Epidural Research Articles

Update on the Obstetric Anesthesia Practice in Flanders/Belgium: A 10-year follow-up survey and review

Background: With 75% of women receiving neuraxial anesthesia for labor and cesarean section (CS) in Flanders, Belgium, obstetric anesthesia is an essential part of perinatal care. Despite advancements in obstetric anesthesia and guidelines being updated regularly, past surveys have shown great variability among hospitals. Objective: This investigation aims to observe current obstetric anesthesia practices, compare them with previous surveys, and assess adherence to guidelines among anesthesiologists. Methods: An online questionnaire-based survey, approved by the KU Leuven Ethics Committee, was conducted focusing on three main topics: analgesia during labor, anesthesia for CS, and postoperative analgesia after CS. The survey, consisting of 127 questions, was distributed via email to the heads of anesthesia departments in 57 Flemish hospitals providing obstetric anesthesia care. Responses were anonymously analyzed. Results: For labor analgesia initiation, a conventional epidural with administration of ropivacaine 0.2% (+- sufentanil) remains the most widespread used technique, although Combined-Spinal Epidural (CSE) has gained significant popularity. Patient-controlled epidural analgesia (PCEA) in combination with continuous epidural infusion (CEI) is the preferred maintenance method, however programmed-intermittent bolus (PIEB) has found its way into standard practice. CSs are mostly done by performing CSE or single shot spinal, using hyperbaric bupivacaine 0.5% with sufentanil. Spinal-induced hypotension is treated with a combination of left lateral tilt, fluid administration and vasopressor administration, usually as a bolus. Post-CS pain is mainly treated by a combination of oral/ parenteral analgesics and neuraxial analgesia (PCEA +- CEI), with only a minority choosing regional techniques such as wound infiltration, transverse abdominal plane blocks, quadratus lumborum blocks, etc. Conclusion: Compared to previous surveys, the Flemish anesthesiologists adhere well to the latest guidelines and gold standards in obstetric anesthesia, consistently modernizing their practices. Nevertheless, with the continual introduction of novel techniques and methods, it is imperative for practitioners to maintain efforts in pursuing ongoing innovation.

An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.

Three settings are required on a programmed intermittent epidural bolus (PIEB) pump for labor analgesia: the PIEB next bolus (PIEBnb), PIEB interval (PIEBi), and PIEB volume (PIEBv). The ideal settings for these parameters are still unknown. We hypothesized a mathematical modeling tool, response surface methodology (RSM), could estimate 3 PIEB pump parameters while balancing 3 clinically important patient outcomes simultaneously. The study objective was to use RSM to estimate PIEB settings (PIEBnb, PIEBi, and PIEBv) while maximizing maternal satisfaction, minimizing the need for clinician-administered boluses, and optimizing the ratio of delivered/requested patient-controlled epidural analgesia (PCEA) boluses simultaneously. With institutional ethics approval, a double-blind randomized trial was completed in a tertiary care labor and delivery center. Nulliparous, English-speaking American Society of Anesthesiologists (ASA) physical status II patients aged 18 to 45 years at full term, single gestation in vertex presentation, in spontaneous labor and ≤7 cm cervical dilation were included. Patients with comorbidities, contraindications to neuraxial analgesia, using chronic analgesics, <152 cm, or body mass index (BMI) >45 kg/m 2 were excluded. After informed consent, labor analgesia was initiated using 10 mL ropivacaine 0.2% with 10 µg/mL fentanyl solution and PCEA (volume 6 mL every 10 minutes). Patients were randomized to predetermined PIEB settings. RSM identified 3 pump settings that represented a stationary point that best maximized or minimized 3 outcomes simultaneously: PCEA ratio (a ratio closest to 1), clinician bolus (optimal is 0), and maternal satisfaction (visual analog scale, 0-100, ideal response is ≥90). Of 287 potential participants, 192 did not meet inclusion criteria or declined to participate, and 26 were withdrawn, leaving 69 patients for study inclusion. Using RSM, the suggested PIEB settings for all the primary study outcomes were as follows: PIEBnb = 29.4 minutes, PIEBi = 59.8 minutes, and PIEBv = 6.2 mL. These PIEB settings corresponded to the following clinical outcomes: maternal satisfaction at 93.9%, PCEA ratio at 0.77, and need for clinician bolus at 0.29. The dermatome sensory score was between T10 and T5 in 89% of the patients. The median lowest Bromage score was 4. This novel study used a mathematical model to estimate PIEB pump settings while simultaneously maximizing 3 clinical outcomes. Equally weighted clinical outcomes prevent maximal outcome optimization and may not reflect patient priorities. Future studies or quality improvement endeavors could use RSM methodology to estimate PIEB pump settings targeting optimal values for a single clinical outcome of determined importance to parturients.

