatment of hypotension in cesarean section under spinal anesthesia]

Maternal hypotension is a common complication after spinal anesthesia for cesarean section, with deleterious effects on the fetus and mother. Among the strategies aimed at minimizing the effects of hypotension, vasopressor administration is the most efficient. The aim of this study was to compare the efficacy of phenylephrine, metaraminol, and ephedrine in the prevention and treatment of hypotension after spinal anesthesia for cesarean section. Ninety pregnant women, not in labor, undergoing cesarean section were randomized into three groups to receive a bolus followed by continuous infusion of vasopressor as follows: phenylephrine group (50μg+50μg/min); metaraminol group (0.25mg+0.25mg/min); ephedrine group (4mg+4mg/min). Infusion dose was doubled when systolic blood pressure decreased to 80% of baseline and a bolus was given when systolic blood pressure decreased below 80%. The infusion dose was divided in half when systolic blood pressure increased to 120% and was stopped when it became higher. The incidence of hypotension, nausea and vomiting, reactive hypertension, bradycardia, tachycardia, Apgar scores, and arterial cord blood gases were assessed at the 1st and 5th minutes. There was no difference in the incidence of hypotension, bradycardia, reactive hypertension, infusion discontinuation, atropine administration or Apgar scores. Rescue boluses were higher only in the ephedrine group compared to metaraminol group. The incidence of nausea and vomiting and fetal acidosis were greater in the ephedrine group. The three drugs were effective in preventing hypotension; however, fetal effects were more frequent in the ephedrine group, although transient.

Intrathecal sufentanil for coronary artery bypass grafting

CONTEXT

Cardiac surgery patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

OBJECTIVE

Evaluate the effect of adding intrathecal sufentanil to general anesthesia on hemodynamics.

DESIGN

Prospective, randomized, not blinded study, after approval by local ethics in Research Committee.

SETTING

Monocentric study performed at Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil.

PATIENTS

40 consenting patients undergoing elective coronary artery bypass, both genders.

EXCLUSION CRITERIA

Chronic kidney disease; emergency procedures; reoperations; contraindication to spinal block; left ventricular ejection fraction less than 40%; body mass index above 32kg/m(2) and use of nitroglycerin.

INTERVENTIONS

Patients were randomly assigned to receive intrathecal sufentanil 1μg/kg or not. Anesthesia induced and maintained with sevoflurane and continuous infusion of remifentanil.

MAIN OUTCOME MEASURES

Hemodynamic variables, blood levels of cardiac troponin I, B-type natriuretic peptide, interleukin-6 and tumor necrosis factor alfa during and after surgery.

RESULTS

Patients in sufentanil group required less inotropic support with dopamine when compared to control group (9.5% vs 58%, p=0.001) and less increases in remifentanil doses (62% vs 100%, p=0.004). Hemodynamic data at eight different time points and biochemical data showed no differences between groups.

CONCLUSIONS

Patients receiving intrathecal sufentanil have more hemodynamical stability, as suggested by the reduced inotropic support and fewer adjustments in intravenous opioid doses.

A randomized, observer-blind comparison between the Neurotip mounted Neuropen and a disposable plastic neurological wheel for assessing the level of spinal blockade at cesarean section

BACKGROUND

Various methods are used to assess the height of sensory block to touch under spinal anesthesia for cesarean section. We tested a novel, inexpensive, miniature, user-dependent plastic neurological wheel against the user-independent Neurotip mounted Neuropen.

METHODS

Patients received either spinal or combined spinal-epidural anesthesia. For each patient assessment, the devices were randomly assigned to one of two independent investigators. The order of device application was randomly permuted. Neither researcher was involved with anesthetic care. At 5-min intervals for 20 min after spinal injection, and again at the end of the operation, the levels of block to loss-of-touch sensation were assessed. While one investigator evaluated the block, the other left the operating room and vice versa. Mixed-effects regression and Bland-Altman analysis were used to weigh agreement between devices.

RESULTS

The mean difference in level-to-touch was 0.04 (95% CI -0.18, 0.27) dermatome levels. Measurement error standard deviation associated with the Neurotip mounted Neuropen and plastic neurological wheel was 1.36 (95% CI 1.26, 1.41) and 1.33 (95% CI 1.26, 1.46) dermatome levels, respectively. The difference in measurement error standard deviation was -0.03 (95% CI -0.16, 0.24). This evidence excludes the possibility, with 95% confidence, of clinically significant bias or measurement error differences between methods. Occasional wide variances in dermatome level were observed with both instruments at the initial assessment only.

CONCLUSION

The compact plastic neurological wheel is as clinically reliable as the Neurotip mounted Neuropen.

Cerebral venous thrombosis complicating severe preeclampsia in the postpartum period: a diagnostic challenge

A 26 year old primigravida with preeclampsia was diagnosed with a cerebral venous thrombosis 6 days following Cesarean section. The diagnosis was initially challenging due to the patient's history of migraines, the preeclampsia, multiple attempts at spinal anesthesia for Cesarean section, and a dural puncture while performing epidural blood patch.

Cost-effectiveness analysis]

OBJECTIVE

To compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery.

MATERIAL AND METHODS

An observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared.

RESULTS

The final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6±160.2min in the subarachnoid anesthesia group, and 210.0±97.5min for the general anesthesia group (P<.001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2±8.3 vs. 18.7±7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P<.001).

CONCLUSIONS

Both techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.

Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature

Lumbar spine surgery can be performed using different anesthetic techniques such as general endotracheal anesthesia (GA) or spinal-based regional anesthesia (RA). Several studies have been performed comparing these two anesthetic techniques and have revealed disparate results. As such, we set out to review the relevant literature. We performed a literature search for clinical articles comparing cohorts of patients who underwent RA versus GA for lumbar spine surgeries. We compared results of these studies between groups with respect to the following outcome variables: heart rate (HR), mean arterial pressure (MAP), blood loss, duration of surgery, time spent in the PACU, post-operative analgesic use or pain scores, urinary retention rates, and nausea or anti-emetic requirements. Eleven studies were identified that compared cohorts of patients who underwent GA or RA. Of these, 4 were randomized control trials, 3 were case control trials, 2 were prospective cohorts, and 2 retrospective analyses. Seven-out-of-seven studies reported reduced HRs and MAPs in the RA compared to GA group, and 7/9 studies reported a lower incidence of post-operative analgesic requirement and/or decreased pain scores for the RA group. Our review of the literature suggests that both RA and GA are safe and effective techniques for lumbar spine surgery and that RA may prove a better alternative than GA for healthy patients undergoing simple lumbar decompression procedures or for patients who are at high risk for general anesthetic complications.

