Dural Puncture Research Articles

Effect of dural puncture epidural technique combined with programmed intermittent epidural bolus on labor analgesia: A randomized, double-blind, parallel-group, controlled clinical trial.

Labor analgesia can be achieved by different approaches. The efficacy and safety of combined dural puncture epidural (DPE) with program intermittent epidural bolus (PIEB) are not well characterized. This study aimed to compare the efficacy and safety of DPE combined with PIEB vs epidural (EP) combined with PIEB for labor analgesia. We performed a prospective, randomized, double-blind, parallel-group, controlled clinical trial. Eligible pregnant nulliparous women received either DPE combined with PIEB (group D) or epidural combined with PIEB (group E) for labor analgesia. Analgesia was initiated with 0.1% ropivacaine + 0.3 µg/mL sufentanil and maintained with PIEB at 12 mL/h. Primary outcome was the proportion of women with adequate analgesia within 10 minutes after the initiation of analgesics. Secondary outcomes (time to achieve analgesia, time to first request for additional analgesic, proportion of women required additional analgesic or epidural catheter adjustment and resetting, total labor duration, total analgesic consumption, level of anesthesia, and motor block), side effects, and patient satisfaction were also documented. Out of 174 enrolled women, 160 were included in the analysis. Baseline characteristics were comparable. The proportion of women who achieved adequate analgesia in group D was significantly greater than that in group E (38.8% vs 20.0%, P < .05). Compared with group E, group D also showed advantages in faster adequate analgesic achievement, more likely to reach adequate analgesia, a longer time to maintain analgesia, lesser requirements for additional analgesic, and better sensory blocks. There were no significant inter-group differences in other outcome measures. Compared with epidural and PIEB mode, DPE and PIEB mode achieved better analgesia without increasing maternal or neonatal side-effects during labor.

Combined spinal-epidural vs. dural puncture epidural techniques for labour analgesia: a randomised controlled trial.

The dural puncture epidural technique is a modification of the combined spinal-epidural technique. Data comparing the two techniques are limited. We performed this randomised study to compare the quality of labour analgesia following initiation of analgesia with the dural puncture epidural vs. the combined spinal-epidural technique. Term parturients requesting labour epidural analgesia were allocated randomly to receive either dural puncture epidural or combined spinal-epidural. Analgesia was initiated with 2 mg intrathecal bupivacaine and 10 μg fentanyl in parturients allocated to the combined spinal-epidural group and with 20 ml ropivacaine 0.1% with 2 μg.ml-1 fentanyl in parturients allocated to the dural puncture epidural group. Analgesia was maintained using patient-controlled epidural analgesia with programmed intermittent epidural boluses. The primary outcome of the study was the quality of labour analgesia, which was defined by a composite of five components: asymmetric block after 30 min of initiation (difference in sensory level of more than two dermatomes); epidural top-up interventions; catheter adjustment; catheter replacement; and failed conversion to neuraxial anaesthesia for caesarean delivery, requiring general anaesthesia or replacement of the neuraxial block. One hundred parturients were included in the analysis (48 combined spinal-epidural, 52 dural puncture epidural). There were no significant differences between the two groups in the primary composite outcome of quality of analgesia (33% in the combined spinal-epidural group vs. 25% in the dural puncture epidural group), risk ratio (95%CI) 0.75 (0.40-1.39); p = 0.486. Median (IQR [range]) pain scores at 15 min were significantly lower in patients allocated to the combined spinal-epidural group compared with the dural puncture epidural group (0 (0-1[0-8]) vs. 1 (0-4 [0-10]); p = 0.018). There were no significant differences in the quality of labour analgesia following initiation of a combined spinal-epidural compared with a dural puncture epidural technique.

Effect of Dural Puncture Epidural Technique on Management of Breakthrough Pain for Parous Women Receiving Labor Analgesia during Induced Labor: A Retrospective Cohort Study.

