Neuraxial Techniques Research Articles

Cystic fibrosis in children: A pediatric anesthesiologist's perspective.

Cystic fibrosis is a multi-systemic disease of impaired sodium and chloride transport across epithelial surfaces. Cystic fibrosis is one of the most common autosomal recessive diseases among Caucasian children. However, recent epidemiologic studies suggest that the disease in Hispanic, African American, and Asian American populations may be more common than previously recognized. The phenotypic expression is characterized by the constellation of pulmonary, pancreatic, hepatobiliary, and gastrointestinal dysfunction. Progressive obstructive lung disease is the hallmark of cystic fibrosis, and end-stage respiratory failure is the primary cause of morbidity and mortality. The most significant advance in the care has been the development of cystic fibrosis modulators, a class of drugs that restore cystic fibrosis transmembrane conductance regulator folding, intracellular processing, or function. Improved diagnostic abilities, a multidisciplinary approach to medical management, and the use of cystic fibrosis modulators have led to improvement in the quality of life and life expectancy. These patients undergo range of procedures such as nasal polypectomy, placement of gastrostomy tubes, vascular access device placement, transbronchial lung biopsies, and other thoracic surgeries. The anesthetic care of children with advanced cystic fibrosis disease is complex. Preoperative optimization can help improve postoperative outcomes. Strategies for pain control should rely on non-opiate, multimodal adjuncts, and regional or neuraxial techniques. Unfortunately for some children, a progressive respiratory disease often leads to end-stage respiratory failure and lung transplant surgery remains the only viable treatment option. Widespread use of lung transplant surgery as a treatment option is severely constraint by donor organ availability. Primary graft dysfunction is the most common cause of early death and can be seen within 48h of surgery. Median long-term survival after lung transplant remains modest. Chronic lung allograft dysfunction, opportunistic infections, and post-transplant lymphoproliferative disorder are the most common causes of morbidity and mortality among long-term survivors.

Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review.

Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.

Dura-to-Spinal Cord Distance at Different Vertebral Levels in Indian Children

Background:Neuraxial techniques provide good postoperative analgesia for painful procedures in the pediatric population. However, any injury to the spinal cord can lead to irreversible long-term effects.Aims:We aimed to evaluate dura-to-cord (DTC) distance from computerized tomography (CT) images of thoracolumbar spine in pediatric age group (1–16 years) at T8–9, T9–10, and L1–2 interspaces to identify the safe space for epidural insertion in Asian children.Settings and Design:It was a retrospective study including 141 children aged 1–16 years who underwent routine CT scan of the thoracolumbar region for unrelated diagnostic indications.Materials and Methods:Patients with spinal abnormalities were excluded. Sagittal CT images of the thoracolumbar spine were obtained to calculate the DTC at T8–9, T9–10, and L1–2 interspaces. The measurements at all levels were obtained perpendicular to the long axis of the vertebral body.Statistical Analysis Used:Continuous data were depicted as mean with standard deviations. The categorical data were presented as counts with percentages.Results:The mean DTC distance at T8–9, T9–10, and L1–2 interspaces was 3.51 ± 0.98 mm (95% confidence interval [CI]: 3.35–3.67), 2.73 ± 0.94 mm (95% CI: 2.57–2.89), and 2.83 ± 1.08 mm (95% CI: 2.66–3.02), respectively. A significant difference was found between the genders at T9–10 (P = 0.02) and L1–2 levels (P = 0.04). No difference in DTC was found in toddlers, preschool children, school-going children, and adolescents. DTC at T8–9 showed a significant correlation with age (R2 = 0.0479; P = 0.04), weight (R2 = 0.038; P = 0.02), and height (R2 = 0.037; P = 0.03).Conclusion:Thoracic epidural space can be used in children and adolescents for epidural catheter placement. T8–9 level showed maximum DTC distance and significant correlation with age, height, and weight in CT imaging in the present study.

Neuraxial anesthesia for a laboring patient with hereditary spastic paraplegia: A case report

Hereditary spastic paraplegia (HSP) is a rare, inherited condition affecting the corticospinal tract, typically characterized by bilateral lower extremity weakness and stiffness. HSP presents challenges to anesthetic management, particularly in the obstetric population due to the paucity of existing recommendations in the literature. Although case reports exist regarding the successful use of general and neuraxial anesthesia for cesarean section, none currently exist with regard to labor analgesia. Here, we report the use of labor epidural anesthesia in a 29-year-old woman with HSP. She delivered via cesarean delivery after laboring for 27 h with an epidural catheter in place. The patient tolerated epidural placement well with no adverse neurologic sequelae. The utilization of neuraxial techniques avoids the risks associated with airway manipulation in a parturient and obviates the need for the use of muscle relaxants in the setting of upper motor neuron disease. Epidural anesthesia appears to be a safe approach to the management of labor and cesarean delivery in a parturient with HSP.

