Anaesthetic Problems Research Articles

Thoracoscopic Repair of Congenital Diaphragmatic Hernia: a Tale from Two Cities

The prolific advances of minimal invasive surgery (MIS) have made many of the complex pediatric surgical problems amenable to these procedures for more benefits. Nowadays, successful repair of congenital diaphragmatic hernia (CDH) by thoracoscopic and laparoscopic techniques is no exception. Our study aims to highlight the surgical technique, initial results, and overview the indications of thoracoscopic repair of congenital diaphragmatic hernia (CDH). A prospective study was conducted from April 2016 to March 2018 in 2 tertiary centers in Egypt. All confirmed CDH patients were assessed for the possibility of thoracoscopic repair. Oxygenation index (OI) was used to assess the severity of persistent pulmonary hypertension (PPH). It is calculated by the following equation: MAP × FiO2 × 100 ÷ PaO2. Babies having OI < 5 are considered to have mild pulmonary hypertension; thus, thoracoscopic repair was offered for them. Thirty four CDH cases met the selection criteria; therefore, they underwent thoracoscopic repair. Group 1 included 14 late-presenting CDH patients, while 20 neonatal presenting CDH were included in group 2. Conversion to open repair occurred in 5 cases, with causes related to surgical factors, and none was due to pure anesthetic problem or general deterioration during thoracoscopy. Recurrence was discovered in 1 case only. Thoracoscopic repair of CDH is safe and feasible in treatment of late-presenting CDH. However, in neonatal CDH should the patients are assessed strictly; safety and feasibility are retained, and the conversion to open surgery is minimized.

FEATURES OF PERIOPERATIVE MANAGEMENT OF PATIENTS AT LAPAROSCOPIC ANTIREFLUX INTERVENTIONS

Aim. The analyzing current available literature on the problem of anesthesiology of antireflux interventions in patients with hernias of the esophageal aperture.&#x0D; Materials and methods. Biblosemantic, comparative and systems analysis. The suggested recommendations are based on the data of contemporary literature analysis, the results of randomized trials and meta-analyzes, devoted to the study of the problem of anesthesiology of antireflux surgery.&#x0D; Results and discussion. The analyzing the problems of anesthesia and analgesia in patients with hernias of the esophageal aperture, it is necessary following next concepts: general inhalation anesthesia in laparoscopic surgery, should be taking into account the technical features of surgery, as well as, the injection and diffusion of CO2 in tissue in time of carboperitoneum, in the same time, besides that to guarantee rapid awakening of the patient without residual sedation. The possibility of developing specific late complications, as well as, ruptures of the esophagus and stomach, pneumothorax makes adjustments in the tactics of the introduction in this category of patients in the perioperative period.The choice of anesthesia method is greatly determined the length of the post-anesthetic rehabilitation period, the stay of the patient with artificial ventilation of the lungs, the need and the length of stay in the intensive care unit.&#x0D; Conclusions. Ourday the question is still remain, which of the methods of inhalation anesthesia Low flow anesthesia or Minimal flow anesthesia is better, in the case of the requirements of comfort, patient’ safety and pharmacoeconomic feasibility.The principles of accelerated rehabilitation are possible not only if the surgical invasion is reduced, but also with the use of managed general anesthesia with adequate perioperative anesthesia.The operation of the patient in time is the best method of prevention of many early and delayed complications of the postoperative period. This provision has been validated by numerous clinical trials and is rarely take into account at present.The ideology of inhaled anesthesia involves not only sufficient control over the depth of anesthesia, but also predictability at the stage of anesthesia.

Dogs Health Related to Ear Cropping

Abstract Ear cropping is a controversial subject with both supporters as well as detractors. Some consider that the procedure is cruel and unnecessary, while others consider it to be routine and harmless. The cropping of the ears of dogs for cosmetic reasons has no medical merit. It is a cosmetic, surgical procedure performed to achieve a specific appearance that matches the desired image and sometimes the standard of certain breeds of dogs. Cosmetic surgery offers the dog the desired look, but it is not a necessity. This procedure must be performed by a licensed veterinarian. Those interventions cause pain and anxiety and, like all surgical procedures, are associated with the risk of anaesthesia problems, blood loss and infection. There is only a thin line between what is convenient for the animal and what is good. Almost every community has legislation on animal welfare which includes amputation issues. If something is considered normal in some countries, this does not necessarily mean that it is also moral. The lack of legal consequences may lead some owners to produce certain breeds of dogs to their liking, but they should not be allowed to cripple their dog for their own personal benefit. Amputation can only be performed legally by a veterinarian and a new problem arises. This is because there are veterinarians who refuse to practice that kind of intervention. Some of them may think that since the legislation is unclear, they might be charged with a crime.

