Combined Spinal-epidural Research Articles

Comparison of conventional and robotic knee arthroplasty results: A retrospective observational study.

This study aimed to determine whether a standard anesthetic protocol consisting of combined spinal epidural anesthesia (CSEA) in conjunction with controlled hypotensive anesthesia (CHA), which was used for conventional total knee arthroplasty (cTKA), could provide equally effective anesthetic conditions for robotic total knee arthroplasty (rTKA). Data were collected from the medical records of 113 patients (median age=67 years; age range=55-84) who underwent elective unilateral cTKA (n=52) or rTKA (n=61) without a tourniquet from 2021 to 2023. The primary outcome measure was the rate of patients whose anesthetic method did not provide adequate motor and sensory block during the surgery and had to be converted to general anesthesia. The secondary outcome measure was to compare perioperative variables, including pain scores, analgesic consumption, blood loss, transfusions, and complications. In 6 patients (11.5%) in group rTKA, it was required to convert CSEA to general anesthesia at 160-180 minutes due to the pain at the operative knee and/or to the movement of the operative leg during surgery compared to none / zero in group cTKA (P=.008). Motor and sensory blocks terminated earlier than the total surgery time in those patients. Mean total surgery time was significantly higher in group rTKA than in group cTKA (151.25 ± 24.51 (120-240) minutes vs. 116.72 ± 4.99 (105-125) minutes, P < .001). Total surgery times tended to decrease gradually in group rTKA after the 11th case, indicating a learning curve for surgical performance. Conversion to general anesthesia was required only in 1 patient after the 11th case compared to the previous 5 patients. Mean pain scores and rescue analgesic consumption were higher in group rTKA at postoperative 0 hour and between 0 and 4 hours (P < .05) but similar at the following time points (P > .05). Blood loss, transfusion, and complication rates were similar (P > .05). Hospital discharge times were higher in group rTKA (P < .05). Although our standard CSEA protocol failed due to the regression of motor and sensory block during surgery in 11.5% of patients in rTKA, the CSEA technique combined with controlled hypotensive anesthesia provided similar anesthetic conditions in the remaining patients in group rTKA as in group cTKA. The CSEA may be considered an effective and safe anesthetic method for rTKA if interventions are applied to extend the duration of the CSEA for this novel surgical technique. Level III, Therapeutic Study.

Research and application of a teaching platform for combined spinal-epidural anesthesia based on virtual reality and haptic feedback technology

BackgroundIntraspinal anesthesia poses significant teaching challenges and inadequate teaching resources, which ultimately limit students’ opportunities for practice. To address this issue, we aimed to develop a virtual platform for combined spinal-epidural anesthesia that merges virtual reality technology with haptic feedback technology, while assessing its educational impact and learning outcomes.MethodsWe utilized MIMICS, 3Ds MAX, and UNITY 3D software to perform 3D reconstruction based on lumbar CT/MRI data from a standard male volunteer. The haptic coefficients were configured on each layer by 20 experienced anesthesiologists in accordance with the Geomagic Touch X force feedback device. A total of 20 anesthesiology interns completed 30 virtual puncture training sessions. Two experienced anesthetists evaluated the efficacy of the platform and the level of mastery achieved using the Global Rating Scale (GRS) and a Checklist score, respectively. Finally, a questionnaire survey was conducted to gather feedback on the virtual platform.ResultsAfter the 10th session, the puncture time stabilized at 2.4 min. As the number of sessions increased, the Global Rating Scale (GRS) score stabilized by the 8th session, and the Checklist scores tended to stabilize by the 10th session. Results from questionnaires indicated that over half of the anesthesiology interns (70%) believed that the platform, which exhibited strong repeatability, improved their anatomical recognition and provided a strong sense of breakthrough in identifying the ligamentum flavum. The majority of them (80%) expressed satisfaction with the virtual platform.ConclusionsThe platform effectively facilitated the acquisition of basic and accurate puncture skills on a virtual patient.

