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Radwan MA, O'Carroll L, McCaul CL. Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review. Int J Obstet Anesth 2024; 59:104208. [PMID: 38781779 DOI: 10.1016/j.ijoa.2024.104208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments. METHODS We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted. RESULTS A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180 min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided. CONCLUSIONS The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.
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Affiliation(s)
| | | | - C L McCaul
- The Rotunda Hospital, Dublin, Ireland; Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine and Medical Sciences, University College Dublin, Ireland.
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Jia C, Zou B, Sun YJ, Han B, Diao YG, Li YT, Cao HJ. The 90% effective concentration of alfentanil combined with 0.075% ropivacaine for epidural labor analgesia: a single-center, prospective, double-blind sequential allocation biased-coin design. J Anesth 2024; 38:377-385. [PMID: 38441686 PMCID: PMC11096240 DOI: 10.1007/s00540-024-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 02/07/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE More literature studies have reported that alfentanil is safe and effective for labor analgesia. However, there is no unified consensus on the optimal dosage of alfentanil used for epidural analgesia. This study explored the concentration at 90% of minimum effective concentration (EC90) of alfentanil combined with 0.075% ropivacaine in patients undergoing epidural labor analgesia to infer reasonable drug compatibility and provide guidance for clinical practice. METHODS In this prospective, single-center, double-blind study, a total of 45 singleton term primiparas with vaginal delivery who volunteered for epidural labor analgesia were recruited. The first maternal was administered with 3 μg/mL alfentanil combined with 0.075% ropivacaine with the infusion of 10 mL of the mixture every 50 min at a background dose of 3 mL/h. In the absence of PCEA, a total of 15 mL of the mixture is injected per hour. The subsequent alfentanil concentration was determined on the block efficacy of the previous case, using an up-down sequential allocation with a bias-coin design. 30 min after epidural labor analgesia, the block of patient failed with visual analog score (VAS) > 3, the alfentanil concentration was increased in a 0.5 μg/mL gradient for the next patient, while the block was successful with VAS ≤ 3, the alfentanil concentration was remained or decreased in a gradient according to a randomized response list for the next patient. EC90 and 95% confidence interval were calculated by linear interpolation and prediction model with R statistical software. RESULTS In this study, the estimated EC90 of alfentanil was 3.85 μg/mL (95% confidence interval, 3.64-4.28 μg/mL). CONCLUSION When combined with ropivacaine 0.075%, the EC90 of alfentanil for epidural labor analgesia is 3.85 μg/mL in patients undergoing labor analgesia.
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Affiliation(s)
- Chang Jia
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
- Graduate School, Dalian Medical University, Dalian, China
| | - Bin Zou
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
| | - Ying-Jie Sun
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
| | - Bo Han
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
| | - Yu-Gang Diao
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
| | - Ya-Ting Li
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China
| | - Hui-Juan Cao
- Department of Anesthesiology, General Hospital of Northern Theater Command of the Chinese People's Liberation Army, Shenyang, China.
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Chaitanya KU, Dhananjay DN, Kumar MK, Vinaik T. A Case Report of Caudal Migration of a Lumbar Epidural Catheter Confirmed by Doppler Ultrasound: Ultrasound to the Rescue! Cureus 2024; 16:e55879. [PMID: 38595886 PMCID: PMC11002969 DOI: 10.7759/cureus.55879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Combined spinal-epidural anaesthesia is an excellent technique for providing intraoperative and postoperative analgesia in patients undergoing total knee arthroplasty. Epidural catheters threaded through a Tuohy needle with a cephalad needle bevel orientation follow a winding pattern within the epidural space. Caudal or downward migration of an epidural catheter may lead to unsatisfactory anaesthesia and epidural failure. Colour flow Doppler sonography is emerging as an effective technique to determine the epidural catheter tip position. We report an interesting case of caudal migration of a lumbar epidural catheter confirmed by colour flow Doppler ultrasound.
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Affiliation(s)
| | - D N Dhananjay
- Department of Anaesthesiology, Sakra World Hospital, Bengaluru, IND
| | - Mahendra K Kumar
- Department of Anaesthesiology, Sakra World Hospital, Bengaluru, IND
| | - Tulika Vinaik
- Department of Anaesthesiology, Sakra World Hospital, Bengaluru, IND
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Djurdjevic Svraka A, Svraka D, Pejic D, Mrdja V. Establishment of Labor Epidural Analgesia Service and its Assessment: An Experience in a Hospital of a Middle-Income Country. Cureus 2024; 16:e55322. [PMID: 38559507 PMCID: PMC10981845 DOI: 10.7759/cureus.55322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES Even though the idea of painless birth is more than 100 years old, it is still underrepresented in some parts of the world despite progress in science, education, anesthesia, spinal and epidural needles, development of catheters, new drugs, and infusion pumps. Maternal care should basically be the safety of the patient (in this case two patients) and also provide all kinds of protection in the form of a multidisciplinary team with an anesthesiologist, especially when it comes to pain therapy and anesthesia for women in labor. In this direction, our hospital departments with low or moderate volume of annual births made the decision to educate ourselves for painless childbirth and contribute more to the care of women in labor. The enthusiasm and dedication of our clinical team prevailed and today we have a high standard of labor epidural service. The aim of this study was to evaluate the establishment of the epidural labor service by comparing the effects of epidural analgesia on labor pain and the course of labor. The secondary objectives were to compare satisfaction with epidural analgesia and the impact of epidural analgesia on the delivery mode. MATERIAL AND METHODS This was a prospective observational hospital-based study conducted on 100 patients after the establishment of epidural service. Parturients who were signed to receive epidural analgesia formed Group A and parturients who did not request epidural analgesia formed Group B. All parturients are induced in the delivery room with a Bishop score of 5 or higher. RESULTS Pain intensity measured through the visual analog scale of pain (VAS score) was significantly lower in Group A (n = 46) compared to Group B (n = 50) at measured points of time (p<0.001). There was a fall in the mean VAS score in Group A from 7.94 to 3.86 within 20 minutes of the bolus dose and starting a continuous infusion. Labor progress according to the Bishop score and till the end of the second stage of labor, or to the transfer to the operating theatre, according to the monitored time in Group A was 176 minutes and it was lower in Group B with 155 minutes; however, by test of linearity we do not gain significance (p = 0.2). There were eight parturients in each group (17% vs 16%) who were indicated for surgical delivery. According to Pearson's correlation test for the outcome of labor between parturients receiving epidural analgesia and parturients without epidural analgesia (p = 0.8), we cannot say that epidural analgesia in labor is correlated with the outcome of surgical delivery. CONCLUSION Establishing a new hospital procedure such as an epidural painless service for childbirth in low or moderate-volume settings of annual births is very challenging. By evaluating epidural labor services in our hospital, we created the best environment for continuous improvement and long-term efficacy and safety of our analgesic techniques aimed at providing excellent care to mothers and their babies.
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Affiliation(s)
- Anita Djurdjevic Svraka
- Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
- Anesthesiology, Resuscitation, and Intensive Care, General Hospital Gradiska, Gradiska, BIH
| | - Dragan Svraka
- Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
- Anesthesiology and Critical Care, University Clinical Center of Republika Srpska, Banja Luka, BIH
| | - Dejan Pejic
- Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
- Obstetrics and Gynaecology, General Hospital Gradiska, Gradiska, BIH
| | - Vladimir Mrdja
- Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
- Anesthesiology and Critical Care, University Clinical Center of Republika Srpska, Banja Luka, BIH
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Oostvogels L, Weibel S, Meißner M, Kranke P, Meyer-Frießem CH, Pogatzki-Zahn E, Schnabel A. Erector spinae plane block for postoperative pain. Cochrane Database Syst Rev 2024; 2:CD013763. [PMID: 38345071 PMCID: PMC10860379 DOI: 10.1002/14651858.cd013763.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects. OBJECTIVES To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects. MAIN RESULTS We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome. AUTHORS' CONCLUSIONS ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.
