Search

Background: Arthroplasty patients are at high risk of hypothermia. Pre-warming with forced air has been shown to reduce the incidence of intraoperative hypothermia. There is, however, a lack of evidence that pre-warming with a self-warming (SW) blanket can reduce the incidence of perioperative hypothermia. This study aims to evaluate the effectiveness of an SW blanket and a forced-air warming (FAW) blanket peri-operatively. We hypothesised that the SW blanket is inferior to the FAW blanket., Methods: In total, 150 patients scheduled for primary unilateral total knee arthroplasty under spinal anaesthesia were randomised to this prospective study. Patients were pre-warmed with SW blanket (SW group) or upper-body FAW blanket (FAW group) set to 38°C for 30 min before spinal anaesthesia induction. Active warming was continued with the allocated blanket in the operating room. If core temperature fell below 36°C, all patients were warmed using the FAW blanket set to 43°C. Core and skin temperatures were measured continuously. The primary outcome was core temperature on admission to the recovery room., Results: Both methods increased mean body temperature during pre-warming. However, intraoperative hypothermia occurred in 61% of patients in the SW group and in 49% in the FAW group. The FAW method set to 43°C could rewarm hypothermic patients. Core temperature did not differ between groups on admission to the recovery room, p = .366 (CI: -0.18-0.06)., Conclusions: Statistically, the SW blanket was non-inferior to the FAW method. Yet, hypothermia was more frequent in the SW group, requiring rescue warming as we strictly held to the NICE guideline., Trial Registration: Clinicaltrials.gov identifier: NCT03408197., (© 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

The treatment of choice for spinal anesthesia-induced hypotension during cesarean section is phenylephrine. As this vasopressor can cause reflex bradycardia, noradrenaline is a suggested alternative. This randomized double-blinded controlled trial included 76 parturients undergoing elective cesarean delivery under spinal anesthesia. Women received noradrenaline in bolus doses of 5 mcg or phenylephrine in bolus doses of 100 mcg. These drugs were used intermittently and therapeutically to maintain systolic blood pressure ≥ 90% of its baseline value. The primary study outcome was bradycardia incidence (<60 bpm) with intermittent bolus administration of these drugs. Secondary outcomes included extreme bradycardia (<40 bpm), number of bradycardia episodes, hypertension (systolic blood pressure > 120% of baseline value), and hypotension (systolic blood pressure < 90% of baseline value and requiring vasopressor use). Neonatal outcomes per the Apgar scale and umbilical cord blood gas analysis were also compared. The incidence of bradycardia in both groups (51.4% and 70.3%, respectively; p = 0.16) were not significantly different. No neonates had umbilical vein or artery pH values below 7.20. The noradrenaline group required more boluses than phenylephrine group (8 vs. 5; p = 0.01). There was no significant intergroup difference in any of the other secondary outcomes. When administered in intermittent bolus doses for the treatment of postspinal hypotension in elective cesarean delivery, noradrenaline, and phenylephrine have a similar incidence of bradycardia. When treating hypotension related to spinal anesthesia in obstetric cases, strong vasopressors are commonly administered, thought these can also have side effects. This trial assessed bradycardia after bolus administration of noradrenaline or phenylephrine, and found no difference in risk for clinically meaningful bradycardia., (© 2023 Acta Anaesthesiologica Scandinavica Foundation.)

Background: Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors., Methods: All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 μg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation., Results: There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis., Conclusions: A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used., (© 2022 Acta Anaesthesiologica Scandinavica Foundation.)

