Anaesthesia For Emergency Caesarean Section Research Articles

Hemodynamic Changes of Women with Preeclampsia Undergoing Spinal Anesthesia for Emergency Cesarean Section: A Prospective Observational Study

Abstract Background: Preeclampsia is a multisystem disorder in pregnancy and remains a significant cause of maternal morbidity and mortality. In this prospective observational study, we used a continuous noninvasive cardiac output monitor to investigate the changes in arterial blood pressure, cardiac output, systemic vascular resistance, stroke volume, and stroke volume variation during the immediate perioperative period. Materials and Methods: Women with preeclampsia undergoing emergency cesarean section under spinal anesthesia were recruited in this prospective observational study. Cardiac output and arterial blood pressures were measured by the Nexfin monitor. Cardiovascular parameters were recorded intraoperatively and up to 48 h postoperatively. The primary outcome was to examine the differences in cardiac output between the intraoperative and postoperative periods. Results: Thirty patients included in the data analysis had a mean age of 35.6 ± 5.2 years and gestation of 35.4 ± 2.1 weeks. Post-spinal anesthesia, 50% experienced hypotension. 26.7% had nausea, 10% vomited, and other events included shivering, reactive hypertension, and bradycardia. The use of spinal anesthesia was associated with a significant reduction in systolic (126.7 ± 16.9 vs. 142.0 ± 21.2 mm Hg, P < 0.001), diastolic (71.2 ± 8.4 vs. 77.0 ± 11.3 mm Hg, P < 0.001), mean arterial pressure (92.6 ± 12.2 vs. 103.7 ± 15.3 mm Hg, P < 0.001), cardiac output, and stroke volume compared to postoperative readings. No significant difference was found in cardiac output, cardiac index, or systemic vascular resistance indices between the intraoperative and postoperative periods. Conclusion: Spinal anesthesia may have short-term hemodynamic changes in women with preeclampsia. Continuous noninvasive cardiac monitoring can be used to monitor specific cardiac hemodynamic parameters, which may resolve in the immediate postoperative period.

Effect of intravenous esketamine in emergency cesarean deliveries: a retrospective analysis of maternal and neonatal outcomes

Background This study investigates the effects of administering intravenous esketamine at a dose of 0.25 mg/kg to pregnant patients receiving epidural anesthesia for emergency cesarean section on both maternal and neonatal outcomes. Methods Medical records of pregnant patients transitioning from labor analgesia to epidural anesthesia for emergency cesarean sections between January 2020 and December 2022 were analyzed. The patients were categorized based on whether they received esketamine infusions during the incision-to-delivery interval. The variables compared between the groups included hemodynamic parameters, perioperative and postoperative adverse reactions, and neonatal outcomes (gender, weight, Apgar scores at 1 and 5 min, need for neonatal intensive care, and umbilical artery/vein blood gas analysis). Results For maternal outcomes, the systolic blood pressure (SBP) in the esketamine group showed a significant increase at 5 and 10 min’ post-administration, and the diastolic blood pressure (DBP) significantly increased at 5 min, compared to the control group (p < 0.01). No significant differences were observed in heart rate (HR) and oxygen saturation (SpO2) at any time point (p > 0.05). The esketamine group experienced a significant rise in the incidence of arrhythmias, dizziness, and nystagmus during the perioperative period, a notable decrease in hypotension incidence, and an increase in postoperative nausea and dizziness. Regarding neonatal outcomes, there were no significant differences in gender, weight, Apgar scores ≤7 at 1 and 5 min, and the need for neonatal intensive care. However, the pH level in the umbilical artery blood of the esketamine group was significantly higher. The levels of PCO2 and PO2 in umbilical artery and venous blood did not show significant differences between the groups. Conclusions In pregnant women undergoing emergency cesarean section, intravenous administration of 0.25 mg/kg esketamine is correlated with favorable maternal and neonatal outcomes.

