Epidural Catheter Research Articles

Epidural Catheter Replacement Rates With Dural Puncture Epidural Labor Analgesia Compared With Epidural Analgesia Without Dural Puncture: A Retrospective Cohort Study

(Int J Obstet Anesth. 2022;52:103590) Lumbar epidural analgesia (LEA) is a common method of labor analgesia. Traditional LEA, dural-puncture epidural (DPE), and combined spinal-epidural analgesia (CSE) are approaches to epidural catheter placement. Epidural catheters are known to malfunction following placement (12% to 13%), requiring replacement or conversion to general anesthesia (GA) if failure occurs during emergency intrapartum cesarean delivery (CD). Factors contributing to placement failure include body mass index (BMI) or weight, procedure type (CSE vs. LEA), gestational age, anesthesiologist experience, type of epidural catheter, patient age, and mode of delivery. Few studies have compared catheter failure rates between LEA and CSE. This retrospective analysis compares epidural catheter failure rates of DPE or LEA.

Effect of Epidural Dexmedetomidine vs Nalbuphine for Labor Analgesia: A Randomized Clinical Trial

Abstract Background The addition of dexmedetomidine or nalbuphine to epidural bupivacaine was tested to reduce labor pain in women undergoing normal delivery. Patients and Methods 64 patients were randomly allocated into two groups of 32 parturients each with conscent from parturients. Groups A and B received a bolus of 12 ml volume consisting of 11 ml of 0.25% bupivacaine and 0.5 μg/ml dexmedetomidine (1 ml volume) through the epidural catheter and then a top up dose of 6 ml volume consisting of 5 ml of 0.25% bupivacaine and 0.5 μg/ml dexmedetomidine (1 ml volume) were given when VAS score becomes 4 or more and a bolus of 12 ml volume consisting of 11 ml of 0.25% bupivacaine and 10 mg nalbuphine (1 ml volume) through the epidural catheter and then a top up dose of 5 ml of 0.25% bupivacaine and 2 mg nalbuphine (1 ml volume) respectively. Assessments included VAS score for pain, vital data monitoring, recording of duration of stages of labor, neonatal APGAR score and adverse effects. Results Parturients in both groups had satisfactory labor analgesia, but those in the dexmedetomidine group had lower pain scores than those in the nalbuphine group. Taking into consideration that dexmedetomidine had a faster onset than nalbuphine. Conclusion Epidural dexmedetomidine seems to offer some advantages over epidural nalbuphine. Thus, it can be used effectively and safely as an adjuvant to epidural bupivacaine in labor analgesia.

Comparative Study of Post-Operative Analgesic Effect between Wound Site Infiltration and Bilateral U/S Guided Transversus Abdominis Plane Block with 0.25% Bupivacaine after Cesarean Section

Abstract Background The analgesic regimen needs to meet the goals of providing safe, effective analgesia, with minimal side effects for the patient, together with inhibition of trauma –induced nociceptive impulses. Objectives This study assessed the postoperative analgesic efficacy of transversus abdominis plane (TAP) block compared to local wound infiltration after cesarean section regarding the pain relief, effect on hemodynamics, requirement of first supplemental doses of analgesia and total number of doses received. All patients were informed with the procedure US guided TAP block and were trained to use the visual analogue scale (VAS). Patients and Methods The study was conducted on 90 randomly chosen patients aged 25 to 55 years, American Society of Anesthesiologists (ASA) class I or II scheduled for cesarean section surgery in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 45 patients each: TAP block Group: received general anesthesia and 20 ml of 0.25% bupivacaine on each side by midaxillary approach under ultrasound guidance. Local wound infiltration: received general anesthesia and with 0.25% bupivacaine 30 ml at surgical site. Results The results of the study revealed that the Patients who received TAP block had significantly lower pain scores for 12 h after operation and decreased total need of analgesic in first 12 h post-operative compared with patients who received wound infiltration. Conclusion Bilateral TAP block was effective in reducing postoperative pain scores for 12 hours and lower total 12 hours postoperative pethidine consumption after cesarean section under general anesthesia, compared to local wound infiltration. This technique can be a promising mode of postoperative analgesia where epidural catheter insertion is contraindicated.

