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Li Y, Hu Q, Wang Q, Liu T, Gao M. Real-time ultrasound-guided sacral plexus block combined with mild sedation for hemorrhoidectomy and hemorrhoidal artery ligation in a patient with amyotrophic lateral sclerosis: a case report. J Med Case Rep 2024; 18:205. [PMID: 38654338 PMCID: PMC11041001 DOI: 10.1186/s13256-024-04493-4] [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: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with amyotrophic lateral sclerosis present perioperative challenges for clinical anesthesiologists for anesthesia-associated complications. CASE PRESENTATION A 54-year-old Han woman with a 2-year history of amyotrophic lateral sclerosis was scheduled for hemorrhoidectomy and hemorrhoidal artery ligation. We performed real-time ultrasound-guided sacral plexus block with dexmedetomidine under standard monitoring. The anesthesia method met the surgical demands and avoided respiratory complications during the procedures. There was no neurological deterioration after the surgery and 3 months after, the patient was discharged. CONCLUSIONS Real-time ultrasound-guided sacral plexus block combined with mild sedation may be an effective and safe technique in patients with amyotrophic lateral sclerosis undergoing hemorrhoidectomy and hemorrhoidal artery ligation.
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Affiliation(s)
- Yan Li
- Department of Anesthesiology, Guangyuan Central Hospital, Guangyuan, 628000, China.
| | - Qianhui Hu
- Department of Anesthesiology, Guangyuan Central Hospital, Guangyuan, 628000, China
| | - Qian Wang
- Department of Anesthesiology, Guangyuan Central Hospital, Guangyuan, 628000, China
| | - Taotao Liu
- Department of Anesthesiology, Guangyuan Central Hospital, Guangyuan, 628000, China
| | - Min Gao
- Department of Anesthesiology, Guangyuan Central Hospital, Guangyuan, 628000, China
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Dubuisson N, de Maere d'Aertrijcke O, Marta M, Gnanapavan S, Turner B, Baker D, Schmierer K, Giovannoni G, Verma V, Docquier MA. Anaesthetic management of people with multiple sclerosis. Mult Scler Relat Disord 2023; 80:105045. [PMID: 37866022 DOI: 10.1016/j.msard.2023.105045] [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: 02/09/2023] [Revised: 08/27/2023] [Accepted: 09/29/2023] [Indexed: 10/24/2023]
Abstract
There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.
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Affiliation(s)
- N Dubuisson
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Neuromuscular Reference Center, Department of Neurology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, Brussels 1200, Belgium.
| | - O de Maere d'Aertrijcke
- Department of Anesthesia and Perioperative Medicine, Cliniques Universitaires Saint-Luc, St Luc Hospital, Avenue Hippocrate 10, Brussels 1200, Belgium
| | - M Marta
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - S Gnanapavan
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - B Turner
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - D Baker
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK
| | - K Schmierer
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - G Giovannoni
- Faculty of Medicine and Dentistry, Blizard Institute (Neuroscience), Queen Mary University London, 4 Newark Street, London E1 2AT, UK; Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - V Verma
- Department of Anesthesia, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M-A Docquier
- Department of Anesthesia and Perioperative Medicine, Cliniques Universitaires Saint-Luc, St Luc Hospital, Avenue Hippocrate 10, Brussels 1200, Belgium
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Doelakeh ES, Chandak A. Risk Factors in Administering Spinal Anesthesia: A Comprehensive Review. Cureus 2023; 15:e49886. [PMID: 38174200 PMCID: PMC10762496 DOI: 10.7759/cureus.49886] [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] [Received: 10/10/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Numerous advantages, including a quick start and consistent anesthesia, are provided by spinal anesthesia, a method often utilized in contemporary medicine for various surgical operations. However, it has some hazards, just like any medical procedure. With an emphasis on identifying and assessing the risk factors associated with administering spinal anesthesia, the review analyzes published literature and clinical investigations carried out in the field of anesthesia. Various key factors, including technique-related procedural and patient-related aspects, can influence the effectiveness of spinal anesthesia. Among these factors are age, sex, body mass index, concurrent conditions (such as cardiovascular disease, diabetes, and respiratory problems), pre-existing neurological issues, allergies, and a history of adverse responses to anesthesia drugs. Additionally, the chance of problems might be increased by physical abnormalities or malformations in the spinal canal and vertebral column. The safety and effectiveness of spinal anesthesia depend significantly on procedural factors, such as the type and dosage of anesthesia agents administered and the patient's position and alignment maintained during the entire surgical procedure and the injection rate. Increased risks can also be caused by inadequate monitoring and a slow response to unfavorable circumstances. Risk factors related to the technique include the expertise and competency of the anesthesiologist or medical professional carrying out the procedure. Inadequate post-procedure monitoring, inadvertent dural puncture, and improper needle placement might lead to complications during or after the spinal anesthesia administration. This review emphasizes the need for a complete preoperative assessment, suitable patient selection, and rigorous procedural planning to reduce the likelihood of problems during the administration of spinal anesthesia. It also emphasizes the significance of ongoing monitoring and timely management of adverse events to guarantee patient safety and the best results. Healthcare professionals may put preventative measures in place and follow best practices to limit possible consequences efficiently by recognizing the risk factors associated with spinal anesthesia. This review helps encourage safer anesthesia practices and improve patient care as medical knowledge and technology advance. However, further study and evidence-based recommendations are required to enhance patient outcomes and risk assessment.
