Pencil-point Spinal Needles Research Articles

The Effect of Spinal Needle Type on Post-Dural Puncture Headache in Spinal Anesthesia: Prospective Randomized Study.

Postdural puncture headache is a headache that occurs after a dura puncture, especially in caesarean sections, and afects patient comfort and mobilization. In this study, we compared the efects of pencil-tipped spinal needles and especially curved, bilateral atraumatic spinal needles in individuals undergoing elective caesarean sections. A total of 886 patients, aged 20-50 years, who had cesarean sections with spinal anesthesia and had American Society of Anesthesiologists II and III scores, were included in the study. The patients were allocated into 3 groups using the closed envelope randomization technique: Group 1 (n=250) received spinal insertions using 25-gauge pencil-point needles; Group 2 (n=245) received spinal insertions using 26-gauge atraumatic needles; and Group 3 (n=250) received spinal insertions using 27-gauge pencil-point needles. Records were kept of the quantity of spinal needle referrals, the type of treatment, the length of hospital stays, and complications. In the study, 745 patients who had cesarean section operations under spinal anesthesia were further analyzed. The mean incidence of post-dural puncture headache (PDPH) was 3.2% (n=24). The incidence of PDPH was higher in group 2 than in group 3 and group 1 (Group 1: 2.8%; Group 2: 6.8%; Group 3: 0%) (P <0.05). Among other complications, low back, back, shoulder, and surgical complications were similar for all 3 groups. In caesarean section operations, pencil-point spinal needles were found to have a lower incidence of postdural puncture headache than Atraucan-cut needles, regardless of needle thickness.

Study to compare the incidence of post-dural puncture headache in obstetric patients using cutting and pencil-point spinal needle in spinal anesthesia

Background: Spinal anesthesia is one of the most commonly used regional anesthesia techniques. Post-dural puncture headache (PDPH) is a well-known iatrogenic consequence of spinal anesthetic and diagnostic lumbar puncture, primarily caused by loss of cerebral spinal fluid. To reduce complications, spinal needles have undergone modifications. The two most important modifiable risk variables for PDPH were needle shape and size. In young expecting mothers, post-cesarean sections are associated with an increased incidence of PDPH. Aims and Objectives: The aims and objectives of the study are to compare the incidence of PDPH in obstetric patients using cutting and pencil-point spinal needles following spinal anesthesia. Materials and Methods: This 1-year double-blind study was carried out in the Department of Anaesthesia from August 2021 to July 2022. The study comprised obstetric patients who were scheduled for elective-segment cesarean section. The subarachnoid block needle was divided into Groups A and B at random: Group A 25-gauge Whitacre spinal needle with a pencil point, whereas Group B 25-gauge Quincke spinal needle with a cutting bevel. Records were kept on age, height, weight, and gestational age. A follow-up was conducted up until the discharge date. The incidence and severity of PDPH after spinal anesthesia were examined in both groups. The results were analyzed with SPSS 20.0, and the Fischer exact and Chi-square tests were used to look for statistical significance. Results: The current study included 120 patients in total, 60 patients in each of Groups A and B. When a pencil point Whitacre was used, the incidence of PDPH was 2 (3.3%), however, when a cutting Quincke needle was used, the incidence was 7 (10.8%). With a P &lt; 0.05, the relationship between the two was considered statistically significant. The pain severity was mild in both patients of Group A. Of the seven patients in Group B, four had mild pain, two had moderate pain, and one had severe pain. Conclusion: The pencil-point 25-G Whitacre spinal needle has a lower incidence of PDPH than the traditional 25-G Quincke needle and was suggested for patients at risk of PDPH. In light of this, the current study suggested using pencil-point spinal needles for lumbar punctures and spinal anesthesia in obstetric patients.

EE92 Economic Impact of Pencil Point Spinal Needles Versus Conventional Cutting Needles on Postdural Puncture Headache

Postdural puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic, or inadvertent lumbar punctures. Compared to conventional cutting or beveled spinal needles, pencil point spinal needles have been conclusively proven to reduce the incidence of PDPH, but their potential economic benefit is not well-known. A customizable cost calculator was created to assess the impact of adopting pencil point spinal (atraumatic) needles over conventional cutting (traumatic) needles.