[Spinal anesthesia for cesarean section: risk factors for emergence of Apgar scores below 7 in Malagasy newborns]

Introduction

La rachianesthésie est courante en obstétrique. L'hypotension artérielle maternelle apparaît dans 50-80%. Elle affecte l’équilibre acido-basique et l’état clinique du nouveau-né. Pour y remédier, l'usage de vasoconstricteurs est incontournable. L’éphédrine était de loin de premier choix en obstétrique. Dans les pays développés, elle est co-administrée avec la phényléphrine. A Madagascar, seule l’éphédrine reste disponible. Notre étude consiste à déterminer les facteurs de risque d'apparition du score d'Apgar inférieur à 7 chez les nouveau-nés.

Méthodes

Une étude rétrospective transversale, analytique, était effectuée à la Maternité de Befelatanana, Antananarivo Madagascar (Décembre 2010-Décembre 2011). Nous avons inclus 344 césariennes opérées sous rachianesthésie. Le critère principal de jugement était l'observation de score d'Apgar inférieur ou égal à 7 à la première minute. Les données étaient analysées sur logiciel Epi Info version 6.04 (IC à 95%, p bilatéral < 0.05).

Résultats

Le score d'Apgar était inférieur ou égal à 7 dans 42%. Les facteurs de risque retrouvés étaient la césarienne en urgence, la dose d’éphédrine dépassant 30mg ainsi que la baisse de la pression artérielle diastolique supérieure à 10% par rapport à sa valeur initiale (p respectif <<0.05).

Conclusion

La précarité de l’état clinique des nouveau-nés à la naissance est multifactorielle. La baisse de la pression artérielle diastolique associée à une dose élevée d’éphédrine est néfaste. De plus, l'augmentation de la catécholaminémie maternelle puis fœtale l'aggrave.

Femoral nerve block: Assessment of postoperative analgesia in arthroscopic anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES

Knee anterior cruciate ligament reconstruction (ACLR) may be painful in the postoperative period. The primary objective of this study was to evaluate whether the use of femoral nerve block (FNB) associated with spinal anesthesia would improve the postoperative pain treatment in ACLR and the secondary objectives were to evaluate tramadol request and adverse events.

METHOD

53 patients were randomly divided into two groups: GA (n =26) received spinal anesthesia and GB (n = 27) received spinal anesthesia and FNB. All patients received multimodal analgesia and rescue analgesics could be requested anytime. Assessments were performed at 6, 12 and 24 hours.

RESULTS

There was no difference between both groups regarding demographic and clinical- surgical variables. There was no difference between groups regarding pain intensity. Mean pain scores were higher at 12 hours in GA and there was no change in GB; 55.6% of patients reported moderate pain in GA and 53.8% mild pain in GB. There was no difference regarding tramadol request. There were no serious adverse events: 80.8% of patients in GB had motor block of the thigh and two fell.

CONCLUSIONS

Analgesia was more effective with the combination of spinal and FNB, which allowed better control of postoperative pain, assessed 12 hours after anesthesia. There was no difference in tramadol request. Patients in this study had no serious adverse events; however, one must be attentive to motor paralysis and the possibility of falling when FNB is performed.

Comparison between intrathecal hyperbaric bupivacaine and levobupivacaine for ambulatory knee arthroscopy

AIM: To compare the effect of hyperbaric levobupivacaine and bupivacaine on the quality of the block, patient satisfaction, and discharge time in patients undergoing arthroscopic knee surgery under unilateral spinal anesthesia.

METHODS: One hundred and thirty-two patients, American Society of Anaesthesiologists I or II, scheduled for elective ambulatory knee arthroscopy were randomly assigned to four double-blind groups. To achieve a unilateral spinal block, Group BF received 5 mg of hyperbaric bupivacaine plus 20 μg of fentanyl intrathecally, Group LF received 5 mg of hyperbaric levobupivacaine plus 20 μg of fentanyl intrathecally, Group B received 5 mg of hyperbaric bupivacaine intrathecally, and Group L received 5 mg of hyperbaric levobupivacaine intrathecally. The level and duration of the sensory block, the intensity and duration of the motor block, the time to first analgesic requirement, and the time elapsed until the patient’s discharge were recorded. Hemodynamic values and adverse effects were also recorded.

RESULTS: The duration of time needed to reach the T12 dermatome level was significantly longer in Group L [7 (3-20) min] than in Group B [6 (3-12) min] (P = 0.006). The maximum sensory level reached on the side undergoing the operation was significantly higher in Group BF than in Group B (P < 0.05). The intensity of the motor blockade was greater in Group BF than in Group LF and L. Complete recovery from motor blockade occurred earlier in Groups LF [75 (45-165) min] and L [63 (35-120) min] than in Group BF [115 (60-180) min] (P < 0.05). The length of time needed for the sensory block to regress to the level of S2 was shorter in Group L (154 ± 50) than in Group BF (192 ± 66) (P < 0.05). The quality of the block was significantly lower in Group L than in Groups BF, LF and B (P = 0.012, P = 0.003, and P < 0.001, respectively). The time elapsed until Visual Analog Scale ≥ 4 was significantly shorter in Group L (110 ± 48) than in Groups BF (200 ± 60), LF (156 ± 61) and B (162 ± 52) (P < 0.05). The time elapsed until the patient’s discharge was shorter in Groups B (244 ± 54) and L (229 ± 55) than in Group BF (288 ± 64) (P = 0.021 and P = 0.001, respectively). There were no differences among the groups regarding hemodynamic parameters and adverse events, except for pruritus. The occurrence of pruritus was significantly more frequent in Groups BF and LF than in other groups.

