Epidural Top-up Research Articles

Comparative evaluation of periarticular infiltration of two cocktail regimens for analgesia in post-operative patients of total knee replacement

PurposeTo compare the efficacy of two periarticular cocktail regimens for analgesia in postoperative patients of total knee replacement. MethodThis is a Randomized Control study done over the duration of 1.5 years. Twenty-five knees of either gender were selected with inclusion criteria (All osteoarthritis patients planned for TKA) and exclusion criteria (Inflammatory arthritis, patients allergic to local anaesthetic e.g. Ropivacaine, bupivacaine, known cardiac disorder patient having AV block, arrhythmia) & divided into 2 groups.Group A was given a cocktail of Ropivacaine, adrenaline, clonidine & cefuroxime.Group B was given a cocktail of bupivacaine, fentanyl, methylprednisolone & cefuroxime. The preoperative pain of the patient was assessed using VAS score. Combined spinal and epidural anaesthesia was given using 0.5% 2 ml of bupivacaine heavy in all patients. After taking bone cuts & before the placement of the implant, cocktail of the drug was infiltrated using sterile technique into 9 specific sites. The amount of drug infiltrated was calculated according to the weight of the patient.The patients were assessed on: Pain relief postoperatively at specific duration using VAS score. The amount & frequency of epidural top-ups required. Knee ROM, Quadriceps strength, Extensor lag & Knee society score were assessed. ResultsOut of the total 25 knees included in the study, 12 belonged to Group A and 13 belonged to Group B. It was observed that 4 (33%) out of 12 Group A patient needed injection tramadol for 2–3 days and fentanyl patch 25mcg. In Group B, one (8%) out of 13 patients required injection tramadol and fentanyl dermal patch for 2–3 days. The difference in additionally required analgesic between patients of the two groups is statistically significant. VAS ScoreThe VAS score of Group B was statistically lower than Group A patients till first 24 h postoperatively.The extension lag was lower in group B compared to group A at 24 h after the surgery and up to 5 days. Overall after 6 weeks of follow-up, the extensor lag between the groups was not statistically significant.Average KSS in group A was 79.58 and in the group, B was 83.99 and the difference in KSS between patients of the two groups was statistically significant. ConclusionBoth the cocktail regimens are effective in pain control postoperatively. The relief in pain with regimen B containing bupivacaine, fentanyl, methylprednisolone and cefuroxime was more striking in the first 24 h. By the end of two days, both regimens were found to be equally effective.

Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section.

It is not clear how converting epidural analgesia for labour to epidural anaesthesia for emergency caesarean section affects either cutaneous vasomotor tone or mean body temperature. We hypothesised that topping up a labour epidural blocks active cutaneous vasodilation (cutaneous heat loss and skin blood flow decrease), and that as a result mean body temperature increases. Twenty women in established labour had body temperature, cutaneous heat loss and skin blood flow recorded before and after epidural top-up for emergency caesarean section. Changes over time were analysed with repeated measures ANOVA. Mean (SD) mean body temperature was 36.8 (0.5)°C at epidural top-up and 36.9 (0.6)°C at delivery. Between epidural top-up and delivery, the mean (SD) rate of increase in mean body temperature was 0.5 (0.5) °C.h-1 . Following epidural top-up, chest (p < 0.001) and forearm (p = 0.004) heat loss decreased, but head (p = 0.05), thigh (p = 0.79) and calf (p = 1.00) heat loss did not change. The mean (SD) decrease in heat loss was 15 (19) % (p < 0.001). Neither arm (p = 0.06) nor thigh (p = 0.10) skin blood flow changed following epidural top-up. Despite the lack of change in skin blood flow, the most plausible explanation for the reduction in heat loss and the increase in mean body temperature is blockade of active cutaneous vasodilation. It is possible that a similar mechanism is responsible for the hyperthermia associated with labour epidural analgesia.

