Perioperative regional anaesthesia and postoperative longer-term outcomes

Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.

Lumbar Ultrasonography for Obstetric Neuraxial Blocks: Sonoanatomy and Literature Review

Ultrasonography has gained popularity in recent years among anaesthesiologists and being used widely for regional blocks and central venous catheterization. Ultrasonography for neuraxial blocks was found beneficial especially for determining the correct needle insertion site and estimating the needle insertion depth of epidural space. In many recent studies, ultrasound guided epidural and spinal blocks have been evaluated among obstetric patients. Pre-procedural lumbar ultrasonography and real time ultrasound guidance for neuraxial blocks was the subject of these studies. We aimed to evaluate lumbar ultrasonography for obstetric neuraxial blocks. We describe the principles of lumbar ultrasound scanning techniques and present a practical review of lumbar sonoanatomy. We discuss the potential impact and benefits of the ultrasound-guided technique in improving obstetric neuraxial blocks and limitations of its use in clinical practice, based on previous studies.

Clonidine versus other adjuncts added to local anesthetics for pediatric neuraxial blocks: a systematic review and meta-analysis

Background

Clonidine is a common adjunct to local anesthetics for pediatric neuraxial block; however, the pros and cons between clonidine and other adjuncts remain unclear. Thus, we performed this meta-analysis of randomized controlled trials to assess the efficacy and adverse effects between clonidine and other adjuncts added to local anesthetics.

Materials and methods

The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Randomized controlled studies were searched in Cochrane (to present), Medline (1946 to present), Embase (1974 to present), and Biosis (1995 to present). Relative risks (RRs), standard mean difference (SMD), and associated CIs were calculated using RevMan statistical software to assess continuous and dichotomous data. Heterogeneity in studies was measured by forest plots and I² values. Subgroup analysis was performed for continuous and dichotomous variables, while meta-regression was applied for continuous data with high I² values.

Results

A total of 15 randomized controlled studies met the inclusion criteria. There was a longer duration of postoperative analgesia in the clonidine group than for other adjuncts (SMD=1.54, p=0.005, I²=96%). The number of patients requiring rescue analgesia was lower in the clonidine group without the addition of epinephrine (RR=0.55, p=0.0002, I²=0), while the RR for the comparison with epinephrine was significant (p=0.62, I²=95%). The duration of motor block was longer in the clonidine group (mean difference [MD]=1.06, p<0.00001, I²=0). The clonidine group also had a lower incidence of postoperative nausea and vomiting (PONV; RR=0.49, p<0.00001, I²=0). Postoperative bradycardia, hypotension, and urinary retention were not significantly different between clonidine and other adjuncts (p>0.05).

Conclusion

Clonidine, compared with other adjuncts, added to local anesthetics for neuraxial block, provides a longer duration of postoperative analgesia with lower incidence of PONV. However, the duration of motor block may also be prolonged by clonidine.

Dura to spinal cord distance at different vertebral levels in children and its implications on epidural analgesia: A retrospective MRI-based study

BACKGROUND

The distance from the dura to spinal cord is not uniform at different vertebral levels. The dura to spinal cord distance may be a critical factor in avoiding the potential for neurological injury caused by needle trauma after a dural puncture. Typically, the greater the dura to spinal cord distance, the larger the potential safety margin. The objective of our study is to measure dura to spinal cord distance at two thoracic levels T₆ -₇ , T₉ -₁₀ , and one lumbar level L₁ -₂ using MRI images.

METHODS

Eighty-eight children under the age of 8 years old qualified for the study. The distance from dural side of ligamentum flavum to the posterior margin of the spinal cord was defined as dura to spinal cord distance. Sagittal T₂ -weighted images of the thoracic and lumbar spine were used to measure the dura to spinal cord distance at the T_6-7 , T_9-10 , and L_1-2 interspaces. Measurements were taken perpendicular to long axis of the vertebral body at each level.

RESULTS

The dura to spinal cord distance was 5.9 ± 1.6 mm at T_6-7 (range: 1.4-9.9 mm), 5.0 ± 1.6 mm at T_9-10 (1.2-8.1 mm), and 3.6 ± 1.2 mm at L_1-2 (1.2-6.8 mm). There were no evident differences in dura to spinal cord distance by gender, age, height, or weight.