TEN-YEAR FOLLOW-UP OF QUALITY IN REGIONAL ANESTHESIA AND ANALGESIA IN OBSTETRICS OBSTETRIC REGIONAL ANESTHESIA: IMPROVING QUALITY.

Quality assessment of provided healthcare is becoming a standard in numerous health institutions worldwide, which is beneficial for both the patient and the institution. In order to achieve this standard, it is necessary to develop quality indicators in all segments of healthcare. Postdural puncture headache is a common complication following neuraxial blocks, especially in obstetric anesthesia. If severe, it is a cause of emotional and psychological distress and must be treated by a blood patch. The aim of this study was to determine whether the number of these complications is reduced when blood patch frequency is monitored and analyzed and to assess the effect of countermeasures in order to improve the quality and safety of regional anesthesia in obstetrics. Before 2009 and during that year at the University Hospital Sveti Duh, there had been a large number of severe postdural puncture headaches after spinal anesthesia and epidural analgesia treated by a blood patch in 6.12% of cases. After noticing the rising number of blood patches, we decided to analyses data every year. We recorded all blood patches injected to obstetric patients within the period of nine year, from 2009 to 2018 and concurrently we introduced a set of measures to improve the quality of neuraxial blocks, such as the use of atraumatic 26 or 27-gauge pencil-point spinal needles and modern neuraxial blockade protocols. Data were collected from anesthesiology and gynecology protocols and analyzed with MedCalc software, version 18.1.2. The frequency of blood patch applications has been reduced from 6.12% to 0.30%, which is statistically significant. The percentage of placed epidural catheters for vaginal birth increased from 21% in 2009 to 38% in 2018. Although not statistically significant, the number of pregnant women undergoing a caesarean section is also growing, while the total number of births is falling. The proportion of cesarean sections in spinal anesthesia varies from year to year. A statistically significant decrease in the number of installed blood patches clearly indicates the positive effect of measures taken to improve quality, which could contribute to the growing interest of pregnant women in childbirth in epidural analgesia. The number of placed epidural catheters is increasing despite the decline in the total number of deliveries and the increase in the number of deliveries completed by cesarean section. Monitoring the incidence of severe post-puncture headaches treated with blood patches has shown great progress in improving the quality and safety of regional anesthesia and analgesia in our institution, so we believe that monitoring the number of blood patches could serve as an indicator of regional anesthesia and analgesia in obstetrics. Monitoring the number of blood patches shows that the frequency of post-puncture headaches does not correlate only with the type of needle or epidural catheter used for neuroaxial blocks, but is also a sensitive indicator of any deviations from the achieved standards. Furthermore, it indicates the need for careful analysis of causes in order to adopt and implement appropriate countermeasures.

Spinal arachnoid sleeves and their possible causative role in cauda equina syndrome and transient radicular irritation syndrome.

We have previously described arachnoid sleeves around cauda equina nerve roots, but at that time we did not determine whether injections could be performed within those sleeves. The purpose of this observational study was to establish whether the entire distal orifice of a spinal needle can be accommodated within an arachnoid sleeve. We carefully dissected the entire dural sacs off four fresh cadavers, opened them by longitudinal incision, and immersed them in saline. Under direct vision, we penetrated the cauda equina roots nerves traveling almost vertically downward at 30 locations each with a 27- and a 25-G pencil-point needle (60 punctures total). We captured the images with a stereoscopic camera. The nerve root offered no noticeable resistance to needle entry. Although the arachnoid sleeves could not be identified with the naked eye, they were translucent but visible under microscopy. In 21 of 30 attempts with a 27-gauge needle, and in 20 of 30 attempts with a 25-gauge needle, the distal orifice of the spinal needle was completely within the arachnoid sleeve. It seems possible to accommodate the distal orifice of a 25- or a 27-gauge pencil-point spinal needle completely within the space of the arachnoid sleeve. An injection within this sleeve could potentially lead to a neurological syndrome, as we have previously proposed.

