Single-shot Spinal Anesthesia Research Articles

Combined Spinal Epidural Causes Higher Level of Block Than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Combined Spinal Epidural Causes Higher Level of Block Than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Combined Spinal Epidural Does Not Cause a Higher Sensory Block than Single Shot Spinal Technique for Cesarean Delivery in Laboring Women

The combined spinal epidural (CSE) technique has been shown to result in a higher sensory block than an equivalent single shot spinal (SSS) in women undergoing elective cesarean delivery. We tested whether this is true also in laboring women who may have variable epidural pressures. We randomized 40 ASA I parturients in established labor for cesarean delivery into our double-blind study. Group S (n = 20) intrathecally received 2 mL of 0.5% hyperbaric bupivacaine by SSS and group CS received CSE (n = 20) of an equivalent dose of hyperbaric bupivacaine. We found that similar maximal sensory blocks were achieved in both groups (group S: median T3 [min-max] T6-1 versus group CS: median T3 [min-max] T4-C7, P = 0.517). As compared with previous reports in nonlaboring parturients, the block characteristics of CSE in our study were indistinguishable from those of SSS in laboring parturients for cesarean delivery.

Combined Spinal-Epidural Causes Higher Level of Block Than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Survey of Anesthesiology: October 2006 - Volume 50 - Issue 5 - p 234 doi: 10.1097/01.sa.0000238920.91400.47

Combined Low-Dose Spinal-Epidural Anesthesia versus Single-Shot Spinal Anesthesia for Elective Cesarean Delivery

Combined Low-Dose Spinal-Epidural Anesthesia versus Single-Shot Spinal Anesthesia for Elective Cesarean Delivery

Combined Spinal Epidural Causes Higher Level of Block than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Combined Spinal Epidural Causes Higher Level of Block than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Emergency Caesarean section: best practice*

Good multidisciplinary communication is crucial to the safe management of women requiring non-elective Caesarean section. Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount. Epidural top-up with levobupivacaine 0.5% is the anaesthetic of choice for women who have been receiving labour epidural analgesia. If epidural top-up fails to provide bilateral light touch anaesthesia from S5 - T5, a combined spinal-epidural technique with small intrathecal dose of local anaesthetic is a useful approach. Pre-eclampsia is not a contra-indication to single-shot spinal anaesthesia, which is the technique of choice for most women presenting for Caesarean section without an epidural catheter in situ. Induction and maintenance doses of drugs for general anaesthesia should not be reduced in the belief that the baby will be harmed. Early postoperative observations are geared towards the detection of overt or covert haemorrhage.

Paraesthesiae during single-shot spinal anaesthesia. A comparison of sitting versus lateral decubitus position

Laya, A.; Taboada, M.; Ulloa, B.; Valiño, C.; Vazquez, M.; Garea, M.; Cortés, J.; Alvarez, J. Author Information

The challenges of single-shot spinal anaesthesia for cesearean section in a morbidly obese patient: a case report

An unusual case of morbid obesity, severe hypertension and twin gestation at 36weeks in an unbooked multigravid patient was presented for cesarean section. She was referred from a private clinic to the obstetric emergency unit of the University College Hospital, Ibadan with history of hypertension in pregnancy. She was a known hypertensive for ten years and her blood pressure was poorly controlled due to non-compliance with medications and medical check-up. She had been having progressive visual loss over the ten year period and had lost three previous pregnancies. Following comprehensive clinical and radiological evaluation, she had a carefully planed single-shot spinal anaesthesia for cesarean delivery of a set of twin which was performed on a double operation table. She remained stable throughout the procedure and post operative period. Keywords: single-shot spinal anaesthesia, obesity, hypertension, cesarean sectionTropical Journal of Obstetrics and Gynaecology Vol. 22(2) 2005: 202-204

Rachianesthésie continue pour fracture du col fémoral chez deux patients présentant un rétrécissement aortique serré

Neuraxial blockade is usually not recommended in patients with aortic stenosis. However, neuroaxial blockade techniques such as continuous spinal or epidural anaesthesia can be tailored to minimize potentially dramatic consequences of decrease in systemic vascular resistance, often encountered after standard single shot spinal anaesthesia. We report the cases of two severe aortic stenosis patients (aortic valve area < 0.5 cm 2) that underwent hip surgery under continuous spinal anaesthesia. Small doses of isobaric 0.25% bupivacaine titrated to limit total dose below 5 mg, injected through the intrathecal catheter allowed the control of haemodynamic parameters. No clinical complication occurred in these two patients.