CONCLUSION

The present study reports that the largest dura to spinal cord distance is found at the T_5-6 level, and the shortest dura to spinal cord distance at the L_1-2 level. There appears to be substantially more room in the dorsal subarachnoid space at the thoracic level. The risk of spinal cord damage resulting from accidental epidural needle advancement may be greater in the lumbar region due to a more dorsal location of the spinal cord in the vertebral canal compared to the thoracic region.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques

Background:

The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management.

Aims and Objectives:

The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery.

Materials and Methods:

Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test.

Results:

A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K.

Conclusion:

Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Prospective observational investigation of body habitus measurements and relationship to epidural depth in term pregnant women

BACKGROUND

High body mass index (BMI) can predict difficult neuraxial block; however, fat distribution may also be important. The primary study aim was to identify body habitus and fat distribution measurements that correlated with ultrasound measured epidural depth. We hypothesized that measurements such as midarm and subscapular fatpad thicknesses and length of cervical spine may correlate better with ultrasound measured epidural depth than a global measure of BMI.

METHODS

Prospective IRB approved study of term pregnant women requiring neuraxial block. We measured height, weight (BMI, kg/m² ), subscapular, midarm fatpad thickness (digital caliper, mm), vertebral column length (C7 to sacral hiatus, cm) and epidural depth (ultrasound, mm). Four experts assessed photographs to assign anticipated difficult neuraxial block in sitting and lateral positions (5-point Likert scale, 1 = very easy, 5 = very difficult).

RESULTS

In all, 131 women completed body habitus measurements. Measured mean (standard deviation) BMI was 30.3 (5.4) kg/m² . Measured BMI, subscapular fatpad and midarm fatpad thickness were significantly correlated with ultrasound depth to epidural space (R² 0.733, 0.626 and 0.633, respectively, P < .0001) but vertebral column length was not. The experts had a high level of agreement (Cronbach's alpha >0.7) for assessment of anticipated difficult block in the sitting and lateral positions; however, anticipated difficult block was not correlated with epidural depth measured by ultrasound for sitting position, R²  = -0.015, P = .87; and lateral position, R²  = -0.087, P = .33.

CONCLUSIONS

Measurements of body habitus and fat distribution were no better than measured BMI to anticipate greater ultrasound measured depth to epidural space. Clinical trial number: Non-interventional observational study, not registered.

It's Never Just a Block: An Analysis of Regional Anesthesia Closed Claims

Anesthesia care increasingly includes use of regional anesthesia techniques, either as a primary anesthetic or to reduce the patient's postoperative pain. Both neuraxial anesthesia and peripheral nerve blockade have several noteworthy functions. These functions include diminishing sensory sensation to pain and potentially producing a motor blockade, both of which may facilitate the surgical procedure. The desire to reduce reliance on opioid medications, protocols to enhance and accelerate patient recovery from surgery, and patient expectations all contribute to the likelihood that use of regional anesthesia will continue to gain popularity. As such, it is essential to understand whether an association exists between regional anesthesia and adverse outcomes of care. The American Association of Nurse Anesthetists Foundation Closed Claim Research Team searched the most current database of closed claims that involved adverse outcomes when either a peripheral nerve block or a neuraxial block was a component of care in the claims. Although there were only 32 claims in the dataset, a thematic analysis resulted in the identification of 3 themes: errors in cognitive decision making, ineffective communication patterns, and production pressure.

PRO AND CONTRA ON ADJUVANTS TO NEUROAXIAL ANESTHESIA AND PERIPHERAL NERVE BLOCKS

Modern approach in surgical treatment and in managing acute and chronic pain is nowadays more and more based on the implementation of all possible techniques of regional anesthesia (RA). Local anesthetics (LA) are needed to achieve standard regional anesthesia. Local anesthetics are primarily characterized by time constraints and duration of action, and depending on the amount applied, adverse effects on the cardiac and central nervous system may occur. Adjuvants are drugs used together with LA due to their synergistic effect, i.e. they improve start latency and duration of sensory and motor blockade and enable reduction of cumulative dose of LA and reduction of adverse effects on cardiac and nervous system. Nowadays, there is a huge variety of drugs that can be administered in combination with LA, and they, in general, can be divided into opioid and non-opioid adjuvants. The administration of opioids in RA over an extended time period was accompanied by some negative characteristics as respiratory depression, nausea, vomiting. So, their usage is still under a special control. Due to the positive effects shown by drugs from non-opioid adjuvants group (e.g. adrenaline, alpha adrenergic agonists, steroids, magnesium, midazolam, ketamine etc.), indications for their administration broadened. However, there are still some restrains in clinical practice based on the fact that neurotoxicity and demonstration of neurological complications in regional anesthesia haven't been properly researched yet.

