Epidural Technique Research Articles

Intraoperative plethysmography variability index directed fluid management versus standard care during intraabdominal surgery in cancer patients

Background: During the past 20 years, numerous publications have described the usefulness of systolic pressure variation, pulse pressure variation, stroke volume variation, etc., to guide intraoperative fluid administration. However, we still lack robust noninvasive physiological variables to successfully predict the response to fluid loading. Aims and Objectives: The present study was designed to evaluate the utility of plethysmography variability index (PVI) to optimize fluid management during intra-abdominal surgery in cancer patients. Materials and Methods: After the Institutional Ethics Committee approval and consent, 60 patients scheduled for elective lower abdominal cancer surgeries were randomized to receive fluid by either PVI-directed management (2 mL/kg/h) or using central venous pressure (8 mL/kg/h) after standardized technique of general and lumbar epidural anesthesia. The PVI was calculated by measuring changes in the PI during the respiratory cycle (PVI = [(PImax - PImin)/PImax] × 100). Arterial blood samples were taken at the time of incision and after 6 h postoperatively. Instances of intraoperative hypotension and oliguria were recorded. Results: Among the 60 patients enrolled in the study, demographic data, ASA status, duration of surgery, and hemodynamics were found to be comparable. The amount of crystalloid given was significantly lesser in Group P (984.70±51.16) as compared to Group C (2395.27±209.68) (P<0.001). Four patients in Group P and three patients in Group C required vasopressors. Conclusion: The use of PVI-guided fluid management was associated with lower lactate levels and crystalloid requirement. Reduced lactate levels in PVI-guided patients suggest that PVI-guided fluid management may be tailored to everyone’s needs.

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.

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.
 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.
 Conclusion: Epidural anaesthesia technique can be performed safely in pregnant women with comorbid mitral regurgitation and atrial fibrillation, with good intraoperative hemodynamic stability.

Landmark-guided versus Real-time Ultrasound-guided Combined Spinal-epidural Anesthesia Techniques: Paramedian Sagittal Oblique and Transverse Interlaminar Approach.

There are different types of real-time ultrasound (US)-guided combined spinal epidural (CSE) anesthesia techniques. We aimed to investigate the effect of real-time US-guided paramedian sagittal oblique (PSO), transverse interlaminar (TI) approach method, and landmark-guided (LG) CSE anesthesia. Ninety patients who underwent CSE block were included in the study. Patients were randomized into LG (n = 30), PSO (n = 30), and TI (n = 30) groups. The primary outcome was number of needle manipulations. The secondary outcomes are the number of attempts, needle visibility, procedure time, procedure success rate, catheter placement difficulty, posterior complex distance, and complications. The number of needle manipulations was statistically significantly lower in the LG technique group (P < 0.000). When the number of attempts, the difficulty of catheter placement, and the procedure's success rate were compared between the three groups, we did not find a statistically significant difference (P > 0.05). In addition, when the procedure times were compared, the time measured for the LG group was statistically significantly lower than in the PSO and TI groups (P < 0.000). In the results of this study, the real-time US-guided CSE anesthesia application had a similar success and complication level with LG technique. The LG method had a shorter processing time and fewer needle manipulations.

Morphology and morphometry of the spinal cord and meninges in Egyptian Baladi goat (Capra hircus): Stereomicroscopy of blue-stained gray matter.

The study objective is to obtain normal morphology and morphometric data from Baladi goat spinal cord segments. Using Tompsett's technique for staining gray matter with a blue stain allowed us to calculate the quantity or area of gray and white matter and thus the total area of each segment. The spinal cord of the goat started at the extent of the middle-third of the occipital condyles, and the tapered end of the spinal cord terminated at the center of the first sacral vertebra. The total length of the spinal cord was 73.3 ± 2.5 cm on average. C3 was the longest spinal segment, measuring 3.95 cm. The gray matter area had a high value at the cervical and lumbar enlargements, with C8 having the highest value of gray matter cross sectional area at 12 mm2 and C7 having the highest value of white matter cross sectional area at 42 mm2 . The area of white matter of the cervical region was higher than that of the other spinal regions. At C7, the total cross section area reached its maximum of 53 mm2 . The cervical enlargement included segments from C6 to T1, while the lumbar enlargement included L5 to S1. The dura mater is connected cranially to the dens of the axis and caudally to the fourth and fifth lumbar vertebrae. The epidural space height between lumbar vertebrae was 2 mm in all lumbar spaces and 3 mm in the lumbosacral space. The normal morphology and morphometric data of the goat spinal cord segments may be useful in pathological conditions of the spinal cord and during epidural anaesthesia technique.