Modern anesthesia in obstetrics as a component of the concept of safe anesthesia

Background. Anesthesia should be selected individually for each labor. Systemic analgesia of labor includes suggestive analgesia, narcotic analgesics, local infiltration and regional blockade, inhalation analgesia. It should be noted that there is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus in any way.&#x0D; Objective. To describe modern anesthesia in obstetrics.&#x0D; Materials and methods. Analysis of literature sources on this issue.&#x0D; Results and discussion. Three groups of antispasmodics are used for analgesia: neurotropic (atropine, scopolamine), myotropic (papaverine, drotaverine) and neuromyotropic (baralgin). The main non-steroidal anti-inflammatory drugs used for this purpose include metamizole sodium, ketorolac tromethamine, diclofenac sodium. Inhalation autoanalgesia with nitrous oxide (N2O) is effective only in 30-50 % of women. When the concentration of N2O exceeds 50 %, the sedative effect increases and oxygenation decreases, which leads to the loss of consciousness and protective laryngeal reflexes. Such analgesia is indicated for low-risk patients who have refused from regional anesthesia. Epidural anesthesia (EDA) is the gold standard of labor anesthesia. The advantages of EDA include the option to change the degree of analgesia, the ability to continue pain relief until the end of labor and the minimal impact on the condition of both child and mother. Before manipulation, be sure to determine the platelet count and heart rate of the fetus. It is recommended to start EDA in the latent stage of labor. In patients with uterine scarring, early EDA is a mandatory component of medical care. The woman’s wish is the main indication for EDA. Indications for early catheterization of the epidural space include the presence of twins, preeclampsia, obesity, respiratory tract with special features. Headache is the most common complication of EDA. The use of pencil-point spinal needles minimizes the frequency of this complication. Adequate analgesia for uncomplicated labor should be performed with minimal concentrations of anesthetics with the least possible motor block. Local anesthetics (lidocaine, bupivacaine (Longocaine, “Yuria-Pharm”), ropivacaine) are used for EDA). Combined spinal-epidural anesthesia provides a rapid effect and long-term analgesia. For this purpose, 0.25 % Longocaine heavy (“Yuria-Pharm”) 2 mg and fentanyl 20 μg are administered intrathecally, followed by 0.225 % Longocaine 10 mg and fentanyl 20 μg epidurally. The technique of epidural dural puncture is a modification of combined spinal-epidural anesthesia. This technique improves the caudal spread of analgesia compared to the epidural technique without the side effects seen with spinal-epidural anesthesia. The ideal local anesthetic should be safe for both mother and fetus, provide sufficient analgesia with minimal motor block, and not affect labor process. A single spinal injection of opioids may be effective, but it should be limited in time. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance compared to basic regional anesthesia. Catheter techniques can be used in case of the increased labor duration. Nalbuphine (“Yuria-Pharm”), which eliminates the side effects of regional anesthesia, can also be successfully used. Analgesic effect of paracetamol (Infulgan, “Yuria-Pharm”) in case of intravenous administration exceeds the analgetic effect of tramadol, and the effect on the newborn condition according to the Apgar scale does not differ (Meenakshi et al., 2015). Paracetamol (Infulgan) is moderately effective for perineal pain on the first day after delivery. The possibility of use during lactation is an another advantage of paracetamol.&#x0D; Conclusions. 1. Pain during labor is an extremely stressful factor, so women should have access to quality analgesia and anesthesia. 2. There is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus. 3. EDA is the gold standard of labor anesthesia. 4. Combined spinal-epidural anesthesia provides rapid effect and long-term analgesia. 5. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance. 6. Nalbuphine and Infulgan have been used successfully for labor pain relief.

Ultrasound increases the success rate of spinal needle placement through the epidural needle during combined spinal-epidural anaesthesia: A randomised controlled study.

Combined spinal-epidural anaesthesia (CSEA) using a needle-through-needle technique is currently widely used. However, successful epidural needle placement does not mean a successful spinal needle placement during CSEA. Whether ultrasound assistance could increase the first-pass success rate of spinal needle placement for CSEA remains unknown. The aim of this study was to investigate if ultrasound assistance could increase the first-pass success rate of spinal needle placement through the epidural needle during CSEA performed by experienced anaesthesiologists in patients undergoing caesarean section. A prospective, randomised, double-blind study. Single centre, Department of Anaesthesiology, Shengjing Hospital, China Medical University, China, from June 2019 to September 2019. A total of 185 patients (aged 24 years to 52 years, American Society of Anesthesiologists grade (ASA) II-III, 38 to 40 weeks gestation) scheduled to undergo elective caesarean section under CSEA were enrolled. The patients were randomised to either an ultrasound group (patients received a preprocedural ultrasound scan, and the puncture site was identified by ultrasound imaging) and a palpation group (patients received a sham procedural ultrasound scan, and the puncture site was identified by conventional palpation). The primary outcome measure was the first-pass success rate for spinal needle placement through the epidural needle. Secondary outcome measures were total duration of CSEA, time required for successful epidural needle and spinal needle placement, number of epidural needle redirections and complications. Preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle compared with conventional palpation (93.8 vs. 68.8%, P < 0.001). Preprocedural ultrasound imaging also decreased the total duration of CSEA (186.9 ± 37.1 vs. 213 ± 60.4 s, P = 0.0015) and the time required for successful spinal needle placement (78.3 ± 22.9 vs. 100.1 ± 53.7 s, P < 0.01) compared with conventional palpation. Fewer patients in the ultrasound group needed epidural needle redirections during the spinal needle placement procedure than in the palpation group (four patients vs. 20 patients, P < 0.01). For experienced anaesthesiologists, preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle for obstetric patients undergoing caesarean section under CSEA. chictr.org.cn, identifier: ChiCTR1900024132.