Neonatal outcomes when intravenous esketamine is added to the parturients transferred from labor analgesia to emergency cesarean section: a retrospective analysis report

ObjectivesThe use of intravenous analgesics during emergency cesarean section may lead to adverse neonatal outcomes. In our study, we investigated whether a single intravenous (i.v.) dose of 25 mg esketamine administered to parturients with inadequate analgesia during epidural anesthesia for cesarean section would affect the neonate.DesignWe reviewed the records of parturients who were transferred from labor analgesia to epidural anesthesia for emergency cesarean section from January 2021 to April 2022. Parturients were grouped by whether they received esketamine infusions during the incision–delivery interval. Neonatal outcomes, including umbilical arterial-blood gas analysis (UABGA), Apgar score, and total days spent by the neonate in the hospital, were compared between the two groups. The secondary outcomes of this study included BP, heart rate (HR), SPO2 and the incidence of adverse effects in parturients during operation.SettingChina.ResultsAfter propensity score matching, 31 patients remained in each of the non-esketamine and esketamine groups. There were no significant differences in neonatal outcomes, including UABGA, Apgar score, and total days in the hospital, between the two groups. Additionally, our study showed a similar hemodynamic performance in parturients between the two groups during operation.ConclusionsIntravenous esketamine (25 mg) is safe for neonates when it is given to parturients transferred from labor analgesia to emergency cesarean section.

Low dose bupivacaine spinal anesthesia for emergency cesarean section in a patient with uncorrected tetralogy of fallot, presenting with placenta previa

Background: Pregnant women with congenital heart disease tetralogy of fallot who undergo cesarean section have their own challenges for the anesthesiologist, not to mention if they have pregnancy complications such as placenta previa. The choice of the safest anesthetic technique is still debated today. The anesthetic technique must be able to maintain systemic vascular resistance, avoid increasing pulmonary vascular resistance, and be aware of the threat of blood loss due to placenta previa. Case Report: 29 years old pregnant woman, weighing 46 kg and height 155 cm, G1P0A0, Gravida 27-28 weeks, single alive fetus, fetal distress, comes with complaints of shortness of breath, vaginal bleeding due to placenta previa with tetralogy of fallot planned emergency cesarean section. The patient presented with functional class NYHA II-III. We used low-dose spinal anesthesia with 5 mg bupivacaine 0.5% and 25 ug fentanyl as an adjuvant. Colloading was done with gelofusin colloid fluid to replace the amount of bleeding. Hemodynamics prior to anesthesia were BP 120/80, Heart Rate 80 x/minure, SpO2 72% with a non-rebreathing mask 10 litre/minute. There was no severe hypotension during surgery, and was hemodynamically stable with limited use of vasopressors. After the cesarean section was completed, the patient was transferred to the ICU and treated for 2 days, and was only discharged after 5 days of treatment without additional complications. Conclusion: The use of low-dose spinal anesthesia in combination with adjuvant fentanyl results in a relatively safe anesthetic technique with minimal hemodynamic changes and adequate analgesia for cesarean delivery.

Anesthetic Conversion of Preexisting Labor Epidural Analgesia for Emergency Cesarean Section and Efficacy of Levobupivacaine with or Without Magnesium Sulphate: A Prospective Randomized Study.

BackgroundFor pregnant women who require an emergency cesarean section (CS), extending labor epidural analgesia as quickly as feasible to good quality anesthesia is a critical issue. This indicates the presence of functional labor epidural analgesia and reduces the need for general anesthesia. Addition of magnesium increases anesthetic and analgesic qualities of epidural anesthesia.ObjectivesThe purpose of this trial was to assess the role of adding magnesium sulfate (MgSO4) with levobupivacaine to speed up the conversion of labor epidural analgesia into enough anesthesia for emergency CS.MethodsFifty parturients were randomly assigned to receive 19.5 mL of levobupivacaine 0.5% with either 0.5 mL of normal saline 0.9% (Group I) or 0.5 mL of MgSO4 10% (Group II) after receiving labor epidural analgesia. We documented the onset of block (loss of pinprick to T6), number of patients needing additional analgesia, the time needed for sensory and motor blockade to recover, and the adverse effects.ResultsThe frequency of patients receiving intraoperative supplements was comparable in the study groups (P = 0.491), although the onset of the block was faster in Group II than in Group I (P = 0.000*). Group II took substantially longer to recover from sensory and motor blockade than Group I (P = 0.001* and P = 0.001*, respectively). In both groups, the occurrence of adverse events was similar.ConclusionsAdding 50 mg of MgSO4 to levobupivacaine 0.5% accelerated the epidural top, and both sensory onset and motor blocks period were prolonged as compared to levobupivacaine alone when extending epidural analgesia for emergency CS.

