Neurologic sequelae after caesarean section

Oxidative DNA Damage-induced PARP-1-mediated Autophagic Flux Disruption Contributes to Bupivacaine-induced Neurotoxicity During Pregnancy

OBJECTIVE

Severe neurologic complications after spinal anesthesia are rare but highly distressing, especially in pregnant women. Bupivacaine is widely used in spinal anesthesia, but its neurotoxic effects have gained attention.

METHODS

Furthermore, the etiology of bupivacaine-mediated neurotoxicity in obstetric patients remains unclear. Female C57BL/6 mice were intrathecally injected with 0.75% bupivacaine on the 18th day of pregnancy. We used immunohistochemistry to examine DNA damage after bupivacaine treatment in pregnant mice and measured γ-H2AX (Ser139) and 8-OHdG in the spinal cord. A PARP-1 inhibitor (PJ34) and autophagy inhibitor (3-MA) were administered with bupivacaine in pregnant mice. Parp-1flox/flox mice were crossed with Nes-Cre transgenic mice to obtain neuronal conditional knockdown mice. Then, LC3B and P62 staining were performed to evaluate autophagic flux in the spinal cords of pregnant wild-type (WT) and Parp-1-/- mice. We performed transmission electron microscopy (TEM) to evaluate autophagosomes.

RESULTS

The present study showed that oxidative stress-mediated DNA damage and neuronal injury were increased after bupivacaine treatment in the spinal cords of pregnant mice. Moreover, PARP-1 was significantly activated, and autophagic flux was disrupted. Further studies revealed that PARP-1 knockdown and autophagy inhibitors could alleviate bupivacaine-mediated neurotoxicity in pregnant mice.

CONCLUSION

Bupivacaine may cause neuronal DNA damage and PARP-1 activation in pregnant mice. PARP-1 further obstructed autophagic flux and ultimately led to neurotoxicity.

Activation of Ca2+/Calmodulin-Dependent Protein Kinase II (CaMKII) with Lidocaine Provokes Pyroptosis of Glioblastoma Cells

The study examines the problem whether pyroptosis of U87-MG glioblastoma cells can result from activation of Ca²⁺/calmodulin-dependent protein kinase II (CaMKII) by a local anesthetic. Glioblastoma cells exposed to various concentrations of typical local anesthetic lidocaine demonstrated augmented cytosolic flux of Ca²⁺, while suppression of CaMKII expression with the corresponding siRNA significantly inhibited this effect in cells treated with 2 mM lidocaine. Lidocaine up-regulated the expression of mRNA caspase-3 and gasdermin GSDME proteins, whereas silencing of CaMKII gene with siRNA significantly moderated this effect. In addition, lidocaine inhibited proliferation of U87-MG cells, and this effect was prevented by silencing CaMKII gene. Thus, lidocaine activated protein kinase CaMKII, which phosphorylated TRPV1 ion channels and induced calcium overload of U87-MG glioblastoma cells, thereby provoking their pyroptosis.

Foot drop after spinal anesthesia for cesarean section: a case report

Objective

Spinal anesthesia is the preferred anesthetic technique for cesarean section. Neurological complications are very rare and often transient after spinal anesthesia.

Case report

In the present case, a 37-year-old woman was considered eligible for cesarean section due to fetal distress. She underwent spinal anesthesia with a 25-gauge pencil-point spinal needle. In the sitting position, 3 mL of 0.5% bupivacaine was injected following free flow of cerebrospinal fluid. The cesarean delivery was uneventful without severe and significant hemodynamic changes. After recovery, the patient complained of tingling and stiffness in the left leg, accompanied with movement disorders and foot drop. Lumbar magnetic resonance imaging was normal. After receiving 500 mg intravenous methylprednisolone daily for 72 hours, she was discharged from the hospital with no particular problems.

Conclusion

Foot drop is a neurological disorder, which occurs following natural childbirth and spinal anesthesia due to direct needle trauma or local anesthetic toxicity. This complication is transient and usually resolves within a few days. In our patient, the neurological complication appeared after labor and anesthesia recovery, which was treated by corticosteroids and anti-inflammatory drugs, with no particular side effects.

Effect of TRPV1 combined with lidocaine on cell state and apoptosis of U87-MG glioma cell lines

OBJECTIVE

To study the effects of Transient receptor potential cation channel, subfamily V, member 1 (TRPV1) combined with lidocaine on status and apoptosis of U87-MG glioma cell line, and explore whether local anesthetic produces neurotoxicity by TRPV1.

METHODS

U87-MG cells were divided into control group, gene silencing group, empty vector group and TRPV gene up-regulation group. For cells in each group, flow cytometry was employed to detect the intracellular calcium ion concentration and mitochondrial membrane potential at different time point from cellular perspective. Cell apoptosis of U87-MG was assayed by flow cytometry and MTT from a holistic perspective.