Effects of electroacupuncture on functional indices and pS6 expression following acute sciatic nerve crush injury in rats.

The aim of this study was to investigate the effect of electroacupuncture (EA) on recovery from acute sciatic nerve crush injury and the expression of pS6 in rats. A total of 108 adult male Sprague-Dawley rats were randomly divided into control, model, EA and EA+rapamycin (EA+Rapa) groups. 28 rats were allocated to undergo measurement of sciatic functional index (SFI); one rat in the EA+Rapa group was unsuccessfully modelled and excluded because of an anaesthetic problem. The remaining 80 rats were allocated to undergo Western blot detection of S6 ribosomal protein (pS6, ser240/244). The model was created by mechanical clamping of the sciatic nerve stem. EA stimulation at GB30 and ST36 for 15 min separately was applied once daily for rats in the EA and EA+Rapa groups. For rats in the EA+Rapa group, rapamycin, a mammalian target of rapamycin (mTor) pathway inhibitor, was injected intramuscularly (1 mg/kg/day) near the site of crush injury in the sciatic nerve and an equivalent amount of dimethyl sulfoxide was injected in the other three groups every other day. After treatment for 7, 14, 28 and 42 days post-operation, the SFI of 27 rats was obtained to evaluate recovery of motor function and five rats from each group per stage were used for Western blot detection of pS6. The SFI values showed that EA could significantly promote recovery of the injured sciatic nerve but rapamycin hindered the therapeutic effect of EA. Moreover, immunoblotting indicated that EA improved the expression of pS6 in the area of the sciatic nerve crush injury and local injection of rapamycin near the injured sciatic nerve decreased its expression. The pS6 level correlated with the extent of recovery of the injury. This study indicated that EA may activate the mTOR signalling pathway to enhance expression of pS6 and facilitate recovery following sciatic nerve crush injury.

Sedation in dental practice in Russia. Status of the question

Проблема обезболивания пациентов в стоматологической практике по-прежнему остается актуальной. Не всегда только местной анестезии бывает достаточно для безопасного проведения вмешательств. Значимо повысить эффективность купирования болевого синдрома можно при помощи анксиолитической премедикации или управляемой седации. Каждому врачу-стоматологу, независимо от специализации, необходимо владеть навыком безопасного обезболивания, а также уметь проводить профилактику и лечение неотложных и экстренных соматических состояний. В статье освещается современное законодательное видение компетенций, трудовых действий и полномочий врачей-стоматологов относительно лечения пациентов с применением седации/премедикации. Допустимые для применения стоматологами седативные препараты обладают успокаивающим действием, не имеют значимого влияния на дыхание и гемодинамику, не вызывают развития привыкания при условии корректного их назначения в соответствии с рекомендациями производителя. При недостаточной эффективности пероральных седативных средств стоматологические пациенты могут быть пролечены в условиях анестезиологического пособия, наиболее востребованной является методика управляемой седации.

Prognosis of pentalogy of Cantrell

Regarded as a lethal condition, pentalogy of Cantrell is a rare congenital syndrome that presents in its complete form the following five defects: defect of the abdominal wall closure at the superior part, sternal fusion defect, cardiac malformations, defect of the diaphragm, and defect of the pericardium. Using data from reported cases of survivors who have received complex treatments for the anomalies, this article aims at describing the possible ways of monitoring these pregnancies and of predicting prenatal and postnatal outcomes. The optimal treatment conditions require supervision by multidisciplinary teams in a third-level maternity with neonatal intensive care units and maternal-fetal departments and neonatal surgery department. Moreover, establishing the chronology for the corrections of the defects, solving anaesthetic problems and postnatal ventilator support are necessary for the correct treatment of this syndrome.