Color Flow Doppler in Spinal Ultrasound: A Novel Technique for Assessment of Catheter Position in Labor Epidurals

(Reg Anesth Pain Med 2022;47:775–779) Epidural analgesia is one of the most common pain relief treatments during labor and delivery and is usually very effective. In a small percentage of epidurals, misplacement of the epidural catheter can cause inadequate anesthetic effects. To reduce instances of insufficient pain relief, it would be beneficial to be able to assess the position and flow of the catheter before administering medication. This study was designed to visualize flow in the epidural space using a structured color flow Doppler assessment, and to describe the location of the flow relative to the catheter insertion site. The primary outcome was the visualization of flow in the epidural space by color flow Doppler ultrasound. Secondary outcomes were visualization of catheter flow at the interspace of insertion, and at the interspaces above and below insertion, as well as visibility from unilateral or bilateral view, and visibility of flow on injection of saline only or an injection of a saline and air mixture.

Investigating the Use of Nonloss of Resistance Syringes for Epidural Insertion: Experience on a Mannequin

(Int J Obstet Anesth. 2022;52:103595) The Obstetric Anaesthetists’ Association (OAA) announced a supply disruption of the Portex Loss of Resistance (LOR) Syringe, a commonly used tool for epidural catheter insertion. Several studies have shown no difference in epidural insertion success rates when using LOR to saline or air. Other methods for epidural space identification are being considered yet limited research compares specific low-resistance syringes with standard syringes. This study aimed to compare specific LOR syringes with syringes commonly used in epidural insertion.

Influence of pre-peritoneal vs. epidural levobupivacaine infusion on troponin I and BNP as predictors of cardiac injury in cancer patients undergoing major upper abdominal operations: A randomized controlled clinical trial

ABSTRACT Background Cancer patients undergoing major noncardiac surgery are more likely to experience perioperative morbidity and mortality due to myocardial damage. Methods Comparative study enrolled 80 patients with upper abdominal malignancies subjected to major abdominal surgeries. Of them, seventy-two patients were eligible and randomly assigned into two groups; Epidural catheter group (n = 37), received thoracic epidural infusion of levobupivacaine, and pre-peritoneal catheter group (n = 35), received preperitoneal infusion of levobupivacaine postoperatively. Primary endpoint was pain severity by NRS immediately after recovery, at 2, 4, 6, 12, 24, 36, and 48 hours. Secondary endpoints were: (1) Patient`s hemodynamics monitored for postoperative 48 hours. (2) Myocardial injury, confirmed by troponin I & BNP levels preoperatively and on postoperative day 1 and 2 (3) Time of first analgesic demand and total postoperative 48 h morphine consumption. (4) Cardiovascular side effects; hypotension, bradycardia & arrhythmia. (5) Morphine side effects; PONV Results NRS scores showed non-significant reduction at most study times between both groups with significant reduction in the ECI group at 6-, 12-, and 24-hour than other group. First analgesic demand was earlier in PCI group than ECI without significant difference, while total 48 h morphine consumption showed a significant reduction in ECI group than PCI group. Hemodynamics were comparable in both groups. Cardiac enzymes, Troponin I and BNP, showed non-significant differences over study time between both groups. Postoperative complications, PONV, were similar in both groups without any significance, but with more cases of hypotension and bradycardia in epidural group. No cases of myocardial injury or heart failure were reported. Conclusions Preperitoneal analgesia is an effective analgesic method comparable to epidural analgesia limiting the occurrence of major cardiovascular events in cancer patients undergoing major abdominal surgeries and can be utilized when epidural analgesia is not desired or forbidden.

Managing a leaky epidural catheter: Thinking out of the box.

Managing a leaky epidural catheter: Thinking out of the box.

Minimally-Invasive Diaphragmatic Plication in Patients with Unilateral Diaphragmatic Paralysis.