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Affiliation(s)
- Elijah Skarlus Doelakeh
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aruna Chandak
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Illescas A, Zhong H, Liu J, Cozowicz C, Poeran J, Memtsoudis SG. Neuraxial Use Among Total Knee and Hip Arthroplasty Patients With Multiple Sclerosis or Myasthenia Gravis. Anesth Analg 2023; 136:1182-1188. [PMID: 36939157 DOI: 10.1213/ane.0000000000006471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Surgical patients with preexisting neurological diseases create greater challenges to perioperative management, and choice of anesthetic is often complicated. We investigated neuraxial anesthesia use in total knee and hip arthroplasty (TKA/THA) recipients with multiple sclerosis or myasthenia gravis compared to the general population. METHODS We retrospectively analyzed patients undergoing a TKA/THA with a diagnosis of multiple sclerosis or myasthenia gravis (Premier Health Database, 2006-2019). The primary outcome was neuraxial anesthesia use in multiple sclerosis or myasthenia gravis patients compared to the general population. Secondary outcomes were length of stay, intensive care unit admission, and mechanical ventilation. We measured the association between the aforementioned subgroups and neuraxial anesthesia use. Subsequently, subgroup-specific associations between neuraxial anesthesia and secondary outcomes were measured. We report odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Among 2,184,193 TKA/THAs, 7559 and 3176 had a multiple sclerosis or myasthenia gravis diagnosis, respectively. Compared to the general population, neuraxial anesthesia use was lower in multiple sclerosis patients (OR, 0.61; CI, 0.57-0.65; P < .0001) and no different in myasthenia gravis patients (OR, 1.05; CI, 0.96-1.14; P = .304). Multiple sclerosis patients administered neuraxial anesthesia (compared to those without neuraxial anesthesia) had lower odds of prolonged length of stay (OR, 0.63; CI, 0.53-0.76; P < .0001) mirroring neuraxial anesthesia benefits seen in the general population. CONCLUSIONS Neuraxial anesthesia use was lower in surgical patients with multiple sclerosis compared to the general population but no different in those with myasthenia gravis. Neuraxial use was associated with lower odds of prolonged length of stay.
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Affiliation(s)
- Alex Illescas
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Haoyan Zhong
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
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Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review. Anaesth Intensive Care 2022; 50:345-360. [DOI: 10.1177/0310057x211065042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Amyotrophic lateral sclerosis, or motor neuron disease, is an uncommon progressive neurological disorder. Professionals working in the perioperative field may encounter patients with amyotrophic lateral sclerosis only rarely. The relevant published literature on amyotrophic lateral sclerosis is broad in scope, but a contemporary review focused on the perioperative period is absent. This structured narrative review seeks to provide a summary of the contemporary management of patients and then focuses on eliciting if there are perioperative management considerations specific to amyotrophic lateral sclerosis that can be optimised. A comprehensive structured narrative literature review, including grey literature searching, indicated worsening ventilatory failure is of prime concern but that patients may present with a broad range of neurological symptoms, and that cardiovascular and cognitive dysfunction specific to amyotrophic lateral sclerosis may exist and be occult. Exacerbation of neuromuscular weakness during the perioperative period is multifaceted and requires the application of a high standard of the core principles of surgical and anaesthetic management of neuromuscular disease. Standard perioperative approaches require rigorous attention and potential exists for significant alteration. There is a potential high risk of postoperative increased morbidity from neurological decline and mortality from pulmonary complications. A meticulous approach to planning preoperative assessment, shared decision-making, intraoperative and postoperative care is required.
