Epidural Technique Research Articles

Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial

The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction. There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15-0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p = .011). Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

A Randomized Controlled Trial of Music Use During Epidural Catheter Placement on Laboring Parturient Anxiety, Pain, and Satisfaction.

Although music is frequently used to promote a relaxing environment during labor and delivery, the effect of its use during the placement of neuraxial techniques is unknown. Our study sought to determine the effects of music use on laboring parturients during epidural catheter placement, with the hypothesis that music use would result in lower anxiety, lower pain, and greater patient satisfaction. We conducted a prospective, randomized, controlled trial of laboring parturients undergoing epidural catheter placement with or without music. The music group listened to the patient's preferred music on a Pandora® station broadcast through an external amplified speaker; the control group listened to no music. All women received a standardized epidural technique and local anesthetic dose. The primary outcomes were 3 measures of anxiety. Secondary outcomes included pain, patient satisfaction, hemodynamic parameters, obstetric parameters, neonatal outcomes, and anesthesia provider anxiety. Intention-to-treat analysis with Bonferroni correction was used for the primary outcomes. For secondary outcomes, a P value of <.001 was considered statistically significant. A total of 100 parturients were randomly assigned, with 99 included in the intention-to-treat analysis. Patient characteristics were similar in both groups; in the music group, the duration of music use was 31.1 ± 7.7 minutes (mean ± SD). The music group experienced higher anxiety as measured by Numeric Rating Scale scores immediately after epidural catheter placement (2.9 ± 3.3 vs 1.4 ± 1.7, mean difference 1.5 [95% confidence interval {CI} 0.2-2.7], P = .02), and as measured by fewer parturients being "very much relaxed" 1 hour after epidural catheter placement (51% vs 78%, odds ratio {OR} 0.3 [95% CI 0.1-0.9], P = .02). No differences in mean pain scores immediately after placement or patient satisfaction with the overall epidural placement experience were observed; however, the desire for music use with future epidural catheter placements was higher in the music group (84% vs 45%, OR 6.4 [95% CI 2.5-16.5], P < .0001). No differences in the difficulty with the epidural catheter placement or in the rate of cesarean delivery were observed. Music use during epidural catheter placement in laboring parturients is associated with higher postprocedure anxiety and no improvement in pain or satisfaction; however, a stronger desire for music with future epidural catheter placements was observed. Further investigation is needed to determine the effect of music use in parturients requesting and using epidural labor analgesia.

Maintenance of epidural labour analgesia: The old, the new and the future.

Neuraxial analgesia is considered the gold standard in labour analgesia, providing the most effective pain relief during childbirth. Improvements have enhanced the efficacy and safety of epidural analgesia through better drugs, techniques and delivery systems. This review describes the history of epidural labour analgesia and recent improvements in labour epidural analgesia. We discuss the role of the combined spinal epidural technique, low-concentration local anaesthetic-opioid epidural solutions, patient-controlled epidural analgesia, and programmed intermittent or automated mandatory boluses in the maintenance of epidural labour analgesia. We also review the newer interactive techniques for drug delivery, such as computer-integrated patient-controlled epidural analgesia and variable frequency automated mandatory bolus. Finally, we discuss future clinical research developments, including the use of data analytics and long-term outcomes associated with childbirth pain management.

