Combined Epidural Anesthesia Research Articles

Enhanced Recovery after lumbar laminectomy using combined epidural and general anesthesia with tolerable endotracheal tube: Randomized controlled study.

Enhanced Recovery after lumbar laminectomy using combined epidural and general anesthesia with tolerable endotracheal tube: Randomized controlled study.

Analgesic Efficacy of Suprainguinal Fascia Iliaca Compartment Block (SFICB) vs Combined Pericapsular Nerve Group (PENG) Block with Lateral Femoral Cutaneous Nerve Block (LFCN) in Hip Surgery

Background: Pain management for hip fracture is challenging due to complex anatomical variations and patient positioning during surgery. Though various modalities of regional techniques are being used for pain management, none of them has proven superiority. Recently fascia iliaca compartment block and pericapsular nerve group block have drawn lots of attention due to simplicity and superior pain control. In this study suprainguinal fascia iliaca compartment block (SFICB) was compared with pericapsular nerve group (PENG) block in combination with lateral femoral cutaneous nerve (LFCN) block to evaluate the analgesic efficacy and utility in fracture neck femur patients.Methods: This prospective study was conducted from January 2022 to December 2022. Total 40 patients were allocated in two groups, suprainguinal fascia iliaca compartment block (Gr-F) or PENG with LFCN block (Gr-P) group. 30 minutes after performing the block, pain was assessed with NPRS scale during positioning for combined epidural anaesthesia. Then pain assessment was done 2 hour for first 12 hours followed by 4 hour in following 12 hours. Haemodynamic profile, duration of analgesia and requirement of rescue analgesics were recorded.Results: During positioning of the patient for central neuraxial block, NPRS was (2.5 ± 0.3) for Gr-P and (4.5 ± 0.6) for Gr-F with p = 0.039. For Gr-F, 20% patient required Dexmedetomidine infusion during positioning. The onset of analgesia in Gr-P was (10.56 ± 3.46) minutes and in Gr-F was (15.86 ± 3.3) minutes with p < 0.05. Duration of analgesia during active movement was 14.6 (±1.09) hours for Gr-P and 10.2 (±2.06) hours for Gr-F with p value < 0.05.Conclusion: Combination of PENG with LFCN block provides a superior analgesia characterised by early onset action, less pain score at rest and on movement during positioning of the patient and prolong duration of action on active movement postoperatively.

Impact of General Anaesthesia Versus Combined Epidural and General Anesthesia on Postoperative Complications and Mortality in Elective Abdominal Aortic Aneurysm Surgeries

Objective: To determine the impact of general anaesthesia versus combined epidural and general anaesthesia on postoperative complications in elective abdominal aortic aneurysm surgeries.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Jun 2018 to Sep 2020.
 Methodology: A total of 100 patients from both genders undergoing elective open abdominal aortic aneurysm surgery under general anaesthesia enrolled in the study after random distribution to drug and control groups in equal proportions. The primary determinants were postoperative complications. Additionally, it determined the impact on postoperative mortality rate. 
 Results: Of 100 participants, 54% of patients were from ASA status II, and 46% were from ASA status III. Among postoperative complications, bowel ischemia was recorded in 16% and 2% among Group-A and Group-B, respectively (pvalue 0.01). Postoperative dialysis was required in 18% of patients in Group-A, whereas among Group-B, only 4%went through it (p-value 0.02). Pulmonary complications variation was not statistically different between the two groups, with 54% and 46% (p-value 0.42) frequencies in Group-A and Group-B, respectively. However, surgical reintervention within 30 days was notable, 36% in Group-A and 14% in Group-B (p-value 0.01).
 Conclusion: Combined general and epidural anaesthesia, when compared with general anaesthesia alone, significantly impacts the reduction of postoperative complications after elective open abdominal aortic aneurysm surgeries without increasing morbidity and mortality.

