Single-shot Spinal Anesthesia Research Articles

High Neuraxial Block in Obstetrics: A 2.5-Year Nationwide Surveillance Approach in the Netherlands.

High neuraxial block is a rare but serious adverse event in obstetric anesthesia that can ultimately lead to respiratory insufficiency and cardiac arrest. Previous reports on its incidence are limited to populations in the United Kingdom and the United States. Little is known about the incidence and clinical features of high neuraxial block in the Netherlands, where the presence of anesthesiologists in the labor and delivery unit is comparatively lower. We aimed to assess the incidence and clinical features of high neuraxial block in obstetrics and to formulate ways to improve obstetric anesthesia on a national level. This nationwide, prospective, population-based cohort study was designed to identify cases of high neuraxial block requiring ventilatory support (with supraglottic airway device or tracheal intubation) or cardiopulmonary resuscitation between November 2019 and May 2022. Cases were prospectively collected using the Netherlands Obstetric Surveillance System (NethOSS) in all hospitals with a maternity unit. Complete case file copies were obtained to determine risk factors and clinical course. During the study period, 5 cases of high neuraxial block requiring tracheal intubation were identified. The estimated incidence of high neuraxial block requiring tracheal intubation was 1 in 29,770 neuraxial procedures in labor (95% confidence interval, 1:12,758-1:91,659). Three of 5 identified cases occurred in the operating room after single-shot spinal anesthesia for Cesarean delivery after epidural analgesia in labor. One case developed in the labor ward due to an inadvertent intrathecal or subdural catheter placed for labor analgesia. The fifth case followed single-shot spinal anesthesia for elective Cesarean delivery. All 5 patients were successfully extubated in the operating room after Cesarean delivery, without the need for intensive care admission. There were no cardiac arrests and no neonatal deaths. High neuraxial block requiring tracheal intubation is a rare but impactful complication in obstetric anesthesia, potentially affecting both mother and fetus. Spinal anesthesia after epidural analgesia in labor is a common cause of high neuraxial block. Meticulous follow-up of epidurals in labor facilitates conversion to surgical anesthesia and may therefore reduce the need for spinal anesthesia after epidural analgesia. Large-scale surveillance systems in obstetric anesthesia are needed to identify those at risk, as well as to formulate further strategies to mitigate this burden.

Layered and Thoracic Segmental Spinal Anaesthesia in Patients with Kyphoscoliosis for Various Surgeries: A Case Series

Kyphoscoliosis involves exaggerated anterior and lateral curvatures of the spine, affecting the dorsolumbar spine. Associated multiple organ system dysfunctions cause difficulties with both general and regional anaesthetic techniques. Co-existing neuromuscular disorders, pulmonary infections, difficulties in securing the airway, postoperative pulmonary morbidities, and the need for mechanical ventilation associated with general anaesthesia make neuraxial anaesthesia the most widely used technique in these cases. Continuous neuraxial techniques in these patients offer advantages over single-shot spinal anaesthesia in achieving the desired level of anaesthesia, managing patchy blocks, extending the duration of anaesthesia, and providing postoperative analgesia, but they are technically more challenging. Single-shot spinal anaesthesia can be a simple, safer, and effective alternative for surgical procedures of shorter duration. Performing thoracic segmental spinal anaesthesia in these patients is very challenging due to the complete distortion of anatomy and possible obliteration of neuraxial spaces. Layered spinal anaesthesia involves combining multiple local anaesthetics with different baricities to produce a successful subarachnoid block. Present series is reported with successful and uneventful use of the layered and thoracic segmental spinal anaesthetic technique in patients with kyphoscoliosis for various surgeries, including laparoscopic procedures.

Impact of Ultrasound-Assisted Method on Success Rate of Spinal Anesthesia Performed by Novice Trainees: A Retrospective Comparative Study.