Epidural Anesthesia vs General Anesthesia in Uterine Artery Embolization

Background: Uterine Artery Embolization (UAE) has been used worldwide for the treatment of uterine fibroids. The aim of the current study is to evaluate the effects of epidural analgesia (EDA) given only intraoperatively to those of general anesthesia (does it still affect in recovery) in women undergoing uterine artery embolization (UAE) for the treatment of systematic uterine fibroids. Patients and methods: A total of 40 ASA1-III patients (ages 35-55) selected for uterine artery embolization were divided into 2 groups i.e. an epidural anesthesia group (A) and a general anesthesia group (B). Each group comprised of 20 individuals. The parameters i.e. pain scoring, incidence of nausea and vomiting, need for opioids, overall patient satisfaction score and discharge from hospital were measured. Pain intensity was measured using VAS (1–10) at 0, 1, 2, 4, 8, 12 and 24 h. Nausea lasting more than 10 min or vomiting was treated with ondansetron 4 mg. Patient satisfaction for postoperative analgesia was recorded according to a satisfaction score (poor=0, fair=1, good=2, excellent=3). All data were recorded with residents of anesthesia. Primary outcome was morphine and or pethidine, consumption in the first 24 h. Secondary outcome measures were; pain intensity, postoperative analgesic consumption, postoperative nausea and vomiting (PONV) and patient satisfaction. Results: Differences in the heart rate between the 2 groups were statistically significant at all readings where group (B) patients developed less significant tachycardia compared to group (A) patients. Differences in systolic blood pressure values between the 2 groups were statistically significant lower in group (B) compared to group (A) at 2 points: after 5 min & after 10 min from induction of anesthesia. Differences in diastolic blood pressure values between the 2 groups were statistically significant lower in group (A) compared to group (B) at all times except preoperative reading. Thus the epidural anesthesia provided more hemodynamic stability than general anesthesia, Postoperative pain severity of the patients significantly decreased in each group at recovery room (time 0) and postoperative 1st, 2nd, 4th, 12th and 24th h (repeated measured variance analysis, p<0.001. However, the reduction of postoperative VAS scores was more in epidural anesthesia group than general anesthesia (repeated measured variance analysis, test, p=0.466. Conclusion: Uterine artery embolization for fibroids is an effective and safe therapeutic modality for symptomatic fibroids especially for those patients who like to preserve their uterus. Recovery and time to return to normal activities is shorter than hysterectomy and open myomectomy. With the results of the present study it can be concluded that epidural anaesthesia was much better in pain relief, less sedating effect and overall patient satisfaction. Thus, epidural anaesthesia technique can be helpful for women undergoing UAE to recover faster providing good symptom relief for most patients.

An Update on Drugs Used for Lumbosacral Epidural Anesthesia and Analgesia in Dogs.

This review aims to report an update on drugs administered into the epidural space for anesthesia and analgesia in dogs, describing their potential advantages and disadvantages in the clinical setting. Databases searched include Pubmed, Google scholar, and CAB abstracts. Benefits of administering local anesthetics, opioids, and alpha2 agonists into the epidural space include the use of lower doses of general anesthetics (anesthetic “sparing” effect), perioperative analgesia, and reduced side effects associated with systemic administration of drugs. However, the potential for cardiorespiratory compromise, neurotoxicity, and other adverse effects should be considered when using the epidural route of administration. When these variables are considered, the epidural technique is useful as a complementary method of anesthesia for preventive and postoperative analgesia and/or as part of a balanced anesthesia technique.

Comparison of the Efficacy and Safety of Morphine and Fentanyl as Adjuvants to Bupivacaine in Providing Operative Anesthesia and Postoperative Analgesia in Subumblical Surgeries Using Combined Spinal Epidural Technique.

Introduction:The combined spinal epidural (CSE) technique involves intentional subarachnoid blockade and epidural catheter placement during the same procedure to combine their individual best features, to reduce the total drug dosage and avoid their respective disadvantages. The addition of opioids to local anesthetics (bupivacaine) for CSE anesthesia (CSEA) is increasingly common to enhance the block. Neuraxial fentanyl is more potent and has shorter duration of action than morphine which provides prolonged anesthesia and analgesia, however at the cost of increased incidence of adverse effects like delayed respiratory depression.Aims and Objectives:The aim is to compare the efficacy and safety of morphine and fentanyl as adjuvants to bupivacaine in subumblical surgeries using CSE technique. The characteristics of sensory and motor block, intergroup variations in pain, cardiorespiratory parameters, and adverse effects were compared between the two groups.Materials and Methods:A total of 60 patients belonging to physical status American Society of Anesthesiologists Classes I and II, aged 18–60 years were randomized into two groups: Group A (n = 30) received intrathecal 0.5% heavy bupivacaine 12.5 mg and morphine 2.85 μg/kg; Epidural Anesthetic bolus (when required/T11Regression) 8 ml 0.25% isobaric bupivacaine and 0.04 mg/kg morphine; Epidural Analgesic bolus (postoperative visual analog scale [VAS] score >30) 5 ml 0.125% isobaric bupivacaine and 0.04 mg/kg morphine and Group B (n = 30) received intrathecal 0.5% heavy bupivacaine 12.5 mg and fentanyl 0.35 μg/kg; Epidural Anesthetic bolus (when required/T11Regression) 8 ml 0.25% isobaric bupivacaine and 0.7 μg/kg fentanyl; Epidural Analgesic bolus (postoperative VAS score >30) 5 ml 0.125% isobaric bupivacaine and 0.7 μg/kg fentanyl.Results and Conclusion:Group A had significantly prolonged two segment regression time, T11 regression time, lower mean VAS score, prolonged effective analgesia, and required lesser number of epidural boluses in 24 h as compared to Group B (P < 0.001). There were no significant differences between the groups considering onset of sensory block, duration of motor block, median maximum sensory block level achieved after spinal component (T6), median highest sensory block level achieved after epidural anesthetic bolus (T7-4seg enhancement after regression to T11), cardiorespiratory parameters and adverse effects. None of the patients had respiratory depression nor was there any failure of spinal/epidural component of CSEA. Thus, addition of morphine to bupivacaine in CSEA produced prolonged effective anesthesia and postoperative analgesia compared to addition of fentanyl to bupivacaine without producing undue adverse effects.