The Benefit and Risk of Combined Epidural and General Anesthesia for Laparoscopic Surgery

Introduction: Laparoscopic surgery, also known as minimally invasive surgery, is a modern surgical technique that allows surgeons to perform operations using small incisions instead of the larger incisions required for open surgery. Combined epidural and general anesthesia for laparoscopic surgery is an anesthesia technique that merges the benefits of both general and epidural anesthesia to achieve improved patient outcomes. Aim of the Study: The aim of this study was to assess the benefit and risk of combined epidural and general anesthesia for laparoscopic surgery. Methods: This cross-sectional study was conducted in Department of Anesthesiology, Holy Family Red Crescent Medical College and Hospital, Dhaka, Bangladesh, during the period from January 2021 to January 2023. Total 300 patients undergoing laparoscopic surgery were in this study. All the patients were divided into two groups: Group A consist of 150 patients operated with only general anesthesia and Group B consist of 150 patients operated with combined epidural and general anesthesia. Result: In this study, no demographic characteristics were statistically significant (P>0.05). The operation time was significantly (p≤ 0.05) higher in group B compared to group A. The duration of anesthesia was also significantly (p≤ 0.05) higher in group B compared to group A. For systolic arterial pressure, no significant differences were found between the two groups at any time point. Similarly, for heart rate, only the difference after anesthesia was significant, with a p-value of 0.0457. For diastolic arterial pressure, the only significant difference was found after anesthesia, with a p-value of <0.0001. Group A had a mean VAS score of 2.8 (SD±1.5), while Group B had a mean VAS score of 1.5 (SD±1.4). The pain score was statistically (p<0.0001) lower in group B. Group A had a mean recovery time of 21.5 minutes with a SD of 8.2, and Group B had a mean recovery time of 15.5 minutes with a SD of 6.8. The recovery ......

Abstract No. : ABS0646: Efficacy of combined epidural general anaesthesia in laparoscopic cholecystectomies - a prospective randomised study

Background &Aims:Pnuemoperitonium in laparoscopy is associated with cardiorespiratory changes. Combination of epidural with general anaesthesia might offer benefits of haemodynamic control and peri-operative analgesia. We aimed to study the efficacy of combinedepidural-general anaesthesia(CEGA) over general anaesthesia in laparoscopic cholecystectomies.Methods:A prospective, randomised, double blind study was conducted on 90 surgical in-patients after obtaining ethical and informed consent from the institution and participants respectively.In Group GE-(n=45), Lumbar epidural analgesia with ropivacaine with GA ;In Group G, only GA was administered. Propofol ,vecuronium, fentanyl, paracetamol, isofluranewereused in both the groups. Along with minimum mandatory monitoringfor study purpose, heart rate(HR), mean arterial Pressure(MAP), end-tidal carbon-dioxide (ETCO2), peripheral oxygen saturation ( SpO2) ,visualanaloguescale score, Ramsay sedation score , requirement of propofol, muscle relaxants and analgesics were studied with recovery and pain in 12 hours post operatively.Statistical analysis was carried out with SPSS version 20. Student’s t test, Chi-square test were used for comparison.Results:Statistical value of p<0.05 was considered significant. We noted significantly lesser readingsin group GE than inGroup G i.e (p<0.001) in MAP, SBP, DBP muscle relaxants, propofol and Fentanyl (p<0.001) . Early recovery and lesser pain scores were noted in group GE than Group G.Conclusion:CEGAtechnique has the benefit of better control of haemodynamics .It reduces requirements of analgesics and anaesthetic drugs and has faster recovery with less post-operative pain in laparoscopic cholecystectomies.

Prophylactic Phenylephrine Increases the Dose Requirement of Oxytocin to Treat Uterine Atony During Cesarean Delivery: A Double-Blinded, Single-Center, Randomized and Placebo-Controlled Trial.

Purpose: Studies involving mouse models and human uterine smooth muscle cells have shown that phenylephrine inhibits uterine contractions in non-pregnant mice and human in vitro cell via cyclic adenosine monophosphate (cAMP) signaling. However, there has been no limited exploration to date of the effect of phenylephrine on uterine contractions in clinical practice. This study aimed to compare the dose requirement of oxytocin with or without the infusion of prophylactic phenylephrine to prevent post spinal hypotension during cesarean delivery under combined spinal and epidural anesthesia. Methods: This was a double-blinded, single-center, randomized, control study. One hundred and sixty pregnant patients provided informed consent and were randomly allocated to the phenylephrine (phenylephrine infusion) and control (saline infusion) groups. Patients randomized to the phenylephrine group received an intravenous prophylactic phenylephrine infusion at a fixed rate of 0.5 μg/kg/min. The control group received a saline placebo at the same rate and used the same apparatus for delivery. After neonatal delivery and clamping of the umbilical cord, patients received a standard institutional oxytocin protocol. The primary outcome measure was the total dose of oxytocin administered during CD. Secondary outcomes including the proportion (%) of patients requiring a secondary uterotonic agent and estimated blood loss (EBL) in the first 24 h after surgery. Results: The median oxytocin dose administered was significantly higher in the phenylephrine group than in the control group [6.9 ± 2.5 international standardized units (IU) vs. 5.4 ± 2.4 IU, p = 0.0004]. The number of patients that required a secondary uterotonic agent was significantly higher in the phenylephrine group than in the control group (24.2% vs. 9.1%; p = 0.034). The EBL in the first 24-h postoperatively was similar between the two groups (467 ± 47 ml vs. 392 ± 38 ml; p = 0.22). Conclusions: Prophylactic infusion of phenylephrine used to prevent post-spinal hypotension during CD was associated with a higher dose of oxytocin. This has important clinical implications, as the suboptimal use of oxytocin is associated with an increased risk of postpartum hemorrhage and increased maternal morbidity and mortality. Further studies are now needed to confirm these findings.

