Lumbar Epidural Anesthesia Research Articles

Age and size of the epidural needle as factors influencing the incidence of low back pain after lumbar epidural anaesthesia for ambulatory surgery

Age and size of the epidural needle as factors influencing the incidence of low back pain after lumbar epidural anaesthesia for ambulatory surgery

Age and size of the epidural needle as factors influencing the incidence of low back pain after lumbar epidural anaesthesia for ambulatory surgery

Age and size of the epidural needle as factors influencing the incidence of low back pain after lumbar epidural anaesthesia for ambulatory surgery

The incidence of back pain after lumbar epidural anaesthesia in ambulatory patients: comparison of two different needle sizes

The incidence of back pain after lumbar epidural anaesthesia in ambulatory patients: comparison of two different needle sizes

The incidence of lumbar ligamentum flavum midline gaps.

Lumbar epidural anesthesia and analgesia has gained increasing importance in perioperative pain therapy for abdominal and lower limb surgery. The loss-of-resistance technique, used to identify the epidural space, is thought to rely on the penetration of the ligamentum flavum. However, the exact morphology of the ligamentum flavum at different vertebral levels remains controversial. Therefore, in this study, we directly investigated the incidence of lumbar ligamentum flavum midline gaps in embalmed cadavers. Vertebral column specimens were obtained from 45 human cadavers. On each dissected level, ligamentum flavum midline gaps were recorded. The incidence of midline gaps per number of viable specimens at the following levels was: L1-2 = 10 of 45 (22.2%), L2-3 = 5 of 44 (11.4%), L3-4 = 5 of 45 (11.1%), L4-5 = 4 of 43 (9.3%), L5/S1 = 0 of 33 (0%). In conclusion, the present study determined the frequency of lumbar ligamentum flavum midline gaps. Gaps in the lumbar ligamentum flavum are most frequent between L1 and L2 but are more rare below this level. When using the midline approach, the ligamentum flavum may not impede entering the epidural space in all patients. The ligamentum flavum is a crucial anatomical landmark for the safe performance of epidural anesthesia. However, the present study demonstrates some failure of the lumbar ligamentum flavum as a landmark. This may mean that, using a midline approach, one cannot always rely on the ligamentum flavum as a perceptible barrier to epidural needle advancement.

Does pregnancy increase the efficacy of lumbar epidural anesthesia?

Pregnancy has been reported to enhance the sensitivity of nerves to local anesthetics and to decrease anesthetic requirements during regional anesthesia. In this study, whether pregnancy increased the efficacy of lumbar epidural anesthesia was evaluated. Two populations (14 pregnant and 14 non-pregnant women) undergoing lumbar epidural anesthesia were studied and received 17 mL of 2% lidocaine-epinephrine (1: 200,000). The pain threshold response after repeated electrical stimulation was used to assess sensory blockade at the L2, S1 and S3 dermatomes. Motor blockade was evaluated using the Bromage score. Demographic data except for weight were comparable between the two groups. There was a significant difference in cephalad spread of anesthesia between the groups. No significant differences in pain threshold or onset of sensory blockade at the L2, S1 or S3 segments were found between the groups. The pain thresholds at the S1 and S3 dermatomes were significantly lower than that at L2 within each group. The mean onset times at the S1 and S3 dermatomes were significantly longer than that at L2 within each group. No differences in Bromage score were found between the groups. In pregnant women, cephalad spread of epidural anesthesia was facilitated but latency of blockade, density and motor blockade were not. It takes over 25 min to achieve satisfactory blockade at sacral segments. Those who perform lumbar epidural anesthesia alone for cesarean section should consider the use of additives (e.g. fentanyl, bicarbonate) to enhance the block, or a greater volume of local anesthetic.

THIS MONTH IN ANESTHESIOLOGY

THIS MONTH IN ANESTHESIOLOGY

Anthropometric Variables and Security against Fecal Contamination due to Caudal Catheter Indwelling in Children

