Neuraxial Blockade Research Articles

Thoracic spinal anaesthesia - An effective alternative to general anaesthesia in breast surgeries: A randomised, non-blinded study.

General anaesthesia (GA) is the preferred modality for breast surgeries; however, neuraxial anaesthesia can be performed in cases where GA poses a significant risk. We hypothesise that neuraxial blockade is a safe and effective alternative to GA in short-duration breast surgeries. This randomised study included 30 patients of the American Society of Anesthesiologists physical status I and II, who were scheduled for elective breast surgeries of a duration of less than 90 min. Group I received thoracic spinal anaesthesia, while in Group II, standardised GA was administered. The primary outcome was the time to the first rescue analgesic, and the secondary outcomes were time to recovery, patient satisfaction and the cost incurred. The demographic characteristics of both groups were comparable (P > 0.05). The time to first rescue analgesic in Group I was more than in Group II (P = 0.001). Patient satisfaction score was superior in Group I compared to Group II (P = 0.002). The average cost was lower in Group I compared to Group II (P = 0.002). Recovery was quicker in Group I than in Group II (P = 0.001). There were no significant haemodynamic disturbances or major complications in either group. Thoracic spinal anaesthesia is an excellent alternative to GA in terms of analgesic efficacy, patient satisfaction, recovery and cost-effectiveness for short-duration breast surgeries.

A Comparative Study of Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia in Major Lower Limb Orthopedic Surgeries.

Background Neuraxial blockade includes epidural and spinal anesthesia (SA) that have gained wide acceptance for major lower limb orthopedic surgery. Both techniques are competent in rendering surgical anesthesia and pain relief, with specific advantages and disadvantages. SA has the merits of rapid onset and adequate anesthesia with a small volume of the drug but has significant hypotension and unpredictable duration. Epidural anesthesia allows for finer control over analgesia and the duration of anesthesia but requires more substantial volumes of drugs and is slower in onset. Combined spinal-epidural anesthesia (CSEA) combines the rapid commencement of action of SA with flexibility in epidural anesthesia, thus optimizing the management of the intraoperative and postoperative phases. This study aims to evaluate hemodynamic changes, compare the severity and duration of sensory and motor block, and track any problems related to CSEA and SA in major lower limb orthopedic procedures. Additionally, this study contrasts the hemodynamic, motor, and sensory changes in the two groups. Methodology A total of 30 individuals were randomized to one of two groups in this prospective comparative trial, which included 60 patients receiving major lower limb orthopedic surgery and meeting the American Society of Anesthesiologists physical status I-II criteria. Group A received CSEA, and Group B received SA. The degree and duration of sensory and motor blockade, hemodynamic changes, and complications were all recorded. A p-value of less than 0.05 was used to evaluate statistical significance using Student's t-test and chi-square test. Results The onset of sensory block in our study was earlier in Group B compared to Group A. In both groups, hemodynamic stability was maintained throughout the study. We recorded the onset/duration of sensory and motor block and hemodynamic changes and took mean values to find any significant difference. Postoperative complications and rescue analgesic requirements were monitored and managed and were a part of our study. Conclusions This study compared CSEA and SA regarding the severity and duration of sensory and motor block, hemodynamic stability, and associated complications in major lower limb orthopedic surgeries. The results shed light on the advantages and shortcomings of each anesthesia technique and, therefore, will help choose the correct method of anesthesia in a given surgery.

Peripheral nerve block (Tetra block) - an effective alternative anesthesia for patients undergoing fractured femur neck surgery with recent myocardial infarction and low ejection fraction: a case report

The fractured neck of the femur (NOF) is a common injury among the elderly population1 . Ischemic heart disease (IHD)is a common comorbid condition in these patients, and recent myocardial infarction (MI)adds a unique challenge for the anesthesiologist1 . The best timing for the surgery is known to be the day of admission or the day after admission. However, this poses a challenge due to patients possibly being on antiplatelet or anticoagulant therapy, which means central neuraxial blockade is not an option1 . General anesthesia (GA) for these patients can lead to cardiovascular and respiratory instability due to associated low ejection fraction (EF)2 . Hemodynamic fluctuations related to anesthesia can be harmful. In this case study, a patient with a NOF fracture and a recent MI with a low EF underwent hemiarthroplasty. The procedure used a peripheral nerve block (PNB) alongside sedation as the sole anesthetic technique. The patient remained stable throughout the surgery and in the postoperative period. Keywords: Neck of femur fracture, Myocardial Infarction, Peripheral Nerve Block, Tetra block, Locoregional, Ejection Fraction.