Background: Diaphragm eventration (DE) represents a frequent problem with consecutive major impacts on respiratory function and the quality of life of the patients. The role of diaphragmatic plication (DP) is still underestimated. The aim of the present study is to evaluate the efficacy of minimally-invasive surgical diaphragmatic plication for the management of unilateral diaphragmatic eventration, to the best of our knowledge, this is the largest series reported in the literature using a non-resectional technique. Methods: All patients with unilateral diaphragmatic paralysis admitted for diaphragmatic plication (DP) between January 2008 and December 2022 formed the cohort of this retrospective analysis. DP procedure was done to plicate the diaphragm without resection or replacement with synthetic materials. Patients were divided into two groups: Group I included patients who underwent DP through an open thoracotomy, and Group II included patients who underwent DP through video-assisted thoracoscopic surgery (VATS). Data from all patients were collected prospectively and subsequently analyzed retrospectively. Patients' characteristics, lung function tests, radiological findings, type of surgical procedures, complications, and postoperative follow-up were compared. The primary outcome measure was the postoperative result (deeper position of the paralyzed diaphragm) and improvement of dyspnea. The secondary outcome was lung function values over a long-term follow-up. Results: The study included a total of 134 patients who underwent diaphragmatic plication during the study period. 94 (71.7%) were males, mean age of 64 (SD ± 14.0). Group I (thoracotomy group) consisted of 46 patients (35 male). Group II (VATS-group) consisted of 88 patients (69 male). The majority of patients demonstrated impaired lung functions (n = 126). The mean length of diaphragmatic displacement was 8 cm (SD ± 113.8 cm). The mean duration of the entire procedure, including placement of the epidural catheter (EDC), was longer in group I than in group II (p = 0.016). This was also observed for the mean length of the surgical procedure itself (p = 0.031). Most patients in group I had EDC (n = 38) (p = 0.001). Patients in group I required more medication for pain control (p = 0.022). A lower position of the diaphragm was achieved in all patients (p < 0.001). The length of hospital stay was 7 (SD ± 4.5) days in group I vs. 4.5 (SD ± 3.2) days in group II (p = 0.036). Minor complications occurred in 3% (n = 4) in group I vs. 2% (n = 3) in group II. No mortality was observed in any of the groups. Postoperative follow-up of patients at 6, 12, and 24 months showed a significant increase in forced vital capacity (FVC) up to 25% (SD ± 10%-35%) (p = 0.019), in forced expiratory volume in 1 s (FEV1) up to 20% (SD ± 12%-38%) in both groups (p = 0.026), also in the diffusion capacity of carbon monoxide (DLCO) up to 15% (SD ± 10%-20%) was noticed in both groups. Chronic pain symptoms were noted in 13% (n = 6) in group I vs. 2% (n = 2) in group II (p = 0.014). Except for one patient in group II, no recurrence of DE was observed. Conclusions: Diaphragm plication is an effective procedure to reduce debilitating dyspnea and improve lung function in patients suffering from diaphragm eventration. Minimally invasive diaphragmatic plication using VATS procedures is a safe and feasible procedure for the management of unilateral diaphragmatic paralysis. VATS-DP is superior to open procedure in terms of pain management and length of hospital stay, hence, accelerated recovery is more likely. Careful patient selection is crucial to achieving optimal outcomes. Prospective studies are needed to validate these results.

Acute pancreatitis after cesarean section

The prevalence of acute pancreatitis in pregnancy is low; similarly to the non-pregnant population, the outcome varies from mild to fatal forms. Occurrence of the disease in pregnancy is mostly in the third trimester or the postpartum period. The most common cause of acute pancreatitis is cholelithiasis but hypertriglyceridemia, fatty diet, obesity and alcohol consumption are further predisposing factors. A 27-year-old twin-pregnant woman developed acute severe pain 2 days after a cesarean section. Labor tests showed elevated amylase (1080 U/L) and lipase (2670 U/L) serum levels. For the purpose of pain relief, we inserted an epidural catheter and indicated an abdominal computer tomography examination. The abdominal imaging did not show morphological disorder of the pancreas or cholangial obstruction. We performed conservative therapy, early per os feeding, pain relief and fluid resuscitation. On the postpartum 7. day, the serum pancreas enzyme levels decreased to normal and the patient - with her babies - was discharged home. Though acute pancreatitis is a rare event in pregnancy, we should consider it in cases with acute, typical or non-typical pain. It is challenging to differentiate the disease from the acute syndromes of pregnancy. Orv Hetil. 2023; 164(31): 1231-1234.