Subdural injection: A possible cause of loss of consciousness during cesarean section

Spinal anesthesia is commonly used for cesarean section as it is safe and effective. However, subdural block can occur which might lead to loss of consciousness. We hereby report a parturient who received epidural analgesia for normal vaginal delivery followed by spinal anesthesia for emergency cesarean section and lost consciousness for 5 min after 10 min of spinal anesthesia induction.

Conversion of Labour Epidural Analgesia to Anaesthesia for Emergency Caesarean Section

Aim: to determine the rates of failed conversion of EA to surgical anaesthesia for patient and clinician information and benchmarking, and to develop an algorithmic approach for safe conversion of EA. Materials and Methods: A retrospective audit of parturients who had labour epidural analgesia (EA) at an advanced tertiary care institute for women and newborn health in south India. Information on EA, caesarean sections, conversion of EA, failure of regional anaesthesia, use of general anaesthesia, alternate techniques and supplemental medications were retrieved from electronic medical records. Results: Emergency cesarean section (CS) was performed for 4,259 (26.93%, 95% CI: 26.25, 27.63) of 15, 812 parturients that had EA at the study institute between Jan 2012 and December 2016. The EA was successful in 4,078 (95.75%, 95% CI: 95.11, 96.32) of these 4,259 women. Seventy three (1.71%, 95% CI: 1.37, 2.15) of the 4,259 women reported mild discomfort on the VAS for pain and required supplemental sedation for the emergency CS and 108 (2.53%, 95% CI: 2.11, 3.05) of the 4,259 women needed alternate techniques. The failure rate of EA was thus 4.25% (95% CI: 3.68, 4.89, n = 181) in this audit. Conclusions: The failure rates of EA at the study institute are well within the recommended standards of the RCA (Royal College of Anaesthesiologists – UK). This audit helped us to develop an algorithmic approach to further improve performance based on problems identified during the audit.

Community Hospital Experience of Surgical times and Outcomes in Patients Undergoing Cesarean Deliveries for Non-Reassuring Fetal Tracing: A Retrospective Cohort

Background: Current guidelines recommend regional anesthesia versus general as a method of choice for women undergoing cesarean deliveries (CS). However, little is known about the surgical times in the operating room and a choice of anesthesia for cesarean deliveries. Objective: This study was designed to compare times from the arrival to the OR to the delivery of the fetus between regional and general anesthesia along with maternal and fetal outcomes, for patients undergoing cesarean sections for non-reassuring fetal tracing. Study Design: Records were reviewed for patients who underwent cesarean delivery for non-reassuring fetal heart rate tracing from February 2012 to May 2018. A total of 190 charts were selected. Seven patients who received epidural or spinal anesthesia and then converted to general anesthesia (GA) were excluded. The primary outcomes were: 1) entering the operating room to skin incision (min); 2) the time from entering the operating room to delivery of the fetus (min). These times were compared among the patients who underwent epidural, spinal and general anesthesia. The secondary criteria included time from skin incision to delivery of the fetus (min), estimated blood loss (ml), Apgars scores, Arterial/venous cord pH, NICU admissions and fetal complications. ANOVA or Kruskal-Wallis Test was used for the continuous variable and Fisher’s exact test was used for the categorical variable to test the differences between groups. Logistic regression model was used for the binary outcomes after adjusting for age, BMI and number of prior laparotomies. Results: Infants in the GA group were delivered significantly faster when compared to epidural and spinal group separately with a P-value of 0.001. The mean time from arrival to OR to delivery of the newborn in GA group was 12.7 minutes, compared to 27 minutes in epidural group and 32.7 minutes in the spinal group. Time intervals from time in the OR to incision and time from incision to delivery of the fetus were also calculated and were significantly shorter in the GA group when compared to spinal and epidural groups, P < 0.001. The estimated blood loss (EBL) was similar between these three groups. Both arterial and venous umbilical cord mean PH were comparable in GA, spinal and epidural groups. Potential complications of GA include 36% of newborns had an Apgar score of less than 7 at 1 minute in GA group when compared to 15% of newborns in the epidural group, and 22% of newborns in the spinal group, which was not statistically significant. When comparing the NICU admission between the groups: 77% of newborns delivered under GA required NICU admission, 54% of the newborns delivered via epidural anesthesia were admitted versus 50% of newborns delivered via spinal anesthesia. Conclusion: The induction of general anesthesia for emergency cesarean section resulted in shorter times to delivery compared to spinal and epidural. General anesthesia was associated with lower, albeit not statistically significant Apgar scores and higher NICU admissions, and had similar cord gases compared to neuraxial anesthesia group.