Intrathecal opioids for the management of post-operative pain.

Intrathecal opioids are highly effective in the management of post-operative pain. The technique is simple with a very low risk of technical failure or complications, and it does not require additional training or expensive equipment such as ultrasound machines and, therefore, is widely practised around the world. The high-quality pain relief is not associated with sensory, motor or autonomic deficits. This study focuses on intrathecal morphine (ITM) which is the only US Food and Drug Administration-approved opioid for intrathecal administration and remains the most commonly used as well as extensively studied. The use of ITM is associated with prolonged analgesia lasting 20-48h after a variety of surgical procedures. ITM has a well-established role in thoracic, abdominal, spinal, urological and orthopaedic surgeries. It is considered the 'gold standard' analgesia technique for caesarean delivery which is generally performed under spinal anaesthesia. As the role of epidural technique in post-operative pain management continues to decrease, ITM has emerged as the neuraxial technique of choice for pain management after a major surgery as a component of multimodal analgesia in Enhanced Recovery After Surgery (ERAS) protocols. ITM is recommended by many scientific groups and societies such as ERAS, PROSPECT, the National Institute for Health and Care Excellence and the Society of Obstetric Anesthesiology and Perinatology. The doses of ITM have decreased successively; today they are a fraction of those used in the early 1980s. With these dose reductions, the risks have decreased; current evidence shows that the risk of the much-feared respiratory depression with low-dose ITM (up to 150 mcg) is no greater than that with systemic opioids used in routine clinical practice. Patients receiving low-dose ITM can be nursed in regular surgical wards. The monitoring recommendations from societies such as the European Society of Regional Anaesthesia and Pain Therapy (ESRA), the American Society of Regional Anesthesia and Pain Medicine and the American Society of Anesthesiologists need to be updated so that the requirements for extended or continuous monitoring at postoperative care units (PACUs), step-down units, high-dependency units, and intensive care units can be eliminated, thereby reducing additional costs and inconvenience and making this simple, versatile and highly effective analgesia technique available to a wider patient population in resource-limited settings.

Comparison of accuracy between augmented reality/mixed reality techniques and conventional techniques for epidural anesthesia using a practice phantom model kit

BackgroundThis study used an epidural anesthesia practice kit (model) to evaluate the accuracy of epidural anesthesia using standard techniques (blind) and augmented/mixed reality technology and whether visualization using augmented/mixed reality technology would facilitate epidural anesthesia.MethodsThis study was conducted at the Yamagata University Hospital (Yamagata, Japan) between February and June 2022. Thirty medical students with no experience in epidural anesthesia were randomly divided into augmented reality (-), augmented reality (+), and semi-augmented reality groups, with 10 students in each group. Epidural anesthesia was performed using the paramedian approach with an epidural anesthesia practice kit. The augmented reality (-) group performed epidural anesthesia without HoloLens2Ⓡ and the augmented reality (+) group with HoloLens2Ⓡ. The semi-augmented reality group performed epidural anesthesia without HoloLens2Ⓡ after 30 s of image construction of the spine using HoloLens2Ⓡ. The epidural space puncture point distance between the ideal insertion needle and participant’s insertion needle was compared.ResultsFour medical students in the augmented reality (-), zero in the augmented reality (+), and one in the semi-augmented reality groups failed to insert the needle into the epidural space. The epidural space puncture point distance for the augmented reality (-), augmented reality (+), and semi-augmented reality groups were 8.7 (5.7–14.3) mm, 3.5 (1.8–8.0) mm (P = 0.017), and 4.9 (3.2–5.9) mm (P = 0.027), respectively; a significant difference was observed between the two groups.ConclusionsAugmented/mixed reality technology has the potential to contribute significantly to the improvement of epidural anesthesia techniques.