A Comparative Study Of Caudal Epidural Bupivacaine And Midazolam-Bupivacaine Mixture For Post-Operative Analgesia In Children Repairing Congenital Inguinal Hernia

Background: Managing postoperative pain in pediatric anesthesia is challenging, with caudal epidural anesthesia being a preferred technique for its safety and efficacy. Enhancing analgesia duration through adjuvants like midazolam may improve outcomes. Objective: This study compares the effectiveness of caudal epidural bupivacaine alone versus a bupivacainemidazolam mixture in children undergoing repair of congenital inguinal hernia, circumcision, and hypospadias repair, focusing on postoperative analgesia duration and side effects. Materials and Methods: A double-blind randomized controlled trial was conducted at Islami Bank Medical College Hospital from October 2023 to March 2024, involving 50 children aged 2-8 years, divided into two groups: Group A (bupivacaine-midazolam) and Group B (bupivacaine alone). Pain was assessed using the FLACC scale at specified intervals up to 24 hours post-surgery. Results: Group A experienced significantly longer postoperative analgesia (10.72 ± 4.07 hours) compared to Group B (6.13 ± 1.98 hours). Mild pain was more common in Group A (72.7%) than Group B (87.5%), while moderate pain was higher in Group A (27.3%) than Group B (12.5%). Side effects were minimal, with Group A having no side effects and Group B experiencing 8% nausea and vomiting and 4% other side effects. Conclusion: The addition of midazolam to caudal bupivacaine significantly prolongs postoperative analgesia and reduces the need for rescue analgesia in children, with minimal side effects

Role of lumbar puncture level on the onset of epidural labor analgesia: a randomized controlled trial.

To compare the speed of achieving painless uterine contractions in parturients undergoing epidural analgesia at different lumbar puncture levels. This study is a randomized controlled trial at a tertiary A hospital with a history of over 80years in Sichuan Province, China. Parturients aged 22-40years old scheduled for vaginal delivery under epidural analgesia were recruited. Eligible patients were randomly allocated into lumbar 2-3 (L2-3) or lumbar 3-4 (L3-4) groups. Epidural analgesia was performed through the interspaces according to grouping. The primary outcome was the percentage of painless uterine contractions 15min after the initiation of analgesia. The secondary outcomes included the percentage of painless status at 5 and 10min, sensory block plane, motor block evaluation, adverse events of parturients, epidural analgesic consumption, Apgar score, and the parturients' evaluation of analgesia. Between April 2023 and August 2023, a total of 150 women were finally recruited, and 136 of them were analyzed (68 in each group). In comparison with the L3-4 groups, there was a significantly larger proportion of painless uterine contractions at 5, 10, and 15min after analgesia initiation in the L2-3 group (20.6% vs. 7.4%, 52.9% vs. 26.5%, and 80.9% vs. 64.7%, P = .026, .002, and .034, respectively). Similarly, the pain scores were lower in the L2-3 group at 5, 10, and 15min than that in the L3-4 group (5(4,7) vs. 6(5,7), 3(2,5) vs. 4(3,6), and 2(1,3) vs. 3(2,5), P = .006, .004, and .020, respectively). Furthermore, puncturing through the L2-3 interspace contributed to a higher evaluation of parturients to the analgesia procedure (9(8,9) vs. 8(8,9), P < .001). However, there was no significant difference in sensory block, motor block, or adverse events between the two groups. Puncturing through the L2-3 interspace is associated with faster pain relief and a better experience for parturients. These findings present a superior option for anesthesiologists when conducting epidural labor analgesia. Key messages What is already known on this topic? Epidural analgesia is an effective way to relieve labor pain. What this study adds? Puncturing via lumbar 2-3 interspace induces more rapid onset of epidural analgesia. How this study might affect research, practice or policy? Lumbar 2-3 interspace is a superior option in terms of the speed of pain relief and satisfaction of parturients when conducting epidural labor analgesia.