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Affiliation(s)
- Lisa Oostvogels
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Meißner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management, BG-Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Serey K, Osse L, Repessé X, Babou J, Banna L, Ayoub M, Elseblani R, Brebion M, Keita H. Cross-legged position versus traditional sitting position for epidural catheter insertion for labor analgesia: a non-randomized prospective study. Int J Obstet Anesth 2024; 57:103938. [PMID: 37891125 DOI: 10.1016/j.ijoa.2023.103938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/24/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023]
Affiliation(s)
- K Serey
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - L Osse
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - X Repessé
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - J Babou
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - L Banna
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - M Ayoub
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - R Elseblani
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - M Brebion
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France
| | - H Keita
- APHP, Hôpital Necker Enfants Malades, DMU ARME, Service d'Anesthésie-Réanimation Pédiatrique et Obstétricale, Paris, France; Unité de Recherche EA 7323 Pharmacologie et Évaluation des Thérapeutiques Chez l'Enfant et la Femme Enceinte, Université de Paris Cité, Paris, France.
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Jin SY, Munro A, Aidemouni M, McKeen DM, Uppal V. The Incidence and Predictors of Failed Spinal Anesthesia After Intrathecal Injection of Local Anesthetic for Cesarean Delivery: A Single-Center, 9-Year Retrospective Review. Anesth Analg 2024; 138:430-437. [PMID: 37014966 DOI: 10.1213/ane.0000000000006459] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND The incidence of failed spinal anesthesia varies widely in the obstetric literature. Although many risk factors have been suggested, their relative predictive value is unknown. The primary objective of this retrospective cohort study was to determine the incidence of failed spinal anesthesia for cesarean deliveries at a tertiary care obstetric hospital, and its secondary objectives were to identify predictors of failed spinal anesthesia in the obstetrics population and quantify their relative importance in a predictive model for failure. METHODS With local institutional ethics committee approval, a retrospective review of our hospital database identified the incidence of failed spinal anesthesia for 5361 cesarean deliveries between 2010 and 2019. We performed a multivariable analysis to assess the association of predictors with failure and a dominance analysis to assess the importance of each predictor. RESULTS The incidence of failed spinal anesthesia requiring an alternative anesthetic was 2.1%, with conversion to general anesthesia occurring in 0.7% of surgeries. Supplemental analgesia or sedation was provided to an additional 2.0% of women. The most important predictors of a failed spinal anesthetic were previous cesarean delivery (odds ratio [OR], 11.33; 95% confidence interval [CI], 7.09-18.20; P < .001), concomitant tubal ligation (OR, 8.23; 95% CI, 3.12-19.20; P < .001), lower body mass index (BMI) (kg·m -2 , OR, 0.94; 95% CI, 0.90-0.98; P = .005), and longer surgery duration (minutes, OR, 1.02; 95% CI, 1.01-1.03; P = .006). Previous cesarean delivery was the most significant risk factor, contributing to 9.6% of the total 17% variance predicted by all predictors examined. CONCLUSIONS Spinal anesthesia failed to provide a pain-free surgery in 4.1% of our cesarean deliveries. Previous cesarean delivery was the most important predictor of spinal failure. Other important predictors included tubal ligation, lower BMI, and longer surgery duration.
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Affiliation(s)
- Sherry Y Jin
- From the Department of Anesthesia, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
- Humber River Hospital, Toronto, Ontario, Canada
| | - Allana Munro
- From the Department of Anesthesia, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Milia Aidemouni
- From the Department of Anesthesia, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Dolores M McKeen
- From the Department of Anesthesia, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
- Discipline of Anesthesia, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Vishal Uppal
- From the Department of Anesthesia, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia, Canada
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8
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Munro A, Sjaus A. General anesthesia for Cesarean delivery: can interinstitutional variation in practice offer deeper insights into our choice of anesthetic modality? Can J Anaesth 2024; 71:169-174. [PMID: 37932651 DOI: 10.1007/s12630-023-02634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 11/08/2023] Open
Affiliation(s)
- Allana Munro
- Department of Women's & Obstetric Anesthesia, IWK Health, 5850/5980 University Ave, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Ana Sjaus
- Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Women's & Obstetric Anesthesia, IWK Health Centre, Halifax, NS, Canada
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Knight G, Mushambi M. Anesthetic challenges of pregnant obesity women. Best Pract Res Clin Obstet Gynaecol 2023; 91:102405. [PMID: 37688846 DOI: 10.1016/j.bpobgyn.2023.102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/24/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
Obesity causes significant morbidity and increases the mortality risk for both mother and fetus. With an increasing projected prevalence, it is vital that the obstetric anesthetist is equipped with the knowledge and tools to manage these women. A multi-disciplinary team approach and early planning is required. Neuraxial analgesia for labor helps to negate the need for general anesthesia, which is associated with increased risk in this subset of women. Catheter techniques for neuraxial anesthesia allow for titration, manipulation, and prolongation of the anesthetic block to reduce the risk of conversion to general anesthesia.
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Affiliation(s)
- Georgia Knight
- University Hospitals of Leicester, Infirmary Square, Leicester 0300 3031573, UK.
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Li P, Ma X, Han S, Kawagoe I, Ruetzler K, Lal A, Cao L, Duan R, Li J. Risk factors for failure of conversion from epidural labor analgesia to cesarean section anesthesia and general anesthesia incidence: an updated meta-analysis. J Matern Fetal Neonatal Med 2023; 36:2278020. [PMID: 37926901 DOI: 10.1080/14767058.2023.2278020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES Ongoing controversies persist regarding risk factors associated with the failure of transition from epidural labor analgesia to cesarean section anesthesia, including the duration of labor analgesia, gestational age, and body mass index (BMI). This study aims to provide an updated analysis of the incidence of conversion from epidural analgesia to general anesthesia, while evaluating and analyzing potential risk factors contributing to the failure of this transition to cesarean section anesthesia. METHODS We conducted an extensive literature search utilizing databases such as PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WANGFANG, and the Chinese Biomedical Literature Database (CBM) up to September 30, 2022. The meta-analysis was performed using STATA 15.1 software. The quality of the included studies was assessed using the 11-item quality assessment scale recommended by the Agency for Healthcare Research and Quality (AHRQ). RESULTS A total of 9,926 studies were initially retrieved, and after rigorous selection, 19 studies were included in the meta-analysis. The overall incidence of conversion from epidural analgesia to general anesthesia was found to be 6% (95% confidence interval [CI]: 5-8%). Our findings indicate that, when compared to patients in the successful conversion group, those in the failure group tended to be younger (weighted mean difference [WMD] = -1.571, 95% CI: -1.116 to -0.975) and taller (WMD = 0.893, 95% CI: 0.018-1.767). Additionally, the failure group exhibited a higher incidence of incomplete block in epidural anesthesia, received a higher dosage of additional epidural administration, experienced a greater rate of emergency cesarean sections, and received anesthesia more frequently from non-obstetric anesthesiologists. However, no statistically significant differences were observed in gestational age, depth of the catheter insertion into the skin, epidural catheter specifics, duration of epidural analgesia, infusion rate of epidural analgesia, primiparity status, cervical dilatation during epidural placement, BMI, or weight. CONCLUSION Our study found that the incidence of conversion from epidural analgesia to cesarean section under general anesthesia was 6%. Notably, the failure group exhibited a higher rate of incomplete block in epidural anesthesia, a greater incidence of emergency cesarean sections, a more frequent provision of anesthesia by non-obstetric anesthesiologists, a higher dosage of epidural administration, and greater height when compared to the success group. Conversely, women in the failure group were younger in age compared to their counterparts in the success group.
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Affiliation(s)
- Pan Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Xiaoting Ma
- Department of Clinical Laboratory, Hebei General Hospital, Shijiazhuang, China
| | - Shuang Han
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Longlu Cao
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Ran Duan
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Jianli Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
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11
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Patel R, Russell R, Plaat F, Bogod D, Lucas N. Inadequate neuraxial anaesthesia during caesarean delivery: a survey of practitioners. Int J Obstet Anesth 2023; 56:103905. [PMID: 37385081 DOI: 10.1016/j.ijoa.2023.103905] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/12/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND We aimed to determine the knowledge, training, practices and attitudes of obstetric anaesthetic practitioners with regard to failed neuraxial anaesthesia for caesarean delivery. METHOD We performed a contemporaneous and representative survey in an innovative fashion. We conducted an international cross-sectional study of obstetric anaesthetic practitioners at the Annual Scientific Meeting of the Obstetric Anaesthetists' Association (OAA 2021). Validated survey questions were collected in real time using an audience response system. RESULTS Of the 426 participants who logged into the survey system, 356 provided responses (4173 responses to 13 questions, across all grades/seniority of practitioner). The number of responses to questions ranged from 81% to 61%. Survey responses suggest that it is routine for respondents to inform patients about the difference between pain and expected intra-operative sensations, (320/327, 97.9%) but less routine to inform patients of the risk of intra-operative pain (204/260, 78.5%), or the possibility of conversion to general anaesthesia. (290/309 93.8%). Only 30% of respondents reported the use of written guidelines for follow-up of patients who experience intra-operative pain under neuraxial anaesthesia, and only 23% reported formal training in management of intra-operative pain under neuraxial anaesthesia. Respondents felt that inadequate block duration, prolonged surgery, and patient anxiety were contributory factors to failed anaesthesia, and the contributory factors differed between grade/seniority of practitioner. Modalities used to test a block were cold, motor block and light touch, with approximately 65% of respondents routinely using three modalities. CONCLUSIONS Our study survey found that the consent process may not always be adequately comprehensive, and that standardised documentation and testing of the block and focused training may be beneficial to prevent patient dissatisfaction and the chance of litigation.
