Post-dural puncture headache in young adults: comparison of two small-gauge spinal catheters with different needle design

The Effect of Fluid Therapy Before Spinal Anesthesia on Prevention of Headache After Cesarean Section: A Clinical Trial

BACKGROUND

Despite numerous studies on postdural puncture headache (PDPH) and the factors affecting it, issues such as prevention methods and techniques that are associated with a lower prevalence of this complication are still under discussion and research. The aim of this study was to evaluate the effect of increasing fluid therapy of patients before surgery on the incidence of postoperative headache.

METHODS

This single-blind clinical trial study was performed on 60 patients undergoing elective surgery with spinal anesthesia based on the inclusion criteria in 2017 in Neyshabur. After obtaining the consent of the patients, the participants were randomly divided into two groups of intervention (A) and test (B) (30 people in each group). Data were created by self-checklist and visual analog scale (VAS) pain measurement criteria were recorded by phone during 4, 7, 24, 48, 72 hours, and 7 days after surgery.

RESULTS

In the study, the average headache increased up to 72 hours after surgery in the experimental group and in the intervention group up to 48 hours after surgery and then decreased.

CONCLUSION

The results of our study generally showed that fluid therapy did not reduce headache, but showed decreasing trend of headache. According to the research results, more research is needed on the causes of headache after spinal anesthesia.

Effect of spinal needle characteristics on measurement of spinal canal opening pressure

OBJECTIVE

A wide variety of spinal needles are used in clinical practice. Little is currently known regarding the impact of needle length, gauge, and tip type on the needle's ability to measure spinal canal opening pressure. This study aimed to investigate the relationship between these factors and the opening-pressure measurement or time to obtain an opening pressure.

METHODS

Thirteen distinct spinal needles, chosen to isolate the effects of length, gauge, and needle-point type, were prospectively tested on a lumbar puncture simulator. The key outcomes were the opening-pressure measurement and the time required to obtain that measure. Pressures were recorded at 10-s intervals until 3 consecutive, identical readings were observed.

RESULTS

Time to measure opening pressure increased with increasing spinal needle length, increasing gauge, and the Quincke-type (cutting) point (P<0.001 for all). The time to measurement ranged from 30s to 530s, yet all needle types were able to obtain a consistent opening pressure measure.

CONCLUSION

Although opening pressure estimates are unlikely to vary markedly by needle type, the time required to obtain the measurement increased with increasing needle length and gauge and with Quincke-type needles.

The anesthetic approach to operative delivery of the extremely obese parturient

Extreme obesity (BMI ≥ 40) is thought to complicate approximately 5% of deliveries in the United States. Extreme obesity puts a pregnant woman at an increased risk for cardiovascular disease, including hypertension, coronary artery disease, and congestive heart failure; respiratory disease, including obstructive sleep apnea and asthma; as well as pregnancy-specific diseases including pregnancy-induced hypertension and gestational diabetes. Extreme obesity also puts a parturient at a significantly increased risk of requiring cesarean delivery. For the anesthesiologist, the physiologic changes of obesity combined with the normal physiologic changes of pregnancy can make for a complex and challenging case. This review will focus on the anesthetic approach to the extremely obese parturient undergoing scheduled operative delivery. With proper planning and a detailed understanding of the patient's comorbidities, a safe and effective anesthetic can be achieved.

Repeated Intrathecal Administration of Ropivacaine Causes Neurotoxicity in Rats

Previous studies have shown that ropivacaine is the least neurotoxic local anaesthetic. Most of the data derive from short-term ropivacaine injection into the subarachnoid space. Intrathecal administration for a prolonged period, and the histological changes and behavioural effects of repeated intrathecal administration, have not previously been investigated. We studied the possible neurotoxicity of intrathecal injection of ropivacaine in a rat model.

Rats received 0.12 ml/kg body weight of ropivacaine at concentrations of 0.5 or 1%, or normal saline only, via an implanted intrathecal catheter at 90-minute intervals for 12 hours. On days 1, 3, 5, 7, 14 and 28, the spinal cord was examined by light and electron microscopy at the L3 level. We assessed sensory thresholds to noxious stimulation, behavioural change and protein kinase B immunoreactivity for possible neuronal injury within the spinal cord.

Ropivacaine 1% induced thermal hyperalgesia and mechanical allodynia, neuronal injury characterised by tissue oedema, proliferation of glial cells, neuronal morphology changes and degeneration and protein kinase B expression. There were no significant differences in motor function as a result of different concentrations of ropivacaine.

Repeated intrathecal injection of ropivacaine 1% can induce neurotoxicity in rats. Our data suggests that expression of protein kinase B might be involved in this neurotoxicity.

[Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma]

We report the case of a 38-year-old primipara who had undergone surgery 2 years earlier for an intradural ependymoma at L2-L3 and who was currently asymptomatic. A combined epidural-subarachnoid block was performed for analgesia during labor but this technique was only effective for the first 2 hours. When analgesia via epidural cannula was no longer adequate, it was decided to perform a continuous subarachnoid block. Later, the fetus's head was seen to be too large to fit through the pelvis; for cesarean section, the mother was administered fractionated doses of local anesthetic via the subarachnoid cannula until analgesia reached T4. The patient did not develop postdural puncture headache. Continuous subarachnoid anesthesia may be considered the technique of choice where the patient has a history of spinal surgery.

Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery

Extended spinal anaesthesia using a spinal micro-catheter was used as a primary method of anaesthesia for elective colorectal cancer surgery in 68 high risk patients over a 14-year period in our institution. The technique was also useful in eight elective and 13 emergency abdominal surgeries. All patients suffered from severe chronic obstructive airway disease requiring multiple inhalers and drugs (ASA III). Thirty nine of these patients also suffered from angina, myocardial infarction, diabetes and other systemic diseases (ASA IV). Surgery included right hemicolectomy, left hemicolectomy, total colectomy, sigmoid colectomy, Hartman's resection, anterior resection of rectum, abdominoperineal resection, cholecystectomy (open and laparoscopic) and obstructed inguinal hernia requiring laparotomy. Spinal anaesthesia was performed under strict aseptic conditions with a 22 gauge spinal needle with a mixture consisting of 2.75ml of 0.5% heavy bupivacaine and 0.25ml of fentanyl (25microg). This was followed by placement of a spinal micro-catheter and the duration of anaesthesia was extended by intermittent injection of 0.5% isobaric bupivacaine. Brief hypotension occurred in 12.4% of patients during the establishment of anaesthetic block height to T6-7 and was duly treated with intravenous administration of fluid and ephedrine hydrochloride. Good anaesthesia resulted in all patients except for brief discomfort in some patients during hemicolectomy surgery possibly due to the dissection and traction on the peritoneum causing irritation to the diaphragm. The use of sedation was avoided. General anaesthesia was administered in one patient and this patient required postoperative ventilation and cardiovascular support in the Intensive Care Unit. The spinal micro-catheter was removed at the end of surgery. Postoperative pain relief was obtained by administering intravenous morphine through a patient controlled analgesia machine in the critical care ward area (High Dependency Unit). There was a low incidence of minor postoperative side effects such as nausea (14.6%), vomiting (7.9%), minor post dural puncture headache (5.6%) and pruritus (5.6%). We conclude that spinal anaesthesia with a micro-catheter may be used as a primary method of anaesthesia for colorectal cancer surgery and other major abdominal surgery in high-risk patients for whom general anaesthesia would be associated with higher morbidity and mortality.

Spinal anesthesia using a continuous spinal catheter for cesarean section in a parturient with prior surgical correction of scoliosis

This case report demonstrates the successful anesthetic management of cesarean section for a 29-year-old primiparous parturient with a past history of a scoliosis operation at 13 years of age. An Isola hook and screw-rod system had been implanted as posterior spinal instrumentation at the level of T3-L3. We titrated hyperbaric bupivacaine 7 mg combined with fentanyl 15 microg through a continuous spinal catheter, placed with a catheter-over-needle technique in order to avoid unintentional wide spread of anesthetic agents. The anesthetic level was T4 at the start of the operation. Her surgery was carried out without any problems. Headache, as a dural tap-related complication, was not observed. Spinal anesthesia with the titration of anesthetic agents for cesarean section is considered to be one of the choices for a parturient who has had spinal instrumentation.

Anaesthesia for brachytherapy—5½ yr of experience in 1622 procedures

BACKGROUND

Brachytherapy presents the anaesthetist with unique problems. Information on anaesthesia for brachytherapy, however, is limited. The aim of this paper is to report on our experience involving a large number of brachytherapy procedures.

METHODS

A retrospective analysis of records of 1622 anaesthetic procedures in 952 patients is presented. Records were analysed in respect of patient data, tumour localization, brachytherapy treatment and the type and duration of anaesthetic procedures.

RESULTS

More than one-third of patients were at high risk (ASA III or IV) and 40% were more than 60 yr. Repetitive treatments were performed on half of the patients. Breast cancer was the most common indication. The average duration of anaesthesia for pelvic brachytherapy was more than 3 h, with a high degree of variability. Regional anaesthesia was used in 30% of all cases and was the predominant technique for pelvic brachytherapy. Spinal catheter techniques represented a high proportion of those receiving regional anaesthesia. Complications resulting from regional and general anaesthesia were minor and no serious incidents occurred.

CONCLUSIONS

Based on a large number of procedures, this study gives an example of anaesthetic management in brachytherapy. A substantial minority of patients would be considered high risk for surgical intervention. Regional anaesthesia was the principal technique used when dealing with tumours of the lower body.