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Combined Spinal Epidural Anaesthesia (CSEA) combines advantages of both component techniques while precluding their known disadvantages. Further, a low dose intrathecal Bupivacaine followed by sequential epidural doses calculated as per the unblocked number of segments may provide sufficient volume extension to precisely and adequately target the required surgical field. 66 patients scheduled for major surgeries under neuraxial anaesthesia were randomized into two groups. GROUP A (n=33) received CSEA with 1.5 ml 0.5% Hyperbaric Bupivacaine (7.5 mg) intrathecally at L3-L4 site followed by 0.75 ml (16 patients) to 1.5 ml (17 patients) 0.5% plain Bupivacaine per unblocked segments through epidural catheter. GROUP B (n=33) received only 2.5 ml 0.5% Hyperbaric Bupivacaine (12.5 mg) intrathecally at L3-L4 site. The maximun level of sensory block was T11 after spinal component of CSEA in group A and T6 in group B. In group a, subsequent epidural dosing of 0.5% Bupivacaine with 1.5 ml per unblocked segments (stat/increment) in 17 patients raised the level by 6-segments. In the other subgroup of 16 patients who received 0.75 ml per segment epidural dose, there was 4-segment raise in block level. Time for 2-segment regression was 0.6±0.2 hours (Group A) compared to 2.4±0.5 hours (Group B) with p<0.001. The total duration of sensory block was 1.9±0.4 hours (Group A) and 4.8 ± 1 hours (Group B) with p< 0.001. For CSEA in major abdominal surgeries, an intrathecal dose of 1.5 ml 0.5% Hyperbaric Bupivacaine (7.5 mg) is sufficient as initialising dose. The surgical need of analgesia for uncovered segments can be provided predictably with epidural 0.5% plain Bupivacaine as increments of 0.75 ml per required segment. [ABSTRACT FROM AUTHOR]

Background: Lumbar epidural analgesia is a safe, effective, and beneficial technique for both the parturient and the fetus. Dural puncture epidural has been claimed to be better than combined spinal epidural and epidural techniques by many. We undertook this study to compare the three techniques regarding duration, quality of analgesia, and side effects. Debate regarding the best neuraxial technique for labor analgesia continues. Materials and Methods: The parturients of ASA grade I and II of age group 20–35 years were randomly divided into three groups of 20 each. Group E (epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 μg fentanyl in the epidural space. Group CSE (combined spinal epidural group) received 2.5 mg of intrathecal isobaric levobupivacaine with 25 μg fentanyl and epidural top up of 15 ml of 0.125% levobupivacaine with 30 μg fentanyl. Group DPE (dural puncture epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 μg fentanyl in epidural space; intrathecal medication was withheld. Epidural top-up doses were given as per Visual Analog Scale (VAS). Analgesic efficacy, extent of sensory and motor block, maternal and fetal outcome, duration of analgesia, and maternal satisfaction score were compared among three groups and analyzed statistically. Results: The onset and symmetry of sensory blockade and VAS score were better in CSE group. DPE group had better sacral coverage and less asymmetric blockade. Groups CSE and DPE had superior maternal and surgeon satisfaction scores in comparison to group E. Both groups E and DPE provided analgesia with minimal motor blockade and ambulation. [ABSTRACT FROM AUTHOR]

Objective: This study aims to compare levobupivacaine 0.125% and ropivacaine 0.2% with fentanyl as epidural drugs for labor analgesia using combined spinal epidural (CSE) technique regarding time for onset, duration of analgesia achieved by first epidural bolus dose and to compare the quality of labor analgesia. In addition, the study is also designed to assess the maternal and fetal outcome, incidence of instrumental delivery, degree of motor blockade, and maternal satisfaction. Materials and Methods: Following approval from Institutional Ethical Committee, 50 American Society of Anesthesiologists Physical Status II pregnant women requesting labor analgesia, satisfying the inclusion criteria were randomly divided equally into Groups L and R. CSE performed, 0.5 ml hyperbaric bupivacaine 0.5% with fentanyl 25 mcg administered intrathecally. IEBs 10 ml of study drugs given through epidural catheter as demand dose. Results: The mean onset of analgesia with Group R and group L were 16.280 ± 1.59 min and 21.480 ± 1.32 min(P = 0.000) respectively. The total duration of analgesia in Group R = 72.08 ± 1.97 min, whereas Group L = 82.160 ± 2.07 min (P = 0.000). There was no difference between the groups in terms of maternal demographic traits, mode of delivery, maternal and fetal outcome, and maternal satisfaction. Both 0.125% levobupivacaine and 0.2% ropivacaine produce excellent-quality of analgesia. Conclusion: Ropivacaine produces an early onset of analgesia than levobupivacaine but levobupivacaine had significantly prolonged analgesia compared to ropivacaine. Both drugs were found to be safe for labor analgesia. Maternal satisfaction and fetal outcome were similar with both the drugs. [ABSTRACT FROM AUTHOR]

