Epidural Catheter Research Articles

Neonatal Outcome with Magnesium Sulphate and Fentanyl as Adjuvants for Epidural Labour Analgesia: A Prospective Comparative Study

Introduction: The pain of childbirth is arguably the most severe pain most women endure in their lifetime. Since pain relief in labor has always been surrounded by myths and controversies, providing effective and safe analgesia during labor has remained an ongoing challenge. Neuraxial techniques are accepted as the gold standard for intrapartum labor analgesia. The study aimed to determine the neonatal outcome with magnesium sulfate and fentanyl as adjuvant for epidural labor analgesia. Methods: This prospective comparative study was conducted at the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine in collaboration with the obstetric department, Dhaka Medical College, Dhaka.Bangladesh. The study was carried out from October 2020 to March 2021. A total of 60 patients were assigned by computer-generated random table to one group (Group A) and another group (Group B). Group-A (n=30): Group-A received Fentanyl 25 micrograms as adjuvant to bupivacaine (0.5% plain bupivacaine 2.5 ml+25 microgram of fentanyl 0.005% 0.5 ml + 7 ml normal saline=10 ml) via epidural catheter. Group B received MgSO4 50 mg as an adjuvant to bupivacaine (0.5% plain bupivacaine 2.5 ml + 50 mg of MgSO4 10% 0.5 ml +7 ml normal saline=10 ml) via epidural catheter. Data were statistically described in terms of mean ± standard deviation (±SD), or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using the Student t-test for independent samples. For comparing categorical data, a Chi-square (x2) test was performed. P values of less than 0.05 were considered statistically significant. F-value was determined by the Repeated measured ANOVA test where data were repeated more than one time. All statistical calculations were done using the computer program SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 22 for Microsoft Windows. Informed written consent ......

Comparison of Complications with Magnesium Sulphate & Fentanyl as Adjuvants for Epidural Labor Analgesia

Introduction: Effective and safe analgesia during labor has remained an ongoing challenge. Many pharmacological and non-pharmacological methods of labor analgesia have been adopted over the years. Of these, neuraxial or regional analgesia has become the most popular method. Possible regional anesthesia techniques include epidural analgesia, spinal analgesia, or a combination of epidural and spinal analgesia. This study aimed to compare the complications with magnesium sulfate and fentanyl as adjuvants for epidural labor analgesia. Methods: This prospective comparative study was conducted at the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine in collaboration with the obstetric department, Dhaka Medical College, Dhaka.Bangladesh. The study was carried out from October 2020 to March 2021. A total of 60 patients were assigned by computer- generated random table to one group (Group A) and another group (Group B). Group-A (n=30): Group-A received Fentanyl 25 micrograms as adjuvant to bupivacaine (0.5% plain bupivacaine 2.5 ml+25 microgram of fentanyl 0.005% 0.5 ml + 7 ml normal saline=10 ml) via epidural catheter. Group B received MgSO4 50 mg as an adjuvant to bupivacaine (0.5% plain bupivacaine 2.5 ml + 50 mg of MgSO4 10% 0.5 ml +7 ml normal saline=10 ml) via epidural catheter. Data were statistically described in terms of mean ± standard deviation (±SD), or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using the student t-test for independent samples. For comparing categorical data, a Chi-square (x2) test was performed. P values of less than 0.05 were considered statistically significant. F-value was determined by the Repeated measured ANOVA test where data were repeated more than one time. All statistical calculations were done using the computer program SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 22 for ........

The dilutional volume of morphine and xylazine administered via caudal epidural catheter affects cranial spread of analgesia in healthy standing horses.

