Combined Spinal-epidural Technique Research Articles

National survey on clinical practice in obstetric analgesia in Spain

IntroductionA national survey was conducted among maternity hospitals nationwide to understand the variability in clinical practice for obstetric analgesia and to reach a consensus on optimal care in the future in Spain. Materials and methodsSpanish experts in obstetric anesthesiology designed a survey on the practice of obstetric analgesia during childbirth, following a Delphi process. The survey was sent to 195 Spanish maternity hospitals between April and September 2022 using Google Forms. A descriptive study of the results was performed. ResultsResponses were obtained from 108 centres (55.4%), of which 88 (83.8%) were public hospitals. The most commonly used technique was epidural analgesia in 97 (92.4%) centres. Nine (8.6%) centres used the combined spinal-epidural (CSE) technique, 5 (4.8%) used spinal analgesia, and 3 (2.9%) used dural puncture epidural (DPE) analgesia. The most commonly used local anaesthetic was levobupivacaine 0.1−0.25% in 82 (78.1%) centres. Fentanyl or sufentanil were added to the local anaesthetic in 96 (91.4%) centres. Epidural maintenance was performed with continuous epidural infusion (CEI) + patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB) + PCEA in 64 (60.9%) and 33 (30.5%) centres, respectively. Fifteen (14.3%) centres lacked alternative techniques to epidural analgesia and 25 (23.8%) did not follow obstetric analgesia protocols. ConclusionDespite the variability in clinical practice for obstetric analgesia in Spain, the vast majority of centres follow recommendations in this field. There is room for improvement, which should be considered a fundamental strategy for progressing towards excellence.

A case report on the use of combined spinal epidural technique in the anaesthetic care of a patient with a large ASD and severe pulmonary hypertension

A defect in the septum between the left and right atrium is known as atrial septal defect which is a congenital heart disease. The defect causes shunting of blood from left to right side of the heart, increasing the blood flow through the lungs. Small atrial septal defects may be found incidentally and never cause a major concern. Larger defects may damage the heart and also the lungs. The use of combined spinal and epidural technique in a patient with ASD can maintain hemodynamic stability, provide perioperative analgesia and also avoid the hemodynamic perturbations associated with general anaesthesia in a patient with severe pulmonary hypertension.

Segmental thoracic anesthesia for transabdominal colectomy with spontaneous ventilation through combined spinal-epidural block. Case report with video

Introduction: The combined spinal-epidural (CSE) technique offers advantages over the epidural or single injection spinal anesthesia alone. Assessing the distance between the dura mater and the spinal cord in the thoracic region with magnetic resonance imaging showed that there is a large space that allows the needle to enter without reaching the spinal cord. Segmental thoracic spinal anesthesia is being used in several types of surgery. Case report: A woman aged 73 years, 64 kg, 163 cm, physical status ASA II, type II diabetic, with systemic arterial hypertension, was scheduled for resection of a tumor in the right colon. The CSE was placed at the T9-T10 interspace and 10mg 0.5% hyperbaric bupivacaine was injected into the subarachnoid space. The epidural catheter (20G) was then inserted four centimeters. Sedation was obtained with 1mg of midazolam as needed (total 5mg). Two hours after 0.5% bupivacaine had to be administered in a bolus of 25 mg through the catheter. There was no necessity for the use of vasopressor drugs or atropine. Conclusion: This case has provided evidence that segmental spinal anesthesia can be an effective anesthetic technique for gastrointestinal surgery with spontaneous ventilation, and the infusion of 0.1% bupivacaine with an elastomeric pump provided 40 hours of analgesia.

Comparison of Two Different Volumes of Epidural Normal Saline for Enhancing the Effects of Spinal Anesthesia in Adult Patients Undergoing Elective Lower Limb Surgeries: A Prospective Randomized Study