Myoclonus in the Post-Operative Period: A Case Report

Involuntary movements/myoclonus are brief, short-lived jerky movements and a complication in the post-operative period are seen following central neuraxial blockade causing distress to the patient but is usually self-limiting. We wish to bring cognizance among fellow anesthesiologists regarding this possible, extremely rare complication and also review the available work for its cause and management.Post-spinal myoclonus was witnessed in a young adult patient in their twenties who underwent closed reduction and internal fixation for a right femur shaft fracture under combined spinal-epidural anaesthesia. The patient developed involuntary jerky movements of the right foot 8 hours after the subarachnoid block gradually reduced in the next 24 hours. After ruling out other possible causes of myoclonus, the case was followed up and discharged on postoperative day 5. Post spinal myoclonus though a rare complication can be distressing to the patient and the doctor. It is a self-limiting complication with no residual effects.

Obstetric Anesthesia

Patient safety and reduction of possible complications are the top priorities for anesthesiologists in everyday clinical practice. Thus, interdisciplinary early assessment and optimization of patient specific medical conditions and risk factors are crucial. In obstetrics, regional anesthesia and general anesthesia are routinely being performed. To ensure maternal and fetal safety, knowledge regarding physiological changes during pregnancy is highly important. Regional anesthesia, particularly epidural analgesia, has its main field of application in the context of natural birth in the delivery room. Spinal anesthesia, as well as epidural and combined spinal-epidural anesthesia (CSE) are widely used for caesarean section. In this context, special attention should be paid to possible bleeding disorders. The combination of risk stratification and strategies to improve the patient's preoperative medical status is capable to reduce maternal and fetal complications.

Efficacy of dexmedetomidine in the prevention and treatment of postanesthetic shivering after cesarean section

Purpose: To assess the efficacy of dexmedetomidine in the prevention and treatment of postanesthetic shivering in cesarean section.Methods: A total of 144 pregnant women who underwent anesthesia for cesarean section between March and December 2022 were randomly divided into the study group (n = 72) and control group (n = 72). The pregnant women were given combined spinal-epidural anesthesia. Following childbirth, those in the study group were given dexmedetomidine, while those in the control group were given normalsaline. The dose of spinal anesthesia was administered based on the following criteria: intraoperative infusion, atropine usage, ephedrine usage, intraoperative bleeding, intraoperative dosage, mean arterial pressure, heart rate, blood oxygen saturation, incidence of shivering, and sedation score. Incidence of adverse reactions were recorded and compared between the two groups.Results: Intraoperative infusion volume, bleeding volume, levels of atropine and ephedrine usage, and spinal anesthesia dose were similar between the two groups (p &gt; 0.05). At 10 min post-treatment, the study group had lower mean arterial pressure, heart rate and incidence of postanesthetic shivering, as well as higher postoperative sedation score than the control group. Compared with the control group, the study group had slightly higher incidence of pregnancy-related adverse reactions, but the difference was non-significant.Conclusion: Dexmedetomidine has good efficacy in preventing and treating postanesthetic shivering in cesarean section patients. However, further clinical trials are required prior to its adoption in clinical practice.

Comparative Study of Effect of Dexmedetomidine and Fentanyl as Epidural Adjuvants in Abdominal Hysterectomies Using Combined Spinal Epidural Technique - A Randomised Prospective Study

Background: Regional anesthesia is defined as loss of sensation in a body produced by administration of anaesthetic agent to the nerves supplying that region. Regional anesthesia whether by spinal, epidural, peripheral nerve blocks offer a number of advantages. Bupivacaine has become standard agent for intrathecal anesthesia. A number of adjuvants can be added to prolong the duration of analgesia. In our study we are comparing fentanyl &amp; dexamedetomidine as an epidural adjuvant to spinal bupivacaine in abdominal hysterectomies. Materials and Methods: A total of 60 patients scheduled for abdominal hysterectomy under CSE were enrolled for this prospective randomized study which was conducted in hospital from November 2019 to October 2020. This work has been granted ethical committee approval. Results: Two groups comprising of 30 patients each were taken randomly. Haemodynamic parameters of heart rate, blood pressure, spo2, were monitored and recorded every 5 min for first 20 minutes and then every 10 minutes till the end of surgery and thereafter postoperatively. The sensory block was assessed by bilateral pin prick method and motor blockade according to Modified Bromage Scale. Duration of anesthesia was taken as time period till VAS of 4 was recorded. Conclusion: In our study we concluded that dexmedetomidine is better adjuvant as compared to fentanyl in combined spinal epidural anaesthesia with intrathecal bupivacaine.