PS01.123: EPIDURAL ANALGESIA AFTER MINIMALLY INVASIVE ESOPHAGECTOMY: EFFICACY AND COMPLICATION PROFILE

Abstract Background Adequate postoperative pain management is essential to facilitate uneventful recovery after esophagectomy. Although epidural analgesia is the gold standard, it is not satisfactory in all patients. The aim of this study was to describe the efficacy and complication profile of epidural analgesia after minimally invasive esophagectomy (MIE). Methods A total of 108 patients who underwent a robot-assisted (McKeown) MIE for esophageal cancer were included from a single center prospective database (2012–2015). The number of patients that could receive epidural analgesia, the sensory block range per day, the number of epidural top-ups, the need for escape pain mediation (i.e. intravenous opioids), the highest pain score per day (numeric rating scale, 0–10), and epidural-related complications were assessed until postoperative day (POD) 4. Results Epidural catheter placement was achieved in 101 patients (94%). A complete sensory block was found in 49% (POD1), 42% (POD 2), 20% (POD3), and 30% (POD4) of patients. An epidural top-up was performed in 26 patients (24%), which was successful in 22 patients. Escape pain medication in the form of intravenous opioids were given at least once in 49 out of 108 patients (45%) on POD 1, 2, 3, or 4. Overall median highest pain scores on the corresponding days were 2.0 (range 0–10), 3.5 (range 0–9), 3.0 (range 0–8), and 4.0 (range 0–9). Epidural related complications occurred in 20 patients (19%) and included catheter problems (n = 11), hypotension (n = 6), bradypnea (n = 2), and reversible tingling in the legs (n = 1). Conclusion In conclusion, epidural analgesia is insufficient and escape pain medication is necessary in nearly half of patients undergoing MIE. Disclosure All authors have declared no conflicts of interest.

Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study.

We conducted a 5-year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room-to-incision interval. Time-to-event analysis was performed for category-1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5-min Apgar score ≥7. There were 677 women who underwent category-1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room-to-incision intervals were: epidural top-up 11 (7-17 [0-87]) min; general anaesthesia 6 (4-11 [0-69]) min; spinal 13 (10-20 [0-83]) min; and combined spinal-epidural 24 (13-35 [0-75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60-2.44; p<0.0001), followed by epidural top-up (reference group), spinal anaesthesia 0.79 (0.65-0.96; p=0.02) and combined spinal-epidural 0.48 (0.35-0.67; p<0.0001). Underweight and overweight body mass indexes were associated with longer operating room-to-incision intervals. General anaesthesia was associated with fewer 5-min Apgar scores ≥7 with an odds ratio (95%CI) of 0.28 (0.11-0.68; p<0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room-to-incision intervals. General anaesthesia is associated with the most rapid operating room-to-incision interval for category-1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room-to-incision intervals were not associated with worse neonatal outcomes.

An observational study to evaluate the effect of different epidural analgesia regimens on dynamic pain scores in patients receiving epidural analgesia for postoperative pain relief after elective gynecological surgery.

Background and Aims:The primary measure of efficacy of any analgesic regimen is pain relief, but it is important to measure dynamic pain relief rather than pain relief at rest. Epidural analgesia is an effective technique for postoperative analgesia. The drug combinations given therein (local anesthetics with adjuvants such as opioids/alpha-2 agonists), however, remain a personal choice. The aim of this study was to evaluate dynamic pain scores in patients receiving different epidural analgesia regimens for postoperative pain relief after elective gynecological surgery used in our institution.Material and Methods:One hundred eighty-seven patients enrolled in this study received postoperatively either bupivacaine 0.125% + morphine 0.1 mg/mL (group BM) or bupivacaine 0.125% + fentanyl 2 μg/mL (group BF) or bupivacaine 0.125% + clonidine 1 μg/mL (group C1) or bupivacaine 0.125% + clonidine 2 μg/mL (group C2) by continuous epidural infusion @ 5 mL/h. Differences in dynamic pain scores (on coughing and mobilization), pain scores at rest, sensory and motor blockade, sedation scores, dry mouth, pruritus, nausea, and vomiting were recorded. Also duration of postoperative analgesia, epidural top-ups, requirement of rescue analgesic, and patient satisfaction were determined. All observations were carried out at 1, 2, 4, 8, and 12 h after surgery and then at 8 am, 12 noon, 4 pm, 8 pm on subsequent postoperative day till removal of epidural catheter (after 96 h).Results:There was no difference in demographic or hemodynamic profile among the four groups (P > 0.05). There was no statistically significant difference in pain scores at rest among the four groups but dynamic pain scores were found to be better in group C2 as compared to group BM, BF, and C1 at most of the time intervals although not statistically significant (P > 0.05). Requirement of rescue analgesics was lower in group BM and group C2 as compared to group BF and C1 (P < 0.01). Incidence of pruritus was 43.5% in group BM and 19% in group BF, while no patients in group C1 or C2 had pruritus. Mean postoperative nausea and vomiting (PONV) scores were higher in group BM and group BF as compared to group C1 and C2 (P < 0.001). Mean sedation scores were comparable in all four groups. Incidence of dry mouth was 22% in group C2 as compared to 11% in group C1, while no patients in group BM or BF had dry mouth. Patients in group C2 were more satisfied as compared to other three groups.Conclusions:Combination of clonidine 2 μg/mL to 0.125% bupivacaine @ 5 mL/h in combined spinal epidural provides better postoperative analgesia as compared to combination of bupivacaine with opioids with greater patient satisfaction and significantly reduced side effects.