A case of spinal nerve neurotoxicity with ropivacaine after combined spinal and epidural anesthesia

BackgroundNeurotoxicity caused by a local anesthetic after regional anesthesia is a rare but serious problem for anesthesiologists. It is difficult to diagnose neurotoxicity from anesthetics because of the large number of possible diagnoses. In this case report, careful monitoring by neurological examinations helped to diagnose local neurotoxicity caused after epidural anesthesia.Case descriptionA 41-year-old pregnant woman who underwent emergency cesarean delivery under combined spinal-epidural anesthesia suffered left leg paralysis after surgery. Multiple neurological examinations (e.g., electromyography, nerve conduction study) revealed that the paralysis was induced by the neurotoxicity of ropivacaine. The neurological examinations were also useful to monitor the recovery process.ConclusionsThis is the first clinical case report that describes the diagnosis of and recovery from local anesthesia-induced neurotoxicity monitored by electromyography and nerve conduction study. Neurological disorders caused by regional anesthetics should be carefully examined and diagnosed using these neurological examinations.

Effects of Combined Epidural Anesthesia and General Anesthesia on Cognitive Function and Stress Responses of Elderly Patients Undergoing Liver Cancer Surgery.

This study aimed at exploring the effects of combined epidural anesthesia and general anesthesia on the cognitive function and stress responses of elderly patients undergoing liver cancer surgery. One hundred and fifteen elderly patients were enrolled as research subjects. They were admitted to our hospital and underwent liver cancer surgery from August 2017 to May 2019. Fifty five cases were treated with general anesthesia (GA) (GA group), while the other sixty cases were treated with combined epidural anesthesia and general anesthesia (joint group). Scoring standards of Mini-Mental State Examination (MMSE) were used to evaluate the patients before and after operation. Their operating time, total fluid input (TFI), spontaneous breathing recovery time (SBRT), preoperative and postoperative indices of stress responses (epinephrine (EPI), cortisol (Cor), and norepinephrine (NE)), and postoperative adverse reactions were observed. There were statistically significant differences between the two groups with respect to anesthesia time, TFI, postoperative SBRT, and postoperative directional recovery time (DRT) (cP < 0.05). There was no difference in operating time, total fluid loss (TFL), and hospitalization time (P > 0.05). After operation, patients in both groups experienced a cognitive decline of different degrees and the MMSE scores decreased. There was no significant difference in the score between the two groups before operation and 3 days and 7 days after operation (P > 0.05). The score was significantly better in the joint group than that in the GA group at 6 hours and 1 day after operation (P < 0.05). There were no significant differences in levels of EPI, Cor, and NE between the two groups before operation (P > 0.05), but there were significant differences after operation. The total incidence of postoperative adverse reactions was 11.67% in the joint group and 25.45% in the GA group. In conclusion, combined epidural anesthesia and general anesthesia can significantly reduce postoperative cognitive dysfunction and inhibit postoperative stress responses in elderly patients undergoing liver cancer surgery. It has good application value in clinical practice.

Epidural space "ballooning" during local anaesthetic injection in infants and children: An ultrasound observational study.