Background: The effects of neuraxial analgesia on fetal heart tracings have been studied in "healthy" pregnancies. Our objective was to compare the impact of intrapartum epidural analgesia (EA) versus combined spinal epidural analgesia (CSE) on fetal heart rate changes in pregnancies at risk for uteroplacental insufficiency (UPI).Methods: Singleton pregnancies diagnosed with chronic hypertension, gestational hypertension and/or preeclampsia, and/or fetal growth restriction (FGR) and receiving neuraxial analgesia intrapartum from 2012 to 2015 were studied retrospectively. The primary outcome was change in fetal heart rate (FHR) category following neuraxial analgesia. Manual review of all FHR tracings was performed and classified by the National Institute of Child Health and Human Development (NICHD) categories. Data collection included maternal demographics, blood pressure, uterine tachysystole, uterine hypertonus, mode of delivery, interventions for FHR abnormalities and neonatal outcomes.Results: Of laboring patients at risk for UPI, 110 patients received EA and 127 patients received CSE. The rate and change in FHR categories and abnormalities following neuraxial analgesia were the same in both groups. Both EA and CSE resulted in a significant increase in NICHD FHR category II, from 27.3 to 65.5% for EA and 20.9 to 64.3% for CSE. The occurrence of maternal hypotension, uterine tachysystole, interventions for FHR abnormalities, and uterine hypertonus following neuraxial analgesia was not found to be significantly different between the two groups. When compared to the EA group, CSE had a higher rate of NICU admission (29.5 versus 16.4%, p = .021).Conclusions: FHR category increased following both CSE and EA. The side effects of maternal hypotension and need for fetal interventions was not different between CSE and EA. [ABSTRACT FROM AUTHOR]

Background: We aim to describe the evaluation and management of a patient with the uncommon combination of both mitochondrial myopathy and possible malignant hyperthermia susceptibility as an important source of information and as a valuable example of the role of regional anesthesia for patients with these diagnoses. Case presentation: A 24 year old woman with a history of possible mitochondrial myopathy and possible malignant hyperthermia susceptibility presented for gynecologic surgery. Surgery was well tolerated with combined spinal epidural anesthesia as well as sedation with midazolam, ketamine, and fentanyl. Conclusions: Anesthetic management of patients with mitochondrial myopathy is challenging, made even more so with concurrent malignant hyperthermia susceptibility. This case adds an example to the literature of employing regional anesthesia as a safe approach to this complex care. [ABSTRACT FROM AUTHOR]

Background: Dragging pain during lower abdominal surgeries under intrathecal anesthesia is a common problem. Epidural steroid seemed to be effective in reducing intra and postoperative pain. Kappa receptor agonist like nalbuphine helps in reduction of visceral pain. Hence, this study was designed to detect the efficacy of epidural steroid dexamethasone with intrathecal Kappa opioid as a sole anesthetic technique in patients subjected to lower abdominal oncology operations. Patients and Methods: Patients were randomly allocated into two groups; epidural placebo group–control group (Group P) – Intrathecal injection of 20 μg fentanyl followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5%, then (epidural injection placebo 15 mL volume of sterile saline 0.9%). Epidural dexamethasone group–study group (Group D) – Intrathecal injection of 0.6 mg nalbuphine followed by intrathecal injection of (15 mg) of hyperbaric bupivacaine 0.5% then (epidural injection of 8 mg dexamethasone in 15 mL total volume using sterile saline 0.9%). Results: Group D recorded significantly longer times to 1st analgesic request, sensory regression to S1 and modified bromage Score 0 with significant lower number of patients that had abdominal dragging pain in comparison with Group P. Visual analog score in the first four postoperative hours, total postoperative nalbuphine dose in 1st 24 h and incidence of nausea and vomiting were significantly lower in Group D. Heart rate and mean arterial pressure were comparable in both groups. Postoperative headache incidence was comparable in both groups. Both patient and surgeon satisfaction were significantly higher in Group D compared to Group P. Conclusion: Combined epidural dexamethasone with intrathecal nalbuphine as a sole anesthetic technique during lower abdominal oncology operations could be an efficient anesthetic technique that offered better block characteristics, with more analgesia and as a result it gained better patient and surgeon satisfaction. [ABSTRACT FROM AUTHOR]

Context: Block augmentation by epidural volume extension has been adequately documented but there have been not enough studies comparing different volumes of normal saline used in this technique to augment the level of block achieved. The study compares different volumes of normal saline(5,10 and 20 ml) for epidural volume extension in combined spinal epidural anaesthesia for lower abdominal surgeries. 120 women, aged between 20-60 years belonging to ASA grade I-II undergoing elective lower abdominal surgeries were included in this study. The patients were randomly allocated into 3 groups and each group comprised of 40 patients. GROUP 1(EVE 5) received 10 mg 0.5% bupivacaine heavy (H) intrathecally with 5 ml normal saline through the epidural catheter as a part of Epidural volume extension. GROUP 2 (EVE10) and GROUP 3 (EVE20) received 10 ml and 20 ml of normal saline as a part of Epidural volume extension respectively in addition to the intrathecal drug. The patients were assessed for sensory block level to loss of pain from pin prick and for motor block using Bromage scale. Peak sensory block height, highest Bromage score, time taken to achieve maximum sensory and motor block and the time to their recovery were recorded. Statstical Analysis. was done using statistical software SSPS version 16.0 and Epi- info version 6.0. Outcome measures were presented as % for qualitative variables and mean±SD for quantitative variables. Demographic data and duration of surgery were similar in all the groups. Sensory block augmentation was found to be significantly higher in the EVE10 and EVE 20 groups. There was no difference in the peak motor block score between the groups during the study. Time to achieve the blocks were significantly shorter for the 20 ml group than the 10 and 5 ml groups; the latter two being comparable. This was associated with a significantly faster motor recovery to Bromage 0 in groups EVE10 and EVE 20. [ABSTRACT FROM AUTHOR]