Background: There is an increasing interest in regional anesthesia for pediatric patients, in particular, the efficacy of the caudal approach is similar to that of lumbar epidural anesthesia, and reduces the risk of damage to the spinal cord and vessels. Although caudal catheterization may increase the likelihood of urofecal contamination, especially in children who are not toilet trained, no significant infection has been reported after caudal epidural catheter indwelling. The purpose of this study was to clarify the anatomic characteristics of the sacrococcygeal area in children by comparing the anthropometric variables of children and adults, and to reconsider the caudal epidural catheter safety with respect to fecal contamination. Methods: Thirty-eight children aged 3-9 years and 47 adults aged 30-75 years, without bony deformities, were enrolled in this study. In left lateral position, Tuffier’s line (A), sacral hiatus (B) and greater trochanter (C) were marked. The shortest distances from A to B, from A to C and from B to the anus (D) were measured and the ratios of BD to subject height, BD to AB and BD to AC were calculated. Results: The shortest AB, AC and BD distances were significantly shorter in children and conversely the ratios of BD/height, BD/AB and BD/ AC were significantly larger. Conclusion: Considering anatomical characteristics of pediatric patients, if a child is toilet trained and the catheter insertion site is well sealed, there should be no difference between the incidence of infection in adults and children after caudal epidural catheter indwelling.

Spinal Process Landmark as a Predicting Factor for Difficult Epidural Block: A Prospective Study in Taiwanese Patients

Although epidural anesthesia is a common practice in neuraxial blockade, difficult access to the epidural space is a frequent problem in operating theaters. We designed this study of epidural blocks to determine if the spinal landmark grading system is valuable in predicting a difficult epidural block. Before the epidural block, we collected the following data: demographics, body habitus (normal, thin, obese, pregnant), spinal anatomy (normal, deformed), spinal level (lumbar, thoracic), and spinal landmark grade (grade 1: spinous processes visible; grade 2: spinous processes not seen but easily palpated; grade 3: spinous processes not seen and not palpated but the interval between them is palpated as a low landmark under the thumb; grade 4: other). We performed all 848 epidural blocks initially using a midline approach and an 18-gauge Touhy needle. We evaluated the technical difficulty of the epidural block using three methods: whether the epidural block was accomplished at the spinal level (first-level success); the total number of attempts at skin puncture (attempts-S); and total number of attempts to change ligament puncture direction (attempts-L) required to complete the epidural block. Of all examined factors, spinal landmark grade correlated best with technical difficulty as measured by all three methods. Deformed spinal anatomy and body habitus both correlated with difficulty, merely from the total numbers of attempts (attempts-S and attempts-L). Thoracic epidurals were more difficult than lumbar epidurals by all three measures of difficulty. We concluded that this spinal landmark grading system is valuable in predicting a difficult epidural block and advocate its use as a predictor by anesthesiologists.

Impossibility of injection through an epidural catheter caused by an incorrect connection of catheter and connector

EDITOR: Situations where it is impossible to inject through an epidural catheter are rare. Reported causes include kinking, knotting [1,2], stretching [3] and blockade by a blood clot in the catheter [4,5]. We describe a case in which it was impossible to inject through an epidural catheter, although a preinsertion patency test had been successful. A 53-yr-old female with degenerative osteoarthropathy of the right hip was scheduled for right total hip replacement. Lumbar epidural anaesthesia was planned. An epidural catheter, which was confirmed to be patent by an injection test before insertion, was inserted through an 18-G Tuohy needle at the L2-L3 interspace using loss of resistance to physiological saline. The epidural catheter was easily threaded 3 cm into the epidural space with no unusual resistance being encountered. After removal of the epidural needle, the epidural catheter was inserted into the connector (Hakko, Nagano, Japan). No blood or cerebrospinal fluid was aspirated through the catheter, and there was a firm resistance on trying to inject a test dose of a local anaesthetic through it. Changing the patient's body position did not allow injection of the local anaesthetic. The probability of the knotting of the epidural catheter was explained to the patient, and she accepted its removal and the insertion of another one. The original catheter was cautiously removed without resistance or paresthesia during the removal. Though neither knotting nor a blood clot were found in the removed epidural catheter, it was still impossible to inject any solution through it. Another catheter was inserted at the same lumber intervertebral space and a local anaesthetic was easily injected through the epidural catheter. Surgery proceeded uneventfully under epidural anaesthesia with intravenous sedation. A close examination revealed that the inability to inject any solution through the catheter was caused by incorrect assembly of the catheter and connector. The connector assembly used had three components: a retaining cap into which a small rubber ball is placed, and a screw cap that pushes the ball against the retaining cap (Fig. 1a). When it is assembled correctly, an epidural catheter passes completely through the lumen of the ball, and the ball fastens it tightly by screwing the retaining and screw caps together. The lumen of the epidural catheter is patent (Fig. 1b). However, if the epidural catheter does not pass completely through the lumen of the ball, the lumen is obstructed by the ball itself when the retaining and screw caps are fastened together (Fig. 1c). This can create a situation where it is impossible to inject through the epidural catheter, as in our case.Figure 1: Connector assembly components: (a) A: Retaining cap; B: rubber ball; C: screw cap; (b) correct connection of the epidural catheter to the connector; (c) incorrect connection of the epidural catheter to the connector.Two cases in which it was impossible to inject through an epidural catheter because of incorrect connector assembly have been reported. Chandhok and Vijayakumar reported a case in which a complete absence of the lumen of the screw cap connector prevented injection [6]. Gupta and colleagues described a situation in which injection was impossible due to incorrect insertion of the epidural catheter into the connector [7]. In this case, the patient did not need the insertion of another catheter as the operation, a Caesarean section, was performed under combined spinal and epidural anaesthesia. In our patient, since only epidural anaesthesia had been explained to and agreed on by our patient, another epidural catheter was reinserted. The most important characteristics of an inability to inject through an epidural catheter that relate to the incorrect assembly of the connector are: injection of the test dose of local anaesthetic through the epidural catheter is impossible - even after a successful preinsertion patency test [7]; and it can be relieved by correct reassembly of the epidural catheter and connector. Subsequent injections become impossible [1-5] in instances of kinking, knotting [1,2], stretching [3] or occlusion (by blood clot) of the catheter [4,5], although a test dose of anaesthetic may have been injected through it. A temporal pattern of obstruction of the epidural catheter may provide the clue to the actual cause. C. Harada T. Sakuragi K. Katori K. Higa Department of Anesthesiology; School of Medicine; Fukuoka University; Fukuoka, Japan