Background: The combined spinal-epidural (CSE) anesthesia technique gives a reliable subarachnoid block as well as the flexible epidural block. One of the modified technique of CSE is epidural volume expansion (EVE) in which normal saline or local anesthetic (LA) is instilled though epidural catheter leading to increase in level of sensory blockade. Aim of the study was to compare two different volumes of normal saline for enhancing the effects of spinal anaesthesia in adult patients undergoing elective lower limb surgeries.
 Methods: 90 patients were randomly divided into two group. Group A - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 10ml of 0.9% normal saline for EVE using CSE technique. Group B - 45 patients who were received intrathecal 2.0ml of 0.5% hyperbaric bupivacaine and epidural 15ml of 0.9% normal saline for EVE using CSE technique.
 Results: The demographic data were comparable in both groups. Significant difference was seen in total duration of sensory blockade between group A (192.11±9.80) and group B (Mean ± SD 215.33±17.57minutes) (p<0.0001). Total duration of motor blockade was longer in group B (Mean± SD: 181.91± 16.42) as compared to group A (Mean ± SD: 162.48 ± 9.35 minutes) (p<0.0001).
 Conclusion: We conclude that epidural volume expansion (EVE) with 15 ml epidural normal saline was associated with faster onset, higher level and early achieve maximum level of sensory blockade, longer two segment regression time, early onset and longer duration of motor blockade as compared to EVE with 10 ml epidural normal saline.

Labor Analgesia Initiation With Dural Puncture Epidural Versus Conventional Epidural Techniques: A Randomized Biased-Coin Sequential Allocation Trial to Determine the Effective Dose for 90% of Patients of Bupivacaine

(Anesth Analg. 2023. doi: 10.1213/ANE.0000000000006691) Neuraxial labor analgesia includes the conventional epidural (EPL) technique as well as the combined spinal epidural and dural puncture epidural (DPE) techniques. Some advantages to the DPE technique have been discovered through research in comparison to the EPL technique. A study was conducted using a biased-coin up-down allocation method to determine the effective dose of bupivacaine needed to achieve initial analgesia in 90% of women in labor (ED90) using the DPE and EPL techniques. It was hypothesized that a lower bupivacaine dose would be needed with the DPE versus the EPL.

Is epidural analgesia non-inferior to intrathecal fentanyl as initiation for neuraxial analgesia in early non-spontaneous labour?

Intrathecal fentanyl, using the combined spinal-epidural (CSE) technique, provides rapid analgesia during early labour. Because of the technique's more complex and invasive nature, as its replacement we assessed the use of epidural analgesia in primiparous parturients with induced labour. The study was registered at www. gov (NCT04645823). The aim was to compare the efficacy, duration of analgesia and maternal satisfaction. The primary outcome was the difference in pain visual analogue scale (VAS) between the interventions at 20 min after the analgesia administration. Sixty volunteering parturients were randomly allocated in 1:1 ratio to receive either intrathecal fentanyl 20 μg or epidural analgesia (fentanyl 100 μg and lidocaine 80 mg). Contraction pain and maternal satisfaction were assessed by 0-100 mm VAS for 30 min, respectively. Foetal heart rate abnormalities, the time to first epidural dose and the incidence of pruritus were recorded. Non-inferiority margin for mean (95% CI) VAS after epidural analgesia was set at 20 mm above the VAS value for intrathecal fentanyl at 20 min. The contraction pain VAS fell from (median [interquartile range, IQR]) 82 (14) to 13 (20) mm and 76 (17) to 12 (27) mm in 20 min following the intrathecal fentanyl and epidural analgesia, respectively. The absolute mean difference (epidural-intrathecal fentanyl) in the VAS values was 3.3(-0.06 to 6.66) mm indicating non-inferiority. The median time to reach VAS <30 mm was 10 min in both groups. The duration until request for supplemental analgesia was 82(69-95) and 91(75-106) min after intrathecal fentanyl and epidural analgesia, respectively. The difference for the duration (epidural-intrathecal fentanyl) was 9 (6-12) min and for satisfaction-VAS 0.3 (-3.0 to 3.7) mm. There were no differences between the groups in the incidence of foetal heart rate abnormalities, while pruritus was more common after intrathecal fentanyl. After 20 min, epidural analgesia by lidocaine and fentanyl was within the non-inferior threshold compared with intrathecal fentanyl in efficacy. The duration of action was not shorter than that of intrathecal fentanyl and maternal satisfaction was also similar.

Comparison of Epidural, Combined Spinal Epidural, and Dural Puncture Epidural Techniques for Labor Analgesia