Background and aim: Neuraxial analgesia techniques are not limited to just standard epidural and CSE blocks. A novel approach called dural puncture epidural (DPE) which is a modification of CSE in terms of practice has gained popularity after its description and use in the obstetric population.  The aim of this review is to address the practice of DPE technique as a novel option by reviewing its benefits as well as side and/or adverse effects and to understand how neuraxial labor analgesia differs by approach based on the information available in the current literatureDiscussion: Despite controversies and concerns, more rapid onset of analgesia, early bilateral sacral analgesia, lower incidence of asymmetric block and fewer maternal and fetal side effects are provided with DPE when compared to epidural.Conclusion: DPE offers a favorable risk-benefit ratio for management of neuraxial analgesia as a novel option. [ABSTRACT FROM AUTHOR]

Background and Aims: The primary measure of efficacy of any analgesic regimen is pain relief, but it is important to measure dynamic pain relief rather than pain relief at rest. Epidural analgesia is an effective technique for postoperative analgesia. The drug combinations given therein (local anesthetics with adjuvants such as opioids/alpha-2 agonists), however, remain a personal choice. The aim of this study was to evaluate dynamic pain scores in patients receiving different epidural analgesia regimens for postoperative pain relief after elective gynecological surgery used in our institution. Material and Methods: One hundred eighty-seven patients enrolled in this study received postoperatively either bupivacaine 0.125% + morphine 0.1 mg/mL (group BM) or bupivacaine 0.125% + fentanyl 2 μg/mL (group BF) or bupivacaine 0.125% + clonidine 1 μg/mL (group C1) or bupivacaine 0.125% + clonidine 2 μg/mL (group C2) by continuous epidural infusion @ 5 mL/h. Differences in dynamic pain scores (on coughing and mobilization), pain scores at rest, sensory and motor blockade, sedation scores, dry mouth, pruritus, nausea, and vomiting were recorded. Also duration of postoperative analgesia, epidural top-ups, requirement of rescue analgesic, and patient satisfaction were determined. All observations were carried out at 1, 2, 4, 8, and 12 h after surgery and then at 8 am, 12 noon, 4 pm, 8 pm on subsequent postoperative day till removal of epidural catheter (after 96 h). Results: There was no difference in demographic or hemodynamic profile among the four groups (P > 0.05). There was no statistically significant difference in pain scores at rest among the four groups but dynamic pain scores were found to be better in group C2 as compared to group BM, BF, and C1 at most of the time intervals although not statistically significant (P > 0.05). Requirement of rescue analgesics was lower in group BM and group C2 as compared to group BF and C1 (P < 0.01). Incidence of pruritus was 43.5% in group BM and 19% in group BF, while no patients in group C1 or C2 had pruritus. Mean postoperative nausea and vomiting (PONV) scores were higher in group BM and group BF as compared to group C1 and C2 (P < 0.001). Mean sedation scores were comparable in all four groups. Incidence of dry mouth was 22% in group C2 as compared to 11% in group C1, while no patients in group BM or BF had dry mouth. Patients in group C2 were more satisfied as compared to other three groups. Conclusions: Combination of clonidine 2 μg/mL to 0.125% bupivacaine @ 5 mL/h in combined spinal epidural provides better postoperative analgesia as compared to combination of bupivacaine with opioids with greater patient satisfaction and significantly reduced side effects. [ABSTRACT FROM AUTHOR]

Background: Combined spinal-epidural anesthesia technique for providing pain relief for orthopedic procedures has gained popularity. It combines the advantages of rapid onset and the reliability of blockade obtained spinally along with the flexibility given by epidural catheter avoiding the disadvantages of either technique used alone. Spinal anesthesia provides dense neural blockade of finite duration while epidural is more titratable producing less hemodynamic swings and postoperative analgesia. The epidural volume extension adds color to combined spinal-epidural anesthesia technique where the onset and the level of blockade obtained spinally are enhanced by administering saline or local anesthetic via the epidural catheter. The ideology behind this is the volume effect accomplished by injecting saline epidurally which would result in intrathecal compression and cephalad migration of spinal local anesthetic. Aim of the study: To identify the effectiveness of block profile provided by extending the epidural volume with normal saline for lower limb orthopedic surgeries using a low dose intrathecal hyperbaric bupivacaine without causing hemodynamic changes. Materials and methods: A prospective randomised controlled study involving 80 patients posted for elective lower limb orthopedic surgeries were divided into two groups of 40 each. Group A received combined spinal-epidural anesthesia with 10 mg of 0.5% bupivacaine with epidural volume extension of 10 ml normal saline. Group B received combined spinal-epidural anesthesia alone. The blood pressure and heart rate changes were observed at the 5th, 10th, 15th, 20th min and then every fifteen minutes. Results: Low dose of intrathecal hyperbaric bupivacaine (10 mg) with 25 micrograms of fentanyl with epidural volume extension (10ml normal saline) is associated with early onset of sensory and motor blockade, high level of sensory block, shorter time of two segment regression. Conclusion: In this study we can safely conclude that combination of spinal epidural with epidural volume extension with normal saline achieves an effective and shorter block time as evident by significantly lower maximum motor block time providing prolonged analgesia by requiring less topup dose of bupivacaine with higher level of sensory block at the tenth minute with shorter mean maximum sensory block time. [ABSTRACT FROM AUTHOR]

