Effects of Adding Intrathecal Epinephrine to Spinal Anesthesia on Anesthesia-Related Cesarean Delivery Outcomes: Should We Reconsider Its Use?

BACKGROUND

 Intrathecal epinephrine is used to increase the duration of spinal anesthesia for amenable surgical procedures anticipated to require additional time; however, in the ambulatory setting, it is associated with a prolonged time to post-anesthesia care unit (PACU) discharge. The current study's authors hypothesized that adding intrathecal epinephrine to spinal anesthesia for cesarean delivery would be associated with a dose-dependent prolonged post-anesthesia unit length of stay.

METHODS

A single-center, retrospective study of patients undergoing repeat cesarean delivery under spinal anesthesia from 2011 to 2015 was conducted. Patients received spinal bupivacaine 12 mg, morphine 150 mcg, and fentanyl 15 mcg with no-epinephrine, 100 mcg, or 200 mcg of epinephrine. The primary outcome was recovery room length of stay. Secondary outcomes were surgical duration, intraoperative vasopressor use, perioperative opioids, and antiemetic use.

RESULTS

 Data were analyzed for 1,362 patients. Median recovery room stay was 123 min (interquartile range, 100 to 150) and was not different among groups. More women receiving epinephrine 200 mcg had ≥2 prior cesarean deliveries compared with no-epinephrine or 100 mcg. No significant differences in surgical duration or intraoperative opioids were identified among the groups. Median intraoperative vasopressor use was increased by 225 mcg of phenylephrine equivalents (99% CI, 25 mcg to 430 mcg) in the 100 mcg group and 250 mcg of phenylephrine equivalents in the 200 mcg group (99% CI, 75 mcg to 500 mcg) compared to no-epinephrine (P<0.001). Recovery room antiemetic and opioid analgesic administration were not different among groups.

CONCLUSIONS

 Based on the results of this study, the addition of intrathecal epinephrine for women undergoing cesarean delivery increases intraoperative vasopressor use but does not prolong PACU length of stay, reduce intraoperative opioids, or increase antiemetic requirements postoperatively. The current study also demonstrated that surgical duration times were not different among the no-epinephrine, 100 mcg, and 200 mcg epinephrine groups.

Clonidine as an Adjunct for the Successful Treatment of Labor Epidural Infusion-Associated Interscapular Pain

Epidural infusion-associated interscapular pain for laboring parturients is a treatment dilemma for obstetric anesthesiologists. We report a case of a parturient who was successfully treated for labor epidural analgesia-associated interscapular pain. Our treatment plan included reducing the volume of local anesthetic administered by adding the adjunct of clonidine, increasing the epidural solution concentration of local anesthetic, and reducing the overall infusion rate. We conclude that epidural clonidine should be considered a safe adjunct when treating laboring parturients who report epidural infusion-associated interscapular pain.

Midazolam for the Successful Treatment of Refractory Spinal-Anesthesia-Associated Hypothermia After Cesarean Delivery

Cesarean deliveries receiving spinal anesthesia with intrathecal morphine are associated with post-operative hypothermia. Lorazepam has been proposed as a reversal agent for treating intrathecal morphine-associated post-cesarean hypothermia. Midazolam is a benzodiazepine familiar to most anesthesia providers and is frequently administered in the perioperative period. We present a post-cesarean delivery spinal anesthesia-associated hypothermia patient successfully treated with intravenous midazolam.

Neuraxial and Regional Anesthesia in a Patient With Amyotrophic Lateral Sclerosis: A Case Report

Patients with amyotrophic lateral sclerosis (ALS) who undergo lower extremity joint arthroplasty are rarely encountered. Patients with ALS are at an increased risk for perioperative anesthetic complications. Anesthetic techniques, regional or general, present different risks to patients with ALS. The historical concern of worsening pre-existing neurologic symptoms with regional anesthesia is being re-examined in light of emerging evidence supporting its use in patients with ALS. Here, we present the successful perioperative management of a patient with severe bulbar ALS undergoing total knee arthroplasty. Despite his advanced bulbar symptoms, he was independently ambulatory with severe knee pain related to osteoarthritis. During multidisciplinary planning with the patient and his wife, it became clear that his primary perioperative concern was avoiding intubation, prolonged ventilation, and tracheostomy placement. With this in mind, we planned for a neuraxial anesthetic without intraoperative sedation, a postoperative adductor canal peripheral nerve block, and multimodal non-opioid analgesia. There were no perioperative complications. At the six-week follow-up, he experienced improved ambulation and showed no signs of worsened ALS symptoms.