RESULTS

Calcium ion concentration increased along with time. The concentration in TRPV1 gene up-regulation group was significantly higher than those in other groups at each time point (P < 0.05). After adding lidocaine, mitochondrial membrane potential in U87-MG significantly increased (P < 0.05). This increasing trend in TRPV1 gene up-regulation group was more significant than other groups (P < 0.05), while in TRPV1 gene silencing group, the trend significantly decreased (P < 0.05). Flow cytometry result and MTT result both showed that cell apoptosis in each group significantly increased after lidocaine was added (P < 0.05). This increasing trend in TRPV1 gene up-regulation group was more significant than other groups (P < 0.05), while in TRPV1 gene silencing group, the trend significantly decreased (P < 0.05). Moreover, apoptosis was more severe along with the increasing concentration of lidocaine (P < 0.05).

CONCLUSIONS

In this study, it was proved that lidocaine could dose-dependently induce the increase of intracellular calcium ion concentration, mitochondrial membrane potential and apoptosis in U87-MG glioma cell line. The up-regulation of TRPV1 enhanced cytotoxicity of lidocaine, which revealed the correlations between them. Lidocaine might have increased intracellular calcium ion concentration by activating TRPV1 gene and induced apoptosis of U87-GM glioma cell line by up-regulating mitochondrial membrane potential.

Spinal anesthesia revisited: toxicity of new and old drugs and compounds

PURPOSE OF REVIEW

Neural toxicity of substances injected into the intrathecal space has been a matter of debate since the introduction of spinal anesthesia in clinical practice. In recent years, new local anesthetics and adjuvants have been proposed for intrathecal use, and new techniques such as the use of ultrasound have been propagated. The present review summarizes recent clinical and experimental data on the neurotoxic effects of drugs and substances used for or in conjunction with spinal anesthesia.

RECENT FINDINGS

Chloroprocaine has been demonstrated to be associated with a lower risk of transient neurologic symptoms compared with lidocaine. However, despite extensive research, the issue of chloroprocaine or bisulfite neurotoxicity has not yet been resolved.Recent experimental data have identified a smaller neurotoxic potential for ropivacaine compared to levobupivacaine, procaine and bupivacaine. The addition of epinephrine has not been shown to increase lidocaine neurotoxicity. In-vivo experimental data suggest that lidocaine and bupivacaine neurotoxicity is not enhanced in diabetic patients.Furthermore, intrathecal introduction of aqueous ultrasound gel has been demonstrated to cause a distinct neuroinflammatory reaction. Finally, a large cohort study did not find the use of chlorhexidine gluconate for skin disinfection before neuraxial block to be associated with the risk of adhesive arachnoiditis.

SUMMARY

Clinical data suggest a high safety profile for intrathecal drugs and substances used for or in conjunction with spinal anesthesia. Recent experimental models for toxicity have provided further insight into the mechanisms and demonstrated possible, albeit clinically small differences in the relative neurotoxic potential of intrathecal drugs. This may contribute to a further increase in the safe use of spinal anesthesia in the clinical setting.

Extracts from rabbit skin inflamed by the vaccinia virus attenuate bupivacaine-induced spinal neurotoxicity in pregnant rats

Extracts from rabbit skin inflamed by the vaccinia virus can relieve pain and promote repair of nerve injury. The present study intraperitoneally injected extracts from rabbit skin inflamed by the vaccinia virus for 3 and 4 days prior to and following intrathecal injection of bupivacaine into pregnant rats. The pain threshold test after bupivacaine injection showed that the maximum possible effect of tail-flick latency peaked 1 day after intrathecal injection of bupivacaine in the extract-pretreatment group, and gradually decreased, while the maximum possible effect in the bupivacaine group continued to increase after intrathecal injection of bupivacaine. Histological observation showed that after 4 days of intrathecal injection of bupivacaine, the number of shrunken, vacuolated, apoptotic and caspase-9-positive cells in the dorsal root ganglion in the extract-pretreatment group was significantly reduced compared with the bupivacaine group. These findings indicate that extracts from rabbit skin inflamed by the vaccinia virus can attenuate neurotoxicity induced by intrathecal injection of bupivacaine in pregnant rats, possibly by inhibiting caspase-9 protein expression and suppressing nerve cell apoptosis.

Postpartum neurologic symptoms following single-shot spinal block for labour analgesia

BACKGROUND

As part of a quality assurance program, we investigated the incidence of postpartum neurologic symptoms in multiparous parturients receiving spinal block for labour analgesia, now in routine use in our labour ward.