Background and Aims: Combined spinal-epidural (CSE) analgesia for labour and delivery is occasionally associated with foetal bradycardia. Decreases in cardiac index (CI) and/or uterine hypertonia are implicated as possible aetiological factors. No study has evaluated CI changes following combined spinal analgesia for labour and delivery. This prospective, double-blind, randomised controlled trial evaluates haemodynamic trends during CSE and epidural analgesia for labour. Methods: Twenty-six parturients at term requesting labour analgesia were randomised to receive either epidural (E) or CSE analgesia. The Electrical Cardiometry Monitor ICON® was used to continuously determine maternal CI non-invasively, heart rate (HR) and stroke volume at baseline and up to 60 min after initiation of either intrathecal or epidural analgesia. In addition, maternal systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded. Results: Both SBP and DBP had a similar, significant decrease following initiation of either epidural or CSE analgesia. However, parturients in the CSE group (n = 10) demonstrated a significant decrease in HR and CI compared to the baseline measurements. On the other hand, the parturients in the E (n = 13) group showed no decreases in either maternal HR or CI. Foetal heart changes were observed in four patients following CSE and one patient following an epidural. Conclusion: Labour analgesia with CSE is associated with a significant decrease in HR and CI when compared to labour analgesia with epidural analgesia. Further studies are necessary to determine whether a decrease in CI diminishes placental blood flow. [ABSTRACT FROM AUTHOR]

Background: The challenging task of postoperative pain relief comes within the realm of the anesthesiologist. Combined spinal epidural (CSE) anesthesia can be used as the sole technique for carrying out surgical procedures and managing postoperative pain using various drug regimes. Epidural administration of opioids in combination with local anesthetic agents in low dose offers new dimensions in the management of postoperative pain. Aims: Comparative evaluation of bupivacaine hydrochloride with nalbuphine versus bupivacaine with tramadol for postoperative analgesia in lower limb orthopedic surgeries under CSE anesthesia to know the quality of analgesia, incidence of side effects, surgical outcome and level of patient satisfaction. Settings and Design: A prospective, randomized and double-blind study was conducted involving 80 patients of American Society of Anesthesiologists physical status I and II coming for elective lower limb orthopedic surgeries carried under spinal anesthesia. Materials and Methods: Anesthesia was given with 0.5% of 2.5 ml bupivacaine intrathecally in both the groups. Epidurally 0.25% bupivacaine along with 10 mg nalbuphine (group A) or tramadol 100 mg (group B) diluted to 2 ml to make a total volume of 10 ml was administered at sensory regression to T10. Statistical Analysis: The data were collected, compiled and statistically analyzed with the help of MS Excel, EPI Info 6 and SPSS to draw the relative conclusions. Results and Conclusions: The mean duration of analgesia in group A was 380 ± 11.49 min and in group B was 380 ± 9.8 min. The mean sedation score was found to be more in group B than group A. The mean patient satisfaction score in group A was 4.40 ± 0.871 and in group B was 3.90 ± 1.150 which was found to be statistically significant (P < 0.05). We concluded that the addition of nalbuphine with bupivacaine was effective for postoperative analgesia in terms of quality of analgesia and patient satisfaction score as compared to tramadol. [ABSTRACT FROM AUTHOR]

Background: Although different techniques have been developed for administering combined spinal epidural (CSE) anaesthesia, none can be described as an ideal one. Objectives: We performed a study to compare two popular CSE techniques: Double segment technique (DST) and single segment (needle through needle) technique (SST) with another alternative technique: Paramedian epidural and midline spinal in the same intervertebral space (single space dual needle technique: SDT). Methods: After institutional ethical clearance, 90 consenting patients undergoing elective lower limb orthopaedic surgery were allocated to receive CSE into one of the three groups (n=30 each): Group I: SST, Group II: SDT, Group III: DST using computerized randomization. The time for technique performance, surgical readiness, technical aspects of epidural and subarachnoid block (SAB) and morbidity were compared. Results: SDT is comparable with SST and DST in time for technique performance (13.42±2.848 min, 12.18±6.092 min, 11.63±3.243 min respectively; P=0.268), time to surgical readiness (18.28±3.624 min, 17.64±5.877 min, 16.87±3.137 min respectively; P=0.42) and incidence of technically perfect block (70%, 66.66%, 76.66%; respectively P=0.757). Use of paramedian route for epidural catheterization in SDT group decreases complications and facilitates catheter insertion. There was a significant number of cases with lack of dural puncture appreciation (SST=ten, none in SDT and DST; P=0.001) and delayed cerebrospinal fluid reflux (SST=five, none in SDT and DST; P=0.005) while performance of SAB in SST group. The incidence of nausea, vomiting, post-operative backache and headache was comparable between the three groups. Conclusion: SDT is an acceptable alternative to DST and SST. [ABSTRACT FROM AUTHOR]