Outcome after anaesthesia and emergency surgery in patients over 100 years old

Deteriorated organ function and reduced stress response in very old patients may cause post-operative morbidity and mortality. We wanted to identify immediate and longer-term outcome after anaesthesia and surgery in the oldest of the old patients. We analysed retrospectively anaesthesia and hospital records of patients who were over 100 years old when undergoing major emergency surgery in our hospital during 1990-2004. Altogether, 12 patients (median age 101 years) underwent 14 operations (nine for hip fracture, four for lower extremity circulatory problems and one for peritonitis). During anaesthesia, invasive arterial pressure was monitored in eight patients while central venous pressure (CVP) was monitored in only one patient. Spinal anaesthesia with bupivacaine was given as a continuous technique in six and as single-shot spinal anaesthesia in five cases. Both spinal (11) and general (3) anaesthesias were characterized by marked drops in arterial pressure. Haemodynamics was managed with intravenous (i.v.) fluids and vasopressors. Five patients had post-operative delirium. Mortality at 30 days, 6 months and 1 year was 25%, 42% and 50%, respectively. Within 15 days of the operation, three patients had died (pneumonia, cerebral infarction and myocardial infarction). Nine patients returned home and six of them lived in their pre-operative mental and physical state for at least a year. Independently of the anaesthetic method, marked drops in blood pressure occurred, requiring pharmacological intervention. We assume that in most of the patients, hypovolaemia explains the intra-operative haemodynamic instability. A 25%, 30-day mortality may be regarded as acceptable and, overall, these very old patients tolerated emergency surgery quite well.

Combined Spinal Epidural Causes Higher Level of Block than Equivalent Single-Shot Spinal Anesthesia in Elective Cesarean Patients

Combined spinal epidural (CSE) is an established technique for lower segment cesarean delivery. In this study we tested the hypothesis that the spinal block from a CSE technique results in a more extensive spread of local anesthetic in the subarachnoid space than the single-shot spinal (SSS) technique. We recruited 30 ASA physical status I parturients admitted for elective lower segment cesarean delivery into our randomized, controlled, double-blind study. All patients intrathecally received 2 mL of 0.5% hyperbaric bupivacaine. The patients were randomized into one of the two groups using sealed opaque envelopes. Group S (n = 15) received a SSS technique. Group CS (n = 15) received a CSE technique using loss of resistance to 2 mL of air, but the epidural catheter was not inserted after the intrathecal drug administration. The maximal sensory block achieved in group CS was statistically higher than that in Group S (median C6 interquartile range, C5 to C8 versus median T3, T2 to T4, P < 0.001). Time taken to reach maximal sensory block was significantly longer in group CS. There were no differences in the time taken for the block to recede to T10, hemodynamic profile, or side effects. In conclusion, the CSE technique without placing an epidural catheter or administering epidural medication resulted in a significantly higher level of sensory block when compared with the SSS technique when the same dose of local anesthetic was given intrathecally.

Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n=50) or spinal anesthesia (n=50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 mug followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 mug for spinal anesthesia. The initial sensory block level was higher in the spinal group (P<0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P<0.05) and nausea and vomiting (P<0.05). Motor recovery was faster in the combined spinal-epidural group (P<0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.

Neuroaxial anaesthesia in obstetrical patients with cardiac disease

Pregnancy and the peripartum period represent a physiological burden for the cardiac patient that can worsen even moderate degrees of cardiac disease. Valvular stenotic diseases, congenital cardiac disease, and coronary insufficiency are relatively frequent in pregnant patients. Since considerable variability exists in the cardiovascular changes and responses to labour among different cardiac diseases and their functional status, recommendations for anaesthetic management are based on reported clinical experience and pathophysiological concepts. Neuroaxial blockade reduces or even abolishes the cardiovascular stress response to pain, mitigates Valsalva effects by decreasing the pushing reflex, and allows the adaptation of analgesia or anaesthesia to labour stage and delivery. Sympathetic blockade caused by standard neuroaxial techniques, however, reduces systemic vascular resistance and cardiac preload followed by reflex tachycardia. Recent development of neuroaxial techniques with spinal opiates for the first stage of labour, carefully titrated segmental epidural analgesia with opiates combined with low concentrations of local anaesthetic for the second stage, and even low spinal anaesthesia for vaginal instrumental delivery, have all been used with good results in patients with severe cardiac disease. Only Tetralogy of Fallot, primary pulmonary hypertension, idiopathic hypertrophic subaortic stenosis, and anticoagulation are considered relative or absolute contraindications for neuroaxial techniques, though slow segmental blockade of dermatomes may offer an alternative. For Caesarean section, single shot spinal anaesthesia is not recommended in moderate or severe heart disease. Adequate cardiovascular invasive monitoring is essential and should be administered and maintained in the postpartum period with the same criteria that reduce morbidity and mortality in cardiac patients undergoing general surgery.