CONCLUSION: In conclusion, 5 mg of hyperbaric bupivacaine and 5 mg of hyperbaric levobupivacaine plus 20 μg of fentanyl provided a better spinal anesthesia than 5 mg of hyperbaric levobupivacaine alone.

Comparison of the effects and complications of unilateral spinal anesthesia versus standard spinal anesthesia in lower-limb orthopedic surgery

INTRODUCTION

A restricted sympathetic block during spinal anesthesia may minimize hemodynamic changes. This prospective randomized study compared unilateral and bilateral spinal anesthesia with respect to the intra- and postoperative advantages and complications of each technique.

MATERIAL AND METHODS

Spinal anesthesia was induced with 0.5% hyperbaric bupivacaine and a 25-G Quincke needle (Dr. J) in two groups of patients with physical status ASA I-II who had been admitted for orthopedic surgeries. In group A, dural puncture was performed with the patient in a seated position using 2.5 cm(3) of hyperbaric bupivacaine. Each patient was then placed in the supine position. In group B, dural puncture was performed with the patient in the lateral decubitus position with 1.5 cm(3) of hyperbaric bupivacaine. The lower limb was the target limb. The speed of injection was 1 mL/30s, and the duration of time spent in the lateral decubitus position was 20 min.

RESULTS

The demographic data were similar in both groups. The time to the onset of the sensory and motor block was significantly shorter in group A (p=0.00). The duration of motor and sensory block was shorter in group B (p<0.05). The success rate for unilateral spinal anesthesia in group B was 94.45%. In two patients, the spinal block spread to the non-dependent side. The incidence of complications (nausea, headache, and hypotension) was lower in group B (p=0.02).

CONCLUSION

When unilateral spinal anesthesia was performed using a low-dose, low-volume and low-flow injection technique, it provides adequate sensory-motor block and helps to achieve stable hemodynamic parameters during orthopedic surgery on a lower limb. Patients were more satisfied with this technique as opposed to the conventional approach. Furthermore, this technique avoids unnecessary paralysis on the non-operated side.

Heart rate variability as a predictor of hypotension after spinal anesthesia in hypertensive patients

Background

Hypotension is a common phenomenon after spinal anesthesia in hypertensive patients. We investigated whether heart rate variability could predict the occurrence of hypotension after spinal anesthesia in hypertensive patients.

Methods

Forty-one patients undergoing spinal anesthesia were included. Heart rate variability was measured at five different time points such as before fluid loading (baseline), after fluid loading as well as 5 min, 15 min and 30 min after spinal anesthesia. Fluid loading was performed using 5 ml/kg of a crystalloid solution. Baseline total power and low to high frequency ratio (LF/HF) in predicting hypotension after spinal anesthesia were analyzed by calculating the area under the receiver operating characteristic curves (AUC).

Results

Moderate hypotension, defined as a decrease of mean arterial pressure to below 20-30% of the baseline, occurred in 13 patients and severe hypotension, defined as a decrease of mean arterial pressure greater than 30% below the baseline, occurred in 7 patients. LF/HF ratiosand total powers did not significantly change after spinal anesthesia. AUCs of LF/HF ratio for predicting moderate hypotension was 0.685 (P = 0.074), severe hypotension was 0.579 (P = 0.560) and moderate or severe hypotension was 0.652 (P = 0.101), respectively. AUCs of total power for predicting moderate hypotension was 0.571 (P = 0.490), severe hypotension was 0.672 (P = 0.351) and moderate or severe hypotension was 0.509 (P = 0.924), respectively.

Conclusions

Heart rate variability is not a reliable predictor of hypotension after spinal block in hypertensive patients whose sympathetic activity is already depressed.

The comparison of levobupivacaine in continuous or single dose spinal anesthesia for transurethral resection of prostate surgery

BACKGROUND

The aim of the study is to compare the efficacy of levobupivacaine induced continuous spinal anesthesia (CSA) versus single dose spinal anesthesia (SDSA) in patients who are planned to undergo transurethral prostate resection.

METHODS

Sixty years or older, ASA I-II or III, 50 patients were included in the study. 12.5mg 0.5% levobupivacaine were administered intrathecally in SDSA group. In CSA group, initially 2mL of 0.25% levobupivacaine were administered through spinal catheter. In order to achieve sensory block level at T10 dermatome, additional 1mL of 0.25% levobupivacaine were administered through the catheter in every 10min. Hemodynamic parameters and block characteristics were recorded. Preoperative and postoperative blood samples of the patients were drawn to determine plasma cortisone and plasma epinephrine levels.

RESULTS

CSA technique provided better hemodynamic stability compared to SDSA technique particularly 90min after intrathecal administration. The rise in sensory block level was rapid and the time to reach surgical anesthesia was shorter in SDSA group. Motor block developed faster in SDSA group. In CSA group, similar anesthesia level was achieved by using lower levobupivacaine dose and which was related to faster recovery. Although, both techniques were effective in preventing surgical stress respond, postoperative cortisone levels were suppressed more in SDSA group.

CONCLUSION

CSA technique with 0.25% levobupivacaine can be used as a regional anesthesia method for elderly patients planned to have TUR-P operation.

Black esophagus (acute esophageal necrosis) after spinal anesthesia

Acute esophagic necrosis or black esophagus is an uncommon clinical entity that owes its name to the endoscopic view of the necrotic esophageal mucosa. It is always related with a critical medical condition and usually has an ischemic etiology. We report the first case of acute esophageal necrosis after a spinal anesthetic for partial hip joint arthroplasty. We discuss the underlying pathophysiological mechanisms.

Laparoscopic ventral hernia repair in obese patients under spinal anesthesia

PURPOSE

The aim of the present study was to evaluate the feasibility and efficacy of laparoscopic ventral hernia repair under spinal anesthesia in obese patients (BMI > 30 kg/m(2)).

METHODS

From January 2007 to February 2010, 23 obese patients had their elective laparoscopic ventral hernia repair under spinal anesthesia. We looked primarily for intra-operative incidences as well as immediate postoperative complications. Long term results and especially recurrences were also to be evaluated.