To test the influence of increasing injectate volumes on the regional effects of xylazine and morphine epidural analgesia, with the hypothesis that increasing volume produces more cranial spread of analgesia as determined by thermal threshold (TT) testing. 6 university-owned research/teaching horses (2 mares, 4 geldings) deemed healthy on physical examination and basic lameness evaluation, aged 6-19 years and weighing 420-560 kg, were used in this prospective, randomized, blinded, cross-over experimental study. After routine placement of a caudal epidural catheter, all animals were subsequently instrumented with a TT testing system at the withers (Location A), the cranial (Location B), and caudal (Location C) abdominal area, over the tuber coxae (Location D), and the hind limb dorsal pasterns (Location E). All horses underwent five testing cycles with 0.2 mg/kg morphine and 0.2 mg/kg xylazine diluted to 20, 35, 50, 75, and 100 mL. TT testing was performed at 2, 4, 6, 8, and 10 hours by blinded investigators. With increased epidural volume, significantly greater cranial spread of analgesic effect was noted. All epidural volumes caused significant changes in TT testing at location E but only the largest volume resulted in a significant TT testing change at location A. Volume influences the regional effects of caudal epidural analgesia in horses but might affect analgesic reliability.

The treatment of persistent spinal pain syndrome with epidural pulsed radiofrequency: improvement of the technique.

In Persistent Spinal Pain Syndrome (PSPS), Pulsed Radiofrequency (PRF) is a used procedure. The results of PRF in PSPS performed with an electrode placed through the sacral hiatus were reported to be successful on pain in only 32% of patients. We have tried to improve the results by applying a new system to PRF. Ten patients were treated with PRF application through a steerable epidural catheter with a reference electrode outside the foramen. This method was named "Optimization Current Flow" (OCF). The duty cycle of PRF was 2 × 10 msec and total exposure time was 150 s. Follow up was planned for 1, 3, and 6 months. The NRS score was considered to be the primary outcome. In the first 10 patients treatment was successful (69% of the patients) at 6 months follow-up. This new modality of PRF in patients with PSPS seems to be superior to procedures done with a needle. Further prospective double-blind randomized long-term studies with a significant number of patients are required to validate this technique as there is a need to improve PRF results in PSPS.

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.

The dural puncture epidural (DPE) technique has a faster onset, better sacral spread, and improved bilateral coverage when compared to the conventional epidural (EPL) technique. Whether these qualities translate into a lower bupivacaine dose to provide initial analgesia is unknown. We sought to determine the effective dose of bupivacaine to achieve initial (first 30 minutes) labor analgesia in 90% of patients (ED90) with the DPE and EPL techniques, using a biased-coin, sequential allocation method. A total of 100 women of mixed parity with term, singleton gestation at ≤5 cm dilation with no major comorbidities were randomized to receive a DPE or an EPL technique. An experienced anesthesiologist performed these techniques and administered an allocated dose of plain bupivacaine diluted with isotonic sterile 0.9% saline to a total volume of 20 mL via the EPL catheter. Bupivacaine doses for each subject were determined by the response of the previous subject, using a biased-coin sequential allocation method, with success defined by a numeric rating scale (NRS) < 3 at 30 minutes. Outcome assessments were performed by an investigator blinded to the technique and bupivacaine dose. Sensory and motor blockade and maternal or fetal side effects were recorded every 5 minutes for the first 30 minutes. The ED90 of bupivacaine with each technique was estimated using centered isotonic regression. A total of 95 women were included in the final analysis. The ED90 of bupivacaine was estimated at 29.30 mg (90% confidence interval [CI], 28.55-31.56) with a DPE technique and 45.25 mg (90% CI, 42.80-52.03) with an EPL technique. Using a biased-coin, sequential allocation method, the DPE technique requires less bupivacaine to achieve effective initial analgesia (ED90) when compared to the EPL technique.