Comparison of single-shot spinal anaesthesia and continuous spinal anaesthesia in patients undergoing open prostatectomy

Comparison of single-shot spinal anaesthesia and continuous spinal anaesthesia in patients undergoing open prostatectomy

The Median Effective Dose of Intrathecal Hyperbaric Bupivacaine Is Larger in the Single-Shot Spinal as Compared with the Combined Spinal-Epidural Technique

The combined spinal-epidural technique (CSE) has been associated with prolonged motor recovery and more frequent arterial hypotension as compared with a single-shot spinal (SSS) technique. We determined the median effective dose (MED) of intrathecal hyperbaric bupivacaine for CSE and SSS by using the up-down sequential allocation technique. Sixty male patients were randomly allocated to receive intrathecal administration through an SSS or CSE technique. Needle insertion occurred at the L3-4 interspace in all patients. In SSS, 9.5 mg of hyperbaric bupivacaine was administered through a 27-gauge Whitacre spinal needle. In CSE, a 17-gauge Tuohy needle with 4 mL of air was used to locate the epidural space, through which a 27-gauge Whitacre spinal needle was introduced and 7.0 mg of hyperbaric bupivacaine was administered. The dosing adjustment was 0.5 mg. A "successful" outcome was arbitrarily defined as sensory anesthesia at or above the T6 dermatome lasting for 60 min. A "success" resulted in a 0.5-mg decrement, whereas a "failure" resulted in a 0.5-mg increment in the next patient. There were 13 successes in both groups. The MED of bupivacaine was 9.18 mg (95% confidence interval, 8.89-9.47 mg) for CSE as compared with 11.37 mg (95% confidence interval, 10.88-11.86 mg) for SSS (P < 0.001). CSE required 19.3% (95% confidence interval, 14.9%-23.6%) less local anesthetic to achieve the defined clinical target. We found significant discrepancies in the MED of hyperbaric bupivacaine between the two techniques. Under similar clinical conditions, a 20% decrement in the dose of bupivacaine may be warranted whenever CSE is intended in place of SSS.

Minimum effective local anaesthetic dose of isobaric levobupivacaine and ropivacaine administered via a spinal catheter for hip replacement surgery

Continuous spinal anaesthesia with spinal catheters allows incremental dosing of local anaesthetic and, consequently, less haemodynamic changes. However, little is known about the required doses. Therefore, we designed a study to assess the minimum effective local anaesthetic dose (MLAD) of levobupivacaine and ropivacaine in this context. Forty-one patients undergoing hip replacement surgery were randomly allocated to one of the two local anaesthetic groups in a double-blind manner. The initial dose of local anaesthetic was determined by the response of the previous patient: the effective dose resulted in a 1 mg decrease in the dose of levobupivacaine or ropivacaine, and an ineffective dose resulted in a 1 mg increase. The MLAD was calculated by the Dixon up-and-down method. The MLAD of levobupivacaine was 11.7 mg (95% CI, 11.1-12.4) and that of ropivacaine 12.8 mg (95% CI, 12.2-13.4). These doses are significantly smaller than doses reported before for single-shot spinal anaesthesia. Continuous spinal anaesthesia allows the use of relatively small doses of local anaesthetic.