Perioperative anesthetic challenges in Alkaptonuria patient with comorbid conditions

Dear Editor, Alkaptonuria (AKU) is a rare autosomal-recessive inborn error of tyrosine metabolism which is a progressive debilitating disease and symptomatic around 30 years of age. In AKU, patient lacks enzyme required to breakdown homogentisic acid and on exposure to air complains of “black nappies.” Deposition of the onchronosis pigment in the large joints and spine causes joint destruction. In addition, there is involvement of airway, respiratory, renal, cardiac and coagulation system.[1] A 56-year-old man with AKU, G6PD deficiency, hypothyroidism, and hypertension, was scheduled for unilateral total knee arthroplasty. He was receiving levo-thyroxine 50 μg and amlodipine 5 μg once a day (OD). Over a span of 13 years the patient underwent multiple surgeries including lumbar thoracic, cervical fixation and, open cholecystectomy under general anesthesia. Neurological examination revealed hyperreflexia and spasticity in the lower limbs with decreased sensation over S1 dermatome. Airway examination revealed mouth opening of 5 cm, thyromental distance of 5.5 cm, limited neck extension (<10°), and a Mallampati class IV. Rest all investigations were normal. Patient was kept nil per oral prior to surgery and amlodipine and levo-thyroxine on the day of surgery. In the operating theatre, an 18 G intravenous line was secured, mandatory monitoring was attached and a difficult airway cart was kept ready. Patient was asked to self-position on the operation table. Following pre-oxygenation, IV fentanyl 2 μg/kg and propofol 2 mg/kg were administered. After loss of eyelash reflex, a check laryngoscopy was done with video-laryngoscope C-MAC® (Karl Storz, Germany) using a D-Blade which revealed a POGO of 75% with a granular deposit over the left posterior arytenoid, which adequate glottic chink. Vecuronium bromide 0.1 mg/kg was administered and trachea was intubated with 8.5 mm ID. Anesthesia was maintained with nitrous in oxygen, propofol infusion at 50-100 μg/kg/min, and intermittent boluses of vecuronium. At the end of surgery, an ultrasound-guided continuous femoral nerve block with 0.2% ropivacaine 15 ml bolus was performed followed by infusion of ropivacaine 0.2% with fentanyl 2 μg/ml. The surgery lasted for 2 h and vitals were stable during the entire period. 1.5 L of crystalloids were infused. Muscle paralysis was reversed. Black discolouration of heat and moisture exchanger as seen in this patient [Figure 1]. Trachea was extubated and the patient had an uneventful postoperative period.Figure 1: Black discolouration of heat and moisture exchanger in this patientCaring for a patient with AKU ochronosis with multiple comorbidities is challenging. Deposition of HGA in the cartilage of the airway and respiratory system can result in glottic stenosis leading to difficult airway management.[2] HGA deposits also make the dura and the arachnoid membrane vulnerable, therefore central neuraxial techniques were not preferred in the present case.[3] Drug-related precautions were observed for G6PD deficiency.[4] The learning points in this case is the preparedness for anticipated difficult airway, multimodal analgesia and good coordination with orthopedic team for perioperative management. Use of VL with shorter learning curve has changed the management in patients with difficult airway.[56] Since there is no approved treatment for AKU, with every repeated surgery these patients have progressively increasing anaesthetic challenges necessitating meticulous anesthetic management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

NEW CONCEPT OF FUSION TECHNICS IN REGIONAL ANESTHESIA.

The aim of this review article is to introduce a newer approach to multimodal anesthesia. In addition to the usual combination of epidural catheter and general anesthesia as standard techniques in surgical procedures accompanied by intense postoperative pain, we want to encourage reflection on the application of various regional techniques in equally complex surgical conditions. By simply modifying the standard neuraxial technique with a higher thoracic approach, excellent abdominal surgery can be performed to awake the patient. However, placement of an epidural catheter is not always possible due to technical difficulties or patient-related conditions that contraindicate its insertion. Trunk-level fascia blocks (PVB, ESPB, RLB) are simple, safe alternative to an epidural catheter because the transverse process, which is the target of ultrasound, is easily visualized and the injection site is away from neuroaxis, pleura, and large vascular structures. In addition, extensive craniocaudal diffusion of anesthetics allows wide coverage with a single injection. It has been confirmed that PVB, ESPB, RLB blocks act on visceral and somatic pain. Therefore, their ultrasound-guided use in laparoscopic and other abdominal surgeries may be useful. With a well-designed fusion of regional techniques in operations of the upper and lower abdomen, it is possible to achieve hemodynamically and respiratory stable anesthesia in an awake patient with reduced postoperative pain.