Appropriate timing for the removal of urinary catheters in gastrointestinal surgery with epidural anesthesia: a randomized controlled trial.

The purpose of this randomized controlled trial was to evaluate whether early urinary catheter removal is feasible during epidural anesthesia during gastrointestinal surgery in male patients at high risk for urinary retention. Male patients who underwent radical surgery for gastric or colon cancer were enrolled in this randomized controlled trial. Patients were randomized 1:1 into 2 groups: the early group, in which the urinary catheter was removed before removal of the epidural catheter on the second or third postoperative day, and the late group, in which the urinary catheter was removed after removal of the epidural catheter. The randomization adjustment factors were age (≥ 65 or < 65 years) and operative site (gastric or colon). The primary endpoint was urinary retention. The secondary endpoints were the incidence of urinary tract infection and length of postoperative hospital stay. Seventy-three patients were enrolled between March 2020 and February 2024 and assigned to the Early (n = 37) and Late (n = 36) groups. Four patients withdrew their consent after randomization. The intention-to-treat analysis showed that urinary retention occurred in 4 patients (11.1%) in the early group and 1 patient (3.0%) in the late group (P = 0.20). Urinary tract infection occurred in 1 patient (3.0%) in the late group. The median postoperative hospital stay was 9 days in both groups. Early urinary catheter removal in male patients undergoing gastrointestinal surgery with epidural anesthesia could increase urinary retention within the expected acceptable range. UMIN000040468, Date of registration: May 21, 2020.

Fusariosis in the Sphere.

In 2012, the US Centers for Disease Control and Prevention reported a fungal meningitis outbreak due to Exserohilum rostratum, caused by methylprednisolone administration. Twelve years later, an iatrogenic outbreak of Fusarium meningitis was documented in Mexico after epidural anesthesia.

Median effective dose of spinal ropivacaine in combined spinal and epidural anesthesia for emergency cesarean delivery following failed vaginal delivery with epidural labor analgesia: a single-blind, sequential dose-finding study.

This study aimed to estimate the median effective dose of intrathecal isobaric ropivacaine without opioid required for adequate cesarean delivery anesthesia after epidural labor analgesia. Patients aged 20-40years with American Society of Anesthesiology scores of I-II, body mass index ≤ 36, who underwent emergency cesarean delivery after failed vaginal delivery with epidural analgesia of a duration ≤ 6h were included in the study. After removal of the epidural used for labor analgesia, a new combined spinal epidural was performed, and a dose of intrathecal isobaric ropivacaine without opioid was administered. The dose was determined using up-down methodology, with the starting patient's dose set to 12mg. Adequate anesthesia, defined as a pinprick level no lower than T6 at 5min after ropivacaine administration, resulted in the next patient receiving a dose of ropivacaine 1mg higher, and inadequate anesthesia 1mg lower. The primary outcome was the median (95% confidence interval (CI)) dose of spinal ropivacaine required for adequate cesarean delivery anesthesia. Of the 46 patients included in the study, 40 were analyzed. The median spinal ropivacaine dose was 8.11mg (95% CI 7.29-8.93mg) by the Dixon and Mood method and 8.06mg (95% CI 6.93-9.00mg) by isotonic regression. Two patients had high spinal anesthesia. Our findings suggest that for 50% of patients undergoing cesarean delivery after failed vaginal delivery with epidural analgesia, an 8-mg spinal dose of isobaric ropivacaine without opioid provides an anesthesia level no lower than T6 at 5min.

Comparison of lidocaine bicarbonate with fentanyl and chloroprocaine for epidural anesthesia during cesarean section: a randomized, controlled, double-blind clinical trial.