Post spinal meningitis with subdural collection: an uncommon complication after spinal anaesthesia for caesarean section

Meningitis after spinal anaesthesia is a rare yet devastating complication of spinal anaesthesia. The exact incidence is unknown. Our patient developed signs and symptoms of meningitis 48 hours after spinal anaesthesia and required intensive care unit admission. Her cerebrospinal fluid was sterile. Computed tomography of brain showed left subdural collection. She recovered well after 6 weeks of intravenous antibiotics. No neurological sequela noted from subsequent follow-up examinations. Our case provides an important insight of meningitis with subdural collection after spinal anaesthesia for emergency caesarean section.

Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section.

It is not clear how converting epidural analgesia for labour to epidural anaesthesia for emergency caesarean section affects either cutaneous vasomotor tone or mean body temperature. We hypothesised that topping up a labour epidural blocks active cutaneous vasodilation (cutaneous heat loss and skin blood flow decrease), and that as a result mean body temperature increases. Twenty women in established labour had body temperature, cutaneous heat loss and skin blood flow recorded before and after epidural top-up for emergency caesarean section. Changes over time were analysed with repeated measures ANOVA. Mean (SD) mean body temperature was 36.8 (0.5)°C at epidural top-up and 36.9 (0.6)°C at delivery. Between epidural top-up and delivery, the mean (SD) rate of increase in mean body temperature was 0.5 (0.5) °C.h-1 . Following epidural top-up, chest (p < 0.001) and forearm (p = 0.004) heat loss decreased, but head (p = 0.05), thigh (p = 0.79) and calf (p = 1.00) heat loss did not change. The mean (SD) decrease in heat loss was 15 (19) % (p < 0.001). Neither arm (p = 0.06) nor thigh (p = 0.10) skin blood flow changed following epidural top-up. Despite the lack of change in skin blood flow, the most plausible explanation for the reduction in heat loss and the increase in mean body temperature is blockade of active cutaneous vasodilation. It is possible that a similar mechanism is responsible for the hyperthermia associated with labour epidural analgesia.

Anesthesia for Emergency Cesarean Section: A Comparison of Spinalversus General Anesthesia on Maternal and Neonatal Outcomes

Background: Despite the relative safety of cesarean section (CS), increasing CS rate is a cause for concern to obstetricians and anesthetists because of the attendant increased health risk one of which is the risk of anesthesia. The choice of anesthesia for cesarean section depends on the indication for the surgery, the urgency of intervention required, the maternal and/or fetal status, and the patient’s desires. Despite the paradigm shift toward spinal anesthesia, general anesthesia is still commonly administered in our facility for some specific indications. Objective: This study was aimed to evaluate the maternal and neonatal outcomes in patients who had emergency CS under spinal anesthesia compared with those who had general anesthesia. Materials and Methods: This was a retrospective study comparing the obstetric outcome of patients who had emergency CS under spinal anesthesia compared with those who had the surgery under general anesthesia. Data analysis was done using statistical Epi Info version 7.2.1. Results: The most common indication for surgery in the spinal group was cephalopelvic disproportion while that for the general anesthesia group was antepartum hemorrhage/placenta previa. Patients who had spinal anesthesia had less intraoperative blood loss compared with those who had general anesthesia (814 ± 124 vs. 842 ± 324; P = 0.0007). There was a significant difference in the intraoperative blood loss >1000 ml among women who had spinal anesthesia relative to women who had general anesthesia (odds ratio [OR]: 0.6832, 95% confidence interval [CI]: 0.3390–0.9779; P = 0.0005). Spinal anesthesia was associated with a reduced risk of having a 1st‑min Apgar score <7 (OR: 0.6096, 95% CI: 0.4066–0.9140; P = 0.016). There was no significant difference in the 5th‑min Apgar score in both groups. There was also no significant difference in the number of neonates admitted into the Intensive Care Units. The maternal and perinatal mortality was not different in both groups. Conclusion: Spinal anesthesia was associated with reduced risk of blood loss and reduced risk of low Apgar score in the 1st min. There was no difference in the 5th‑min Apgar score and maternal and neonatal mortality. Keywords: Emergency cesarean section, general anesthesia, spinal anesthesia.