EFFECT OF SCLEROTHERAPY USING COPPER WIRES ASSOCIATED WITH CORTICOSTEROIDS IN THE TREATMENT OF VASCULAR LESIONS

Vascular injuries in the oral cavity cause anesthetic and functional problems, and a high risk of severe hemorrhages in simple surgical treatments; therapy with copper wires and corticosteroids generates local coagulation and fibrosis and are effective for an uncomplicated resection. Through a series of cases, clinical and anatomopathologic characteristics of the combined sclerotherapy effects are described, as an alternative for the treatment of vascular malformations performed on 7 patients, using intralesional corticoid (0.2 mL/cm2) for 2 or 3 weeks, followed by a cerclage with copper wires, for 1 week, until color change from red or purple to lighter color and a fibrous consistency was observed. Continued resection of the lesion occurred in the absence of bleeding. Histologic studies were performed, which revealed neoformation of fibrous tissue, hyalinization of blood vessels, and loss of endothelial continuity. The result was favorable in 100% of the cases.

Optimization of the management of a patient with a backache (with clinical observation)

Back pain in terms of socio-economic losses over the past 5 years has come to the first place among the causes of disability, and therefore the problem of rapid effective anesthesia and rehabilitation of this large group of patients is topical. In most cases, the main sources of back pain are the structures of the musculoskeletal system, and the reasons are their microtraumatization due to sudden unprepared movements, prolonged stay in a static position, heavy physical labor. The task of clinical and instrumental examination is to exclude specific causes of dorsalgia. It is also important to present the results of the survey in an accessible form, in particular to correctly interpret the data from neuroimaging research methods. Adequate anaesthesia for acute back pain, informing the patient about the favorable prognosis of the disease and early motor activation are essential to prevent the transition of the physiological feeling of pain into the pathological process - chronic pain syndrome. When dealing with chronic pain, the interaction of specialists of different profiles in the multidisciplinary team is required. Kinesiotherapy, ergotherapy, cognitive-behavioural therapy are the main methods of non-drug treatment of lower back painIt is recommended that the patient maintains the usual level of physical activity and then increases it. It is necessary to teach the patient to correctly perform movements in the social, professional and domestic spheres, to explain how to avoid unsafe movements that can provoke dorsalgia. The article presents the observation of a patient with chronic back pain. Success in treatment has been achieved through effective anesthesia through rational selection of non-steroidal anti-inflammatory drugs (Dexalgin), local administration of local anesthetics to overcome kinesiophobia, and a combination of cognitive-behavioural therapy, kinesiotherapy, and ergotherapy.

English

English

Algorithm-based preventive strategies for avoidance of residual neuromuscular blocks

Postoperative residual neuromuscular block (train of four ratio <0.9) is an outcome-relevant problem in balanced anesthesia, which increases postoperative morbidity and mortality. Implementation of medium and short-acting muscle relaxants, quantitative neuromuscular monitoring and pharmacological reversal of muscle relaxation reduce the incidence of residual neuromuscular block. The question arises whether this is suitable to create apragmatic algorithm integrating these three individual methods to reduce paralysis-associated complications? A selective literature search was carried out in PubMed and guidelines of national specialist societies were searched using special terms. The incidence of residual neuromuscular block varied among the studies but was as high as 93%. Using calibrated acceleromyography it is possible to identify a residual relaxation with anegative predictive value of 97% (95% confidence interval, CI 83-100%). Reversal by administration of the acetylcholinesterase inhibitor neostigmine reduces the incidence of residual neuromuscular block to 15.4%, in combination with calibrated acceleromyography to 3.3%. Reversal with sugammadex can nearly completely eliminate residual neuromuscular block. Quantitative neuromuscular monitoring and pharmacological reversal can be suitably integrated into astage-based, pragmatic treatment algorithm. The algorithm-based concept of quantitative neuromuscular monitoring and pharmacological reversal using neostigmine and sugammadex enables residual neuromuscular block to be treated within 10 min before extubation of the patient. Ongoing educational programs are essential for implementation of modern muscle relaxant management concepts. Quantitative neuromuscular monitoring should be mandatory for all patients receiving neuromuscular blocking drugs. It would be desirable that German-speaking societies for anesthesiology make appropriate recommendations in guidelines.

Update On Cenegermin Eye Drops In The Treatment Of Neurotrophic Keratitis.

Neurotrophic keratitis is an underdiagnosed degenerative condition induced by impairment to the corneal nerves which may lead to persistent epithelial defects and corneal blindness. Current medical and surgical treatments are only supportive and poorly tackle the underlying problem of corneal anesthesia; hence, fail to provide a permanent cure. Cenegermin is a newly introduced recombinant human nerve growth factor (rhNGF) that may address this issue. Preliminary clinical trials have demonstrated the safety and efficacy of topical cenegermin in patients with moderate to severe neurotrophic keratitis; however, the clinical experience with this drug is still limited. This review summarizes the pathogenesis and management of neurotrophic keratitis as well as the mechanism of action, uses, and limitations of cenegermin eye drops in the treatment of neurotrophic keratitis.