Background: Lumbar epidural analgesia is a safe, effective, and beneficial technique for both the parturient and the fetus. Dural puncture epidural has been claimed to be better than combined spinal epidural and epidural techniques by many. We undertook this study to compare the three techniques regarding duration, quality of analgesia, and side effects. Debate regarding the best neuraxial technique for labor analgesia continues. Materials and Methods: The parturients of ASA grade I and II of age group 20–35 years were randomly divided into three groups of 20 each. Group E (epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 µg fentanyl in the epidural space. Group CSE (combined spinal epidural group) received 2.5 mg of intrathecal isobaric levobupivacaine with 25 µg fentanyl and epidural top up of 15 ml of 0.125% levobupivacaine with 30 µg fentanyl. Group DPE (dural puncture epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 µg fentanyl in epidural space; intrathecal medication was withheld. Epidural top-up doses were given as per Visual Analog Scale (VAS). Analgesic efficacy, extent of sensory and motor block, maternal and fetal outcome, duration of analgesia, and maternal satisfaction score were compared among three groups and analyzed statistically. Results: The onset and symmetry of sensory blockade and VAS score were better in CSE group. DPE group had better sacral coverage and less asymmetric blockade. Groups CSE and DPE had superior maternal and surgeon satisfaction scores in comparison to group E. Both groups E and DPE provided analgesia with minimal motor blockade and ambulation.

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.

Current status of the combined spinal-epidural technique in obstetrics and surgery.

Epidural and spinal blocks are well-accepted neuraxial techniques but both have several disadvantages. Combined spinal-epidural (CSE) can combine the best features of both techniques and reduce or eliminate these disadvantages. It provides the rapidity, density, and reliability of subarachnoid block with the flexibility of catheter epidural technique to extend the duration of anesthesia/analgesia (and to improve spinal block). It is an excellent technique for determining minimum intrathecal drug doses. Although most commonly employed in obstetric practice, CSE is also used in a wide variety of non-obstetric surgical procedures including orthopedic, vascular, gynecological, urological, and general surgical procedures. The needle-through-needle technique remains the most commonly used method to perform CSE. Several technical variations including Sequential CSE and Epidural Volume Extention (EVE) are commonly used particularly in obstetric and high-risk patients such as those with cardiac disease where a slower onset of sympathetic block is desirable. The risks of complications such as epidural catheter migration through the dural hole, neurological complications, and subarachnoid spread of epidurally administered drugs are possible but have not been a clinically relevant problem in the 40+ years of their existence. In obstetrics, CSE is used for labor pain because it produces rapid-onset analgesia with reduced local anesthetic consumption and less motor block. The epidural catheter placed as part of a CSE is more reliable than a catheter placed as part of a conventional epidural. Less breakthrough pain throughout labor is noted and fewer catheters require replacing. Side effects of CSE include greater potential for hypotension and more fetal heart rate abnormalities. CSE is also used for cesarean delivery. The main purpose is to decrease the spinal dose so that spinal-induced hypotension can be reduced. However, reducing the spinal dose requires an epidural catheter to avoid intra-operative pain when surgery is prolonged.

Comparison of the incidence of fetal prolonged deceleration after induction of labor analgesia between dural puncture epidural and combined spinal epidural technique: a pilot study

BackgroundAbnormal cardiotocogram (CTG) tracing may appear after induction of neuraxial labor analgesia. Non-reassuring fetal status (NRFS) indicated by severely abnormal tracings, such as prolonged deceleration (PD) or bradycardia, can necessitate immediate operative delivery. Combined spinal epidural analgesia (CSEA) is known to result in more frequent abnormal tracings than epidural analgesia (EA); however, the corresponding data related to dural puncture epidural (DPE) are unclear. We aimed to evaluate the rates of incidence of severe abnormal CTG after induction of DPE and CSEA.MethodsIn this study of nulliparous women with full-term pregnancy, data for the DPE intervention group were prospectively collected, while those for the CSEA control group were obtained from medical records. Neuraxial analgesia was performed with cervical dilation ≤ 5 cm, administering initial epidural dosing of 15 mL of 0.125% levobupivacaine with fentanyl 2.5µg/mL for DPE, and intrathecal 0.5% bupivacaine 2.5 mg (0.5ml), fentanyl 10 µg (0.2ml), and 1.3 mL of saline for CSEA. The primary outcome was the incidence of PD, defined as a fetal heart rate reduction ≥ 15 bpm below the baseline and with a lowest value < 80 bpm, and lasting for ≥ 2 min but < 10 min (fetal heart rate < 80 bpm does not have to last for ≥ 2 min), within 90 min after induction of neuraxial labor analgesia.ResultsA total of 302 patients were analyzed, with 151 in each group. The incidence of PD after DPE induction was significantly lower than that after CSEA induction (4.0% vs. 14.6%, P = 0.0015, odds ratio = 0.243, 95% confidence interval = 0.095–0.617).ConclusionDPE appears to be a safer method compared to CSEA for neuraxial labor analgesia in the early stages of labor for nulliparous women.Trial registrationUMIN-CTR: UMIN000035153. Date registered: 01/01/2019.