RESULTS

Median operative time was 55 min (range 20-100). Intraoperatively, six patients (26%) complained of shoulder pain, three patients (13%) developed bradycardia and two (8.7%) hypotension. Postoperatively, nausea and/or vomiting were recorded in four patients (17.4%), four patients (17.4%) experienced urinary retention and one patient developed wound infection. Median pain score at 4th, 8th and 24th postoperative hour was 0.5 (0-5), 1.5 (0-6), and 1.5 (0-5) respectively. The median length of hospital stay was one day (1-2). At a median follow up of 39 months, one patient was diagnosed with a recurrence.

CONCLUSION

Spinal anesthesia for LVHR in obese patients (BMI > 30 kg/m(2)) proved an efficient and safe alternative to general anesthesia in the given patient sample.

Atropine injection followed by coronary artery spasm with ventricular tachycardia during spinal anesthesia -A case report-

Bradycardia may occur during spinal anesthesia with atropine commonly used as a treatment. A 44-year-old female with no known history of any underlying diseases, developed a coronary spasm following ventricular tachycardia when 0.5 mg of atropine was injected intravenously to treat bradycardia during spinal anesthesia. The imbalance caused by atropine in the sympathovagal activity may predispose the coronary artery to develop spasms with ventricular tachycardia. Therefore prudent use of atropine should be accompanied by close monitoring.

Comparison between monitored anesthesia care with remifentanil under ilioinguinal hypogastric nerve block and spinal anesthesia for herniorrhaphy

Background

The use of monitored anesthesia care (MAC) as the technique of choice for a variety of invasive or noninvasive procedures is increasing. The purpose of this study to compare the outcomes of two different methods, spinal anesthesia and ilioinguinal-hypogastric nerve block (IHNB) with target concentrated infusion of remifentanil for inguinal herniorrhaphy.

Methods

Fifty patients were assigned to spinal anesthesia (Group S) or IHNB with MAC group (Group M). In Group M, IHNB was performed and the effect site concentration of remifentanil, starting from 2 ng/ml, was titrated according to the respiratory rate or discomfort, either by increasing or decreasing the dose by 0.3 ng/ml. The groups were compared to assess hemodynamic values, oxygen saturation, bispectral index (BIS), observer assessment alertness/sedation scale (OAA/S), visual analogue scale (VAS) for pain score and patients' and surgeon's satisfaction.

Results

BIS and OAA/S were not significantly different between the two groups. Hemodynamic variables were stable in Group M. Thirteen patients in the same group showed decreased respiratory rate without desaturation, and recovered immediately by encouraging taking deep breaths without the use of assist ventilation. Although VAS in the ward was not significantly different between the two groups, interestingly, patients' and surgeon's satisfaction scores (P = 0.0004, P = 0.004) were higher in Group M. The number of the patients who suffered from urinary retention was higher in Group S (P = 0.0021).

Conclusions

IHNB under MAC with remifentanil is a useful method for inguinal herniorrhaphy reflecting hemodynamic stability, fewer side effects and higher satisfaction. This approach can be applied for outpatient surgeries and patients who are unfit for spinal anesthesia or general anesthesia.

Optimal dose of dexmedetomidine for sedation during spinal anesthesia

Background

Sedation in spinal anesthesia can reduce patient's anxiety and discomfort. Dexmedetomidine has a sedative, hypnotic, analgesic, and minimal respiratory depression effect. However, use of the dexmedetomidine is associated with prolonged recovery. This study was designed to investigate the optimal dose of intravenous dexmedetomidine for proper sedation with minimal recovery time in spinal anesthesia.

Methods

One hundred twenty eight patients, aged 20-70 years (58.8 ± 0.7), were recruited. After performing the spinal anesthesia with hyperbaric bupivacaine (13 mg), a loading dose of dexmedetomidine (1 µg/kg) was administered for 10 min, followed by the maintenance infusion of the following: Group A (n = 33; normal saline), Group B (n = 35; dexmedetomidine 0.2 µg/kg/hr), and Group C (n = 39; dexmedetomidine 0.4 µg/kg/hr). Heart rate, blood pressure, and the bispectral index score (BIS) were recorded during the operation. In the recovery room, modified aldrete score (MAS) was measured.

Results

There were no significant differences in mean blood pressure and heart rate among the three groups. BIS was not significantly different among the three groups from baseline to 60 min after the infusion of dexmedetomidine. BIS were significantly increased in Group A after 70 and 80 min, and Group A and B after 90, 100, 110 min of dexmedetomidine infusion (P < 0.05). MAS was higher in Group A as compared to Group B and C, within 30 min after admission in the recovery room (P < 0.05).

Conclusions

The loading dose (1 µg/kg/10 min) of dexmedetomidine was sufficient for surgery of less than 60 min. Dexmedetomidine infusion followed by maintenance dose (0.2 µg/kg/hr) was sufficient for surgery within 90 min.

Comparison of meperidine and nefopam for prevention of shivering during spinal anesthesia

BACKGROUND

Shivering is a frequent event during spinal anesthesia and meperidine is a well-known effective drug for prevention and treatment of shivering. Nefopam is a non-opiate analgesic and also known to have an anti-shivering effect. We compared nefopam with meperidine for efficacy of prevention of shivering during spinal anesthesia.

METHODS

Sixty five patients, American Society of Anesthesiologists physical status I or II, aged 20-65 years, scheduled for elective orthopedic surgery under spinal anesthesia were investigated. Patients were randomly divided into two groups, meperidine (Group M, n = 33) and nefopam (Group N, n = 32) groups. Group M and N received meperidine 0.4 mg/kg or nefopam 0.15 mg/kg, respectively, in 100 ml of isotonic saline intravenously. All drugs were infused for 15 minutes by a blinded investigator before spinal anesthesia. Blood pressures, heart rates, body temperatures and side effects were checked before and at 15, 30, and 60 minutes after spinal anesthesia.

RESULTS

The incidences and scores of shivering were similar between the two groups. The mean arterial pressures in Group N were maintained higher than in Group M at 15, 30, and 60 minutes after spinal anesthesia. The injection pain was checked in Group N only and its incidence was 15.6%.

CONCLUSIONS

We conclude that nefopam can be a good substitute for meperidine for prevention of shivering during spinal anesthesia with more stable hemodynamics, if injection pain is effectively controlled.