Anesthesia for emergency cesarean section: A comparison of spinal versus general anesthesia on maternal and neonatal outcomes

Background: Despite the relative safety of cesarean section (CS), increasing CS rate is a cause for concern to obstetricians and anesthetists because of the attendant increased health risk one of which is the risk of anesthesia. The choice of anesthesia for cesarean section depends on the indication for the surgery, the urgency of intervention required, the maternal and/or fetal status, and the patient’s desires. Despite the paradigm shift toward spinal anesthesia, general anesthesia is still commonly administered in our facility for some specific indications. Objective: This study was aimed to evaluate the maternal and neonatal outcomes in patients who had emergency CS under spinal anesthesia compared with those who had general anesthesia. Materials and Methods: This was a retrospective study comparing the obstetric outcome of patients who had emergency CS under spinal anesthesia compared with those who had the surgery under general anesthesia. Data analysis was done using statistical Epi Info version 7.2.1. Results: The most common indication for surgery in the spinal group was cephalopelvic disproportion while that for the general anesthesia group was antepartum hemorrhage/placenta previa. Patients who had spinal anesthesia had less intraoperative blood loss compared with those who had general anesthesia (814 ± 124 vs. 842 ± 324; P = 0.0007). There was a significant difference in the intraoperative blood loss >1000 ml among women who had spinal anesthesia relative to women who had general anesthesia (odds ratio [OR]: 0.6832, 95% confidence interval [CI]: 0.3390–0.9779; P = 0.0005). Spinal anesthesia was associated with a reduced risk of having a 1st‑min Apgar score <7 (OR: 0.6096, 95% CI: 0.4066–0.9140; P = 0.016). There was no significant difference in the 5th‑min Apgar score in both groups. There was also no significant difference in the number of neonates admitted into the Intensive Care Units. The maternal and perinatal mortality was not different in both groups. Conclusion: Spinal anesthesia was associated with reduced risk of blood loss and reduced risk of low Apgar score in the 1st min. There was no difference in the 5th‑min Apgar score and maternal and neonatal mortality. Keywords: Emergency cesarean section, general anesthesia, spinal anesthesia.

A case report of emergency cesarean section in parturient with kyphoscoliosis

Anesthesia for emergency cesarean section for the pregnancy with kyphoscoliosis is associated with potential risks for both mother and fetus due to alterations in maternal physiology and the pathological changes seen in kyphoscoliosis. The anesthetic management must include the well-being of both mother and fetus. The need of anesthesia for delivery in pregnant women with kyphoscoliosis is more than the normal parturient. We report the case of a 23-year-old female, full-term primigravida with kyphoscoliosis who was posted for emergency caesarean section. The anesthetic management of this patient is presented here.

Anaesthesia for emergency caesarean section in a morbidly obese achondroplastic patient with PIH: Feasibility of Neuraxial anaesthesia?

Anaesthesia for emergency caesarean section in a morbidly obese achondroplastic patient with PIH: Feasibility of Neuraxial anaesthesia?