Estudo Comparativo entre a bupivacaína a 0,5% e a mistura enantiomérica de bupivacaína (S75-R25) a 0,5% em anestesia peridural em pacientes submetidos a cirurgia ortopédica de membros inferiores

With the objective of finding a safer drug than racemic bupivacaine, several animal studies were performed with its enantiomers. This study aimed at evaluating the efficacy of 0.5% bupivacaine enantiomeric mixture (S75-R25) as compared to 0.5% bupivacaine in lumbar epidural anesthesia for lower limb orthopedic surgery. Participated in this randomized double-blind study 38 adult patients, aged 17 to 69 years, physical status ASA I and II submitted to lower limb orthopedic surgery, who were distributed in two groups: Group B - 30 ml of 0.5% bupivacaine and Group BEM - 30 ml of 0.5% bupivacaine enantiomeric mixture (S75-R25). Sensory and motor block characteristics were investigated, in addition to the incidence of side effects. There have been significant weight differences in group BEM. Hemodynamic parameters were similar in both groups. There were no differences in time to reach Bromage score and peak block height. Also time to total motor block regression was similar between groups. There has been a significant difference in Bromage 2 score between groups, which was higher in group BEM. Adequate sensory and motor block for surgery was achieved in both groups with few side effects, suggesting that both solutions are safe in lumbar epidural anesthesia for orthopedic surgery.

Efficacy of 1% ropivacaine at sacral segments in lumbar epidural anesthesia

Background and Objectives: It is suggested that the potency of 1% ropivacaine is comparable to that of 0.75% bupivacaine and higher than that of 2% lidocaine. Alkalinized lidocaine reportedly enhances the block of sacral segments during lumbar epidural anesthesia. We hypothesized that 1% ropivacaine might also block at the lumbosacral segments adequately during lumbar epidural anesthesia. Methods: Forty-two patients undergoing lumbar epidural anesthesia at L4-5 or L5-S1 were randomly divided into 3 groups and received either 14 mL 2% lidocaine (lidocaine group), 2% lidocaine with epinephrine 1:200,000 and bicarbonate (lidocaine-epinephrine-bicarbonate group), or 1% ropivacaine (ropivacaine group). Pain threshold after repeated electrical stimulation was used to assess sensory block at the L2, S1, and S3 segments while motor block was evaluated using the modified Bromage Scale. Results: Demographic data were comparable between the groups. Significant differences in the pH of each local anesthetic solution were found between the 3 groups. Pain thresholds at the S1 and S3 segments in the lidocaine-epinephrine-bicarbonate group were significantly higher and sensory block onset faster than in the other groups. However, no significant differences were found in either the pain threshold or the onset of sensory block of the L2 segment between the groups. No significant differences in the pain threshold, onset of sensory block, or Bromage Scale were found between the lidocaine and ropivacaine groups. Conclusions: We conclude that 1% ropivacaine does not improve block of sacral segments within 20 minutes following epidural ropivacaine administration. Reg Anesth Pain Med 2003;28:208-214.