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Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
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Post-partum relapse in women with multiple sclerosis after neuraxial labour analgesia or neuraxial anaesthesia: A multicentre retrospective cohort study. Anaesth Crit Care Pain Med 2021; 40:100834. [PMID: 33753296 DOI: 10.1016/j.accpm.2021.100834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/01/2020] [Accepted: 09/29/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The proportion of women with multiple sclerosis experiencing a relapse in the post-partum period after neuraxial labour analgesia or neuraxial anaesthesia remains uncertain. This study aimed to assess the association between neuraxial labour analgesia or neuraxial anaesthesia and the occurrence of relapse during the first three months post-partum. METHODS In this retrospective cohort study, cases of women with a diagnosis of multiple sclerosis delivering between January 2010 and April 2015 were analysed. Demographic, anaesthetic and obstetric characteristics, occurrence and number of relapses in the year preceding pregnancy, during pregnancy, and the first three post-partum months, were recorded. Logistic regression analyses were performed for the identification of factors associated with the occurrence of post-partum relapse. RESULTS A total of 118 deliveries in 104 parturients were included, these were 78 (66%) vaginal deliveries and 40 (34%) caesarean deliveries. Neuraxial analgesia was provided in 50 deliveries, and neuraxial anaesthesia in 46 deliveries; no neuraxial anaesthesia or analgesia was administered in remaining 22 deliveries. Post-partum relapse occurred in 31 women (26%). There was no association between obstetric or anaesthetic characteristics and post-partum relapse. Both the occurrence and number of relapses prior to and during pregnancy, and the time between last relapse and delivery, were significantly associated with post-partum relapse in univariate analysis. The occurrence of relapse within the year preceding the pregnancy was the sole independent factor associated with post-partum relapse. CONCLUSION Neuraxial procedures were not associated with increased rate of post-partum relapse; only disease activity prior to pregnancy was predictive of post-partum relapse.
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Anesthesia for muscle biopsy to test susceptibility to malignant hyperthermia. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31053363 PMCID: PMC9391910 DOI: 10.1016/j.bjane.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Malignant hyperthermia is an autosomal dominant pharmacogenetic disorder, characterized by hypermetabolic crisis triggered by halogenated anesthetics and/or succinylcholine. The standard method for diagnosing malignant hyperthermia susceptibility is the in vitro muscle contracture test in response to halothane-caffeine, which requires muscle biopsy under anesthesia. We describe a series of anesthetic procedures without triggering agents in malignant hyperthermia, comparing peripheral nerve block and subarachnoid anesthesia. Method We assessed the anesthetic record charts of 69 patients suspected of malignant hyperthermia susceptibility who underwent muscle biopsy for in vitro muscle contracture in the period of 7 years. Demographic data, indication for malignant hyperthermia investigation, in vitro muscle contracture test results, and surgery/anesthesia/recovery data were analyzed. Results Sample with 34 ± 13.7 years, 60.9% women, 65.2% of in vitro muscle contracture test positive. Techniques used: peripheral nerve blocks — lateral femoral and femoral cutaneous, latency 65 ± 41 min — (47.8%); subarachnoid anesthesia (49.3%), and total venous anesthesia (1.4%). There was 39.4% failure of peripheral nerve block and 11.8% of subarachnoid anesthesia. Adverse events (8.7%) occurred only with subarachnoid blockade (bradycardia, nausea, and transient neurological syndrome). All patients remained in the post-anesthesia care unit until discharge. Age and weight were significantly higher in patients with blockade failure (ROC cut-off point of 23.5 years and 59.5 kg) and blockade failure was more frequent in the presence of increased idiopathic creatine kinase. Conclusion Anesthesia with non-triggering agents has been shown to be safe in patients with malignant hyperthermia susceptibility. Variables such as age, weight, and history of increased idiopathic creatine kinase may be useful in selecting the anesthetic technique for this group of patients.
