Spinal Anesthesia In Obstetrics Research Articles

Agreement between three noninvasive temperature monitoring devices during spinal anaesthesia for caesarean delivery: a prospective observational study.

Hypothermia during obstetric spinal anaesthesia is a common and important problem, yet temperature monitoring is often not performed due to the lack of a suitable, cost-effective monitor. This study aimed to compare a noninvasive core temperature monitor with two readily available peripheral temperature monitors during obstetric spinal anaesthesia. We undertook a prospective observational study including elective and emergency caesarean deliveries, to determine the agreement between affordable reusable surface temperature monitors (Welch Allyn SureTemp® Plus oral thermometer and the Braun 3-in-1 No Touch infrared thermometer) and the Dräger T-core© (using dual-sensor heat flux technology), in detecting thermoregulatory changes during obstetric spinal anaesthesia. Predetermined clinically relevant limits of agreement (LOA) were set at ± 0.5°C. We included 166 patients in our analysis. Hypothermia (heat flux temperature < 36°C) occurred in 67% (95% CI 49 to 78%). There was poor agreement between devices. In the Bland-Altman analysis, LOA for the heat flux monitor vs. oral thermometer were 1.8°C (CI 1.7 to 2.0°C; bias 0.5°C), for heat flux monitor vs. infrared thermometer LOA were 2.3°C (CI 2.1 to 2.4°C; bias 0.4°C) and for infrared vs. oral thermometer, LOA were 2.0°C (CI 1.9 to 2.2°C; bias 0.1°C). Error grid analysis highlighted a large amount of clinical disagreement between methods. While monitoring of core temperature during obstetric spinal anaesthesia is clinically important, agreement between monitors was below clinically acceptable limits. Future research with gold-standard temperature monitors and exploration of causes of sensor divergence is needed.

Spinal anaesthesia in obstetrics.

This article provides a comprehensive review of the technique, drugs of choice, and potential side effects and complications associated with the drugs used and the single-shot spinal anaesthesia (SSS) technique for caesarean delivery. Although neuraxial analgesia and anaesthesia are generally considered safe, all interventions come with potential adverse effects. As such, the practice of obstetric anaesthesia has evolved to minimize such risks. This review highlights the safety and efficacy of SSS for caesarean delivery while also discussing potential complications such as hypotension, postdural puncture headache, and nerve injury. In addition, drug selection and dosages are examined as well, emphasizing the importance of individualized treatment plans and close monitoring for optimal outcomes.

Comparative evaluation of two doses of phenylephrine infusion to prevent intra-operative nausea and vomiting during elective obstetric spinal anesthesia

Comparative evaluation of two doses of phenylephrine infusion to prevent intra-operative nausea and vomiting during elective obstetric spinal anesthesia

Troubleshooting obstetric spinal anaesthesia at district hospital level.

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

Total Spinal Anaesthesia in Obstetrics, Case Report and Literature Review

The use of spinal anesthesia in obstetrics is justified by the advantages it has over general anesthesia. It is a simple and easy technique. However, the possibility of serious complications or even death with this technique during cesareans leads to questions about its place. We report a case of totalization of spinal anesthesia during a cesarean section, that had a favorable evolution for both mother and child.

Diabetic Foot Push

The use of spinal anesthesia in obstetrics is justified by the advantages it has over general anesthesia. It is a simple and easy technique. However, the possibility of serious complications or even death with this technique during cesareans leads to questions about its place. We report a case of totalization of spinal anesthesia during a cesarean section, that had a favorable evolution for both mother and child.

Неврологические, травматические и септические осложнения нейроаксиальных методов обезболивания. Отдельные главы из монографии «Спинномозговая анестезия в акушерстве»

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Effect of prophylactic combination of glycopyrrolate, ondansetron, and ephedrine upon hypotension during obstetric spinal anaesthesia-A randomised controlled trial.