Infants and children require a larger dose of a local anaesthetic (LA) to establish epidural analgesia than adults, but the reason for this remains unclear. We hypothesised that prominent ventro-dorsal expansion of the epidural space limits cranio-caudal spread of LA in infants. Accordingly, we studied the dimensions of the epidural space with real-time ultrasound (US) before and after epidural injection. Ninety-six infants and children aged 0-12years who underwent abdominal surgery under combined epidural and general anaesthesia were examined in this prospective observational study. Using a micro-convex probe, US recordings of the posterior epidural space were performed while a LA (0.5mlkg-1 ) was infused at 0.54mls-1 . The width in the ventro-dorsal dimension (VDD) of the posterior epidural space before and after injection was recorded; the change in VDD was defined as "ballooning". Correlations between "ballooning" and patient age, body mass index, and volume and rate of LA administration were analysed. "Ballooning" correlated positively but weakly with age (R2 =0.25; p<.001) and the infused LA volume (R2 =0.32; p<.001). The "magnitude of ballooning" ("ballooning" per ml of injected LA) correlated negatively but weakly with age (R2 =0.27; p<.001). "Magnitude of ballooning" of the epidural space become inconspicuous with growing during epidural injection. This effect may slow the cranio-caudal spread of LA and explain partially why larger volumes of LA are required to effect a block in children.

Combined Spinal Epidural Anaesthesia Technique with Ketamine Infusion for Emergency Laparotomy of a Known COVID-19 Case at High Altitude of 12000 Feet Above Mean Sea Level

SARS-CoV-2 is a highly infectious virus known to cause severe acute respiratory syndrome in humans known as COVID-19. It is well established that the mode of transmission is through aerosol generation. Since the invasive procedures like endotracheal intubation place the anaesthesiologist and the operating room staff highly exposed to the risk of infection it is prudent to follow regional anaesthesia technique wherever possible. The present case is of a 34-year-old COVID 19 positive male patient who underwent emergency laparotomy in a service hospital of armed forces at 12000 feet above sea level under combined spinal and epidural anaesthesia supplemented with sedation using intravenous infusion of Ketamine. After the attachment of standard ASA monitor and taking in account of baseline readings patient was administered an 18-gauge epidural secured in the T12-L1 level with the catheter was fix at 12 cm on the skin. Sub arachnoid block was administered to the patient using 2.75 ml of 0.5 % Bupivacaine (heavy) and 25 mcg of Fentanyl in L2-L3 space using a 26-gauge spinal needle in sitting position. Once the height of the block was ascertained at T6 level by loss of temperature sensation the surgery commenced. Patient was administered with 3.0 mg of Morphine in epidural space for perioperative analgesia. For allaying intraoperative discomfort patient was sedation infusion of Ketamine of 0.6mg/kg/hr to keep the Ramsay sedation score between 3-4. The intraoperative period was uneventful, and the patient did not require any supplemental analgesia during the surgery. Post operatively the patient was pain free and comfortable with no features of hypopnea, post-operative nausea vomiting and shivering and was shifted to the post-operative care unit in the covid facility of the hospital.

A Randomized Comparative Trial to Study the effect of Preoperative single shot Epidural with Ropivacaine in Lumbar Laminectomy

Background: laminectomy surgeries are usually performed in cases of spinal canal stenosis, disc prolapse etc. It has been reported that the use of regional anesthesia techniques in combination to general anaesthesia has shown better heamodynamic stability intraoperatively, better pain scores and reduced intraoperative blood loss. The present study was conducted to evaluate the efficacy of fusion technique of combining epidural and general anaesthesia in patients undergoing lumbar laminectomies. Aim: To evaluate the efficacy of combined epidural general anesthesia for lumbar laminectomy surgeries with epidural ropivacaine. Materials and Methods: A prospective randomised study was conducted in 100 patients who are scheduled for lumbar laminectomy surgeries belonging to ASA Class I and II age between 40-60 years were randomly allocated into two groups (Group E and Group F) of 50 each. Group E: 12ml of 0.5% Ropivacaine and 50µg fentanyl epidurally. Group F:12ml of Normal Saline and 50µg fentanyl epidurally. The parameters recorded were intraoperative analgesia by heart rate and blood pressure, Rescue analgesia, Blood loss. Results: Intraoperatively requirement of general anesthetics, Heart rate, MBP, Blood loss, is lesser in Group E when compared with Group F. It was observed that longer time to rescue analgesia in group E than in group F. Conclusion: combined epidural general anesthesia with local anesthetic (ropivacaine) with narcotic (fentanyl) is a better technique for anesthetic management of patients posted for lumbar laminectomy. Thus from our study we conclude that combined epidural general anesthesia technique with epidural ropivacaine is a better alternative to general anesthesia providing stable hemodynamics, reducing dose of general anesthetics, less blood loss.