Posterior instrumented correction and fusion of adolescent idiopathic scoliosis

Balanced frontal curve correction with horizontal shoulder levels, restoration of sagittal plane and vertebral derotation with afusion length as short as possible. Curves larger than 40-50° Cobb angle; furthermore age, location, degree of rotation, and sagittal plane deviation have to be considered. Posteriorly, segmental pedicle screw instrumentation with ahigh screw density (80%) and both titanium alloy and cobalt chrome rods. Freehand screw placement under consideration of both natural and deformity-induced pedicle morphology. Correction via reduction screws or instruments. Combined correction technique with rod rotation, segmental screw approximation to the generally concave rod and segmental correction of vertebral translation. Moderate concave distraction and convex compression. If needed, final in situ bending of the rods. Schwab typeI osteotomies; in rigid curves typeII osteotomies. Fusion with local bone, allogenic bone and/or bone substitutes (i.e.,tricalcium phosphate). Intraoperative placement of athoracic epidural catheter for postoperative pain control. Neurological monitoring throughout the procedure. Mobilization on postoperative day1 with focus on pain management and nutrition. Return to school after 4weeks. Physiotherapy after 3months, cycling after 3-6months, and full sport activities after 1year. Frontal curve correction of 60-80%, sufficient sagittal plane correction. Correction of rib hump 40%. Patient satisfaction is high at 95% and long-term revision rates of < 10%.

Pemberian Analgetik Epidural Lumbal Kontinu sebagai Tatalaksana Nyeri Kanker dengan Metastasis

Pain is the most common symptom of cancer patients. Pain in cancer patients is mainly caused by cancerprogressivity and tissue necrosis. Management of chronic pain needs considerable high socioeconomic costs. As an alternative for chronic pain management, a continuous infusion of local anesthetics via epidural catheter is recommended to alleviate chronic pain which caused by cancer pain in certain concentration that can relieve pain. We report 3 cases of patients with cancer pain related to metastatic process. All three patients had previously prescribed with oral opioids and fentanyl patches, which were inadequate in eliminating pain. In all these three patients, lumbal epidural catheter was placed and continuous local anesthetic drugs were administered in 1-2 ml/hour rate. The local anesthetics solution contains levobupivacaine 0.1%, morphine 0.08 mg/ml and klonidin 1.2 mg/ml.

Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery

Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery. ClinicalTrials.gov Identifier: NCT03915574.

The Efficacy of Dural Puncture Epidural Performed by 27-gauge Whitacre Needle in Labour Epidural Analgesia: Randomized Single-Blinded Controlled Study.

Dural puncture epidural technique is refinement of standard epidural technique. Its goal is to overcome drawbacks of standard epidural. We assessed whether dural puncture epidural technique performed by 27-gauge spinal needle would provide higher quality of labour epidural analgesia by using 10 mL epidural bolus of 0.125% bupivacaine. Additionally, the impact of dural puncture epidural on epidural analgesia onset, course of labour and occurrence of maternal side effects was examined. We designed prospective, randomized, single-blind study. A total of 76 healthy nulliparous parturients were randomly allocated to dural puncture or standard epidural group. After identification of epidural space, spinal Whitacre needle was used for dural puncture. Intrathecal drug administration was omitted at that point. Both groups received a bolus of local anaesthetic mixture, followed by a continuous infusion of diluted local anaesthetic via epidural catheter. Pain was assessed by numeric pain rating scale. The number of top-ups and mode of delivery were recorded in both groups. After 10 minutes, there was a statistically significant difference in numeric pain rating scale ≤3 reported (P=0.028), with 97.4% subjects in dural puncture epidural group achieving adequate analgesia after 10 minutes. There was no statistically significant difference in the number of additional boluses, time to delivery, Bromage scale achieved or maternal outcomes between groups. Dural puncture epidural technique appears to be effective in providing faster onset of epidural analgesia. However, the need for additional boluses remains unchanged. It can be safely used in obstetrics, without deleterious effect on the course of labour.

Faktor Risiko Perioperatif Terhadap Kejadian Delirium Saat Pulih Sadar Setelah Anestesi Umum Pada Pasien Dewasa Yang Menjalani Operasi Elektif Di RSUP Dr Sardjito