Effect of preoperative oral rehydration before cesarean section on ultrasound assessment of gastric volume and intraoperative hemodynamic changes: a randomized controlled trial

BackgroundCesarean section often requires an urgent transfusion load due to decreased blood pressure after spinal anesthesia. This prospective randomized study aimed to investigate whether a preoperative oral rehydration solution (ORS) stabilized perioperative circulatory dynamics.MethodsSixty-three parturients scheduled for cesarean section under combined spinal epidural anesthesia (CSEA) were randomly allocated to one of three groups: Group O received 500 mL ORS before bedtime and 500 mL 2 h before CSEA; Group M received mineral water instead of ORS; and Group C had no fluid intake (controls). After entering the operating room, stomach size was measured using ultrasound. Blood samples were obtained, and CSEA was induced. Vasopressors were administered when systolic blood pressure was < 90 mmHg or decreased by > 20%. As a vasopressor, phenylephrine (0.1 mg) was administered at ≥ 60 beats/min heart rate or ephedrine (5 mg) at < 60 beats/min heart rate. The primary outcome was the total number of vasopressor boluses administered. Secondary outcomes were the cross-sectional area of the stomach antrum, maternal plasma glucose levels, serum sodium levels, total intravenous fluid, bleeding volume, urine volume, operative time, and cord blood gas values after delivery.ResultsThe total number of vasopressor boluses was lower in Group O than in Group C (P < 0.05). Group O had lower total dose of phenylephrine than Group C (P < 0.05). There were no significant differences between Group M and other groups. No differences were detected regarding secondary outcomes.ConclusionsIn women scheduled for cesarean section, preoperative ORS stabilized perioperative circulatory dynamics. Neither ORS nor mineral water consumption increased the stomach content volume.Trial RegistrationThis trial is registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000019825: Date of registration 17/11/2015).

Combined spinal-epidural anaesthesia in a high-risk abdominoplasty - A case report

Abdominoplasty is generally performed with admission of the patient for one night. It is a usual beautifying technique. It is reported that abdominoplasty can cause death and morbidity. For performing abdominoplasty numerous anaesthesia techniques are reported. Morbidly obese patients with compromised heart ailment undergoing abdominoplasty pose exceptional challenges to the anaesthesiologist. It is necessary to use the anaesthetic procedure such that it causes minimal haemodynamic instabilities with supreme safety for the patient. In this case report a 53-year-old male, morbidly obese patient with a body mass index (BMI) of 43.8 Kg/m, belonging to American Society of Anaesthesiologist (ASA) grade IV, and overhanging abdomen till the level of knee, with ventricular bigeminy, severe pulmonary hypertension, obstructive sleep apnea and chronic kidney disease is described. Abdominoplasty of this patient was performed under combined spinal-epidural anaesthesia. The implications of combined spinal-epidural anaesthesia were that the hemodynamic parameters such as heart rate, respiratory rate, non-invasive blood pressure, SpO2 were stable during the procedure and no complications were observed post-operatively. The results were excellent with speedy recovery.

Remimazolam dosing for intraoperative sedation in elderly patients undergoing hip replacement with combined spinal-epidural anesthesia.