Effects of Continuous versus Single Dose Spinal Anesthesia in Octogenarians Undergoing Hip Surgery: Randomized Control Trial

Abstract Background Continuous spinal anesthesia (CSA) is an anesthetic technique that offers several clinical advantages for anesthesia and analgesia in elderly patients. The level of sensory blockade can be titrated to the desired dermatomal level with great precision with intrathecal (IT) catheters, allowing better control of the hemodynamic consequences of sympathetic blockade associated with spinal anesthesia compared to epidural or single shot spinal techniques. Octogenarians are expected to suffer more from hemodynamic instability with spinal anesthesia. Objective The primary outcome is to compare the incidence of hypotension (defined as decrease in mean arterial blood pressure > 20% from the base line) in continuous spinal anesthesia CSA versus single dose spinal anesthesia in octogenarians undergoing hip surgery. The secondary outcome is to determine the total use of vasopressor (Ephedrine) and the incidence of spinal complications as nausea, vomiting and post Dural puncture headache. Methods This is a randomized controlled clinical trial done at Ain-shams University Hospitals, Cairo, Egypt within a period of 6 months from approval of medical ethics committee. Twenty patients in CSA group received increments of (0.5 ml) of plain bupivacaine 0.5% until T10 level blockade is achieved. Twenty patients in SDA group received single shot of (2.5ml) of bupivacaine 0.5%. Results The main finding of this study is that while MAP was significantly lower between 5-35 minutes (<0.001), it was significantly higher between 40-75 minutes in SDA group than CSA group (0.05).Total bupivacaine dose was significantly higher in SDA (12.5±0.8) group than CSA group (7.6±1.3) (p < 0.001). The total ephedrine dose needed was significantly higher in the SDA group (19.5 ±11.3) than in CSA group (4.5±1.7) (p.0.006). Conclusion The main finding of this study is that for octogenarians undergoing hip surgery, while MAP was significantly lower between 5-35 minutes, it was significantly higher between 40-75 minutes in single dose spinal anesthesia group than continuous spinal anesthesia group. Episodes of bradycardia were similar in both groups. The bupivacaine dose as well as total ephedrine dose was significantly higher in SDA group than CSA group. Groups were similar in the incidence of postoperative complications related to the neuraxial blockade. The impact of these changes on the overall cardiovascular status and outcome in octogenarians undergoing hip surgery could not be determined from our study design.

Anaesthetic Challenge in a Child with Hurler’s Syndrome: Encouraging Experience with Neuraxial Blockade

Mucopolysaccharidoses are uncommon genetic diseases with multisystem involvement. The potential for airway difficulties and varying success rate of neuraxial blockade demands considerable expertise in the anesthetic management in these patients. Airway management has evolved significantly in such syndromic patients with the increasing use of video laryngoscopes and Supraglottic airway devices. However, airway catastrophes are not uncommon. This calls for better utilization of neuraxial and peripheral nerve blocks along with the use of newer agents for sedation having a favorable pharmacological profile. Here, we present a case of child having Hurler disease with an inguinal hernia successfully operated under subarachnoid blockade.

Improving safety: Neuraxial blockade guided by thromboelastography for patients with uncertain coagulation profile.

Neuraxial blockade procedures are essential for anesthesia and pain management but pose risks in patients with uncertain coagulation profiles. Traditional coagulation tests often fail to predict bleeding risks associated with neuraxial blockade. Thromboelastography (TEG) offers real-time insights into coagulation status, potentially improving safety outcomes. In this case series, six patients underwent neuraxial blockade guided by TEG analysis. An individualized anesthetic plan was formulated based on TEG findings to mitigate bleeding risks while ensuring pain management. Tailoring anesthetic techniques to real-time TEG data improved safety outcomes with minimized bleeding complications and satisfactory pain control. In conclusion, neuraxial blockade guided by TEG enhances safety in patients with uncertain coagulation profiles. Further studies are needed to validate benefits in broader clinical settings.