Anesthesia Management in Caesarean Section with Preeclampsia and Partial HELLP Syndrome

Introduction. Pre-eclampsia is a significant cause of maternal and fetal mortality and morbidity. Pre-eclampsia is characterized by hypertension (blood pressure ≥ 140/90 mmHg), oedema and amount of protein in urine 300 mg in the 24-hour, which appears after 20 weeks of gestation. Pre-eclampsia can cause complications, one of which is HELLP syndrome. This case report discusses the use of anaesthesia in a patient who underwent a cesarean section with indications for pre-eclampsia and partial HELLP syndrome.&#x0D; Case Presentation. A woman, 41 years old, G4P3A0 34 weeks pregnant with pre-eclampsia + syndrome HELLP will undergo emergency cesarean section with ASA IIE physical statusLabouror pain management was carried out using regional spinal anaesthesia technique, using bupivacaine 0.5% hyperbaric agent 12.5 mg. The operation lasted for 1 hour 30 minutes, with 300 ml bleeding, hemodynamically stable.&#x0D; Conclusion. Difficult intubation in emergency cases can be avoided by choosing of neuraxial anaesthesia technique is recommended. It will lead to better uteroplacental perfusion, good analgesia/anaesthesia quality, reducing surgical stress, reducing drugs that enter the uteroplacental circulation, and maternal psychological to be able to see the baby at birth.

Anesthetic management of placenta accreta spectrum at an academic center and a comparison of the combined spinal epidural with the double catheter technique: A retrospective study

Study objectivesTo describe the anesthetic management and outcomes of placenta accreta spectrum (PAS) cases at our institution over a 19 year period and to compare outcomes associated with the lumbar combined spinal epidural (CSE) technique versus the double catheter technique (lumbar CSE with thoracic epidural catheter). DesignRetrospective cohort study. SettingLabor and delivery unit at a tertiary care center. Patients113 female patients who had histologically confirmed PAS on the final pathology report after cesarean delivery or cesarean hysterectomy. InterventionNeuraxial anesthesia, including CSE and the double catheter technique, and general anesthesia for PAS cases (including scheduled and unscheduled cases and those known or unknown as PAS preoperatively). MeasurementsThe medical records were reviewed for demographic information, intraoperative management, anesthetic technique, and outcomes. We describe anesthetic management and outcomes of cases classified as scheduled vs. unscheduled and known vs. unknown PAS. We also compare the CSE and double catheter techniques with the primary outcome being conversion to general anesthesia (GA). Main resultsWe included 113 cases: 60 (53.1%) scheduled/known cases, 12 (10.6%), scheduled/unknown cases, 22 (19.5%) unscheduled/known, and 19 (16.8%) unscheduled/unknown cases. All scheduled cases except two were started with a neuraxial technique. General anesthesia (GA) was used to start 18/41 (44%) of unscheduled cases. The double catheter technique (n = 35) was associated with a lower GA conversion rate (5.7% vs. 29.7%, P = 0.036) compared to the CSE technique (n = 37). ConclusionsNeuraxial anesthesia is the most commonly used technique for PAS cases in our practice. The double catheter technique was associated with lower GA conversion rates compared to the CSE technique in our cohort.

Preprocedural ultrasound for neuraxial blockade in nonobstetric patients. Should it be considered as a standard of care?

Preprocedural ultrasound for neuraxial blockade in nonobstetric patients. Should it be considered as a standard of care?

Regional Anesthesia for Labor, Operative Vaginal Delivery and Cesarean Delivery: A Narrative Review

(Anaesthesia. 2021;76(suppl 1):136–147) Intrapartum and postpartum pain management is important to recovery from childbirth regardless of mode of delivery. While multimodal analgesia is often the first choice in cesarean delivery (CD), it may not always be suitable for all patients. As the availability of ultrasound grows, regional anesthesia may play a larger role in obstetric anesthesia. This narrative review aims to describe the current clinical applicability of regional nerve blocks for intrapartum analgesia for and recovery following CD. When possible, intrapartum nerve blocks are compared with placebo, systemic opioids and neuraxial techniques. Comparisons are made in terms of opioid consumption, pain scores, time to first analgesic use, quality of recovery scores, and incidence of adverse events.