Dehydroepiandrosterone (DHEA) Serum Levels Indicate Cerebrospinal Fluid Levels of DHEA and Estradiol (E2) in Women at Term Pregnancy

Neuroactive steroids such as dehydroepiandrosterone (DHEA), estradiol (E2), and progesterone (P4) are associated with structural and functional changes in the central nervous system (CNS). Measurement of steroid levels in the CNS compartments is restricted in accessibility. Consequently, there is only limited human data on the distributional equilibrium for steroid levels between peripheral and central compartments. While some neuroactive steroids including DHEA and E2 have been reported to convey excitatory and proconvulsant properties, the opposite was demonstrated for P4. We aimed to elucidate the correlation between peripheral and central DHEA, E2, and P4 levels in women at term pregnancy. CSF and serum samples of 27 healthy pregnant women (22–39 years) at term pregnancy were collected simultaneously under combined spinal and epidural anesthesia and used for DHEA ELISA and E2, and P4 ECLIA. All three neuroactive steroids were detected at markedly lower levels in CSF compared to their corresponding serum concentrations (decrease, mean ± SD, 97.66 ± 0.83%). We found a strong correlation for DHEA between its serum and the corresponding CSF levels (r = 0.65, p = 0.003). Serum and CSF levels of E2 (r = 0.31, p = 0.12) appeared not to correlate in the investigated cohort. DHEA serum concentration correlated significantly with E2 (r = 0.58, p = 0.0016) in CSF. In addition, a strong correlation was found between DHEA and E2, both measured in CSF (r = 0.65, p = 0.0002). Peripheral DHEA levels might serve as an indicator for central nervous levels of the neuroactive steroids DHEA and E2 in pregnant women.

Anesthetic management for mastectomy and total hysterectomy in a 49-year-old woman with type 1 sialidosis: a case report

BackgroundSialidosis is an autosomal recessive glycoprotein storage disorder, caused by neuraminidase deficiency which leads to abnormal intracellular accumulation and urinary excretion of sialylated oligosaccharides, resulting in various morphological and functional disorders. Only a few reports have described the anesthetic managements of patients with sialidosis.Case presentationA 49-year-old woman with type 1 sialidosis suffered from all limb contractures, an ocular cherry-red spot, and myoclonic seizures of the limbs. She had been cognitively normal. She was separately scheduled for mastectomy under total intravenous anesthesia and total hysterectomy under combined general and epidural anesthesia uneventfully.ConclusionsOur patient with type 1 sialidosis received both general and epidural anesthesia uneventfully. Anesthesiologists should carefully assess patients with sialidosis and give careful consideration to individually tailored anesthetic managements.

The Impact of Total Intravenous Propofol Anaesthesia versus Sevoflurane Anaesthesia on Perioperative Pain in Patients Undergoing Colonic Cancer Surgery

Background: Cancer colon is one of the most common malignancies. After colon cancer surgery patients may experience severe pain. Several studies have reported that a significant decrease in postoperative pain with propofol while other studies have showed this effect was not significant. Aim: Our goal was to assess the effect of combined epidural anaesthesia either with propofol or sevoflurane on intraoperative fentanyl consumption and postoperative pain in patients undergoing open surgical resection of colon cancer. Patients and Methods: 48 adult patients suffering from cancer colon scheduled for open surgical resection randomly allocated either to receive epidural-propofol by total intra venous anaesthesia (TIVA) (n = 24) or epidural-sevoflurane anaesthesia (n = 24), intraoperative heart rate and fentanyl consumption and postoperative pain score (verbal analogue scale, 0 - 10) were recorded. Results: In our study we found that the intensity of postoperative pain was low in all patients and the propofol based anaesthesia had relatively lower pain scores up to 24 hrs postoperatively in comparison to sevoflurane based anaesthesia, intraoperative fentanyl consumption was lower with sevoflurane and heart rate lower with propofol group. Conclusions: we recommend that use of multimodal analgesia decrease postoperative pain in all cancer colon patients undergoing open surgery who anaesthetized with either propofol or sevoflurane. Also use of propofol showed better analgesic outcomes postoperatively.