A Study of the Clinical Effects of Sequential Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Patients Undergoing Orthopedic Surgeries.

In orthopedic surgeries, there has been an increase in the usage of the neuraxial blockade to provide excellent surgical conditions and prolonged postoperative analgesia. The introduction of the sequential combined spinal epidural anesthesia (SCSEA) technique provides benefits for both spinal anesthesia (SA) and epiduralanesthesia. The focus of this study was to analyze the time needed to attain a desired level of sensory block, to compare the period of sensory block, and to study the intraoperative hemodynamics in the SCSEA and SA groups. The study was conducted on patients admitted for elective lower limb orthopedic surgeries. The sample size for this prospective randomized study is two groups of 67 subjects each. Patients aged between 18 and 65 years, posted for orthopedic surgeries for two to three hours, and of American Society of Anaesthesiologists (ASA) Grades 1 and 2 were included and divided into two groups. Group A patients received SCSEA with an epidural-test dose of 3 ml lignocaine (2%) with adrenaline and spinal bupivacaine (0.5%) of 1.5 ml-7.5 mg + fentanyl .25 mic if the sensory level was below T8. An epidural top-up was given with 2 ml per segment of 0.5% bupivacaine to bring the sensory level to T8. Group B patients received SA with spinal bupivacaine (0.5%) of 3 ml-15 mg + fentanyl .25 mic. Intraoperative hemodynamics, the duration to achieve a sensory level of T8, the time for two-segment regression of sensory block, and the complications that occurred were recorded. The study included a total of 134 subjects with each group having 67 subjects admitted for lower limb surgery. The mean value (SD) of the time taken to attain sensory block in the SCSEA group was prolonged when compared to the SA group (7.15 ± 0.75 and 5.01 ± 0.88). The time for two-segment regression in the SCSEA group was 86.77 ± 3.60and the SA group was 106.4 ± 8.01, which indicated that the SA group has a longer and better sensory block. Substantially, the study shows that the SCSEA group (P< 0.05) has better hemodynamics when compared to the SA group. The SCSEA technique has better intraoperative hemodynamic stability with a longer analgesic effect when compared to SA. SA shows a sudden change in hemodynamics but reveals a greatersensory block.

EFFICACY AND SAFETY OF CONVENTIONAL EPIDURAL VERSUS COMBINED SPINAL EPIDURAL IN PERCUTANEOUS NEPHROLITHOTOMY: A PROSPECTIVE AND RANDOMIZED CLINICAL STUDY

Objectives: The aim of the study was to compare the efficacy and safety of conventional epidural (ED) versus combined spinal epidural (CSE) in percutaneous nephrolithotomy (PCNL) with addition of opiods and dexmedetomidine. Methods: This prospective, randomized, and double-blinded clinical study was conducted in the in patients undergoing PCNL. Group CSE had received CSE anesthesia and Group ED given conventional epidural anesthesia. Time to first rescue analgesic and total dose of rescue analgesic along with hemodynamic parameters were compared up to 24 h. Patient, surgeon satisfaction score, and post-operative complications were also compared. Results: Time from onset of sensory block to first requirement of analgesia was prolonged in group CSE (218.4±18.30 min) as compared to Group ED (210±17.88 min). (p&lt;0.001) Mean time for first rescue analgesia postoperatively was highly significant in group CSE (2.42±0.49) as compared to Group ED (2.08±0.28). (p&lt;0.0001) Total dose of levobupivacaine required was high in Group ED (49.66±7.02) as compared to Group CSE (45.66±3.12). (p&lt;0.001) In Group ED, surgeon score was good in 20 (44.44%) patients and which was highly significant. In Group CSE, surgeon score was excellent in 41 (91.1%) patients and which was highly significant. (p&lt;0.001) Post-operative complications in both the group were comparable (p&gt;0.05). Conclusion: This study concluded that though both the anesthesia techniques are safe and efficient with each having its own benefits. CSE had proven superiority over the epidural technique.