Neuraxial and Peripheral Misconnection Events Leading to Wrong-route Medication Errors: A Comprehensive Literature Review

(Reg Anesth Pain Med. 2021;46:176–181) Neuraxial and peripheral anesthetic techniques are used in a variety of perioperative and peripartum settings. Opportunities for misconnection and drug administration errors occur, which can negatively and substantially impact patient morbidity and mortality. In addition, they create financial burdens on patients and hospitals. The aim of this narrative review is to identify and characterize misconnection errors and motivate organizations to mitigate them.

Analgesic considerations for induction of labor.

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.

Anesthetic considerations in lung transplantation: past, present and future

Lung transplantation is a very complex surgical procedure with many implications for the anesthetic care of these patients. Comprehensive preoperative evaluation is an important component of the transplant evaluation as it informs many of the decisions made perioperatively to manage these complex patients effectively and appropriately. These decisions may involve pre-emptive actions like pre-habilitation and nutrition optimization of these patients before they arrive for their transplant procedure. Appropriate airway and ventilation management of these patients needs to be performed in a manner that provides an optimal operating conditions and protection from ventilatory injury of these fragile post-transplant lungs. Pain management can be challenging and should be managed in a multi-modal fashion with or without the use of an epidural catheter while recognizing the risk of neuraxial technique in patients who will possibly be systemically anticoagulated. Complex monitoring is required for these patients involving both invasive and non-invasive including the use of transesophageal echocardiography (TEE) and continuous cardiac output monitoring. Management of the patient’s hemodynamics can be challenging and involves managing the systemic and pulmonary vascular systems. Some patients may require extra-corporeal lung support as a planned part of the procedure or as a rescue technique and centers need to be proficient in instituting and managing this sophisticated method of hemodynamic support.

Efficacy of serratus anterior plane block versus thoracic paravertebral block for postoperative analgesia after breast cancer surgery - a randomized trial

BackgroundBreast cancer surgery is associated with considerable acute post-surgical pain and restricted mobility. Various regional and neuraxial anesthesia techniques have been used to alleviate post-mastectomy pain. Ultrasound-guided serratus anterior plane block (SAPB) has been considered a simple and safe technique. This randomized control study was performed to compare the efficacy of SAPB with the thoracic paravertebral block (TPVB) for postoperative analgesia after breast cancer surgery. MethodsA total of 40 adult ASA physical status I - II female patients undergoing radical mastectomy were randomly allocated into two groups to receive either ultrasound-guided TPVB or SAPB with 0.4 mL.kg-1 0.5% ropivacaine, 30 min before surgery. All patients received standardized general anesthesia for surgery. Injection diclofenac and tramadol were used for postoperative rescue analgesia. The time to first rescue analgesia, total analgesic consumption in the first 24 hours, postoperative pain scores, and any adverse effects were recorded. ResultsThe time to first rescue analgesia was significantly longer in the SAPB group (255.3 ± 47.8 min) as compared with the TPVB group (146.8 ± 30.4 min) (p < 0.001). Total diclofenac consumption in 24 hours was also less in the SAPB group (138.8 ± 44.0 mg vs 210.0 ± 39.2 mg in SAPB and TPVB group respectively, p < 0.001). Postoperative pain scores were significantly lower in the SAPB group as compared with TPVB group (p < 0.05). The incidence of PONV was also less in the SAPB group (p = 0.028). No block-related adverse effects were reported. ConclusionWe found that the serratus anterior plane block was more effective than the thoracic paravertebral block for postoperative analgesia after breast cancer surgery.