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Affiliation(s)
- R Patel
- Surgical Outcomes Research Centre, Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK.
| | - R Russell
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F Plaat
- Division of Anaesthesia, Critical Care and Theatres, Imperial College Healthcare NHS Trust, UK
| | - D Bogod
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, UK
| | - N Lucas
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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12
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Poma S, Bonomo MC, Gazzaniga G, Pizzulli M, De Silvestri A, Baldi C, Broglia F, Ciceri M, Fuardo M, Morgante F, Pellicori S, Roldi EM, Delmonte MP, Mojoli F, Locatelli A. Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:42. [PMID: 37880725 PMCID: PMC10601237 DOI: 10.1186/s44158-023-00127-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.
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Affiliation(s)
- S Poma
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy.
| | - M C Bonomo
- Department of Anaesthesia and Intensive Care, ASST Bergamo EST, Seriate Hospital, Seriate, Italy
| | - G Gazzaniga
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - M Pizzulli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - A De Silvestri
- Clinical Epidemiology and Biostatistics, Scientific Direction, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - C Baldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Broglia
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Ciceri
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M Fuardo
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Morgante
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - S Pellicori
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - E M Roldi
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - M P Delmonte
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
| | - F Mojoli
- Department of Anaesthesia and Intensive Care 1, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, Italy
| | - A Locatelli
- Anaesthesia and Postoperative Intensive Care, Department of Anaesthesia and Intensive Care 3, I.R.C.C.S. Policlinic San Matteo Hospital Foundation, Pavia, 27100, Italy
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Nandoliya KR, Sadagopan NS, Alwakeal A, Kemeny H, Cloney M, Dahdaleh NS, Koski T, El Tecle N. Adolescent Idiopathic Scoliosis and Pregnancy. Cureus 2023; 15:e46782. [PMID: 37954752 PMCID: PMC10633849 DOI: 10.7759/cureus.46782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Objective This study examined the interaction between adolescent idiopathic scoliosis (AIS) and pregnancy, focusing on pregnancy outcomes, changes in back pain, and anesthesia use. Methods A retrospective analysis was conducted on adult patients with AIS who gave birth at our institution between 2006 and 2022. Results A total of 163 AIS patients with 263 pregnancies were included. The median age at delivery was 33 (range 18 to 50) years. Among 157 patients with information on prior scoliosis treatment, 66.9% had not received treatment, 20.4% had undergone spinal fusion, and 12.7% had received bracing. Of the 260 pregnancies with available data, 90.4% were delivered at term and 8.5% were preterm. Of the 257 pregnancies with information on anesthesia type, 35.0% received epidural anesthesia, 17.9% received spinal anesthesia, 37.7% received combined spinal and epidural anesthesia, 8.2% received no anesthesia, and 1.2% received intravenous or general anesthesia. Difficulty administering neuraxial anesthesia was reported in 6.1% of cases, and these patients were less likely to receive combined spinal and epidural anesthesia (6.3% versus 39.8%, p = 0.0123). Among 116 cases with recorded back pain during pregnancy, 67.2% reported increased pain, 31.9% reported similar pain, and one patient reported decreased pain. Of the 16 patients with pre and postpartum radiographs, eight showed a Cobb angle increase ≥ 3°, with five patients having an increase ≥ 5°. Conclusions Pregnancy can exacerbate back pain and pose challenges for neuraxial anesthesia in some AIS patients. Further large-scale, multi-institutional studies with standardized data collection are needed to fully understand the impact of pregnancy on AIS.
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Affiliation(s)
- Khizar R Nandoliya
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Nishanth S Sadagopan
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Amr Alwakeal
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Hanna Kemeny
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Michael Cloney
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Nader S Dahdaleh
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Tyler Koski
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Najib El Tecle
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
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Theroux J, Brown BT, Marchese R, Selby M, Cope V, McAviney J, Beynon A. The impact of pregnancy on women with adolescent idiopathic scoliosis: a scoping review. Eur J Phys Rehabil Med 2023; 59:505-521. [PMID: 37746783 PMCID: PMC10548399 DOI: 10.23736/s1973-9087.23.08086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Adolescent idiopathic scoliosis is the most common spinal deformity encountered in adolescents and larger curves are more prevalent in girls. For females with scoliosis, women's health issues are of particular concern, especially pregnancy. The aim of this review was to summarise the best available evidence to determine the influence of pregnancy on scoliosis-related outcomes in women with scoliosis and whether scoliosis affects maternal-health outcomes, differentiating between patients who have been managed conservatively and/or surgically. EVIDENCE ACQUISITION A search was conducted using CINAHL, Scopus, Cochrane Database, MEDLINE, and EMBASE from inception to May 2023 to identify relevant articles in any language. The scoping review followed the PRISMA-ScR guidelines. Studies were eligible if they included pregnant women (primiparous or multiparous) with a diagnosis of scoliosis of unknown aetiology. The results were summarized by outcomes, including pregnancy and scoliosis-related outcomes and type of management. EVIDENCE SYNTHESIS Our comprehensive search strategy identified 6872 articles, of which 50 articles were eligible for this review. Back pain appears to be more prevalent in this population during pregnancy and associated with the major curve and the decrease of lumbar lordosis. There have been reports of failed attempted spinal anaesthesia among patients with instrumented scoliosis correction and minor complications related to epidural anaesthesia at a higher rate compared to non-instrumented patients and healthy controls, however successful spinal analgesia can be achieved in patients with instrumented scoliosis correction. Overall, the caesarean section rate was similar in scoliosis patients compared to controls without scoliosis and to national averages. Curve progression occurs in some but not all patients during pregnancy, and this phenomenon occurs irrespective of the treatment received. CONCLUSIONS Higher-quality prospective longitudinal research is needed to understand the relationship between pregnancy and adolescent idiopathic scoliosis. Further, the patient's perspective, concerns and fears surrounding pregnancy with scoliosis are yet to be explored. Exploring the impact of pregnancy on women with adolescent idiopathic scoliosis would have clinically relevant outcomes and could help provide pertinent answers to patients and healthcare workers and help guide future research.