In current practice, single-shot spinal anesthesia has traditionally been performed using the conventional surface-anatomic-Landmark-Guided technique. This "blind" technique has significant critical issues such as a high risk of complications due to the numerous attempts at spinal needle placement and the negative impact on the learning curve of the trainees. Ultrasound-Assisted spinal anesthesia could reduce these critical issues and allow trainees to perform the procedure more easily and with fewer complications for the patient. We performed a before-and-after monocentric retrospective comparative study at the University of Naples "Federico II" (Naples, Italy). Inclusion criteria were as follows: patients aged 18 years or older; ASA physical status between I and IV; and elective orthopedic surgery under single-shot spinal anesthesia performed by supervised trainees between January 2022 and December 2022. In the selected cohort, 88 patients were included in group A (Landmark-Guided spinal anesthesia) and 91 in group B (Ultrasound-Assisted spinal anesthesia). The number of attempts by trainees (p-value < 0.005), procedure performing time (<0.001), and patient discomfort (<0.001) were significantly lower in group B than in group A. Ultrasound-Assisted single-shot spinal anesthesia performed by novice trainees reduces the number of attempts, complication rate, periprocedural pain, and patient discomfort.

ISOBARIC LEVOBUPIVACAINE VERSUS HYPERBARIC BUPIVACAINE IN PREGNANT WOMEN UNDERGONE CESAREAN SECTIONS: A RANDOMIZED CONTROLLED TRIAL

To compare isobaric levobupivacaine versus hyperbaric bupivacaine for pregnant women who have undergone cesarean sections. In this randomized controlled trial, 70 patients with ASA physical status I-II, scheduled i.e for elective lower segment cesarean section (LSCS), were divided into two equal-sized groups (n = 35 each). Group A was treated with 2.5 ml of isobaric levobupivacaine, while Group B was treated with 2.5 ml of hyperbaric bupivacaine. Both groups' sensory and motor block features were evaluated using the pinprick test and the Bromage scale. Additionally, any instances of hypotension and potential side effects were meticulously recorded. Subsequently, the collected data underwent statistical analysis employing appropriate tests. The initiation of sensory blockage was observed to be slower, and the regression duration for two segments was extended while using isobaric levobupivacaine (p &lt; 0.001). Nevertheless, it generated sufficient surgical anesthetic with a reduced duration of motor blocking and fewer side effects compared to hyperbaric bupivacaine. This study concludes that single-shot spinal anesthesia with different local anesthetics is effective for prompt surgical anesthesia induction in elective cesarean section procedures. Among these options, levobupivacaine is a superior choice due to its smaller duration of motor block, reduced side effects, and lower risk of hypotension, making it particularly well-suited for such procedures.

Effect of Continuous versus Single Shot Spinal Anesthesia on Hemodynamic and Postoperative Cognitive Function for Elderly Patients Undergoing Lower Limb Surgeries; Randomized Controlled Study

Effect of Continuous versus Single Shot Spinal Anesthesia on Hemodynamic and Postoperative Cognitive Function for Elderly Patients Undergoing Lower Limb Surgeries; Randomized Controlled Study

Labour analgesia by single shot spinal for any parturient?-A retrospective one-year single centre audit.

Single shot spinal (SSS) provides effective analgesia for multiparous parturients during advanced labour. Its utility in early labour or primiparous parturients may be limited by the insufficient duration of action. Regardless, SSS may offer a reasonable labour analgesia option in certain clinical scenarios. In this retrospective study, we analyse the failure rate of SSS analgesia by assessing pain after the SSS and by determining the need for additional analgesic interventions in primiparous or early-stage multiparous parturients compared to multiparous parturients in advanced labour (cervix ≥6 cm). Following institutional ethical board approval, the patient files of all parturients receiving SSS analgesia during a 12-month period in a single centre were analysed for any recorded notes regarding recurrent pain or subsequent analgesia interventions (a new SSS, epidural, pudendal or paracervical bloc) as a marker for insufficient analgesia. A total of 88 primiparous and 447 multiparous parturients (cervix <6 cm: N = 131; cervix ≥6 cm: N = 316) received SSS analgesia. The odds ratio for the insufficient duration of analgesia was 1.94 (1.08-3.48) in primiparous and 2.08 (1.25-3.46) in early-stage multiparous parturients compared to advanced multiparous labour (p < .01). Primiparous and early-stage multiparous parturients were also 2.20 (1.15-4.20) and 2.61 (1.50-4.55) times more likely, respectively, to receive new peripheral and/or neuraxial analgesic interventions during delivery (p < .01). SSS appears to provide adequate labour analgesia for the majority of parturients in whom it is used, including nulliparous and early-stage multiparous parturients. It remains a reasonable option in certain clinical scenarios, including resource-limited settings where epidural analgesia is unavailable.