The aim of the study was to investigate the 50% and 95% effective doses (ED50 and ED95) of remimazolam for intraoperative sedation in elderly patients undergoing hip replacement with combined spinal-epidural anesthesia (CSEA). We retrospectively analyzed the clinical data of 50 patients who underwent hip replacement with CSEA in our hospital from October 2021 to June 2022. There were 29 males and 21 females, aged 60-80 years old, with body mass indexes (BMI) ranging from 18 to 24 kg/m2, and American Society of Anesthesiologists (ASA) classifications of I or II. The modified Dixon sequential method was used to determine the dose of remimazolam for each patient. Each patient's initial dose was 0.1 mg/kg/h, and the dose gradient was 0.01 mg/kg/h. The bispectral index (BIS) and the modified observer's assessment of alertness/sedation score (MOAA/S) were used to evaluate the sedation of the patient. An MOAA/S score ≤3 and a BIS <85 at three or more time points during surgery indicated the sedation was satisfactory. The induction dose of the next patient was adjusted by 0.01 mg/kg/h based on the level of sedation achieved, and the study was terminated after eight crossovers. The ED50 and ED95 of remimazolam for sedation of elderly patients undergoing hip replacement with CSEA are 0.212 mg/kg/h (95% CI: 0.121-0.231 mg/kg/h) and 0.288 mg/kg/h (95% CI: 0.254-0.884 mg/kg/h), respectively. Two patients experienced transient bradycardia, five experienced hypoxemia, three experienced postoperative nausea, and three experienced postoperative delirium. No patients experienced adverse reactions such as injection pain, hypotension, vomiting, delayed awakening, or emergence agitation. The ED50 and ED95 of remimazolam for sedation of elderly patients undergoing hip replacement with CSEA are 0.212 mg/kg/h and 0.288 mg/kg/h, respectively.

The optimal oxytocin infusion rate for preventing uterine atony during cesarean delivery in elderly parturients with prior history of cesarean delivery.

Background: An estimate of 90% effective dose (ED90) of oxytocin infusion has already been proved effective in non-laboring parturients. However, the requirements of oxytocin for elderly parturients with prior history of cesarean delivery (CD) may be higher. The aim of this study was to find the optimum oxytocin infusion rate for preventing uterine atony during CD in elderly parturients with prior history of CD. Method: We performed a randomized, double-blinded study in 120 healthy elderly parturients with prior history of CD scheduled for elective CD under combined spinal-epidural (CSE) anesthesia. Participants were treated with oxytocin infusion randomly at the rates of 0, 4, 8, 12, 16, or 20IUh-1 after the delivery of infants. Following oxytocin administration, a blinded obstetrician evaluated the uterine tone (UT), verbally describing it using numerical scales (0-10: 0, no UT; 10, optimal UT) as either adequate or inadequate at the time intervals of 3, 6, and 9min. Maternal adverse effects, requirements for additional uterotonic agents, delivery-placenta delivery time (PD), and estimated blood loss (EBL) were recorded. Results: The 50% effective dose (ED50) and 90% effective dose (ED90) of oxytocin infusion were 14.6IUh-1 (95% confidence interval 12.0-18.4IUh-1) and 27.7IUh-1 (95% confidence interval 22.5-39.4IUh-1), respectively. As the rate of infusion was increased in parturients, the rescue oxytocin dose and delivery-PD time were decreased. Parturients who received 0IUh-1 oxytocin at 3, 6, and 9min obtained lower UT scores than those who received 16 and 20IUh-1 oxytocin (p < 0.05, respectively). No significant differences were observed among groups in EBL and maternal adverse effects. Conclusion: The infusion rate of oxytocin at 14.57 and 27.74IUh-1 produces adequate UT in 50% and 90% of elderly parturients with prior history of CD, respectively. An oxytocin infusion rate of 27.7IUh-1 is suggested to be the optimal dose for preventing uterine atony during CD in elderly parturients with prior history of cesarean delivery. Clinical Trial Registration: [https://www.chictr.org.cn/bin/project/edit?pid=62489], Identifier: [ChiCTR2000038891].

Exploring the predictive value of combined ultrasound parameters for spinal anesthesia-induced hypotension in cesarean section: a prospective observational study