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Affiliation(s)
- Jean Theroux
- School of Allied Health, Murdoch University, Perth, Australia -
| | - Benjamin T Brown
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- ScoliCare, Kogarah, Australia
| | | | - Michael Selby
- South Australian Scoliosis Service, International Spine Centre, and Adelaide Spine and Brain Clinic, Adelaide, Australia
| | - Vicki Cope
- School of Allied Health, Murdoch University, Perth, Australia
- School of Nursing, Murdoch University, Perth, Australia
| | | | - Amber Beynon
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
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15
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Rao WY, Xu F, Dai SB, Mei Z, Chen XP, Lv CC, Liu CL, Ngan Kee W, Chen XZ. Comparison of Dural Puncture Epidural, Epidural and Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Controlled Trial. Drug Des Devel Ther 2023; 17:2077-2085. [PMID: 37484190 PMCID: PMC10362875 DOI: 10.2147/dddt.s415684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose Catheter-based techniques such as combined spinal-epidural (CSE) anesthesia which are sometimes indicated for obstetric anesthesia have a complex mechanism of action. The application of the dural puncture epidural (DPE) anesthesia for cesarean section (CS) has not been well investigated. The present study compared the relatively novel DPE technique with epidural (EA) and CSE anesthesia. Patients and Methods We randomly assigned 150 parturients who underwent elective CS to receive DPE, EA or CSE anesthesia. The primary outcome was the onset of sensory anesthesia to the T5 dermatome assessed using the Cox proportional hazards model. Secondary outcomes included median time to sensory block, quality of block, patient and surgeon satisfaction, APGAR scores and other side effects. Results For DPE anesthesia versus EA anesthesia, the onset of anesthesia was faster (hazard ratio 2.47 [95% CI 1.56 to 3.90], adjusted P < 0.001) and the median time to surgical level was shorter (16 [IQR 14-18] min versus 19 [15.5-21] min, adjusted P < 0.001); the incidence of intraoperative pain was lower (7/48 versus 17/47, adjusted P = 0.046) and the median patient satisfaction score was higher (9 [IQR 9-10] versus 8 [8-9.5], adjusted P = 0.004). In the CSE group, the onset of anesthesia was faster than in the other two but the incidence of hypotension was higher (P < 0.001) and the phenylephrine requirement was greater (P < 0.001). Conclusion DPE anesthesia had a faster onset and better quality of block than EA anesthesia and provided less influence to maternal hemodynamic parameters than CSE anesthesia for CS. These results suggest that the dural puncture plays a significant role in enhancing the effectiveness of epidural top-ups during CSE anesthesia and indicates enlightenment that contributes to the satisfaction of anesthetic effect in DPE technique labor analgesia transferred to CS.
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Affiliation(s)
- Wan-Yi Rao
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Fang Xu
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Shao-Bing Dai
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Zhong Mei
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, People’s Republic of China
| | - Xiao-Ping Chen
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Chang-Cheng Lv
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Chun-Lei Liu
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Warwick Ngan Kee
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xin-Zhong Chen
- Department of Anesthesia, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
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16
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Stav M, Matatov Y, Hoffmann D, Heesen P, Gliesche V, Binyamin Y, Ioscovich A, Eidelman LA, Orbach-Zinger S. Incidence of conversion to general anaesthesia and need for intravenous supplementation in parturients undergoing caesarean section under spinal anaesthesia: A retrospective observational study. Acta Anaesthesiol Scand 2023; 67:29-35. [PMID: 36056463 DOI: 10.1111/aas.14146] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/14/2022] [Accepted: 08/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors. METHODS All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 μg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation. RESULTS There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis. CONCLUSIONS A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used.
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Affiliation(s)
- Michael Stav
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Yuri Matatov
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Dana Hoffmann
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Leonid A Eidelman
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Orbach-Zinger
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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17
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Yurashevich M, Taylor CR, Dominguez JE, Habib AS. Anesthesia and Analgesia for the Obese Parturient. Adv Anesth 2022; 40:185-200. [PMID: 36333047 DOI: 10.1016/j.aan.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Obesity is a worldwide epidemic and is associated with an increased risk of hypertension, diabetes, and obstructive sleep apnea. Pregnant patients with obesity experience a higher risk of maternal and fetal complications. Anesthesia also poses higher risks for obese parturients and may be more technically challenging due to body habitus. Safe anesthesia practice for these patients must take into consideration the unique challenges associated with the combination of pregnancy and obesity.
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Affiliation(s)
- Mary Yurashevich
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Jennifer E Dominguez
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA.
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van den Bosch OFC, Gleicher Y, Arzola C, Siddiqui N, Downey K, Carvalho JCA. Color flow Doppler in spinal ultrasound: a novel technique for assessment of catheter position in labor epidurals. Reg Anesth Pain Med 2022; 47:775-779. [PMID: 36215115 DOI: 10.1136/rapm-2022-103948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound. METHODS We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients. RESULTS We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients. CONCLUSION Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion. TRIAL REGISTRATION NUMBER NCT05126745.
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Affiliation(s)
- Oscar F C van den Bosch
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yehoshua Gleicher
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cristian Arzola
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Naveed Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kristi Downey
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jose C A Carvalho
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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19
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Berger A, Jordan J, Li Y, Kowalczyk J, Hess P. Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Int J Obstet Anesth 2022; 52:103590. [DOI: 10.1016/j.ijoa.2022.103590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 07/05/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
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20
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Lardone E, Sarotti D, Giacobino D, Ferraris E, Franci P. Thoracic epidural anaesthesia vs intrathecal morphine in dogs undergoing major thoracic and abdominal surgery: clinical study. BMC Vet Res 2022; 18:200. [PMID: 35624498 PMCID: PMC9137148 DOI: 10.1186/s12917-022-03296-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is scant clinical research on neuraxial analgesia in dogs undergoing major surgery. With this study we compared the perioperative analgesic effects of thoracic epidural anaesthesia (TEA) and intrathecal morphine (ITM) in dogs scheduled for thoracic or cranial abdominal surgery. The dogs received methadone and dexmedetomidine, were anaesthetized with propofol maintained with sevoflurane, and randomly assigned to receive either TEA (ropivacaine 0.5% at 0.2 mg/kg and morphine 0.1 mg/kg administered at T12-T13) or ITM (morphine 30 μg/kg administered at L6-L7). Intraoperative rescue analgesia (iRA) was fentanyl 1 μg/kg administered if heart rate or mean arterial pressure increased by 30% above the pre-stimulation level. Glasgow Pain Composite Scale score (GPCS) dictated the use of postoperative rescue analgesia (pRA) with methadone 0.2 mg/kg. RESULTS There was a statistically significant difference in iRA, median time to first fentanyl bolus, median fentanyl dose after surgical opening, and median GPCS score at 30 minutes (min), 1 ,2, 4, 6, and 8 hours (h) between the two groups (p<0.001; p<0.001; p<0.001; p<0.01; p<0.01; p<0.001; p<0.01; p=0.01; p=0.01, respectively). Fewer TEA than ITM group dogs required iRA during surgical opening and pRA: 5% (1/18) and 2/18 (11%), respectively, in the TEA and 83% (16/18) and 10/18 (55%), respectively, in the ITM group. Side effects were urinary retention in 3/18 (16%) TEA group dogs and 2/18 (11%) ITM group dogs and prolonged sedation in 2/18 (11%) in ITM group dogs. TEA and ITM were effective in managing perioperative pain in dogs undergoing thoracic or cranial abdominal surgery.
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Affiliation(s)
- E Lardone
- Department of Veterinary Sciences, School of Veterinary Medicine, University of Turin, 2 Largo Paolo Braccini, 10095, Grugliasco, Italy.
| | - D Sarotti
- Centro Veterinario Fossanese, 29/E Via Cuneo, 12045, Fossano, Italy
| | - D Giacobino
- Department of Veterinary Sciences, School of Veterinary Medicine, University of Turin, 2 Largo Paolo Braccini, 10095, Grugliasco, Italy
| | - E Ferraris
- Department of Veterinary Sciences, School of Veterinary Medicine, University of Turin, 2 Largo Paolo Braccini, 10095, Grugliasco, Italy
| | - P Franci
- Department of Veterinary Sciences, School of Veterinary Medicine, University of Turin, 2 Largo Paolo Braccini, 10095, Grugliasco, Italy
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Patel R, Kua J, Sharawi N, Bauer ME, Blake L, Moonesinghe SR, Sultan P. Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review. Anaesthesia 2022; 77:598-604. [PMID: 35064923 DOI: 10.1111/anae.15657] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 12/26/2022]
Abstract
Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.
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Affiliation(s)
- R Patel
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, UK
| | - J Kua
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, UK
| | - N Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AK, USA
| | - M E Bauer
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - L Blake
- University of Arkansas for Medical Sciences, Little Rock, AK, USA
| | - S R Moonesinghe
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, London, UK
| | - P Sultan
- Department of Anesthesiology, Peri-Operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Khan E, Garcia D, Huang S, Mendonca R, Vadhera R. Dual epidural catheters for labor analgesia in a spinal cord injury patient: a case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022:S0104-0014(22)00033-1. [PMID: 35296426 PMCID: PMC10362440 DOI: 10.1016/j.bjane.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/26/2022] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
Impediment to local anesthetic solution in the epidural space results in unsatisfactory pain relief during labor epidural. Patients with a history of back trauma and spinal instrumentation have increased rates of epidural failure due to patchy spread of local anesthetic with obliterated epidural space. Dual Epidural Catheters (DEC) can be used in such clinical scenarios with complete labor analgesia and improved patient satisfaction. We present the successful management of a parturient with vertebral fracture at risk for epidural failure and neurologic injury due to bone fragments and inserted cranial and caudal to the fractured vertebra using ultrasound to avoid neurologic sequelae.