Background and Aims:Various pharmacological and non-pharmacological strategies have been employed to minimise hypotension during obstetric spinal anaesthesia. We compared a prophylactic combination of glycopyrrolate, ondansetron, and ephedrine in terms of total vasopressor consumption, with standard treatment in this randomised controlled trial.Methods:One hundred patients undergoing elective caeserean sections were randomly divided into two groups of 50 each, the study group received prophylactic ondansetron and glycopyrrolate boluses followed by an infusion of ephedrine, while the control group received ephedrine boluses as required. The total ephedrine consumption (primary objective), incidence and degree of hypotension, heart rate variations, and neonatal APGAR scores (secondary objectives) were analysed.Results:The median ephedrine requirement was lesser in the study group compared to the control group [13.2 mg (10--15.75) vs. 27.7 mg (12--24)], with a P value of 0.02. Fewer participants experienced hypotension in the study group before baby delivery compared to the control group (12 vs. 36, P = 0.004). Heart rate was higher in the study group. No significant differences were observed in neonatal APGAR scores and incidence of adverse events.Conclusion:A combination of glycopyrrolate, ondansetron, and ephedrine might offer better haemodynamic stability and reduce vasopressor consumption in obstetric patients undergoing spinal anaesthesia as opposed to standard treatment.

Management of obstetric spinal hypotension in resource-limited areas

Hypotension following obstetric spinal anesthesia is a common problem and has remained a focus of research and controversy for many decades. Recent advances on this subject have resulted in numerous recommendations for management of obstetric spinal hypotension. However, these advances have failed to reduce the unacceptable number of fatalities that occur in resources limited environments which constitutes more than 75% of the world’s population. The reason being the failure of translation of the research done in resource-rich environments, and its application and performance in resource-poor environments. This review focuses on the problems faced by clinical environment that are deficient in appropriate resources and manpower. It further proposes an outline for management of spinal hypotension and recommends suitable research agenda to address the deficiencies.&#x0D; Received: 5 Sep 2018Reviewed: 7 Nov 2018Accepted: 10 Nov 2018&#x0D; Citation: Ismail S. Management of obstetric spinal hypotension in resource-limited areas. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S133-S136

Quick Entonox/nitrous oxide: Oxygen to ease spinal anesthesia in obstetrics

Sir, Entonox has been one of the modalities as a part of labor analgesia. It is safe and can be implemented immediately.[1] Although epidural analgesia plays a primary role in the management of labor analgesia, the use of 50:50 oxygen (O2)/nitrous oxide (N2O) is still a useful practice in operation theater (OT) for obstetric surgeries. Not many obstetric patients come to OT from the labor room with an epidural catheter in situ. However, anesthesiologists continue to receive patients for cesarean sections with ongoing labor pain. Nonprogress of labor, cephalopelvic disproportions, maternal requests, and failure of epidural analgesia are some indications for lower segment cesarian section (LSCS) of semi-urgent nature where patients are received with ongoing labor pain. These patients are uncooperative for proper positioning during subarachnoid block (SAB); as a result, there can be an increase in the number of attempts and chances of failure or partial block can be observed. Can Entonox/N2O:O2 help? Three cases of the American Society of Anesthesiologists II obstetric patients were posted for emergency LSCS with no indication of fetal distress with ongoing labor pain. They were subjected to N2O:O2 inhalation in the form of 4 L of O2 and 4 L of N2O on the operation table with anesthesia workstation (Datex Ohmeda) via closed circuit. After 4–6 breaths, the patients were comfortable, quiet, and cooperative. This facilitated the performance of SAB by the anesthesiologist. It helped in performance of the SAB procedure with ease by keeping patients comfortable during positioning. Once SAB was done, the patient was turned supine and 100% O2 was given for 10 min or till delivery of the baby. Entonox in the form of O2 and N2O gas flows in the ratio of 50:50 has been used to supplement patchy blocks of spinal anesthesia or partial failures during cesarean section surgeries.[2] There were no adverse effects on the newborn in our cases and had good Apgar scores. Entonox has been used for labor analgesia either in continuous form or intermittently with the onset of labor pain without any consequences on the neonatal outcome.[34] Orthopedic patients with fractures and obstetric patients are the known categories where compliance in positioning for neuraxial anesthesia might face problems due to pain resulting in failed spinal anesthesia.[5] In these circumstances N2O:O2 combination can be effective for analgesia for acute pain relief. It proves safer in obstetric patients than systemic analgesia which is considered in nonobstetric patients.[5] The duration of use of N2O:O2 to help SAB is ultra short. We suggest the use of Entonox inhalation in the form of N2O:O2/50:50 mixture of gas flow, especially in obstetric patients with ongoing labor pain to facilitate performance of SAB. This will help the mother to cooperate well and facilitates the anesthesiologist to perform SAB. The use of Entonox can ease the anticipated difficult SAB in anxious and hollering obstetric patients promoting a successful SAB. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention.