Risk factors for epidural anesthesia blockade failure in cesarean section: a retrospective study

BackgroundEpidural anesthesia (EA) is the regional anesthesia technique preferred over spinal anesthesia for pregnant women requiring cesarean section and post-operative pain control. EA failure requires additional sedation or conversion to general anesthesia (GA). This may be hazardous during sedation or GA conversion because of potentially difficult airways. Therefore, this retrospective study aimed to determine the risk factors for epidural failure during cesarean section anesthesia.MethodsWe retrospectively analyzed parturients who underwent cesarean section under EA and catheterization at the Chang Gung Memorial Hospital in Taiwan between January 1 and December 31, 2018. Patient data were collected from the medical records. EA failure was defined as the administration of any intravenous anesthetic at any time during a cesarean section, converting it into GA.ResultsA total of 534 parturients who underwent cesarean section were recruited for this study. Of them, 94 (17.6%) experienced EA failure during cesarean section. Compared to the patients with successful EA, those with EA failure were younger (33.0 years vs. 34.7 years), had received EA previously (60.6% vs. 37%), were parous (72.3% vs. 55%), and had a shorter waiting time (14.9 min vs. 16.5 min) (p < 0.05). Younger age (OR 0.91, 95% CI 0.86–0.95), history of epidural analgesia (OR 2.61, 95% CI 1.38–4.94), and shorter waiting time (OR 0.91, 95% CI 0.87–0.97) were estimated to be significantly associated with a higher risk of epidural anesthesia failure.ConclusionThe retrospective study found that parturients of younger age, previous epidural catheterization history, and inadequate waiting time may have a higher risk of EA failure. Previous epidural catheterization increased the risk of EA failure by 2.6-fold compared to patient with no history of catheterization.

Epidural anaesthesia with traditional technique versus epidural catheterization technique in buffaloes

Epidural anaesthesia in buffaloes is done at sacro coccygeal or at first inter-coccygeal space. A new technique of injecting epidural anaesthesia was compared with traditional technique at first inter coccygeal space. Two group were done with Group 1 consisting of 10 cases and Group 2 with 6 cases were with affections of Tail gangrene, prolapse of vagina, caesarean section, vaginal tear and tail wound studied at Department of Veterinary Surgery and Radiology, College of Veterinary and Animal Sciences, Udgir. Group 1 was anesthetized by traditional method by inserting needle at 45 degree angle at first inter coccygeal space. Group 2 was anaesthetized by catheterization where in first as traditional technique 16 G spinal needle passed into epidural space then catheter was inserted and directed inside 1 to 1.5 inch inside and placed by confirming site. Study showed catheterization useful when incremental dose is necessary. It required care and experience to maintain catheter in position. Injury or trauma was minimum compared to traditional technique.

THU094 Multiple Endocrine Neoplasia Type 1 Tumor Recurrence After Loss To Follow Up