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Affiliation(s)
- Ejaz Khan
- University of Texas Medical Branch at Galveston, Department of Anesthesiology, Texas, USA; NYC H+ Hospitals, Metropolitan Medical Center, Department of Anesthesiology, New York, USA
| | - David Garcia
- NYC H+ Hospitals, Metropolitan Medical Center, Department of Anesthesiology, New York, USA.
| | - Shaopeng Huang
- NYC H+ Hospitals, Metropolitan Medical Center, Department of Anesthesiology, New York, USA
| | - Roni Mendonca
- NYC H+ Hospitals, Metropolitan Medical Center, Department of Anesthesiology, New York, USA
| | - Rakesh Vadhera
- University of Texas Medical Branch at Galveston, Department of Anesthesiology, Texas, USA
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Comparison of neonatal outcomes of cesarean sections performed under primary or secondary general anesthesia: a retrospective study. Int J Obstet Anesth 2022; 50:103538. [DOI: 10.1016/j.ijoa.2022.103538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 01/26/2022] [Accepted: 03/12/2022] [Indexed: 11/23/2022]
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Abstract
Neuraxial drug administration, i.e., the injection of drugs into the epidural or intrathecal space to produce anesthesia or analgesia, is a technique developed more than 120 years ago. Today, it still is widely used in daily practice in anesthesiology and in acute and chronic pain therapy. A multitude of different drugs have been introduced for neuraxial injection, only a part of which have obtained official approval for that indication. A broad understanding of the pharmacology of those agents is essential to the clinician to utilize them in a safe and efficient manner. In the present narrative review, we summarize current knowledge on neuraxial anatomy relevant to clinical practice, including pediatric anatomy. Then, we delineate the general pharmacology of neuraxial drug administration, with particular attention to specific aspects of epidural and intrathecal pharmacokinetics and pharmacodynamics. Furthermore, we describe the most common clinical indications for neuraxial drug administration, including the perioperative setting, obstetrics, and chronic pain. Then, we discuss possible neurotoxic effects of neuraxial drugs, and moreover, we detail the specific properties of the most commonly used neuraxial drugs that are relevant to clinicians who employ epidural or intrathecal drug administration, in order to ensure adequate treatment and patient safety in these techniques. Finally, we give a brief overview on new developments in neuraxial drug therapy.
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Toledano RD, Leffert L. What's New in Neuraxial Labor Analgesia. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:340-347. [PMID: 34466127 PMCID: PMC8390543 DOI: 10.1007/s40140-021-00453-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
Purpose of Review This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. Recent Findings There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.
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Affiliation(s)
- Roulhac D. Toledano
- NYU Langone Health, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Hospital, Brooklyn, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Harvard Medical School, Boston, USA
- Obstetric Anesthesia Division, Massachusetts General Hospital, Boston, MA USA
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Keita H, Deruelle P, Bouvet L, Bonnin M, Chassard D, Bouthors AS, Lopard E, Benhamou D. Raising awareness to prevent, recognise and manage acute pain during caesarean delivery: The French Practice Bulletin. Anaesth Crit Care Pain Med 2021; 40:100934. [PMID: 34400388 DOI: 10.1016/j.accpm.2021.100934] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022]
Abstract
The incidence of acute pain during caesarean section varies between studies, with a reported rate ranging between 0.5%-17% for spinal anaesthesia and 1.7%-20% for epidural anaesthesia. Leaders from the French Club anesthésie-réanimation en obstétrique (CARO) convened to provide a clinical framework and practice bulletin to prevent, recognise and treat acute pain during caesarean section. First, a steering group agreed on 5 themes guiding quality of anaesthesia care for caesarean section: (1) appropriate neuraxial anaesthesia and testing of the surgical block prior to incision (PREVENTION); (2) appropriate organisation around decision to delivery time (COMMUNICATION); 3) appropriate management of pain before and/or after skin incision (RECOGNITION & RESPONSE); (4) appropriate prevention, identification and management of post-traumatic stress disorder (SCREENING, PREVENTION AND MANAGEMENT OF COMPLICATIONS); (5) management of medico-legal issues (MITIGATION). Then, an interdisciplinary multi-professional taskforce composed of obstetric anaesthesiologists, obstetricians, neonatologists, psychiatrists, midwifes, nurse anaesthetists, lawyers and patients, developed 23 statements that contribute to optimise care for caesarean section under neuraxial anaesthesia, of which 10 were deemed key recommendations. A decision-tree was built to optimise prevention, communication, recognition, response and management. The aim of this practice bulletin, which was endorsed by 6 societies, is to raise awareness on the risks associated with severe acute pain during caesarean section and to provide best clinical practices; pain during caesarean is not acceptable and should be prevented and managed by all stakeholders.
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Affiliation(s)
- Hawa Keita
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Necker Enfants Malades - APHP, Université Paris Descartes, 149 rue de Sèvres, 75015 Paris Cedex 15, France; Unité de Recherche EA 7323 Pharmacologie et Évaluation des Thérapeutiques Chez l'Enfant et la Femme Enceinte, Université Paris Descartes, Paris, France.
| | - Philippe Deruelle
- Pôle de Gynécologie-Obstétrique, Hôpitaux Universitaires de Strasbourg, Collège National des Gynécologues et Obstétriciens Français, Strasbourg, France
| | - Lionel Bouvet
- Service d'Anesthésie-Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Femme-Mère-Enfant, 59, boulevard Pinel, 69500 Bron, France
| | - Martine Bonnin
- Pôle Femme Et Enfant, CHU Hôpital Estaing, 1 place Lucie Aubrac, 63000 Clermont-Ferrand, France
| | - Dominique Chassard
- Service d'Anesthésie-Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Femme-Mère-Enfant, 59, boulevard Pinel, 69500 Bron, France
| | - Anne-Sophie Bouthors
- Clinique d'Anesthésie-Réanimation, Unité Médicale D'anesthésie-Analgésie-Réanimation Obstétricale, Maternité Jeanne de Flandre, CHRU Lille, France
| | - Eric Lopard
- Hôpital Saint-Joseph, 185, rue Raymond Losserand, 75014 Paris, France
| | - Dan Benhamou
- Département d'Anesthésie-Réanimation, Hôpital Bicêtre, Université Paris-Saclay, 48 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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Ismail S, Raza A, Munshi K, Tabassum R. Failure rate of labor epidural: An observational study among different levels of trainee anesthesiologists in a university hospital of a developing country. J Anaesthesiol Clin Pharmacol 2021; 37:210-215. [PMID: 34349368 PMCID: PMC8289669 DOI: 10.4103/joacp.joacp_39_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 09/13/2019] [Accepted: 03/14/2020] [Indexed: 11/24/2022] Open
Abstract
Context: Frequent use of labor epidural has also led to a corresponding increase in failed epidural analgesia (FEA). Aims: This study aims to identify the overall rate of FEA and evaluate its association with trainee anesthesiologist at different years/levels of anesthesia residency training. Settings and Design: Prospective observational study was conducted for one year in the labor room suit of a university hospital. Methods and Material: After university ethics committee approval, full-term parturient receiving labor epidurals and consenting for the study were included. FEA was identified by the presence of one or more set criteria of failure including; pain of numeric rating scale of >4 at 45 minutes after epidural placement, accidental dural puncture, need to re-site the epidural, abandoning the procedure, and maternal dissatisfaction with labor pain relief. Statistical Analysis Used: A binary logistic regression was used to assess the association between failure rate of labor epidural and grades of anesthesiologists. Odds ratio (OR) and 95% confidence interval (CI) were reported. P value ≤0.05 was considered significant. Results: Out of 500 women included, 76 (15.2%) had FEA, which was significantly high in 2nd and 3rd year residents compared to 5th year and above level anesthesiologists [OR = 2.08; 95% CI: 1.17 to 3.67; P = 0.012]. Failure rate was also high but insignificant in 4th year residents compared to senior level anesthesiologists [OR = 1.78; 95%CI: 0.89 to 3.53; P = 0.098]. Conclusions: The incidence of FEA is comparable to those quoted in literature from developed countries and shows association to experience and year of training of anesthesia residents.
