Anesthesia In Obstetric Patients Research Articles

Preprocedural Ultrasound Assessment Does Not Improve Trainee Performance of Spinal Anesthesia for Obstetrical Patients: A Randomized Controlled Trial

(J Clin Anesth. 2017;37:21–24) Although spinal ultrasound can assist with identification of axial anatomical structures and intervertebral spaces, there are ergonomic challenges with needle angulation and depth. In fact, some studies with residents have suggested that there is no benefit to using ultrasound assistance for epidural placement. However, these studies were limited by small size or specificity to center. In the present study, the authors evaluated the impact of additional information provided by preprocedural ultrasound examination among trainee anesthesiologists performing spinal anesthesia in obstetric patients undergoing elective cesarean delivery in a blinded, randomized controlled trial.

Effect of Anaesthesia Method on Preoperative Anxiety Level in Elective Caesarean Section Surgeries.

In this study, the effect of the anaesthesia method on preoperative anxiety in parturients scheduled to undergo elective caesarean surgery was investigated. After Dicle University Ethics Committee approval, 100 American Society of Anesthesiologists (ASA) II parturients, aged between 18 and 45 years, were included in this study from 2011 to 2012 at the Dicle University Faculty of Medicine, Department of Anaesthesiology. The parturients were divided into two groups, with 50 patients in each group: general anaesthesia (GA) and spinal anaesthesia (SA). Patients were evaluated during the preoperative visit. Demographic data and STAI TX-1 form to measure preoperative anxiety were recorded. There were no significant differences between the two groups in maternal age, gestational age, level of education and number of children (p>0.05). The average anxiety score was significantly higher in the SA group than in the GA group (p<0.05). In conclusion, spinal anaesthesia is associated with a higher preoperative anxiety level than general anaesthesia in obstetric patients. Therefore, it is necessary to take prevention against preoperative anxiety for the patients undergoing caesarean section surgeries under spinal anaesthesia.

Prophylactic crystalloids or prophylactic crystalloids with ephedrine: Comparison of hemodynamic effects during caesarean section under spinal anaesthesia using 0.5% bupivacaine

Background: Spinal anaesthesia is usually chosen for caesarean section not only because of its faster onset and reliability but also because general anaesthesia is associated with more complications. However, hypotension is one of the most common complications of spinal anaesthesia in obstetric patients. Several measures have been devised to prevent hypotension, which include left uterine displacement, infusion of crystalloids before giving spinal anaesthesia (preloading) and administration of a prophylactic vasopressor. This study compared the hemodynamic effects of preloading crystalloids or crystalloids with ephedrine for caesarean section under spinal anaesthesia using 0.5% bupivacaine. Materials and Method: In this randomized, single blind, comparative clinical study, 80 parturients (American Society of Anesthesiologists grade 1) presenting for elective caesarean section under spinal anaesthesia were allocated to one of the two groups; group I received crystalloid preload and group II received crystalloid with ephedrine before spinal block. After institution of spinal anaesthesia in the lateral position with 2.0 ml (10 mg) of bupivacaine, 0.5% (heavy) using 25 G Quincke type spinal needle, parturients were made to assume a supine position with left lateral tilt. Heart rate, systolic blood pressure and diastolic blood pressure were monitored intraoperatively every 2 minutes till delivery and every 5 minutes after delivery. The amount of ephedrine used intraoperatively was also noted and compared among different groups. Results: Incidence of hypotension was 70% in the crystalloid group and 5% in the crystalloid with ephedrine group. This difference between the two groups was statistically significant (P < 0.001). The number of patients receiving rescue bolus of ephedrine was higher in the crystalloid group (40% before delivery and 30% after delivery) compared to crystalloid with ephedrine group (5% before delivery and none after delivery); the difference was statistically significant (P < 0.001). Sixteen patients (40%) in the crystalloid group experienced nausea compared to 6 patients (15%) in the crystalloid with ephedrine group; the difference was statistically significant with a P value of 0.012. Conclusion: This study demonstrates that prophylactic ephedrine given by infusion along with crystalloids is not only a simple and effective method for prevention of hypotension during spinal anaesthesia during elective caesarean section in ASA Grade I patients but also contributes to less incidence of intraoperative nausea and vomiting.