Dural Puncture Epidural Analgesia for Labor: A Randomized Comparison Between 25 and 27 G Pencil Point Spinal Needles

(Reg Anesth Pain Med. 2019;44:750–753) Dural puncture epidural analgesia (DPEA) is the technique of passing a small gauge spinal needle through a Tuohy needle located in the epidural space to create a hole in the dura. Following the creation of this hole, the spinal needle is withdrawn without injection of intrathecal medication, and a catheter is placed within the epidural space. DPEA performed with 25 and 26 G pencil point spinal needles have demonstrated shorter onset time and improved sacral blockade compared with the traditional epidural technique; however, a large prospective trial demonstrated an increased incidence of postdural puncture headache (PDPH) after using a 25 G compared with a 27 G needle. Thus, the goal of this study was to compare DPEA using 25 and 27 G pencil point spinal needles. The primary outcome was onset time, which was defined as the temporal interval required after catheter placement to obtain a pain score ≤1 using a 0 to 10 Numeric Rating Scale.

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

BackgroundThis double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar...

Effects of 0.5% heavy bupivacaine at room versus body temperature on shivering and analgesia after spinal anesthesia in patients undergoing cesarean section

Background: Shivering is an undesirable, unpleasant experience after spinal anesthesia. Injecting cold bupivacaine has been incriminated as a contributory factor. Aims and Objective: In this prospective study we evaluated the efficacy of warming the heavy bupivacaine to body temperature for prevention of shivering and if it influences analgesic quality of spinal anesthesia. Materials and Methods: In this double blind, randomized controlled study, 100 patients aged 20-35 years of American Society of Anesthesiologist physical status I and II undergoing elective or emergency Caesarean sections were included and allocated to either Room temperature group (RT Group, n= 50), or Body temperature group (BT group, n = 50). A standard spinal anesthetic of 2ml of 0.5 % heavy bupivacaine plus 20 microgram of fentanyl was administered using 25G pencil point spinal needle in the sitting position. Besides the incidence and intensity of shivering and effect on intraoperative analgesia, effect on hemodynamics, nausea, vomiting, blood loss, pruritis and Apgar scores were recorded. Data was analyzed using SPSS (The Statistical Package for Social Sciences) version 22.0 software (International Business Machines Corporation, Armonk, New York, USA). P < 0.05 was considered significant. Results: The patients were comparable in terms of demographic variables. Shivering was present in 31 (62%) and 7 (14%) patients respectively in RT and BT Groups, which was statistically significant (P = 0.0001). Intensity of shivering ≥3 was observed in 15 (30%) patients of RT group and 5 (10%) patient in BT group. We did not note any difference in the analgesic status intraoperatively nor any difference in the duration of analgesia. Surprisingly, the incidence of pruritis was significantly reduced in the BT group as compared to RT group (P = 0.037). Conclusions: Warming the heavy bupivacaine to body temperature is effective in preventing shivering and reducing pruritis secondary to spinal anesthesia without affecting analgesia.

Impact of spinal needle type on postdural puncture headache among women undergoing Cesarean section surgery under spinal anesthesia: A meta-analysis.