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Affiliation(s)
- Samina Ismail
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Amir Raza
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Kahif Munshi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Rabia Tabassum
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
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Bakhet WZ. A randomized comparison of epidural, dural puncture epidural, and combined spinal-epidural without intrathecal opioids for labor analgesia. J Anaesthesiol Clin Pharmacol 2021; 37:231-236. [PMID: 34349372 PMCID: PMC8289667 DOI: 10.4103/joacp.joacp_347_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/22/2020] [Accepted: 03/12/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Dural puncture epidural (DPE) has been shown to improve labor analgesia over epidural (EPL), with fewer side effects than a combined spinal-epidural (CSE). However, there is some debate regarding the superiority of DPE over EPL and CSE. Therefore, we aimed to compare the effects of EPL, DPE, and CSE without intrathecal opioids on the epidural local anesthetic (LA) consumption and occurrence of side effects in early labor. Material and Methods We randomly assigned parturient to one of the 3 groups; EPL, DPE, or CSE. EPL and DPE groups received a 10 mL loading dose of 0.1% bupivacaine with fentanyl 2 μg/mL. CSE group received intrathecal 2.5 mg bupivacaine (without opioids). Labor analgesia was maintained in all patients via patient-controlled epidural analgesia (PCEA). The primary outcome was the mean hourly consumption of epidural LA. Results The mean hourly consumption of epidural LA anesthetic was significantly lower in CSE (9.55 mL), compared with the EPL (11 mL), and DPE (10.5 mL), P < 0.01; but no significant difference was seen between EPL and DPE. Compared with EPL and DPE, CSE achieved faster time to complete analgesia defined as a numeric rating pain scale (NRPS) ≤1 and sensory block, lower NRPS in the first hour and higher frequencies of complete analgesia. There were no differences between groups in terms of physician top-up boluses, the occurrence of side-effects, mode of delivery, Apgar scores, and maternal satisfaction. Conclusion Compared with EPL and DPE, CSE without intrathecal opioids, had a less epidural LA consumption, faster onset of analgesia, with no difference in the incidence of side effects. Trial Registration This study was registered at www.clinicaltrials.gov (NCT03980951).
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Affiliation(s)
- Wahba Z Bakhet
- Anesthesia Departments, Ain Shams University, Cairo, Egypt
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29
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Ituk U, Wong CA. Anesthetic Choices for Intrapartum Cesarean Delivery in Patients with Epidural Labor Analgesia. Adv Anesth 2021; 38:23-40. [PMID: 34106837 DOI: 10.1016/j.aan.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Unyime Ituk
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 6JCP, Iowa City, IA 52242, USA
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, JCP6618, Iowa City, IA 52242, USA.
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Orlando B, Donovan J, Stein D, Saloum M, Epstein J, Marenco J, Mahoney B, Kassapidis D. Does Pre-Procedure Neuraxial Ultrasound Using the GE Logiq® Improve Midline Placement of Combined Spinal Epidural when Compared to a Palpation Technique Performed by Experienced Anesthesiologists? A Prospective Randomized Study. JOURNAL OF SCIENTIFIC INNOVATION IN MEDICINE 2021. [DOI: 10.29024/jsim.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Yesilyurt M, Dostbil A, Sakci Z, Ince I, Ogul H. Postpartum intraventricular pneumocephalus following epidural anaesthesia. Br J Hosp Med (Lond) 2021; 82:1. [PMID: 34076523 DOI: 10.12968/hmed.2020.0566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mustafa Yesilyurt
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Aysenur Dostbil
- Department of Anesthesiology, Medical Faculty, Ataturk University, Erzurum, Turkey.,Anesthesiology, Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Zakir Sakci
- Department of Radiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Ilker Ince
- Department of Anesthesiology, Medical Faculty, Ataturk University, Erzurum, Turkey.,Anesthesiology, Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Hayri Ogul
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey.,Anesthesiology, Clinical Research Office, Ataturk University, Erzurum, Turkey
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Arnolds D, Scavone B. Neuraxial labor analgesia failure rates in women with a body mass index ≥50 kg/m 2: a single-center retrospective study. Int J Obstet Anesth 2021; 48:103176. [PMID: 33994271 DOI: 10.1016/j.ijoa.2021.103176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The failure rate of neuraxial labor analgesia has not been investigated in super-obese women (body mass index ≥50 kg/m2). METHODS We performed a retrospective study of neuraxial labor analgesia in super-obese women (January 2012 to August 2019). The primary outcome was the failure rate of the first neuraxial catheter. Secondary outcomes were failure rates by neuraxial technique, at cesarean delivery, and rate of catheter replacement. RESULTS Neuraxial labor analgesia was used by 233 super-obese women: 153 epidural catheters placed using a combined spinal-epidural (CSE) or dural puncture epidural techniques with visualization of cerebrospinal fluid; 63 placed without dural puncture (including procedures without attempted dural puncture or attempted CSE or dural puncture epidural); and 17 intrathecal catheters (seven intentional). Thirty-two of 233 neuraxial catheters failed (13.7%, 95% Confidence Interval [CI] 9.9 to 18.7%). Epidural catheters placed using CSE or dural puncture epidural had a lower failure rate than those placed without dural puncture (9.2% [95% CI 5.5% to 14.7%] vs 28.6% [95% CI 18.9 to 40.7%]; P<0.001). Catheter migration was documented for 29.4% (95% CI 16.8 to 46.2%) of catheters that failed. CONCLUSIONS Epidural catheters placed using CSE or dural puncture epidural techniques were more reliable than those placed without dural puncture in super-obese parturients. It is unclear whether the result was driven by grouping procedures without attempted dural puncture with those in which dural puncture was attempted but cerebrospinal fluid was not obtained. Catheter migration was a major source of failure.
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Affiliation(s)
- D Arnolds
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL, USA.
| | - B Scavone
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL, USA; Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL, USA
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Anaesthesia for the parturient with obesity. BJA Educ 2021; 21:180-186. [PMID: 33927890 DOI: 10.1016/j.bjae.2020.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/22/2020] [Indexed: 12/20/2022] Open
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Obesity in pregnancy. Int Anesthesiol Clin 2021; 59:8-14. [PMID: 33883427 DOI: 10.1097/aia.0000000000000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Using ultrasound for nerve blocks and neuraxial anaesthesia: The PERSEUS guidelines. Eur J Anaesthesiol 2021; 38:215-218. [PMID: 33538430 DOI: 10.1097/eja.0000000000001422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Spitzer D, Wenger KJ, Neef V, Divé I, Schaller-Paule MA, Jahnke K, Kell C, Foerch C, Burger MC. Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients. J Clin Med 2021; 10:jcm10051013. [PMID: 33801401 PMCID: PMC7958619 DOI: 10.3390/jcm10051013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.
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Affiliation(s)
- Daniel Spitzer
- Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany;
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Katharina J. Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany;
| | - Vanessa Neef
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany;
| | - Iris Divé
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany
| | - Martin A. Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Kolja Jahnke
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Christian Kell
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Michael C. Burger
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany
- Correspondence: ; Tel.: +49-69-6301-87711
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Orbach‐Zinger S, Eidelman LA, A.Wazwaz S, Ben‐Haroush A, Fireman S, Heesen M, Hadar E, Weiniger CF, Kornilov E. The relationship between resited epidural catheters after secondary epidural catheter failure and vaginal delivery: A retrospective case-control study. Acta Anaesthesiol Scand 2021; 65:397-403. [PMID: 33147366 DOI: 10.1111/aas.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited. METHODS A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals). RESULTS There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11). CONCLUSIONS Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.
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Affiliation(s)
- Sharon Orbach‐Zinger
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Leonid. A. Eidelman
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Susan A.Wazwaz
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Avi Ben‐Haroush
- Department Maternal‐Fetal Medicine Unit Helen Schneider Hospital for ParturientsRabin Medical Center Petach Tikva Israel
| | - Shlomo Fireman
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Michael Heesen
- Department of Anesthesia Kantonsspital Baden Baden Switzerland
| | - Eran Hadar
- Department Maternal‐Fetal Medicine Unit Helen Schneider Hospital for ParturientsRabin Medical Center Petach Tikva Israel
| | - Carolyn F Weiniger
- Department of Anesthesia Critical Care and Pain Medicine Tel Aviv Medical Centre Tel‐Aviv Israel
| | - Evgeniya Kornilov
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
- Department of Neurobiology Weizmann Institute of Science Rehovot Israel
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Ring L, Landau R, Delgado C. The Current Role of General Anesthesia for Cesarean Delivery. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:18-27. [PMID: 33642943 PMCID: PMC7902754 DOI: 10.1007/s40140-021-00437-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/20/2022]
Abstract
Purpose of the Review The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use. Recent Findings Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery. Summary Rates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.