Neuraxial anesthesia in obstetric patients with intracranial hypertension: ten questions and answers

This review covers the actual problem - the use of neuraxial anesthesia in obstetrics in women with intracranial hypertension of various etiologies. Neuraxial anesthesia in pregnant patients with intracranial pathology is possible, but this requires an individual approach, a joint discussion of anesthesiologists, obstetricians, neonatologists and neurologists. An assessment of the likelihood of increased intracranial pressure and related potential adverse effects.

Intracranial Subdural Hematoma Following Neuraxial Anesthesia in the Obstetric Population: A Literature Review With Analysis of 56 Reported Cases

(Int J Obstet Anesth. 2016;25:58–65) Intracranial subdural hematoma is a rare but life-threatening complication of dural puncture that can occur following epidural or spinal anaesthesia. Severe neurological sequelae can be avoided, however, if early diagnosis is made and prompt treatment initiated. The objective of this study was to identify cases of intracranial subdural hematoma following neuraxial anesthesia in obstetric patients, summarize presentation and outcomes and identify risk factors.

A Systematic Review of the Effects of Adding Neostigmine to Local Anesthetics for Neuraxial Administration in Obstetric Anesthesia and Analgesia

(Int J Obstet Anesth. 2015;24:237–246) Neostigmine, an acetyl-cholinesterase inhibitor, has been used for both epidural and intrathecal anesthesia in obstetric patients. In order to quantify its benefits and/or adverse effects as an adjuvant in neuraxial anesthesia, the authors of this meta-analysis reviewed randomized, placebo-controlled studies in which neostigmine was administered in combination with local anesthetics or other adjuvants.

Persistent Paralysis After Spinal Anesthesia for Cesarean Delivery

Anterior spinal artery syndrome has rarely been reported as a cause of permanent neurologic complications after neuraxial anesthesia in obstetric patients. A parturient developed anterior spinal artery syndrome after spinal anesthesia for cesarean delivery. A healthy 32-year-old parturient presented at 41(2/7) weeks for primary elective caesarean delivery for breech presentation. Spinal anesthesia was easily performed with clear cerebrospinal fluid, and block height was T4 at 5 minutes. Intraoperative course was uneventful except for symptomatic bradycardia (37-40 beats per minute) and hypotension (88/44 mm Hg) 4 minutes postspinal anesthesia, treated with ephedrine and atropine. Dense motor block persisted 9 hours after spinal anesthesia, and magnetic resonance imaging of the lumbosacral region was normal, finding no spinal cord compression or lesion. Physical examination revealed deficits consistent with a spinal cord lesion at T6, impacting the anterior spinal cord while sparing the posterior tracts.

Efficacy of intravenous tramadol in the control of shivering following spinal anaesthesia for caesarean section.

The aim of this study was to evaluate the efficacy of intravenous tramadol in control of shivering in obstetric patients under spinal anaesthesia and to determine the minimal dose of tramadol that is effective. This was a prospective, randomised, double-blind, cross-sectional study of 144 pregnant women at term who had an indication for caesarean section. The patients were randomly allocated into three groups at the occurrence of shivering. Group T0.5 received 0.5 mg/kg of tramadol (n = 47), Group T0.25 received 0.25 mg/kg tramadol (n = 47) and Group TNS received 0.05 ml/kg of normal saline (n = 46). Statistical analysis was performed using Statistical Package for Social Sciences version 17. There were no significant differences between the groups with regard to age, weight and duration of surgery. There was a statistically significant difference in the time of cessation of shivering after the treatment for various groups (P = 0.000). A total of 80.1% responded to the treatment in Group T0.5, while for Group T0.25 and TNS, a total of 44.7% and 4.3%, respectively, responded. There were statistically significant differences in the recurrence rates of shivering among the groups (P = 0.000). Tramadol is effective in control of shivering during spinal anaesthesia in obstetric patients. Tramadol 0.5 mg/kg controlled shivering better than 0.25 mg/kg. Therefore, 0.5 mg/kg of tramadol can be used to manage shivering following caesarean section under spinal anaesthesia.