Role of Dexmedetomidine in anesthetic management of lower limb orthopaedic surgery in a patient with low ejection fraction

Cardiac patient for non cardiac surgery has since forever been a topic of interest for the anaesthesiologist. Few cases have only been reported with their own suitable line of management, however the simultaneous use of combined epidural spinal anaesthesia and Dexmedetomidine, an ?2 agonist has been studied by only a handful. Use of epidural for incremental doses of local anaesthetic for allaying the postoperative pain and thereby reducing the occurrence of ischemic events is also being described. Keywords: Ischaemic Heart Disease, Epidural Anaesthesia, Ejection Fraction, Dexmedetomidine.

Myocardial function after off-pump coronary artery bypass grafting with combined epidural and inhalation anesthesia

There are certain debates regarding epidural anesthesia (EA) and analgesia in cardiac surgery.The objective: to evaluate functions of left ventricle (LV) and right ventricle (RV) function with echocardiography after off-pump coronary artery bypass grafting (OPCAB) using combined inhalation and epidural anesthesia.Subjects and methods: 68 patients were randomized into 2 groups, differed by anesthesia techniques. In Group 1 (GA, n = 34), we used general anesthesia with sevoflurane and fentanyl, while in Group 2 (CA, n = 34) – its combination with epidural anesthesia by 0.5% ropivacaine followed by infusion of 0.2% ropivacaine after OPCAB. Parameters of cardiac performance and ventricular function were assessed by echocardiography.Results. There were no differences in systolic function of LV, RV, diastolic function of LV between the groups. The difference in the left atrial strain was revealed before hospital discharge and made 18.0 (14.5‒21.5) % in CA Group and 24.0 (18.0–26.0)% in GA Group (p = 0.028).Conclusions. The use of epidural anesthesia and analgesia is not associated with clinically significant changes in inotropic and lusitropic functions of LV as well as RV systolic function after OPCAB.

Peri-operative oxygen consumption revisited: An observational study in elderly patients undergoing major abdominal surgery.

Monitoring oxygen consumption (VO2) is neither recommended nor included in peri-operative haemodynamic algorithms aiming at optimising oxygen delivery (DO2) in major abdominal surgery. Estimates of peri-operative VO2 changes are uncertain in earlier publications and have limited generalisability in the current high-risk surgical population. In a prospective non-interventional observational study in elderly patients undergoing major abdominal procedures, we investigated the change of VO2 after induction of anaesthesia and secondarily, the further changes during and after surgery in relation to DO2 and estimated oxygen extraction ratio (O2ER) by routine monitoring. VO2 was determined by indirect calorimetry (QuarkRMR) in 20 patients more than 65 years (ASA II to IV), scheduled for elective open upper abdominal surgery with combined epidural and general anaesthesia. Data were collected during 20-minute periods pre-operatively and after anaesthesia induction, with subsequent measurements during surgery and postoperatively. Simultaneously, DO2 was monitored using LiDCOplus. The O2ER was estimated from arterial-central venous oxygen content calculation. Mixed models were used to analyse the peri-operative changes. VO2 decreased after induction of anaesthesia by a mean of 34% (95% CI, 28 to 39). After 2 h of surgery, VO2 was reduced by 24% (95% CI, 20 to 27) compared with the awake baseline measurements. Pre-operative mean DO2 was 440 (95% CI, 396 to 483) ml min m and decreased by a mean of 37% (95% CI, 30 to 43) during anaesthesia. The estimated O2ER did not change intra-operatively 0.24 (95% CI, 0.21 to 0.26) but increased postoperatively to 0.31 (95% CI, 0.27 to 0.36). The changes of VO2 were parallel with changes of DO2 and O2ER in the intra-operative period. General anaesthesia reduced VO2 by approximately a third in elderly patients undergoing major abdominal surgery. Parallel changes of intra-operative VO2 and delivery were demonstrated while oxygen extraction was low. The relevance of these changes needs further assessment in relation to outcomes and haemodynamic interventions. Clinicaltrials.gov NCT03355118.

Extending epidural analgesia for intrapartum cesarean section following epidural labor analgesia: a retrospective cohort study