Early exposure to general anesthesia impairs social and emotional development in rats.

Several animal and emerging human studies suggest an association between an early exposure to general anesthesia (GA) and long-lasting problems with complex social and emotional behaviors such as inattentiveness, impulsivity, anxiogenic tendencies, as well as difficulties engaging in proper social intercourse, with significant increase in attention deficit and hyperactivity-type behaviors. To further investigate these behaviors, and to examine the potential of presently available rodent behavioral models to guide future assessments of long-term socio-emotional impairments in humans, we examined the long-term effects of GA on anxiety/fear and social behaviors. We exposed male and female Sprague-Dawley infant rats at the peak of their synaptogenesis to either GA containing midazolam (9mg/kg, i.p.), 70% nitrous oxide (N2O) and 0.75% isoflurane (Iso) administered in 29-30% oxygen (experimental), or air (with 30% oxygen) plus the vehicle, 0.1% dimethyl sulfoxide (Sham) for 6h. Behavioral experiments were conducted at adolescence (the open-field test) and young adulthood (the open-field test, the elevated plus-maze and the social novelty test). We report that an early exposure to GA during critical stages of brain development results in long-lasting increase in risk-taking tendencies and significant changes in the anxiety-related behaviors when tested in young adult rats. In addition, we noted novelty-seeking tendencies/less guarded behavior with changes in social discrimination. We conclude that early exposure to anesthesia may have lasting influences on emotional and social development. Importantly, our results show that currently used rodent behavioral models could be a good correlate to assess long-term socio-emotional GA-induced impairments observed in humans.

A framework for the management of the pediatric airway.

Critical airway incidents in children are a frequent problem in pediatric anesthesia and remain a significant cause of morbidity and mortality. Young children are at particular risk in the perioperative period. Delayed management of airway obstruction can quickly lead to serious complications due to the short apnea tolerance in children. A simple, time critical, and pediatric-specific airway management approach combined with dedicated teaching, training, and frequent practice will help to reduce airway-related pediatric morbidity and mortality. There is currently no pediatric-specific universal framework available to guide practice. Current algorithms are modifications of adult approaches which are often inappropriate because of differences in age-related anatomy, physiology, and neurodevelopment. A universal and pragmatic approach is required to achieve acceptance across diverse pediatric clinicians, societies, and groups. Such a framework will also help to establish minimum standards for pediatric airway equipment, personnel, and medications whenever pediatric airway management is required.

The general anesthesia treatment of the patient with the unforeseen tracheal amyloidosis

The tracheobronchial amyloidosis is a rare pulmonary disease, especially the tracheobronchial type, but the mechanism remains unknown. The clinical characteristics and manifestations of the disease were not typical. Patients will develop the onset of cyanosis when tracheal stenosis occurs because of the invasion of amyloid. The critical problem of anesthesia is that the suitable tracheal catheter is hard to be insert into the trachea during the induction. An anesthesia treatment and analysis about the patient with tracheal amyloidosis was reported. Key words: Trachea; Amyloidosis; Anesthesia, general; Intubation, intratracheal

Anaesthetic management of acute abdomen: a clinical study

Background: Patients of acute abdomen present anaesthetic problems like fluid and electrolyte loss, intraoperative vomiting, regurgitation and aspiration, postoperative sickness, electrolyte imbalance, prolonged total parenteral alimentation etc. This study focused on intraoperative and postoperative complications with reference to anaesthetic management.Methods: Around 300 patients, suffering from acute abdomen, operated during routine or emergency were randomly distributed in three groups, Group I General anaesthesia with narcotic analgesics and relaxants; Group II General anaesthesia with inhalational agents; Group III Spinal subarachnoid analgesia. No modification of pre and post-operative hospital care and treatment was done.Results: There was a preponderance of younger age group patients (15 to 34years), more often in male patients. The mean duration in Group I was highest. Intraoperative Hypotension was the commonest (86 patients) followed by regurgitation and aspiration. Post-operative pyrexia was the commonest complication (120 patients) followed by postoperative nausea. ASA Grade III had a mortality of 22 patients (11.6%), ASA Grade IV having mortality of 46 patients (60.52%). About 221 patients had long duration of operations and the mortality was 28.95% as compared to 79 patients operated for short duration having mortality of 13.92%.Conclusions: Outcome and the survival of the patients depend on the surgical disease, duration of surgery, preoperative ASA grading, degree of dehydration, and the anaesthetic technique.