Intracranial subdural haematoma following neuraxial anaesthesia in the obstetric population: a literature review with analysis of 56 reported cases

BackgroundIntracranial subdural haematoma is a rare but serious complication of neuraxial anaesthesia. With early diagnosis and treatment, severe neurological sequelae can be avoided. A literature search of intracranial subdural haematoma following neuraxial anaesthesia in obstetric patients was performed. Based on the findings, a flow chart on how to assess postpartum headache following a neuraxial procedure is proposed. MethodsMedline, Embase and Cochrane databases were searched for cases of intracranial subdural haematoma following neuraxial anaesthesia in obstetric patients. Epidemiological factors, clinical symptoms and signs, treatment, outcome and the effect of performing an epidural blood patch were assessed. ResultsReview of the literature identified 56 cases following neuraxial procedures (epidural n=34, spinal n=20, combined spinal-epidural n=2). Predisposing risk factors were present in only a minority of patients. Persistent headache that stopped responding to postural change was the most important symptom with occurrence in 83% of patients. Focal neurological signs were present in 69% of women. Eleven percent of women were left with residual neurological deficits; the mortality rate was 7%. ConclusionIntracranial subdural haematoma following neuraxial anaesthesia in obstetric patients is rare but serious complications may result. Vigilance is required whenever a headache becomes non-postural, prolonged and/or whenever focal neurological signs occur.

Anesthetic management of a patient with gestational thrombocytopenia for elective cesarean section

Thrombocytopenia is a common manifestation in pregnancy. It is mostly dilutional when no pathological causation is evident. There are no clear-cut guidelines to determine the platelet count at which anesthesiologists can safely administer regional anesthesia in obstetric patients. A safe approach in an asymptomatic mother is outlined here.

Rare Neurological Complications after Epidural Anesthesia in Obstetric Patients: 2 Case Reports (P5.026)

Rare Neurological Complications after Epidural Anesthesia in Obstetric Patients: 2 Case Reports (P5.026)

Caesarean Delivery Complicated by Unintentional Subdural Block and Conversion Disorder

Combined spinal epidural (CSE) can provide excellent labor analgesia. Subdural block is also a potential but rare complication of attempted epidural placement during a CSE procedure, which may present as a block that is usually patchy in nature, with a component of sensory and/or motor deficit and a variable duration of action. In addition, a conversion disorder or a functional neurological disorder has been described with epidural and spinal anesthesia in obstetric patients. In this clinical report, we describe a 33-year-old G4P3 at 40 weeks gestation that received an unintentional subdural block as part of her labor analgesia and after an uneventful caesarean delivery presented with a conversion disorder. The rarity of the association between a subdural block and a conversion disorder complicated by the fact that the neurological deficit produced by the subdural block and that produced by a conversion disorder are similar in distribution made the clinical presentation and diagnosis a challenge for the obstetric anesthesia team. A functional neurological disorder of this nature complicating a subdural block in an obstetric anesthesia clinical practice has not been described so far.

Postpartum headache: diagnosis and management

Postpartum headache is described as a complaint of headache and neck or shoulder pain in the first 6 weeks after delivery. It is one of the most common symptoms with up to 39% of parturients experiencing headache in the first postpartum week. Regional anaesthesia has become the preferred choice for analgesia and anaesthesia in obstetric patients. With increasing awareness among our non-anaesthetic colleagues that post-dural puncture headache (PDPH) is a complication of regional anaesthesia, it is common for obstetric anaesthetists to be asked to review women with postpartum headache. It is very important therefore that anaesthetists are familiar with the possible differential diagnoses of postpartum headache and the management options available. In this article, we will discuss the causes of postpartum headache, their diagnosis, and management. In particular, we will focus on PDPH as this continues to be a significant cause of postpartum headache which poses particular challenges for the obstetric anaesthetist.