Obstetric and anesthetic management in parturients with ventriculoperitoneal shunt: a case series.

Further study is needed to determine the safest mode of delivery and anesthetic management for parturients with ventriculoperitoneal shunts (VP). Prior recommendation for delivery in women with ventriculoperitoneal shunts was cesarean delivery. However, both vaginal delivery and neuraxial anesthesia have been shown to be safe in women with appropriately functioning VP shunts. We present a case series of parturients with VP shunt. Parturients with VP shunts were identified and VP shunt placement indications, neurologic symptoms during pregnancy, delivery mode, anesthetic type, and postpartum complications were reviewed. Forty patients were identified, and fifteen women with twenty deliveries were included. Two women experienced neurological symptoms during pregnancy and one required postpartum shunt revision for blurry vision and ataxia. There were ten cesarean deliveries and ten vaginal deliveries (eight normal spontaneous, one vacuum assisted, and one forceps assisted). Assisted vaginal deliveries were performed to decrease Valsalva including the patient with neurological symptoms related to shunt malfunction. Of the vaginal deliveries, six (60%) had epidural analgesia. Anesthesia for cesarean delivery included neuraxial anesthesia (n = 5) and general anesthesia (n = 5). In our cohort, women with VP shunt received neuraxial blockade without complication. Neuraxial techniques should be offered to women with appropriately functioning VP shunt.

Evaluating Thromboprophylaxis Strategies for High-Risk Pregnancy: A Current Perspective.

Venous thromboembolism (VTE) represents one of the leading causes of death during pregnancy. The greatest risk for it is the presence of medical or family history of VTE, stillbirth, cesarean section and selected thrombophilia. Appropriate thromboprophylaxis has the potential to decrease the risk of VTE in at-risk pregnant patients by 60-70%. Based on this, the authors reviewed the PubMed, Web of Science and Scopus databases to identify the possibilities of thromboprophylaxis in pregnant patients with a high risk of VTE. Moreover, they summarized its management in specific situations, such as cesarean delivery or neuraxial blockade. Currently, low-molecular-weight heparins (LMWH) are the preferred drugs for anticoagulant thromboprophylaxis in the course of pregnancy and postpartum due to easy administration and a lower rate of adverse events.

Comparison of ropivacaine, bupivacaine, and lignocaine in femoral nerve block to position fracture femur patients for central neuraxial blockade in Indian population.

Patients with a fractured femur experience intense pain during positioning for neuraxial block for definitive surgery. Femoral nerve block (FNB) is therefore often given prior to positioning for analgesia. In our study, we compare the onset and quality of block of 0.25% bupivacaine, 0.5% ropivacaine, and 1.5% lignocaine for FNB in fracture femur patients. Seventy-five adult femur fracture patients were equally and randomly divided into three groups to receive 15 ml of either 0.25% bupivacaine (group B), 0.5% ropivacaine (group R), or 1.5% lignocaine (group L) for FNB prior to positioning for neuraxial blockade. Onset and quality of block were assessed, as well as improvement in visual analog scale (VAS) score, ease of positioning, and patient satisfaction. Percentage decrease in VAS was found to be highest in group R (82.8%) followed by groups L and B. Time to achieve a VAS of less than 4 was found to be 26.2±2.4 minutes in group B, 8.5±1.9 minutes in group R, and 4.1±0.7 minutes in group L (P<0.001). In group B, 12 patients required additional fentanyl to achieve a VAS <4. Patient positioning was reported to be satisfactory in all patients in group R and L, while in B it was satisfactory in 13 (52%) patients only. Patient acceptance of FNB was 100% in group R and L, but only 64% in group B. Based on our findings, 0.5% ropivacaine is a favorable choice for FNB due to early onset, ability to yield a good quality block, and good safety profile.

Comparison of efficacy and safety of three different concentrations of ropivacaine for labor pain management using patient-controlled epidural analgesia (PCEA): A double-blind, randomized controlled trial.