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9
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[Anesthesia for muscle biopsy to test susceptibility to malignant hyperthermia]. Rev Bras Anestesiol 2019; 69:335-341. [PMID: 31053363 DOI: 10.1016/j.bjan.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/17/2019] [Accepted: 02/06/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Malignant hyperthermia is an autosomal dominant pharmacogenetic disorder, characterized by hypermetabolic crisis triggered by halogenated anesthetics and/or succinylcholine. The standard method for diagnosing malignant hyperthermia susceptibility is the in vitro muscle contracture test in response to halothane-caffeine, which requires muscle biopsy under anesthesia. We describe a series of anesthetic procedures without triggering agents in malignant hyperthermia, comparing peripheral nerve block and subarachnoid anesthesia. METHOD We assessed the anesthetic record charts of 69 patients suspected of malignant hyperthermia susceptibility who underwent muscle biopsy for in vitro muscle contracture in the period of 7 years. Demographic data, indication for malignant hyperthermia investigation, in vitro muscle contracture test results, and surgery/anesthesia/recovery data were analyzed. RESULTS Sample with 34±13.7 years, 60.9% women, 65.2% of in vitro muscle contracture test positive. Techniques used: peripheral nerve blocks - lateral femoral and femoral cutaneous, latency 65±41minutes - (47.8%); subarachnoid anesthesia (49.3%), and total venous anesthesia (1.4%). There was 39.4% failure of peripheral nerve block and 11.8% of subarachnoid anesthesia. Adverse events (8.7%) occurred only with subarachnoid blockade (bradycardia, nausea, and transient neurological syndrome). All patients remained in the post-anesthesia care unit until discharge. Age and weight were significantly higher in patients with blockade failure (ROC cut-off point of 23.5 years and 59.5kg) and blockade failure was more frequent in the presence of increased idiopathic creatine kinase. CONCLUSION Anesthesia with non-triggering agents has been shown to be safe in patients with malignant hyperthermia susceptibility. Variables such as age, weight, and history of increased idiopathic creatine kinase may be useful in selecting the anesthetic technique for this group of patients.
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10
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Porto LB, Berndl AML. Pregnancy 5 Years After Onset of Amyotrophic Lateral Sclerosis Symptoms: A Case Report and Review of the Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:974-980. [PMID: 30528837 DOI: 10.1016/j.jogc.2018.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/18/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pregnancy in patients with amyotrophic lateral sclerosis (ALS) is extremely rare and often results in delivery of a healthy baby when patients are in the early stages of the disease. CASE This report describes the case of a successful pregnancy 5 years after ALS onset. Significant worsening of weakness, unsteady balance, and dysphagia were noticed around the third trimester. A healthy child was delivered at term by planned Caesarean section. After delivery the patient developed remarkable weakness, dysphagia, and dysarthria. CONCLUSION A literature search found 22 cases through PubMed and Ovid, with key words "amyotrophic lateral sclerosis" and "pregnancy." Both slow progression and rapid progression of ALS during pregnancy have been reported. Worsening of symptoms seems to be common, but little is still known about the influence of pregnancy on ALS onset and progression.
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11
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Harazim H, Štourač P, Janků P, Zelinková H, Frank K, Dufek M, Štourač P. Obstetric anesthesia/analgesia does not affect disease course in multiple sclerosis: 10-year retrospective cohort study. Brain Behav 2018; 8:e01082. [PMID: 30047260 PMCID: PMC6160638 DOI: 10.1002/brb3.1082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/22/2018] [Accepted: 07/01/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Multiple sclerosis (MS) often occurs in young women and the effect of obstetric anesthesia/analgesia on the disease is poorly understood. No previous study has investigated the course of the disease in women in labor in the Czech Republic. The aim of this study was to evaluate the occurrence or absence of relapses in the 6-month postpartum period in MS parturients with and without obstetric anesthesia/analgesia. MATERIALS AND METHODS We retrospectively studied all deliveries (n = 58,455) at the University Hospital Brno from 2004 to 2013 and identified those of the women with an ICD-10 code G35 (MS) recorded anytime in their medical history (n = 428). We included only deliveries of women with confirmed diagnosis at the time of labor (n = 70). Statistical analysis was performed using the Fischer Exact Test. RESULTS There were 70 deliveries of 65 women, including 45 vaginal deliveries and 25 Cesarean deliveries (16 under general anesthesia, 8 with epidural anesthesia and 1 with spinal anesthesia). Epidural obstetric analgesia was performed in 11 deliveries. There was no statistically significant difference in relapses between the vaginal delivery group (n = 15; 33%) and Cesarean section group (n = 10; 40%), p = 0.611. CONCLUSION Neither delivery mode (vaginal vs Caesarean) nor type of obstetric anesthesia/analgesia was found to have any impact on the course of MS at 6 months postpartum in women with this condition.