Background: Crystalloid fluid infused during the induction of spinal anesthesia is involved in a complex set of physiological responses, including vasodilatation, reactive vasoconstriction, and changes in mean arterial pressure (MAP). The present evaluation compares the modeled capillary leakage in anesthetized versus nonanesthetized body regions., Methods: Ten female volunteers (mean age, 29 years) received 25 ml/kg of Ringer's acetate over 60 min during experimental spinal anesthesia. Blood hemoglobin was measured repeatedly in the radial artery (reference), arm (cubital) vein, and leg (femoral) vein for 240 min. Each pattern of data served as a dependent variable in volume kinetic analyses that used mixed models software and MAP as covariate., Results: The capillary leakage of fluid from the plasma to the extravascular space peaked at 17 ml/min when MAP was 100 mmHg, and the two venous curves were virtually identical. At MAP 60 mmHg, the rate was reduced to 10-12 ml/min when assessed in arterial blood and leg vein blood, but only 5 mmHg in blood collected from the arm vein. The distribution half-life of infused fluid was then 40 min in the leg and 80 min in the arm. These results suggest that vasoconstriction in nonanesthetized body regions halves the capillary leakage that is observed in vasodilated, anesthetized body regions., Conclusion: Graded hypotension during spinal anesthesia reduced the capillary filtration of fluid as determined by volume kinetic analysis. The effect was twice as great when venous blood was sampled from a nonanesthetized body region than from an anesthetized body region., (© 2021 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Shivering during caesarean section (CS) under spinal anaesthesia is a common phenomenon. It could not only alter patient's physiology by increasing oxygen consumption but also affect the parturient's experience of childbirth. Shivering is thought to be associated with intraoperative hypothermia, but the risk factors and exact mechanism remain unclear., Methods: We conducted a prospective, observational study to examine the potential risk factors for intraoperative shivering, including anxiety levels. Two hundred patients undergoing elective CS under spinal anaesthesia were recruited. Parturient anxiety levels were evaluated using the State-Trait Anxiety Inventory (STAI) questionnaire. Age, weight, height, BMI, anxiety level, number of previous deliveries, sensory block level, level of education, temperature difference during surgery and American Society of Anesthesiologists score were investigated as potential risk factors. Stepwise logistic regression was used to assess the predictors for shivering., Results: Data from 155 parturients were analysed. Shivering incidence was 21.9% (34 parturients). The statistical model predicted 8.5% of a shivering incidence variability (R-square Nagelkerke = 0.085). Out of all measured variables, only the number of previous deliveries [(W) = 4.295 Exp(B) = 0.562 P < .05] and STAI-X1 [(W) = 4.127 Exp(B) = 1.052 P < .05] were significant. In our model, the risk of shivering decreased by 44% with every previous delivery and increased by 5.2% with each 1-point increase in STAI-X1., Conclusion: We failed to prove a strong correlation between the measured variables and shivering. Our findings, however, support the hypothesis, that to a limited extent, anxiety promotes shivering during CS., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: The serotonergic system is known to be involved in control of post-anesthetic shivering. Our hypothesis was that prophylactic granisetrone (serotonin antagonist) might reduce incidence of post-spinal anesthesia shivering in cesarean section., Methods: Parturient scheduled for elective cesarean delivery under spinal anesthesia were allocated to receive 0.9% saline (Group I, n = 71), 1 mg granisetron (Group II, n = 69), or 0.7 mg granisetron (Group III, n = 72) before the spinal block. Assessment parameters included; hemodynamics, tympanic membrane temperature, neonatal Apgar score, shivering score, patient satisfaction scores about shivering prophylaxis and adverse effects., Results: Clinically significant shivering was recorded in 55/71 patients (77.5%) in group I, 11/69 (15.9%) in group II and 21/72 (29.2%) in group III (P = 0.000). The intensity of shivering was significantly lower in patients who received granisetron 1 mg compared with granisetron 0.7 mg or saline (P = 0.000). Patients who received prophylactic granisetron 1 mg reported lower mean intraoperative arterial pressure and heart rate values and consumed higher doses of iv ephedrine compared with 0.7 mg granisetron or saline placebo (P < 0.05). Pruritus significantly decreased from (22.5%) in control group to (0%) in granisetron groups (P = 0.000). Nausea was reported in 8 vs 10 and four in group I, II and III, respectively (P < 0.03). Sixteen vs eight and six patients vomited in group I, II, and III, respectively (P < 0.03). Higher patient satisfaction scores were recorded in group II (9.83 ± 0.29, P < 0.03) and III (9.14 ± 1.04, P < 0.04), compared with control group (8.23 ± 1.14)., Conclusion: Prophylactic granisetron effectively reduced incidence and severity of perioperative shivering in a dose dependent manner, compared to placebo controls., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification., Methods: In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia., Results: In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA., Conclusion: Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery., Methods: Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed., Results: Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597-0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655-0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570-0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041)., Conclusions: Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension., (© 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Intravenous ketamine has been used during general and regional anaesthesia for caesarean section. No systematic review and meta-analysis on the desired effects and adverse effects of ketamine administration during caesarean section have yet been performed., Methods: After a systematic literature search a meta-analysis was conducted with the random effects model. Weighted mean difference (WMD) or risk ratio and 95% confidence intervals (CIs) were computed., Results: Twelve randomised controlled double-blind trials comprising 953 patients were included: seven studies reported on spinal anaesthesia and five on general anaesthesia. Significant differences in the aforementioned outcome variables were found only in the spinal anaesthesia studies. In the spinal anaesthesia studies the time to the first analgesic request was significantly longer in ketamine-treated women, the WMD was 49.36 min (95% CI 43.31-55.41); visual analogue scale pain scores at rest 2 h after surgery were significantly lower. No differences were observed for maternal nausea, vomiting, pruritus, and psychomimetic effects. Only few data were found for neonatal outcomes., Conclusions: We conclude that ketamine enhances post-operative analgesia after caesarean section under spinal anaesthesia. There is a paucity of data for several maternal adverse effects as well as for neonatal well-being. Further studies are needed for general anaesthesia., (© 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: The risk of fetal and neonatal complications is higher in pregnant women with congenital heart disease (CHD). It remains unknown whether umbilical cord blood gas values are different between pregnant women with CHD and healthy women undergoing elective cesarean section during combined spinal-epidural anesthesia. The purpose of the present study was to compare umbilical cord blood acid-base status and gas values in pregnant women with CHD vs. healthy pregnant women undergoing elective cesarean section during combined spinal-epidural (CSE) anesthesia., Methods: Patients with singleton pregnancy undergoing elective cesarean delivery under CSE anesthesia were enrolled. Patients were divided into two groups: healthy pregnant women (group H) and pregnant with congenital heart disease (group CHD). Immediately after delivery, umbilical cord arterial blood sample and venous blood sample were collected and measured. The comparison between two groups was performed using grouped t-test., Results: Forty-four women in group H and 33 women in group CHD were analyzed finally. Umbilical arterial blood pH, base excess (BE) and HCO3 (-) (pH 7.29 ± 0.05, BE -1.4 ± 1.9 mmol/L, HCO3 (-) 21.5 ± 1.4 mmol/L) were significantly lower in pregnant women with CHD than in healthy pregnant women (pH 7.33 ± 0.03, BE -0.1 ± 2.1 mmol/L, HCO3 (-) 22.5 ± 1.4 mmol/L)., Conclusions: The lower values of umbilical arterial blood pH, BE and HCO3 (-) were observed in pregnant women with CHD than in healthy women undergoing elective cesarean section during CSE anesthesia., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Analyses of closed claims provide insight into the characteristics of rare complications. Serious complications related to spinal and epidural blocks are relatively rare. In Finland, all malpractice cases are primarily handled by the Patient Insurance Centre (PIC) within a 'no-fault scheme'., Methods: All claims attributed to central neuraxial blocks and settled by the PIC during the period, 2000-2009 were analysed. The number of spinal and epidural procedures performed during this time was estimated based on a questionnaire sent to all surgical hospitals in Finland in 2009, surveying the numbers and types of neuraxial blocks carried out in 2008., Results: During the study period, 216 closed claims were flagged with spinal or epidural blocks. In 41 of 216 instances, the neuraxial block was apparently responsible for a serious (fatal or critical or lasting >1 year) complication. These included six fatalities and 13 epidural haematomata (two in conjunction with fondaparinux, three with excessive doses of low molecular weight heparins, six where present guidelines were not observed). Fatalities occurred in 1 : 775,000 spinals for surgery, 1 : 62,000 in epidurals for surgery or acute pain relief, 1 : 12,000 epidurals for chronic pain relief, 1 : 89,000 in combined spinal and epidural for surgery, and 1 : 144,000 epidurals for labour. The incidence of neuraxial haematoma after spinal block was 1 : 775,000, that for epidural block 1 : 26,400, and in the case of combined spinal and epidural, 1 : 17,800. Irrespective of the method of neuraxial technique, the majority of patients suffering serious complications were the elderly having comorbidities., Conclusions: In this closed claims analysis, major problems related to neuraxial blocks were rare. Epidural or a combined spinal and epidural technique resulted in more complications than did spinal procedure., (© 2013 The Acta Anaesthesiologica Scandinavica Foundation.)