Focal Neurologic Deficit After Epidural Catheter Removal Leads to Meningioma Diagnosis

We present an unusual case of a 60-year-old female who developed subtle, new-onset left upper and lower extremity weakness on day five of perioperative thoracic epidural placement. The onset of a focal neurological deficit after epidural placement usually raises suspicion for the presence of an epidural hematoma, abscess, or traumatic cord lesion. However, in this patient, brain imaging revealed a large, previously undiagnosed intracranial mass. Classically, the risk of mass-related intracranial pressure shifts leading to neurological changes is associated with spinal techniques, including diagnostic lumbar puncture, combined spinal-epidural catheter analgesia, and unintended dural puncture during epidural placement. However, based on this case and our summary of case reports in the literature, we determined that symptom onset associated with an intracranial mass may also arise after apparently uncomplicated epidural placement. Symptom onset in our case series ranged from six hours to ten days and was highly variable depending on tumor location, with reported signs and symptoms including headache, vision changes, focal deficits, or alterations of consciousness. Further studies are required to establish definitive causation between the epidural technique and changes in cerebrospinal fluid pressures leading to symptom onset. Though rare, this is a time-sensitive diagnosis that must be considered for any patient with unexplained neurological findings after neuraxial anesthesia.

Vocal Fold Paralysis After Spinal and Epidural Anesthesia: A Case Report and Scoping Review

OBJECTIVES

Cranial nerve paralysis is a rare complication of spinal and epidural anesthesia, and some cases of vocal fold paralysis (VFP) have been reported. The aim of this article is to report a case, identify evidence supporting the possibility of VFP being a complication of spinal and epidural anesthesia and to investigate the frequency, the characteristics, and the possible mechanisms of such a complication.

DATA SOURCES

CINAHL Complete, Google Scholar, Cochrane Library, Pubmed, and EMBASE.

METHODS

Case report according to CARE guidelines; scoping review according to PRISMA-ScR criteria. All types of studies that reported on patients of any age and sex, all types of spinal/epidural anesthesia regardless of the location and of drugs used were included. A data extraction sheet was completed for each study selected for inclusion based on the full-text screenings. Extracted data included: study characteristics, participant characteristics, intervention characteristics, outcome measures, clinical investigations. The study did not receive external funding.

RESULTS

Eight studies met inclusion criteria and a total of 13 events (in 12 patients, including ours) were reported to date. Although there are some hypotheses in regard to the mechanism underlying the phenomena, including mechanical and inflammatory ones, the exact cause is still unclear.

CONCLUSIONS

Only few cases of VFP after spinal or epidural anesthesia have been reported to date; however, it seems possible that VFP might be a potential underreported complication of such procedures. We believe that more research on the topic is warranted, especially considering the wide population potentially at risk.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3477-3484, 2024.

Caudal Neuraxial Blocks for Pain Relief From Pelvic Neuropathy Caused by Extensive Diffuse Large B-cell Lymphoma