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Affiliation(s)
- Hana Harazim
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty of Masaryk University, University Hospital Brno, Brno, Czech Republic
| | - Pavel Štourač
- Department of Neurology, Medical Faculty of Masaryk University, University Hospital Brno, Brno, Czech Republic
| | - Petr Janků
- Department of Gynaecology and Obstetrics, Medical Faculty of Masaryk University, University Hospital Brno, Brno, Czech Republic
| | - Hana Zelinková
- Institute of Biostatistics and Analysis, Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Kamil Frank
- Department of Gynaecology and Obstetrics, Medical Faculty of Masaryk University, University Hospital Brno, Brno, Czech Republic
| | - Michal Dufek
- First Department of Neurology, Medical Faculty of Masaryk University, St Anne's University Hospital, Brno, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Medical Faculty of Masaryk University, University Hospital Brno, Brno, Czech Republic
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12
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Epidural anesthesia for open gastrostomy in a patient with amyotrophic lateral sclerosis. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Parish M, Farzin H. Adult patient with Becker dystrophy undergoing orthopedic surgery: an anesthesia challenge. Int Med Case Rep J 2018; 11:33-36. [PMID: 29497338 PMCID: PMC5818840 DOI: 10.2147/imcrj.s150037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Muscular dystrophies are considered to be a series of neuromuscular diseases with genetic causes and are characterized by progressive muscle weakness and degeneration of the skeletal muscle. The case of an adult man with Becker dystrophy referred for repair of the patella tendon tearing and patella fracture is described. He underwent successful surgery using total intravenous anesthesia without any complications.
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Affiliation(s)
- Masoud Parish
- Anesthesiology Department, Tabriz University of Medical Sciences, Shohada Teaching Hospital, Tabriz, Iran
| | - Haleh Farzin
- Anesthesiology Department, Tabriz University of Medical Sciences, Shohada Teaching Hospital, Tabriz, Iran
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Xiao W, Zhao L, Wang F, Sun H, Wang T, Zhao G. Total intravenous anesthesia without muscle relaxant in a parturient with amyotrophic lateral sclerosis undergoing cesarean section: A case report. J Clin Anesth 2017; 36:107-109. [DOI: 10.1016/j.jclinane.2016.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/15/2016] [Accepted: 10/27/2016] [Indexed: 12/11/2022]
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Anson JA, Vaida S, Giampetro DM, McQuillan PM. Anesthetic management of labor and delivery in patients with elevated intracranial pressure. Int J Obstet Anesth 2015; 24:147-60. [PMID: 25794413 DOI: 10.1016/j.ijoa.2015.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 12/31/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
Abstract
The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.
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Affiliation(s)
- J A Anson
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - S Vaida
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - D M Giampetro
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - P M McQuillan
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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16
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Quispe Ricci AC. Management of anesthesia during C-section of a multiple sclerosis pregnant woman: Case report and literature review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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17
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Management of anesthesia during C-section of a multiple sclerosis pregnant woman: Case report and literature review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543010-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Quispe Ricci AC. Manejo anestésico en cesárea de una gestante con esclerosis múltiple: reporte de un caso y revisión de la literatura. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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19
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Martucci G. Should we feel free to use loco-regional anesthesia in multiple sclerosis? Saudi J Anaesth 2014; 8:313-4. [PMID: 25191177 PMCID: PMC4141375 DOI: 10.4103/1658-354x.136383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia & Critical Care, ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
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Sethi S, Kapil S. Anesthetic management of a patient with multiple sclerosis undergoing cesarean section with low dose epidural bupivacaine. Saudi J Anaesth 2014; 8:402-5. [PMID: 25191198 PMCID: PMC4141396 DOI: 10.4103/1658-354x.136633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 32-year-old Indian female 38 weeks pregnant, with a history of multiple sclerosis since 2008 was admitted in obstetric ward for safe confinement. She had a history of diminution of vision in both eyes and limb weakness, relapsing – remitting type with movement-induced muscle spasms, in all the four limbs. Her symptoms were usually diplopia, difficulty in vision and ataxic gait. Sh was then treated with methylprednisolone. She was on oral dimethyl fumarate trial, which was stopped at the beginning of pregnancy. Presently, she was completely asymptomatic. Epidural anesthesia with an indwelling catheter was administered with 15 ml of 0.25% bupivacaine in 5 ml increments. A total of 3 mg of epidural morphine was given for post-operative analgesia. The surgery evolved without any intercurrences and patient was discharged from the hospital 72 h after surgery without worsening of her symptoms. We report a safe anesthetic management of a patient with MS undergoing cesarean section with low dose epidural bupivacaine with the addition of morphine for post-operative analgesia.