Objective To determine the effectiveness of extending epidural analgesia following epidural labor analgesia for intrapartum cesarean section, and provide a reference for clinical practice. Methods Data of 1254 singleton parturient who failed trial of epidural labor analgesia and underwent intrapartum cesarean section were retrospectively included. After entering the operating room, parturient were given 3 ml of 1.5% lidocaine with 1:200,000 epinephrine 15 µg as a test dose, followed by a dose of 10 ml 0.75% ropivacaine plus 5 ml of 2% lidocaine mixed solution was administered via the epidural catheter. Case data were reviewed and analyzed of cesarean section anesthesia implementation methods, results and maternal and neonatal outcomes. Results Of the 1254 parturient, 4.7% (59 of 1254) underwent general anesthesia directly, 7.1% (89 of 1254) were given combined spinal and epidural anesthesia, and the other 88.2% (1106 of 1254) underwent extending epidural anesthesia, 3.5% (39 of 1106) of them were given general anesthesia after extending epidural anesthesia failed, and 96.5% (1067 of 1106) parturient have a successful extending epidural anesthesia. Adverse reactions of extending epidural anesthesia: 6.7% (72 of 1067) parturient experienced hypotension and 12.1% (129 of 1067) of nausea and vomiting occurred. For the neonatal Apgar scores at 1 min, eleven of 1254 (0.9%) newborns were between 0 and 3 points, 107 (8.5%) newborns between 4 and 7 points, and 1136 (90.6%) newborns Apgar scores between 8 and 10 point. 24 (1.9%) newborns with Apgar scores between 4 to 7 points at 5 min transferred to the department of neonatology, and the rest 1230 (98.1%) newborns with Apgar scores 8–10 points. Conclusion Extending epidural analgesia using the well-functioning epidural catheter for epidural labor analgesia might be a reliable and effective anesthetic method for intrapartum cesarean section.

Influence of combined epidural anesthesia on cognitive function, inflammation and stress response in elderly liver cancer patients undergoing surgery.

Effects of combined epidural anesthesia on the cognitive function, inflammation and stress response in the elderly liver cancer patients undergoing surgery were explored. Elderly liver cancer patients (n=100) undergoing surgery in the Second Affiliated Hospital of Dalian Medical University from January 2015 to December 2018 were enrolled and randomly divided into observation group (n=50) and control group (n=50). In control group only conventional anesthesia was performed using 2 µg/kg fentanyl, 1.5 mg/kg propofol and 0.2 mg/kg atracurium, in addition to the procedures in the control group, combined epidural anesthesia was administered using 0.5% bupivacaine for 15 sec and maintained via 0.25% bupivacaine in the observation group. The anesthetic effect was observed and the arterial oxygen saturation (SaO2), heart rate (HR), mean arterial pressure (MAP) and mini-mental state examination (MMSE) and cognitive function scores by cognitive abilities screening instrument (CASI) were evaluated in the patients, and their blood was drawn to detect the inflammatory factors interleukin (IL)-6, IL-1 and tumor necrosis factor-α (TNF-α), superoxide dismutase (SOD), malondialdehyde (MDA), catalase (CAT), norepinephrine and epinephrine. The observation group exhibited a better anesthetic effect and obviously smaller decreases in the SaO2 and MAP and increase in HR than the control group (P<0.05). The MMSE and CASI scores, and the content of IL-1, IL-6, TNF-α, MDA, CAT, norepinephrine and epinephrine in the observation group was obviously lower than that in the control group (P<0.05), while the content of SOD was evidently higher than that in the control group (P<0.05). Overall postoperative conditions in the observation group was superior to the control group (P<0.05), with the incidence rate of cognitive disorder lower than that in the control group (P<0.05). Combined epidural anesthesia dramatically improves the postoperative conditions and cognitive function and relieve inflammatory and stress responses in the patients with a better anesthetic effect, thus holding promise for application.

Mepivacaine-induced anaphylactic shock in a pregnant woman undergoing combined spinal and epidural anesthesia for cesarean delivery: a case report

BackgroundAnaphylactic shock during pregnancy is a rare but life-threatening event for both the mother and the newborn.Case presentationA 42-year-old woman, who was pregnant with twins, was scheduled for cesarean delivery under combined spinal and epidural anesthesia. An epidural catheter was placed uneventfully. After spinal anesthesia, the patient exhibited skin symptoms and severe hypotension. The patient was diagnosed with anaphylaxis, and subsequently, treatment was started. Fetal heart rate monitoring revealed sustained bradycardia, and it was decided to proceed with cesarean delivery. After delivery, the mother’s vital signs recovered. Both infants were intubated due to birth asphyxia. Currently, the twins are 4 years old and exhibit no developmental problems. Clinical examination identified mepivacaine as the causative agent of anaphylaxis.ConclusionsThis case report highlights that upon occurrence of anaphylaxis during pregnancy, maternal treatment and fetal assessment should be started immediately. Indication for immediate cesarean delivery should be considered and a definite identification of the causative factor pursued.