Anestesia subaracnoidea continua en obstetricia

Despite the theoretical advantages of continuous anesthesia in obstetric patients (good-quality blockade at low doses, good hemodynamic stability, rapid onset of effect, and no risk of toxicity), little has been published on this technique and its use in pregnancy. Moreover, few descriptive studies or comparative trials have evaluated the efficacy and safety of continuous spinal anesthesia, probably because of concerns about potential adverse effects-principally neurologic complications and postdural puncture headache. We review the literature on the use of continuous spinal anesthesia in obstetric patients, analyzing the advantages and disadvantages, indications, and adverse effects of this technique.

Epidural Tramadol, is it a Good Option for Cesarean Section?

Dear Editor, I read the article entitled “The Maternal and Neonatal Effects of Adding Tramadol to 2% Lidocaine in Epidural Anesthesia for Cesarean Section” (1). The authors demonstrated that tramadol 50 mg or 100 mg associated to lidocaine is appropriate for this surgery and also improve sensory and motor blockade effects without any increase in complications. However some important reflections and some missing data may be consider for full understanding of the article. For instance, one question came to my mind during the analysis-why haven’t the article focused on tramadol applied on spinal anesthesia? Neuraxial anesthesia is undoubtedly the most appropriate technique for elective cesarean delivery since the relative risk of mortality from general versus regional anesthesia is 16. 7 (2). General anesthesia in obstetric patients is a procedure with higher rates of serious and life-threatening complications, mainly related to airway management once the physiologic changes of pregnancy determine higher incidence of pulmonary aspiration of gastric contents and difficult airway (3,4). Until 1980, epidural anesthesia was the primary choice of neuraxial technique for cesarean delivery because spinal anesthesia was associated with a high risk of postdural puncture headache. After this period, the introduction of pencil-point spinal needles and several other advantages, the single-shot spinal anesthesia became the technique of choice for cesarean (5, 6). Besides that, tramadol intrathecal have been used with success for labor and major gynecological surgeries (7, 8). Other important comments when reflecting about the results section, I was wondering the following points could have been provided to allow fully result analysis: The mean dose of lidocaine and sufentanil request intraoperative were presented, but it was not showed the number of patients that demanded complementation analgesia and when; Around 30% of patients present some complications but they did not mention what kind of complications and these numbers is relatively bigger than other found on literature (9) and They also comment that general anesthesia is an option when maternal apnea lasts longer than 20 seconds or enable to speech or if the mother lost consciousness or did not respond to stimuli but they did not comment if some patients need it, considering the risks of general anesthesia, it is an important date. Finally, the article core idea is very interesting, since epidural tramadol has comparable analgesic efficacy with lower side effects than epidural morphine, specifically concerning about respiratory depression (10). Although, this article still demands further improvements.

The relationship of abdominal circumference and trunk length with the level of spinal anesthesia in obstetric patients

The relationship of abdominal circumference and trunk length with the level of spinal anesthesia in obstetric patients

Length of spinal needles

Our hospital has recently moved to using Braun spinal packs (‘Norfolk and Norwich Spinal Pack’, B. Braun, Sheffield, UK) due to supply problems with the previous packs. These new packs contain Braun’s 25-G Pencan spinal needle and introducer. There have been several occasions when performing spinal anaesthesia in obstetric patients when the needle has not been long enough to reach the dura. This has occurred even when the patient was not grossly obese and seemingly more often than with the equivalent Pajunk Sprotte needles (Pajunk UK Ltd, Newcastle Upon Tyne, UK) we were using previously. Closer inspection of the Braun Pencan needle and introducer reveals that the hub of the spinal needle does not actually fit into the hub of the introducer needle. This, coupled with the fact that the introducer is comparatively large, shortens the effective length of the needle from the stated 88–66 mm. The 25-G 90 mm Pajunk Sprotte needle is reduced to 78 mm when using the introducer (Fig. 4). Pajunk 25-G 90 mm Sprotte spinal needle with introducer (top) and Braun 25-G 88 mm Pencan needle with introducer (bottom). The introducer needle helps to reduce deflection of the spinal needle [1] and so is particularly useful in obese patients. When at maximum depth and indenting the skin, normally only the introducer needle needs to be steadied when the needle hubs fit within each other. With the Pencan, both the introducer and the needle have to be steadied which is more awkward and may increase the chance of the needle moving and an inadequate block occurring. When faced with an overweight patient who needs an urgent Caesarean section I automatically use a ‘longer’ Pajunk Sprotte needle and not the Pencan. This has obvious cost implications. With the incidence of obesity in pregnant women [2] and the general population increasing this is a problem that will not be solved unless Braun changes their introducer needles or we change our packs again.