Intrathecal bupivacaine with clonidine or dexmedetomidine as adjuvant in gynecological surgery: an enigma

BackgroundAddition of adjuvants to routinely used intrathecal drugs is cornerstone in safe and effective prolongation of single shot spinal block for gynecological surgery. In resource deficient countries, where epidural anesthesia is usually not used because of cost factor, adjuvants are routinely used to prolong the effect of regional anesthesia. Alpha 2 agonists are considered best drugs as adjuvants, but there is inconclusive data in literature about the block characteristic, dose at which to be used and side effect after use of these drugs.MethodsClonidine 30 µgm or dexmedetomidine 5 µgm was used intrathecally as an adjuvant with 15 mg bupivacaine 0.5% in 90 female patients undergoing gynecological surgery in this randomized, prospective, single blind study.ResultsThe mean time to onset of sensory block a (T6 level) and time to attain maximum sensory height were significantly early in group D over group C (124.44 ± 20.64 s, 175.09 ± 68.01 s, p < 0.0001) and (13.53 ± 2.97 min, 18.64 ± 4.82 min, p < 0.0001)respectively. Time to two segment sensory regression, total duration of analgesia, duration of motor blockade was (115.24 ± 8.9 min, 370.60 ± 17.98 min, 316.67 ± 21.39 min) in group D and (103.58 ± 11.25 min, 323.91 ± 23 min, 273.51 ± 18.95 min) in group C respectively (p < 0.001). The post-operative visual analogue scale score (VAS) was more in group C at 240 min onwards (p ≤ 0.01). Analgesic use and intraoperative complications were similar in both the groups. (p > 0.05).ConclusionsWe recommend clonidine 30 µg over dexmedetomidine 5 µg as an adjuvant to intrathecal bupivacaine, to effectively and safely prolong the effect of single shot spinal anesthesia.

Height-adjusted dose of intrathecal bupivacaine on surgical anesthesia for the cesarean section

Background: In the spinal anesthetic technique, local anesthetic dose (concentration and volume) is the main determinant of its adequacy and success of block to be achieved. The lack of pain during surgical intervention rather than on dermatome sensory block level is considered to be an appropriate indicator of surgical anesthesia. Spinal anesthesia is the most common anesthetic technique to provide anesthesia for the elective or emergent cesarean section (CS). However, spinal block-induced maternal hypotension is the most common adverse effect during single-shot spinal anesthesia. In our study, we aim to study the height-adjusted dose of 0.5% Bupivacaine Heavy (BH) in achieving surgical anesthesia and its effect on maternal hypotension. Participants and Method: One hundred parturients scheduled for elective CS were enrolled and were compared to the parallel arms of parturients receiving conventional BH. Fifty parturients in each group were included. In the conventional group (B), participants received spinal block with 12 mg of 0.5% BH, and in the height adjusted-dose group (H), participants received a dose of 0.5% BH in 0.06 mg per centimetre height. A sensory block level of T6 dermatome or higher was consider adequate to start surgery. The adequate surgical anesthesia is considered to be achieved if cesarean delivery can be performed without supplementary analgesia. The need of supplementary analgesia, conversion to general anesthesia, or no block till 15 min of intrathecal BH is considered spinal failure. Results: 4% of the height-adjusted dose group have a low block level. Two cases complained of pain, and of them, one received supplementary analgesia and one was converted to general anesthesia. Systolic hypotension of a maternal blood pressure of less than 90 mm Hg was found in 19 (38%) and 10 (20%) in the conventional group and HAD group, respectively, which was highly significant statistically (p value 0.001%). Conclusion: Intrathecal hyperbaric bupivacaine in height adjusted 0.06 mg per cm height of patient can achieve surgical anesthesia with maintainance of systolic blood pressure. However, low dosing of intrathecal BH has higher cases of block failure in comparison to the conventional fixed dose regime of spinal anesthesia.