Purpose: The combined spinal epidural (CSE) technique for labor analgesia has become increasingly popular owing to its rapid onset of analgesia. However, incidences of fetal bradycardia following CSE have been reported. This study aimed to identify predictors of fetal bradycardia post CSE, such as a decrease in pain scores, the block height, Prostin (dinoprostone; Pfizer) use, and dosage of oxytocin. Methods: From May 2008 to October 2008, 29 patients were identified to have had an episode of fetal bradycardia. Each case was then matched to three controls, according to age and American Society of Anesthesiology status, selected from 2345 parturients who received a CSE during this period. Results: A unit improvement in the pain score was associated with an increase in the odds of fetal bradycardia by 1.28 (95 % confidence interval [CI]: 1.02-1.60). In a second logistic regression model including sensory level higher than T9, the effect size remained consistent with an odds ratio of 1.22 (95 % CI: 0.97-1.53), supporting the theory that a higher level of sympathetic block (with a higher sensory block taken as a surrogate marker) results in an increased risk of fetal bradycardia. The dosage of oxytocin and the quantity of Prostin used were not found to be risk factors. Conclusion: The difference between pre- and post-CSE pain scores, and a higher sensory block height, which are surrogates for a greater degree of sympatholysis, were found to be risk factors for fetal bradycardia post CSE. [ABSTRACT FROM AUTHOR]

Aim: We aimed to present an audit on delivery rates and obstetric anesthesia techniques at Gazi University Hospital in Turkey over a period of seven years to compare it with national or international standards. Materials and methods: Annual rate of different modes of deliveries (vaginal or caesarean section) and obstetric anesthesia techniques were retrospectively audited over seven years. Results: Our audit shows a progressive rise in the rate of caesarean section (CS) from 33.72% in 2002, to 57.41% in 2008 over vaginal deliveries. There is also an increased use of regional anesthesia for CS. While the practice of epidural anesthesia for CS has decreased, utilization of CSE and spinal anesthesia has increased over 7 years. Conclusion: We conclude that over the last 7 years, the rate of CS, spinal anesthesia for elective CS and neuraxial analgesia for labour in our unit has progressively increased. [ABSTRACT FROM AUTHOR]

Peripartum cardiomyopathy (PPCM) is a rare but life threatening condition and anaesthetic management of a patient with PPCM for caesarean section is often a major challenge. We discuss the case of a 33-yr-old fifth gravida with gestational hypertension who had been diagnosed with PPCM at 34 weeks of pregnancy, when her echocardiography revealed global hypokinesia with severe left ventricular systolic dysfunction (ejection fraction 25%). She had then been started on medications digoxin, furosemide, spironolactone and carvedilol. At 37 weeks she presented for elective caesarean section for placenta previa, which was done under low dose combined spinal epidural (CSE) with 6 mg hyperbaric bupivacaine and 25 mcg fentanyl given intrathecally. Non-invasive monitoring was used for observing patient's vital parameters. The low dose CSE technique provided adequate intraoperative anaesthesia and postoperative analgesia without causing significant hemodynamic variations, and the surgery and postoperative recovery were uneventful. There is a growing literature suggesting that low dose CSE preserves the maternal hemodynamics and hence may be a suitable regional anaesthesia technique for CS in high risk obstetric patients with cardiac disease. We briefly review here the literature on anaesthetic management in PPCM and the use of low dose CSE in high risk obstetric cases. [ABSTRACT FROM AUTHOR]

Objectives: The highly lipid-soluble opioids, sufentanil and fentanyl, are used in combination with low-concentration bupivacaine to provide combined spinal epidural (CSE) analgesia during labour. We designed a prospective, randomized, single-blind study to compare the efficacy of these two opioids with bupivacaine in terms of the quality of analgesia, side-effects and maternal and foetal outcome. Methods: Sixty parturients requesting labour analgesia were divided into two groups randomly. Group S (n=30) received bupivacaine heavy (2.5 mg) and sufentanil (5 mcg) intrathecally and 10 mL intermittent bolus of sufentanil 0.30 mcg/mL in bupivacaine 0.125% as epidural top-ups. Group F (n=30) received bupivacaine heavy (2.5 mg) and fentanyl (25 mcg) intrathecally and 10 mL intermittent bolus of fentanyl 2.5 mcg/mL in bupivacaine 0.125% as epidural top-ups. Duration of intrathecal and epidural analgesia, mean duration between epidural top-ups and total analgesic requirements were noted. Pain and overall satisfaction scores were assessed with a 10-point visual scale. Mode of delivery and neonatal Apgar scores were recorded. Results: Maternal demographic characteristics were comparable between the groups. Although CSE provided satisfactory analgesia in both the groups, parturients of group S had a significant prolongation of analgesia through the intrathecal route compared with parturients of group F. Incidence of caesarean, instrumental delivery did not differ between the groups. No difference in the incidence of motor blockade or cephalad extent of sensory analgesia was observed. Neonatal outcome and incidence of side-effects were similar in both the groups. Conclusion: We conclude that combined spinal epidural using sufentanil and fentanyl achieved high patient satisfaction and excellent labour analgesia without serious maternal or neonatal side-effects. Sufentanil provided a significantly longer duration of labour analgesia compared with fentanyl. [ABSTRACT FROM AUTHOR]

