Neuraxial Anesthesia In Patients Research Articles

Neuraxial Anesthesia in Obstetric Patients with Thrombocytopenia: Practice Patterns and Clinical Correlates

Introduction: Thrombocytopenia, (platelets under 150x10 9/L) is observed in 10% of pregnancies with counts below 100x10 9/L seen in 1-2% (Reese et. al, 2018, Gernsheimer, 2012). Neuraxial anesthesia is an effective pain management strategy for vaginal delivery and a safe alternative to general anesthesia for c-section. Although the precise risk of spinal hematoma has not been established in this patient population, it remains a common barrier to neuraxial procedures (Bernstein et. al, 2016). The hematology/maternal fetal medicine clinic (MFM) was created in our academic institution in February 2018 in response to the need to provide multidisciplinary care to patients with hematologic disorders in the context of pregnancy, including those with thrombocytopenia. Objectives: To establish the rate of neuraxial anesthesia in patients with thrombocytopenia seen in the multidisciplinary hematology/MFM clinic in our academic institution between 2018 and 2023 and identify clinical characteristics and practice patterns that affect the ability of this patient cohort to receive neuraxial procedures. Methods: Medical charts from all patients with thrombocytopenia affecting pregnancy evaluated in the hematology/MFM clinic (n=40 patients) were retrospectively reviewed. Baseline demographics, laboratory values, medical interventions (platelets directed treatment, neuraxial anesthesia, delivery route) and delivery outcomes were captured and analyzed using descriptive statistics (Table 1). Results: 40 patients underwent 44 deliveries. 33 (75%) were able to receive neuraxial anesthesia for delivery (15 vaginal and 18 c-section) ( Table 1) The median platelet count at the time of delivery was 105x10 9/L with 30 of 33 of the neuraxial deliveries occurring with platelet counts greater than 70x10 9/L (threshold recommended by the SOAP consensus (Bauer et. al, 2021)). The median platelet count at time of delivery for those who received neuraxial anesthesia was higher than for those who did not receive neuraxial (110x10 9/L vs 77x10 9/L). Rates of platelet directed treatment were similar in all patients independent of whether they received neuraxial anesthesia. Overall patients that did not receive neuraxial anesthesia delivered earlier and many delivered prior to their scheduled date. Despite the hematology/MFM clinic facilitating OB anesthesia consultations, a large proportion of patients were not evaluated prior to admission for delivery. Of the 11 patients that did not receive neuraxial anesthesia, 4 did not desire it, but would have been eligible based on their platelet counts at delivery ( Figure 1). Conclusions: These preliminary results indicate that a multidisciplinary approach can effectively treat thrombocytopenia in pregnant people and enable them to receive desired neuraxial anesthesia. Pre-term labor, precipitous delivery, and medical complications of pregnancy remain challenges to pregnant patients receiving neuraxial anesthesia. Future directions include examining which clinical interventions facilitate neuraxial anesthesia for pregnant patients in a larger population.

Prediction of Hypotension During Neuraxial Anesthesia in Patients with Pregnancy-Induced Hypertension Through Subclavian Vein Collapsibility Index

Objective: To explore and evaluate the predictive value of subclavian vein collapsibility index (SCV-CI) on hypotension during neuraxial anesthesia in patients with pregnancy-induced hypertension (PIH). Methods: Pregnant women with PIH who underwent elective cesarean section in our hospital from January to July 2021 were selected as the research subjects. Patients who experienced hypotension during anesthesia were included into the hypotension group, whereas patients who had a normal blood pressure during anesthesia were included in the normotensive group. The SCV-CI was then calculated for three respiratory cycles, the average value was taken as the base value, and the patient was monitored for another 20 minutes. The blood pressure, heart rate, blood oxygen saturation, and SCV-CI of the patients were measured, and the incidence of maternal nausea and vomiting and cord blood gas were recorded. Then, a correlation analysis was conducted on the relationship between subclavian vein collapsibility index and hypotension. A receiver operating characteristic curve was drawn to seek the threshold value of subclavian vein collapsibility index for post-anesthesia hypotension. Results: There was no significant difference in systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) between the two groups before anesthesia (P > 0.05). After anesthesia, the above indexes (SBP, 103.25 ± 12.48 mmHg; DBP, 58.94 ± 7.46 mmHg; and HR, 52.96 ± 6.48 beats/min) were significantly lower than those of the normal blood pressure group, and the difference was statistically significant (P < 0.05). In comparison, the SCV-CI in the hypotension group was 35.82 ± 4.93% greater than that in the normal blood pressure group (23.85 ± 5.27%), and the incidence of nausea and vomiting in the hypotension group (40.0%) was significantly higher than that in the normotensive group (10.53%), and the difference was statistically significant (P < 0.05). The area under the curve of SCV-CI prediction against hypotension in patients with PIH under neuraxial anesthesia was 0.825 (95% CI: 0.762–0.893, P < 0.001), the cut-off value was 25.68%, the predictive sensitivity was 92.68%, and the specificity was 81.24%. Conclusion: SCV-CI has a good predictive value for the occurrence of hypotension in patients with PIH during neuraxial anesthesia.