Labor pain is consistently ranked high on the various pain rating scales, when compared to other painful life experiences, and the experience of labor during the process of childbirth is both complex and subjective. Though patient-controlled epidural analgesia (PCEA) using dilute concentrations of local anesthetics (LAs) has been a popular method to control labor pain, yet the optimal dose and regimen for PCEA remain ambiguous. So, the present study was undertaken to evaluate the safety and efficacy of three different concentrations of ropivacaine for labor analgesia using PCEA. Seventy-five healthy nulliparous women who gave voluntary consent for labor analgesia using PCEA were randomly assigned to three groups to receive three different ropivacaine concentrations (0.0625%, 0.1%, and 0.125%) with adjuvant fentanyl 2 μg/ml, after double-blinding. Analgesic efficacy, neuraxial blockade, vital parameters, neonatal outcomes, maternal satisfaction, and side effects were assessed. Primary outcome was total dose of ropivacaine consumed in milligrams. Number of pain breakthroughs (Visual Analog Score >4) and PCEA demand and rescue boluses were found to be statistically more in group 0.0625% (P < 0.01), followed by group 0.1% and were the least in 0.125%. Still, total drug consumed in milligrams was significantly less in 0.0625% group. Maternal satisfaction was comparable among the three groups (P = 0.33). There was no significant difference in maternal side effects and neonatal APGAR scores among the three groups. When three different concentrations of ropivacaine, that is, 0.0625%, 0.1%, and 0.125%, are used for labor analgesia, the use of 0.125% ropivacaine leads to higher total amount of ropivacaine consumed. Despite the lower efficacy in terms of breakthrough pain episodes observed with a 0.0625% ropivacaine concentration for labor analgesia, maternal satisfaction remained consistent across all three doses of ropivacaine. PCEA demand and rescue boluses for the lowest concentration, that is, 0.0625%; and did not affect maternal satisfaction with the management of labor pain.

The impact of ultrasound- guided neuraxial blockade on anaesthetic outcomes in morbidly obese parturients: A case report

Obesity being a global epidemic is increasing in parturients nowadays, leading to super morbid obese parturient undergoing caesarean section. Caesarean section in morbidly obese poses many anaesthetic challenges under general anaesthesia a well as neuraxial anaesthesia. We report a case of super-super obese parturient with body mass index (BMI) of 63kg/m who underwent elective caesarean section under combined spinal epidural anaesthesia with ultrasound guidance successfully. We aim to highlight the anaesthetic considerations and implications associated with such patients.

Retrograde intrarenal surgery with central neuraxial blockade versus general anesthesia: A systematic review and meta-analysis.

The aim of the article is to assess the impact of retrograde intrarenal surgery under central neuraxial blockade in comparison to general anesthesia (GA). This systematic review was conducted following the guidelines set out by the preferred reporting items for systematic reviews and meta-analyses. We conducted a comprehensive search across major electronic databases, including various types of studies such as descriptive studies and full-text literature, all of which were incorporated into the current review from 2018 to 2023. We involved those studies, which included the comparative study of spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal epidural anesthesia with GA. In our meta-analysis of 12 studies, it was found that anesthesia technique significantly affected operation time, with neuraxial anesthesia (NA) showing a mean difference of -2.28 (95% confidence interval (CI): -3.5 to -1.04, P = 0.003) compared to GA. However, there were no significant differences in rates of stone clearance, 24-h pain scores and length of hospital stay among patients administered with NA or GA for retrograde intrarenal surgery (RIRS). On the basis of the outcomes of study, NA can serve as a viable alternative to GA for RIRS. Our analysis reveals no significant differences in rates of stone clearance, operation duration, 24-h pain scores, complication rates, and length of hospital stay between NA in addition to GA in the context of RIRS. This suggests that given the potential economic advantages, NA might be a preferable choice over GA, contingent on patient preferences, baseline characteristics, and stone burden.