Comparison of Epidural Analgesia Using 0.2% Bupivacaine and 0.2% Ropivacaine for the Management of Postoperative Pain in Major Orthopedic Surgery.

Introduction:Ropivacaine is preferred over racemic bupivacaine for postoperative analgesia as it is less cardiotoxic and has high selectivity for sensory fibers. We aim to compare postoperative epidural analgesia using 0.2% bupivacaine and 0.2% ropivacaine in major lower limb orthopedic surgery.Materials and Methods:In a prospective, randomized, double-blind study, 100 patients, aged 18–70 years, undergoing elective major lower limb orthopedic surgery under spinal anesthesia, were randomly allocated to receive either 7 ml ropivacaine 0.2% (Group R) or 7 ml bupivacaine 0.2% (Group B) for postoperative analgesia through a lumbar epidural catheter. The onset and duration of epidural analgesia, total epidural dose requirement, mean number of epidural topup, rescue analgesia, incidence of motor blockade, and adverse effects were recorded.Results:No differences were noted in demographic data and hemodynamic variables in either group. The onset time of epidural analgesia was 10.46 min ± 0.68 (Group B) and 10.52 min ± 0.71 (Group R). The duration of analgesia was 253.10 ± 17.46 min (Group B) and 251.80 ± 15.77 min (Group R). The total analgesic dose requirement was 78.40 mg ± 6.93 in Group B while in Group R, it was 78.96 mg ± 6.79. Epidural topup requirement and the need for rescue analgesia were similar in both the groups. Motor blockade, hypotension, and nausea were noted more in Group B compared to Group R.Conclusion:In patients undergoing major lower limb orthopedic surgery under subarachnoid block, epidural ropivacaine 0.2% produces effective postoperative analgesia similar to bupivacaine 0.2% with a distinct sensory-motor dissociation resulting in analgesia without motor blockade.

Crack in the epidural catheter filter port.

Sir, Disconnection of epidural catheter and filter is not unknown.[1] However, damage to the injection port of the epidural catheter filter is uncommon. We encountered such a problem during the use of an epidural catheter set for postoperative pain relief. A 68-year-old man posted for right total knee replacement for which lumbar epidural catheter (B. Braun Melsungen AG, Melsungen, Germany) was placed at L3–L4 space through the midline approach. The catheter assembly was used uneventfully for the initial 48 h while the patient received intermittent top-up doses of bupivacaine and morphine mixture. After 72 h, we witnessed slight leakage of the analgesic solution from injection port of the epidural catheter filter during injection of the top-up dose [Figure 1a]. On closer evaluation, we noticed that there was a crack in the catheter filter port leading to the spillage.Figure 1: (a) Epidural Filter Hub Crack. (b) Different nozzle diameters of 10-ml syringes of different makesWhile investigating the possible cause of this occurrence, we came to know that different brands of disposable 10-ml syringes are supplied to our hospital. On closer observation, we also noticed that there exists slight difference in nozzle diameter of these syringes [Figure 1b]. We suspect use of a syringe with a slightly larger diameter might have led to the damage to injection port of epidural filter. We inadvertently try to snugly fit the syringe nozzle into the injection port of the catheter filter applying excessive force. We speculate that such an attempt might have contributed to the damage and the consequent leakage of medication. If gone unnoticed, such a spillage might cause inadequate pain relief and patient dissatisfaction, apart from creating other problems. Although this event shows a lack of regulatory standardization, we suggest keeping in mind this unusual complication while administering the epidural top-up doses. Gentle application of syringe in the filter port and looking for any leakage during drug administration should be practiced. Another possible solution is use of syringes and epidural set of the same manufacturer to avoid these types of problems. Written consent for publication was obtained by the patient. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Influence on number of top-ups after implementing patient controlled epidural analgesia: A cohort study.

Postoperative epidural analgesia often needs rate readjustment using top-ups. Patient-controlled epidural analgesia (PCEA) is said to reduce the requirement of epidural top-ups when compared to continuous epidural analgesia (CEA). We compared CEA and PCEA in major thoracic and abdominal surgery, in a cohort study. The primary endpoint was the required number of epidural top-ups. Secondary endpoints were pain scores, side effects and workload differences. We analysed 199 patients with CEA and 187 with PCEA. Both groups had similar pain scores. The total number of top-ups was 75 in 57 patients (CEA) versus 20 top-ups in 18 patients (PCEA). (p = 0.0001) Sedation tended to occur more frequently in patients with CEA versus PCEA, 5.5% vs 1.6% (p = 0.05). Implementation of PCEA led to a decreased number of top-ups, fewer side-effects and decreased use of the postoperative care unit.

Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital

BackgroundAt our institution, the emergency obstetric ‘code green’ activates the system for immediate birth, usually by caesarean section. This study aimed to determine the incidence of immediate birth, indications, modes of anaesthesia, and short-term neonatal and maternal outcomes. MethodA review was performed for all women at the Royal Women’s Hospital, Parkville, Australia who underwent immediate birth over a two-year period: January 1, 2013 to December 31, 2014. ResultsWithin the study period 14,115 women gave birth, of which 387 women underwent an immediate birth, the majority (83%) by caesarean section. The commonest indication for immediate birth was prolonged fetal bradycardia (53%), however cord prolapse (4%) produced the most rapid decision-to-delivery interval, with a median [IQR] time of 14 [13–16] min versus 18 [14–23] min for all immediate births (P<0.01). Epidural top-up was the most common anaesthesia method. Conversion to general anaesthesia following inadequate neuraxial anaesthesia occurred in 6.2% of women. Among 103 general anaesthetics, there was one failed intubation (successful ventilation) and one dental injury. Nine women (2.3%) were admitted to the high dependency or intensive care units, and there were no maternal deaths. Babies born by caesarean section with a decision-to-delivery interval of less than 30min were more likely to have longer times to establish respiration (22.6% vs 16.7%, P<0.001). ConclusionRequest for immediate delivery is a common obstetric emergency. Epidural top-up has become the most common anaesthetic technique. Rapid delivery times can be achieved with an integrated emergency response system.

Combined Spinal–epidural with Levobupivacaine or Ropivacaine with Fentanyl for Labor Analgesia: A Comparative Study

ABSTRACT Introduction Combined spinal–epidural analgesia to provide pain relief in labor has become the technique of choice. It provides benefits of both spinal analgesia and flexibility of an epidural catheter. In this study, we compared levobupivacaine with fetanyl and ropivacaine with fentanyl in terms of onset and duration of sensory blockade. Materials and methods This was a double-blind randomized study on 60 parturients of American Society of Anesthesiologists status 1 and 2, all primipara with singleton pregnancy in active labor, were allocated randomly into two groups of 30 each. Group L received 3 mg of levobupivacaine intrathecally with 25 µg fentanyl followed by epidural top-ups of 14 mL levobupivacaine 0.125% with fentanyl 30 µg, whereas group R received 4 mg of ropivacaine intrathecally with 25 µg of fentanyl followed by epidural top-ups of 14 mL ropivacaine 0.2% with fentanyl 30 µg. Sensory and motor characteristics, hemodynamics, maternal and fetal outcomes, side effects, and complications were observed and analyzed statistically using Student's unpaired t-test and chi-squared test. Results A rapid onset of analgesia in group L (4.67 ± 0.35) as compared with group R (5.57 ± 0.27) was observed. Duration of analgesia was also prolonged in group B (116.83 ± 6.91) as compared with group R (88.87 ± 5.10). Patients remained hemodynamically stable, and side effects and complications were comparable in both groups. Conclusion Levobupivacaine with fentanyl combination was found to be more promising in terms of onset and duration of labor analgesia as compared with ropivacaine and fentanyl combination. How to cite this article Sharma YK, Agrawal M. Combined Spinal–epidural with Levobupivacaine or Ropivacaine with Fentanyl for Labor Analgesia: A Comparative Study. Int J Adv Integ Med Sci 2017;2(2):73-77.

Does obesity complicate regional anesthesia and result in longer decision to delivery time for emergency cesarean section?

Maternal obesity can cause problems with anesthesia and surgery which may be reflected in emergency cesarean sections (CS) as an increased decision-to-delivery interval (DDI). To study the association of elevated maternal BMI with DDI and the failure of regional anesthesia. Eight hundred and forty-two consecutive emergency CSs during a period of 1 year in a tertiary hospital were studied retrospectively. DDIs were analyzed in Crash and < 30-min urgency categories (n = 528), while the time required to establish regional anesthesia and its success were analyzed for all emergency CS cases. The urgency distribution of the CSs was 11%, 52%, and 37% in Crash, < 30-min, and > 30-min urgency categories respectively. Increased BMI was associated with longer DDI time in the < 30-min urgency category (33(13-176) vs. 38(18-118) min; P < 0.05 for BMI < 30 and > 35 group respectively). Regional anesthesia failures (new regional anesthesia, conversion to general anesthesia, or complaint of pain during surgery) took place in 3.7%, 6.8%, and 8.5% in the BMI < 30, 30-35, and > 35 groups respectively (P = 0.021). Epidural top-up resulted in shorter DDI and time delay between arrival at the operating room and skin incision across all urgency and BMI groups than combined spinal epidural (CSE) anesthesia. Higher BMI was associated with longer DDI and more regional anesthesia failures. Epidural top-up was faster than CSE for establishing CS anesthesia.

Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block

(Anesth Analg. 2016;123:684–689) Combined spinal-epidural (CSE) provides faster and better first-stage analgesia and fewer epidural top-up boluses than traditional epidural methods. Deliberate injection into the epidural space can increase anesthetic level. This mechanism, referred to as epidural volume extension (EVE), is not fully understood; the fluid in the epidural space may be compressing the dural sac. The current authors thus tested 2 hypotheses. First, an epidural injection of 10 mL normal saline while initiating CSE would increase the initial anesthetic sensory block height by 15 minutes. Second, compared with CSE alone, CSE with EVE would result in a higher sensory block at 30 minutes while decreasing pain scores, analgesia onset time, and motor block.

Comparison of Postoperative Pain After Epidural Anesthesia Using 0.5%, 0.75% Ropivacaine and 0.5% Bupivacaine in Patients Undergoing Lower Limb Surgery: A Double-Blind Study.

Background:Ropivacaine (S (-)-1-propyl-2”, 6”; pipecoloxylidide hydrochloride) a newer long-acting amide local anesthetic has various clinical and pharmacokinetic advantages over bupivacaine.Aims:The aim of this study is to compare the onset as well as the duration of sensory block, hemodynamic variables, and postoperative analgesia with 0.5%, 0.75% ropivacaine and 0.5% bupivacaine after epidural anesthesia for lower limb orthopedic surgery.Patients and Methods:Sixty American Society of Anesthesiologists I and II patients scheduled for lower limb orthopedic surgery were enrolled into this randomized, double-blind study. Epidural block was obtained with 15 ml of 0.5% ropivacaine (Group I), 15 ml of 0.75% ropivacaine (Group II), and 15 ml of 0.5% bupivacaine (Group III). The onset time, duration, and maximum level of sensory blockade achieved, as well as hemodynamic parameters and any side effects, were noted and treated accordingly. Postoperative monitoring for pain by visual analog scale (VAS) was done every 2 hourly for 24 h and transient neurological symptoms for 72 h.Statistical Analysis:Chi-square test for nonparametric data and ANOVA for parametric data.Results:Demographic characteristics were similar among groups. The onset of sensory block varied from 22.35 ± 2.74 min (mean ± standard deviation [SD]) in Group I, 16.95 ± 2.96 min (mean ± SD) in Group II, and 19.70 ± 2.25 min (mean ± SD) in Group III. The mean duration of analgesia in Group III (157 ± 14.90 min)was comparable to Group II (149 ± 16.51 min) but it was significantly more than Group I (141.5 ± 17.55 min). Postoperatively, VAS scores were higher in Group I patients who required more number of postoperative epidural top-ups with tramadol. Adverse effects were noted and treated accordingly. There was no incidence of transient neurological symptoms postoperatively.Conclusion:Both ropivacaine and bupivacaine provided effective epidural anesthesia for lower limb surgery. Postoperative pain was less with 0.5% bupivacaine and 0.75% ropivacaine as compared to 0.5% ropivacaine.

Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia

Background: Both epidural analgesia and combined spinal epidural analgesia (CSEA) are employed for pain relief during labor because they provide reliable analgesia compared to other modalities. Studies are equivocal with respect to their effect on the rate of cervical dilatation, duration of labor, and labor outcome. The primary outcome of the present study was to compare the effect of epidural analgesia alone with CSEA with respect to the rate of cervical dilatation. Materials and Methods: One hundred and twenty parturients with an initial cervical dilatation of <4 cm were randomized to receive CSEA or epidural analgesia alone for pain relief during labor. The rate of cervical dilatation, onset of effective analgesia, number of epidural top-ups requested, labor outcome, and the quality of analgesia was assessed in both the study groups. Statistical Analysis: Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. Results: The results of the study showed that the rate of cervical dilatation was rapid with CSEA compared to epidural analgesia alone [median (interquartile range) 2 (1.2,3) v/s 1.16 (1,2)]. The onset of analgesia was earlier with combined spinal epidural (CSE v/s EA, 3.7 ± 1.3 min v/s 23.8 ± 5.8 min). Labor outcome and quality of analgesia was similar between the two groups. The incidence of pruritus was higher with CSEA than with epidural analgesia alone. Conclusion: CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone.