Chloroprocaine and lidocaine bicarbonate are commonly used for epidural anesthesia because of their rapid onset, particularly in the case of conversion from epidural labor analgesia to emergency cesarean section. However, it is unclear whether lidocaine bicarbonate combined with fentanyl has an advantage over chloroprocaine alone in emergency cesarean section. In this study, 102 women who underwent elective cesarean section received 15mL 3% chloroprocaine and 1mL saline (CP group) or 15mL 1.73% lidocaine bicarbonate and 1mL fentanyl 50μg (LF group) for epidural anesthesia. Nociceptive block level was assessed by pinprick and recorded every minute. The primary outcome was the onset time to T6 block. The median onset time to T6 analgesia was 10 [10, 10] min in the CP group and 10 [7, 10] min in the LF group (COX model for CP versus LF, HR 0.47, 95% CI 0.23-0.95, p = 0.035). The median onset time to T8 analgesia was 7 [5, 9] min in CP group and 5 [4, 7] min in LF group (COX model for CP versus LF, HR 0.61, 95% CI 0.39-0.95, p = 0.027). The proportion of hypotension episodes occurring before delivery in LF group was lower than that in CP group (p = 0.011). The incidence of block level ≥ T4 after supplemental dosing in the LF group was lower than that in the CP group (p = 0.031). Compared with 3% chloroprocaine, 1.73% lidocaine bicarbonate combined with fentanyl 50μg has a slightly faster onset time and less hypotension in epidural anesthesia for cesarean section. Clinical Trial Registration: http://www.chictr.org.cn/index.html, identifier ChiCTR2200056180.

Comparison of Perioperative Pain Management between Arthroscopic Rotator Cuff Repair and Total Knee and Hip Arthroplasty

Background Although postoperative shoulder pain surgery is severe, the quality of its management has not been studied in comparison with pain after other orthopedic surgeries. Furthermore, reports have investigated daytime pain, but none have discussed nighttime pain. Objective This study aimed to compare perioperative pain management in patients who underwent Arthroscopic Rotator Cuff Repair (ARCR) and those who underwent lower extremity arthroplasty. Methods The study population included 33 patients who underwent ARCR and 21 patients who underwent lower-extremity arthroplasty between August 2015 and March 2016. For postoperative analgesia, an interscalene brachial plexus block was used for ARCR, and an epidural block was used for lower extremity arthroplasty. The Visual Analog Scale (VAS) for rest and night pain was measured from the day before the operation to the fourth postoperative day. Results In ARCR, night pain was significantly weaker on the day of surgery (VAS, ARCR 23.9 vs. lower extremity arthroplasty 47.9; P = 0.008); however, it was significantly stronger on the second and third postoperative days (2nd, 45.6 vs. 23.2; P = 0.002 / 3rd, 38.1 vs. 23.5; P = 0.021). There were no significant differences in rest pain. Conclusion It was confirmed that postoperative pain can be well managed in patients undergoing ARCR. However, because the pain worsened after the removal of the block, further improvement is required.

Morphological and morphometric analysis of the Sacral Hiatus using lumbosacral spine CT scans: clinical relevance in Caudal Epidural Analgesia.

To conduct a morphological and morphometric analysis of the sacral hiatus (SH) using lumbosacral spine CT scans and to evaluate its clinical relevance in caudal epidural analgesia (CEA). This retrospective study analyzed 77 lumbosacral spine CT scans from a diverse patient population. The shape of the SH was classified into common types: inverted U, inverted V, irregular, and bilobed. Morphometric measurements included the length, width, and depth at the apex of the SH. The apex level of the SH was also determined in relation to the sacral vertebrae, and statistical analysis was performed to identify any correlation between the apex level and the morphometric dimensions. The most frequent SH shape was inverted U (68.83%), followed by inverted V (20.77%), irregular (9%), and a single instance of a bilobed shape (1.29%). The apex of the SH was most commonly located at the level of the S4 vertebra (75.32%), followed by the S3 vertebra (20.77%), S5 in two (2.59) and S2 in one (1.29%). No significant correlation was found between the level of the apex and the length, width, or depth of the SH. These findings indicate a high degree of anatomical variability in the SH, independent of the apex level. The anatomical variability of the SH, as observed in this study, underscores the need for individualized assessment during CEA. The lack of correlation between the apex level and the morphometric dimensions of the SH highlights the importance of imaging modalities such as ultrasound or fluoroscopy to ensure precise localization and effective analgesia administration. These insights can improve clinical outcomes by enhancing the accuracy and safety of caudal epidural procedures.