Abstract Disclosure: S.J. Sternlieb: None. K.G. Romo: None. R.S. Boothe: None. D. Englert: None. N. Manuel: None. Q.Z. Iqbal: None. Multiple Endocrine Neoplasia Type 1 Tumor Recurrence After Loss to Follow-up Sternlieb, S. J., Romo, K.G., Boothe, R., Manuel, N., Iqbal, Q.Z., Grissett, B., Englert, D. Background: MEN1 is a rare, autosomal dominant tumor disorder due to mutations in the MEN1 tumor suppressor gene. It is characterized by parathyroid, enteropancreatic and pituitary tumors. We present a young woman with MEN1 with prolactinoma, primary hyperparathyroidism and multiple pancreatic neuroendocrine tumors. Clinical Case: A 30-year-old woman with MEN1 presented with complaints of abdominal pain and GI bleeding (GIB). She was diagnosed with a prolactinoma at age 14 after presenting for primary amenorrhea and galactorrhea. She didn’t tolerate medical therapy with bromocriptine or cabergoline and required transphenoidal resection. At age 19, she presented with hypoglycemia and was found to have multiple pancreatic neuroendocrine tumors (NET) as well as a left (L) adrenal gland tumor. She underwent distal pancreatectomy and L adrenalectomy. Ten tumors in the pancreas stained variably for insulin, glucagon, gastrin and VIP. Multiple cortical adenomas were found in the adrenal gland. Post-operatively she developed a spinal cord hematoma related to placement of an epidural catheter for pain control, which led to permanent paraplegia. At age 21, she was diagnosed with primary hyperparathyroidism. She underwent left parathyroidectomy, then was lost to follow-up for 9 years. EGD showed multiple superficial duodenal ulcers. MRI brain identified a right (R) cavernous sinus mass inseparable from the R pituitary. CT abdomen showed a pancreatic head mass. Given the concern for neuroendocrine etiology, she underwent an EUS showing a pancreatic mass and a liver mass. Pancreatic mass pathology confirmed low-grade NET with Ki67 proliferation rate &amp;lt;1%, positive synaptophysin and chromogranin staining. After multidisciplinary discussion, the consensus was to continue PPI and sucralfate for GI ulcers, start lanreotide, and obtain somatostatin receptor scintigraphy. Surgery was not recommended unless significant GIB occurred on maximal therapy. She was referred to follow-up with GI, endocrinology, and NSGY. Since discharge, she has presented several times to other hospitals for abdominal pain, but has not adhered to follow-up. Conclusions: This case of recurrent neuroendocrine and pituitary tumors despite prior resections demonstrates the consequences of prolonged loss to follow-up with MEN1. Without routine surveillance, recurrence is likely. This patient lives in a rural area with lack of access to nearby subspecialty care, which is a barrier. More resources are needed to support patients with social barriers and progressive endocrinopathies. Key words: MEN1, prolactinoma, gastrinoma, NET, health care barriers Presentation: Thursday, June 15, 2023

Monitored epidural catheter placement-ultrasound-guided neurostimulation-aided thoracic catheter placement via caudal route for perioperative analgesia in neonatal thoracotomies: A technical feasibility study.

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates.

Comparative efficacy of Micropore™ surgical dressing, Tegaderm™ and Lockit plus® for lumbar epidural catheter fixation in children: a prospective parallel group randomized controlled trial.

Proper fixation of an epidural catheter is necessary for desired drug effect and to prevent catheter displacement. Different techniques have been used for epidural catheter fixation. The aim of the study was to compare the relative efficacy of Micropore™ surgical dressing, Tegaderm™, and Lockit plus® in preventing lumbar epidural catheter migration in children. We studied 167 patients aged 5-16 years, for up to 48 h. After the elective abdominal or lower limb surgery. Patients were randomly assigned to one of three groups: (1) Micropore™ surgical dressing (group M), (2) Tegaderm™ (group T), or (3) Lockit plus® (group L). Incidence and extent of epidural catheter migration in centimetres (cm); was compared at 24 and 48 h post epidural fixation. Correlation between epidural catheter migration and patient characteristics, and relative incidence of complications in three groups was also analysed. Incidence of catheter migration was 9.6% at 24 h (group M: 7.1%, group T: 21.1% and group L: 0%) and 45.5% at 48 h (group M: 66.1%, group T: 45.6% and group L: 24.1%). After 48 h, absolute migration (mean migration rounded off to the nearest 0.5 cm) was least in patients in group L: 0.34 cm (1.39) compared to group M 1.22 cm (SD: 1.85) group T: 0.94 cm (1.94) (p = <0.001). Up to 48 h after surgery, the Lockit plus® device demonstrated the less epidural catheter migration when compared to micropore surgical dressing or tegaderm in children undergoing elective abdominal or lower limb surgery.

Ultrasound: A novel alternative technique for cervical epidural space visualization-A pilot study.