BackgroundProphylactic vasopressor infusion can effectively assist with fluid loading to prevent spinal anesthesia-induced hypotension. However, the ideal dose varies widely among individuals. We hypothesized that hypotension-susceptible patients requiring cesarean section (C-section) could be identified using combined ultrasound parameters to enable differentiated prophylactic medical interventions.MethodsThis prospective observational trial was carried out within a regional center hospital for women and children in Sichuan Province, China. Singleton pregnant women undergoing combined spinal-epidural anesthesia for elective C-sections were eligible. Women with contraindications to spinal anesthesia or medical comorbidities were excluded. Velocity time integral (VTI) and left ventricular end-diastolic area (LVEDA) in the supine and left lateral positions were measured on ultrasound before anesthesia. Stroke volume, cardiac output, and the percentage change (%) in each parameter between two positions were calculated. Vital signs and demographic data were recorded. Spinal anesthesia-induced hypotension was defined as a mean arterial pressure decrease of > 20% from baseline. The area under the receiver operating characteristic curve (AUROC) was used to analyze the associations of ultrasound measurements, vital signs, and demographic characteristics with spinal anesthesia-induced hypotension. This exploratory study did not have a predefined outcome; however, various parameter combinations were compared using the AUROC to determine which combined parameters had better predictive values.ResultsPatients were divided into the normotension (n = 31) and hypotension groups (n = 57). A combination of heart rate (HR), LVEDAs, and VTI% was significantly better at predicting hypotension than was HR (AUROC 0.827 vs. 0.707, P = 0.020) or LVEDAs (AUROC 0.827 vs. 0.711, P = 0.039) alone, but not significantly better than VTI% alone (AUROC 0.827 vs. 0.766, P = 0.098).ConclusionThe combined parameters of HR and LVEDAs with VTI% may predict spinal anesthesia-induced hypotension more precisely than the single parameters. Future research is necessary to determine whether this knowledge improves maternal and neonatal outcomes.Trial registrationChiCTR1900025191.

Landmark-guided versus Real-time Ultrasound-guided Combined Spinal-epidural Anesthesia Techniques: Paramedian Sagittal Oblique and Transverse Interlaminar Approach.

There are different types of real-time ultrasound (US)-guided combined spinal epidural (CSE) anesthesia techniques. We aimed to investigate the effect of real-time US-guided paramedian sagittal oblique (PSO), transverse interlaminar (TI) approach method, and landmark-guided (LG) CSE anesthesia. Ninety patients who underwent CSE block were included in the study. Patients were randomized into LG (n = 30), PSO (n = 30), and TI (n = 30) groups. The primary outcome was number of needle manipulations. The secondary outcomes are the number of attempts, needle visibility, procedure time, procedure success rate, catheter placement difficulty, posterior complex distance, and complications. The number of needle manipulations was statistically significantly lower in the LG technique group (P < 0.000). When the number of attempts, the difficulty of catheter placement, and the procedure's success rate were compared between the three groups, we did not find a statistically significant difference (P > 0.05). In addition, when the procedure times were compared, the time measured for the LG group was statistically significantly lower than in the PSO and TI groups (P < 0.000). In the results of this study, the real-time US-guided CSE anesthesia application had a similar success and complication level with LG technique. The LG method had a shorter processing time and fewer needle manipulations.

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour.

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour.

Finding the optimal anesthetic technique during PCNL for renal stone disease: A comparison of general, spinal, and combined spinal epidural anesthesia

Background: Renal stone disease is prevalent worldwide. Percutaneous nephrolithotomy (PCNL) has become an important mode of treatment for large size renal stones. Various anesthetic techniques have described for performing PCNL, with each having its own merits and demerits. There is lacuna in evidence for the ideal mode of anesthesia with best results and least associated complications. Aims and Objectives: PCNL is a common procedure for renal stones. It can be performed under various anesthesia techniques. Selection of an appropriate anesthetic technique is essential for successful outcome. In this study, we compared three anesthesia techniques during PCNL and their outcomes. Materials and Methods: Retrospective and observational study involved all cases of PCNL performed from February 2022 to January 2023. Baseline clinical and anesthesia parameters were recorded. Three groups based on anesthesia method were made; Group A for general anesthesia (GA), B for spinal anesthesia (SA), and C for combined spinal epidural anesthesia (CSEA). Intraoperative variables including heart rate (HR), blood pressure, operation time, and analgesia adequacy were noted. Post-operative pain level, hospital stay, stone free rate (SFR), complications, patient, and surgeon satisfaction were recorded. Results: Seventy-two cases (56 Male and 16 Female) with a mean age of 36.2±15.9 years were included in the study. Age and body mass index were lower in Group A, while ASA status and comorbidities were comparable. Intraoperative HR and mean blood pressure were higher in Group A than in B and C (P=0.000, P=0.003). Hypotension was more frequent in Group B (24.1%, P=0.046). Operation time, hospital stay, transfusion rates, SFR, and overall patient satisfaction were similar. Group A patients experienced more post-procedure pain (Visual analogue scale 4.1 vs. 2.2 vs. 2.1; P=0.001). Nausea-vomiting and shivering episodes were also higher in Group A (P=0.033, P=0.021). Anesthetic effect weaned-off in 6 patients of SA. Post-operative headache was higher but non-significant in Group B and C (P=0.621). Conclusion: CSEA appears a superior alternative to both SA and GA, with additional adequate post-operative comfort.