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Affiliation(s)
- Sameer Sethi
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sonia Kapil
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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21
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Is cervical decompression beneficial in patients with coexistent cervical stenosis and multiple sclerosis? J Clin Neurosci 2014; 21:2189-93. [PMID: 25088960 DOI: 10.1016/j.jocn.2014.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/23/2014] [Accepted: 05/04/2014] [Indexed: 11/23/2022]
Abstract
Cervical stenosis (CS) and multiple sclerosis (MS) are two common conditions with distinctive pathophysiology but overlapping clinical manifestations. The uncertainty involved in attributing worsening symptoms to CS in patients with MS due to extremely high prevalence of asymptomatic radiological CS makes treatment decisions challenging. A retrospective review was performed analyzing the medical records of all patients with confirmed diagnosis of MS who had coexistent CS and underwent surgery for cervical radiculopathy/myeloradiculopathy. Eighteen patients with coexistent CS and MS who had undergone cervical spine decompression and fusion were identified. There were six men and 12 women with an average age of 52.7 years (range 40-72 years). Pre-operative symptoms included progressive myelopathy (14 patients), neck pain (seven patients), radiculopathy (five patients), and bladder dysfunction (seven patients). Thirteen of the 14 patients (92.9%) with myelopathy showed either improvement (4/14, 28.6%) or stabilization (9/14, 64.3%) in their symptoms with neck pain and radiculopathy improving in 100% and 80% of patients, respectively. None of the seven patients with urinary dysfunction had improvement in urinary symptoms after surgery. To conclude, cervical spine decompression and fusion can improve or stabilize myelopathy, and significantly relieve neck pain and radiculopathy in the majority of patients with coexistent CS and MS. Urinary dysfunctions appear unlikely to improve after surgery. The low rate of surgical complications in our cohort demonstrates that cervical spine surgery can be safely performed in carefully selected patients with concomitant CS and MS with a good clinical outcome and also eliminate CS as a confounding factor in the long-term management of MS patients.
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22
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Makris A, Piperopoulos A, Karmaniolou I. Multiple sclerosis: basic knowledge and new insights in perioperative management. J Anesth 2013; 28:267-78. [DOI: 10.1007/s00540-013-1697-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/06/2013] [Indexed: 01/24/2023]
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Wipfli M, Arnold M, Luginbühl M. Repeated spinal anesthesia in a tetraparetic patient with Guillain-Barré syndrome. J Clin Anesth 2013; 25:409-412. [DOI: 10.1016/j.jclinane.2013.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 01/16/2013] [Accepted: 01/24/2013] [Indexed: 11/28/2022]
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Thampi SM, David D, Chandy TT, Nandhakumar A. Anesthetic management of a patient with amyotrophic lateral sclerosis for transurethral resection of bladder tumor. Indian J Anaesth 2013; 57:197-9. [PMID: 23825825 PMCID: PMC3696273 DOI: 10.4103/0019-5049.111863] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Suma M Thampi
- Department of Anesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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25
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Epidural blood patch in a patient with multiple sclerosis: is it safe? Can J Anaesth 2013; 60:479-83. [DOI: 10.1007/s12630-013-9904-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/29/2013] [Indexed: 10/27/2022] Open
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26
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Acar A, Nuri Deniz M, Erhan E, Ugur G. Anesthetic technique in a patient with multiple sclerosis scheduled for laparoscopic nephrectomy for a renal tumor: a case report. Anesth Pain Med 2013; 2:138-40. [PMID: 24244925 PMCID: PMC3821132 DOI: 10.5812/aapm.7550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 10/01/2012] [Accepted: 10/19/2012] [Indexed: 11/29/2022] Open
Abstract
Perioperative stress and anesthesia are risk factors for exacerbation of Multiple Sclerosis (MS) attacks. Infection, emotional labiality and hyperpyrexia are also known to increase the risk of postoperative MS attacks. Appropriate preoperative evaluation, administration of a good premedication, control of fever, selection of the anesthetic agents and effective postoperative pain control can prevent problems after prolonged major surgery in patients with MS diagnosed. This report presents the anesthetic technique in a patient who was a known case of MS for past nine years and presented with renal tumor to undergo laparoscopic nephrectomy under general anesthesia.