Regional anesthesia is the preferred technique for Cesarean delivery. Strict aseptic precautions should be taken; otherwise, infectious complications including abscess formation, meningitis and necrotizing fasciitis may result. We report a case of a 26-year-old post-partum female who presented with necrosis of the skin of back following spinal anesthesia, which was administered for Cesarean delivery 5 days prior at a private nursing home. On presentation, she was drowsy, appeared dehydrated and febrile. Examination of her back revealed necrosis of skin extending from just below the scapula to the gluteal region. Debridement of skin over the back was performed, and intravenous antibiotics started. After three debridements following which skin grafting was performed, she made complete recovery. Infectious complications following regional anesthesia are rare, and most of the literature focuses on colonization of epidural catheters or epidural abscess. There is no report of necrotizing fasciitis following spinal anesthesia so far. Sources of infection that are suspected in our case include: local anesthetic solution used for subcutaneous infiltration, nonadherence to aseptic precautions, skin flora of patient, endogenous source and nasopharyngeal flora of anesthesiologist. We considered each possibility, and the most likely cause in our case appears to be infection from an already-used vial of a local anesthetic agent. Local anesthetics have bacteriostatic properties, but infection may still be transmitted through contaminated solutions. The present case highlights the importance of maintaining strict aseptic precautions, avoiding reusing multidose vials and early recognition of this complication as timely intervention can be lifesaving., (© 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Hyperbaric prilocaine 20 mg/ml may be preferable for perianal outpatient surgery. The aim of this prospective, single-centre, randomised, single-blinded, controlled clinical trial was to determine the optimal dosage of hyperbaric prilocaine 20 mg/ml for a spinal anaesthesia (SPA) in patients undergoing perianal outpatient surgery., Methods: One hundred and twenty patients (18-80 years/American Society of Anesthesiologists grade I-III) were enrolled in this study. The patients were randomised to receive 10, 20 or 30 mg of prilocaine for SPA. We measured expansion of the sensory and motor block, evaluated times to walk, void and being eligible for discharge, and determined the demand of analgesics., Results: 116/120 patients were available for analysis. The expansion of the sensory block gained with an increasing dosage: 10 mg: 3(1-6) dermatomes; 20 mg: 4(2-6) dermatomes; 30 mg: 5(3-7) dermatomes (P < 0.0001). Dermatomes were counted upwards beginning with S(5). Also, the motor block gained with an increased dosage (Bromage score 1-3: 10 mg: n = 3, 20 mg: n = 8 and 30 mg: n = 18, P = 0.0002). Patients receiving 10 mg were ready for discharge earlier compared with both other groups (10 mg: 199 ± 39 min; 20 mg: 219 ± 47 min; 30 mg: 229 ± 32 min, P = 0.0039). Pain occurred earlier in the 10 mg group than in the 30 mg group (10 mg: 168 ± 36 min; 30 mg: 205 ± 33 min, P = 0.0427). The demand of additional analgesics was comparable in all dosage groups., Conclusion: Hyperbaric prilocaine 20 mg/ml can be applied in dosages of 10, 20 and 30 mg for SPA in perianal surgery. Because of sufficient analgesia, missing motor block and shorter recovery times, 10 mg of hyperbaric prilocaine 20 mg/ml can be recommended for perianal outpatient surgery., (© 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Dexmedetomidine (DMT) has been shown to prolong spinal anaesthesia. We evaluated the effects of intravenous DMT on low-dose bupivacaine spinal anaesthesia in elderly patients., Methods: Fifty-one elderly patients undergoing transurethral resection of the prostate were randomized into two groups receiving either 1.0 μg/kg DMT (DMT group, n = 26) or normal saline (control group n = 25) intravenously prior to spinal anaesthesia with 1.2 ml of bupivacaine, 5 mg/ml., Results: The mean time to two-segment regression (39 min vs. 78 min for cold, 41 min vs. 61 min for pinprick) and that to motor regression (23 min vs. 46 min) were longer in the DMT group than in the control group. The atropine-requiring bradycardia was more frequent in the DMT group than in the control group (24.0% vs. 3.8%). The median sedation scores (ranges) during surgery were 4 (2-6) in the DMT group and 2 (1-3) in the control group (P < 0.001). Two patients in the DMT group showed oxygen desaturation (peripheral oxygen saturation < 90%) during surgery. The duration of post-operative care unit stay was longer in the DMT group than in the control group (58 min vs. 96 min). Post-operative pain intensity was lower and the mean time to first request for post-operative analgesia was longer in the DMT group compared to the control group (6.6 h vs. 2.1 h)., Conclusion: Intravenous DMT prolonged the duration of spinal anaesthesia and improved post-operative analgesia. However, more profound sedation with desaturation was observed with more frequent bradycardia, and delayed recovery should be considered in elderly patients., (© 2012 The Authors Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background and Objectives: The reported incidence of cardiac arrest during spinal anaesthesia is 6.4+1.2 per 10,000 patients. Many of these arrests occurred in healthy young patients during minor surgery. This raises the question of whether some of them were avoidable. We investigated the value of Heart Rate Variability (HRV) to identify patients prone to developing severe bradycardia during spinal anaesthesia., Methods: Eighty ASA I-II patients, 21-60 years of age, undergoing elective surgery under spinal anaesthesia were studied. The HRV was assessed for 25 min before the spinal block. Two spectral components of HRV were calculated: a low-frequency (LF) and a high-frequency (HF) component. Patients were grouped according to whether bradycardia did or did not develop during spinal anaesthesia., Results: Nineteen patients developed severe bradycardia (<45 b.p.m.). The mean value of HF before spinal anaesthesia was significantly increased in the bradycardic group (P<0.05). The correlation between baseline heart rate (HR(baseline)) and minimum heart rate and LF, HF during spinal anaesthesia was significant (P<0.01). A receiver operator curve characteristic analysis showed a sensitivity and specificity of HF and HR(baseline) of 65% and 74%, respectively, to predict bradycardia <45 b.p.m. after spinal anaesthesia., Conclusions: The present study shows that HF and clinical factors such as patient's HR(baseline) could identify patients prone to developing severe bradycardia during spinal anaesthesia., (© 2010 The Authors. Journal compilation © 2010 The Acta Anaesthesiologica Scandinavica Foundation.)