Unilateral sudden sensorineural hearing loss after combined spinal-epidural anesthesia for emergency cesarean section -A case report-

Unilateral sudden sensorineural hearing loss after combined spinal-epidural anesthesia for emergency cesarean section -A case report-

Nörofifibromatozis Tip 1 ve Pickwick Sendromu Olan Gebe Hastada Acil Sezaryen Spinal Anestezisi

Nörofifibromatozis Tip 1 ve Pickwick Sendromu Olan Gebe Hastada Acil Sezaryen Spinal Anestezisi

Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt.

Sir, Association of atrial septal defect (ASD) and pulmonary stenosis (PS) with bidirectional shunt in pregnancy is a very rare entity. Death can occur anytime during pregnancy or labour in these patients, precipitated by altered cardiovascular physiology of pregnancy.[1] A 25-year-old primi, an unbooked case with 38 weeks of gestation was posted for emergency caesarean section (CS) for cephalopelvic disproportion. In the second trimester, assessment of breathlessness (NYHA Grade III) with two-dimensional echocardiography revealed an ostium secundum type of ASD (8 mm × 10 mm) with predominantly right to left shunt (Qp: Qs - 0.85), severe PS (Maximum velocity [Vmax ]/peak pressure gradient [PGmax ] - 4.8 m/s/70.4 mm Hg), mild tricuspid regurgitation (Vmax /PGmax - 2.7 m/s/30.5 mm Hg), mild pulmonary regurgitation (Vmax /PGmax - 2.1 m/s/17.58 mm Hg), right ventricular hypertrophy (right ventricle diastolic wall thickness 6 mm) and normal biventricular function with ejection fraction of 60%. In the operation room, oxygen saturation (on room air) was 90-95%, pulse rate was 114/min regular and noninvasive blood pressure was 150/90 mmHg. The patient was premedicated with injection ranitidine (50 mg) and injection metoclopramide (10 mg) and colloid was started at 50 ml/h. Injection ceftriaxone 1 g was administered for antibiotic coverage. The initial central venous pressure was 13 cm H2O and was maintained between 12 and 14 cm H2O. Under aseptic precautions, an 18-gauge epidural catheter was inserted at L3 -L4 epidural interspace. A total volume of 20 ml local anaesthetic solution (13 ml of 2% lignocaine with adrenaline (5 μg/ml) and 1 ml of sodium bicarbonate and 1 ml (50 mg) of tramadol diluted with 5 ml saline) was administered through the epidural catheter in 5 ml increments for achieving a block height up to T4 dermatome. At the time of skin incision, injection ketamine (50 mg) and injection midazolam (1 mg) was administered in titrating doses. CS proceeded uneventfully, and a healthy male baby was delivered with Apgar score of 8 and 9 at 1 and 5 min, respectively. A bolus dose of 0.4 mg intravenous methylergometrine was administered slowly, and a slow infusion of oxytocin 10 units was started. The surgery lasted for about 60 min, and the blood loss was 500 ml. A total of 450 ml colloid and 100 ml oxytocin-normal saline infusion was given. Post-operative analgesia was provided with epidural top-up, whenever the patient complained of pain or visual analogue score was ≥4. At 48th h of follow-up, she had maximal scores for post-operative pain relief and overall satisfaction. She was discharged on the 7th post-operative day and referred to cardiology department for further management. The mortality in patients with ASD and severe PS with right to left shunt in pregnancy is unknown,[2] as many unsuccessful cases are not reported. In our case, although the patient was having reversal of shunt, she was asymptomatic and had no signs of chronic cyanosis. This may be due to hyperdynamic circulation of pregnancy producing increased pulmonary gradients and the restrictive ASD causing inadequate mixing of blood to produce clinical cyanosis.[3] Epidural anaesthesia (EA) was planned because of its slower onset and less and delayed haemodynamic variations compared to spinal and combined spinal-epidural technique.[4] General anaesthesia (GA) poses clear risks related to pulmonary vascular resistance and magnitude of the shunt. As the patient was in labour, we had no sufficient time for further cardiac evaluation. Pulse oximeter is used to assess the degree of right to left shunt during the peri-operative period.[5] Our principle was to maintain the cardiac output and to avoid the fall in systemic vascular resistance (SVR). We optimised the SVR based on mean arterial pressure to avoid the increase in shunt magnitude. Oxytocin bolus can cause direct vasodilatation and reduce SVR with a compensatory increase in heart rate and cardiac output in pregnant women. Use of methylergometrine lowered the use of vasoconstrictors[6] and added to haemodynamic stability. Colloids provide greater haemodynamic stability by remaining in the intravascular space for longer time and avoid volume overloading; this helps to decrease the magnitude of shunt and right ventricular failure.[7] The use of lower dose of lignocaine with adrenaline, bicarbonate and tramadol provided a more rapid onset and superior quality block to touch.[8] We did not institute any thromboprophylaxis measures; EA itself can reduce risk of perioperative venous stasis and embolism. To conclude, EA can be safely and effectively used for CS in pregnant patients having pulmonary vascular disease with reversal of shunts provided the SVR is maintained throughout the surgical procedure. Major haemodynamic complications and risk of embolism during GA can be avoided if EA is properly planned and administered. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt

Sir, Association of atrial septal defect (ASD) and pulmonary stenosis (PS) with bidirectional shunt in pregnancy is a very rare entity. Death can occur anytime during pregnancy or labour in these patients, precipitated by altered cardiovascular physiology of pregnancy.[1] A 25-year-old primi, an unbooked case with 38 weeks of gestation was posted for emergency caesarean section (CS) for cephalopelvic disproportion. In the second trimester, assessment of breathlessness (NYHA Grade III) with two-dimensional echocardiography revealed an ostium secundum type of ASD (8 mm × 10 mm) with predominantly right to left shunt (Qp: Qs - 0.85), severe PS (Maximum velocity [Vmax ]/peak pressure gradient [PGmax ] - 4.8 m/s/70.4 mm Hg), mild tricuspid regurgitation (Vmax /PGmax - 2.7 m/s/30.5 mm Hg), mild pulmonary regurgitation (Vmax /PGmax - 2.1 m/s/17.58 mm Hg), right ventricular hypertrophy (right ventricle diastolic wall thickness 6 mm) and normal biventricular function with ejection fraction of 60%. In the operation room, oxygen saturation (on room air) was 90-95%, pulse rate was 114/min regular and noninvasive blood pressure was 150/90 mmHg. The patient was premedicated with injection ranitidine (50 mg) and injection metoclopramide (10 mg) and colloid was started at 50 ml/h. Injection ceftriaxone 1 g was administered for antibiotic coverage. The initial central venous pressure was 13 cm H2O and was maintained between 12 and 14 cm H2O. Under aseptic precautions, an 18-gauge epidural catheter was inserted at L3 -L4 epidural interspace. A total volume of 20 ml local anaesthetic solution (13 ml of 2% lignocaine with adrenaline (5 μg/ml) and 1 ml of sodium bicarbonate and 1 ml (50 mg) of tramadol diluted with 5 ml saline) was administered through the epidural catheter in 5 ml increments for achieving a block height up to T4 dermatome. At the time of skin incision, injection ketamine (50 mg) and injection midazolam (1 mg) was administered in titrating doses. CS proceeded uneventfully, and a healthy male baby was delivered with Apgar score of 8 and 9 at 1 and 5 min, respectively. A bolus dose of 0.4 mg intravenous methylergometrine was administered slowly, and a slow infusion of oxytocin 10 units was started. The surgery lasted for about 60 min, and the blood loss was 500 ml. A total of 450 ml colloid and 100 ml oxytocin-normal saline infusion was given. Post-operative analgesia was provided with epidural top-up, whenever the patient complained of pain or visual analogue score was ≥4. At 48th h of follow-up, she had maximal scores for post-operative pain relief and overall satisfaction. She was discharged on the 7th post-operative day and referred to cardiology department for further management. The mortality in patients with ASD and severe PS with right to left shunt in pregnancy is unknown,[2] as many unsuccessful cases are not reported. In our case, although the patient was having reversal of shunt, she was asymptomatic and had no signs of chronic cyanosis. This may be due to hyperdynamic circulation of pregnancy producing increased pulmonary gradients and the restrictive ASD causing inadequate mixing of blood to produce clinical cyanosis.[3] Epidural anaesthesia (EA) was planned because of its slower onset and less and delayed haemodynamic variations compared to spinal and combined spinal-epidural technique.[4] General anaesthesia (GA) poses clear risks related to pulmonary vascular resistance and magnitude of the shunt. As the patient was in labour, we had no sufficient time for further cardiac evaluation. Pulse oximeter is used to assess the degree of right to left shunt during the peri-operative period.[5] Our principle was to maintain the cardiac output and to avoid the fall in systemic vascular resistance (SVR). We optimised the SVR based on mean arterial pressure to avoid the increase in shunt magnitude. Oxytocin bolus can cause direct vasodilatation and reduce SVR with a compensatory increase in heart rate and cardiac output in pregnant women. Use of methylergometrine lowered the use of vasoconstrictors[6] and added to haemodynamic stability. Colloids provide greater haemodynamic stability by remaining in the intravascular space for longer time and avoid volume overloading; this helps to decrease the magnitude of shunt and right ventricular failure.[7] The use of lower dose of lignocaine with adrenaline, bicarbonate and tramadol provided a more rapid onset and superior quality block to touch.[8] We did not institute any thromboprophylaxis measures; EA itself can reduce risk of perioperative venous stasis and embolism. To conclude, EA can be safely and effectively used for CS in pregnant patients having pulmonary vascular disease with reversal of shunts provided the SVR is maintained throughout the surgical procedure. Major haemodynamic complications and risk of embolism during GA can be avoided if EA is properly planned and administered. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The clinical practice of sitting position with pencil point spinal needle for spinal anesthesia in emergency cesarean section