Background: Epidural volume extension (EVE) with saline in the epidural space during a CSE technique can result in cephalad extension of the block and may be accompanied by episodes of hypotension. It also allows CSE to be performed with small initial intrathecal doses of local anesthetic. Objectives: We investigated the difference in block characteristics and hemodynamic profile with CSE-EVE using either saline or colloid in the epidural space. Materials and Methods: This prospective, randomized, controlled study was conducted in 99 parturients, ASA grade I or II, with gestational age 37 weeks or more, undergoing elective cesarean section under CSEA. Women were randomly distributed into three groups: Group NEVE (CSE with no EVE), Group EVE-S (CSE followed by EVE using 5 ml of 0.9% saline), and Group EVE-H (CSE followed by EVE using 5 ml of 6% hydroxyethyl starch (HES) 200/0.5). All the groups received 6 mg of 0.5% hyperbaric bupivacaine with 25 mcg fentanyl intrathecally, while Groups EVE-S and EVE-H also received 5 ml of saline or HES in the epidural space. All blocks were performed using needle through needle CSE technique via midline approach at the L4-5 interspace with the women in the left lateral position. Block characteristics and hemodynamic parameters were recorded by an independent anesthesiologist. Data were compared with Chi-square, t test, and ANOVA using Epi info 6 with P < 0.05 as significant. Results: The peak sensory level and the time taken to achieve it was significant in Group EVE-S (P = 0.003 temperature, P = 0.007 pinprick, P = 0.000 time) as compared to Group NEVE while Group EVE-H was intermediate as compared to the other two groups. In Group EVE-S, there was a difference in the mean peak sensory levels as assessed by temperature (thoracic T4.88±1.01) and pinprick (T5.04±1.02), whereas it was the same in the other two groups (T6.10±1.41 in Group NEVE and T5.44±1.35 in Group EVE-H). The requirement for ketamine supplementation was significantly more in Group NEVE (54.5%) as compared to Group EVE-S (24.2%) and Group EVE-H (27.3%), P = 0.018. The motor block characteristics were comparable in all the three groups (P > 0.05).The lowest attained values of heart rate, systolic, and diastolic blood pressure were significantly less in Group EVE-S versus Group NEVE (P = 0.019, 0.008, and 0.001, respectively), while hemodynamic parameters in Group EVE-H were intermediate. Incidence of hypotension was significantly more in Group EVE-S (n = 20, 60.6%), as compared to Group NEVE (n = 9, 27.3%, P = 0.02) and Group EVE-H (n = 13, 39.4%). Conclusion: We conclude that an intrathecal dose of 6 mg hyperbaric bupivacaine with 25 mcg fentanyl is adequate for cesarean section when used in CSE with the EVE technique, using 0.9% saline or 6% HES. However, EVE with HES provides optimal hemodynamic profile as compared to EVE with saline. [ABSTRACT FROM AUTHOR]

Background: Previous trials have documented failure of block augmentation with epidural volume extension, when applied after the intrathecal injection of hyperbaric bupivacaine was made in sitting position. However, there is no study comparing the effect of change in patient position during block performance, on the results of epidural volume extension. Materials and Methods: The study was conducted in two parts in American Society of Anesthesiologists physical status I or II parturients scheduled for elective cesarean section under regional anesthesia. In the first part, 28 patients were randomized to one of the two groups, depending on whether epidural volume extension was applied following the block in sitting (group SE) or lateral position (group LE) (n=14 each). In the second part of the study another 28 patients were recruited and randomized to receive the block in sitting (group S) or lateral (group L) position ( n=14 each), without epidural volume extension. All patients received combined spinal epidural block using needle-through-needle technique with intrathecal injection of 9 mg hyperbaric bupivacaine (0.5%) and 10 µg fentanyl. Epidural volume extension was performed using 5 ml normal saline in groups SE and LE. Results: In the first part of the study, the maximum sensory block level was higher in group LE vs. SE (P<0.05). In the second part of the study, no significant difference was seen in the maximum sensory level between group S and group L (P>0.05). Conclusions: If epidural volume extension is being applied with intention of rapid extension of sensory block when hyperbaric bupivacaine has been injected intrathecally, the combined spinal epidural block should be performed in lateral position rather than in the sitting position. [ABSTRACT FROM AUTHOR]