Establishing a sustainable anaesthetic education programme at Jimma University Medical Centre, Ethiopia.

Lack of continuing education and physician anaesthetist support are commonly cited problems amongst Ethiopian anaesthetic providers. Whilst operating at Jimma University Medical Centre (JUMC), Operation Smile volunteers identified a clear need for improvement in anaesthetic care delivery at JUMC. JUMC is a 450-bed university teaching hospital 350 km southwest of Addis Ababa. At the start of this programme it had two physician anaesthetists, with the majority of anaesthesia historically having been provided by non-physician anaesthesia providers. A visiting lecturer programme was established at JUMC in 2012 following collaboration between two consultant anaesthetists, working for Operation Smile and JUMC respectively. UK trainee anaesthetists in their final years of anaesthetic training volunteered at JUMC for periods of two to six months, providing sustainable education and consistent physician anaesthetist presence to support service provision and training. Over its six-year history, nine visiting lecturers have volunteered at JUMC. They have helped establish a postgraduate training programme in anaesthesia, assisting in the provision of a future physician anaesthetist workforce. Four different training courses designed for low- and middle-income countries (LMICs) have been delivered and visiting lecturers have trained local anaesthetists in subsequent course delivery. Patient safety and quality improvement projects have included introducing the World Health Organization Surgical Safety Checklist, Lifebox pulse oximeters, obstetric spinal anaesthesia packs, improving critical care delivery and establishing two post-anaesthetic care units. Development of partnerships on local, national and global platforms were key to the effective delivery of relevant sustainable education and support. Instilling local ownership proved fundamental to implementing change in the local safety culture at JUMC. Sound mentorship from anaesthetic consultant supervisors both in the UK and in Jimma was crucial to support the UK trainee anaesthetists working in a challenging global setting. This model of sustainable capacity building in an LMIC with a significant deficit in its physician workforce could be replicated in a similar LMIC setting.

Core Temperature Monitoring in Obstetric Spinal Anesthesia Using an Ingestible Telemetric Sensor

(Anesth Analg. 2018;126(1):190–195) Maternal core temperature is difficult to monitor during cesarean delivery (CD) under spinal anesthesia (SA). A drop in maternal core temperature &lt;36.0°C during the perioperative period is associated with increased risks of postoperative morbidity. Current knowledge of the thermal insult associated with obstetric SA is limited to small randomized controlled trials. In the present study, the authors used continuous core temperature recording to generate high-resolution data on thermal insult and thermal recovery associated with CD under SA.

Core Temperature Monitoring in Obstetric Spinal Anesthesia Using an Ingestible Telemetric Sensor.

Perioperative hypothermia may affect maternal and neonatal outcomes after obstetric spinal anesthesia. Core temperature is often poorly monitored during spinal anesthesia, due to the lack of an accurate noninvasive core temperature monitor. The aim of this study was to describe core temperature changes and temperature recovery during spinal anesthesia for elective cesarean delivery. We expected that obstetric spinal anesthesia would be associated with a clinically relevant thermoregulatory insult (core temperature decrease >1.0°C). A descriptive study was conducted in 28 women. An ingestible telemetric temperature sensor was used to record core temperature over time (measured every 10 seconds). The primary outcome was the maximum core temperature decrease after spinal anesthetic injection. The secondary outcomes were lowest absolute core temperature, time to lowest temperature, time to recovery of core temperature, hypothermic exposure (degree-hours below 37.0°C), and the time-weighted hypothermic exposure (median number of degrees below 37.0°C per hour). Basic descriptive statistics, median spline smooth, and integration of the area below the 37.0°C line of the temperature-over-time curve were utilized to analyze the data. Intestinal temperature decreased by a mean (standard deviation) of 1.30°C (0.31); 99% confidence interval (CI), 1.14 to 1.46 after spinal anesthetic injection. The median (interquartile range [IQR]) time to temperature nadir was 0.96 (0.73-1.32) hours (95% CI, 0.88-1.22). Fourteen of the 28 participants experienced intestinal temperatures below 36.0°C after spinal injection. Temperature was monitored for a minimum of 8 hours after spinal injection. In 8 of 28 participants, intestinal temperature did not recover to baseline during the monitored period. A median (IQR) of 4.59 (3.38-5.92) hours (95% CI, 3.45-5.90) was required for recovery to baseline intestinal temperature in the remaining 20 patients. Participants experienced a median (IQR) of 1.97 (1.00-2.68) degree-hours of hypothermic exposure (95% CI, 1.23-2.45). The median (IQR) number of degrees below 37.0°C per hour was 0.45 (0.35-0.60) (95% CI, 0.36-0.58). During cesarean delivery under spinal anesthesia, women experienced a rapid decrease in core temperature. Using an intestinal telemetric sensor, the perioperative thermal insult and recovery were documented with high resolution. Fifty percent of participants in this study became hypothermic. Although the surgical procedure is typically of short duration, women undergoing spinal anesthesia for cesarean delivery experience significant hypothermic exposure and compromised thermoregulation for several hours.