Inadequate Neuraxial Anesthesia in Patients Undergoing Elective Cesarean Section: A Systematic Review

(Anaesthesia. 2022;77:598–604) While neuraxial anesthesia (NA) is often a common and safe form of anesthesia, it does not always properly manage pain, especially during cesarean delivery (CD). Previous studies determining the rate of inadequate NA during CD have small sample sizes and different diagnostic criteria, resulting in a wide range of reported rates of neuraxial failure, from 1.7% to 19.7%. Understanding the incidence and risks associated with failed NA would provide valuable data to guide clinicians in counseling their patients, to prompt earlier recognition and intervention if NA failure occurs, and to direct future research. By systematic review, this study sought to investigate the rate of failed neuraxial block during CD as defined by the need to repeat NA or abandon NA in favor of general anesthesia, administer intraoperative IV analgesia (excluding benzodiazepines), or supplement the epidural during the procedure. Secondary outcomes included comparing neuraxial mode failure rates and determining the rates of conversion to general anesthesia.

Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery.

We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.

Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review.

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.

Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial

Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Management of anesthesia for surgery in prone position for a patient with hereditary neuropathy with liability to pressure palsies. A case report and narrative literature review

The reported case describes a patient with hereditary neuropathy with liability to pressure palsies (HNPP) requiring a neurosurgical laminotomy procedure for an arachnoid cyst with medullary compression. HNPP is a rare pathology requiring meticulous anesthetic and surgical management. We give a detailed overview of the planning, simulation, and performance of the anesthesia procedure in order to minimize all potential risk factors for perioperative nerve injury. During the preparation of this case, where the positioning was extremely challenging, we reviewed the available literature for guidance. A few papers report the use of neuraxial anesthesia in patients previously diagnosed with HNPP. No reports could be found on the management of general anesthesia and positioning for major surgery in those patients.

A physician survey of perioperative neuraxial anesthesia management in patients on a direct oral anticoagulant

BackgroundThe perioperative management of patients taking a direct oral anticoagulant (DOAC) who require a high‐bleed‐risk surgery and/or neuraxial anesthesia is uncertain. We surveyed clinician practices relating to DOAC interruption and related perioperative management in patients having high‐bleed‐risk surgery with neuraxial anesthesia, and assess the suitability of a randomized trial of different perioperative DOAC management strategies. MethodsWe surveyed members of the American Society of Regional Anesthesia and Pain Medicine, the Canadian Anesthesia Society and Thrombosis Canada. We developed four clinical scenarios involving DOAC‐treated patients who required anticoagulant interruption for elective high‐bleed‐risk surgery. In three scenarios, patients were to receive neuraxial anesthesia, and in one scenario they were to receive general anesthesia. We also asked about the merit of a randomized trial to compare a 2‐day versus longer (3‐ to 5‐day) duration of DOAC interruption. ResultsThere were 399 survey respondents of whom 356 (89%) were anesthetists and 43 (11%) were medical specialists. The responses indicate uncertainty about the DOAC interruption interval for high‐bleed‐risk surgery and/or neuraxial anesthesia; anesthetists favor 3‐ to 5‐day interruption whereas medical specialists favor 2‐day interruption. Anesthetists were unwilling to proceed with neuraxial anesthesia in patients with a 2‐day DOAC interruption interval, preferring to cancel the surgery or switch to general anesthesia. There is general agreement on the need for a randomized trial in this field to compare a 2‐day and a 3‐ to 5‐day DOAC interruption management strategy. ConclusionsThere is variability in practices relating to the perioperative management of DOAC‐treated patients who require a high‐bleed‐risk surgery with neuraxial anesthesia; this variability relates to the duration of DOAC interruption in such patients.

Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study

ObjectiveTo examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery.DesignComparative effectiveness study using linked,...

Administration of Neuraxial Anesthesia in Adults with Pre-Existing Bleeding Disorders and Tendencies: Methodology for Delphi Consensus Recommendations

Introduction Epidural and spinal hematoma are rare but potentially devastating complications of neuraxial anesthesia. Individuals with pre-existing bleeding disorders and tendencies are likely at higher risk of these feared complications, however there are currently no comprehensive recommendations to direct the use of neuraxial anesthesia in these patients. Objective Our objectives were to create a set of consensus recommendations to advise clinicians on appropriate treatment thresholds prior to neuraxial anesthesia for patients with a variety of common and uncommon bleeding disorders and tendencies, and to propose safe hemostatic thresholds for administration and removal of neuraxial anesthetics in these individuals. Materials and Methods A steering committee comprised of 14 hematologists, anesthesiologists and methodologists created and refined a set of Delphi statements regarding the use of neuraxial anesthesia in the following pre-existing bleeding disorders and tendencies: von Willebrand disease, immune thrombocytopenia, gestational thrombocytopenia, platelet function disorders, thrombocytopenia associated with hypertensive disorders of pregnancy, coagulation factor deficiencies and fibrinogen disorders. Statements were developed using data obtained from a previously conducted scoping review of existing literature supplemented with the expert opinion of the steering committee in areas where there are minimal published data. Statements include varying hemostatic laboratory parameters in the context of high or low bleeding risk as measured by either a validated bleeding assessment tool (BAT) or pre-defined criteria for excessive bleeding. We plan to recruit approximately 30 international panelists from the fields of hematology and anesthesiology to participate in a modified (i.e. electronic) Delphi technique. Three Delphi rounds will be conducted, during which we will ask panelists to rate their agreement with each Delphi statement on a 5-point Likert scale. Results will be analyzed for statistical consensus, defined as a Cronbach's alpha value of greater than or equal to 0.70. Statements that achieve consensus will be included in the final recommendations. Results Results of the modified Delphi study are pending. Conclusions Administration of neuraxial anesthesia in patients with pre-existing bleeding disorders and tendencies continues to present a significant management challenge for clinicians. We anticipate that the resultant recommendations will become a helpful tool for the future management of neuraxial anesthesia in these patients. Disclosures Martin: Borden Ladner Gervais LLP:Consultancy.Carvalho:Gauss Surgical:Consultancy.Kuter:Dova:Consultancy, Honoraria;Daiichi Sankyo:Consultancy, Honoraria;Actelion (Syntimmune):Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Principia Biopharma:Consultancy, Honoraria, Other, Research Funding;Protalix Biotherapeutics:Consultancy;Shionogi:Consultancy;Protalex:Consultancy, Honoraria, Research Funding;Kezar Life Sciences, Inc:Other, Research Funding;CRICO:Consultancy, Honoraria;Genzyme:Consultancy, Honoraria;Principia:Consultancy, Research Funding;Shire:Consultancy, Honoraria;Shionogi:Consultancy, Honoraria;Sanofi (Genzyme):Consultancy, Honoraria;Incyte:Consultancy, Honoraria;Immunovant:Consultancy, Honoraria;Kyowa-Kirin:Consultancy, Honoraria;Merck Sharp Dohme:Consultancy, Honoraria;Momenta:Consultancy, Honoraria;Novartis:Consultancy, Honoraria;Pfizer:Consultancy, Honoraria;Zafgen:Consultancy, Honoraria;Up-To-Date:Consultancy, Honoraria, Patents & Royalties;UCB:Consultancy, Honoraria;Platelet Disorder Support Association:Consultancy, Honoraria;Argenx:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Bristol-Myers Squibb:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Caremark:Consultancy, Honoraria;Immunovant:Other: Travel Expenses, Research Funding;Alnylam:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Agios:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Amgen:Consultancy, Honoraria, Other: Travel Expenses, Research Funding;Takeda (Bioverativ):Consultancy, Honoraria, Other, Research Funding;Rigel:Consultancy, Honoraria, Other, Research Funding;Protalex:Consultancy, Honoraria, Other, Research Funding.Lavin:Tremeau Pharmaceuticals:Membership on an entity's Board of Directors or advisory committees;Siemens Healthineers:Other: Speaker's fees;Takeda:Research Funding;Shire:Research Funding.Sholzberg:Takeda:Honoraria, Other: Scientific Advisory Board, Research Funding;Novartis:Honoraria, Other: Scientific Advisory Board;NovoNordisk:Honoraria, Other: Scientific Advisory Board;Octapharma:Honoraria, Other: Scientific Advisory Board, Research Funding;Amgen:Honoraria, Other: Scientific Advisory Board, Research Funding.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential...

Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials.

Neuraxial anesthesia is a common practice in obstetrics. Evidence suggests that preprocedural ultrasound versus the conventional landmark location method accurately identifies a given intervertebral space and predicts the needle insertion depth required to reach the spinal canal. However, whether the preprocedural ultrasound examination improves the first-pass success (FPS) rate remains elusive. Major databases were systematically searched for all relevant studies published in English up to June 2019. Eighteen randomized controlled trials including 1844 patients were enrolled. The quality of eligible studies was assessed, and predefined outcomes were synthesized by meta-analysis. The primary results showed that preprocedural ultrasound increased the FPS rate in patients with predicted puncture difficulty but not in patients who were easily punctured. Preprocedural ultrasound reduced the number of redirections and punctures and decreased the incidence of vascular puncture and backache. There was no evidence of a reduction in failed punctures. We also noted that preprocedural ultrasound prolonged the identification time but not the procedure time. Thus, this systematic review provides evidence that preprocedural ultrasound does not improve the FPS rate of neuraxial anesthesia in patients who are easily palpated, although it increases the FPS rate in patients who are difficult to palpate.

Ultrasound-guided continuous transmuscular quadratus lumborum block as a sole anesthetic technique for inguinal hernia repair in a high-risk patient

Quadratus lumborum (QL) block has been described as a postoperative analgesic technique by Blanco following superficial abdominal surgeries but has not been used as a sole anesthetic technique. This ipsilateral block with an indwelling catheter inserted for continuous QL block provided the pain-free course. It decreased opioid use both during intra and postoperative periods with a sensory block of T8–L1, thus avoiding complications related to general and neuraxial anesthesia in patients with low cardiac reserve. We report a high-risk case undergoing inguinal mesh hernioplasty under continuous QL block.

Neuraxial Anesthesia in Children With Ventriculoperitoneal Shunts.

Neuraxial anesthesia has been demonstrated to be safe and effective for children undergoing subumbilical surgery. There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with a ventriculoperitoneal shunt. We evaluated a series of 25 patients with indwelling ventriculoperitoneal shunts for complications within 30 days of any procedure performed with a neuraxial technique. One patient required a ventriculoperitoneal shunt revision 5 days after a lumbar catheter placement. The neurosurgeon determined the revision to be likely unrelated to the patient's lumbar catheter. Concerns about the use of neuraxial anesthesia in patients with an indwelling ventriculoperitoneal shunt may be overstated.

Baclofen Pump Replacement in a Patient With End-Stage Amyotrophic Lateral Sclerosis: A Case Report Demonstrating Transversus Abdominis Plane Block as the Sole Anesthetic.

A patient with end-stage amyotrophic lateral sclerosis (ALS) presented for Baclofen pump replacement. She underwent a left transversus abdominis plane block to anesthetize the left lower quadrant of the abdomen. No sedatives or analgesics were administered, and the procedure was successfully completed without complication. It is prudent to consider anesthetic plans that avoid complications associated with general or neuraxial anesthesia in patients with ALS. This case report demonstrates successful placement of a transversus abdominis plane block in a patient with ALS and offers a safe anesthetic technique that can be performed in other high-risk patients.