Background. Emergence delirium in anesthesia is a common problem after anesthesia especially in recovery room,but the incidence and risk were unclear. Emergence delirium makes serious complication and impact in morbidity and mortality were no treated properly. So this study built. Objective. To determine the perioperative risk factors of emergence delirium after general anesthesia of elective surgery at Dr Sardjito Hospital. Method. Ninety-nine patients who have surgery under general anesthesia were prospectively observed and variables were potentials perioperative risk factors for delirium at recovery room were dated. The data were statistically analyzed by bivariate and multivariate analysis based on the incidence of delirium after recovery. Results. Total sample of the study were 99 patients who had delirium 55 (55.6%). The results of multivariate analysis showed risk factor of emergence delirium were age 18-25 years old (p=0,045, OR 5,54, 95%CI 1,02-15,189), smoker (p=0,06, OR 6,83, 95%CI 1,769-21,069), alkoholism (p=0,018, OR 10,34, 95%CI 2,09-78,98), ophthalmology (p=0,005, OR 5,43, 95%CI 1,86-32,266), alprazolam premedication (p=0,045, OR 4.035, 95%CI = 1.029-15.819), general anesthesia/ET (p=0,024, OR 5,23, 95%CI 1,697-21,792), duration of surgical procedure &gt; 2 jam (p=0,025, OR 10.320, 95% CI 1.331-79.987), duration 1-2 jam (p=0.023, OR 6.554, 95% CI 1.291-33.266), opioid analgetic (p=0,019, OR 4,15, 95%CI 1,028-17,819) epidural cath (p=0,021, OR 5,83, 95%CI 1,981-20,069), artery line/CVC (p=0,043, OR 9,79, 95% CI 1,08-89,32), DC (p=0.010, OR 0.074. 95%CI 0.010-0.529), blood transfusion and vasopressors (p=0.004, OR 10,38, 95% CI = 2.11-51,08), pain scale/NRS &gt;7 (p=0.049, OR 10.598, 95%CI 0.933-120.386), and NRS 3-7 (p=0.039, OR 5.465, 95%CI 1.091-27.372), PONV dan shivering (p=0.006, OR 3,77, 95% CI = 1.47-9,67). Conclusions. Age 18-25 years old, smoking and alcoholism, ophthalmology surgery, alprazolam premedication, general anesthesia/ET, duration surgery &gt; 1 hour, opioid and epidural catheter analgesia, artery line/CVC, DC, blood transfusion and vasopressor, post operative pain with NRS &gt;3, PONV/shivering have increased risk for emergence delirium.

Üç Farklı Kateter Sabitleme Tekniğinde Epidural Kateter Migrasyonunun Karşılaştırılması: Prospektif Randomize Bir Çalışma

Objective: We hypothesized that subcutaneous tunnelling will be more efficacious in preventing epidural catheter migration in the postoperative period. To compare three different fixation techniques for migration of epidural catheter in the postoperative period. Methods: Patients undergoing elective surgery with planned postoperative analgesia with lumbar epidural were included. They were divided into 3 groups based on catheter fixation – Group I: transparent adhesive dressing tape, Group II: fixator device (Locklt Plus® ) and Group III: catheter subcutaneously tunnelled vertically. The catheter mark was noted during insertion and on removal at the end of second day. The primary outcome measure was epidural catheter migration; the secondary outcome measures were complications and patient satisfaction scores. Results: Of the 170 patients recruited, 150 patients were included. The Likelihood Ratio (LR) of migration of group I in comparison to group II was 13.28 (p&lt;0.001) while with group III was 7.06 (p=0.007). There was no significant difference between groups II and III (LR 1.12, p=0.29). The satisfaction scores were comparable among Groups II and III. There was no difference in complications among groups. Conclusion: Epidural migration is significantly reduced by both tunnelling and Lockit plus® methods in comparison to a transparent adhesive dressing in patients on continuous lumbar epidural analgesia in the first two postoperative days. The subcutaneous tunnelling method is as safe in terms of migration as the LockIt plus® method of fixation. Keywords: Catheter adverse effects, epidural analgesia, epidural catheter, postoperative pain

Removing knotted or stuck epidural catheters: a systematic review of case reports.

The knotting or in vivo entrapment of epidural catheters is an uncommon but challenging issue for anesthesiologists. This study aimed to identify the possible causes behind entrapped epidural catheters and the effective methods for their removal. A systematic review of relevant case reports and series was conducted using the patient/population, intervention, comparison and outcome framework and keywords such as "epidural," "catheter," "knotting," "stuck," "entrapped," and "entrapment." The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed, and the review protocol was registered with International Prospective Register for Systematic Reviews (CRD42021291266). The analysis included 59 cases with a mean depth of catheter insertion from the skin of 11.825 cm and an average duration of 8.17 h for the detection of non-functioning catheters. In 27 cases (45.8%), a radiological knot was found, with an average length of 2.59 cm from the tip. The chi-squared test revealed a significant difference between the initial and final positions of catheter insertion (P = 0.049). Deep insertion was the primary cause of epidural catheter entrapment. To remove the entrapped catheters, the lateral decubitus position should be attempted first, followed by the position used during insertion. Based on these findings, recommendations for the prevention and removal of entrapped catheters have been formulated.