Spinal anesthetic management for discectomy in a patient with amyotrophic lateral sclerosis -A case report-

Amyotrophic lateral sclerosis (ALS), also referred to as Lou Gehrig's disease, is a degenerative disorder of motor neuron system of the spinal cord and the cortical neuron. Patients with ALS present a unique challenge to the anesthesiologist. Respiratory muscle weakness, for instance, can result in trouble with proper breathing after general anesthesia. We report a case of spinal anesthesia for discectomy in a patient with ALS.

Post spinal puncture headache, an old problem and new concepts: review of articles about predisposing factors

Post spinal puncture headache (PSPH) is a well known complication of spinal anesthesia. It occurs after spinal anesthesia induction due to dural and arachnoid puncture and has a significant effect on the patient's postoperative well being. This manuscript is based on an observational study that runs on Babol University of Medical Sciences and review of literatures about current concepts about the incidence, risk factors and predisposing factors of post spinal puncture headache. The overall incidence of post-dural puncture headache after intentional dural puncture varies form 0.1-36%, while it is about 3.1% by atraumatic spinal needle 25G Whitacre. 25G Quincke needle with a medium bevel cutting is popular with widespread use and the incidence of PSPH is about 25%, but its incidence obtained 17.3% by spinal needle 25G Quincke in our observation. The association of predisposing factors like female, young age, pregnancy, low body mass index, multiple dural puncture, inexpert operators and past medical history of chronic headache, expose the patient to PSPH. The identification of factors that predict the likelihood of PSPH is important so that measures can be taken to minimize this painful complication resulting from spinal anesthesia.

Intrathecal morphine in two patients undergoing deep hypothermic circulatory arrest during aortic surgery -A case report-

We retrospectively report the first use of intrathecal morphine prior to incision in two male patients undergoing a complex aortic reconstruction, who required complete circulatory arrest under deep hypothermia for intraoperative and postoperative pain control. We administered intrathecal morphine to two male patients undergoing circulatory arrest and deep hypothermia. Patients were fully heparinized prior to cardiopulmonary bypass. Deep hypothermic circulatory arrest was performed by cooling the patients to 18℃. Following the surgery, the neurologic status was monitored. The management of postoperative pain is a quality standard in health care. During the first 24 hours after surgery, we observed excellent analgesia without the associated side effects, thus, reducing the time required for pain control by the nursing staff. A successful analgetic strategy not only enhances the patient satisfaction, but may improve the postoperative outcome. However, complications, such as increased risk of epidural hematoma formation, are of special concern in cardiac surgery.

The effect of adjuvant midazolam compared with fentanyl on the duration of spinal anesthesia with 0.5% bupivacaine in opium abusers

Background

There are a number of adjuvants to be used for local anesthetics in spinal block. The aim of this study was to demonstrate the possible effect of intrathecal midazolam compared with bupivacaine as adjuvants in spinal anesthesia with bupivacaine in chronic opium abuses.

Methods

In a double blind, randomized clinical trial, 90 opium abuser patients undergoing lower limb orthopedic surgery were selected and randomly assigned into 3 groups (30 cases each). The patients received 15 mg plain bupivacaine, or 15 mg bupivacaine plus 25 mcg fentanyl or 15 mg bupivacaine plus 1 mg midazolam, intrathecally.

Results

The duration of anesthesia was much longer in the bupivacaine-midazolam group than the bupivacaine-fentanyl group; both were longer than the plain bupivacaine group (P < 0.05).

Conclusions

Subarachnoid injection of adjuvant midazolam or fentanyl with plain 0.5% bupivacaine in opium abusers in lower limb orthopedic surgery increases the duration of sensory block. Therefore midazolam is more effective than fentanyl in such cases.

[Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia]

Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor.

Randomized, placebo-controlled trial of granisetron for control of nausea and vomiting during cesarean delivery under spinal anesthesia

OBJECTIVES

The objective of this study was to evaluate the efficacy and safety of granisetron (5HT3 receptor antagonist) on the incidence of nausea and vomiting in cesarean deliveries under spinal anesthesia.

METHODS

In the randomized, double-blind study, 80 parturients received granisetron 40 μg/kg or placebo (n = 40 each) intravenously, immediately after clamping of the fetal umbilical cord. Nausea, vomiting, and adverse events were then observed for 24 h after administration of spinal anesthesia.

RESULTS

A complete response (defined as no postoperative nausea and vomiting) during 0-4 h after administration of spinal anesthesia was achieved in 80 % of patients with granisetron and in 45 % of patients with placebo. The corresponding incidences during (4-24 h) were 82.5 and 55 % (P value <0.05). No difference in adverse events was observed in any of the groups.

CONCLUSIONS

Prophylactic use of granisetron is effective for preventing emetic episodes during spinal anesthesia for cesarean delivery.

Comparison of clinical effects according to the dosage of sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section

Background

Subarachnoid block is a widely used technique for cesarean section. To improve the quality of analgesia and prolong the duration of analgesia, addition of intrathecal opioids to local anesthetics has been encouraged. We compared the effects of sufentanil 2.5 µg and 5 µg, which were added to intrathecal hyperbaric bupivacaine.

Methods

We enrolled 105 full term parturients were randomly divided into 3 groups: Group 1 (control), Group 2 (sufentanil 2.5 µg), and Group 3 (sufentanil 5 µg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We determined the maximum level of sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and side effects.

Results

There were no significant differences among the 3 groups in the maximum level of the sensory block and motor block. Recovery rate of the sensory block, however, was significantly slower in Group 3 than Group 1. Quality of intraopertive analgesia, muscle relaxation, and duration of effective analgesia were enhanced by increasing the dosage of intrathecal sufentanil. Frequencies of hypotension, maximum sedation level, and pruritus were directly related to the dosage of intrathecal sufentanil, whereas nausea and vomiting occurred only in the groups using sufentanil.

Conclusions

The addition of sufentanil 2.5 µg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia with minimal adverse effects on the mother.

Spinal anesthesia or caudal anesthesia for anorectal surgery: An analysis of 74 cases

AIM: To observe the clinical effect of spinal anesthesia and caudal anesthesia in anorectal surgery.