Evaluation of the Effects of Doses of Dexmedetomidine as Adjuvants to Hyperbaric Bupivacaine in Subarachnoid Blocks for Elective Caesarean Sections: A Prospective, Randomised, Triple-blind Controlled Study

Introduction: Since single-shot spinal anaesthesia for caesarean section operations provides limited postoperative analgesia, several adjuvants are employed to obtain the prolonged duration of sensory block. Dexmedetomidine (DMT) used as an adjuvant to 0.5% hyperbaric bupivacaine is found to provide a longer duration of analgesia. Aim: To evaluate the block characteristics and neonatal effects of three doses of DMT 2.5 μg, 5 μg and 7.5 μg used as adjuvants to 0.5% hyperbaric bupivacaine (10 mg). Materials and Methods: A prospective randomised multi arm triple-blind controlled study was conducted at the Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Andhra Pradesh, India from May 2020 to May 2022 on parturients who were assigned to four groups of 20 each. Parturients of Groups A, B and C were given 0.5% hyperbaric bupivacaine (10 mg) with DMT 2.5 μg (0.1), 5 μg (0.2 ) or 7.5 μg (0.3 ) ml respectively as adjuvant and those in Group D were given 2 mL of 0.5% hyperbaric bupivacaine alone and the final volume was made 2.5 in all four groups by adding sterile normal saline (0.9% NaCl). Characteristics of the mother and neonate like age, height, body weight, Body Mass Index (BMI), gravida status etc., were recorded, the duration of analgesia, the total quantity of the analgesic medicine consumed during the 1st 24 hours of the postoperative period, duration of the motor and sensory blocks, changes in haemodynamic variables were also noted. Ramsay Sedation Scores (RSS), surgeon and patient satisfaction scores were recorded for statistical analysis. Parametric data was analysed using the Analysis of Variance (ANOVA) and Tukey’s post-hoc test and non parametric data using the Chi-square test. Statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 20.0 and a p-value of ≤0.05 was considered statistically significant. Results: Parturients of Groups A, B and C had an earlier onset of sensory block 4.3±0.8, 3.6±0.5, 2.7±0.5 minutes respectively compared to control 5.7±0.6 minutes (p-value &lt;0.001). They also had a longer duration of analgesia 203.6±14.4, 320.2±24.0, 340.0±14.4 minutes respectively compared to those in control 150.1±7.1 minutes (p-value &lt;0.0001) and consumed a lesser amount of analgesic medication; 165.0±14.4, 110.0±30.7, 100.0±0.0 mg compared to control 190.0±30.7 mg (p-value &lt;0.001). Surgeon scores regarding the anaesthetic technique were satisfactory in a greater proportion/percentage of parturients in Groups A, B and C; 13 (65%), 16 (80%) and 18 (90%), respectively vs 9 (45%) in control p-value &lt;0.01198. Patient scores regarding the anaesthetic technique were satisfactory in a greater proportion/percentage of parturients in Groups A, B and C; 14 (70%), 17 (85%), 19 (95%), respectively vs 10 (50%) in control p-value &lt;0.00652. Conclusion: On the basis of the results of the present study, it was concluded that 5 µg DMT added as an adjuvant to 10 mg of 0.5% hyperbaric bupivacaine intrathecally was the optimal drug combination to be used for spinal anaesthesia for caesarean section cases, whereas a higher dose of 7.5 µg DMT had resulted in greater fluctuations in Pulse Rate (PR) and Mean Arterial Pressure (MAP) and a lower dose of 2.5 µg DMT had resulted in a shorter duration of analgesia.