Comparative Evaluation of Continuous Thoracic Paravertebral Block and Thoracic Epidural Analgesia Techniques for Post-operative Pain Relief in Patients Undergoing Open Nephrectomy: A Prospective, Randomized, Single-blind Study.

Background:Open surgical procedures are associated with substantial postoperative pain; an alternative method providing adequate pain relief with minimal side effects is very much required.Aim:The aim of this study was a comparative evaluation of the efficacy of continuous thoracic paravertebral block (PVB) and thoracic epidural analgesia (EA) for postoperative pain relief in patients undergoing open nephrectomy.Settings and Design:Prospective, randomized, and single-blind study.Materials and Methods:Sixty adult patients undergoing open nephrectomy under general anesthesia were randomized to receive a continuous thoracic epidural infusion (Group E) or continuous thoracic paravertebral infusion (Group P) with bupivacaine 0.1% with 1 μg/ml fentanyl at 7 ml/h; both infusions were started after induction of anesthesia. The primary outcome measures were postoperative pain during rest (static pain), deep inspiration, coughing, and movement (getting up from supine to sitting position); the secondary outcome measures were postoperative nausea and vomiting, requirement of rescue antiemetic, hypotension, sedation, pruritus, motor block, and respiratory depression. These were assessed till the morning of the third postoperative day.Statistical Analysis:Results were analyzed by the one-way ANOVA, Chi-square test, and Mann–Whitney U-test. P < 0.05 was considered significant.Results:Both the groups were similar with regard to demographic factors (P > 0.05). The visual analog scale scores at rest, deep breathing, coughing and movement, and postoperative fentanyl consumption were similar in the two groups (P > 0.05); the incidence of side effects was also similar in the two groups (P > 0.05).Conclusions:Continuous thoracic PVB is as effective as continuous thoracic EA in providing pain relief in patients undergoing open nephrectomy in the postoperative period. The side effect profile of the two techniques was also similar.

Graded epidural anaesthesia for caesarean section in a parturient with severe left ventricular dysfunction from dilated cardiomyopathy: A case report

Dilated cardiomyopathy (DCM) is a primary disorder of heart muscle characterised by left ventricular (LV) or biventricular dilatation and impaired ventricular contractility. During pregnancy, women with DCM have a higher incidence of cardiac events than the non-pregnant patient. When DCM is associated with severe LV dysfunction, anaesthetic management is particularly challenging, because severe LV dysfunction is a predictor of sudden cardiac death and poor quality of life. The goals of anaesthetic management in DCM consist of maintaining normovolaemia, and avoiding myocardial depression and drug overdose during induction (as circulation time is slow). It also includes preventing increases in ventricular afterload and sudden hypotension when regional anaesthesia is a choice. This case report describes the successful anaesthetic management of a parturient with DCM and a severely low LV ejection fraction of 20%, wherein the child was delivered via caesarean section using a graded epidural anaesthesia technique.