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Affiliation(s)
- Laurence Ring
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY USA
| | - Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
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Knafo S, Picard B, Morar S, Aghakhani N, Samadi M, Parker F, Benhamou D. Management of Chiari malformation type I and syringomyelia during pregnancy and delivery. J Gynecol Obstet Hum Reprod 2020; 50:101970. [PMID: 33157323 DOI: 10.1016/j.jogoh.2020.101970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 10/16/2020] [Accepted: 10/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although a recurrent question in clinical practice, the management of Chiari malformation type I (CMI) and/or syringomyelia during pregnancy and delivery is still debated. The aim of this study was to investigate the modalities of delivery and anesthesia in women presenting with CMI and/or syringomyelia at a national reference center, and to question their potential role in the natural history of these conditions. STUDY DESIGN We conducted a retrospective cohort study using a standardized questionnaire, a customized clinical severity score and data from medical records. RESULTS 83 patients were included in the final analysis: 32 had CMI without syringomyelia, 27 had CMI with syringomyelia and 24 had non-foraminal syringomyelia. Most patients (55/83) were not diagnosed at the time of their pregnancy, 12 had surgery before being pregnant and 16 were diagnosed but not operated. Most women underwent vaginal delivery (62 %) and neuraxial (i.e. epidural or spinal) anesthesia (69 %). However, the proportion of cesarean procedures increased to 53.6 % and even 83.3 % when considering only patients already diagnosed or operated on, respectively. Nonetheless, neither vaginal compared to cesarean delivery (change in clinically severity score: -1.5 ± 0.4 versus -0.9 ± 0.4, p = 0.4) nor neuraxial compared to general anesthesia (-1.2 ± 0.3 versus -1.5 ± 0.6, p = 0.7) were associated with increased clinical deterioration. CONCLUSION Although individual evaluation is mandatory, this study supports that neither delivery nor anesthesia modalities affect the natural history for the vast majority of patients with CMI and/or syringomyelia.
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Affiliation(s)
- Steven Knafo
- Department of Neurosurgery, CRMR C-MAVEM, Bicêtre Hospital, AP-HP, France; Department of Anesthesiology and Intensive Care, Bicêtre Hospital, AP-HP, France.
| | - Benjamin Picard
- Department of Anesthesiology and Intensive Care, Bicêtre Hospital, AP-HP, France; University Paris-Sud Medical School, Paris-Saclay University, France
| | - Silvia Morar
- Department of Neurosurgery, CRMR C-MAVEM, Bicêtre Hospital, AP-HP, France; University Paris-Sud Medical School, Paris-Saclay University, France
| | - Nozar Aghakhani
- Department of Neurosurgery, CRMR C-MAVEM, Bicêtre Hospital, AP-HP, France; University Paris-Sud Medical School, Paris-Saclay University, France
| | - Maryam Samadi
- Department of Neurosurgery, CRMR C-MAVEM, Bicêtre Hospital, AP-HP, France
| | - Fabrice Parker
- Department of Neurosurgery, CRMR C-MAVEM, Bicêtre Hospital, AP-HP, France; University Paris-Sud Medical School, Paris-Saclay University, France
| | - Dan Benhamou
- Department of Anesthesiology and Intensive Care, Bicêtre Hospital, AP-HP, France; University Paris-Sud Medical School, Paris-Saclay University, France
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Schnabel A, Weibel S, Meißner M, Reichl SU, Kranke P, Meyer-Frießem CH, Zahn PK, Pogatzki-Zahn E. Erector spinae plane block for postoperative pain. Hippokratia 2020. [DOI: 10.1002/14651858.cd013763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
| | - Stephanie Weibel
- Department of Anesthesiology and Critical Care; University Hospital Wuerzburg; Wuerzburg Germany
| | - Michael Meißner
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
| | - Sylvia U Reichl
- Department of Anesthesiology, Perioperative and Intensive Care Medicine; Paracelsus Medical University; Salzburg Austria
| | - Peter Kranke
- Department of Anesthesiology and Critical Care; University Hospital Wuerzburg; Wuerzburg Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management; BG-Universitätsklinikum Bergmannsheil gGmbH; Bochum Germany
| | - Peter K Zahn
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management; BG-Universitätsklinikum Bergmannsheil gGmbH; Bochum Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
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Tan HS, Liu N, Sultana R, Han NLR, Tan CW, Zhang J, Sia ATH, Sng BL. Prediction of breakthrough pain during labour neuraxial analgesia: comparison of machine learning and multivariable regression approaches. Int J Obstet Anesth 2020; 45:99-110. [PMID: 33121883 DOI: 10.1016/j.ijoa.2020.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Risk-prediction models for breakthrough pain facilitate interventions to forestall inadequate labour analgesia, but limited work has used machine learning to identify predictive factors. We compared the performance of machine learning and regression techniques in identifying parturients at increased risk of breakthrough pain during labour epidural analgesia. METHODS A single-centre retrospective study involved parturients receiving patient-controlled epidural analgesia. The primary outcome was breakthrough pain. We randomly selected 80% of the cohort (training cohort) to develop three prediction models using random forest, XGBoost, and logistic regression, followed by validation against the remaining 20% of the cohort (validation cohort). Area-under-the-receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were used to assess model performance. RESULTS Data from 20 716 parturients were analysed. The incidence of breakthrough pain was 14.2%. Of 31 candidate variables, random forest, XGBoost and logistic regression models included 30, 23, and 15 variables, respectively. Unintended venous puncture, post-neuraxial analgesia highest pain score, number of dinoprostone suppositories, neuraxial technique, number of neuraxial attempts, depth to epidural space, body mass index, pre-neuraxial analgesia oxytocin infusion rate, maternal age, pre-neuraxial analgesia cervical dilation, anaesthesiologist rank, and multiparity, were identified in all three models. All three models performed similarly, with AUC 0.763-0.772, sensitivity 67.0-69.4%, specificity 70.9-76.2%, PPV 28.3-31.8%, and NPV 93.3-93.5%. CONCLUSIONS Machine learning did not improve the prediction of breakthrough pain compared with multivariable regression. Larger population-wide studies are needed to improve predictive ability.
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Affiliation(s)
- H S Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - N Liu
- Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore
| | | | - N-L R Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, Singapore
| | - C W Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - J Zhang
- Duke-NUS Medical School, Singapore
| | - A T H Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore.
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Xu J, Zhou R, Su W, Wang S, Xia Y, Papadimos T, Zhao J, Xu X. Ultrasound-guided bilateral pudendal nerve blocks of nulliparous women with epidural labour analgesia in the second stage of labour: a randomised, double-blind, controlled trial. BMJ Open 2020; 10:e035887. [PMID: 32843515 PMCID: PMC7449485 DOI: 10.1136/bmjopen-2019-035887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To explore whether an ultrasound-guided pudendal nerve block (PNB) could decrease anaesthetic use, thereby shortening the length of the second stage of labour in women undergoing epidural analgesia. DESIGN Prospective, single-centre, randomised, double-blind, controlled trial. SETTING An obstetric centre in a general hospital in China. PARTICIPANTS 72 nulliparous women were randomised, and 71 women completed the study. INTERVENTION An ultrasound-guided bilateral PNB was administered to all study participants; the PNB group were given 0.25% ropivacaine 10 mL, while the control group were given 10 mL saline. MAIN OUTCOME MEASURE The primary outcome measure was the duration of the second stage of labour. Secondary outcomes included additional bolus administration, total hourly bupivacaine consumption, difference in thickness between the contracted and relaxed rectus abdominis muscle before (DRAM1) and 30 min after (DRAM2) PNB, urge to defecate, maternal cooperation, preservation of the lower limb motor function, tightness of the perineum, and Numeric Rating Scale (NRS) score for pain. RESULTS The duration of the second stage of labour was shorter in the PNB group than in the control group (difference of 33.8 min (95% CI 15.6 to 52.0), p<0.001). Additional bolus administration and total hourly bupivacaine consumption were lower in the PNB group than in the control group (p<0.001). DRAM2 was greater (p<0.001), rate of parturient women with the urge to defecate was higher (p=0.014), maternal cooperation was superior (p=0.002), and lower limb motor function preservation was greater (p=0.004) in the PNB group relative to the control group. Tightness of the perineum was eliminated from the results due to the inconsistent application of the criteria by the nursing staff. There was no significant difference in NRS scores between the groups. CONCLUSIONS Nulliparous women with epidural analgesia who received an ultrasound-guided bilateral PNB may reduce their need for bupivacaine and consequently shorten the length of the second stage of labour, therein indicating that a bilateral PNB may serve as an additional effective adjunct method of labour analgesia. TRIAL REGISTRATION NUMBER ChiCTR-IOR-16009121.