This study assessed the effectiveness of the dural puncture epidural (DPE) technique in managing breakthrough pain in parous women receiving labor analgesia during induced labor. This single-center retrospective cohort study included term pregnant women with singleton pregnancies who received treatment for breakthrough pain during labor. All participants underwent induced labor, and some parous women among them underwent DPE. The DPE technique consisted of placing an epidural catheter after dural puncture with a 27-gauge spinal needle. Eligible women were allocated into a DPE group and conventional epidural (CE) anesthesia group. Pain was assessed with a numerical rating scale (NRS), and a patient-controlled epidural analgesia (PCEA) bolus was administered when the NRS score was ≥3. Breakthrough pain was defined as an NRS score ≥3 during PCEA management. The primary outcome was the efficacy of rescue interventions in managing breakthrough pain, as determined by a reduction in pain intensity to an NRS score <3 before birth. Among the 55 parous women who received labor analgesia, 44 required additional rescue administration for breakthrough pain. Of the remaining women, 23 received DPE and 19 received CE anesthesia. The DPE group experienced significantly more effective relief of breakthrough pain before birth than did the CE group (DPE: 100%; CE: 68.4%; p=0.005). In parous women, DPE anesthesia was more effective than CE anesthesia in providing analgesia for breakthrough pain immediately before delivery during induced labor.

Exploration of the optimal programmed intermittent epidural bolus volume with the dural puncture epidural technique for labour analgesia: a biased-coin up-and-down sequential allocation study.

To determine the optimal programmed intermittent epidural bolus (PIEB) volume for providing effective analgesia in 90% of patients (EV90) during the first stage of labour using the dural puncture epidural (DPE) technique to initiate labour analgesia. We conducted a biased-coin up-and-down sequential allocation study. We included 40 nulliparous women requiring epidural labour analgesia. We used a 25G Whitacre spinal needle to puncture the dural mater and then administered a loading dose of 12mL of ropivacaine 0.1% and sufentanil 0.3μg·mL-1. Subsequently, the PIEB pump delivered boluses with an identical solution at a fixed 40-min interval, starting 1hr after epidural initiation. The bolus volume for the first patient was 7mL and was adjusted for subsequent patients according to the study protocol (bolus volume, 7-12mL). The primary endpoint was effective analgesia, indicated by no need for patient-controlled or manual boluses within 6hr after analgesia initiation or until complete cervical dilation, whichever came first. Outcome evaluators assessed the patients' pain ratings, Bromage scores, sensory blockade level, and maternal blood pressure hourly. Using the truncated Dixon and Mood method, the estimated EV90 was 9.2mL (95% confidence interval [CI], 8.5 to 9.9) whereas the isotonic regression method yielded a value of 8.8mL (95% CI, 8.6 to 9.8). None of the patients experienced a motor block. Two patients experienced hypotension without the need for vasopressors. The estimated PIEB EV90 for ropivacaine 0.1% and sufentanil 0.3μg·mL-1 approached 9mL when DPE was combined with a fixed 40-min interval. ChiCTR.org.cn ( ChiCTR2300067281 ); first submitted 3 January 2023.

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

The Relationship Between Age and The Incidence of Post Dural Puncture Headache in Post Sectio Caesarea Patients with Spinal Anesthesia

Background: Caesarean Section (CS) is a surgical procedure involving incisions in the abdominal wall and uterus. Spinal anesthesia is the preferred method due to the lower maternal morbidity and mortality risks compared to general anesthesia. However, the most common complication associated with spinal anesthesia is Post Dural Puncture Headache (PDPH), caused by a dural puncture. Age is a significant factor influencing PDPH occurrence. Patients aged 20-40 are at a higher risk, while those over 50 years have a reduced risk due to the decrease in cranial elasticity and pain sensitivity with age. Purpose: This study aims to assess the correlation between age and the incidence of PDPH following spinal anesthesia in CS patients. Methods: This study employed a cross-sectional analytic correlation design. The sample included all CS patients who received spinal anesthesia and met the study criteria, totaling 35 respondents. Data were analyzed using univariate and bivariate analysis, with the correlation significance tested at 0.05 (2-tailed). Findings: The study revealed that 14.3% of respondents experienced PDPH, while 85.7% did not. A significant correlation was found between age and PDPH incidence, with a p-value of 0.05. The highest incidence of PDPH was observed in the 20-40 age group, decreasing notably in individuals aged 50 and above. Conclusion: This study highlights that PDPH risk is highest in patients aged 20-40 and significantly decreases in patients older than 50. Age-related changes in cranial structure and pain sensitivity likely contribute to this decreased risk.