Comparative study between dexmedetomidine and fentanyl as adjuvants to bupivacaine for postoperative epidural analgesia in abdominal surgeries: A randomized controlled trial

ABSTRACT Background Epidural analgesia is an efficient strategy to relieve postoperative pain after abdominal surgeries. This study aimed to evaluate dexmedetomidine or fentanyl when added to bupivacaine, providing postoperative epidural analgesia after abdominal procedures. Patients and methods Epidural catheter was placed on 75 patients scheduled for lower abdominal procedures under general anesthesia, and they were randomly assigned into three equal groups. Epidural analgesia was activated before the procedure was completed by injection of bupivacaine (0.125%) plus dexmedetomidine or fentanyl or normal saline mixture, according to the study groups. After complete recovery from general anesthesia, the epidural block was evaluated. Then, the infusion started through an elastomeric pump with an infusion rate of 5 ml/hr and continued for 24 hr postoperatively. Group D Dexmedetomidine 1 ml (100 μg) plus normal saline 1 ml were added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Group F: 2 ml (100 μg) fentanyl was added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Group C: Normal saline 2 ml was added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Measured outcomes Primary outcomes The onset of sensory analgesia (from the beginning of epidural infusion until scoring 1 on a 3-point scale) and the duration of analgesia (from the start of epidural infusion till the first demand for further pain medication) were observed and recorded. Secondary outcomes Postoperative pain was evaluated using a visual analogue scale (VAS), and the number of patients requesting additional analgesia with pethidine over paracetamol as well as the pethidine consumption during postoperative 24 hr were recorded. The hemodynamic parameters, including heart rate (HR) and mean arterial blood pressure (MAP), were monitored and recorded at baseline, 2, 6, 12, and 24 hr, and any adverse events were properly recorded and managed during the study period. Results The dexmedetomidine group showed an earlier onset and longer duration of analgesia, with a highly significant difference (P-value <0.001) than other groups. The study groups differed significantly concerning pethidine needs and consumption (P-value <0.05). The VAS revealed a considerable decrease in the dexmedetomidine group compared to other groups, with a significant difference (P-value <0.05) at the intervals of (baseline, 12 hr, and 24 hr) and a highly significant difference (P-value <0.001) at the intervals of (2 and 6 hr). Postoperative blood pressure and heart rate measurements in the dexmedetomidine group were lower than in other groups. MAP showed a statistically highly significant difference at 6 and 24 hr (P-value <0.001) and a significant difference after 12 hr (P-value <0.05), while HR showed a statistically significant difference after 6 hr (P-value <0.05) and a highly significant difference at 12 and 24 hr (P-value <0.001). Regarding postoperative adverse events, no statistical difference was detected between groups except in pruritis and dry mouth. Conclusion Dexmedetomidine is preferred to fentanyl when added to epidural bupivacaine to relieve pain after abdominal procedures.

Effective prevention of post-dural puncture headache with insertion of an intrathecal catheter in parturients: a retrospective study and meta-analysis

BackgroundAccidental dural puncture is a common complication of labour analgesia. It can trigger post-dural puncture headache, with associated morbidity and increased costs. Intrathecal catheter placement is a prophylactic procedure which can reduce incidence and severity of post-dural puncture headache.MethodsWe conducted a retrospective single-centred study to define incidence and risk factors of accidental dural puncture and post-dural puncture headache in an obstetric population. We also evaluated effectiveness of intrathecal catheter placement compared to epidural catheter replacement in reducing incidence of post-dural puncture headache. We then conducted a systematic review and meta-analysis which included all studies comparing intrathecal catheter placement to epidural catheter replacement in obstetric patients with accidental dural puncture assessing the outcome of reduced incidence of post-dural puncture headache as a dichotomous variable.ResultsAccidental dural puncture had an incidence of 0.25% (60 cases). Of these, 66% developed post-dural puncture headache. A total of 77% (47/60) of patients with accidental dural puncture were treated with an intrathecal catheter placement, while 23% (13/60) had an epidural catheter replacement. Incidence of post-dural puncture headache was lower in the intrathecal catheter group (spinal 26/47, 60.5% epidural 11/13, 84.6%), although not reaching statistical significance (RR 0.71, CI 95%: 0.51–1.00; p = 0.049). The meta-analysis revealed that intrathecal catheter placement significantly reduced incidence of post-dural puncture headache compared to epidural catheter replacement (pooled RR 0.81, 95% CI 0.72–0.91, p < 0.001).ConclusionsIntrathecal catheter placement is a promising measure to prevent post-dural puncture headache, especially if followed by a pain management protocol and a continuous saline infusion.