METHODS

Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting spinal analgesia were asked to participate in this prospective study. All parturients received our standard intrathecal analgesia (ITA): 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) using a 27-gauge Quincke-type needle. The patients filled in a questionnaire on the first day after delivery and again upon discharge. Complaints typical of neurologic sequelae were noted and a neurologic examination was performed, if necessary. All patients with postdural puncture headache (PDPH) and transient neurologic symptoms (TNSs) were interviewed by telephone 2 weeks after discharge to determine the course of the symptoms.

RESULTS

Two hundred and twelve parturients were included in the study. Eighteen (8.5%) parturients complained of PDPH, the severity of which was mild in eight (4%), moderate in seven (3%), and severe in three (1%) patients, respectively. Fifteen (7%) mothers were treated with analgesics or bedrest only. Three (1%) patients were given an epidural blood patch. The paramedian approach was associated with the development of PDPH (P = 0.04). Transient neurologic symptoms were experienced by nine (4.2%) mothers, lasting 1-3 days, mostly presenting as bilateral pain in the buttocks or thighs. One parturient suffered from paraesthesia of the left foot lasting for 3 days. Forty (19%) mothers complained of non-postural headache and 28 (13%) of new-onset back pain. Three mothers (1%) would not want to receive a further spinal block.

CONCLUSION

Transient neurologic symptoms (TNSs) after spinal block occurred infrequently. The incidence of PDPH was higher than in the obstetric population in general and calls for re-evaluation of our spinal block methods. Despite the occurrence of neurologic sequelae, patient acceptability was high.

Change in anaesthetic practice for Caesarean section in Germany

BACKGROUND

Initial data from 1996 revealed that in contrast to several other countries general anaesthesia was the preferred anaesthetic technique for Caesarean section in Germany. However, anaesthetic practice for Caesarean section has changed during the last decades world-wide. This investigation was performed to obtain more actual data on anaesthetic procedures in obstetric patients in German hospitals.

METHODS

Questionnaires on the practice of anaesthesia for Caesarean section were mailed to 918 German departments of anaesthesiology. Furthermore, the survey evaluated severe perioperative complications in obstetric patients.

RESULTS

The 397 completed replies in this survey represent 41.3% of all German deliveries in 2002. Spinal anaesthesia is now the most common technique (50.5%) for elective Caesarean section. In case of urgent and emergency Caesarean, delivery figures decrease to 34.6% and 4.8%, respectively. Epidural anaesthesia is performed in 21.6% of scheduled and 13.2% and 1.0% of non-scheduled urgent or emergency Caesarean sections, respectively. Four maternal deaths and several non-fatal episodes of gastric content aspiration were reported by the respondents.

CONCLUSIONS

Compared to data obtained 6 years ago a significant increase in regional anaesthesia for Caesarean section has developed, with spinal anaesthesia being the preferred technique. Surveys can help to initiate discussion and improve current practice of anaesthetic care.

PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies

PURPOSE

Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency, onset, and duration of PDPH.

METHODS

Citations on PDPH in the obstetrical population were identified by computerized searches, citation review, and hand searches of abstracts and conference proceedings. Citations were included if they contained extractable data on frequency, onset, or duration of PDPH. Using meta-analysis, we calculated pooled estimates of the frequency of accidental dural puncture for epidural needles and pooled estimates of the frequencies of PDPH for epidural and spinal needles.

RESULTS

Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to 1.5%) risk of accidental dural puncture with epidural insertion. Of these, approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk of PDPH from spinal needles diminishes with small diameter, atraumatic needles, but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%). PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days.

CONCLUSION

PDPH is a common complication for parturients undergoing neuraxial blockade.

Anaesthesia for non-scheduled caesarean delivery

In many countries there has been an increase in the number of women who deliver by caesarean section. This article reviews anaesthetic management of non-scheduled caesarean section. The choice of anaesthetic technique (regional anaesthesia versus general anaesthesia) is discussed and highlighted particularly from the viewpoint of urgency of operative delivery. A multidisciplinary approach is mandatory especially in emergency cases to prevent morbidity and mortality in mothers and neonates.

Complications associated with regional anesthesia in the obstetric patient

The majority of obstetric patients are concerned about labor pains but also have fears regarding regional anesthesia and its potential effects on themselves and their babies. Anesthesiologists and obstetricians alike must be familiar with potential complications of obstetric regional anesthesia and analgesia, and also be able to provide the information and reassurance each patient needs. If a problem occurs during labor and delivery, it must be dealt with expertly and immediately. This article discusses the diagnostic clues, laboratory tests, and management of neurologic complications related to obstetric delivery and regional anesthesia, as well as the topics of infections, obstetric- and anesthetic-related neurologic deficits, and special tips on neurologic examination. The most common neurologic complication of spinal and epidural anesthesia, postdural puncture headache, will not be discussed in detail here.