Epidural Volume Extension Technique - A Novel Approach for Anaesthetic Management of RHD with Severe AR Posted for Elective LSCS

Epidural Volume Extension Technique - A Novel Approach for Anaesthetic Management of RHD with Severe AR Posted for Elective LSCS

Determination of the Optimal Volume of Programmed Intermittent Epidural Bolus When Combined With the Dural Puncture Epidural Technique for Labor Analgesia: A Random-Allocation Graded Dose-Response Study.

The dural puncture epidural (DPE) and the programmed intermittent epidural bolus (PIEB) techniques are recent innovations for labor analgesia. The optimal volume of PIEB during traditional epidural analgesia has been investigated previously but it is unknown whether these findings are applicable to DPE. This study aimed to determine the optimal volume of PIEB for effective labor analgesia after initiation of analgesia using DPE. Parturients requesting labor analgesia received dural puncture with a 25-gauge Whitacre spinal needle and then had analgesia initiated with 15 mL of ropivacaine 0.1% with sufentanil 0.5 μg/mL. Analgesia was maintained using the same solution delivered by PIEB with boluses given at a fixed interval of 40 minutes starting 1 hour after the completion of the initial epidural dose. Parturients were randomized to 1 of 4 PIEB volume groups: 6, 8, 10, or 12 mL. Effective analgesia was defined as no requirement for a patient-controlled or manual epidural bolus for 6 hours after the completion of the initial epidural dose or until full cervical dilation. The PIEB volumes for effective analgesia in 50% of parturients (EV50) and 90% of parturients (EV90) were determined using probit regression. The proportions of parturients with effective labor analgesia were 32%, 64%, 76%, and 96% in the 6-, 8-, 10-, and 12-mL groups, respectively. The estimated values for EV50 and EV90 were 7.1 (95% confidence interval [CI], 5.9-7.9) mL and 11.3 (95% CI, 9.9-15.2) mL, respectively. There were no differences in side effects, including hypotension, nausea and vomiting, and fetal heart rate (FHR) abnormalities among groups. Under the conditions of the study, after initiation of analgesia using DPE, the EV90 of PIEB for effective labor analgesia using ropivacaine 0.1% with sufentanil 0.5 μg/mL was approximately 11.3 mL.

Comparison of the incidence of fetal prolonged deceleration after induction of labor analgesia between dural puncture epidural and combined spinal epidural technique: a pilot study

BackgroundAbnormal cardiotocogram (CTG) tracing may appear after induction of neuraxial labor analgesia. Non-reassuring fetal status (NRFS) indicated by severely abnormal tracings, such as prolonged deceleration (PD) or bradycardia, can necessitate immediate operative delivery. Combined spinal epidural analgesia (CSEA) is known to result in more frequent abnormal tracings than epidural analgesia (EA); however, the corresponding data related to dural puncture epidural (DPE) are unclear. We aimed to evaluate the rates of incidence of severe abnormal CTG after induction of DPE and CSEA.MethodsIn this study of nulliparous women with full-term pregnancy, data for the DPE intervention group were prospectively collected, while those for the CSEA control group were obtained from medical records. Neuraxial analgesia was performed with cervical dilation ≤ 5 cm, administering initial epidural dosing of 15 mL of 0.125% levobupivacaine with fentanyl 2.5µg/mL for DPE, and intrathecal 0.5% bupivacaine 2.5 mg (0.5ml), fentanyl 10 µg (0.2ml), and 1.3 mL of saline for CSEA. The primary outcome was the incidence of PD, defined as a fetal heart rate reduction ≥ 15 bpm below the baseline and with a lowest value < 80 bpm, and lasting for ≥ 2 min but < 10 min (fetal heart rate < 80 bpm does not have to last for ≥ 2 min), within 90 min after induction of neuraxial labor analgesia.ResultsA total of 302 patients were analyzed, with 151 in each group. The incidence of PD after DPE induction was significantly lower than that after CSEA induction (4.0% vs. 14.6%, P = 0.0015, odds ratio = 0.243, 95% confidence interval = 0.095–0.617).ConclusionDPE appears to be a safer method compared to CSEA for neuraxial labor analgesia in the early stages of labor for nulliparous women.Trial registrationUMIN-CTR: UMIN000035153. Date registered: 01/01/2019.