Neuraxial ultrasound (US), a newer modality, can be used for neuraxial imaging, helping in visualizing and aiding in epidural space catheterization. The aim of this study was to evaluate the efficacy of the US for cervical epidural access and to determine the failure rate and complication associated with this technique. A prospective single-arm pilot study was conducted on 21 participants. The neuraxial US image quality assessment by Ultrasound Visibility Score (UVS), epidural space depth measurement by US and by conventional loss of resistance (LOR) technique, and post-procedure epidural catheter confirmation by real-time US were the study parameters. Any procedural complications or failure rate were recorded. The Kolmogorov-Smirnov test, paired-samples t-test, and Chi-square test were used for the statistical comparison. The pre-procedural UVS by the transverse interlaminar view (x/21) was 2.81 ± 1.94 and by the oblique paramedian sagittal view was 16.66 ± 2.39 with UVS being best in the paramedian oblique sagittal view (P- value < 0.05). The comparison of depth of the epidural space identified by USG and that by the LOR technique was statistically insignificant (P = 0.83). The average puncture attempts were 1.1 ± 0.3. Post-procedure US epidural catheter confirmation score (x/3) was 1.44 ± 0.44 with either epidural space expansion or microbubbles seen or both. The pilot study has successfully demonstrated the implication of US for visualizing and aiding in epidural space catheterization. Also, the failure rate and procedural complications were drastically minimized with the help of US as compared to the traditional blind technique.

Знеболювання в пологах - порівняння і аналіз класичної методики епідуральної аналгезії та модифікованої з пункцією твердої мозкової оболонки

Epidural analgesia (EA), most commonly used for labor analgesia, is an effective and relatively safe technique, but may be associated with slow onset, inadequate block. The use of Dural puncture epidural (DPE) is designed to find a balance between improving the quality of analgesia and reducing the frequency of side effects. Purpose - to compare two methods of labor analgesia. Materials and methods. All women (n=80) were divided into two groups: the Group I (n=40) used DPE, the Group II (n=40) used EA. In both groups, the same technique of epidural puncture and catheterization was used, in the Group I additionally puncture of the dura mater. Analgesia was evaluated using the visual analog pain rating scale (VAS). The quality and effectiveness of analgesia, the hemodynamics of the woman were evaluated. Complications and unwanted effects were recorded. Fetal condition: cardiotocography (CTG), umbilical cord blood lactate, pH. A statistical analysis of the obtained data was carried out. Results. The first contraction (VAS1) in the Group I were fixed on 11.43.3 min, and in the Group II on 21.57.2 min (p0.05). Monolateral block in the Group I - 4 (10%) versus 10 (25%) (p0.05). Contractions (VAS 1) after 30 min in the Group II - 7 (17.5%) versus the absence of such in the Group I. Stroke volume in the Group I decreased by 2.1% versus 1.5% in the Group II. The data for hypotension and occurrence of complications, CTG, cord blood lactate, and pH were not different by group. Conclusions. The use of the DPE technique against EA gives better results in terms of the quality and effectiveness of analgesia. The mother’s hemodynamics remained stable when using DPE. The DPE technique does not increase the frequency of complications compared to EA. There was no difference between the groups when assessing the state of the fetus according to CTG data, pH indicators and umbilical cord blood lactate. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the author.

Effects of dural puncture epidural technique with different drug delivery methods for labor analgesia: A randomized controlled clinical trial.

This study aimed to investigate the effect of dural puncture epidural (DPE) combined with small-dose lidocaine for labor analgesia. Parturients were randomly divided into epidural anesthesia (EA), DPE1, and DPE2 groups. In the EA group, 5 mL of 1% lidocaine was administered via conventional L2-L3 puncture catheterization; in the DPE1 group, epidural drug was administered after catheterization using the DPE technique; in the DPE2 group, epidural puncture drug was administered through the epidural puncture needle before catheterization using the DPE technique. The primary outcome was the onset time of analgesia. The secondary outcomes included the numerical rating scale (NRS) scores during uterine contraction before bolus injection of experimental dose (T0) and the second time (T1), the fifth time (T2) and the tenth time (T3) after bolus injection of experimental dose; NRS scores at the second stage of labor (T4) and during perineal suture (T5); operation time of anesthesia; puncture related complications; anesthesia related complications; delivery outcome; use of local anesthesia during vaginal suture; and Apgar score of the neonates. There were 115 women included. The onset time in the DPE2 group was markedly shorter than in the EA and DPE1 groups (P < .001). The NRS scores in the DEP2 group at T1 and T4 were significantly lower than in the EA and DEP1 groups (P < .001). The overall incidence of puncture related complications in the DEP1 and DEP2 groups was markedly higher than in the EA group (P < .05). In dural puncture epidural analgesia, when the experimental dose was injected directly through the epidural puncture needle, the onset time was shorter and the analgesic effect was better as compared to the injection of test dose after inserting the epidural catheter.