90% effective volume of 0.1% ropivacaine combined with 0.4 µg/ml sufentanil for epidural labour analgesia with push pump at a rate of 400 mL/hr and a bolus interval of 30 min: a double-blind sequential dose-finding study

BackgroundIt was reported that either shorter programmed intermittent epidural bolus (PIEB) intervals or high-speed bolus can produce more extensive epidural spread. We hypothesized that a combination of shortened time interval and increased speed of epidural bolus might further improve analgesic effect and therefore reduce the hourly volume for epidural labour analgesia.MethodsThis double-blind dose-finding study used a biased coin up-and-down sequential allocation method to determine the 90% effective bolus volume of ropivacaine combined with sufentanil while using the push pump at a rate of 400 mL/hr and interval of 30 min to provide effective analgesia without breakthrough pain. We used 0.1% ropivacaine with 0.4 µg/mL sufentanil, with bolus volumes ranging from 3 to 6 mL. The first patient was assigned a volume of 3 mL, and the remaining volumes were assigned according to the biased coin-up-and-down method.ResultsThe estimated 90% effective volume (EV90) of ropivacaine combined with sufentanil for epidural labour analgesia at a time interval of 30 min was 4.88 mL (95% confidence interval 4.83–5.38).ConclusionsThe optimum bolus volume of ropivacaine with sufentanil while using push pump at a time interval of 30 min is approximately 5 mL. It could probably further reduce the hourly bolus volume for epidural labour analgesia.

South Asian women’s views on and experiences of maternity care services in Hong Kong: A qualitative study

BackgroundHealth disparities among ethnic minority and migrant women can lead to adverse maternal and neonatal outcomes. This study explores the maternity care experiences of South Asian women in Hong Kong, providing insights for woman-centred and culturally responsive care in the East Asia. ObjectiveTo understand South Asian women’s views and experiences regarding maternity care services in Hong Kong. MethodsA qualitative descriptive study was conducted with 20 English-speaking South Asian women who had used maternity care services in Hong Kong within the past 5 years. Data were analysed by thematic analysis. FindingsFour themes were identified: 1) Comparing maternity care services in their home country versus Hong Kong; birth location, mode of birth and care. 2) Navigating Hong Kong maternal medical care system; including private public dual care and learning information from other South Asians. 3) The discrepancy in perception of optimum care; including a preferring for assistance with daily tasks, epidural anaesthesia, doctor-led care, and priority to infants’ health. 4) The impact of the COVID-19 pandemic on maternity care experiences, including the cancellation of translation services and limited visiting hours. DiscussionSouth Asian appreciate Hong Kong’s public maternity services due to its perceived greater cost-effectiveness. The major incongruence between expectations and services provided being women-staff communication. ConclusionThe quality of healthcare in Hong Kong is appreciated. Individualized care should be offered to cater to diverse needs. Improvements in staff attitude and provision of detailed information should help alleviate feelings of differential treatment.

Effect of Early Removal of Urinary Catheter in Patients Undergoing Abdominal and Thoracic Surgeries with Continuous Thoracic Epidural Analgesia on Postoperative Urinary Retention

Background: Postoperative continuous thoracic epidural analgesia (TEA) is an integral aspect of pain management after major abdominal and thoracic surgery. Under TEA, postoperative urinary retention (POUR) is frequently noted, prompting a common practice of maintaining the transurethral catheter (UC) until the cessation of TEA to avoid the necessity for reinsertion of the UC. This study analyzes the effect of an early bladder catheter removal during TEA on POUR incidence. Methods: The retrospective study was conducted on 71 patients undergoing elective abdominal and thoracic operations with TEA for postoperative pain control. Patients were divided into two groups based on the UC removal time in relation to the epidural catheter removal. In the early removal group (ERG), the UC was removed within 3 days of surgery, while in the standard group (SG), it was removed after completion of TEA. All patients in the ERG were still receiving TEA at the time of the UC removal. The primary outcome assessed was the incidence of POUR, while secondary outcomes included urinary tract infections (UTI), hospital length of stay (LOS), and patient’s comfort. Results: The overall prevalence of POUR was 7%, with five POUR cases – two (4.9%) of 41 patients in SG and three (10%) of 30 in ERG (p = 0.644). No significant difference was found in POUR occurrence between ERG and SG (p = 0.644). Additionally, no UTIs were observed in the study. The postoperative pain scores (visual analog scale [VAS]) 72 h and 96 h and the LOS (SG: 16.74 [±8.39] days; ERG: 14.53 [±6.99] days; p = 0.3) were similar between both study groups. Conclusion: Based on our results, it can be concluded that the removal of UC in the early postoperative period, even during TEA, can be performed safely without significantly increasing the risk of recatheterization.