Central neuraxial blocks can be a vital therapeutic tool for neuropathic pain, but they are infrequently implemented for pain management in cancer patients. Upon a literature review, further data on the role or efficacy of central nerve blocks for neuropathic cancer pain would be beneficial. Additionally, evidence-based guidelines and practices are lacking regarding additional interventions for neuropathic pain relief, a common manifestation of cancer burden. Here, we report the case of a 29-year-old male patient who presented in the ED with intractable neuropathic pain from extensive diffuse large B-cell lymphoma. The patient demonstrated left lower extremity pain, fevers, chills, and tenderness with erythema over the site of his port-a-catheter on his chest. The patient was also hypotensive, despite IV fluid resuscitation. Recent imaging showed a hypermetabolic soft tissue mass in the left upper quadrant of the abdomen. There was also extensive cancer spread in the peripheral pelvis, presacral region, and within multiple sacral foramina, with a secondary perineural spread of the tumor. The patient previously positively responded to a caudal nerve block at an outpatient pain clinic. The patient was admitted to the ICU for three days, and following the resolution of sepsis, the patient received caudal and sciatic nerve blocks on admission day 8. Upon further imaging showing metastasis to the brain, the patient was discharged to inpatient hospice on hospitalization day 10 following a palliative conversation with the patient and family.

Perioperative management of patients with prosthetic heart valves-A narrative review

Worldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high-risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.

High Neuraxial Blockade in a Parturient After Epidural Placement: A Quality Improvement Simulation

Background Epidural anesthesia is a commonly used procedure in obstetrics for managing labor pain, with a potential complication of high neuraxial blockade. Proficiency in performing epidural or spinal anesthesia and promptly recognizing and managing high neuraxial blockade are critical components of anesthesiology residency training. Methods A simulated case was designed involving a 21-year-old female in labor receiving epidural anesthesia. After the administration of local anesthetic, she develops symptoms of nausea, hypotension, and respiratory distress, progressing to high neuraxial blockade. The simulation environment included a labor and delivery suite setup, an epidural cart, airway supplies, a Laerdal SimMan 3G PLUS mannequin (Laerdal Medical, Stavanger, Norway), and an M43B Kyoto Kagaku Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan). Post-simulation, participants completed surveys via REDCap (Vanderbilt University, Nashville, USA) to assess their comfort levels in recognizing and managing high neuraxial blockades. Results Nine participants, including anesthesiology residents (PGY1-4) and student registered nurse anesthetists (SRNAs), completed the pilot simulation. Survey feedback was collected to evaluate the simulation's impact on participants' learning and confidence. Discussion Participants provided positive feedback, highlighting the simulation's value in their training and its realism. Suggestions for improvement included using an actual labor and delivery bed to better mimic real-world challenges. A limitation of the study is the small sample size, additional sessions with future cohorts will help further assess the simulation's efficacy. Plans are in place to incorporate this simulation annually into the anesthesiology residency curriculum at the institution. Conclusion Simulation-based training in anesthesiology residency programs enables learners to practice managing complex and high-stakes scenarios in a controlled environment. This simulation effectively reinforced critical skills, including endotracheal intubation, epidural catheter placement, and the management of a hemodynamically unstable pregnant patient. Furthermore, it provided valuable experience in recognizing and treating high neuraxial blockade, a serious but rare complication of epidural anesthesia.

Dual- vs. Single-Plane Ultrasonic Scan-Assisted Positioning during Lumbar Spinal Puncture in Elderly Patients: A Randomized Controlled Trial

The purpose of this study was to investigate the ability of single- versus dual-plane ultrasound scan-assisted spinal anesthesia techniques to improve the success rate and efficacy of spinal anesthesia in elderly patients undergoing lower extremity surgery. A total of 120 elderly patients undergoing lower extremity surgery were randomly assigned to either receive single-plane (Group A) or dual-plane ultrasonic scan-assisted spinal anesthesia (Group B). The primary outcome analyzed by this study was first-attempt success rate. Secondary outcomes analyzed included number of needle insertion attempts, needle redirections, locating time, procedural time, total time, puncture depth, quality of ultrasound images, level of block, adverse reactions, and complications. The first-attempt success rate was significantly higher in Group B compared to Group A (88.3% vs. 68.3%, p = 0.008). In comparison with Group A, the number of needle insertion attempts (1 (1−2) vs. 1 (1−1), p = 0.005) and needle redirections (2 (1−3) vs. 1 (0−2), p < 0.001) were both significantly lower in Group B; Group B also had a shorter procedural time (249.2 ± 30.1 vs. 380.4 ± 39.4 s, p < 0.001) but a longer locating time (250.1 ± 26.2 vs. 137.8 ± 13.5 s, p < 0.001). The dual-plane ultrasonic scan-assisted spinal anesthesia technique warrants consideration for application in elderly patients.