Objective To study the effects of sitting position with pencil point spinal needle in spinal anesthesia for emergency Cesarean-section.Methods Four hundred ASA physical status of Ⅰ or Ⅱ parturients undergoing emergency cesarean section were divided randomly into four groups (100 cases each).Spinal anesthesia was performed with pencil pointed needle in sitting position in group A,or with pencil pointed needle in lateral position in group B,or with ordinary inclined plane needle in sitting position in group C,or with ordinary inclined plane needle in lateral position in group D.Spinal anesthesia was induced with 1.8 ml-2.2 ml of 5％ bupivacaine (9 mg-1 1 mg) following successful puncture.The parturients were escorted to wards when analgesia block level dissipated to T10 after operation.All patients must be in supine position for six hours.Postoperation follow-up lasted for three days.The frequency of puncture,puncture time,the rate of successful puncture,the time from skin incision to delivery.Intraoperation and postoperative complications were recorded.Results Compared with group B and D,the frequency of puncture were declined significantly in group A and C[group B(3.2±0.9) and D(4.1±0.4) vs group A(1.1±0.5) and C(1.2±0.6)],the rate of successful puncture were increased [group B (90％) and group D (92％) vs group A (100％) and group C (98％)],the time of puncture were shorter [group B (5.2±0.6) min and D (4.1±0.9) min vs group A (1.2±0.8) min and C (2.1±0.7) min],the time of performed spinal anesthesia were shorter [group B (7.1±0.5) rmin and D (6.2±0.8) min vs group A (3.4±0.7) min and C (4.3±0.6)min],the time from beginning puncture to skin incision were shorter [group B (15.2±6.3) min and D (17.1±4.4) min vs group A (10.4±0.5) min and C (11.3±0.7) min] (P＜0.05).Compared with group C and D,the rate of intraoperation hypotension were reduced in group A and B [group C(18％) and group D (20％) vs group A (8％) and group B (10％],There were no postdural puncture headache and low back pain in group A and B [group C(3％) and group D(4％) vs group A(0) and group B(0)](P＜0.05).Conclusions Spinal anesthesia with fine needle in sitting position is simple to perform and needs shorter time and fewer puncture times and has higher successful rate and fewer intraoperation and postoperation complications.It can be widely used in emergency cesarean section. Key words: Sitting position; Fine needle; Anesthesia, spinal; Cesarean-section

Pituitary Apoplexy with Reversible Cerebral Vasoconstrictive Syndrome after Spinal Anaesthesia for Emergency Caesarean Section: An Uncommon Cause for Postpartum Headache

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.