Obstetric spinal hypotension: Preoperative risk factors and the development of a preliminary risk score - the PRAM score.

Obstetric spinal hypotension is a common and important problem during caesarean delivery. Identifying patients at risk for hypotension may guide clinical decision-making and allow timeous referral. Using preoperative risk factors, to develop a simple scoring system to predict systolic hypotension. This prospective, single-centre, observational study of patients undergoing elective or urgent caesarean delivery assessed body mass index, baseline heart rate, baseline mean arterial pressure (MAP), maternal age, urgency of surgery (elective v. non-elective) and preoperative haemoglobin concentration as predictors of spinal hypotension (systolic blood pressure &lt;90 mmHg). We used empirical cut-point estimations in a logistic regression model to develop a scoring system for prediction of hypotension. From 504 eligible patients, preoperative heart rate (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.00 - 1.03; p=0.012), preoperative MAP (OR 0.97, 95% CI 0.95 - 0.98; p&lt;0.001) and maternal age (OR 1.05, 95% CI 1.02 - 1.08; p=0.002) were found to be predictors of hypotension. We derived a preliminary scoring system (pulse rate &gt;90 bpm, age &gt;25 years, MAP &lt;90 mmHg - the PRAM score) for the prediction of systolic hypotension following obstetric spinal anaesthesia. Patients with three factors had a 53% chance of developing hypotension, compared with the overall incidence of 30%. The PRAM score showed good discrimination, with a c-statistic of 0.626 (95% CI 0.576 - 0.676) and good calibration. Preoperative heart rate, preoperative MAP and maternal age were predictive of hypotension in elective and emergency caesarean delivery. The PRAM score shows promise as a simple, practical means to identify these patients preoperatively, but requires prospective validation.

Postoperative analgesia using bupivacaine wound infiltration with intravenous tramadol or dexamethasone following obstetric spinal anaesthesia.

Effective management of postcesarean section (CS) pain is important for the well-being of mother and child; even in limited-resource areas, there are drug options which can be explored to achieve this. This study aimed to compare the analgesic effects of a combination of bupivacaine wound infiltration with either intravenous (IV) dexamethasone or tramadol after CS. This study was a randomized, double-blind, comparative study in a tertiary hospital. Clearance obtained from the Institution's Ethics and Research Committee. One hundred and twenty American Society of Anesthesiologists I or II pregnant women scheduled for CS under spinal anesthesia were recruited after giving consent. At the end of skin closure, all the patients received 20 ml of 0.1% plain bupivacaine for wound infiltration and IV dexamethasone 8 mg (Group BD) or tramadol 100 mg (Group BT). Outcome measures were time to first analgesic request, visual analog scale (VAS) scores, side effects, and patients' satisfaction. Time to first analgesic request was 3.2 ± 1.87 and 3.3 ± 2.01 h for BD and BT groups, respectively (P = 0.778). VAS scores for the first 2 h were lower in the bupivacaine/tramadol group compared to bupivacaine/dexamethasone group; the differences were statistically significant at 30 and 60 min (P = 0.027 and 0.008), respectively. Ninety percent versus 93% of the patients in BD and BT groups, respectively, expressed good to excellent satisfaction with pain relief. Combination of bupivacaine wound infiltration and IV tramadol provided better quality pain relief.

Recipes for obstetric spinal hypotension: The clinical context counts.

Hypotension following obstetric spinal anaesthesia remains a common and important problem. While recent research advances have brought us closer to the perfect recipe for the obstetric spinal anaesthetic, these advances have not been translated into practical guidelines able to reduce the unacceptable number of fatalities that occur in environments where resources are limited. In South Africa, more than half of anaesthetic deaths are still related to spinal hypotension. A gap exists between the 'perfect recipe', developed from a clinical context rooted in resource-rich research environments, and its application and performance in real-world resource-poor environments - conditions experienced by more than 75% of the world's population. This review attempts to define this knowledge gap and proposes a research agenda to address the deficiencies.