Quality of Labor Analgesia With Dural Puncture Epidural Versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study

(Anesthesiology. 2022;136:678–687) Dural puncture epidural technique is a nested needling procedure wherein a spinal needle is passed through the epidural needle and through the dura, without the injection of intrathecal (IT) medications. Delivery of neuraxial analgesia is initiated only through the epidural catheter. Even in the absence of additional medication, dural puncture’s purported advantage over standard epidural placement is the unambiguous return of cerebrospinal fluid (CSF) through the spinal needle, confirming midline placement. Dural puncture may also facilitate the transfer of epidural drugs through the dural breach to help establish onset and quality of analgesia. Evidence for the efficacy of this approach is limited with some mixed data showing no clear clinical advantage. Obese parturients are particularly susceptible to epidural failure, and also at higher risk for emergency cesarean delivery wherein well-initiated neuraxial analgesia would be a further asset to avoid general anesthesia. The ostensible advantage of improved analgesic effect with the use of dural puncture vs standard epidural technique is investigated in obese patients who have the potential to draw strong benefit from an enhanced success rate for quality analgesia given the challenges inherent to this patient population.

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement Over Conventional Labor Epidural Analgesia?

(Anesthesiology. 2022;136:667–669) Continued innovations of the standard epidural technique have allowed for improvement of the quality of analgesia experienced by laboring women. The introduction of conventional neuraxial analgesia offered effective and safe pain relief to parturients, with relatively infrequent adverse outcomes, and is utilized in &gt;73% of contemporary births in the United States. Procedural refinements over time have offered improvement in analgesia quality, including continuous local anesthetic infusions, optimizations of volume and concentrations of medications delivered, the addition of opioids to the injectate, timed bolus injections, and patient-controlled epidural analgesia. As protocol variations, both combined spinal-epidural and dural puncture epidural utilize a smaller spinal needle that is passed through the epidural needle. In combined spinal-epidural, small doses of opioid and local anesthetic are injected into the intrathecal (IT) space. With dural puncture epidural, the spinal needle is used to intentionally puncture the dura, but no drugs are injected. Initial evidence suggested improved analgesia with this technique over standard epidural and combined spinal-epidural, but the literature has produced mixed results since. In the same issue of this journal, Tan et al deliver results from a randomized clinical trial of obese parturients receiving dural puncture epidural vs conventional epidural to determine if analgesia quality is enhanced by dural puncture in this population at higher risk for epidural failure.

Labour analgesia-epidural/combined spinal epidural/dural puncture epidural/entonox - A cafeteria choice for the patient or just research!

Labour analgesia-epidural/combined spinal epidural/dural puncture epidural/entonox - A cafeteria choice for the patient or just research!

Transforaminal Epidural Autologous Conditioned Serum Injection in the Treatment of Unilateral Lumbar Radicular Pain: A Randomized, Controlled, Double-Blind Clinical Trial

Background: Low back pain could related to disc herniation and managed by surgery. Also, less invasive options, including epidural corticosteroid injection, are available; however, it is associated with side effects. This study aimed to evaluate the effectiveness of autologous conditioned serum (ACS) in treating unilateral lumbar radicular pain. Materials and Methods: In this randomized, controlled, double-blind clinical trial study, a total of 68 patients received the transforaminal epidural injection, 28 patients received ACS, and 30 patients received 40 mg triamcinolone. Under fluoroscopic guidance in anterior-posterior and lateral views, a single injection of ACS or triamcinolone was done via the transforaminal epidural technique. Pain intensity was assessed with a visual analogue scale (VAS) and Oswestry disability index (ODI) at three weeks, three months, and six months. Results: A significant reduction in pain intensity was observed in patients of two groups. There was no significant difference between the two groups during the three months of the study. At the final evaluation at six months, the ACS group showed superiority over the triamcinolone based on the VAS score (P&lt;0.05) and ODI (P=0.007). Conclusions: ACS therapy is a new effective option in treating lumbar radicular pain due to herniated disc. Since no specific complication has been reported, it can be used as a substitute for corticosteroids in such cases.