BILE DUCT INJURIES

Objective: To find out frequency of bile duct injuries during cholecystectomyprocedures either open or laparoscopic. Study design: Prospective observational study. Placeand duration of study: This study was conducted at Surgical department, Liaquat UniversityHospital Jamshoro and Dow International Hospital Karachi, from July 2012 to December2013. Methodology: This study consisted of hundred patients. Patients were divided in twogroups. Group A for open cholecystectomy (OC) comprising of 50 patients who underwentelective open cholecystectomy. Group B for Laparoscopic cholecystectomy (LC) comprisingof 50 patients who underwent elective Laparoscopic cholecystectomy. Inclusion criteria wereall patients diagnosed case of gallstones on the basis of ultrasound abdomen, any age andboth gender. Exclusion criteria included not willing for surgery, General anesthesia problem,pregnant ladies due to risk of foetal loss, carcinoma of gall bladder, stone in CBD and obstructivejaundice. Results: Out of 100 cases of gallstone were operated for either laparoscopic / opencholecystectmy. In open cholecystectomy group 20(40 % ) were male and 30(60 %) female.Ratio male: female ratio of 1:1.5. In laparoscopic cholecystectomy group 11(22 % ) were maleand 39(78 %) female with male: female ratio of 1:3.5. There was wide variation of age rangingfrom a minimum of 10 year to 70 year in both group. The mean age was 41.28+12.30 yearsfor OC group and 38.44+13.50 years for LC group (p 0.02). Common bile duct injury wereoccurred 2(4%) patients in laparoscopic cholecystectomy group while 3(6%) patients observedin open cholecystectomy group. Conclusions: We conclude that found bile duct injury 2(4%)patients in laparoscopic cholecystectomy group while 3(6%) patients observed in opencholecystectomy group

DOMESTIC ANESTHESIOLOGY IN THE FIRST HALF OF THE XX CENTURY: SCIENTIFIC PRIORITIES

The article notes that the problems of anesthesia in the first half of the XX century were developed by joint efforts of surgeons and anaesthesiologists, who distinguished their discipline as a narrow specialty from clinical medicine. Local anesthesia by the method of creeping infiltrate, anatomically developed and physiologically grounded prof. A.V. Vishnevsky, has become very popular not only in our country, but also abroad. It is shown that many other surgeons began to perform under local anesthesia surgical interventions on the organs of the thoracic cavity, esophagus, lungs, and heart. About 90% of lung operations for tumors, bronchiectasis, tuberculosis were performed using the creeping infiltrate method under local anesthesia. It was stressed that in the 50s of the 20th century it became evident that in many cases of severe and deeply traumatic surgery, especially on the chest cavity, only protection against pathological reflexes in the field of intervention achieved by the Novocaine blockade is insufficient, since it was necessary to preserve and maintain the function of the whole organism. The use of barbiturates in surgery has received a lot of attention, and a technique has been developed that made it possible to carry out large operations lasting up to 2 hours or more (under the action of hexenal). It was shown that hexenal anesthesia was not injected and almost all of it was abandoned. In the post-war period, intratracheal ether-oxygen anesthesia began to be used in surgical practice. It was noted that the absence of vomiting, the patient’s open face, bronchial tamponade, the ability to increase intrabronchial pressure, spread the lungs, provide artificial ventilation and maintain a high oxygen content in the blood - all this contributed to the spread of this method. Consequently, anesthesia in surgical interventions, the use of modern pharmacological agents and anesthesia at that time, turned into special problems, the solution of which became practiced by doctors specially trained in the field of therapy, physiology, pharmacology and pathological physiology. Thus, a new discipline arose, anesthesiology, and all preparation for surgery, anesthesia during surgery and an early postoperative period is transferred to the direct management of anesthesiologists.

Laparoscopic pancreaticoduodenectomy for resection of periampullary tumors should be routine?