Spinal anaesthesia is contraindicated in patients with elevated intracranial pressure or space-occupying intracranial lesions. Drainage of the lumbar cerebrospinal fluid (CSF) can increase the pressure gradient between the spinal, supratentorial and infratentorial compartments. This can result in rapid herniation of the brain stem or occluding hydrocephalus. We present a case of a female patient with an occult brain tumour who received a spinal anaesthesia for an orthopaedic procedure. The primary course of anaesthesia was uneventful. Several hours after surgery, the patient became increasingly disoriented and agitated. The next day, she was found comatose. A computed tomogram of the head revealed herniation of the brain stem, resulting in an occluding hydrocephalus due to a prior not known infratentorial mass. By acute relieving of the intracranial pressure by external CSF drainage, the mass was removed 2 days later. The further post-operative course was uneventful and the patient was discharged from the hospital without neurological deficit 3 weeks after the primary surgery.

Background: Spinal anaesthesia for caesarean section may cause hypotension, jeopardizing the foetus and its mother. We aimed to identify the spectrum of definitions of hypotension used in the scientific literature. In a second part, we applied these definitions to a prospective cohort in order to evaluate the effect of different definitions on the incidence of hypotension., Methods: A systematic literature search in PubMed was performed from 1999 to 2009 with the search terms 'hypotension' and 'caesarean section'. Consecutive parturients undergoing caesarean section under spinal anaesthesia were included in a prospective study., Results: Sixty-three eligible publications (7120 patients) were retrieved, revealing 15 different definitions of hypotension. A decrease below 80% baseline and the combined definition of a blood pressure below 100 mmHg or a decrease below 80% baseline were the two most frequent definitions, found in 25.4% and 20.6% of the papers, respectively. When applying the spectrum of definitions to a prospective cohort, the incidences of hypotension varied between 7.4% and 74.1%. The incidence increased from 26.7% to 38.5% when using a value below 75% of baseline instead of below 70% of baseline., Conclusion: There is not one accepted definition of hypotension in the scientific literature. The incidence of hypotension varies depending on the chosen definition. Even minor changes of the definition cause major differences in the frequency of hypotension. This makes it difficult to compare studies on interventions to treat/prevent hypotension and probably hampers progress in this area of research.