Association of duration of skin-to-skin contact after cesarean delivery in China: a superiority, multicentric randomized controlled trial

In China, rates of early initiation and exclusive breastfeeding are low. The high cesarean section rates further contribute to low breastfeeding outcomes. Skin-to-skin contact (SSC), a key component of Early Essential Newborn Care, is known to be associated with improved breastfeeding initiation and exclusivity; however, the necessary duration has not been subjected to an RCT. To determine the association of duration of SSC after cesarean section on breastfeeding outcomes and maternal and neonatal health outcomes in China. A multi-centric RCT was conducted at four hospitals in China. 720 participants ≥37 gestational weeks with singleton pregnancy receiving elective cesarean section, using epidural anesthesia or spinal anesthesia or combined spinal-epidural anesthesia were randomly divided into 4 groups at the ratio of 1:1:1:1. The control group received routine care. Intervention group 1 (G1), 2 (G2) and 3 (G3) received 30, 60 and 90 minutes of SSC immediately after cesarean section, respectively. Between January 3 and October 14, 2021, 659 participants were recruited, including 173 in control group, 176 in G1, 146 in G2, and 164 in G3. Among G1, G2 and G3, the rate of early initiation of breastfeeding within 60 minutes of birth was 56%, 71% and 72%, compared to 22% in control group (p<0.001). The exclusive breastfeeding rate at discharge were 69%, 62% and 71%, compared to 57% in control group (p=0.003). EENC practices were associated with reduction in postpartum blood loss and NICU or neonatal ward admission (p< 0.001, p=0.022) . Our findings highlight that prolonged SSC after cesarean section was associated with higher initiation and exclusive breastfeeding at discharge. It also found associations with reduced postpartum blood loss and NICU or neonatal ward admission.

Fetal heart rate changes and labor neuraxial analgesia: a machine learning approach

BackgroundNeuraxial labor analgesia has been associated with fetal heart rate changes. Fetal bradycardia is multifactorial, and predicting it poses a significant challenge to clinicians. Machine learning algorithms may assist the clinician to predict fetal bradycardia and identify predictors associated with its presentation.MethodsA retrospective analysis of 1077 healthy laboring parturients receiving neuraxial analgesia was conducted. We compared a principal components regression model with tree-based random forest, ridge regression, multiple regression, a general additive model, and elastic net in terms of prediction accuracy and interpretability for inference purposes.ResultsMultiple regression identified combined spinal-epidural (CSE) (p = 0.02), interaction between CSE and dose of phenylephrine (p < 0.0001), decelerations (p < 0.001), and the total dose of bupivacaine (p = 0.03) as associated with decrease in fetal heart rate. Random forest exhibited good predictive accuracy (mean standard error of 0.92).ConclusionUse of CSE, presence of decelerations, total dose of bupivacaine, and total dose of vasopressors after CSE are associated with decreases in fetal heart rate in healthy parturients during labor. Prediction of changes in fetal heart rate can be approached with a tree-based random forest model with good accuracy with important variables that are key for the prediction, such as CSE, BMI, duration of stage 1 of labor, and dose of bupivacaine.

A Study of the Clinical Effects of Sequential Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Patients Undergoing Orthopedic Surgeries.