Efficacy of 1% Ropivacaine at Sacral Segments in Lumbar Epidural Anesthesia

Efficacy of 1% Ropivacaine at Sacral Segments in Lumbar Epidural Anesthesia

Intervertebral epidural anesthesia in 2,050 infants and children using the drip and tube method

Background and Objectives: Pediatric epidural anesthesia has increased in popularity in the last 2 decades, but its success rate and the frequency of complications has not been fully elucidated. We therefore reviewed our experience with 2,050 cases of epidural anesthesia in infants and children. Methods: We recorded the number of attempts at epidural space location, complications, and effectiveness in 2,050 cases of single-shot sacral intervertebral, lumbar, and thoracic epidural anesthesia. We used the drip and tube method for identification of the epidural space and administration of local anesthetic solution. Results: The overall rate of successful epidural block and epidural space location on the first attempt was 96.4% and 89.8%, respectively. Complications included uncomplicated dural penetration (0.54%), spinal anesthesia (0.05%), bloody tap (0.34%), and intravascular injection (0.20%). Complications were more frequent in patients ≤10 kg body weight. There were no permanent neurological sequelae. Conclusions: Intervertebral epidural anesthesia using the “drip and tube” method is safe and practical in infants and children. Reg Anesth Pain Med 2003;28:103-107.

Block of the sacral segments in lumbar epidural anaesthesia

Block of the first sacral segment is often delayed in lumbar epidural anaesthesia. The addition of either epinephrine or sodium bicarbonate to the local anaesthetic enhances the efficacy of epidural block. We assessed the block of lumbo-sacral segments in lumbar epidural anaesthesia adding epinephrine and/or bicarbonate to lidocaine. Twenty-seven patients undergoing lumbar epidural anaesthesia with lidocaine 2%, 17 ml at L4-5 or L5-S1 were randomly divided into three groups. Plain lidocaine, lidocaine with 1:200,000 epinephrine or lidocaine-epinephrine-bicarbonate was administrated via an epidural catheter. The pain threshold after repeated electrical stimulation was used to assess the sensory block at the L2, S1, and S3 segments. Motor block was evaluated using the Bromage scale. Patient characteristics were comparable between the groups. The pH of lidocaine in the lidocaine-epinephrine-bicarbonate group was significantly higher than that in other groups. Pain thresholds at the S1 and S3 segments in the lidocaine-epinephrine-bicarbonate group were significantly higher than those in the lidocaine-epinephrine group. However, differences in the pain threshold at the L2 segment between groups were insignificant. The time to onset of sensory block at the S1 and S3 in the lidocaine-epinephrine-bicarbonate group was significantly shorter than that in the lidocaine group. Pain threshold by pinprick test was approximately within the 30-50 mA range. A combination of lidocaine, bicarbonate, and epinephrine increases the pain threshold over the sacral segments.

Quantification and Comparison of D-dimer after Pneumatic Tourniquet Release in Patients Undergoing Arthroscopic Knee Surgery on General Anesthesia and Epidural Anesthesia

Background: Several studies have indicated that lumbar epidural anesthesia may decrease the incidence of deep vein thrombosis and pulmonary embolism, particulary after total hip replacement. Moreover venous thromboembolism also occurs after the release of a tourniquet in orthopedic surgery. The d-dimer test has been reported to be useful for predicting lower limb DVT and PE. Of the d-dimer test methods, the latex agglutination method shows excellent sensitivity and specificity. Methods: We compared the quantity of d-dimer for General (n = 21) and Epidural (n = 20) anesthesia after tourniquet release in patients undergoing arthroscopic knee surgery. Results: D-dimer significantly increased after tourniquet release in both groups, whereas the increase of d-dimer in the Epidural group was no smaller than that in the General group. Epidural group showed a correlation between tourniquet application and d-dimer. Conclusions: The present data suggest that DVT and PE after tourniquet release could occur during arthroscopic knee surgery and that epidural anesthesia may increase the fibrinolysis of a tourniquet induced thrombus.