Spinal anesthesia is the most frequently performed anesthesia for cesarean section. The American Society of Anesthesiology recommends using pencil-point spinal needles (SNs) over cutting-bevel SNs to reduce postdural puncture headache (PDPH) in their practice guidelines for obstetric anesthesia. However, there is no meta-analysis addressing the impact of the type of SNs on PDPH among women undergoing Cesarean section surgery. We conducted a systematic review and meta-analysis including randomized controlled trials comparing the incidence of PDPH of pencil-point SNs with cutting-bevel SNs in patients undergoing Cesarean section with spinal anesthesia. A comprehensive search of PubMed, Cochrane Library, EMBASE, and CINAHL without using any language and time restrictions were performed. A total of 4936 patients from 20 studies (31 comparisons) were included. Pencil-point SN leads to reduced PDPH (risk ratio [RR] 0.33, 95% confidence intervals [CI] 0.25 to 0.45) and reduced requirement of epidural blood patch (RR=0.21, 95% CI 0.09 to 0.51) compared to cutting-bevel SN. The incidence of anesthesia failure, non-PDPH, backache, and other adverse effects was not statistically significantly difference between the two SNs. Overall quality of evidence was moderate to low. Using pencil-point SN appears to be beneficial for preventing PDPH in patients undergoing Cesarean section without increasing any potential adverse effects. Further research addressing the specific gauge of pencil-point SNs, which might further reduce the incidence of PDPH is highly desired.

Postdural puncture headache: Incidence and predisposing factors in a university hospital.

Postdural puncture headache (PDPH) may occur 12-72 hours after spinal anesthesia. PDPH causes patient discomfort following spinal anesthesia and therefore it presents a challenging situation for anesthetists. This prospective randomized study enrolled 613 patients who were 18 years or older and who had been operated under spinal anesthesia. The spinal anesthesia procedure was performed with the patient in a sitting position through the L3-4, L4-5 interspaces, using 25 and 26 gauge (G) quincke and pencil-point spinal needles. The gender, age, body mass index, level of sensory block, mobilization time of the patients and also the experience and physical fatigue condition of the physicians were recorded. In the postoperative period all patients were questioned as to whether they experienced headache. These questions were repeated at postoperative 1st, 24th, 48th and 72nd hours in the hospital and on the 7th day by phone after they were discharged. Compared to older patients, patients between the ages of 25 to 40 (p<0.001) and compared to other operations, C/S patients (p: 0.003) experienced headaches more frequently in the postoperative period. The other two important factors were the experience (p: 0.013) and the physical fatigue of the physician (p: 0.001) on the day of surgery. The experience and good physical condition of the physician, TUR or anorectal surgery, a patient over 40 years of age and using pencil-point spinal.

Comparação de três agulhas diferentes usadas para raquianestesia em relação ao risco de transporte de células epiteliais escamosas

To investigate the differences in the number of squamous epithelial cells carried to the spinal canal by three different types of spinal needle tip of the same size.Patients were allocated into three groups (Group I, Group II, Group III). Spinal anesthesia was administered to Group I (n=50) using a 25G Quincke needle, to Group II (n=50) using a 25G pencil point spinal needle, and to Group III (n=50) using a non-cutting atraumatic needle with special bending. The first and third drops of cerebral spinal fluid (CSF) samples were taken from each patient and each drop was placed on a slide for cytological examination. Nucleated and non-nucleated squamous epithelial cells on the smear preparations were counted.There was statistically significant difference between the groups in respect to the number of squamous epithelial cells in the first drop (p<0.05). Group III had lower number of squamous epithelial cells in the first drop compared to that of Group I and Group II. Mean while Group I had higher number of squamous epithelial cells in the third drop compared to the other groups. The number of squamous epithelial cells in the first and third drops was statistically similar in each group respectively (p>0.05 for each group).In this study of different needle tips, it was seen that with atraumatic needle with special bending a significantly smaller number of cells were transported when compared to the Quincke tip needles, and with pencil point needles.

Pencil-point Needle Bevel Direction Influences ED50 of Isobaric Ropivacaine With Fentanyl in Spinal Anesthesia for Cesarean Delivery: A Prospective, Double-blind Sequential Allocation Study

(Int J Obstet Anesth. 2015;24:225–229) There are few studies on the effect of bevel direction on the quality of spinal anesthesia when using a pencil-point spinal needle. The authors’ clinical experience suggested a lower local anesthetic dose was needed to achieve satisfactory anesthesia for cesarean delivery (CD) when the distal aperture of a Whitacre spinal needle was oriented cephalad. Their present double-blind study used the minimum local analgesic dose model to investigate if the median effective dose (ED50) of isobaric ropivacaine for CD spinal anesthesia varied based on the distal aperture direction of a Whitacre pencil-point needle.

Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis.

Background:Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle.Methods:We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data.Results:Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001).Conclusions:Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.

A comparison of three different needles used for spinal anesthesia in terms of squamous epithelial cell transport risk

Background and objectivesTo investigate the differences in the number of squamous epithelial cells carried to the spinal canal by three different types of spinal needle tip of the same size. MethodsPatients were allocated into three groups (Group I, Group II, Group III). Spinal anesthesia was administered to Group I (n=50) using a 25G Quincke needle, to Group II (n=50) using a 25G pencil point spinal needle, and to Group III (n=50) using a non-cutting atraumatic needle with special bending. The first and third drops of cerebral spinal fluid (CSF) samples were taken from each patient and each drop was placed on a slide for cytological examination. Nucleated and non-nucleated squamous epithelial cells on the smear preparations were counted. ResultsThere was statistically significant difference between the groups in respect to the number of squamous epithelial cells in the first drop (p<0.05). Group III had lower number of squamous epithelial cells in the first drop compared to that of Group I and Group II. Mean while Group I had higher number of squamous epithelial cells in the third drop compared to the other groups. The number of squamous epithelial cells in the first and third drops was statistically similar in each group respectively (p>0.05 for each group). ConclusionsIn this study of different needle tips, it was seen that with atraumatic needle with special bending a significantly smaller number of cells were transported when compared to the Quincke tip needles, and with pencil point needles.

The Wiley Spinal Catheter-Over-Needle System for Continuous Spinal Anesthesia: A Case Series of 5 Cesarean Deliveries Complicated by Paresthesias and Headaches.

Intrathecal catheter devices using a catheter-over-needle design and softer flexible material have been introduced to clinical practice with the aim of reducing some of the complications such as postdural puncture headaches and paresthesias seen with previous versions of intrathecal catheters. We present a case series of 5 cesarean deliveries using the Wiley Spinal intrathecal system (Epimed, Johnstown, New York), which was recently approved by the US Food and Drug Administration. The intrathecal catheter system consists of a flexible 23-gauge intrathecal cannula over a 27-gauge pencil-point spinal needle. The placement of the intrathecal catheter was successful in all 5 cases; however, paresthesias in 3 cases and postdural puncture headaches in 2 cases complicated the placement and use of the device. Although the unique catheter-over-needle design facilitates the use of smaller-gauge spinal needles for dural puncture and larger-gauge catheters for medication administration, this case series using the Wiley Spinal suggests that paresthesias and postdural puncture headaches may still limit its widespread utilization. Future studies are needed to determine the true incidence of complications and to determine the role of continuous spinal anesthesia in the obstetric population.

The clinical practice of sitting position with pencil point spinal needle for spinal anesthesia in emergency cesarean section

Objective To study the effects of sitting position with pencil point spinal needle in spinal anesthesia for emergency Cesarean-section.Methods Four hundred ASA physical status of Ⅰ or Ⅱ parturients undergoing emergency cesarean section were divided randomly into four groups (100 cases each).Spinal anesthesia was performed with pencil pointed needle in sitting position in group A,or with pencil pointed needle in lateral position in group B,or with ordinary inclined plane needle in sitting position in group C,or with ordinary inclined plane needle in lateral position in group D.Spinal anesthesia was induced with 1.8 ml-2.2 ml of 5％ bupivacaine (9 mg-1 1 mg) following successful puncture.The parturients were escorted to wards when analgesia block level dissipated to T10 after operation.All patients must be in supine position for six hours.Postoperation follow-up lasted for three days.The frequency of puncture,puncture time,the rate of successful puncture,the time from skin incision to delivery.Intraoperation and postoperative complications were recorded.Results Compared with group B and D,the frequency of puncture were declined significantly in group A and C[group B(3.2±0.9) and D(4.1±0.4) vs group A(1.1±0.5) and C(1.2±0.6)],the rate of successful puncture were increased [group B (90％) and group D (92％) vs group A (100％) and group C (98％)],the time of puncture were shorter [group B (5.2±0.6) min and D (4.1±0.9) min vs group A (1.2±0.8) min and C (2.1±0.7) min],the time of performed spinal anesthesia were shorter [group B (7.1±0.5) rmin and D (6.2±0.8) min vs group A (3.4±0.7) min and C (4.3±0.6)min],the time from beginning puncture to skin incision were shorter [group B (15.2±6.3) min and D (17.1±4.4) min vs group A (10.4±0.5) min and C (11.3±0.7) min] (P＜0.05).Compared with group C and D,the rate of intraoperation hypotension were reduced in group A and B [group C(18％) and group D (20％) vs group A (8％) and group B (10％],There were no postdural puncture headache and low back pain in group A and B [group C(3％) and group D(4％) vs group A(0) and group B(0)](P＜0.05).Conclusions Spinal anesthesia with fine needle in sitting position is simple to perform and needs shorter time and fewer puncture times and has higher successful rate and fewer intraoperation and postoperation complications.It can be widely used in emergency cesarean section. Key words: Sitting position; Fine needle; Anesthesia, spinal; Cesarean-section