Is General Anesthesia for Peripheral Vascular Surgery Correlated with Impaired Outcome in Patients with Cardiac Comorbidity? A Closer Look into the Nationwide Danish Cohort

ObjectiveGeneral anesthesia (GA) may impair outcome after vascular surgery. The use of anticoagulant medication is often used in patients with cardiac comorbidity. Regional anesthesia (RA) requires planning of discontinuation before neuraxial blockade(s) in this subgroup. The aim was to describe the effect of anesthesia choice on outcome after vascular surgery in patients with known cardiac comorbidity. DesignRetrospective cohort study. SettingDanish hospitals. Participants6302 patients with known cardiac comorbidity, defined as ischemic heart disease, valve disease, pulmonary vascular disease, heart failure, and cardiac arrhythmias, undergoing lower extremity vascular surgery between 2005 and 2017. InterventionsGA versus RA. Measurements and Main ResultsData were extracted from national registries. GA was defined as anesthesia with mechanical ventilation. Multivariable regression models were used to describe the incidence of postoperative complications as well as 30-day mortality, hypothesizing a better outcome after RA. The rate of RA decreased from 48% in 2005 to 20% in 2017. The number of patients with ≥1 complications was 9.7 vs 6.2% (p <.001) and 30-day mortality was 6.0 vs 3.4% (p <.001) after GA. After adjusting for baseline differences, odds ratio (OR) was significantly lower for medical complications (cardiac, pulmonary, renal, new dialysis, intensive care unit and other medical complications) (OR 0.97 (0.95-0.98)) and 30-day mortality (OR 0.98 (0.97-0.99)) after RA. ConclusionsRA may be associated with a better outcome than GA after lower extremity vascular surgery, in patients with cardiac comorbidity. Prioritizing RA, despite the inconvenience of discontinuing anticoagulants, may be recommended.

Outbreak of Fusarium solani Meningitis in Immunocompetent Persons Associated With Neuraxial Blockade in Durango, Mexico, 2022-2023.

Fungal meningitis can be associated with epidural anesthesia procedures. Fusariosis is a rare infection typically affecting immunocompromised patients and rarely causes meningitis. During 2022-2023, public health officials responded to a large outbreak of Fusarium solani meningitis associated with epidural anesthesia in Durango, Mexico. The public health response and epidemiological and clinical features of patients affected by this outbreak were described. Coordinated actions were addressed to identify the etiological agent, determine its drug susceptibility, develop diagnostic tests, and implement clinical and epidemiological protocols. Retrospective analyses of clinical variables and outcomes were performed to determine association with better patient survival. A total of 1801 persons exposed to epidural anesthesia were identified, of whom 80 developed meningitis. Fusarium solani was found in 3 brain biopsies and showed susceptibility to voriconazole and amphotericin B. After F solani polymerase chain reaction (PCR) implementation, 57 patients with meningitis were PCR-screened, and 31 (38.8%) had a positive result. Most patients were female (95%), and cesarean section was the most common surgical procedure (76.3%). The case fatality rate was 51.3% (41 patients) and the median hospitalization duration was 39.5 days (interquartile range, 18-86 days). Seventy-one patients (88.8%) received voriconazole/amphotericin B and 64 subjects (80%) additionally received steroids. Cox regression analysis showed an increased lethality risk in patients who received antifungal treatment after 5 days (hazard ratio, 2.1 [95% confidence interval, 1.01-4.48], P < .05). The F solani meningitis outbreak in Durango was an unprecedented medical challenge. Timely treatment and effective healthcare management were associated with better survival outcomes.

Role of Intravenous Dexmedetomidine in the Prevention and Treatment of Shivering in Pregnant Patients Undergoing Cesarean Section Under Central Neuraxial Blockade: A Systematic Review and Meta-Analysis