Combined Spinal-Epidural Anesthesia Using Epidural Volume Extension for Elective Cesarean Delivery

Background: Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique involved the enhancement of a small-dose intrathecal block using epidural saline boluses. We compared the EVE technique and single-shot spinal anesthesia with respect to sensory and motor block profiles and hemodynamic stabilities. Methods: Seventy parturients undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacine 10 mg plus fentanyl 15 or CSE anesthesia (comprising intrathecal hyperbaric 0.5% bupivacine 7 mg with fentanyl 15 followed by 0.9% saline (5.0 ml)) through a Tuohy needle. In each group, the lowest systolic blood pressure, sensory block level and peak sensory block height to loss of cold sensation to ice were recorded at 1 min intervals. Modified Bromage motor scores and time for sensory regression to the tenth thoracic dermatome () were compared between groups in the PACU. Results: Patients in the CSEA group demonstrated significantly faster motor recovery to modified Bromage 0 (82.2 18.7 min versus 121.1 15.2 min respectively, P

Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger?s syndrome

We describe the use of continuous spinal anesthesia (CSA) for an elective cesarean section in a 29-year-old parturient with Eisenmenger's syndrome at 30 weeks of gestation. It is essential in patients with Eisenmenger's syndrome to prevent significant increases in right-to-left shunt following the reduction in systemic vascular resistance. In this case, the patient hoped to be awake during the operation because of her fear of death. We therefore applied CSA to this patient because single-shot spinal anesthesia and epidural anesthesia might cause sudden cardiovascular depression. In fact, sudden cardiovascular changes were avoided by the titration of local anesthetics and the operation was uneventful, although prompt treatment of hypotension was essential and adjustment of the anesthetic levels was difficult. Postoperative patient-controlled spinal analgesia provided satisfactory pain relief with hemodynamic stability and no significant side effects. However, thorough experience with the requisite techniques is critical in CSA because of the technical difficulty of the procedure, and anesthesiologists must gain such experience in less-demanding cases before attempting to administer it in patients presenting extreme challenges as described in this case report.

Why bother with continuous spinal anaesthesia?

Conventional spinal anaesthesia is simple, safe and well established. Why then should anyone choose to complicate the issue with a catheter? This is currently the view of most anaesthetists and it a view with much to comment it. However, single shot spinal anaesthesia (SSSA) does have limitations. A small percentage of SSSA blocks produce unilateral anaesthesia with an inadequate block. Alternatively, a block may wear off before surgery is complete. Although there is little published work on the safety of administering sedation or general anaesthesia immediately after spinal anaesthesia, anecdotal evidence points to significant problems, especially with hypotension. Lastly, there is the problem that the spinal anaesthesia provides exceptional analgesia for the surgery and recovery period, but does not provide analgesia postoperatively. There are also many patients for whom the risk of complications of SSSA, such as muscle paralysis, hypotension and the risk of a high block may lead to only general anaesthesia being considered. Continuous spinal anaesthesia (CSA) may therefore have a role in patients who are having surgery of the lower body, who have significant comorbidities and for whom SSSA is not absolutely contraindicated. There are too few publications to produce evidence-based guidelines on where CSA is best used, however, personal experience suggests

Regional anaesthesia for caesarean section

In the UK, over 80% of caesarean sections are performed under regional anaesthesia. There are four categories of surgery depending on the degree of urgency. Informed consent is vital and must be documented. All women should receive aspiration prophylaxis premedication (H 2-antagonist, metoclopramide, and within 30 minutes of surgery, a non-particulate antacid). Regional anaesthesia should be established in theatre. In emergencies, some authorities advocate topping up indwelling epidural catheters before transfer to theatre. Standards for monitoring and anaesthetic assistance are the same for obstetric and general surgery. Intravenous access must always be obtained before regional anaesthesia. Fetal heart rate monitoring should be continued during institution of the block and until the start of surgery. Supplemental oxygen is no longer considered mandatory for the mother in the absence of fetal distress. Institution of blockade must be performed in an aseptic manner. Sterile gloves are essential and face masks and gowns are highly recommended. Hypotension should be minimized by avoiding aortocaval compression, vasopressors (prophylactically/therapeutically) and colloid preloading. Single-shot spinal (SSS), combined spinal-epidural (CSE), and epidural may be used. SSS is simple and quick to perform. CSE is associated with the lowest rate of conversion to general anaesthesia and greater haemodynamic stability than SSS. Epidural anaesthesia has the highest failure rate, but if an epidural has been placed for labour, most practitioners would advocate its use rather than resorting to intrathecal anaesthesia. A block to touch from S1 to T5 or above is essential. All patients should be assessed postoperatively.