Comparison of 0.2% Bupivacaine with 0.2% Ropivacaine in Femoral Nerve Block for Preoperative Positioning and Postoperative Analgesia in Femur Fractures

Introduction: Femur fractures are very painful. The peripheral nerve block provides good analgesia in these patients before performing regional anesthesia. This study aims to compare 2 local anesthestics in femoral nerve block for analgesia in preoperative positioning and postoperative analgesia of patientsMethods: Prospective, randomized study was conducted on 60 patients (18-60 years) of ASA I&amp;II scheduled for femur surgery under combined spinal epidural. anaesthesia In group B (n=30), femoral nerve block(FNB) was performed with 0.2% bupivacaine (30ml) and in group R(n=30), 0.2% ropivacaine (30 ml) was used. Various parameters like numeric rating pain scale, time to spinal anaesthesia, sensory and motor block onset times and durations, time to first analgesic use, intraoperative &amp; postoperative visual analog scale (VAS) data, post- operative epidural top ups, vitals and side effects were recorded for each patient.Results: Pain assessed on visual analogue scale (VAS) during positioning was significantly less in FNB group using 0.2%bupivacaine at 5 minutes. Time to perform spinal block was significantly shorter in FNB group using 0.2% bupivacaine (8.30 min) versus ropivacaine group (17.30 min). But postoperative analgesic requirements were more in ropivacaine group and duration of analgesia was prolonged in bupivacaine group.Conclusion: With bupivacaine time to perform spinal anesthesia was reduced and postoperative analgesia was better with bupivacaine group.

Abstract PR207

Background & Objectives: We conducted a service evaluation of anaesthesia in morbidly obese parturients in our unit. Our aims were to quantify the extent of the issue locally, identify the level of anaesthetist involved and make recommendations. Materials & Methods: Following hospital governance approval, cases were identified from the Anaesthesia Obstetric Database. Women with a Body Mass Index (BMI) more than 40 kg/m2 who required an anaesthetic intervention between 1st of January 2014 to 31st of December 2014 were included. Two hundred and fourteen individual cases were identified out of 5,848 deliveries. We obtained 151 case notes. Seventeen cases were excluded due to missing data or discrepancies, leaving 134 cases for analysis. Data was collected for demographics, mode of delivery, analgesia technique, anaesthesia, complications (resites, bloody taps, dural punctures), grade of anaesthetist and outcomes. Results: BMI ranged between 40 to 65 kg/m2 at term. Sixty-one women were seen in our dedicated antenatal high BMI clinic. Seventy-three women underwent a Lower Segment Caesarean Section (LSCS). There were six category 1 Caesarean sections with five general anaesthesia cases and one epidural top-up. A Decision to Delivery Interval time (DDI) of less than 30 minutes was achieved in all cases. Seven women had assisted vaginal delivery and fifty-four a normal vaginal delivery. Our rate of labour epidural/CSE in morbidly obese patients was 69.81%, with a failure rate of 17.15%. We found a poor correlation between the antenatally ultrasound estimated depth of epidural space and the actual depth found in labour. The following complications were identified: eight cases of multiple attempts (one being impossible), three cases of accidental dural punctures and three bloody taps. Our super-morbidly obese patients (BMI more than 50 kg/m2) were managed by senior anaesthetists (seventeen cases) and three cases were by juniors. Conclusion: Our data is similar to internationally published studies of morbidly obese parturients in terms LSCS incidence (54.47%), rate of labour epidural and regional anaesthesia failure.1 We recommended threading more length of epidural catheter in the space to account for its movement with position related tissue expansion.2 There should be senior anaesthetic involvement with all super-morbidly obese patients. The demographic data from this audit was used to inform a successful bid for equipment funding from the Department of Health.

Evaluation of failed and high blocks associated with spinal anesthesia for Cesarean delivery following inadequate labour epidural: a retrospective cohort study.