THE HEMODYNAMIC EFFECTS OF COMBINED SPINAL-EPIDURAL VERSUS SPINAL ANESTHESIA IN CESAREAN SECTION

Background &#x0D; Hypotension and bradycardia are the main problems in parturients anesthetized with spinal anesthesia for cesarean section. It is a common cause of maternal and fetal morbidity and mortality; the combined spinal-epidural anesthesia technique is a new way to solve the problem.&#x0D; Objectives &#x0D; The hemodynamic effects of combined spinal-epidural anesthesia will be compared to spinal anesthesia alone in cesarean section.&#x0D; Patients and Methods&#x0D; After the approval of the local ethical committee and taking patients’ consent, 100 parturients at Sulaimani Maternity Hospital scheduled for cesarean section were involved in the study. They were divided into two groups; group S (n_50) received (3ml) of bupivacaine in a single spinal shot technique. Group CSE (n_50) received (2 ml) of the same drug with the insertion of an epidural catheter to give additional doses later in a combined spinal-epidural technique. Blood pressure and pulse rate were measured regularly at 5 minutes intervals throughout the operation. After shifting the patient to the ward, they continued the measurement postoperatively for one hour with 15 minutes intervals. &#x0D; Results&#x0D; Hypotension was more common in group S in 42 cases versus 7 in the CSE group. It was significant (P=0.012). Also, bradycardia occurred in 15 cases in the S group while it was only in 6 cases in the CSE group which were significant (P = 0.008).&#x0D; Conclusion&#x0D; The maternal hemodynamic changes were less significant with the combined Spinal-Epidural technique compared to routine spinal anesthesia of cesarean section.

Dural Puncture Epidural for labour analgesia in Indian parturients may need dose alteration for maximal benefits!

Dear Editor, Dural puncture epidural (DPE) is a relatively new technique for labour analgesia (LA) performed by creating an intentional dural hole using a spinal needle, followed by insertion of an epidural catheter in the epidural space through which local anaesthetics with or without adjuvants are injected.[1] The dural hole acts as a passage for medications to slowly pass from epidural space into subarachnoid space, which provides improved block quality with fewer maternal and foetal side effects.[2,3] Previously, a bolus of 20 ml of 0.125% bupivacaine was found effective in DPE for LA. At our institute, a randomised controlled trial of DPE in LA comparing 0.125% of ropivacaine and 0.125% levobupivacaine was undertaken by the present authors. In the original protocol, DPE was performed in L2-L3 or L3-L4 interspace with a 16-G Tuohy epidural needle and 26-G Whitacre spinal needle with an initial bolus of epidural 20 ml of 0.125% ropivacaine with 2 μg/ml fentanyl or 20 ml of 0.125% levobupivacaine with 2 μg/ml fentanyl. The drug was fractionated into four 5 ml boluses injected over 5 minutes as previously described.[1] In seven of first ten patients, complications of hypotension, motor blockade, and foetal heart rate variability developed [Table 1]. This prompted us to look for possible overlooked causes. On minute analysis, the height of the parturient was found more than that of the present group.[1] The protocol was modified to a maximal drug injection of 20 ml with the end point specified as a decrease in numerical rating scale (NRS) labour pain to 50% of baseline. Thus, about 4 ml of the drug was injected every 2 minutes till the end point was reached. With the modified protocol, considerably less volume of DPE drug was required (about 12 ml) in the next 20 parturients with no further reported morbidity [Table 2].Table 1: Data of first ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaineTable 2: Data of ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaine with the modified protocol: Graded epidural of 0.125% local anaesthetics, with a maximum limit of 20 mlEpidural injection for LA is associated with slow onset, inadequate sacral spread, and epidural catheter failure, whereas a combined spinal epidural technique gives rapid onset of blockade but is associated with maternal pruritus, maternal hypotension, and foetal bradycardia.[1] To retain the advantages of both and decrease the disadvantages, DPE for LA has been studied with the most effective results seen with a bolus of 20 ml of 0.125% bupivacaine.[2-4] In all previous studies, the height or body mass index (BMI) was more than that of the present study group[2-4] [Table 3]. After reported morbidity, the present protocol was modified to slower injections of the drug with a ceiling to the injected volume targeted to till 50% reduction in labour NRS rather than a fixed volume as previously reported. This significantly decreased the morbidity.Table 3: Studies comparing DPE to Epidural for LATo conclude, DPE with 0.125% of a local anaesthetic agent for LA in Indian parturients should be given in a graded manner till labour pain NRS reduces by 50% of baseline rather than a bolus of 20 ml. The proposal of a graded local anaesthetic for DPE for LA has never been reported previously. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Neuraxial Labor Analgesia Failure Rates in Women With a Body Mass Index ≥50 kg/m2: A Single-center Retrospective Study