Objective: Neuraxial blocks are increasingly used for anesthesia, postoperative analgesia, and pain management. In spite of advancements in neuroaxial block procedures, difficulty or failure to obtain satisfactory block is still the main isue. Data on operational failure which can be defined as inability to achieve planned blockade technique, its inadequacy or deficiency, differ due to the variability in description of the criteria of failure, and also methodologic differences. In this study we aimed to determine the rates of failure and causal correlations in cases with neuraxial blocks as to guide future attempts. Material and Method: After the approval of Research Committee, records of 7263 patients aged =18 years who had received neuraxial blocks between 1998-2008 were examined. Patients (n=297) who were given epidural blocks under general anesthesia were excluded from the study. From the records of the remaining 6966 patients, demographic, and medical historical data of the patients, coexisting health problems, methodologic, and operational features, causes and criteria of failure, as well as surgical details were extracted. Chi-square, Student-t, and Mann-Whitney U tests were used for statistical evaluations. Among parameters deemed as significant indicators of failure, independent risk factors were determined using logistic regression analyses. Results: The neuraxial blocks were performed for 10,69 % of our surgical anesthesia cases. Total failure rate was 5,4 %, being 3,9 % in spinal, 10,9 % in epidural, 6,4 % in combined spinal-epidural blocks, respectively. Independent risk factors were detected as paramedian approach (p<0,001/OR 30,8), peripheral vascular disease (p<0,001/OR 2,5), epidural block (p<0,001/OR 2,6), duration of surgery (p<0,001/OR 2,3), requirement for expert experience (p<0,001/ OR 1,9), chronic obstructive pulmonary disease (p=0,014/OR 1,7), and body weight (p=0,023/OR,1,0). Conclusion: In conclusion, careful patient evaluation, selection of anesthetic technique appropriate for surgical procedure, earlier consultation to an experienced expert. and keeping the patient records accurately will decrease the rate of operational failure and increase the safety of the patient. [ABSTRACT FROM AUTHOR]

Epidural analgesia provides the most effective pain relief in labor, but it is not known if it causes adverse long-term effects. The objective of this study was to assess the long-term effects of two mobile epidural techniques relative to high-dose epidural analgesia in a randomized controlled trial. A total of 1,054 nulliparous women were randomized to traditional high-dose epidural, combined spinal epidural, or low-dose infusion. Women in all groups were followed-up at 12 months postpartum by postal questionnaire to assess long-term symptoms. The primary long-term outcome was backache occurring within 3 months of the birth persisting for longer than 6 weeks. Secondary outcomes were frequent headaches and fecal and urinary stress incontinence. No significant differences were found in long-term backache after combined spinal epidural or low-dose infusion relative to high-dose epidural. Significantly less headache occurred in combined spinal epidural analgesia than high-dose epidural (OR: 0.57, 95% CI: 0.36-0.92), but no difference was found for low-dose infusion. Significantly less fecal incontinence (OR: 0.51, 95% CI: 0.30-0.87) and stress incontinence (OR: 0.65, 95% CI: 0.42-1.00) occurred with low-dose infusion. Trial evidence showed no long-term disadvantages and possible benefits of low-dose mobile relative to high-dose epidural analgesia. (BIRTH 38:2 June 2011) [ABSTRACT FROM AUTHOR]

Spinocerebellar degeneration or olivopontocerebellar degeneration denotes a group of disorders of various etiologies manifesting as degenerative changes of various part of the central nervous system. We describe the anesthetic management of a patient with severe olivopontocerebellar degeneration posted for vaginal hysterectomy. A combined spinal epidural technique was performed at the level of L2-L3. The anesthetic implications of the various aspects of spinocerebellar degeneration are discussed. [ABSTRACT FROM AUTHOR]

Objective. We aimed to investigate the efficacy of either plain or hyperbaric solutions of intrathecal bupivacaine and ropivacaine on maternal block characteristics, complications, side effects and neonatal parameters to find out which is superior in a single study. Methods. One hundred and three term parturients were randomly assigned to receive intrathecal 10 mg hyperbaric bupivacaine ( Group Bh), 10 mg plain bupivacaine ( Group Bp), 15 mg hyperbaric ropivacaine prepared with dextrose 30% ( Group Rh) or 15 mg plain ropivacaine ( Group Rp) coadministered with fentanyl 20 μg. Sensory and motor block characteristics, analgesia duration, ephedrine consumption, and neonatal and maternal parameters were recorded. Results. Time to maximum cephalad spread of sensory block was longer in Group Rp than both bupivacaine groups. Time to achieve sensory block at T6 dermatome was similar between both hyperbaric groups (Group Bh:4.5 ± 1.6, Group Rh:4.6 ± 1.1, p > 0.05) but Group Rp needed significantly longer time (7.5 ± 5.5 min, p = 0.003) than both hyperbaric groups. Duration of motor block was shorter in ropivacaine groups (Group Rh: 90.6 ± 17.3, Group Rp 121.6 ± 33.7) vs. bupivacaine groups (Group Bh: 140.2 ± 33.3, Group Bp: 149.7 ± 46.0); Group Rh being shorter than Group Rp ( p < 0.05). Ephedrine consumption was less in Groups Rh (20.0 ± 11.9 mg) and Rp (18.3 ± 12.4 mg) vs. Groups Bh (30.0 ± 14.9 mg) and Bp (27.8 ± 15.4 mg) ( p = 0.006). Conclusions. Intrathecal hyperbaric ropivacaine 15 mg with fentanyl 20 μg for CSE is suitable since it provides early motor recovery leading to faster patient ambulation, rapid onset of sensory block with less ephedrine. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the effectiveness of automated intermittent bolus (AIB) with continuous epidural infusion (CEI). An overview of the methodology used for the study is provided, including study protocol and statistical analysis. Researchers found no difference between patients in the AIB and CEI groups concerning the percentage that reported pain. They also found that epidural local anaesthesia for maintenance of labour analgesia through regular AIB administration did not lessen the incidence of pain.