Feasibility of Cervical Epidural Anesthesia for Breast Cancer Surgery

Background Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse. Methods Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed. Results In 26 patients (66,7%, 95% CI 51,7–81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0–7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7–19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7–30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4–96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed. Discussion Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques.

Comparison of epidural versus systemic analgesia for major surgeries in neonates and infants

Background and Aims: Postoperative analgesia in neonate reduces acute behavioral responses to pain. It also protects the developing nervous system from persistent sensitization of pain pathway and potential damaging effects of altered neural activity on central nervous system development. We compared the effectiveness of epidural versus systemic modes of analgesia for major surgeries in neonates and infants. Materials and Methods: This randomized, single center, prospective, controlled study was conducted in sixty patients, aged 1 day to 6 months, weighing 2–5 kg belonging to the American Society of Anesthesiology physical Grade II to IV, posted for major thoracic and abdominal surgery. After general anesthesia, in Group A, the epidural catheter was inserted through standard caudal epidural technique. Initial bolus of 0.125% bupivacaine (0.75 ml/kg) and postoperatively caudal infusion of 0.0625% bupivacaine (0.1 ml/kg/h) was given. Intraoperatively Group B received fentanyl (1–2 μg/kg) and paracetamol (10 mg/kg) intravenously and postoperatively paracetamol (10 mg/kg)/intravenous (IV) six hourly or pain score > 4. Postoperative pain was assessed using face, legs, activity, cry, and consolability pain scale and sedation score was assessed by using four-point sedation score for 48 h. Results: Patients in Group A remained hemodynamically stable except occasional bradycardia below 100 which was successfully managed with anticholinergics. There was less requirement of sevoflurane in the intraoperative period and good quality of analgesia. While in Group B, multiple and regular dosage of IV paracetamol was required to maintain adequate analgesia. Conclusion: Very efficient postoperative analgesia can be achieved via caudal epidural catheter in combination with general anesthesia compared to IV paracetamol in neonates and infants.

Comparative Study of Post Operative Analgesia with Epidural Clonidine and Epidural Normal Saline Using Combined Spinal Epidural Technique

Comparative Study of Post Operative Analgesia with Epidural Clonidine and Epidural Normal Saline Using Combined Spinal Epidural Technique

Raman Spectroscopy Differentiates Each Tissue from the Skin to the Spinal Cord: A Novel Method for Epidural Needle Placement?

Neuraxial anesthesia and epidural steroid injection techniques require precise anatomical targeting to ensure successful and safe analgesia. Previous studies suggest that only some of the tissues encountered during these procedures can be identified by spectroscopic methods, and no previous study has investigated the use of Raman, diffuse reflectance, and fluorescence spectroscopies. The authors hypothesized that real-time needle-tip spectroscopy may aid epidural needle placement and tested the ability of spectroscopy to distinguish each of the tissues in the path of neuraxial needles. For comparison of detection methods, the spectra of individual, dissected ex vivo paravertebral and neuraxial porcine tissues were collected using Raman spectroscopy (RS), diffuse reflectance spectroscopy, and fluorescence spectroscopy. Real-time spectral guidance was tested using a 2-mm inner-diameter fiber-optic probe-in-needle device. Raman spectra were collected during the needle's passage through intact paravertebral and neuraxial porcine tissue and analyzed afterward. The RS tissue signatures were verified as mapping to individual tissue layers using histochemical staining and widefield microscopy. RS revealed a unique spectrum for all ex vivo paravertebral and neuraxial tissue layers; diffuse reflectance spectroscopy and fluorescence spectroscopy were not distinct for all tissues. Moreover, when accounting for the expected order of tissues, real-time Raman spectra recorded during needle insertion also permitted identification of each paravertebral and neuraxial porcine tissue. This study demonstrates that RS can distinguish the tissues encountered during epidural needle insertion. This technology may prove useful during needle placement by providing evidence of its anatomical localization.

Combined Spinal Epidural Technique for Labor Analgesia Does Not Delay Recognition of Epidural Catheter Failures: A Single-center Retrospective Cohort Survival Analysis.