Assessing the duration of obstetric analgesia and the time elapsed between analgesia and delivery. Observational trial

Introduction: The duration of labor and the immediate puerperium are affected by obstetric and maternal-fetal factors. Interventions to provide obstetric analgesia may prolong the hospital stay.&#x0D; Objective: To characterize the procedure for obstetric analgesia and describe the time elapsed between analgesia and delivery and postpartum surveillance in healthy mothers.&#x0D; Methods: Observational, descriptive trial. The time elapsed between analgesia and delivery, and postpartum surveillance were measured in healthy pregnant women with vaginal delivery and a prescription of a neuraxial analgesia technique.&#x0D; Results: 226 patients were included. The mean time elapsed between analgesia an delivery was 4 hours (IQR 3-7). 50.7 % (n = 114) received early analgesia (neuraxial technique with ≤ 4 centimeters of cervical dilatation), of which 48.2 % (n = 109) experienced a duration of analgesia until delivery longer than expected. The mean cervical dilatation at the time of the neuraxial approach was 4 centimeters (IQR 4-6) and the epidural technique was the most frequently used – 92.9 % (n = 210). The mean postpartum surveillance was 20 hours (IQR 15-27).&#x0D; Conclusions: Half of the patients included received early analgesia and around fifty percent of them took longer than expected in completing delivery. The postpartum surveillance time was consistent with the provisions of the Ministry of Health and with the current trend of a short postpartum surveillance aimed at early hospital discharge and the benefits thereof.

The trends of obstetric anesthesia practice: In a tertiary care center in the Kingdom of Saudi Arabia.

Introduction:Obstetric anesthesia provides several methods for the analgesia of labor pain. The neuraxial technique is considered the standard of care for parturient women. The epidural block is widely used in vaginal delivery while the spinal block is the preferred method for cesarean section (C-section). We aim to know the practice of obstetric anesthesia in our center.Methods:A retrospective cross-sectional study was conducted at a tertiary center in Riyadh, Saudi Arabia. The data of all delivery cases from 1/7/2019 to 30/9/2019 were reviewed.Results:We identified a total of 2,140 cases during the 3 months, vaginal delivery was the most common with 72.4% (1550) while the C-section cases were 27.6% (590). Regarding the type of analgesia/anesthesia for vaginal deliveries, intramuscular analgesia was the commonest group with 34.8% (540), followed by the group of ladies who did not receive any analgesia/anesthesia with 31.9% (495), thirdly was epidural cases with 31.8% (493), and the fourth type was spinal 0.6% (10). Regarding C-section, the emergency cases were 65.4% (386). The types of anesthesia for all C-sections were as follows spinal 63.5% (375), GA 23.8% (141), and epidural 12% (74). Regarding anesthesia for elective cases, spinal was 85% (174), GA 14% (28), and epidural 1% (2). Regarding anesthesia for emergency cases, spinal was 52% (201), GA 29% (113), and epidural 19% (72).Conclusions:The use of epidural was low, and the spinal use was relatively on par if we compare with leading western countries. More focused studies and multicenter studies are needed in the country.

Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease.

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.

What's New in Neuraxial Labor Analgesia.

Purpose of ReviewThis article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed.Recent FindingsThere has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia.SummaryNeuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.

Ein deutsch-deutsches Schicksal: Heinz Ruppert – ein in Vergessenheit geratener Pionier der Periduralanästhesie und der letzte Schiffsarzt der PAMIR

In the fall of 1957 there was amomentous ship disaster, during which the four-masted barque PAMIR sank in the Hurricane Carrie northwest of the Azores and 80crew members were killed. Among the crew members killed was the ship's doctor Dr. med. Heinz Ruppert, aspecialist in anesthesiology, gynecology and obstetrics from the University Women's Hospital of the Charité in East Berlin. Since he was also aspecialist in anaesthesiology he was primarily responsible for the anaesthesiological care of patients at the University Women's Hospital at the Charité. As an avid supporter of neuraxial conduction anaesthesia techniques, he primarily worked on this topic scientifically and tried to establish peridural anaesthesia in obstetrics. In 1954 he was able to habilitate at the Charité with athesis on this subject and was appointed as lecturer. His scientific oeuvre has so far not been appreciated, areason to remember this forgotten German protagonist of gynecological obstetric anaesthesia.

Rectus Sheath Catheters versus Thoracic Epidural Analgesia for Elective Open Abdominal Aortic Aneurysm Repair: A New Dawn?

Thoracic epidural analgesia (TEA) is the gold standard for analgesia in elective open abdominal aortic aneurysm (AAA) repair. However, there is limited evidence for alternative methods of analgesia. Rectus sheath catheters (RSCs) have been shown to be noninferior to TEA in colorectal surgery and could provide an alternative to epidurals in elective AAA repair. RSCs are associated with fewer adverse effects and may be used when neuraxial techniques are difficult or contraindicated. We sought to compare the outcomes of patients undergoing elective open AAA repairs who received TEA or RSC at a tertiary vascular center, which carries out approximately 60 elective open AAA repairs per year.