Effects of Body Roundness Index on Spinal Anesthesia Block Characteristics

Body roundness index (BRI) is based on the assumption that the human body's shape is an ellipse, which combines height and waist circumference. We aimed to investigate the effect of BRI on spinal anesthesia [SA] sensory levels and hypotension in patients undergoing elective surgery. In this observational study, we prospectively enrolled 18-80 years old patients with ASA physical status I-III who underwent single-shot spinal anesthesia using 15 mg 0.5% hyperbaric bupivacaine at L3–L4 intervertebral space for transurethral and lower limb surgery. Maximum sensory blockade level at 15th and 30th min, block regression time to L2 level, hypotension, bradycardia occurrence were recorded. BRI, waist, and hip circumference were found as independent predictive factors in a maximum sensory blockade level at 15th min [OR=65.7 95% CI: 1.304-3310, p=0.036; OR=0.733 95% CI: 0.558-0.963, p=0.026; OR=1.065 95% CI: 1.001-1.133, p=0.047; respectively]. Hypotension after SA was not associated with anthropometric variables. BRI can be used as a new practical tool to predict the increased cephalic spread of local anesthetic in patients undergoing SA.

Continuous Spinal Anaesthesia Versus Single-Shot Spinal Anaesthesia in Terms of Hemodynamic Stability

Continuous Spinal Anaesthesia Versus Single-Shot Spinal Anaesthesia in Terms of Hemodynamic Stability

Total failure of spinal anesthesia for cesarean delivery, associated factors, and outcomes: A retrospective case-control study.

Spinal anesthesia is the anesthetic technique of choice for patients undergoing cesarean delivery. In the present study, total spinal anesthesia failure was defined as a case when an absent blockade or inadequate surgery required general anesthesia administration with an endotracheal tube. This study aimed to investigate factors related to this condition and report its maternal and neonatal outcomes.This retrospective matched case–control study was conducted by recruiting 110 patients with failed spinal anesthesia and 330 control patients from September 1, 2016, to April 30, 2020, in the largest university hospital, Thailand.Of 12,914 cesarean deliveries, 12,001 patients received single-shot spinal anesthesia (92.9%) during the study period. Total spinal anesthesia failure was experienced by 110/12,001 patients, giving an incidence of 0.9%. Factors related to the failures were a patient body mass index (BMI) ≤29.5 kg/m2 (adjusted odds ratio 1.9; 95% confidence interval 1.2–3.1; P = .010) and a third-year resident (the most senior trainee) performing the spinal block (adjusted odds ratio 2.4; 95% confidence interval 1.5–3.7; P < .001). In the group with failed spinal anesthesia, neonatal Apgar scores at 1 and 5 minutes were lower than those of the control group (both P < .001). Two patients in the failed spinal anesthesia group (2/110; 1.8%) had difficult airways and desaturation.Independent factors associated with total spinal anesthesia failure were a BMI of ≤29.5 kg/m2 and a third-year resident performing the spinal block. Although the incidence of total failure was infrequent, there were negative consequences for the mothers and neonates. Adjusting the dose of bupivacaine according to the weight and height of a patient is recommended, with a higher dose appropriate for patients with a lower BMI.