METHODS: Seventy-four patients who underwent anorectal surgery between September 2009 and May 2012 were reviewed retrospectively. The patients were divided into spinal anesthesia group (n = 36) and caudal anesthesia group (n = 38). There were no significant differences in age, sex, illness, and operation time between the two groups. Anesthesia effect, onset time, cardiovascular complication, urinary retention, and time to sensory recovery were compared between the two groups.

RESULTS: The rate of satisfaction with anesthesia effect was 95% in the spinal anesthesia group and 79% in the caudal anesthesia group (P < 0.05). The morbidity of cardiovascular complication was 30.6% in the spinal anesthesia group and 5.3% in the caudal anesthesia group (P < 0.01). The mean onset time was 1.98 min in the spinal anesthesia group and 8.99 min in the caudal anesthesia group (P < 0.01). Urinary retention occurred in 4 cases in the spinal anesthesia group and in 3 cases in the caudal anesthesia group (P > 0.05). Mean time to sensory recovery was 324 min in the spinal anesthesia group and 288 min in the caudal anesthesia group (P > 0.05).

CONCLUSION: Spinal anesthesia has better clinical effect than caudal anesthesia when used in anorectal surgery, but the blood pressure and heart rate must be closely monitored and cardiovascular changes must be handled on time.

Comparative evaluation of intrathecal midazolam and low dose clonidine: efficacy, safety and duration of analgesia. A randomized, double blind, prospective clinical trial

Background:

The study was planned to assess the comparative efficacy, safety and duration of analgesia produced by low-dose clonidine and midazolam when used as adjuvant for spinal anesthesia.

Materials and Methods:

This is a randomized, participant and observer blind, prospective, parallel group clinical trial. Fifty ASA grade I and II patients posted for lower abdominal surgery were randomly allocated into two groups. BC group received spinal clonidine 30 μg and BM group received preservative-free midazolam 2 mg with 15 mg hyperbaric bupivacaine. Postoperative analgesia, analgesic requirement in 24 hours, onset and duration of block, hemodynamic stability and adverse effects were observed (P<0.05 – considered significant, P<0.01 considered highly significant).

Results:

The duration of postoperative analgesia was prolonged in BM group (391.64 ± 132.98 min) than BC group (296.60 ± 52.77 min) (P<0.01). The mean verbal rating pain score was significantly less in BM group than BC group (P<0.01). The number of analgesic doses in 24 hours were significantly less in BM group (P<0.05). Nine patients (36%) in BC group required additional analgesia as against none in BM group (P<0.01). The onset of sensory block and peak sensory level was significantly earlier in BM group as compared to BC group. Duration of sensory block was longer in BM group (P<0.05). Subjects in BC group(36%) had bradycardia as compared to none in BM group (P<0.01). Hypotension was observed in 44% patients in BC group as against 16% in BM group (P<0.05).

Conclusion:

Postoperative analgesia with clonidine is short lived with some bradycardia. Intrathecal midazolam provides superior analgesia without clinically relevant adverse effects.

Effect of preoperative warming during cesarean section under spinal anesthesia

Background

Postoperative hypothermia and shivering is a frequent event in patients during cesarean section under spinal anesthesia. We assessed the effect of preoperative warming during cesarean delivery under spinal anesthesia for prevention of hypothermia and shivering.

Methods

Forty five patients undergoing elective cesarean section were randomly assigned to three groups. Group F received warmed intravenous fluid (40℃). Group A patients were actively warmed by forced air-warming. Group C was the control group. Forced air-warming and warmed fluid was maintained for the 15 min preceding spinal anesthesia. Core temperature (tympanic membrane) and the skin temperature of arm and thigh were measured and shivering was graded simultaneously.

Results

The core temperature at 45 min decreased less in Groups F and A than Group C (-0.5℃ ± 0.3℃ vs -0.6℃ ± 0.4℃ vs -0.9℃ ± 0.4℃, respectively; P = 0.004). The arm temperature at 15 min and 30 min exhibited a greater increase in Group A than Group F and Group C (P = 0.001 and P = 0.012, respectively). Leg temperature increased similarly among the three groups. The incidence of shivering was significantly less in Group A and Group F than Group C (20%, 13.3%, and 53.3%, respectively; P = 0.035).

Conclusions

Preoperative forced air-warming and warmed fluid prevents hypothermia and shivering in patients undergoing elective cesarean delivery with spinal anesthesia.

A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty

Background

Several factors, such as compromised cardiopulmonary function, anticoagulative therapy, or anatomical deformity in the elderly, prevent general anesthesia and neuraxial blockade from being conducted for total knee replacement arthroplasty (TKRA). We investigated the efficacy of femoral/sciatic nerve block with lateral femoral cutaneous nerve block (FSNB) as an alternative procedure in comparison with combined spinal epidural nerve block (CSE) in patients undergoing TKRA.

Methods

In this observational study, 80 American Society of Anesthesiologists physical status I-III patients scheduled for elective unilateral TKRA underwent CSE (n = 40) or FSNB (n = 40). Perioperative side effects, intraoperative medications, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale pain scores were assessed. Statistical analysis was done using Chi-square test, Student's t-test, and repeated-measures analysis of variances.

Results

There was significantly more use of antihypertensives, analgesics, and sedatives in the FSNB group. There were no significant differences of perioperative side effects, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale scores between the two groups.

Conclusions

FSNB with a sophisticated use of antihypertensives, analgesics, and sedatives to supplement insufficient block offers a practical alternative to CSE for TKRAs.

Intrathecal fentanyl for prevention of shivering in spinal anesthesia in cesarean section

BACKGROUND

Shivering is one of the common problems in spinal anesthesia. The objective of the present study was to evaluate the effect of intrathecal fentanyl (25 µg) on incidence and severity of intraoperative and postoperative shivering.

METHODS

A double-blind randomized controlled study was conducted in eighty healthy women (ASA Physical status I) scheduled for elective cesarean section under spinal anesthesia. Subjects were randomly divided into two equal groups. The patients received 12.5 mg (2.5ml) of 0.5% hyperbaric bupivacaine combined with 25 µg (0.5 ml) fentanyl in Group F as a study group and 12.5 mg (2.5ml) of 0.5% hyperbaric bupivacaine combined with 0.5 ml normal saline in Group S as a control group. Incidence of shivering during 30 and 60 minutes of surgery and recovery and complications were evaluated.