We investigated retrospectively the duration of hospital stay of 1,619 women who received general (GA) (n = 582) or neuraxial anaesthesia (combined spinal-epidural [CSEA] (n = 614), epidural [EA] (n = 423)) for caesarean delivery over the years 2002-2005. Hospital stay was also analysed for the different obstetricians involved. Overall duration of hospital stay differed between 2002 and 2005 (p < 0.0001) but not between CSEA and EA (p = 0.460). Overall duration of hospital stay differed between neuraxial and GA group (p < 0.001). Duration of hospital stay of the GA group showed a progressive decrease between 2002 and 2005 (p = 0.002). Duration of hospital stay after neuraxial anaesthesia differed between 2002 and 2005 (p = 0.013) and among different surgeons (p < 0.001). Discharge rates from the hospital were shorter after neuraxial anaesthesia versus GA for the 3rd and 4th postoperative days (p < 0.001 and p < 0.001, respectively). Neuraxial anaesthesia for caesarean section seems to be associated with shorter duration of hospital stay than GA. [ABSTRACT FROM AUTHOR]

Background: hip replacement surgery is common among elderly patients. These patients have increased risk for perioperative mortality and morbidity due to additional comorbidities, such as cardiac, endocrine, renal, cerebral and respiratory diseases. Aim of the Work: to compare between continuous spinal anesthesia and combined spinal epidural anesthesia in patients scheduled for elective major hip surgeries as regards their effectiveness and possible complications during operation. Patients and Methods: after obtaining the approval of the ethical committee of faculty of medicine, Ain-Shams University, and patients' written informed consents, this prospective randomized clinical trial study was conducted at Ain Shams University Hospitals at the orthopedics operating theatre. Seventy two patients aged older than 30 years, of both sexes and American Society of Anesthesiologists (ASA) class I, II, scheduled for elective major hip surgeries like total hip replacement or hemi arthroplasty were included in the study. All Patients were assigned randomly by using a computer generated program with closed envelops to one of the two equal groups:CSAgroup(36)patient and CSEgroup(36)patient. Results: there was no statistically significant differences between the CSA and CSE groups as regards demographic data; Age, Sex or BMI. Baseline HR was similar in both groups. The heart rate was significantly higher in the CSE group at 5 min and 15 min when compared to CSA group. The mean blood pressure was significantly lower in group CSE at 5min anf 15 min when compared to CSA group. The total dose of bupivacaine 0.5% mg collectively given was much lower in the CSA group than the CSE group. The onset of sensory block (time between the end of injection and the time to reach T10sesnsory level) and degree of motor block between two groups showed no statistically significant difference but the level of sensory block was significantly higher in CSE group than CSA group. there was no significant difference as regard PDPH, Post operative nausea and vomiting, Bradycardia but there was significant difference as regard incidence of hypotension being higher in CSE group than CSA group. The time of first analgesic request showed no significant difference between the two groups. Conclusion: both continuous spinal anesthesia and compined spinal epidural anesthesia are safe anesthetic techniques for lower limb surgeries. CSA offers possibilities of more hemodynamic stability with smaller doses of local anesthetics than CSE with rapid onset of sensory block and good extendede post operative analgesia. [ABSTRACT FROM AUTHOR]

Horner's Syndrome (HS) with brachial plexus involvement following lumbar epidural anesthesia may be a startling event for the patient and providers. We present a case of Horner's Syndrome and complete brachial plexus blockade following epidural bolus of lidocaine for labor analgesia that was initially misdiagnosed as a cerebrovascular accident. Use of the catheter was discontinued and the episode resolved with expectant management. This complication is otherwise benign and resolves without sequelae. [ABSTRACT FROM AUTHOR]

The anesthetic management of a patient with dilated cardiomyopathy (DCM) undergoing non-cardiac surgery poses a challenge for anesthesiologist either due to pre-existing or a risk of precipitating congestive heart failure. We report a successful use of combined spinal epidural for emergency appendicectomy in a patient of DCM. Different anesthetic concerns and agents, some recent advances are also discussed. [ABSTRACT FROM AUTHOR]

Maternal neurological injuries may be intrinsic to the labour and delivery process or may result directly or indirectly from obstetric or anaesthetic intervention. This intrinsic obstetric palsy is a rare complication of labour but can have devastating impact on a previously healthy mother. A 23-year-old gravida1, para0 who had epidural for labour analgesia, was augmented for slow progress and had a normal vaginal delivery. She was diagnosed post delivery with intrinsic obstetric palsy involving several peripheral nerves and lumbosacral nerve roots with a guarded prognosis. In this article we have discussed the risk factors and mechanisms of intrinsic obstetric palsy and proposed further investigation into the potential protective role of ambulatory analgesia i.e. CSE (Combined Spinal Epidural) or LDI (Low Dose Infusion). [ABSTRACT FROM AUTHOR]