Enhanced Recovery After Surgery (ERAS®) Protocol for Liver Surgery: The impact of epidural catheter placement

Enhanced Recovery After Surgery (ERAS®) Protocol for Liver Surgery: The impact of epidural catheter placement

Multimodal Analgesia in Pediatric Cancer Pain Management: A Retrospective Single-Center Study.

Objectives A multimodal approach to pain management, including potential interventional techniques, is suggested to achieve adequate pain control. This study discusses the techniques and medications employed to manage pain in pediatric oncology patients. Methodology This study included 90 patients under 18 years of age who underwent pain management in the algology clinic between 2002 and 2020. From the algology follow-up records, the following data were recorded: demographic information, follow-up time, cancer diagnosis and stage, cause and location of pain, systems involved, duration and intensity of pain, analgesic and adjuvant drugs prescribed, routes and duration of drug administration, complications, interventional procedures if performed, "pain intensity" scores prior to and following treatment, and daily and total analgesic consumption of the patients. Results The mean age was 11.4±4.1 years (min-max: 2-17). Leukemia and lymphoma were the most frequently diagnosed (30%). Of the 31 features identified in the staging, 27 (87.1%) were stage 4 at admission. The causes of pain in children were neoplasms in 81.2% (n = 73). At admission, 72.3% (n = 65) had severe pain for at least a month. It was determined that 90% (n = 81) of the patients were using opioids and 28.9% (n = 26) were using dual opioids. The mean tramadol dose was 129.0±97.9 mg/day (12-380 mg/day), and the mean morphine dose was 14.8±11.3 mg/day (1-52 mg/day). The mean transdermal fentanyl dose was 33.2±21.6 µgr/h (12-75 µgr/h). Adjuvant therapy was administered in 25.6% (n = 24) of the patients. Epidural catheterization was performed on 6.6% (n = 6) of the patients. The mean initial pain scores were 5.2±1.7, which decreased to 1.5±0.7 with a significant difference (p < 0.001). In the study, 93% (n = 84) of the patients had no pain management complications noted. Conclusions The pain level that pediatric cancer patients endure critically influences their and their family's quality of life. The fact that opioid-related adverse effects associated with pediatric pain management occur far less frequently than previously thought may help prevent opiophobia. Effective and safe analgesia can be provided with multimodal analgesia to manage pediatric cancer pain.

Transesophageal echocardiography for thoracic spinal cord imaging and confirmation of epidural catheter placement in pediatrics