Effect of encouraging a combined spinal epidural technique for cesarean delivery anesthesia

A combined spinal epidural anesthetic technique allows an anesthesia provider to administer local anesthetic through an epidural catheter in the event of a failed spinal anesthetic. Prior to May 2019, our hospital performed single-shot spinal anesthesia exclusively for cesarean deliveries. In May 2019, anesthesia providers at our hospital were encouraged to perform combined spinal epidural anesthesia for cesarean delivery. We hypothesized that subjects who received combined spinal epidural anesthesia would have superior anesthetic outcomes compared to subjects who received single-shot spinal anesthesia. We performed a retrospective review of subjects who had cesarean deliveries at our hospital from May 15, 2019, through April 15, 2021, who received either single-shot spinal anesthesia or combined spinal epidural anesthesia. Subjects who received combined spinal epidural anesthesia were older, had a higher body mass index, had higher parity, were more likely to have had a cesarean delivery in the past, were more likely to have had the neuraxial anesthetic technique performed by a junior resident, and had a lower intrathecal dose of hyperbaric bupivacaine. Combined spinal epidural anesthesia had similar anesthetic outcomes to single-shot spinal anesthesia for cesarean delivery despite more complex subjects with less experienced operators.

Системна запальна відповідь після операцій на кульшовому суглобі: порівняння спінальної анестезії та комбінації спінальної анестезії з паравертебральною блокадою

Актуальність. C-реактивний білок (CRP) як біохімічний маркер неспецифічного запалення є об’єктивною мірою інвазивності при протезуванні кульшового суглоба. Мета дослідження. Порівняння рівнів CRP після операцій на кульшовому суглобі в умовах або комбінації спінальної анестезії з паравертебральною блокадою, або однієї лише спінальної анестезії. Матеріали та методи. 22 пацієнти, які мали однобічні операції на кульшовому суглобі, були випадковим чином розподілені на дві групи. У контрольній групі (n = 11) проводилась одноразова спінальна анестезія. У дослідній групі (n = 11) під час операції застосовувалась така сама спінальна анестезія, а після операції — однобічна пролонгована паравертебральна блокада. Результати. У 1, 3 і 7-й післяопераційні дні рівні CRP були статистично значуще (p &lt; 0,05) нижчими у дослідній групі, ніж у контрольній. Висновки. Післяопераційне знеболювання пролонгованою паравертебральною блокадою після інтраопераційної спінальної анестезії для операцій на кульшовому суглобі супроводжується меншим зростанням рівня CRP, ніж після однієї лише спінальної анестезії.

Spinal Anesthesia in Patient with Congestive Heart Failure due to Congenital Atrial Septal Defect, and Pulmonary Hypertension Undergoing Cesarean Section Procedure: A Case Report

Introduction. In patients suffering from heart disease, pregnancy is a risk factor for mortality. Heart disease in pregnant women can be in form of rheumatic heart disease, cardiomyopathy, or congenital heart disease. This case report is about the successful spinal anesthesia technique in cesarean section (C-section) patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension (PH).&#x0D; Case presentation. A pregnant woman, 24 years old, planned to have an emergency C-section. She complained about shortness of breath for 2 days before admission. Three months ago, the patient started to feel shortness of breath during activity and also complained her legs swelled. She has a history of congenital heart i.e. atrial septal defect (ASD), but not routinely been treated. Her examination showed tachypnea, murmur, bibasilar fine crackles lung sound, and pretibial pitting edema. Echocardiography showed ASD with pulmonary hypertension. Spinal Anesthesia using 0.5% isobaric bupivacaine 7.5 mg and fentanyl 25 µcg was given before surgery. Drugs was injected in L3-L4 level with the upper target was as high as T6. the head position is raised 30 degrees. Procedure went well and the APGAR score was 8/9, Patient was admitted to the ICU for one day and discharged from hospital at the 5 days of hospital care.&#x0D; Conclusion. Spinal single-shot spinal anesthesia with small doses of bupivacaine and adjuvant can be used as an alternative technique in emergency C-section for patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension.

Anesthetic management of obese and morbidly obese parturients.