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Affiliation(s)
- Arzu Acar
- Anaesthesiology and Reanimation Department, Ege University, Izmir, Turkey
| | - Mustafa Nuri Deniz
- Anaesthesiology and Reanimation Department, Ege University, Izmir, Turkey
- Corresponding author: Mustafa Nuri Deniz, Department of Anaesthesiology and Reanimation, School of Medicine, Ege University, 35100, Izmir, Turkey. Tel.: +90-2323902140, Fax: +90-2323397687, E-mail:
| | - Elvan Erhan
- Anaesthesiology and Reanimation Department, Ege University, Izmir, Turkey
| | - Gulden Ugur
- Anaesthesiology and Reanimation Department, Ege University, Izmir, Turkey
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27
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Errando CL, Navarro L, Vila M, Pallardó MA. Anesthetic management of a patient diagnosed with CADASIL (cerebral arteriopathy, autosomal dominant, with subcortical infarcts and leukoencephalopathy). ACTA ACUST UNITED AC 2012; 59:102-6. [PMID: 22480557 DOI: 10.1016/j.redar.2012.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 02/06/2012] [Indexed: 10/28/2022]
Abstract
CADASIL (cerebral arteriopathy, autosomal dominant, with subcortical infarcts and leu-koencephalopathy) is an infrequent inherited disease that could have anesthetic implica-tions. However these have rarely been reported. We present a male patient previously diagnosed with CADASIL, who had suffered an ischemic vascular cerebral accident with a MRI compatible with leukoencephalopathy, and who was dependent for daily activities, and sustained dementia, mood alterations, apathy, and urine incontinence. He had famil-ial antecedents of psychiatric symptoms and ischemic stroke events in several relatives including his father, two brothers and one sister. He was scheduled for arthrodesis of the left knee because of multiple infectious complications of prosthetic knee surgery. He was under clopidogrel treatment which was withdrawn seven days before surgery. The pro-cedure was performed under combined spinal-epidural anesthesia, intraoperative seda-tion with midazolam, and postoperative multimodal analgesia including epidural patient controlled analgesia. The perioperative management was uneventful and we outline the adequacy of managing these patients under regional anesthesia and analgesia, as these permit to maintain hemodynamic stability leading to adequate cerebral perfusion, key to avoid an increase in the effects of the chronic arteriopathy patients with CADASIL sustain.
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Affiliation(s)
- C L Errando
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, España
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28
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Criado A, Uña R. [Anaesthesia in rare diseases]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:61-63. [PMID: 22480550 DOI: 10.1016/j.redar.2012.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 02/06/2012] [Indexed: 05/31/2023]
Affiliation(s)
- A Criado
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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29
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Ehiozie-Osifo AA, Olatosi JO, Kushimo OT. Emergency Caesarean section in a patient with known sickle-cell disease and myasthenia gravis. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2010. [DOI: 10.1080/22201173.2010.10872715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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30
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Mayorga Buiza M, Caba Barrientos F, Suárez Cordero F, Echevarría Moreno M. Analgesia epidural para el trabajo de parto en gestante con esclerosis múltiple. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.resed.2010.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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D'hooghe MB, Nagels G, Bissay V, De Keyser J. Modifiable factors influencing relapses and disability in multiple sclerosis. Mult Scler 2010; 16:773-85. [PMID: 20483884 DOI: 10.1177/1352458510367721] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A growing body of literature indicates that the natural course of multiple sclerosis can be influenced by a number of factors. Strong evidence suggests that relapses can be triggered by infections, the postpartum period and stressful life events. Vaccinations against influenza, hepatitis B and tetanus appear to be safe. Surgery, general and epidural anaesthesia, and physical trauma are not associated with an increased risk of relapses. Factors that have been associated with a reduced relapse rate are pregnancy, exclusive breastfeeding, sunlight exposure and higher vitamin D levels. A number of medications, including hormonal fertility treatment, seem to be able to trigger relapses. Factors that may worsen progression of disability include stressful life events, radiotherapy to the head, low levels of physical activity and low vitamin D levels. Strong evidence suggests that smoking promotes disease progression, both clinically and on brain magnetic resonance imaging. There is no evidence for an increased progression of disability following childbirth in women with multiple sclerosis. Moderate alcohol intake and exercise might have a neuroprotective effect, but this needs to be confirmed.