IntroductionTransesophageal echocardiography (TEE) use continues to expand to include extracardiac applications. However, there is limited research investigating the use of TEE as a tool to confirm the position of the epidural catheter. This prospective observational study aimed to evaluate whether TEE could be used to visualize the anatomy of the thoracic spinal canal in pediatrics. A subsequent prospective case series was conducted to evaluate whether TEE could be used to assist in the placement of epidural catheters in pediatric surgical patients. MethodsSeventy-five patients (50 pediatric and 25 adult subjects) were enrolled. The operators attempted to identify four structures (spinal cord, cerebrospinal fluid, dura mater, epidural space) within the thoracic spinal canal with TEE. After demonstrating the feasibility of this technique for observing the spinal anatomy, 20 pediatric surgical patients were enrolled in a case series. These patients had epidural catheter placement, and the final catheter position was confirmed with TEE. ResultsThe total number of thoracic spinal segment visualized in pediatric patients was 542 out of 550 (99%) segments, and 191 out of 275 (70%) segments in adult subjects (difference, 29% [95% confidence interval, 23–34]; p < 0.001). Additionally, a case series of 20 pediatric surgical patients demonstrated successful caudal or epidural catheter placement at target spinal level in 17 cases. ConclusionsThis observational study demonstrated the successful visualization of the thoracic spinal cord at virtually every level in pediatric patients. A subsequent case series demonstrated that TEE could be used to successfully confirm the position of the epidural catheter in the targeted thoracic spinal segment for pediatric surgical patients.

Analgesia for Knee Ligamentoplasty: Comparisons of Three Techniques using the Silverman Integrating Approach (SIA Score)

The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty using an integration score, the SIA score. Hypothesis. The use of a statistical approach to integrate data from pain scores and morphine consumption will identify four patient subgroups that may hamper the accuracy of the comparative study Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. We evaluated cumulative morphine consumption, pain estimation at rest using a numerical scale (EN) from 1 to 10, and an integration of these two parameters. Results. - The mean age was identical for all three groups, at around 30 years. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Morphine consumption was lower in the AF group. The lowest mean rank was in the AF group, followed by the AIA group, and the difference was statistically significant with an H = 6.89 and a p= 0.032. The difference was significant between the AS group and the AF group (p = 0.09); the other inter-group differences were not significant. 23.2% of patients had an AIS score between [-100, -200], and were in little pain and consumed little morphine (effective treatment); 14.2% of patients had an AIS score between [100, 200] and were in great pain and consumed a lot of morphine (morphine-resistant or very sensitive to pain). For the difference (ranked pain score - ranked morphine), 4.5% of cases had values between [- 100, - 200] and were therefore not very painful but consumed a lot of morphine (propensity), while 3.9% had values between [100, 200] and were therefore very painful but consumed little morphine (intolerant). Discussion. - This study suggests that the use of a statistical approach to integrating data from pain scores and morphine consumption, such as the Silverman Integrating Approach (SIA), will yield four patient subgroups that may hamper the accuracy of the comparative study, including the morphine-resistant subgroup and the propensity subgroup. Comparison of the means of the therapeutic efficacy group will eventually be more precise. Continuous femoral block really does provide added analgesia and morphine sparing, and should therefore be preferred wherever possible to intra-articular or systemic therapy.

Comparative Study Between Systemic Balanced Analgesia, Continuous Femoral Perineural Analgesia and Continuous Intra-articular Analgesia for Primary Reconstruction Surgery of the Anterior Cruciate Ligament of the Knee

Introduction. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty and quadricipital deficit with a view to early physiotherapy. Hypothesis. Continuous intra-articular analgesia and well-managed systemic analgesia could replace continuous femoral peri-nerve analgesia in resource-limited countries. Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption, pain estimation at rest and on mobilization using a numerical scale (EN) from 1 to 10, and quadriceps deficit were evaluated. Results. - Morphine consumption was lower in the AF group and the difference was statistically significant with an F = 3.539(2) and a p = 0.031. A mean difference of 6.12 ± 2.41 between the AS and AF groups with a significant p = 0.012, a mean difference of 1.67 ± 2.41 with a non-significant p = 0.49 between the AF and AIA groups and a mean difference of 4.45 ± 2.31 with a p = 0.056 at the limit of significance between the AS and AIA groups. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Efficacy was statistically significant at H4, then from H24 to H36 compared with systemic analgesia, but not significant compared with intra-articular analgésia. Intra-articular analgesia was only significantly effective compared with systemic analgesia at H36. Quadriceps muscle deficit is an incident specific to femoral blocks. Discussion. - This study suggests that a continuous intra-articular or even a well-conducted systemic analgesia provides satisfactory analgesia for knee ligamentoplasty, compared with a more effective femoral peri-nerve. The quadricipital lock absent in intra-articular treatment could be an advantage in speeding up functional recovery.