It is unclear whether recognition of epidural catheter failures is delayed with combined spinal epidural technique (CSE) compared to traditional epidural technique (EPID) when used for labor analgesia. The authors hypothesized that recognition of failed catheters is not delayed by CSE. Anesthetic, obstetric, and quality assurance records from 2,395 labor neuraxial procedures (1,440 CSE and 955 EPID) performed at Forsyth Medical Center (Winston-Salem, North Carolina) between June 30 and December 31, 2012, were retrospectively analyzed. The primary outcome was catheter survival (failure-free) time during labor analgesia. A proportional hazards model with the counting method was used to assess relationships between the techniques and survival (failure-free) time of catheters, while controlling for subjects' body mass index and providers' level of training in the final best-fit multivariable regression model. Cumulative incidence of epidural catheter failures was 6.6% for CSE and 11.6% for EPID (P = 0.001). In the multivariable regression model, catheters placed with CSE versus epidural were less likely to fail (hazard ratio, 0.58; 95% CI, 0.43 to 0.79; P = 0.0002) for labor analgesia. Among the catheters that failed, there was no overall difference in failure time course between the techniques (hazard ratio, 1.17; 95% CI, 0.89 to 1.54; P = 0.26) even though more failed catheters with CSE (48.4%) than with EPID (30.6%) were recognized within the first 30 min of placement (P = 0.009). In this cohort, CSE has a significantly lower risk of overall epidural catheter failures than EPID and does not delay recognition of epidural catheter failures. Choice of CSE versus EPID should be based on overall risk of failure, efficacy, and side effects.

Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis

(Reg Anesth Pain Med. 2016;41(2):251–260) Using an ultrasound to examine a patient’s spine prior to the administration of spinal or epidural anesthesia is a new development in regional anesthesia. Such an examination allows anesthesiologists to observe the underlying anatomy and helps improve the accuracy of needle placement. Previous reports have described spinal and epidural techniques that use ultrasound for real-time guidance, which is distinct from this ultrasound-assisted approach. This review assessed the evidence in favor of preprocedural neuraxial ultrasound as a supplementary procedure to lumbar spinal and epidural anesthesia in adults.

External Cephalic Version: Some Tricks of the Trade.

External Cephalic Version: Some Tricks of the Trade.

Comparative Study of the Localisation of the Epidural Space Using Epidural Balloon Technique versus Saline Filled Syringe Technique – A Prospective, Randomised Study

Background and aims:The success of epidural anaesthesia begins with proper identification of epidural space. There are different techniques used for identification of the epidural space. In this study we compare the localisation of epidural space using epidural balloon technique versus normal saline filled syringe technique .Method: 200 adult patents of ASA I &II status posted for elective lower abdominal and lower limb surgery were randomly allocated in two groups of 100 each. After taking consent and IV access epidural anaesthesia was given to the patients. In group I epidural space was localised by epidural balloon technique while in group II epidural space was located by normal saline filled syringe technique using the loss of resistance method. The parameters studied were time taken for epidural space localisation, the number of attempts,the ease of passing the epidural catheter after localisation, success or failure rate of the localisation of the epidural space by resident anaesthesiologistsand the incidence of complications if any.Student unpaired ‘t’ test and chi square test were used for statistical analysis. Results:90% cases from group I(epidural balloon group) had localisation of epidural space in first attempt which was significantly more as compared to 78% in group II(saline filled syringe group). Mean duration of procedure in group I was 20.74 seconds which was significantly less as compared to 43.54 seconds in group II. 12% of cases from group II had complications during the procedure which was significantly more as compared to none from group I. Conclusion: For epidural space localisation epidural balloon technique is better than saline filled syringe technique in terms of number of attempts, mean duration of procedure, incidence of complications and ease of technique.

Double Invasive Blood Pressure Monitoring for Cesarean Delivery in a Pregnant Woman With Aortic Coarctation.

Aortic coarctation is a discrete narrowing of the proximal thoracic aorta. It is poorly tolerated during pregnancy because of its association with hypertension, cerebrovascular accident, and aortic rupture. We report a case of severe uncorrected congenital aortic coarctation in a 31-year-old symptomatic pregnant woman at 29 weeks of gestation who underwent successful cesarean delivery with an epidural anesthetic technique. Transthoracic echocardiography showed a gradient of 75 mm Hg. To avoid undiagnosed arterial hypotension and inadequate uteroplacental flow distal to the coarctation, double (radial and femoral) invasive arterial blood pressure measurement was used to monitor both pre- and postcoarctation arterial blood pressure.