Causes, Effects &amp; Management of Post Dural Puncture Headache among Obstetric Patients in a Tertiary Care Hospital: An Observational Study

Causes, Effects &amp; Management of Post Dural Puncture Headache among Obstetric Patients in a Tertiary Care Hospital: An Observational Study

Prevention and treatment approaches of post-dural puncture headache in obstetric patients: A comprehensive review

Neuraxial anesthesia and analgesia are administered to many patients. The incidence of dural puncture is about 1%, with a higher occurrence in laboring women. Post dural puncture headache (PDPH) develops in 60%-80% of patients after dural puncture which is usually positional and sometimes is accompanied by neck stiffness, photophobia, nausea, or hearing symptoms. It can also drive-up healthcare costs by increasing the length of hospital stay for chronic headache and back pain. PDPH has the potential to cause significant morbidity in the obstetric patients which prolongs the hospital stay. Epidural blood patch (EBP) is considered the gold standard for the management of PDPH. Proper scheduling of analgesics and supporting the patient psychologically as she cares for her newborn is needed. If the intensity of headache is severe, additional agents may be considered. In this review, the different methods and therapeutic approaches for prevention and treatment of PDPH are comprehensively discussed.

Headache Due to Spontaneous Intracranial Hypotension Treated with Cervical Epidural Blood Patch

Abstract Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid and it is characterized by an orthostatic headache without a history of trauma or dural puncture. Epidural blood patches have been regarded as the mainstay of therapy for SIH, often providing instantaneous relief of symptoms in 90% of cases regardless of the site of the leak. We present a rare case report of an epidural leak treated with a cervical epidural blood patch.

The Prophylactic Effect of Acetaminophen and Caffeine on Post Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Double-Blind Clinical Trial.

Post-dural puncture headache (PDPH) is the most common complication following spinal anesthesia among parturients undergoing cesarean section surgery. The purpose of this study was to evaluate the effectiveness of acetaminophen and caffeine in preventing PDPH. This double-blind, randomized clinical trial was conducted on 96 obstetric women, who were candidates for elective cesarean section. Following the randomization of participants into two groups, participants in the intervention group received tablets of acetaminophen (500 mg)+caffeine (65 mg), and participants in the control group received placebo tablets orally 2 hours before spinal anesthesia induction and then every 6 hours after surgery up to 24 hours. All parturients were evaluated for frequency and intensity of PDPH every 6 hours until 24 hours after surgery and then 48 and 72 hours after surgery. Overall satisfaction during the first 72 hours of postpartum was evaluated. The data were analyzed using SPSS software. P<0.05 was considered statistically significant. Participants in the intervention group were 70% less likely to experience PDPH after spinal anesthesia (OR=0.31 P=0.01, 95% CI [0.12-0.77]). They also experienced significantly milder headaches 18 hours, 48 hours, and 72 hours later. Participants in the intervention group reported higher levels of satisfaction at the end of the study (P=0.01). No side effects related to the intervention were reported. Prophylactic administration of acetaminophen+caffeine decreases 70% the risk of PDPH and significantly attenuates pain intensity in obstetric patients who underwent spinal anesthesia for cesarean section.

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.

FACTFINDERS FOR PATIENT SAFETY: Minimizing risks with cervical epidural injections

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections.Evidence in support of the following facts is presented.Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections – 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks.Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections – the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes.Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

Obstetric Outcomes of Nighttime Versus Daytime Delivery with Labor Epidural: An Observational Retrospective Study.

Background: Variability in obstetric outcomes in terms of the number and type of deliveries related to the day-night cycle has been described in previous studies. This 11-year retrospective analysis explores the effects of nighttime versus daytime delivery with labor epidural on obstetric outcomes. Methods: Data on deliveries performed between 1 October 2008 and 1 October 2019 were collected and differentiated into daytime, occurring from 8:00 a.m. to 7:59 p.m., and nighttime deliveries, occurring from 8:00 p.m. to 7:59 a.m. of the following day. The data collected included the patient history and maternal and neonatal outcomes. Results: A total of 29831 patients were included in the analysis. A positive and statistically significant correlation between the number of cesarean sections (Odds Ratio 1.35; 95% confidence interval = 1.26-1.44; p < 0.001) and the number of vaginal operative deliveries (Odds Ratio 1.21; 95% confidence interval = 1.01-1.44; p < 0.05) in patients who did not receive an epidural at nighttime was reported. Regarding the labor epidurals, a significantly greater incidence of accidental dural punctures with needles (0,4%; p < 0.05) in the nighttime versus daytime was reported. Conclusions: The absence of labor epidurals was associated with a significant increase in the number of cesarean sections and vaginal operative deliveries occurring at nighttime, without significant differences in labor duration. The incidence of anesthesiologic complications was greater in deliveries performed at nighttime.