Epidural Anaesthesia Technique in Caesarean Section Operation in Pregnant Patients with Rheumatic Heart Disease and Severe Mitral Stenosis

Introduction: Mitral stenosis (MS) is the most common form of rheumatic heart disease (RHD). Pregnant women with moderate/severe MS are more prone to heart failure and pulmonary edema than normal pregnant women. It is very important to prevent the potential for maternal heart failure before delivery. This study aimed to present a case report on the epidural anaesthesia technique in caesarean section in pregnant patients with rheumatic heart disease and severe mitral stenosis.&#x0D; Case presentation: A 31-year-old pregnant woman patient came to the hospital with complaints of shortness of breath and found rheumatic heart disease and severe mitral stenosis. The patient was premedicated with fentanyl 50 mcg and midazolam 1 mg intravenously, followed by oxygen supplementation with a 2 lpm nasal cannula. Anaesthesia was performed using a lumbar epidural technique, with the insertion of an epidural catheter in the L1-L2 intervertebral space, targeting the T10-L1 dermatome and T6-L1 target of the viscerotome. The local anaesthesia agent chosen was plain bupivacaine with a concentration of 0.5% and a volume of 25 ml. The onset of action of epidural anaesthesia is achieved within 15 minutes as long as the operation is reached a total blockade as high as T6. During surgery, the patient is monitored with standard monitors and an artery line. There were no complaints of shortness of breath felt by the patient during the operation.&#x0D; Conclusion: Epidural anaesthesia technique can be performed safely in pregnant women with comorbid mitral regurgitation and atrial fibrillation, with good intraoperative hemodynamic stability.

Clinical Presentation and Management of Malignant Psoas Syndrome: A Scoping Review of Case Reports and Case Series.

Malignant psoas syndrome (MPS) is a rare and underreported clinical syndrome that significantly impacts the quality of life of cancer patients throughmetastatic infiltration of the iliopsoas muscle. Patients suffering from MPS often present with painful hip flexion, loss of mobility, and immense pain in their legs and back. The current literature describing the clinical presentation, management, and prognosis of MPS is limited primarily to case reports and outdated literature reviews. There remains a gap in the current knowledge of MPS and in the management of this complex cancer-related pain syndrome. Thus, this scoping review aimed to map current case reports and case series on MPS for clinical presentation, treatment modalities, and resulting prognoses of MPS in late-stage cancer patients. A systemized search using the databases Embase and PubMed (Medline) was conducted to access case reports and case series published between January 1990 and October 2022 that met the study's inclusion criteria: (1) adult patients with metastatic cancer; (2) MPS symptoms secondary to infiltration of iliopsoas; (3) clinical presentation, treatment modality, and prognosis; and (4) English-language text. Our search strategy yielded 1926 citations. After removing 629 duplicates, 1,283 reports were excluded due to failure to meet eligibility criteria (n=1,271) or inaccessibility (n=12). Using the JBI appraisal tools for case reports and case series, a total of 14 articles remained for the final review. With histories of either genitourinary, hepatic, gastric, or skin cancer, each case reported new onset intense pain in the legs, back, abdomen, or pelvis with associated symptoms such as flexion of the hip or gait disorder. A computerized tomography (CT) scan, magnetic resonance imaging (MRI), orpositron emission tomography (PET) scantypically confirmed metastasis into the iliopsoas causing these symptoms, which suggested MPS. Each case utilized two to seven different pain management strategies to alleviate MPS symptoms. Many cases first used opioids for pain relief. Following a necessitated increase in morphine equivalent daily dose, a subsequent increase in the strength of analgesic, change in route of administration, and integration of combination drug therapy were generally added to the treatment regime. Many cases reported successful management of symptoms through utilizing methadone, radiation therapy, botulinum toxin injection, increased opioid dosage, or epidural catheter administration of opioids. A unified clinical definition of MPS may be required to inform physicians of this syndrome to help support clinical decisions regarding treatments for patients. The studies indicated that a clearer guideline for treatment protocol may be warranted as most cases reported utilizing various treatment medication dosages and procedures with vastly differing results.