In orthopedic surgeries, there has been an increase in the usage of the neuraxial blockade to provide excellent surgical conditions and prolonged postoperative analgesia. The introduction of the sequential combined spinal epidural anesthesia (SCSEA) technique provides benefits for both spinal anesthesia (SA) and epiduralanesthesia. The focus of this study was to analyze the time needed to attain a desired level of sensory block, to compare the period of sensory block, and to study the intraoperative hemodynamics in the SCSEA and SA groups. The study was conducted on patients admitted for elective lower limb orthopedic surgeries. The sample size for this prospective randomized study is two groups of 67 subjects each. Patients aged between 18 and 65 years, posted for orthopedic surgeries for two to three hours, and of American Society of Anaesthesiologists (ASA) Grades 1 and 2 were included and divided into two groups. Group A patients received SCSEA with an epidural-test dose of 3 ml lignocaine (2%) with adrenaline and spinal bupivacaine (0.5%) of 1.5 ml-7.5 mg + fentanyl .25 mic if the sensory level was below T8. An epidural top-up was given with 2 ml per segment of 0.5% bupivacaine to bring the sensory level to T8. Group B patients received SA with spinal bupivacaine (0.5%) of 3 ml-15 mg + fentanyl .25 mic. Intraoperative hemodynamics, the duration to achieve a sensory level of T8, the time for two-segment regression of sensory block, and the complications that occurred were recorded. The study included a total of 134 subjects with each group having 67 subjects admitted for lower limb surgery. The mean value (SD) of the time taken to attain sensory block in the SCSEA group was prolonged when compared to the SA group (7.15 ± 0.75 and 5.01 ± 0.88). The time for two-segment regression in the SCSEA group was 86.77 ± 3.60and the SA group was 106.4 ± 8.01, which indicated that the SA group has a longer and better sensory block. Substantially, the study shows that the SCSEA group (P< 0.05) has better hemodynamics when compared to the SA group. The SCSEA technique has better intraoperative hemodynamic stability with a longer analgesic effect when compared to SA. SA shows a sudden change in hemodynamics but reveals a greatersensory block.

Preoperative cerebrospinal fluid biomarkers may be associated with postoperative delirium in patients undergoing knee/hip arthroplasty: the PNDABLE study

BackgroundIn the global aging population, the incidence of postoperative delirium (POD) is increasing. Therefore, finding its effective predictive tools becomes crucial. We aimed to identify potential Cerebrospinal fluid (CSF)biomarkers for POD.MethodsA total of 825 patients undergoing knee/hip arthroplasty under combined spinal-epidural anesthesia were selected. The patients were aged 40 to 90 years with American Society of Anesthesiologists physical status I~II. The Mini-Mental State Examination was completed 1 day before the operation. CSF was extracted after successful spinal-epidural combined puncture, and α-synuclein (α-syn), amyloid beta40 (Aβ40), amyloid beta42 (Aβ42), t-Tau, phosphorylated Tau (p-Tau), progranulin (PGRN) and soluble triggering receptor expressed on myeloid cells 2 (sTREM2) in the CSF were measured by enzyme-linked immunosorbent assays (ELISA). The patient’s operation time, anesthesia time, intraoperative blood loss and fluid input were also recorded. After the operation, the occurrence rate and severity of POD were determined by the Confusion Assessment Method and the Memorial Delirium Assessment Scale (MDAS), respectively. Patients were categorized into POD group and non-POD group. Logistic regression analysis was performed on the indicators with statistically significant differences, and the area under the ROC curve (AUC) was used to estimate the predictive accuracy of the biomarkers for POD.ResultsA total of 92 patients developed POD and the incidence of POD was 11.15%. The results of the multivariable logistic regression showed that CSF t-Tau (P = 0.004, OR = 1.006, 95%CI 1.002~1.009) and α-syn (P = 0.004, OR = 1.001, 95%CI 1.000~1.001) were positively associated with the occurrence rate of POD, while Aβ42 (P < 0.001, OR = 0.989, 95%CI 0.986~0.993), CSF PGRN (P = 0.002, OR = 0.999, 95%CI 0.999~1.000), Aβ42/ t-Tau (P < 0.001, OR = 0.181, 95%CI 0.102~0.319) and Aβ42/p-Tau (P < 0.001, OR = 0.617, 95%CI 0.526~0.725) were inversely proportional to the occurrence of POD. ROC curve analysis indicated that Aβ42/t-Tau (AUC = 0.823), CSF Aβ42 (AUC = 0.813), Aβ42/p-Tau (AUC = 0.810), α-syn (AUC = 0.644) and PGRN (AUC = 0.638) could predict the occurrence rate of POD. The combination of all these biomarkers showed a greater AUC(0.896) than using any of them alone.ConclusionsCSF Aβ42, PGRN, α-syn, Aβ42/t-Tau and Aβ42/p-Tau might be associated with the occurrence rate of POD in patients undergoing knee/hip arthroplasty.Trial registrationClinical Registration No. ChiCTR2000033439.