Comparison of programmed intermittent epidural bolus injection and continuous epidural injection in controlling nighttime pain and improving sleep quality after thoracotomy.

Postoperative pain after open thoracotomy is known to be very severe and affects sleep quality. This study aimed to investigate the effects of a programmed intermittent epidural bolus injection versus continuous epidural injection for controlling nighttime pain and improving sleep quality after thoracotomy. Seventy-six patients scheduled for open thoracotomy for lung cancer or other lung diseases were enrolled. The participants were divided into 2 groups. Group A was continuously injected with 0.2% levobupivacaine at 1.1 mL/h, and group B was injected intermittently with 3 mL 0.2% levobupivacaine at 3 hours intervals through a thoracic epidural catheter via a programmed infusion pump. Within 48 hours after surgery, the degree of pain control using visual analog scale and the patients' sleep conditions on postoperative day (POD) 0 and 1 were evaluated, and other adverse events were investigated. On POD 1 night, the visual analog scale in group B showed lower than group A (P = .009). Comparison of time to fall asleep showed no differences between 2 groups. Total sleep time was no difference on POD 0 but was longer in group B than that in group A on POD 1 (P = .042). Awakening from sleep on POD 0 was lower in group B than that in group A (P = .033), and satisfaction with sleep quality on POD 0 was superior in group B compared to group A (P = .005). Postoperative nausea and vomiting occurred more frequently in group B than in group A (P = .018). The programmed intermittent epidural bolus technique of patient-controlled epidural analgesia reduces postoperative nighttime pain and improves sleep quality in patients undergoing thoracotomy for lung cancer or other lung diseases.

Percutaneous fully endoscopic surgical management of the ruptured epidural catheter: Rescue of the novice anesthesiologist from his dilemma.

BackgroundEpidural nerve block and analgesia are basic anesthetic techniques for anesthesia. Epidural catheter rupture and partial retention are adverse events and rare complications of epidural catheterization technique. The probability of occurrence when applied by novice doctors is high. Removal of the residual catheter by conventional surgery causes more trauma and bleeding, slows recovery, and may causes medical disputes. We hypothesized that percutaneous spinal endoscopy a safe and effective remediation technique. This study was to analyze the efficacy and safety of removing the residual dural catheter by a percutaneous full-endoscopic technique(PFET) and discuss the clinical technique and precautions.MethodsThis was a retrospective analysis of 7 patients with ruptured epidural catheters treated in our department from October 2015 to October 2019 using the PFET to remove the remaining epidural catheter. The operation time, intraoperative bleeding volume, surgical complications, and neurological symptoms before and after surgery were recorded. The Self-Rating Anxiety Scale (SAS) was used to assess the anxiety level of the anesthesiologist and the patient before and after the catheter removal operation, and the postoperative low back pain VAS score was recorded.ResultsThe remaining epidural catheter was successfully removed from all 7 patients. The operation time was 54.14 ± 14.45 (32–78) minutes, and the intraoperative blood loss was 9.134 ± 3.078 (5–15) ml. There were no cases of dural damage, cerebrospinal fluid leakage, sensorimotor dysfunction of the lower limbs, or bowel dysfunction. The anxiety symptoms of the patient and the anesthesiologist disappeared after removal of the residual epidural catheter. The patients' postoperative back pain VAS score was 0 to 2 points.ConclusionPFET is a safe and effective minimally invasive technique for removing residual epidural catheters. It causes less trauma and less bleeding, allows a faster recovery. It does not affect the recovery of patients from other surgical operations and reduces both medical risks and medical costs. At the same time, it avoids or reduces the occurrence of medical disputes and eliminates the pressure on novice anesthesiologists regarding similar adverse events.

Selective Calpain Inhibition Improves Functional and Histopathological Outcomes in a Canine Spinal Cord Injury Model.