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Affiliation(s)
- Jialing Xu
- Department of Obstetrics and Gynecology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang, China
| | - Riyong Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijue Su
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shi Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yun Xia
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Papadimos
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Junzhao Zhao
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xuzhong Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Patient satisfaction with continuous epidural analgesia after major surgical procedures at a Swedish University hospital. PLoS One 2020; 15:e0235636. [PMID: 32614891 PMCID: PMC7331990 DOI: 10.1371/journal.pone.0235636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/18/2020] [Indexed: 12/01/2022] Open
Abstract
Objective The use of epidural analgesia after major surgery is a well-established analgesia method. Epidural analgesia for postoperative pain relief needs to be monitored regularly in order to evaluate patient satisfaction and avoid side effects. However, due to the new available regional techniques, the role of epidural analgesia is being questioned and data about patient satisfaction is lacking. The current study was designed to evaluate patient satisfaction with epidural analgesia, its efficacy and reasons for premature termination of epidural analgesia. Materials and methods We conducted a retrospective survey of all patients who undergone surgery at Uppsala University hospital between October 2012 and January 2014 requiring continuous epidural analgesia for postoperative pain relief. Patients’ satisfaction with epidural analgesia and its effectiveness were evaluated by using paper questionnaire. Results During the study period 579 epidurals were inserted in patients scheduled for vascular, hepatobiliary, esophageal and other major abdominal surgery. The average treatment time was 3.8±1.8 days. Epidural analgesia consisted either of bupivacaine 0.1%+sufentanil 1 μg/ml solution or ropivacaine 0.2% solution. If patient needed opiates during treatment with epidural analgesia, only ropivacaine 0,2% solution was used. 494 (87.9%) patients were satisfied with their analgesia with no difference in satisfaction between sexes being observed. In 62 cases (11.2%) patient controlled analgesia was used on top of epidural analgesia with ropivacaine 0.2% solution, and 50.8% of patients were satisfied in this group. 514 (91.4%) patients were reported as having a good effect, 24 (4.3%) patients reported or were tested to show some effect, and 24 (4.3%) had no effect. No major neurological complications (epidural hematoma or abscess) were observed. Conclusions Our retrospective survey indicates that patients are satisfied with continuous epidural analgesia used in major surgery.
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Pires AF, Mendes TM, Reis AA, Pacheco AF, Fagundes V, Mesquita M. Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia. Eur J Case Rep Intern Med 2020; 7:001425. [PMID: 32133317 PMCID: PMC7050972 DOI: 10.12890/2020_001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus. Case description We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus. Discussion The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis. LEARNING POINTS Pneumocephalus is the presence of air in the intracranial cavity and its development after spinal or epidural anaesthesia is extremely infrequent.Headache that occurs in the setting of lumbar epidural anaesthesia should not be labelled as post-dural puncture headache.The suspicion of pneumocephalus, based on the characteristics of the headache, should be maintained to obtain an emergent brain CT scan.
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Affiliation(s)
- Ana Filipa Pires
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Teresa Martins Mendes
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Ana Areia Reis
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Ana Ferreira Pacheco
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Vítor Fagundes
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Mari Mesquita
- Serviço de Medicina Interna, Hospital Padre Américo, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Nanji JA, Carvalho B. Pain management during labor and vaginal birth. Best Pract Res Clin Obstet Gynaecol 2020; 67:100-112. [PMID: 32265134 DOI: 10.1016/j.bpobgyn.2020.03.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 11/20/2022]
Abstract
Neuraxial analgesia provides excellent pain relief in labor. Optimizing initiation and maintenance of neuraxial labor analgesia requires different strategies. Combined spinal-epidurals or dural puncture epidurals may offer advantages over traditional epidurals. Ultrasound is useful in certain patients. Maintenance of analgesia is best achieved with a background regimen (either programmed intermittent boluses or a continuous epidural infusion) supplemented with patient-controlled epidural analgesia and using dilute local anesthetics combined with opioids such as fentanyl. Nitrous oxide and systemic opioids are also used for pain relief. Nitrous oxide may improve satisfaction despite variable effects on pain. Systemic opioids can be administered by healthcare providers or using patient-controlled analgesia. Appropriate choice of drug should take into account the stage and progression of labor, local safety protocols, and maternal and fetal/neonatal side effects. Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.
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Affiliation(s)
- Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive MC: 5640, Stanford, CA, 94305, USA.
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Suksompong S, von Bormann S, von Bormann B. Regional Catheters for Postoperative Pain Control: Review and Observational Data. Anesth Pain Med 2020; 10:e99745. [PMID: 32337170 PMCID: PMC7158241 DOI: 10.5812/aapm.99745] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/22/2020] [Accepted: 01/29/2020] [Indexed: 12/11/2022] Open
Abstract
Context Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures. Evidence Acquisition This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. Results As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. Conclusions Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.
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Affiliation(s)
| | | | - Benno von Bormann
- Institute of Medicine, Suranaree University of Technology, Korat, Thailand
- Corresponding Author: Institute of Medicine, Suranaree University of Technology, 111 Maha Witthayalai Rd, Nakhon Ratchasima 30000, Thailand. Tel: +66(0)918825723,
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Bjornestad EE, Haney MF. An obstetric anaesthetist-A key to successful conversion of epidural analgesia to surgical anaesthesia for caesarean delivery? Acta Anaesthesiol Scand 2020; 64:142-144. [PMID: 31628671 DOI: 10.1111/aas.13493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/05/2019] [Accepted: 09/15/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael F. Haney
- Anesthesia and Intensive Care Medicine University Hospital of Umeå Umeå University Umea Sweden
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Ashagrie HE, Ahmed SA, Melesse DY. The incidence and factors associated with failed spinal anesthesia among parturients underwent cesarean section, 2019: A prospective observational study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Goyal R, Mahajan S, Naskar S, Tewari D, Goyal M. Return of pain in a well-working labor epidural – A cause of alert. INDIAN JOURNAL OF PAIN 2020. [DOI: 10.4103/ijpn.ijpn_67_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tang JZJ, Weinberg L. A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery. Anesth Pain Med 2019; 9:e94441. [PMID: 32280615 PMCID: PMC7118737 DOI: 10.5812/aapm.94441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023] Open
Abstract
CONTEXT The optimal analgesic method for patients undergoing major open hepato-pancreatic-biliary surgery remains controversial. Continuous epidural infusion at the thoracic level remains the standard choice, however concerns have been raised due to associated complications. Single shot intrathecal morphine has emerged as a promising alternative offering similar analgesia with an enhanced safety profile. EVIDENCE ACQUISITION This review aimed to evaluate the literature comparing intrathecal morphine analgesia to other analgesic modalities following major open hepato-pancreatic-biliary surgery. The primary outcome was pain scores at rest and on movement 24 h after surgery. Secondary outcomes were postoperative opioid consumption within 72 postoperative hours, length of stay (LOS), intra-operative fluid administration and post-operative fluid administration within 72 postoperative hours, and overall systemic complication rate within 30 postoperative days. RESULTS Eleven trials matching the inclusion criteria were analysed. Intrathecal morphine resulted in equivalent or lower pain scores when contrasted to alternative techniques, but required higher amounts of postoperative opioid. Intrathecal morphine also offered reduced LOS and reduced fluid administration requirements to epidural analgesia, and there was no difference observed in major complication rate between analgesic modalities. CONCLUSIONS In summary the evidence suggests that intrathecal morphine may be a better first-line analgesic modality than epidural analgesia in the context of major open hepato-pancreatic-biliary surgery, but high-quality evidence supporting this is limited.
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