Post-procedure adhesive arachnoiditis following obstetric spinal anaesthesia.

Sir, Adhesive arachnoiditis is a crippling disorder in which the pia-arachnoid undergoes extensive inflammatory reactions to injurious stimulus, resulting in subarachnoid scarring. A Swedish study reports the incidence of neurological complications as one case per 2834 subarachnoid blocks and at least one permanent damage for every 923 epidural blocks.[1] A Finnish study reports an incidence of serious complications as 0.45/10,000 for intrathecal and 0.52/10,000 for epidural blocks.[2] A 35-year-old mother with no significant medical history, in her second pregnancy, underwent spinal anaesthesia for an elective caesarean section at 40 weeks gestation at another hospital. As per the information obtained, spinal anaesthesia in sitting position was performed with due aseptic precautions in L2-L3 interspace using 10% povidone-iodine (betadine™) solution. The cerebrospinal fluid (CSF) tap could be obtained on the second attempt. After aspiration of clear, free-flowing CSF, 12 mg of 0.5% hyperbaric bupivacaine was administered. Surgery proceeded uneventfully. On the second post-operative day, on the removal of the urinary catheter, the patient complained of urinary incontinence with the loss of sensation over the perineal area and buttocks. Gradually she also complained of constipation, following which an enema was given on the fourth post-operative day. She passed stool but, subsequently, lost her bowel control too. The patient was referred 11 days post-partum to our centre with signs of S2-S4 radiculopathy, urinary retention, constipation with faecal impaction, loss of sensation over buttocks and perineal area with weak perianal reflex. All her records from the previous hospital were obtained. A thorough examination demonstrated localised unilateral right-sided sensory loss over T11-T12 dermatome. The rectum was hugely loaded with faecal matter. A lumbosacral spine magnetic resonance imaging (MRI) [Figure 1] showed thickening, clumping and nodular enhancement of cauda equina nerve roots, suggestive of arachnoiditis. CSF analysis showed mild lymphocytosis.Figure 1: Axial magnetic resonance imaging of lumbosacral spine T2 weighted, the arrow showing thickening, clumping and nodular enhancement of cauda equina nerve roots-suggestive of arachnoiditis (likely post-surgery/procedure)A neurosurgical opinion was taken and the patient was put on a short course of steroids (tablet deflazacort six mg thrice daily). She was asked to undergo physiotherapy and was also suggested transcutaneous electrical nerve stimulation therapy. The patient was discharged to a rehabilitation centre where she received oral methylprednisolone 16 mg once daily for 7 weeks with gabapentin 100 mg thrice daily for 3 weeks. A repeat MRI 2 months later showed mild enhancement of cauda, clumping of root and resolution compared to the previous MRI. The patient was advised pelvic floor exercises with dietary adjustments to control the faecal incontinence. Steroids were tapered over 2 months after reviewing her 30 days later. She was advised to remove catheter under medical guidance and watch for retention and bladder sensation. At 12 months follow-up, the patient has significantly regained her bladder control. There was still considerable impairment in bowel control. The anal tone had not completely resolved till the date of submission of this manuscript. Contamination of intrathecal local anaesthetic drugs with noxious chemicals has been widely suggested as an aetiology in cases of adhesive arachnoiditis; phenolic, acidic and detergent contaminants all being known neurotoxic agents.[34] Alcoholic chlorhexidine, in 2008, was the identified as a culprit in a case of arachnoiditis in a trial held at the United Kingdom.[5] We considered povidone-iodine contamination as a possibility in this case, by contamination of the injectate or improper cleaning of povidone iodine from the skin before proceeding with the subarachnoid block. Without more definitive data, neuraxial blocks should be done under stringent aseptic, atraumatic techniques after discarding all sources of contamination. It also seems pertinent to explain to patients the risks of late, permanent neurological deficit while obtaining informed consent. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement This case study was supported by the entire Department of Anaesthesiology and Intensive Care Medicine, B. R. Singh Hospital, Eastern Railway, Kolkata. We are also thankful to the Department of Gynaecology and Obstetrics, B. R. Singh hospital, the nursing staff and attendants for the support in patient care and to the patient and her family for giving consent to proceed with submission for publication of the report.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Ultrasound-guided spinal anaesthesia in obstetrics

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