Post-dural puncture headache treated with grater occipital nerve block

Introdution: post-dural puncture headache (PDPH) is an importante and relatively frequent complication after dural puncture. It is a intense pain that worsens when sitting or standing and improves when lying down. Epidural blood tamponade is the most effective treatment, but it is invasive. Objective is to demonstrate the results of greater occipital nerve (GON) block in the treatment of PDPH. Method: 3 patients after cesarean section with PDPH were evaluated. They agreed to GON blockade after failure of hydration, bed rest and analgesics. Blockade was performed bilaterally with 2 ml of lidocaine (20 mg/ml) and 2 ml of dexametasone (2 mg/ml). Results: analogic visual scale (AVS) before the procedure was 8 for the first patient, 8 for the second and 9 for the third respectively, with the patients sitting (average 8.3). After 2 hours of GON blockade, the AVS was 1, 2 and 2 respectively (average 1.6). After 24 hours, the AVS was 0, 1 and 1 (average 0.6). No side effects were reported. Conclusion: in the cases in question, GON blockade showed good efficacy in the treatment of PDPH. The procedure is simple and quite safe. Although epidural blood patching is the definitive treatment for PDPH, GON blockade is an option to be considered for the treatment of these patients.

CT-Guided Epidural Contrast Injection for the Identification of Dural Defects.

Post-dural puncture headache (PDPH) is an increasingly recognized cause of chronic headache. Outside of clinical history and myelography that requires an additional dural puncture, there is no reliable diagnostic test to evaluate for persistent dural defects. We describe the injection of iodinated contrast into the dorsal epidural space under CT guidance in five patients as a potential tool to visualize persistent dural defects.ABBREVIATIONS: PDPH = post-dural puncture headache; SIH = spontaneous intracranial hypotension; DSM = digital subtraction myelography; CTM = CT myelography.

Prophylactic cosyntropin after unintentional dural puncture and incidence of post-dural puncture headache and epidural blood patch use: A retrospective cohort study (2019–2022)

BackgroundCosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP). MethodsWe conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded. ResultsCosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI −6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI −5% to 28%, p = 0.17). ConclusionsProphylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.

Neuropsychiatric Manifestations, As a Rare Presentation of Venous Sinus Thrombosis Two Weeks After Cesarean Section: First Report in the Gambia

Cerebral venous sinus thrombosis (CVST) is a rare and potentially fatal condition, accounting for about 0.5% of all cerebrovascular disease cases globally. It is challenging to diagnose due to its rarity and diverse clinical presentations that can mimic other acute neurological conditions [1]. The reported worldwide incidence of CVST during pregnancy and postpartum is approximately 3 to 4 cases per million, with superior sagittal sinus thrombosis (SSST) being the most prevalent type. Risk factors include the prothrombotic state of pregnancy in the third trimester, obesity, accidental dural puncture, deficiencies in protein C and S, antiphospholipid syndrome, and the use of oral contraceptives among others. Symptoms typically manifest within the first three weeks postpartum, with severe headache being the most common complaint. The low number of reported cases in sub-Saharan Africa suggests underdiagnosing or underreporting, with infection being the primary cause in this region. We report a case at our facility who, two weeks after a cesarean section, presented with severe headache, confusion, irritability, restlessness, and later developed a focal motor deficit. Imaging studies were crucial in diagnosing SSST and ruling out other conditions causing acute brain injury. This is the first reported case in The Gambia, and one of the few described in West Africa related to an obstetric procedure. The onset, characterized by neuropsychiatric symptoms, is unusual and interesting, as these manifestations are less common than the typical headache, seizure, and focal motor deficit described in the literature.

A study to Assess the Effectiveness of Lumbar Massage on Backache among Patients Underwent Spinal Anesthesia in Selected Hospitals