The prevalence of obese parturients is increasing worldwide. This review describes safe analgesic techniques for labor and anesthetic management during cesarean sections in obese parturients. The epidural analgesic technique is the best way to provide good pain relief during the labor phase and can be easily converted to a surgical anesthetic condition. However, the insertion of the epidural catheter in obese parturients is technically more difficult compared to that in non-obese parturients. The distance from the skin to the epidural space increases in proportion to the body mass index (BMI): 4.4 cm in mothers of normal weight and 7.5 cm in mothers with BMI 50 and above. Neuraxial blocks are the ideal anesthetic methods and gold standard techniques for cesarean section in pregnant women with obesity. Single-shot spinal anesthesia is the most common type of anesthesia used for cesarean sections. The advantage of single-shot spinal anesthesia is a dense-sufficient block of rapid onset. A combined spinal-epidural (CSE) anesthetic technique is also recommended as an attractive alternative method. In obese parturients, the operation time can be longer than expected, and therefore, the CSE technique provides the advantage of rapid onset and intense block for prolonged operation with postoperative pain control. The risk of postoperative complications is very high in obese parturients. Therefore, detailed communication of the parturient's medical condition and the details of surgery and anesthesia between the anesthesiologist and obstetrician is important prior to cesarean section in obese pregnant women.

Associated factors with umbilical arterial pH after cesarean delivery under spinal anesthesia: a retrospective cohort study

BackgroundMaximum decrease of blood pressure and number of minutes of hypotension were independently associated with umbilical arterial pH. However, the impact of hypotension considering the duration of it on umbilical arterial pH is unknown. MethodsPregnant women aged ≥ 20 years who delivered a baby at full-term via a cesarean delivery under a single-shot spinal anesthesia between January 2017 and March 2019 were included. The main outcome was to predict umbilical arterial pH, based on the value of the time integral of hypotension. Patient demographics, patient comorbidities, and intraoperative data, including the total dose of ephedrine and phenylephrine by fetal delivery and cumulative duration of maternal hypotension, were evaluated. Maternal hypotension was reflected as a decrease in systolic arterial pressure and mean arterial pressure to < 80% of baseline values. The systolic arterial pressure and mean arterial pressure were independently included in a multiple regression analysis along with all other explanatory factors to predict the umbilical arterial pH. ResultsOf the 416 eligible patients, 381 were enrolled. When including the systolic arterial pressure or mean arterial pressure in the model, emergency cases, the total dose of ephedrine, hypertensive disorders of pregnancy, and systolic arterial pressure or mean arterial pressure values were found to be significant predictive factors of umbilical arterial pH. ConclusionOur results suggest that an elevated time integral of maternal hypotension may have a negative impact on umbilical arterial pH. Therefore, to minimize the risk of fetal acidosis, maternal hypotension should be prevented with the consideration of vasopressors selection.

Sensory block level prediction of spinal anaesthesia with 0.5% hyperbaric bupivacaine: a retrospective study

There is still no consensus on how to determine the dose of spinal anaesthesia with adequate sensory block for a planned surgery. This retrospective study aimed to explore the associations of miscellaneous factors with peak sensory block level after spinal anaesthesia with hyperbaric bupivacaine, and to construct a predictive model for single-shot spinal anaesthesia. We collected the records of 401 non-pregnant adults who underwent spinal anaesthesia with 0.5% hyperbaric bupivacaine at the L3–4 or L4–5 intervertebral space for lower body surgeries. Multiple linear regression analysis was used to investigate predictors of the block level and build up the predictive model. Five variables were identified as independent predictors of the peak sensory block level, including bupivacaine dose, height, weight, gender and age. The predictive model for peak block level after spinal anaesthesia could be expressed as a formula with these five variables and the estimated predictive power was 0.72. Based on this model, it is possible to determine a reasonable dose of hyperbaric bupivacaine for spinal anaesthesia, which gives adequate sensory block required for diverse surgical procedures in various patients and could be considered as a dose reference for sensory block height in spinal anaesthesia.

Spinal subdural hematoma and subdural anesthesia following combined spinal\u2013epidural anesthesia: a case report

BackgroundSubdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal–epidural anesthesia.Case presentationA 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34+ 5 weeks underwent cesarean delivery. Routine combined spinal–epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal.ConclusionsAll anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.

Fundamentals and innovations in regional anaesthesia for infants and children.

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.