Modern approaches to choosing the method of regional anesthesia during video-assisted thoracoscopic surgery

The objective was to analyze the literature on modern approaches to the choice of regional anesthesia method for thoracoscopic surgical interventions. Materials and methods. A review of the most common approaches to the choice of regional anesthesia method for thoracoscopic surgical interventions was carried out.Results. The analysis of the literature has shown that to date, in the practice of an anesthesiologist and intensivist, there is no single standard for anesthesia of patients during and after thoracoscopic operations, but the use of regional anesthesia methods can increase the positive effects of minimally invasive methods, which include video-assisted thoracoscopic surgeries (VATS). Further studies comparing the efficacy of regional anesthesia methods in thoracic surgery are needed.Conclusion. At the moment, the evidence collected in the world specialized literature confirms that thoracic epidural analgesia (TEA), paravertebral block, erector spinae plane block, and serratus anterior plane block can be considered comparatively effective methods of regional anesthesia in VATS. Meanwhile, high-quality comparative clinical studies that allow us to choose the most effective and safe method of regional anesthesia are limited.

Impact of regional anesthesia on left and right ventricular performance after off-pump coronary artery bypass grafting: randomized controlled study

Introduction. New anesthesia techniques require evidence of the safety of their implementation, however there is still the opinion about negative impact of regional anesthesia on heart performance and central hemodynamics. The objective of our study was to evaluate effect of regional anesthesia on systolic and diastolic myocardial function in off-pump coronary artery bypass grafting (OPCAB).Materials and methods. A prospective randomized controlled trial included 45 patients who underwent elective OPCAB, equally divided into 3 groups – general anesthesia in combination with epidural anesthesia (GA+EA), general anesthesia with erector spinae plane block (GA+ESPB) and general anesthesia without regional anesthesia (GA). The systolic function of the left (LV) and right ventricle (RV), as well as the diastolic function of the LV were evaluated during five stages perioperatively, using echocardiography and thermodilution via Swan-Ganz catheter.Results. There were no intergroup differences in parameters of LV or RV systolic function and LV diastolic function during study stages. Perioperatively, there was a decrease in LV end-diastolic volume in the groups of OA+ESPB (p = 0.001) and OA (p = 0.003).At the end of the first postoperative day (POD), pulmonary artery wedge pressure decreased in the groups of OA+EA (p = 0.003) and OA+ESPB (p = 0.008); meanwhile, ejection time (p = 0.003) and velocity-time integral (p = 0.005) from RV reduced only in the OA+ESPB group. In the OA+EA group at the end of POD1, the reservoir strain of left atrium (p = 0.022) and isovolumic relaxation time (p = 0.006) decreased.Conclusion. In OPCAB, epidural anesthesia and ESPB do not result in deterioration of LV systolic and diastolic function and do not have a negative impact on the RV.

Epidural Anesthesia Management for Unilateral Salpingo-Oophorectomy in Patients with Ovarian Mass : A Case Report

with sedation and mainly used in elderly patients or those with medical problems, including those who had ovarian mass. Epidural administration of amide local anesthetics in combination with opioids is widely used for pain relief because of the dose minimizing and side effects reducing benefits. Case: Patient was diagnosed with ovarian mass. The patient also had pleural effusion, ascites, and hypoalbuminemia. Epidural anesthesia used in this patient as a resource for perioperative and postoperative pain management. Discussion: Patient underwent unilateral salpingo-oophorectomy for her ovarian mass. Anesthetic doses were given carefully due to patient conditions with pleural effusion and ascites. Opioid and Neuromuscular Blocking Agents (NMBAs) effects were absolutely decreased due to hypoalbuminemia, but were overcome with Naloxone and Sugammadex. Epidural anesthesia used to stabilize the drugs and pain management for this patient. Conclusion: Epidural anesthesia is an excellent choice for unilateral salpingo-oophorectomy in patients with ovarian mass. It has been proven to provide excellent pain control after major surgeries and may be associated with a lower incidence of postoperative complications.

Analysis of the Effects of Epidural Anesthesia on the Nociception Level Index (NOL®) during Abdominal Surgery.

