Caesarean delivery in a parturient with a femoro-femoral crossover graft and congenital aortic stenosis repaired by the Ross procedure

Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial

Background and objectives

Epidural Volume Extension (EVE) involves instillation of normal saline into the epidural space soon after an intrathecal injection, with the aim to augment the sensory block height. Its clinical relevance lies in the possibility of using reduced intrathecal dose and yet achieving the desired sensory block level. Intrathecal dose is a known determinant of the level of sensory block. Whether EVE is dependent on intrathecal dose is not known.

Methods

We conducted a randomized, controlled, double-blind study to compare the maximum sensory level (S_max) achieved with or without application of EVE to two different reduced intrathecal doses. Eighty four adult male patients of ASA status I or II with body weight between 50–70 kg and height in the range of 150–180 cm, scheduled for orthopedic lower limb surgery using combined spinal epidural anesthesia were randomized to receive, either intrathecal dose (5 or 8 mg) with or without EVE, in accordance to group allocation.

Results

S_max was lowered by application of EVE to 5 mg intrathecal bupivacaine (T_8.9 ± 4.3 vs. T_6.4 ± 1.9 with and without EVE respectively; p = 0.030). S_max was similar when EVE was applied to 8 mg intrathecal bupivacaine than without it (T_5.8 ± 1.8 vs. T_6.4 ± 2.2 respectively; p =  0.324).

Conclusion

EVE should not be applied to 5 mg plain bupivacaine during a combined spinal epidural block in patients undergoing lower limb orthopedic surgery as it may result in a decrease in the maximum sensory level.

Adult congenital heart disease and pregnancy

Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.

Epidural volume extension: a review

Epidural volume extension is a technical modification of the combined spinal epidural block. It involves the epidural injection of normal saline or a small volume of local anaesthetic after an intrathecal injection, aiming to augment the post-spinal sensory level. Although the consequent sensory block augmentation has been adequately documented, the probable factors influencing epidural volume extension and its implications for clinical practice are not well defined. This article reviews published literature relating to the probable factors affecting epidural volume extension, its clinical implications, case reports of its successful clinical application and summarises its unexplored effects.