(Int J Obstet Anesth. 2021;48:103176) Rates of emergency cesarean delivery (CD) are higher in obstetric patients with a body mass index (BMI) of 50 kg/m2 or more, known as super obesity. Reliable neuraxial techniques are needed in the event of emergency CD. While combined spinal-epidural technique results in a lower proportion of catheters replaced than epidurals without dural puncture (EPI) in the general population, it is not clear if this is also true for super-obese patients. This study aimed to determine the failure rate of first neuraxial catheter placement for labor analgesia in super-obese parturients.

Effect of encouraging a combined spinal epidural technique for cesarean delivery anesthesia

A combined spinal epidural anesthetic technique allows an anesthesia provider to administer local anesthetic through an epidural catheter in the event of a failed spinal anesthetic. Prior to May 2019, our hospital performed single-shot spinal anesthesia exclusively for cesarean deliveries. In May 2019, anesthesia providers at our hospital were encouraged to perform combined spinal epidural anesthesia for cesarean delivery. We hypothesized that subjects who received combined spinal epidural anesthesia would have superior anesthetic outcomes compared to subjects who received single-shot spinal anesthesia. We performed a retrospective review of subjects who had cesarean deliveries at our hospital from May 15, 2019, through April 15, 2021, who received either single-shot spinal anesthesia or combined spinal epidural anesthesia. Subjects who received combined spinal epidural anesthesia were older, had a higher body mass index, had higher parity, were more likely to have had a cesarean delivery in the past, were more likely to have had the neuraxial anesthetic technique performed by a junior resident, and had a lower intrathecal dose of hyperbaric bupivacaine. Combined spinal epidural anesthesia had similar anesthetic outcomes to single-shot spinal anesthesia for cesarean delivery despite more complex subjects with less experienced operators.

Combined Spinal-Epidural (CSE) technique plus ketamine in research laparotomies with vertical incision: Case report

The combined spinal-epidural (CSE) technique, a comparatively new anesthetic choice, includes an initial subarachnoid injection followed by epidural catheter placement and subsequent administration of epidural medications. Clinical studies have demonstrated that the CSE technique provides excellent surgical conditions as quickly as with single-shot subarachnoid block conditions that are better than with epidural block alone. A 72-year-old man with pelvic tumor undergoing laparotomy surgery underwent combined regional anesthesia (Th12 - O1) plus small doses of Ketamine via intravenus infusion. The combined spinal-epidural technique along with intravenous Ketamine offers a better analgesic and hemodynamic result.

Combined Spinal-Epidural (CSE) technique plus ketamine in research laparotomies with vertical incision: Case report

Combined Spinal-Epidural (CSE) technique plus ketamine in research laparotomies with vertical incision: Case report

Abstract No. : ABS0549: Comparison of dural puncture epidural technique with combined spinal epidural Technique for labour analgesia. A prospective randomised study.

Background & Aims:The Dural puncture epidural technique (DPE) is where the dura is punctured but no intrathecal drug is given. thus avoiding potential side effects of intrathecal drugs. The goal of our study was to find whether DPE technique provides safe and better quality of analgesia compared to CSE.Methods:60 parturients of American Society of Anesthesiologists ( ASA) grade ll were divided into two groups. In DPE group, dura was punctured with spinal needle followed by insertion of epidural catheter. A test dose of 3ml of 2% lignocaine with adrenaline was given followed by 5ml of 0.125% bupivacaine. In CSE group, 1.25mg of 0.25% plain bupivacaine with 20µg fentanyl wasgiven in subarachnoid space and epidural catheter was threaded Background infusions were given in both the groups.Results:The onset time of analgesia was 460.67+/-72.96 seconds (7.67 min.) in DPE. While with CSE it was223.33+/-50 seconds (3.8 min). The time for the 1st top up, was 135.23± 22.05 minutes in group DPE and 135.67 ± 13.19 minutes in group CSE. The mean duration of labour was 245.87 ± 31.18 minutes in Group DPE and 238.23 ± 34.03 minutes in CSE group (p =0.369). The maternal haemodynamic changes were similar in both study groups. In group DPE, 80% (24) patients had normal vaginal delivery 3 (10%) underwent lower segment caesarean section (LSCS), 3 (10%) had instrumental delivery. In group CSE 73.3% (22) patients had normal vaginal delivery while 13 % (4) each underwent LSCS and instrumental forceps delivery (p=0.83). There was no significant difference in motor block between the two groups( p values greater than 0.05). Eight patients (26.7%) reported pruritus in CSE group while none in the group DPE (p = 0.005). Seven patients reported nausea in group CSE against one in group DPE (p =0.05).Foetal bradycardia was more in CSE(6) compared to DPE(1)( p=0.10). APGAR score was more than 7 in both groups.Conclusion:The quality of analgesia was good with both DPE and CSE, though onset of analgesia was slightly faster in CSE group. The maternal and foetal outcomes were better with DPE group.