Background and Aims: Dexmedetomidine has been used as an anti-shivering agent in the perioperative period in pregnant patients undergoing caesarean section (CS), but its effectiveness remains inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of intravenous Dexmedetomidine in the management of shivering. Methods: PubMed, MEDLINE, Embase, Scopus, Web of Science, CENTRAL, and Google Scholar were explored for the randomised controlled trials (RCTs), which compared intravenous administration of Dexmedetomidine with normal saline (placebo) or other anti-shivering agents for the prevention or treatment of shivering in pregnant patients undergoing CS under central neuraxial blockade. The primary outcome was either incidence and/or severity (for prevention) and duration and/or success rate (for treatment) of shivering between the two groups. The secondary outcome measures were adverse effects (bradycardia, hypotension, sedation, nausea and vomiting, and effect on the APGAR scores of the baby) if observed. Data were synthesised using a random effect model. We calculated the odds ratio (95% CI) for presenting the categorical outcome and standardized mean difference (95% CI) for continuous outcomes. Heterogeneity was assessed using I2 statistics and was investigated using sensitivity analysis. Results: A total of 15 RCTs were included in the present systematic review and data from 10 RCTs comparing Dexmedetomidine with normal saline were pooled into the meta-analysis for primary outcome measure. The incidence and severity of shivering at 30 and 60 minutes weresignificantly less in the Dexmedetomidine group compared to the normal saline group [OR = 0.30, 95% CI: 0.19 to 0.47, P &lt; 0.0001; MD = -0.54, 95% CI: -0.81 to -0.26, Z = 3.78, P = 0.0002 and MD = -1.06, 95% CI: -1.46 to -0.66, Z = 5.23, P &lt; 0.0001 respectively]. Similarly, the time to reduce shivering was significantly lower and the success rate of treatment was higher in the Dexmedetomidine group compared to the normal saline group [MD = -13.55, 95% CI: −17.78 to -9.12, Z = 6.0, P &lt; 0.0001 and OR = 0.03, 95% CI: 0.02 to 0.07, P &lt; 0.0001 respectively]. There was no heterogeneity among the studies for incidence, severity at 60 minutes, and success rate of treatment outcome, while the severity of shivering at 30 minutes and time to reduce shivering demonstrated moderate heterogeneity. The side effect profile was comparable between the Dexmedetomidine and control (active and passive) group. Conclusion: This meta-analysis shows that intravenous administration of Dexmedetomidine for both prophylaxis and treatment is superior to normal saline in the management of perioperative shivering during CS, but is comparable to other most commonly used anti-shivering agents. There is no statistically significant difference in the incidence of side effects between the two groups.

Crystalloid Preloading versus Prophylactic Ephedrine Infusion for Prevention of Hypotension during Caesarean Section

Context: Central neuraxial blockade is widely practiced in obstetric anesthesia. The prevention of maternal systemic hypotension is of importance. Aim: To compare between crystalloid preloading and prophylactic intravenous ephedrine in the prevention of maternal systemic hypotension after spinal anesthesia for cesarean section. Settings and Design: Study was conducted in a tertiary care hospital; comparative observational study. Methods and Materials: One hundred fifty six healthy parturients, posted for elective cesarean section. The parturients who were preloaded with 10 mL/kg of Ringer Lactate over 20 minutes before spinal anesthesia by treating anesthesiologist were included in Group P. Parturients were administered prophylactic ephedrine 0.125 mg/kg infusion after spinal anesthesia at the onset of sympathetic block by treating anesthesiologist were included in Group E. Statistical Analysis Used: Data were entered in Microsoft excel and analyzed using SPSS software version 25 (IBM). Results: In our study, we found that fall in blood pressure was statistically significant from fourth to 14th minute in Group P compared to Group E. The mean arterial pressure became significantly low in Group P compared to Group E. Heart rate was found to increase in Group P from second minute compared to sixth minute in Group E. Fetal wellbeing assessed by appearance (colour), pulse, grimace (response to touch), activity (tone) and respiration (APGAR) score was better in Group E compared to Group P and was statistically significant. Nausea and vomiting were more in Group P compared to Group E and was statistically significant. Conclusions: We conclude that prophylactic ephedrine infusion has better control over maternal hemodynamic than crystalloid preloading in cesarean section under spinal anesthesia.

Association between perioperative neuraxial local anesthetic neurotoxicity and arachnoiditis: a narrative review of published reports.

Arachnoiditis is a rare but devastating disorder caused by various insults, one of which is purported to be local anesthetic neurotoxicity following neuraxial blockade. However, the relationship between local anesthetics administered into the neuraxis and the development of arachnoiditis has not been clearly elucidated. We aimed to summarize the existing complex body of literature and characterize both the essential features and strength of any association between neuraxial local anesthetic neurotoxicity and arachnoiditis with a view toward mitigating risk, enhancing prevention, and refining informed consent discussions. We reviewed all published reports of arachnoiditis attributed to local anesthetic neurotoxicity following perioperative neuraxial anesthesia. This narrative review was based on a systematic search methodology, which included articles published up until December 2022. Thirty-eight articles were included, comprising 130 patients, over one-half of which were published prior to this century and inconsistent with modern practice. Neuraxial techniques included 78 epidurals, 48 spinals, and 5 combined spinal-epidurals, mostly for obstetrics. Reporting of essential procedural data was generally incomplete. Overall, at least 57% of patients experienced complicated needle/catheter insertion, including paresthesia, pain, or multiple attempts, irrespective of technique. The onset of neurological symptoms ranged from immediate to 8 years after neuraxial blockade, while the pathophysiology of arachnoiditis, if described, was heterogeneous. The existing literature attributing arachnoiditis to local anesthetic neurotoxicity is largely outdated, incomplete, and/or confounded by other potential causes, and thus insufficient to characterize the features and strength of any association.