Background: The NOL® system (PMD-200™ Nociception Level Monitor; Medasense Ltd., Ramat Gan, Israel) is used for the real-time detection of physiological nociception in anesthetized patients by assessing the parameters indicative of sympathetic activity, such as photoplethysmography, skin conductance, peripheral temperature, and accelerometry, which are quantified into the NOL®-Index. This index is more sensitive than traditional clinical parameters in estimating pain and stress responses. While its effectiveness in general anesthesia is well documented, its efficacy in epidural anesthesia needs further investigation. Methods: This retrospective study analyzed NOL®-Index dynamics compared to conventional parameters after epidural administration of bupivacaine. Following ethics committee approval, 119 NOL® measurements were retrospectively analyzed after thoracic epidural catheter administration in 40 patients undergoing abdominal and urological surgery. The NOL-Index® was assessed at 0, 1, 3, and 5 min post application and compared to heart rate, blood pressure, and bispectral index dynamics. Results: This study showed a significant decrease in the NOL®-Index post-local-anesthetic administration with better sensitivity than classical clinical parameters (0 min = 38 ± 11; 1 min = 22 ± 13*; 3 min = 17 ± 11*; 5 min = 12 ± 10*). Higher doses of local anesthetics led to a significant, dose-dependent decrease in NOL®-Index (low dose, 5 min = 15 ± 10*; high dose, 5 min = 8 ± 8*). Conclusions: This study is the first to demonstrate the effectiveness of the NOL®-Index in measuring nociceptive effects following epidural administration, highlighting its potential superiority over conventional parameters and its sensitivity to dose variations.

Effect of orientation angle for needle-free jet injection

In this paper, we report on the delivery efficiency of needle-free jet injections using injectors with typical jet speed vj≈140m/s, orifice diameter do=157μm, and volume V=0.1 mL. The target substrates were either hydrogel tissue phantoms or porcine tissues combined with excised human skin. The novelty of this study is two-fold: First, we investigate the influence of injection angle relative to the skin surface, and second, we also study the influence of the jet path relative to the orientation of muscle fibers. While most commercial jet injectors employ a fitting that would render the device normal to the skin surface, recent studies have proposed oblique injections, which may be beneficial for intradermal or subcutaneous tissue injection. Furthermore, for deeper intramuscular injections, we propose that an angled jet path taking the muscle fiber orientation into account may result in a bolus or dispersion zone that is conducive to increased cellular uptake of the drug.

Upper back, neck, and shoulder pain during labor epidural analgesia: a quality improvement initiative

BackgroundSevere upper back/interscapular, neck and shoulder pain during labor epidural analgesia (PLEA) is not uncommon. The objective of this quality initiative was to evaluate the incidence, demographic associations and management of PLEA. MethodsAn eight-month, single-center quality improvement initiative was performed for the detection and management of PLEA. After survey-based consensus among obstetric anaesthetist attendings and fellows, a three-step PLEA treatment protocol with interventions and numeric rating scale (NRS, 0 – 10 scale) pain assessments was introduced. Demographic data and outcomes were compared among parturients with and without PLEA. ResultsAmong 2888 women who received labor epidural analgesia from October 2022 through May 2023, 36 (1.2% [95% CI 0.9% to 1.7%]) reported PLEA. Women with PLEA were younger, more likely to be nulliparous, and had a higher body mass index (BMI) than women without PLEA (p < 0.05 for all). A total of 72.2% (26/36) of women with PLEA received at least one protocol treatment. Twenty-three women received first-line therapy, with pain relief in 91.3% (21/23). The median NRS score decreased from 9 [IQR 8–10] to 3 [1–4]. Women with PLEA had a higher incidence of cesarean delivery (CD) and a longer interval between epidural placement and delivery; 52.8 vs. 17.5% (p < 0.001) and 16.5 vs. 6.9 hours (p < 0.001), respectively. ConclusionsThe incidence of PLEA was higher than previously reported. Patients with PLEA were younger, more commonly nulliparous, had higher BMI, longer epidural infusion times and higher CD rates. A three-step treatment protocol was successful in managing PLEA.

Outcome of Deliveries Following Labour Epidural Analgesia in a Malaysian Teaching Hospital

Outcome of Deliveries Following Labour Epidural Analgesia in a Malaysian Teaching Hospital