A Case of Multidisciplinary Approach to Post-Radiotherapy Dilative Cardiomyopathy Undergoing Elective Cesarean Delivery: Anesthetic and Intensive Care Management

Cardiovascular diseases are the most common non-obstetric cause of maternal death. These cases became more common thanks to the improvement in cardiovascular therapies. A multidisciplinary team is necessary to manage these pregnancies. A 32 years old women at the 25th week of gestation for acute heart failure in pre-existing left ventricular dysfunction induced by radio-chemotherapy admitted to the Coronary Unit of IRCCS Policlinico Universitario Agostino Gemelli for worsening of dyspneic symptoms and anuria not responding to diuretic therapy. At the echocardiogram: ejection fraction 30%, enlarged left atrium, systolic pulmonary arterial pressure 38 mmHg, bilateral pleural effusion, bilateral diffused pulmonary B lines. A multidisciplinary team composed by cardiologists, gynecologists, anesthesiologists, cardiac surgeons, neonatologists and bioethicists decided for an elective cesarean delivery at the 27th week of gestation in the hybrid cardio-thoracic operating theater. Anesthesia was provided by combined spinal-epidural technique under invasive continuous hemodynamic monitoring with the Edwards Lifesciences HemoSphere with Hypotension Prediction Index (HPI) and ForeSight technology (Edwards Lifesciences, Irvine, USA) through catheterization of the left radial artery. The femoral arteries were left available for extracorporeal circulation. Continuous norepinephrine infusion was started once liquor was collected in the spinal needle at a 0.1 mcg/kg/minute through a central line and was continued until the end of surgery. Fluid management consisted of a total of 200 ml of crystalloids. HPI values never reached alarm values (maximum value =10). The patient was discharged home on the 5th day after delivery with good hemodynamic compensation. The baby was intubated at birth and then gradually weaned from mechanical ventilation, then discharged.

Anesthetic management of placenta accreta spectrum at an academic center and a comparison of the combined spinal epidural with the double catheter technique: A retrospective study

Study objectivesTo describe the anesthetic management and outcomes of placenta accreta spectrum (PAS) cases at our institution over a 19 year period and to compare outcomes associated with the lumbar combined spinal epidural (CSE) technique versus the double catheter technique (lumbar CSE with thoracic epidural catheter). DesignRetrospective cohort study. SettingLabor and delivery unit at a tertiary care center. Patients113 female patients who had histologically confirmed PAS on the final pathology report after cesarean delivery or cesarean hysterectomy. InterventionNeuraxial anesthesia, including CSE and the double catheter technique, and general anesthesia for PAS cases (including scheduled and unscheduled cases and those known or unknown as PAS preoperatively). MeasurementsThe medical records were reviewed for demographic information, intraoperative management, anesthetic technique, and outcomes. We describe anesthetic management and outcomes of cases classified as scheduled vs. unscheduled and known vs. unknown PAS. We also compare the CSE and double catheter techniques with the primary outcome being conversion to general anesthesia (GA). Main resultsWe included 113 cases: 60 (53.1%) scheduled/known cases, 12 (10.6%), scheduled/unknown cases, 22 (19.5%) unscheduled/known, and 19 (16.8%) unscheduled/unknown cases. All scheduled cases except two were started with a neuraxial technique. General anesthesia (GA) was used to start 18/41 (44%) of unscheduled cases. The double catheter technique (n = 35) was associated with a lower GA conversion rate (5.7% vs. 29.7%, P = 0.036) compared to the CSE technique (n = 37). ConclusionsNeuraxial anesthesia is the most commonly used technique for PAS cases in our practice. The double catheter technique was associated with lower GA conversion rates compared to the CSE technique in our cohort.