Calpain activation has been implicated in various pathologies, including neurodegeneration. Thus, calpain inhibition could effectively prevent spinal cord injury (SCI) associated with neurodegeneration. In the current study, a dog SCI model was used to evaluate the therapeutic potential of a selective calpain inhibitor (PD150606) in combination with methylprednisolone sodium succinate (MPSS) as an anti-inflammatory drug. SCI was experimentally induced in sixteen mongrel dogs through an epidural balloon compression technique. The dogs were allocated randomly into four groups: control, MPSS, PD150606, and MPSS+PD150606. Clinical evaluation, serum biochemical, somatosensory evoked potentials, histopathological, and immunoblotting analyses were performed to assess treated dogs during the study. The current findings revealed that the combined administration of MPSS+PD150606 demonstrated considerably lower neuronal loss and microglial cell infiltration than the other groups, with a significant improvement in the locomotor score. The increased levels of inflammatory markers (GFAP and CD11) and calcium-binding proteins (Iba1 and S100) were significantly reduced in the combination group and to a lesser extent in MPSS or PD150606 treatment alone. Interestingly, the combined treatment effectively inhibited the calpain-induced cleavage of p35, limited cdk5 activation, and inhibited tau phosphorylation. These results suggest that early MPSS+PD150606 therapy after acute SCI may prevent subsequent neurodegeneration via calpain inhibition.

Dural Puncture Epidural for labour analgesia in Indian parturients may need dose alteration for maximal benefits!

Dear Editor, Dural puncture epidural (DPE) is a relatively new technique for labour analgesia (LA) performed by creating an intentional dural hole using a spinal needle, followed by insertion of an epidural catheter in the epidural space through which local anaesthetics with or without adjuvants are injected.[1] The dural hole acts as a passage for medications to slowly pass from epidural space into subarachnoid space, which provides improved block quality with fewer maternal and foetal side effects.[2,3] Previously, a bolus of 20 ml of 0.125% bupivacaine was found effective in DPE for LA. At our institute, a randomised controlled trial of DPE in LA comparing 0.125% of ropivacaine and 0.125% levobupivacaine was undertaken by the present authors. In the original protocol, DPE was performed in L2-L3 or L3-L4 interspace with a 16-G Tuohy epidural needle and 26-G Whitacre spinal needle with an initial bolus of epidural 20 ml of 0.125% ropivacaine with 2 μg/ml fentanyl or 20 ml of 0.125% levobupivacaine with 2 μg/ml fentanyl. The drug was fractionated into four 5 ml boluses injected over 5 minutes as previously described.[1] In seven of first ten patients, complications of hypotension, motor blockade, and foetal heart rate variability developed [Table 1]. This prompted us to look for possible overlooked causes. On minute analysis, the height of the parturient was found more than that of the present group.[1] The protocol was modified to a maximal drug injection of 20 ml with the end point specified as a decrease in numerical rating scale (NRS) labour pain to 50% of baseline. Thus, about 4 ml of the drug was injected every 2 minutes till the end point was reached. With the modified protocol, considerably less volume of DPE drug was required (about 12 ml) in the next 20 parturients with no further reported morbidity [Table 2].Table 1: Data of first ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaineTable 2: Data of ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaine with the modified protocol: Graded epidural of 0.125% local anaesthetics, with a maximum limit of 20 mlEpidural injection for LA is associated with slow onset, inadequate sacral spread, and epidural catheter failure, whereas a combined spinal epidural technique gives rapid onset of blockade but is associated with maternal pruritus, maternal hypotension, and foetal bradycardia.[1] To retain the advantages of both and decrease the disadvantages, DPE for LA has been studied with the most effective results seen with a bolus of 20 ml of 0.125% bupivacaine.[2-4] In all previous studies, the height or body mass index (BMI) was more than that of the present study group[2-4] [Table 3]. After reported morbidity, the present protocol was modified to slower injections of the drug with a ceiling to the injected volume targeted to till 50% reduction in labour NRS rather than a fixed volume as previously reported. This significantly decreased the morbidity.Table 3: Studies comparing DPE to Epidural for LATo conclude, DPE with 0.125% of a local anaesthetic agent for LA in Indian parturients should be given in a graded manner till labour pain NRS reduces by 50% of baseline rather than a bolus of 20 ml. The proposal of a graded local anaesthetic for DPE for LA has never been reported previously. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.