Laparoscopic cholecystectomy under spinal anesthesia in a patient with limb-girdle muscular dystrophy

To the Editor, A 61-yr-old gentleman with longstanding muscular dystrophy presented with acute cholecystitis and sepsis. Three months later, with a biliary drainage tube still in place, he presented for semi-elective laparoscopic cholecystectomy. This patient kindly gave consent for publication of this report. The exact type of the patient’s muscular dystrophy was unclear despite extensive workup by his neurologist; however, his presentation was most in keeping with limbgirdle muscular dystrophy Type 2A. His symptoms began at age 14 yr when he developed proximal upper arm weakness and subsequent muscle wasting. By age 50 yr, he began to develop progressive weakness and wasting of his proximal lower limbs. He is now unable to climb out of bed or climb stairs easily. His echocardiogram was unremarkable and, surprisingly, so was the result of his preoperative spirometry test. Nevertheless, his respiratory therapist noted he was quite dyspneic at the end of the spirometry testing. Limb-girdle muscular dystrophy, a class of muscular dystrophy, is a heterogeneous group of neuromuscular diseases characterized by progressive muscle weakness and atrophy of the shoulder and/or hip girdle muscles. Cardiac involvement is rare. Respiratory involvement may be present in long-standing disease. Although laparoscopic cholecystectomy is generally performed with endotracheal intubation and positive pressure ventilation, we were concerned about the ability to wean this patient from the ventilator postoperatively. Laparoscopic cholecystectomy under spinal anesthesia has been described. Sinha et al. published a retrospective review of 3,492 laparoscopic cholecystectomy procedures under spinal anesthesia. Findings included a lower incidence of nausea and vomiting and decreased intravenous analgesic requirements. Abdominal muscle relaxation was not problematic. Shoulder and neck pain occurred in 12.3% of patients. Conversion to general anesthesia was required in 0.5% of cases. Given our concerns about the potential for problematic weaning from ventilation, a discussion took place between anesthesiology and general surgery about how best to proceed. We elected to offer this patient spinal anesthesia for his procedure. Complicating this choice was a significant language barrier. His daughter offered to join us intraoperatively for translation and emotional support. Her presence was invaluable. We performed a subarachnoid block at approximately the L3/4 level with a midline approach using a 25G pencilpoint spinal needle. This was performed in the right lateral position as the patient was unable to sit due to his muscle weakness. A T4-level block was achieved using 0.75% hyperbaric bupivacaine 21 mg (2.8 mL) and fentanyl 20 lg. The patient was placed in a supine, not Trendelenburg, position to achieve this block. Invasive blood pressure monitoring was used, and blood pressure was supported throughout the surgery with a phenylephrine infusion when required. The patient complained of diaphragmatic discomfort and right shoulder pain intermittently, which was managed using a remifentanil infusion of 0.05 0.15 lg kg min, shoulder massage, and reassurance from his daughter. The surgeon also sprayed the patient’s diaphragm with 1% M. C. Chuang, MD L. V. Duggan, MD (&) R. D. van Heest, MD W. MacLeod, MD Department of Anesthesiology and Perioperative Medicine, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada e-mail: laura.duggan@fraserhealth.ca; lauraduggan@yahoo.com

The role of the direction of the pencil point spinal needle hole on the mean local anaesthetic dose

Valsamidis, D.; Stammatakis, E.; Hadzilia, S.; Saiti, A.; Leontopoulou, S. Author Information