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Affiliation(s)
- M B D'hooghe
- National Center For Multiple Sclerosis, Melsbroek, Belgium.
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32
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Logvinova AV, Litt L, Young WL, Lee CZ. Anesthetic concerns in patients with known cerebrovascular insufficiency. Anesthesiol Clin 2010; 28:1-12. [PMID: 20400036 DOI: 10.1016/j.anclin.2010.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This review outlines the perioperative anesthesia considerations of patients with vascular diseases of the central nervous system, including occlusive cerebrovascular diseases with ischemic risks and various cerebrovascular malformations with hemorrhagic potential. The discussion emphasizes perioperative management strategies to prevent complications and minimize their effects if they occur. Planning the anesthetic and perioperative management is predicated on understanding the goals of the therapeutic intervention and anticipating potential problems.
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Affiliation(s)
- Anna V Logvinova
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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33
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Anaesthesia in children with inherited neuromuscular diseases. SRP ARK CELOK LEK 2010; 138:768-76. [DOI: 10.2298/sarh1012768s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Children with inherited neuromuscular diseases often require anaesthesia for
diagnostic or therapy procedures. These patients have an increased risk of
perioperative complications due to the nature of the disease and medications
administered during anaesthesia. Many anaesthetics and muscle relaxants can
aggravate the underlying disease and trigger life-threatening reactions
(cardiorespiratory complications, malignant hyperthermia). Besides, the
neuromuscular disorders are associated with atypical and undesirable
responses to drugs used during anaesthesia and the perioperative period. The
paper presents pathophysiological basis of inherited/genetic neuromuscular
diseases and specific anaesthesiological problems. The recommendations are
suggested with the aim to make the perioperative course in children optimally
safe.
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Abstract
During the previous decades, women with Multiple Sclerosis (MS) were discouraged from having children, as pregnancy was deemed dangerous for pregnancy outcome and a contributing factor for exacerbation of MS. Current knowledge shows that women with MS are no more likely to have pregnancy or delivery complications compared to healthy women. Immunomodulatory therapies should be avoided during pregnancy and while breastfeeding. However, despite that it is still not recommended during pregnancy, Glatiramer acetate has fewer risks than the other MS drugs with respect to pregnancy outcome. IVIg treatment appears to be safe in unblinded studies and may be used after the first trimester to prevent the exacerbation of postpartum relapses. Gestation is a period of decreased risk for a relapse, whereas relapses are more common in the first six months after childbirth, compared to the pre-pregnancy period. Breastfeeding and epidural anaesthesia are not associated with increased incidence of post-partum relapses.
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Affiliation(s)
- Andreas A Argyriou
- Department of Neurology, Saint Andrew's General Hospital of Patras, Greece.
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35
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Ozkardesler S, Ozzeybek D, Alaygut E, Unek T, Akan M, Astarcioglu H, Karademir S, Astarcioglu I, Elar Z. Anesthesia-related complications in living liver donors: the experience from one center and the reporting of one death. Am J Transplant 2008; 8:2106-10. [PMID: 18828770 DOI: 10.1111/j.1600-6143.2008.02367.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Living donor liver transplantation has become an alternative therapy for patients with end-stage liver disease. Donors are healthy individuals and donor safety is the primary concern. The objective of this study was to evaluate the anesthetic complications and outcomes for our donor cases; we report one death. The charts of the patients who underwent donor hepatectomy from February 1997 to June 2007 were retrospectively reviewed. Right hepatectomy (resection of segments 5-8) was done in 101 donors, left lobectomy (resection of segments 2-3) in 11 donors, and left hepatectomy (resection of segments 2-4) in one donor. Minor anesthetic complications were shoulder pain, pruritus and urinary retention related to epidural morphine, and major morbidity included central venous catheter-induced thrombosis of the brachial and subclavian vein, neuropraxia, foot drop and prolonged postdural puncture headache. One of 113 donors died from pulmonary embolism on the 11th postoperative day. This procedure has some major risks related to anesthesia and surgery. Although careful attention will lower complication rate, we have to keep in mind that the risks of donor surgery will not be completely eliminated.
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Affiliation(s)
- S Ozkardesler
- Department of Anesthesiology and Reanimation, Medical Faculty of 9 Eylul University, Izmir, Turkey
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36
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Neurological complications following central neuraxial blockades in obstetrics. Curr Opin Anaesthesiol 2008; 21:275-80. [DOI: 10.1097/aco.0b013e3282f8e22f] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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