感染経路不明の敗血症で発症した腰部硬膜外膿ようの１例

We treated a case of epidural lumbar abscess in whom the route of sepsis could not be identified. Epidural spinal abscess is extremely rare and often the subject of delayed diagnosis and treatment. A previously healthy 68-year-old man developed back pain one week earlier and was hospitalized with fever, back pain, right shoulder pain, confusion, hypotension, vomiting, and urinary incontinence. He reported bilateral paresthesia over the lateral aspect of his thighs. The skin on his upper chest, bilateral upper extremities, and hands bore a reddish hue. Laboratory examination revealed serum CRP of 33.4mg/dl and a white cell count of 24, 050/mm3. Our tentative diagnosis was sepsis, although its origin remained unknown. Lumbar CT and MRI showed multiple space-occupying lesions in the iliopsoas and paravertebral muscles and in the lumbar epidural space. S. aureus (MSSA) grew in blood culture and appropriate antibiotics and gamma globulin were administered as soon as possible after admission. On hospital day 3, his condition improved. On hospital day 5, however, he again developed severe back pain, fever, and weakness of both lower extremities. Lumbar CT showed expansion of the space-occupying lesions, so we surgically drained the abscesses in the iliopsoas muscles. The man's condition improved neurologically but worsened again on hospital day 10. On hospital day 12, we surgically drained the abscesses in the epidural lumbar space, removing purulent material, and conducted L1-L4 decompressive laminectomy. He eventually improved satisfactorily and was discharged in good general condition after 3 months of hospitalization. Although time elapsed before surgical treatment due to the difficulty of making a definitive diagnosis, we achieved a successful outcome without obvious sequelae with intensive antimicrobial therapy started early and surgical drainage of abscesses in the iliopsoas muscles, which ultimately prevented worsening of the epidural abscess.

Acute Deafness After Spinal Anesthesia

We report a case of acute deafness after spinal anesthesia. CASE REPORT A seventy six year old patient received for a total knee replacement a combined spinal and epidural lumbar anesthesia at the height L 3⁄4. She got 3,5 ml bupivacaine 0,5% intrathecal; the epidural catheter was put in 15 cm from skin level. Neurological diseases or hearing defects weren't listed in case history. Within two hours the surgery was practiced without difficulties. Following the surgery a Patient Control Analgesia (PCA) – pump administering 4 ml ropivacaine 0,2%/h was connected to the epidural catheter. Additionally, the patient was able to receive boli of 5 ml ropivacaine 0,2% all 30 minutes at most. Due to the above mentioned therapy the patient was painless and no complications took place. After an increased mobilization out of bed starting at the 4 th postoperative day the patient suddenly complained about severe unilateral deafness. 15 hours later she also complained about a headache reinforcing in upright position. Due to frequent bolus requirements of app. 10 ml ropivacaine 0,2% (20 mg) by the patient during several days the unilateral deafness was explained as a central sign of overdosing the ropivacaine. As a result the PCA – pump was taken away. During four days the patient got app. 400 mg of ropivacaine a day up until that point of time. The thought of a possible complication concerning the spinal anesthesia wasn't taken into account until a position – related headache appeared. Within five days the hearing ability recovered very well and on account of the administration of dipyrone the headache vanished after two days. DISCUSSION In medical literature temporary unilateral deafness of the inner ear is discussed as a controversial complication following spinal anesthesia. Thus, Panning [4] sees no need for a patient to be routinely enlightened about the risk of temporary deafness prior to spinal anesthesia due to the low incidence of that particular complication. Dreyer, however, conducted a prospective study which projects an incidence rate of 16% a frequency which would make patient enlightenment about potential postoperative deafness mandatory. The unilateral deafness described in Dreyer`s publication appeared on the second day after spinal anesthesia and disappeared three days later without any therapy. The unilateral deafness, which usually concerns typically the low and the medium frequencies, is attributed to a decreased pressure in the subarachnoid space due to a loss of liquor [2]. This results in a modification of the endolymphatic pressure difference and therefore triggers a change in the oscillatory characteristics of the basilar membrane. Another study-group examined the incidence of temporary deafness following general and spinal anesthesia. They concluded that the intraoperatively administered fluid volume played a key role whereas the anesthesiological procedure itself could not be established as a contributing factor []. Constantinidis [1] et al. present a case with unilateral cochlear dysfunction and sensorineural hearing loss after inguinal hernia operation under controlled anesthesia. Acute Deafness After Spinal Anesthesia 2 of 3 According to Constantinidis [] at al., however, spinal anesthesia seems to generate a higher incidence of acute unilateral deafness. In that respective case, unilateral deafness did not appear until the fourth postoperative day. As a consequence, the physicians in charge did not instantly attribute this symptom to the spinal puncture. They rather considered it to be a side effect of the continuously administered local anesthetic. It was not until the onset of a typical postspinal headache and the persistence of unilateral deafness after discontinuation of the local anesthetic that a loss of liquor was considered as a potential cause. The fact that the symptoms occurred four days after surgery can be explained by the protracted immobilization of the patient, which made it impossible for the patient to assume an upright position to sit or walk. Our case indicates that the possibility of a loss of liquor has to be taken into account even in a case of delayed postoperative partial deafness. Another interesting point is, that hearing loss developing after spinal anesthesia is more frequent and severe in the young than in the elderly patients [3]. In this study it is again hypothesized that the cerebrospinal fluid leakage after dural puncture plays an important role regarding the developing of a hearing loss after spinal anesthesia. Additionally, it has to be emphasized that temporary unilateral deafness can be regarded a not uncommon complication few doctors seem to be aware of. Further studies need to answer the following question: Is unilateral deafness only a result of spinal anesthesia or can this complication also be attributed to general anesthesia? Divergent opinions regarding this issue seem to prevail in current medical literature. CORRESPONDENCE TO Peter Lierz, M.D, Department of Anesthesiology, Pain Control and Critical Care Medicine Marienkrankenhaus Soest Widumgasse 5 D-59494 Soest Soest, Germany, Europe Tel: +49-2921-3911201 Fax: +49-2921-3911209 Email: dr.lierz@marienkrankenhaus-soest.de