Background: PD is acomplex abdominal procedure. The hospital mortality rate has decreased to <5% however the rate of postoperative morbidities remains high 40%. Laparoscopic pancreaticoduodenectomy (LPD) has not yet been well established approach for periampullary tumour. We present our experience with LPD. Methods: Patients undergoing LPD between 2014 and 2018 Included in the study. Patients who underwent a hybrid LPD (HLPD) mobilization approach and resection followed by open reconstruction and totally LPD (TLPD) approach were included in this study. Operative characteristics, perioperative outcomes, and pathological were collected. Results: Thirty Eight patients underwent LPD including 10 HLPD (26.3%) and 28 TLPD (73.7%) patients. HLPD patients were mostly converted to open for planned reconstruction or anesthetic problem. Median operating time was 370 min (420 min for TLPD). Median length of hospital stay was 6 days. Histology showed 35 invasive malignancies, two neuroendocrine tumours, and one benign lesions. Median nodal harvest was 14. Margin negative resection was achieved in 97.4 % of patients. Twenty-two percent of patients developed a Grade 3∕4 complication, including 12% clinically significant pancreatic fistula. There was one perioperative mortality (2.6%) due to pancreatic fistula. These results are comparable with a well marched cases underwent open PD in the same period of study. Conclusions: LPD is a technically challenging operation with a steep learning curve. The early surgical outcomes are satisfactory. LPD offers benefits to patients as it is minimal invasive procedure so it should be a routine procedure in a well equipped center with good selection of the patients.

Comparison of Ephedrine vs. Norepinephrine in Treating Anesthesia-Induced Hypotension in Hypertensive Patients: Randomized Double-Blinded Study

BackgroundHypotension is a common problem in general anesthesia. Maintaining the mean arterial pressure by choosing a vasopressor with minimal complications is still discussed in various surgeries.ObjectivesThe aim of this study is comparison of ephedrine versus norepinephrine in treating anesthesia-induced hypotension in hypertensive patients in spinal surgery in a randomized double-blinded study.MethodsThis randomized, double-blinded study was approved by Iran University of Medical Sciences, operating room of medical center. Data collection was completed between Jan to Dec 2017. Inclusion criteria included age between 20 and 75 years, history of high blood pressure (a patient who has been treated for maximum 5 years with a anti hypertensive medication), and patients under general anesthesia in spinal surgery. The exclusion criteria were based on American Society of Anesthesiologists physical status of 3 or higher, history of arrhythmia, heart valve disease, cerebrovascular disease, kidney failure, beta-blocker use and diabetes, as well as intra operative massive blood loss. After initiation of anesthesia, when the pressure reaches less than 60, the patient entered the protocol and simultaneously administration of 5 mL/kg serum crystalloid and vasopressor. Patients were randomized to the ephedrine group (n = 28) who received 5 mg ephedrine intravenous (i.v.) or norepinephrine Group (n = 28) who received 10 µg (i.v.) bolus norepinephrine at anesthesia-induced hypotension. The administration of 5 mL/kg serum crystalloid and vasopressor was simultaneous. If the mean arterial pressure (MAP) had not reached 60 mmHg, the same dose should be repeated at a maximum of three or more times at five-minute intervals in the ephedrine group and at two minutes intervals in the norepinephrine group. All parameters were collected before and at the end of administration anesthesia drug and during episodes of hypotension. Hemodynamic variables, frequency of hypotension, and total number of vasopressors doses during anesthesia were recorded and analyzed.ResultsThe mean number of hypotension times, the number of vasopressors doses in the first hypotension, the total number of doses consumed during the anesthesia, and heart rate at the end of anesthesia were lower in the norepinephrine group (P) respectively. MAP, 5 minutes after the first episode of hypotension and MAP at the end of anesthesia were higher in norepinephrine group.ConclusionsNorepinephrine is more effective than ephedrine in maintenance of MAP in hypertensive patients undergoing spinal surgery under general anesthesia.

Reliability of Pressure Waveform Analysis to Determine Correct Epidural Needle Placement in Laboring Women

(Anaesthesia. 2017;72(7):840–844) Epidural failure is a significant problem in obstetric anaesthesia with one survey of parturients reporting a failure rate of 23%. There can be many causes of epidural failure, including technical failure due to misidentification of the epidural space. A false loss-of-resistance during epidural needle advancement is a common cause of misidentification. Pressure waveform analysis has been used to provide confirmation of correct epidural needle position when the loss-of-resistance technique was used to identify the epidural space during thoracic epidural procedures. Accurate needle placement is confirmed if a pulsatile waveform synchronized with arterial pulsations is seen. In one study, the failure rate decreased from 24% with loss-of-resistance only to 2% with the addition of pressure waveform analysis. However, the reliability of this technique for lumbar epidural analgesia for labor is unclear. This observational study was performed to determine the reliability of pressure waveform analysis in identifying accurate epidural needle placement during lumbar epidural insertion for labor analgesia.