RESULTS

The total incidence of shivering in Group F was significantly lower than Group S (10% in group F; 75% in group S, p< 0.0001). Almost all patients started shivering in the first hour after spinal anesthesia and the rate of shivering especially in second 30 minutes was higher than first 30 minutes in both groups. None in Group F but 22 patients (55%) in Group S had shivering during recovery and all of them reported shivering at the first 30 minute at recovery. The severity of shivering in Group F was significantly lower than Group S (p <0.0001).

CONCLUSION

Intrathecal bupivacaine combined with fentanyl is associated with a lower incidence and severity of shivering.

The effect of type of anesthesia on intra-and postoperative blood loss at elective cesarean section

BACKGROUND

In cesarean section (c-sec) it is known that women receiving spinal anesthesia have decreased intraoperative blood loss compared to women receiving general anesthesia. However, we should always consider postoperative bleeding (postpartum bleeding) that may follow. The amount of postpartum bleeding can be substantial. Therefore, we sought to evaluate the effect of type of anesthesia retrospectively on intra- and postoperative blood loss by comparing the changes of postoperative Hb, Hct at c-sec.

METHODS

We retrospectively compared the medical records of 287 elective c-sec patients. We excluded medical and obstetric conditions that may predispose such patients to increased blood loss. Subsequent detailed record analysis included 152 patients that received spinal anesthesia (group S), and 135 patients that received sevoflurane for general anesthesia (group G).

RESULTS

In comparison with the preoperative Hb, rates of Hb in the 1(st) postoperative day in group S significantly decreased compared to group G, but there was no significant difference in decreasing rates of Hb in the 3(rd) postoperative day between groups S and G. Estimated blood loss (EBL) of the intraoperative and operative day in group S was significantly lower compared to group G, but there was no significant difference in EBL of 1(st) and 2(nd) postoperative day between groups S and G.

CONCLUSIONS

We conclude that group S had a decrease in blood loss between the intraoperative and operative day and there was no significant differences in postoperative blood loss compared with group G.

Fatal pulmonary embolism and coincidental cerebral infarction after spinal anesthesia -A case report-

A pulmonary embolism and cerebral infarction are the second and third most common acute cardiovascular diseases after a myocardial infarction. Early diagnosis and appropriate management are important clinical challenges. In this case, a fatal pulmonary embolism and extensive cerebral infarction caused cardiac arrest during spinal anesthesia for total hip replacement surgery. Transesophageal echocardiography indicated a pulmonary embolism and brain CT showed large area of acute infarction at right middle cerebral artery territory. Pulmonary CT angiogram revealed massive pulmonary embolism findings. This paper reviews this case and suggests other preventive modalities.

Comparison of hemodynamic changes between phenylephrine and combined phenylephrine and glycopyrrolate groups after spinal anesthesia for cesarean delivery

BACKGROUND

Hypotension remains a common clinical problem of spinal anesthesia for cesarean delivery and phenylephrine is used as a vasopressor to address this. However, phenylephrine reduces maternal cardiac output (CO) due to reflex bradycardia. Glycopyrrolate is safe for the fetus, and increases heart rate (HR). Using a noninvasive measure of CO, we compared maternal hemodynamic changes between the phenylephrine only group (group P) and the phenylephrine plus glycopyrrolate group (group PG).

METHODS

In this randomized study, 60 women scheduled for elective cesarean delivery were allocated to group P (n = 30) or group PG (n = 30). In both groups, phenylephrine was infused at 50 µg/min. This infusions stopped if systolic blood pressure (SBP) was higher than the baseline value, and phenylephrine 100 µg was injected if SBP was lower than 80% of the baseline value from spinal anesthesia to delivery. In group PG, glycopyrrolate 0.2 mg was injected intravenously after spinal anesthesia. Hemodynamic parameters, such as SBP, heart rate (HR), stroke volume index (SVI), cardiac index (CI) were measured before and until 15 min after spinal anesthesia.

RESULTS

There were no significant differences in SBP and SVI compared to the baseline value in each group and between the two groups. HR and CI reduced significantly from 8 min to 15 min in group P compared to the baseline value as well as group PG for each time-point. However, HR and CI were maintained in group PG.

CONCLUSIONS

The use of glycopyrrolate added to phenylephrine infusion to prevent hypotension by spinal anesthesia for cesarean delivery was effective in maintaining HR and CI.

Comparison of Duration of Spinal Anesthesia with Lidocaine or Lidocaine plus Epinephrine between Addicts and Non-addicts

BACKGROUND

Duration of spinal anesthesia depends on the type of anesthetic agent, dosage and additive materials such as epinephrine, ephedrine and opioid. We compared the duration of spinal anesthesia with lidocaine 5% with or without epinephrine in addict and non-addict patients undergoing inferior limb fracture surgery.

METHODS

This single blinded randomized clinical trial was performed on 201 males (height ranged 150-180 cm) who referred to the Shahid Bahonar Hospital of Kerman for the inferior limb fracture. Their physical class was matched to the American association standard class 1 and 2, and they were appropriate candidates for the spinal anesthesia. The addict or non-addict groups were each divided into two subgroups. 75 mg of 5% lidocaine was prescribed for one subgroup, and the other subgroup received 75 mg of 5% lidocaine plus 0.2 mg epinephrine. The level of primary anesthesia was elevated to T6. Duration of returning to the 4 primary sensory levels was measured since baseline.

FINDINGS

A significant increase in the duration of anesthesia level in both addict and non-addict patients receiving lidocaine plus epinephrine was observed compared to the subgroups receiving lidocaine alone (P < 0.01). Duration of decrease in sensory level in addict subgroups receiving lidocaine or lidocaine plus epinephrine was lower compared to non-addict patients (P < 0.001). In addict subgroup receiving lidocaine alone, a significant decrease was observed in the time needed for decrease in sensory level (P < 0.01).