The Analgesic Effects of Epidural Dexamethasone after Simple Lumbar Discectomy

Background: Epidural steroids have been suggested to prevent postoperative epidural fibrosis after lumbar laminectomy. The purpose of this prospective study was to compare the degree of postoperative pain in patients undergoing simple lumbar discectomy with and without epidural dexamethasone administration. ethods: Thirty-six patients undergoing simple lumbar discectomy were randomly allocated to two groups to be given the following agents, just after the end of surgery via an epidural lumbar catheter previously inserted by the surgeon: normal saline 6 ml (group I), and a total of 6 ml normal saline with dexamethasone 5 mg (group II). The outcome measures included pain scores at 1, 2, 6, 12, and 24h and total morphine consumption over the first 24 postoperative hours. Results: There were significant differences in the postoperative visual analogue scale (VAS) score at 1 and 2 h between the two Groups, and the 24h total morphine consumption in Group II was significantly lower than in Group I. Conclusions: Epidural administration of dexamethasone decreased the degree of postoperative pain after simple lumbar discectomy.

Circulatory, respiratory and metabolic changes after thigh tourniquet release in combined epidural-propofol anaesthesia with preservation of spontaneous respiration.

Twelve elderly patients undergoing total knee arthroplasty received lumbar epidural anaesthesia and propofol infusion at 5 mg.kg(-1).h(-1) following a 1.5-2.0 mg.kg(-1) bolus dose with preservation of spontaneous respiration via a laryngeal mask airway. Circulatory, respiratory and metabolic variables were measured before and 1, 3, 5, 15 and 30 min after release of a pneumatic thigh tourniquet. The blood pressure was decreased at all time-points and the respiratory rate increased at 1 min. The P(a)CO(2) was increased only at 1 min. Arterial blood pH and base excess were decreased at 1 and 3 min and 1, 3 and 5 min, respectively. Arterial blood lactate levels were increased at all times. These characteristics were considered to be identical to those under regional anaesthesia with conscious spontaneous respiration, showing that spontaneous respiration under this anaesthetic regimen has a similar respiratory capacity to that of conscious spontaneous respiration.

Anesthetic Management of Cesarean Section in Parturient with Systemic Sclerosis

Systemic sclerosis is a multisystemic disorder of unknown etiology characterized by fibrosis of skin, blood vessel, and visceral organ. A 38-week pregnant, 29 year-old woman with systemic sclerosis and migraine was scheduled for cesarean section under lumbar epidural anesthesia because of dyspnea, decreased diffusion lung capacity and Raynaud's phenomenon. She suffered from sudden onset of severe headache, repetitive nausea, vomiting, and hypertension during cesarean section under the epidural anesthesia. The above symptoms did not respond to -blocker, vasodilator during the operation period. In the recovery room, the headache and vomiting were relieved by intravenous injection of ketorolac and metoclopramide. She experienced single tonic-clonic generalized seizure and intermittent migraine after operation in the ward, and discharged 7 days after operation.