Block of the sacral segments in lumbar epidural anaesthesia

Neuraxial labor analgesia: Initiation techniques

The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.

Comparison of saddle, lumbar epidural and caudal blocks on anal sphincter tone: A prospective, randomized study

Objective

To compare the effects of saddle, lumbar epidural and caudal blocks on anal sphincter tone using anorectal manometry.

Methods

Patients undergoing elective anorectal surgery with regional anaesthesia were divided randomly into three groups and received a saddle (SD), lumbar epidural (LE), or caudal (CD) block. Anorectal manometry was performed before and 30 min after each regional block. The degree of motor blockade of the anal sphincter was compared using the maximal resting pressure (MRP) and the maximal squeezing pressure (MSP).

Results

The study analysis population consisted of 49 patients (SD group, n = 18; LE group, n = 16; CD group, n = 15). No significant differences were observed in the percentage inhibition of the MRP among the three regional anaesthetic groups. However, percentage inhibition of the MSP was significantly greater in the SD group (83.6 ± 13.7%) compared with the LE group (58.4 ± 19.8%) and the CD group (47.8 ± 16.9%). In all groups, MSP was reduced significantly more than MRP after each regional block.

Conclusions

Saddle block was more effective than lumbar epidural or caudal block for depressing anal sphincter tone. No differences were detected between lumbar epidural and caudal blocks.

Perioperative epidural analgesia in children undergoing major abdominal tumor surgery--a single center experience

PURPOSE

The purpose of this study was to assess the use of continuous epidural analgesia in pediatric patients undergoing major abdominal tumor surgery.

METHODS

Children undergoing major abdominal tumor surgery at our institution between 2008 and 2012 (n=40) received continuous epidural analgesia via an epidural catheter. Surgical trauma scores, pain scores, and clinical data of the children were compared to a pair-matched historical control group operated on between 2002 and 2007 without epidural analgesia.

RESULTS

Pain levels in the study group on day 1 and 3 after surgery were lower compared to the control group. The differences did, however, not reach statistical significance (p=0.15 and 0.09). Children in the study group received significantly fewer additional doses of piritramide or morphine (45% versus 82%, p<0.001). Despite significantly higher surgical trauma scores in the study group (p=0.018), there were no statistical differences regarding clinical parameters, such as mechanical ventilation time, time on intensive care unit, and total hospital stay. There were no catheter-related complications.

CONCLUSIONS

Continuous epidural analgesia is beneficial for children undergoing complex abdominal tumor surgery with regard to pain levels, postoperative recovery, and general clinical course. Expertise of the managing team, a careful patient selection, and a continuous quality assessment are essential for success.

Warming the epidural injectate improves first sacral segment block: a randomised double-blind study

This study investigated the effect of local anaesthetic temperature on block of the first sacral segment. Twenty-four patients undergoing lumbar epidural anaesthesia at L2-3 or L3-4 were randomly divided in double-blind fashion into two groups to receive 22 ml of lignocaine 2% with adrenaline 1:200,000, sodium bicarbonate and fentanyl, at either 21 degrees C (cold group) or 37 degrees C (warm group). The sensory block was assessed by loss of sensation to pinprick and the pain threshold after repeated electrical stimulation at L2, S1 and S3 dermatomes. Motor block was evaluated using the modified Bromage scale. Patient characteristics were comparable between the groups. Onset of block at the first sacral segment (S1) was faster in the warm group than in the cold (10 vs. 17.5 minutes, P < 0.001). The pain threshold at S1 was significantly higher in the warm group. We concluded that epidural lignocaine 2% with adrenaline 1:200,000, sodium bicarbonate and fentanyl injected at 370C hastens SI block within 10 minutes of administration.

Anesthetic effect of epidural anesthesia with cephalad or caudad catheterization for ankle surgery or hemorrhoidectomy

BACKGROUND

The larger size of the first sacral nerve root has been reported to be an unfavorable factor leading to sacral sparing in epidural anesthesia. Previous studies have shown that an adequate analgesic effect of the epidural block was achieved with the catheter placement in the caudal direction. In this study, the anesthetic effect of epidural anesthesia with catheter placement of a cephalic or caudad direction was compared in ankle and hemorrhoid surgery.

METHODS

Twenty-one ASA physical status I or II patients undergoing surgery for ankle fractures with epidural anesthesia were enrolled and randomized into two groups. The epidural catheter was placed either to a cephalad (AU group) or caudal (AD group) direction. Another 21 patients undergoing hemorrhoidectomy were also randomized into two groups to receive epidural anesthesia in a similar way (HU and HD groups). The onset for, duration of, and recovery time from epidural anesthesia and the incidence of analgesic request were recorded.

RESULTS

No significant differences were demonstrated when age, height, weight or sex were compared between the four study groups. The onset time of the block and the incidence of intrasurgical analgesic request were lower in the caudal subgroup when the ankle surgery patients were compared. Otherwise, there were no significant differences in the duration of anesthesia and time to recovery or level of anesthesia.

CONCLUSION

Injection of local anesthetic solution through a caudally oriented epidural catheter produces faster onset and superior quality of anesthesia in comparison with the injection through the cephaladly oriented catheter in ankle surgery, but not hemorrhoidectomy.

Does pregnancy increase the efficacy of lumbar epidural anesthesia?

Pregnancy has been reported to enhance the sensitivity of nerves to local anesthetics and to decrease anesthetic requirements during regional anesthesia. In this study, whether pregnancy increased the efficacy of lumbar epidural anesthesia was evaluated. Two populations (14 pregnant and 14 non-pregnant women) undergoing lumbar epidural anesthesia were studied and received 17 mL of 2% lidocaine-epinephrine (1: 200,000). The pain threshold response after repeated electrical stimulation was used to assess sensory blockade at the L2, S1 and S3 dermatomes. Motor blockade was evaluated using the Bromage score. Demographic data except for weight were comparable between the two groups. There was a significant difference in cephalad spread of anesthesia between the groups. No significant differences in pain threshold or onset of sensory blockade at the L2, S1 or S3 segments were found between the groups. The pain thresholds at the S1 and S3 dermatomes were significantly lower than that at L2 within each group. The mean onset times at the S1 and S3 dermatomes were significantly longer than that at L2 within each group. No differences in Bromage score were found between the groups. In pregnant women, cephalad spread of epidural anesthesia was facilitated but latency of blockade, density and motor blockade were not. It takes over 25 min to achieve satisfactory blockade at sacral segments. Those who perform lumbar epidural anesthesia alone for cesarean section should consider the use of additives (e.g. fentanyl, bicarbonate) to enhance the block, or a greater volume of local anesthetic.