The purpose of this retrospective cohort study was to investigate factors associated with failed and high spinal blocks in patients who received spinal anesthesia for Cesarean delivery following a labour epidural that was inadequate for surgical anesthesia. We searched our perioperative database for women with a labour epidural who received spinal or combined spinal-epidural anesthesia for Cesarean delivery due to the inadequacy of the existing epidural. The primary outcome was the occurrence of failed spinal blocks, and the secondary outcome was the occurrence of high blocks following spinal administration. Of the 263 patients in the analysis, there were 29 (11%) failed spinals and nine (3%) high spinals. There was a significant difference between patients with failed spinals and those with successful spinals with regards to receipt of an epidural top-up dose for Cesarean delivery within 30 min of the spinal, type of neuraxial block, body mass index, age, and dose of hyperbaric bupivacaine. In a multivariable analysis, only receipt of an epidural top-up dose was associated with failure (OR, 6.0; 95% CI, 2.1 to 17.0; P < 0.001). As for the risk of a high spinal, patient characteristics and block details were not different amongst patients, except for a younger age in those with a high block. Administration of spinal anesthesia within 30 min of an epidural top-up dose is associated with increased risk of failure. We speculate that this may be due in part to the presence of a large volume of local anesthetic in the epidural space, which may be mistaken for cerebrospinal fluid during spinal placement.

Gabapentin vs pregabalin as a premedication in lower limb orthopaedics surgery under combined spinal epidural technique.

Background:Pregabalin and gabapentin are the gamma-aminobutyric acid analogs used as a part of multimodal analgesic regimen.Aim:To compare the postoperative analgesic benefits of gabapentin or pregabalin as a premedication for lower limb orthopedic surgery under combined spinal-epidural techniques.Settings and Design:Randomized double-blind study.Materials and Methods:A total of 90 patients were divided into three groups: G, P, C who received gabapentin 1200 mg, pregabalin 300 mg, and placebo, respectively 1.5 h before surgery. All patients received combined spinal-epidural block with 3 ml of 0.5% intrathecal bupivacaine. Assessment of pain was made with visual analog scale (VAS). Postoperative analgesia was provided with epidural top-ups with 2.5 ml of 0.5% bupivacaine and fentanyl 25 μg when VAS >3. Rescue analgesia in the form of injection diclofenac (75 mg) intramuscularly was given if VAS >3 even after epidural top-up. A total number of epidural top-ups, rescue analgesia, pain-free interval postspinal anesthesia, and sedation score were noted.Statistical Analysis:This was done using SPSS version 17. Mean and standard deviation were calculated using Chi-square test and analysis of variance.Results:The total postoperative analgesic time was 7.23 h in Group G, 14.80 h in Group P, and 4.17 h in Group C. A total number of epidural top-ups were 2.43 in Group G, 0.77 in Group P, and 4.43 in Group C.Conclusion:Pregabalin 300 mg and gabapentin 1200 mg significantly reduce the need of postoperative rescue analgesia, epidural top-ups, and increase the duration of postspinal anesthesia without altering hemodynamics with sedation as a major side effect.

Incremental epidural anaesthesia for emergency caesarean section in a patient with ostium secundum atrial septal defect and severe pulmonary stenosis with right to left shunt.