CONCLUSION

According to the results of this study, regardless of the anesthetic agent being used, duration of spinal anesthesia was shorter in addict patients compared to non-addict ones. Addition of epinephrine to lidocaine 5% increased the duration of spinal anesthesia in both addict and non-addict patients.

Hemodynamic effects of continuous intravenous injection and bolus plus continuous intravenous injection of oxytocin in cesarean section

Background

Oxytocin may cause adverse cardiovascular effects, including tachycardia and hypotension, whereas the optimal dose of oxytocin at elective cesarean section is unclear. To determine the lowest effective dose of oxytocin, we studied the hemodynamic effects of three doses during spinal anesthesia for elective single cesarean delivery.

Methods

Sixty women received oxytocin by continuous (0.5 IU/min) or bolus-continuous (2 or 5 IU prior to 0.25 IU/min continuous intravenous injection) intravenous injection after clamping of the umbilical cord. We compared changes in heart rate (HR), mean arterial pressure (MAP) and estimated blood loss (EBL). Uterine tone (UT) was assessed by palpation on a linear analog scale (LAS) at 5, 10, 15, 20 and 25 minutes after the oxytocin injection. In addition, oxytocin-related side-effects such as nausea and vomiting were recorded.

Results

Marked hemodynamic changes such as HR and MAP occurred in the bolus-continuous groups but not in the continuous groups. Although we were not able to observe a variation of EBL in each group, the UT significantly increased in the bolus-continuous groups when compared with that the continuous groups. In addition, the hemodynamic changes such as HR and MAP were lower in the two IU bolus-continuous group than those in the five IU group.

Conclusions

Although bolus-continuous injection of oxytocin resulted in more hemodynamic changes than continuous injection, bolus-continuous injection had a greater effect on uterine contraction. Furthermore, two IU bolus-continuous injection showed lower hemodynamic changes than in the five IU bolus-continuous injection.

The effect of the intravenous phenylephrine on the level of spinal anesthesia

Background

Spinal anesthesia causes hypotension and bradycardia due to sympathetic nerve block and it is difficult to predict the level of sensory block and the duration of blockade. Recent studies have reported that intravenous phenylephrine can reduce the rostral spread of spinal anesthesia in pregnant women. We think a phenylephrine infusion will be useful for maintaining the baseline blood pressure by reducing the rostral spread of spinal anesthesia during the elective surgery of non-obstetric patients.

Methods

Sixty patients who were undergoing urologic surgery were randomized into two groups: Group C (the control group without phenylephrine) and Group P (with the addition of phenylephrine). After a bolus infusion of 50 µg phenylephrine following the spinal injection, phenylephrine was continuously infused at the rate of 200 µg/hr. We compared the dermatomal spreads of spinal anesthesia, the hemodynamic parameters (blood pressure, heart rate) and the incidences of hypotension between the two groups.

Results

At 20 minutes, the level of the upper dermatome blocked against cold sensation was a median of T8 (interquartile range: T8-T10) for the phenylephrine group, as compared with T4 (interquartile range: T4-T6) for the control group (P < 0.001).

Conclusions

Intravenous phenylephrine can decrease the rostral spread of spinal anesthesia during urologic surgery.

Predicting the difficulty in performing a neuraxial blockade

BACKGROUND

Traumatic placement of a needle during a neuraxial blockade has been related to many complications such as postdural puncture headache, trauma to neural structures and even spinal hematoma, causing permanent neurologic deficits. Although efforts to minimize the complications caused by traumatic neuraxial blockade have been made, nothing was found to be clear. The authors investigated the predictors of difficult neuraxial blockade using the first puncture success and number of attempts as measures to assess the difficulty.

METHODS

In this prospective observational study, 253 patients scheduled for elective surgery underwent spinal or epidural anesthesia. Patient data (age, sex, height, weight, body mass index, and quality of anatomical landmarks), the provider's level of experience, type of blockade (spinal or epidural), needle type/gauge and the distance from skin to subarachnoid or epidural space were recorded. Significant variables were first determined by Student's t-test and Pearson's chi square test and then logistic and Poisson regression tested the association of the first puncture success and number of attempts with the significant variables.

RESULTS

The provider's level of experience and the distance from skin to subarachnoid or epidural space were significant in logistic and Poisson regression. Body mass index was significant only in Poisson regression and the quality of anatomical landmarks was significant only in logistic regression.

CONCLUSIONS

Provider's level of experience and the distance from skin to subarachnoid or epidural space influenced the difficulty in performing a neuraxial blockade.

Epidural hematoma occurred by massive bleeding intraoperatively in cesarean section after combined spinal epidural anesthesia -A case report-

We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.

Post-dural Puncture Headache: A Comparison Between Median and Paramedian Approaches in Orthopedic Patients

Background:

Post-dural puncture headache (PDPH) is an iatrogenic complication of spinal anesthesia. Reported risk factors for PDPH include sex, age, pregnancy, needle tip shape and size, bevel orientation, approach and others. Little is known regarding the effect of different approaches on the incidence of PDPH.

Objectives:

In this study we aimed to compare the incidence of PDPH in the case of median and paramedian approaches in patients undergoing spinal anesthesia for orthopedic operations.

Patients and Methods:

Patients scheduled for orthopedic surgery under spinal anesthesia between 2007 and 2008 were studied in a double-blinded randomized controlled trial. The patients were randomized to receive spinal anesthesia by either a median (n = 75) or paramedian (n = 75) approach through a 25-gauge Crawford needle. No premedication was given, and all patients received 500 mL of normal saline intravenously and 4 mL of 0.5% isobaric Marcaine 30 minutes prior to surgery in both approaches.

Results:

Fifteen patients (10%) developed PDPH. There was no significant difference in the incidence of PDPH in both groups, with 7 (9.3%) patients in the median approach group versus 8 (10.7%) in the paramedian approach group developing typical PDPH (P = 0.875). However, a significant difference in PDPH incidence (P = 0.041) was observed between females (9; 16.7%) and males (6; 6.3%).

Conclusions:

There is no difference between median and paramedian approaches with respect to PDPH incidence; the paramedian approach is therefore recommended, especially for older patients with degenerative changes in the spine and intervertebral spaces and those who cannot take the proper position. Moreover, the rate of PDPH was found to be significantly higher in females than in males.