General Anesthesia for Cesarean Delivery for Thrombocytopenia in Hypertensive Disorders of Pregnancy: Findings From the Obstetric Airway Management Registry

(Anesth Analg. 2023;136:992–998) In Africa, maternal morality following cesarean delivery is 50× more likely compared to morality rates in high-income countries, and spinal anesthesia (SA) is the preferred anesthetic method during cesarean delivery. For parturient patients with hypertensive disorders (ie, preeclampsia, eclampsia, or gestational hypertension), there is an increased risk for adverse outcomes, including spinal epidural hematoma following SA, so thrombocytopenia should be excluded before neuraxial blockade. An accurate platelet count is necessary before SA in emergent situations of fetal distress, which can be complicated when laboratory services are unavailable or off-site. The primary aim of this study was to determine which patients received general anesthesia (GA) when the presence of thrombocytopenia was known versus suspected. The secondary aim was perioperative platelet counts of patients with suspected thrombocytopenia to determine how often GA may have been avoided in favor of SA if platelet count was known.

Regional anesthesia and sickle cell crisis in pediatric patients: An educational-focused review.

Sickle cell disease (SCD) is the most common inherited hemoglobinopathy, affecting approximately 100 000 patients in United States and millions worldwide. Although the mainstay of pain management for VOC remains systemic opioids, given the potential for adverse effects including respiratory depression and hypoxemia, there remains interest in the use of regional anesthetic techniques (neuraxial or peripheral nerve blockade). A systematic search of pubMed, Scopus, and Google Scholar was conducted using the terms sickle cell disease, sickle cell crisis, pain crisis, vaso-occlusive crisis, regional anesthesia, peripheral nerve blockade, and neuraxial anesthesia. We identified 7 publications, all of which were retrospective case series or single case reports, outlining the use of neuraxial anesthesia in a total of 26 patients with SCD. Additionally, we identified 4 publications, including one retrospective case series and 3 single case reports, entailing the use of peripheral blockade in patients with VOC and SCD. The available literature, albeit all retrospective or anecdotal, suggests the potential utility of regional anesthesia to treat pain in patients with SCD. Additional benefits have included avoidance of the potential deleterious physiologic effects of systemic opioids and in one case series, an improvement in respiratory function as judged by pulse oximetry. The anecdotal and retrospective nature of the available reports with an absence of prospective trials limits the evidence based medicine available from which to develop to guidlines for the optimal local anesthetic agent to use, its concentration, the rate of infusion, and the choice of adjunctive agents.

Graded Epidural Anaesthesia as a Sole Anaesthetic Technique for Lower Limb Surgeries in Patients with Low Ejection Fraction: A Case Series

In patients with a history of ischemic heart disease with low ejection fraction, it’s always a challenge for the Anaesthesiologist to make a decision on whether to administer General Anaesthesia (GA), central neuraxial blockade, or both. When the Left ventricular ejection fraction (LVEF) percentage reduces to less than 35%, it indicates the presence of severe systolic dysfunction. Both general anaesthesia and regional anaesthesia carry potential risks due to these patients' low cardiac output status. Hemodynamic fluctuations associated with anaesthesia can be detrimental in these patients. A clear intraoperative plan should be designed to manage the hemodynamics of these patients. Here we report two cases of ischemic heart disease with low ejection fraction posted for orthopedic surgeries. Graded epidural anaesthesia was used as a sole anaesthetic technique. The patients were hemodynamically stable in the intraoperative as well as postoperative period. Keywords: Ischemic heart disease, Low Left Ventricular Ejection Fraction, Graded Epidural Anaesthesia, Cemented modular hemiarthroplasty, PFNA2.