Use of the narcotic analgesic fentanyl to correct violations of the autonomic regulation of childbirth

Background. The problem of effective prolonged epidural analgesia (PEA) in case of hypotonic labor, which allows minimal intervention in the process of labor activity while providing adequate analgesia, remains unresolved. A study was conducted to increase the effectiveness of PEA use during the first state of childbirth in women with hypotonic labor. The purpose: to increase the effectiveness of prolonged epidural analgesia in case of hypotonic labor during vaginal childbirth. Materials and methods. We performed analgesia to 60 women with a diagnosis of stage 1 hypotonic labor who were divided in 2 groups: the main one (n = 35) and the controls (n = 25). ASA status in both groups was I–II. In both groups, the epidural space was punctured at L1-L2. A test 4-ml dose of 2% lidocaine solution was administered and 5 minutes after, the epidural catheter was inserted. Then, in the main group, 1 ml of fentanyl solution and 6 ml of 0.9% NaCl were injected into the epidural space; in the control group, 6–8 ml of 0.125% bupivacaine solution. The effectiveness was evaluated according to the visual analogue scale, hemodynamic changes and the outcome of childbirth (conservative or operative). The condition of the fetus was assessed according to cardiotocography data. Statistical processing of the material was carried out using Excel. Results. The use of fentanyl in 69 % of cases allowed finishing the birth conservatively, the condition of the fetus and newborn was considered satisfactory. In the control group, 72 % of births resulted in cesarean section. Indications for surgery were hypotonic labor and fetal distress. Conclusions. The use of the narcotic analgesic fentanyl for prolonged epidural analgesia in hypotonic labor effectively relieves pain and increases the likelihood of conservative childbirth. It is safe for mother, fetus and newborn.

Safety and Efficiency of Low-Dose Spinal Analgesia Compared to Epidural Analgesia in Treatment of Pain during Labour: A Case Control Study.

The epidural catheter for analgesia has been used for decades and has become the gold standard in pain therapy for pregnant women in labour. However, procedural parameters such as time to pain relief and duration to implementation pose hurdles for patients shortly before delivery. Low-dose spinal analgesia (LDSA) is an alternative procedure that was investigated in the study with regard to patient satisfaction and complication rates compared to epidural catheter. In a retrospective monocentric study, a total of 242 patients receiving low-dose spinal analgesia or epidural catheters were evaluated using propensity score matching. Subjective patient satisfaction as well as complication rates were primarily analysed. We hypothesise that LDSA is a safe procedure and provides a similar level of satisfaction compared with the epidural catheter. For this purpose, both procedures were performed according to in-house standards and the patients were interviewed afterwards. Patients who required surgical delivery were excluded to prevent bias. The LDSA was rated on average as very good [1.09 ± 0.311 vs. 1.07 ± 0.431] in terms of satisfaction by the patients compared to the epidural catheter without showing a significant difference (p = 0.653). Complications were in the low single-digit non-significant range for both procedures [6 (5%) vs. 7 (6%); p = 0.776]. The evaluation showed more perineal tears I° and II° in the low-dose spinal analgesia group [I°: 28 (23%) vs. 3 (2%); p < 0.001-II°: 30 (25%) vs. 2 (2%); p < 0.001]. Neonatal parameters differed significantly only in umbilical cord base excess and umbilical cord venous pH [-5.40 vs. -6.40; p = 0.005]. LDSA represents a low complication procedure for patients at the end of labour with a high satisfaction level. With the LDSA in the repertoire of pain relief during childbirth, it is possible to also achieve pain reduction for women with deliveries of high velocity without compromising patient satisfaction or perinatal morbidity.