Background: Spinal anesthesia is the most commonly used type of regional anesthesia in many surgeries, including genit ourinary surgery, cesarean section and lumbar surgery.P ost dural puncture pain is common complication after spinal anesthesia and is characterized by persistent pain around the spinal cord in the absence of radicular pain.Therapeutic massage involves manipulating the body’s tissues with certain techniques.The goal of massage therapy is to affect cellular changes in tissues to promote healing and reduce pain and increase overall wellbeing.  Aim: To determine the effect of lumbar massage on back pain in patients underwent general anesthesia in selected hospitals.  Design: Quasi-experimental design, Pretest Post-test non- equivalent group design.  Participants: Thirty patients who met the inclusion criteria were selected to receive spinal anesthesia through convenience sampling.  Methods: A study was done with 30 patients who underwent spinal anesthesia, 15 of which were interventional and 15 of which were observational group. The pain scale was used for the assessment tools.  Results: According to the research results, it can be concluded that the average percentage of the difference after the experiment and control is 47% for the pain index numbers in the total area comparison. There was a full size distinction between the pre and post test scores of the patients in the interventional group who received spinal anesthesia there has been a big distinction in the sufferer’s post test rankings. The t test score is 12.43 and is significant (P&lt;0.05). There was a significant difference in post patient scores. No significant relationship was found between patients receiving spinal anesthesia and demographic difference.  Conclusion: The effects showed that the average score of the patient in the control group receiving spinal anesthesia after the back pain examination was 7.33 ± 1.06,while the average score of the experimental group after the backache examination was 3.07 ±0.54.It shows that lumbar massage is beneficial for patients underwent spinal anesthesia.

Effects of Continuous versus Single Dose Spinal Anesthesia in Octogenarians Undergoing Hip Surgery: Randomized Control Trial

Abstract Background Continuous spinal anesthesia (CSA) is an anesthetic technique that offers several clinical advantages for anesthesia and analgesia in elderly patients. The level of sensory blockade can be titrated to the desired dermatomal level with great precision with intrathecal (IT) catheters, allowing better control of the hemodynamic consequences of sympathetic blockade associated with spinal anesthesia compared to epidural or single shot spinal techniques. Octogenarians are expected to suffer more from hemodynamic instability with spinal anesthesia. Objective The primary outcome is to compare the incidence of hypotension (defined as decrease in mean arterial blood pressure &amp;gt; 20% from the base line) in continuous spinal anesthesia CSA versus single dose spinal anesthesia in octogenarians undergoing hip surgery. The secondary outcome is to determine the total use of vasopressor (Ephedrine) and the incidence of spinal complications as nausea, vomiting and post Dural puncture headache. Methods This is a randomized controlled clinical trial done at Ain-shams University Hospitals, Cairo, Egypt within a period of 6 months from approval of medical ethics committee. Twenty patients in CSA group received increments of (0.5 ml) of plain bupivacaine 0.5% until T10 level blockade is achieved. Twenty patients in SDA group received single shot of (2.5ml) of bupivacaine 0.5%. Results The main finding of this study is that while MAP was significantly lower between 5-35 minutes (&amp;lt;0.001), it was significantly higher between 40-75 minutes in SDA group than CSA group (0.05).Total bupivacaine dose was significantly higher in SDA (12.5±0.8) group than CSA group (7.6±1.3) (p &amp;lt; 0.001). The total ephedrine dose needed was significantly higher in the SDA group (19.5 ±11.3) than in CSA group (4.5±1.7) (p.0.006). Conclusion The main finding of this study is that for octogenarians undergoing hip surgery, while MAP was significantly lower between 5-35 minutes, it was significantly higher between 40-75 minutes in single dose spinal anesthesia group than continuous spinal anesthesia group. Episodes of bradycardia were similar in both groups. The bupivacaine dose as well as total ephedrine dose was significantly higher in SDA group than CSA group. Groups were similar in the incidence of postoperative complications related to the neuraxial blockade. The impact of these changes on the overall cardiovascular status and outcome in octogenarians undergoing hip surgery could not be determined from our study design.

Posterior Reversible Encephalopathy Syndrome After Inadvertent Dural Puncture Vs Bupivacaine-Induced Adverse Drug Reaction: A Case Report

A case involving a 29-year-old female patient with a known case of hypothyroidism at 38 weeks gestation. She developed a fronto-occipital, postural type of headache. This ensued on the second postoperative day after undergoing an unintended dural puncture with the introducer needle during spinal anesthesia for an elective cesarean section. It was initially treated as a post-dural puncture headache until she developed generalized tonic–clonic seizures the next day. Magnetic resonance imaging (MRI) of the brain exhibited features of posterior reversible encephalopathy syndrome (PRES). With anticonvulsants and antibiotics, the neurological symptoms subsided, and the patient was discharged home symptom-free. We call attention to the importance of suspecting PRES in obstetric cases with an inadvertent dural puncture in a normotensive patient. Neuroimaging plays a crucial role in making a diagnosis of headaches, especially during the peripartum period. Lastly, keeping in view, the potential medicolegal implications in such cases, further research seems vital, especially in the Asian population.