OC-108 THE EFFECT OF COMBINED SPINAL EPIDURAL ANESTHESIA ON SHOULDER PAIN IN LAPAROSCOPIC EXTRAPERITONEAL HERNIA SURGERY

Abstract Background Shoulder pain is a condition that seriously discomforts patients which develops due to peritoneal tear in laparoscopic extra peritoneal hernia repair (TEP) surgeries. Although surgeons generally prefer general anesthesia for the TEP technique, many studies have been carried out for the use of regional anesthesia in recent years. In our study, we aimed to investigate the efficacy and safety of the combined spinal/epidural anesthesia (CSEA) method in order to prevent shoulder pain in the TEP technique. Method The patients which operated with TEP procedure were divided into two groups; SA (Group 1) and CSEA (Group 2). The two patient groups were compared in terms of sex, age, body mass index, duration of surgery, total operation time, patient satisfaction, pain scores, length of hospital stay, adverse effect, intra operative and postoperative complications. Results The number of patients in group 1 was 42 and the group 2 was 40. The mean operation time was recorded as 55.9 and 80.2 minutes in groups 1 and 2 respectively, which was statistically significantly shorter in group 1 (p&amp;lt;0.001). Postoperative pain was significantly less in group 2 for the 4th hour (p&amp;lt;0.0001) and the 12th hour (p: 0.047). There was no difference between the two groups in terms of peritoneal tear (p:0.860). Intra operative and postoperative shoulder pain was significantly less in group 2 (p: 0.038, p:0015 respectively). Conclusion CSEA is an effective and safe anesthesia method in preventing shoulder pain that develops after TEP surgeries.

EFFICACY AND SAFETY OF CONVENTIONAL EPIDURAL VERSUS COMBINED SPINAL EPIDURAL IN PERCUTANEOUS NEPHROLITHOTOMY: A PROSPECTIVE AND RANDOMIZED CLINICAL STUDY

Objectives: The aim of the study was to compare the efficacy and safety of conventional epidural (ED) versus combined spinal epidural (CSE) in percutaneous nephrolithotomy (PCNL) with addition of opiods and dexmedetomidine. Methods: This prospective, randomized, and double-blinded clinical study was conducted in the in patients undergoing PCNL. Group CSE had received CSE anesthesia and Group ED given conventional epidural anesthesia. Time to first rescue analgesic and total dose of rescue analgesic along with hemodynamic parameters were compared up to 24 h. Patient, surgeon satisfaction score, and post-operative complications were also compared. Results: Time from onset of sensory block to first requirement of analgesia was prolonged in group CSE (218.4±18.30 min) as compared to Group ED (210±17.88 min). (p&lt;0.001) Mean time for first rescue analgesia postoperatively was highly significant in group CSE (2.42±0.49) as compared to Group ED (2.08±0.28). (p&lt;0.0001) Total dose of levobupivacaine required was high in Group ED (49.66±7.02) as compared to Group CSE (45.66±3.12). (p&lt;0.001) In Group ED, surgeon score was good in 20 (44.44%) patients and which was highly significant. In Group CSE, surgeon score was excellent in 41 (91.1%) patients and which was highly significant. (p&lt;0.001) Post-operative complications in both the group were comparable (p&gt;0.05). Conclusion: This study concluded that though both the anesthesia techniques are safe and efficient with each having its own benefits. CSE had proven superiority over the epidural technique.