Sir, Association of atrial septal defect (ASD) and pulmonary stenosis (PS) with bidirectional shunt in pregnancy is a very rare entity. Death can occur anytime during pregnancy or labour in these patients, precipitated by altered cardiovascular physiology of pregnancy.[1] A 25-year-old primi, an unbooked case with 38 weeks of gestation was posted for emergency caesarean section (CS) for cephalopelvic disproportion. In the second trimester, assessment of breathlessness (NYHA Grade III) with two-dimensional echocardiography revealed an ostium secundum type of ASD (8 mm × 10 mm) with predominantly right to left shunt (Qp: Qs - 0.85), severe PS (Maximum velocity [Vmax ]/peak pressure gradient [PGmax ] - 4.8 m/s/70.4 mm Hg), mild tricuspid regurgitation (Vmax /PGmax - 2.7 m/s/30.5 mm Hg), mild pulmonary regurgitation (Vmax /PGmax - 2.1 m/s/17.58 mm Hg), right ventricular hypertrophy (right ventricle diastolic wall thickness 6 mm) and normal biventricular function with ejection fraction of 60%. In the operation room, oxygen saturation (on room air) was 90-95%, pulse rate was 114/min regular and noninvasive blood pressure was 150/90 mmHg. The patient was premedicated with injection ranitidine (50 mg) and injection metoclopramide (10 mg) and colloid was started at 50 ml/h. Injection ceftriaxone 1 g was administered for antibiotic coverage. The initial central venous pressure was 13 cm H2O and was maintained between 12 and 14 cm H2O. Under aseptic precautions, an 18-gauge epidural catheter was inserted at L3 -L4 epidural interspace. A total volume of 20 ml local anaesthetic solution (13 ml of 2% lignocaine with adrenaline (5 μg/ml) and 1 ml of sodium bicarbonate and 1 ml (50 mg) of tramadol diluted with 5 ml saline) was administered through the epidural catheter in 5 ml increments for achieving a block height up to T4 dermatome. At the time of skin incision, injection ketamine (50 mg) and injection midazolam (1 mg) was administered in titrating doses. CS proceeded uneventfully, and a healthy male baby was delivered with Apgar score of 8 and 9 at 1 and 5 min, respectively. A bolus dose of 0.4 mg intravenous methylergometrine was administered slowly, and a slow infusion of oxytocin 10 units was started. The surgery lasted for about 60 min, and the blood loss was 500 ml. A total of 450 ml colloid and 100 ml oxytocin-normal saline infusion was given. Post-operative analgesia was provided with epidural top-up, whenever the patient complained of pain or visual analogue score was ≥4. At 48th h of follow-up, she had maximal scores for post-operative pain relief and overall satisfaction. She was discharged on the 7th post-operative day and referred to cardiology department for further management. The mortality in patients with ASD and severe PS with right to left shunt in pregnancy is unknown,[2] as many unsuccessful cases are not reported. In our case, although the patient was having reversal of shunt, she was asymptomatic and had no signs of chronic cyanosis. This may be due to hyperdynamic circulation of pregnancy producing increased pulmonary gradients and the restrictive ASD causing inadequate mixing of blood to produce clinical cyanosis.[3] Epidural anaesthesia (EA) was planned because of its slower onset and less and delayed haemodynamic variations compared to spinal and combined spinal-epidural technique.[4] General anaesthesia (GA) poses clear risks related to pulmonary vascular resistance and magnitude of the shunt. As the patient was in labour, we had no sufficient time for further cardiac evaluation. Pulse oximeter is used to assess the degree of right to left shunt during the peri-operative period.[5] Our principle was to maintain the cardiac output and to avoid the fall in systemic vascular resistance (SVR). We optimised the SVR based on mean arterial pressure to avoid the increase in shunt magnitude. Oxytocin bolus can cause direct vasodilatation and reduce SVR with a compensatory increase in heart rate and cardiac output in pregnant women. Use of methylergometrine lowered the use of vasoconstrictors[6] and added to haemodynamic stability. Colloids provide greater haemodynamic stability by remaining in the intravascular space for longer time and avoid volume overloading; this helps to decrease the magnitude of shunt and right ventricular failure.[7] The use of lower dose of lignocaine with adrenaline, bicarbonate and tramadol provided a more rapid onset and superior quality block to touch.[8] We did not institute any thromboprophylaxis measures; EA itself can reduce risk of perioperative venous stasis and embolism. To conclude, EA can be safely and effectively used for CS in pregnant patients having pulmonary vascular disease with reversal of shunts provided the SVR is maintained throughout the surgical procedure. Major haemodynamic complications and risk of embolism during GA can be avoided if EA is properly planned and administered. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Intravenous analgesia with opioids versus femoral nerve block with 0.2% ropivacaine as preemptive analgesic for fracture femur: A randomized comparative study.

Background and Objective:Femoral fractures are extremely painful and pain invariably worsens on any movement. Anesthesia for fracture femur surgery is usually provided by spinal block. This study was undertaken to compare the analgesic effects of femoral nerve block (FNB) using nerve stimulator with 0.2% ropivacaine (15 ml) and intravenous (I.V.) fentanyl before patient positioning for fracture femur surgery under spinal anesthesia.Materials and Methods:A prospective, randomized, double-blind, comparative study was conducted on 60 American Society of Anesthesiologists I and II patients (18–60 years) scheduled for femur surgery under combined spinal epidural anesthesia. Patients in Group I (n = 30), were administered FNB using nerve stimulator with 0.2% ropivacaine (15 ml) and in Group II patients (n = 30), I.V. fentanyl 0.5 μg/kg was given as preemptive analgesia. Parameters observed included time to spinal anesthesia, intra-operative and postoperative visual analog scale (VAS) for any pain and postoperative epidural top-ups dosages.Results:Demographic profile was comparable in both the groups. VAS at 2 min in Group I was 5.63 and in Group II it was 8.00. Satisfaction score was better in Group I as compared to Group II patients. Time to administer subarachnoid block was 17.80 min in patients of Group I as compared to 25.03 min in Group II patients. Postoperatively, VAS scores were lower in Group I than Group II patients. The frequency of epidural top-ups was higher in Group II than in Group I patients.Conclusions:FNB is comparatively better in comparison to I.V. fentanyl when used as preemptive and postoperative analgesic in patients being operated for fracture femur.