Managing anesthesia for cesarean section in obese patients: current perspectives.

Obesity is a worldwide epidemic. It is associated with increased comorbidities and increased maternal, fetal, and neonatal complications. The risk of cesarean delivery is also increased in obese parturients. Anesthetic management of the obese parturient is challenging and requires adequate planning. Therefore, those patients should be referred to antenatal anesthetic consultation. Anesthesia-related complications and maternal mortality are increased in this patient population. The risk of difficult intubation is increased in obese patients. Neuraxial techniques are the preferred anesthetic techniques for cesarean delivery in obese parturients but can be technically challenging. An existing labor epidural catheter can be topped up for cesarean delivery. In patients who do not have a well-functioning labor epidural, a combined spinal epidural technique might be preferred over a single-shot spinal technique since it is technically easier in obese parturients and allows for extending the duration of the block as required. A continuous spinal technique can also be considered. Studies suggest that there is no need to reduce the dose of spinal bupivacaine in the obese parturient, but there is little data about spinal dosing in super obese parturients. Intraoperatively, patients should be placed in a ramped position, with close monitoring of ventilation and hemodynamic status. Adequate postoperative analgesia is crucial to allow for early mobilization. This can be achieved using a multimodal regimen incorporating neuraxial morphine (with appropriate observations) with scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Thromboprophylaxis is also important in this patient population due to the increased risk of thromboembolic complications. These patients should be monitored carefully in the postoperative period, since there is increased risk of postoperative complications in the morbidly obese parturients.

Pain after sternotomy - review

Adequate analgesia after sternotomy reduces postoperative adverse events. There are various methods of treating pain after heart surgery, such as infiltration with a local anesthetic, nerve block, opioids, non-steroidal anti-inflammatory drugs, alpha-adrenergic agents, intrathecal and epidural techniques, and multimodal analgesia. A review of the epidemiology, pathophysiology, prevention and treatment of pain after sternotomy. We also discuss the various analgesic therapeutic modalities, emphasizing advantages and disadvantages of each technique. Heart surgery is performed mainly via medium sternotomy, which results in significant postoperative pain and a non-negligible incidence of chronic pain. Effective pain control improves patient satisfaction and clinical outcomes. There is no clearly superior technique. It is believed that a combined multimodal analgesic regimen (using different techniques) is the best approach for treating postoperative pain, maximizing analgesia and reducing side effects.

Thoracic Epidural Versus General Anaesthesia for MRM Surgeries

Background : General anaesthesia is still the preferred technique amongst many practitioners for oncologic breast surgeries. However the TEA technique has a lot of advantages over the conventional GA technique. Objective: We attempted to evaluate the two techniques of anaesthesia for MRM surgeries. Materials and Method: Sixty ASA I-II patients undergoing MRM were randomly assigned to two study groups of 30 patients each. In the TEA group (group T), an epidural catheter was inserted at T7-T8 level, and 8-10 ml of 0.5% bupivacaine was titrated and administered. GA (group G) was induced with 2mg/kg of propofol and was maintained with Isoflurane, intermittent inj. Vecuronium and 70% N2O in oxygen. The authors evaluated the adequacy of anesthesia, surgical condition, post anesthetic recovery, post anesthetic analgesia and patients' satisfaction. Results: The intra operative haemodynamics was comparable in between the two groups. The incidence of nausea and vomiting was significantly lower in the TEA group (16.5% in group T and 39.6% in group G , P = 0.02). The mean immediate VAS score was also lower in TEA group ( group T =2.4 , group G =5.8,P = 0.001). Aldrete recovery score was 9/10 in 1 st hr in a significant proportion in the TEA group (89.1% in group T v/s 59.4% in group G , P = 0.003). Patient satisfaction was significantly higher. The surgeons were however satisfied with both the methods. Conclusion: Use of thoracic epidural technique as a sole anaesthetic technique for MRM surgeries provides adequate operating conditions, better side effect profile, better pain management and patient satisfaction.