Emergency Cesarean Section under Spinal Anesthesia in an Operated Patient of Meningocele during Her Infancy: A Case Report

Introduction: Neuraxial techniques of anesthesia and analgesia are the current choice in obstetrics for efficacy and general low risk of major complications. Concern exists about neuraxial anesthesia in patients with occult neural tube defects, regarding both labor analgesia and anesthesia for cesarean section. Here, we discuss the case of a pregnant woman attending at our institution with operated case of asymptomatic Meningocele who landed up for emergency cesarean section. She underwent emergency operative delivery with spinal anesthesia with no complications. Keywords: Full stomach, hypothyroidism, meningocele, prematurity 28th week, severe fetal growth restriction, severe pregnancy-induced hypertension, spinal anesthesia.

Neuraxial anesthesia in patients with multiple sclerosis - a systematic review

Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. A systematic literature search with the keywords "anesthesia or analgesia" and "epidural, peridural, caudal, spinal, subarachnoid or intrathecal" in combination with "multiple sclerosis" was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis.

Combined Sciatic, Femoral, and Obturator Nerve Blocks for Ankle Surgery in a Patient with Severe Pulmonary Hypertension—A Case Report

We report a patient with severe pulmonary arterial hypertension (PAH) undergoing tibio-talo-calcaneal fusion due to Charcot joint. Despite the advancement in the management of PAH, the risks of anesthesia, surgery, and postoperative morbidity and mortality still remain high. A 46-year-old female was presented with severe PAH and end stage renal disease requiring hemodialysis three times a week. Ultrasound-guided sciatic, femoral, and obturator nerve blocks were performed with 0.5% levobupivacaine 15 ml, 10 ml, and 5 ml, respectively. All the blocks were successful, and the patient underwent uneventful anesthesia and surgery. In addition, the postoperative pain control lasted for 15 h and the patient was discharged on POD 5 without any complications. Therefore, ultrasound-guided sciatic, femoral, and obturator nerve blocks are valuable alternative to the general or neuraxial anesthesia in patients with severe pulmonary hypertension.

Neuraxial anesthesia in patients with multiple sclerosis – a systematic review

Background and objectivesCurrent guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. MethodsA systematic literature search with the keywords “anesthesia or analgesia” and “epidural, peridural, caudal, spinal, subarachnoid or intrathecal” in combination with “multiple sclerosis” was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Results and conclusionsOver a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis.

Is Neuraxial Anesthesia Safe in Patients Undergoing Surgery for Treatment of Periprosthetic Joint Infection?

There is concern that neuraxial anesthesia in patients undergoing surgery for treatment of a periprosthetic joint infection (PJI) may increase the risk of having a central nervous system infection develop. However, the available data on this topic are limited and contradictory. We wished to determine whether neuraxial anesthesia (1) is associated with central nervous system infections in patients undergoing surgery for a PJI, and (2) increases the likelihood of systemic infection in these patients. All 539 patients who received neuraxial or general anesthesia during 1499 surgeries for PJI from October 2000 to May 2013 were included in this study; of these, 51% (n = 764) of the surgeries were performed in 134 patients receiving neuraxial anesthesia and 49% were performed in 143 patients receiving general anesthesia. Two hundred sixty-two patients received general and neuraxial anesthesia during different surgeries. We used the International Classification of Diseases, 9(th) Revision codes and the medical records to identify patients who had an intraspinal abscess or meningitis develop after surgery for a PJI. Multivariate analysis was used to assess the effect of type of anesthesia (neuraxial versus general) on postoperative complications. There were no cases of meningitis, but one epidural abscess developed in a patient after neuraxial anesthesia. This patient underwent six revision surgeries during a 42-day period. Patients who received neuraxial anesthesia had lower odds of systemic infections (4% versus 12%; odds ratio, 0.35; 95% CI, 023-054; p < 0.001). Central nervous system infections after neuraxial anesthesia in patients with a PJI appear to be exceedingly rare. Based on the findings of this study, it may be time for the anesthesiology community to reevaluate the risk of sepsis as a relative contraindication to the use of neuraxial anesthesia.