Horner syndrome after unintended subdural block. A report of 2 cases

Horner syndrome is considered a common finding after epidural analgesia or anesthesia in obstetric patients. Conversely, Horner syndrome is very uncommon in nonobstetric patients. We report 2 cases of Horner syndrome after attempted epidural lumbar anesthesia in 2 patients undergoing peripheral vascular surgery. Spinal fluoroscopy with contrast medium showed subdural catheterization in both cases. Horner syndrome after lumbar epidural anesthesia can be an indicator of inadvertent subdural catheter placement.

Control of Shivering Under Regional Anesthesia in Obstetric Patients With Tramadol

Tramadol in a dose of 1 mg·kg−1 iv is effective in the treatment of shivering after general anesthesia. The current study aimed to investigate (I) whether tramadol was equally effective for shivering under regional anesthesia in obstetric patients and (2) whether effective treatment could be achieved with lower doses. In a randomised, double-blind study, 36 obstetric patients who shivered during Cesarean section under regional anesthesia and who requested anti-shivering treatment were allocated to one of three groups foriv treatment: Group T0.5 received tramadol 0.5 mg·kg−1 (n= 12), Group T0.25 tramadol 0.25 mg·kg−1 (n= 13) and Group NS normal saline 0.05 ml·kg−1 (n= 11). Treatment efficacy was evaluated subjectively by the parturient as no improvement, slight improvement, or marked improvement. The attending anesthesiologist who was blinded also independently noted the time elapsed from treatment to the time shivering subsided. Side effects such as nausea, vomiting or sedation and Apgar scores of the newborn were also noted. Eighty percent of parturients in Group T0.5 and 92% in Group T0.25 were judged by observers to have shivering controlled compared with 27% in Group NS (P < 0.001). The response rates of Group T0.5 and Group T0.25 were not different. There was no increased incidence of side effects in the treatment groups. We conclude that tramadoliv was effective in the treatment of intraoperative shivering during regional anesthesia for Cesarean section. There was no demonstrable difference in response rate or incidence of side effects between the two doses of 0.5 mg·kg−1 and 0.25 mg·kg−1.

The incidence of transient radicular irritation after spinal anesthesia in obstetric patients

Background and Objectives. Transient radicular irritation (TRI) has been described after spinal anesthesia, particularly with 5% hyperbaric spinal lidocaine. The purpose of this study was to determine the incidence of TRI in obstetric patients. Methods. All obstetric patients undergoing spinal anesthesia during a 9-month period were enrolled in the study (n = 303). Details of the anesthetic technique were recorded at the time of anesthesia. A blinded anesthesia nurse contacted each patient on post-operative day 2 and asked about symptoms of TRI. Results. Most patients received either intrathecal hyperbaric bupivacaine 0.75% (n = 232) or lidocaine 5% (n = 67) through pencil-point needles. Cerebrospinal fluid was used to dilute the spinal lidocaine in 63% of patients. Patients receiving bupivacaine were more often in the supine position, underwent significantly longer procedures, and more often received intrathecal opioid. The incidence of TRI after lidocaine spinal anesthesia was 0% (95% confidence interval 0–4.5%). Conclusions. The incidence of TRI after spinal lidocaine anesthesia in the obstetric population is low.