Background: Inguinal herniorrhaphy can be successfully performed using general, regional or local anaesthesia. Paravertebral block (PVB) has been used for unilateral procedures such as thoracotomy, breast surgery, chest wall trauma, hernia repair or renal surgery., Methods: We compared unilateral lumbar PVB with conventional spinal anaesthesia (SA) in 60 consenting ASA I and II males aged 18-65 years, scheduled for unilateral inguinal hernia repair. Patients were randomly assigned into two groups, P (n=30) or S (n=30) to receive either PVB or SA, respectively. Two patients (7%) in group P had to be converted to general anaesthesia due to block failure. During surgery, patients of both groups received intravenous infusion of propofol titrated to light sedation., Results: The time to first post-operative analgesic requirement (primary outcome measure) as 342 +/- 73 min in group P and 222 +/- 22 min in group S (P<0.0001). Time to ambulation was 234 +/- 111 min in group P and 361 +/- 32 min in group S (P<0.0001). Urinary retention requiring catheterization were found in zero (0%) patients in group P compared with five (16%) in group S (P=0.024)., Conclusion: It can be concluded that unilateral PVB is more efficacious than conventional SA in terms of prolonging post-operative analgesia and reducing morbidities in patients undergoing elective unilateral inguinal hernia repair.

Background: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice., Methods: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008., Results: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks., Conclusions: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

Background: Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine., Methods: Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs., Results: In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade., Conclusion: After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

Background: Low-dose hyperbaric bupivacaine has been used to produce unilateral spinal anaesthesia for outpatient surgery. Unilateral spinal anaesthesia is associated with reduction of hypotension, faster recovery and increased patient satisfaction. Small doses of clonidine have shown effectiveness in intensifying spinal anaesthesia. We investigated the effect of adding 15 microg of clonidine to 5 mg hyperbaric bupivacaine on unilaterality., Methods: Sixty patients undergoing outpatient knee arthroscopy were randomly allocated to receive either 1.2 ml (6 mg) of hyperbaric bupivacaine or a 1.2 ml solution containing 1.0 ml (5 mg) hyperbaric bupivacaine, 0.1 ml (75 microg) clonidine and 0.1 ml sterile water. The motor block was assessed by a modified Bromage scale and the sensory block by a pinprick., Results: There was a significant difference in the spread of anaesthesia between the operated and contralateral sides in both groups. Seventy-seven per cent of the blocks were unilateral in group B and 73% in group B-C. There was no significant difference between the groups, in unilaterality. The motor block was prolonged in group B-C but it did not affect home-readiness. Patients receiving clonidine needed more vasopressors. There was a significant difference in blood pressures between the groups, being lower in group B-C after 1 h 45 min., Conclusion: Using 5 mg hyperbaric bupivacaine with 15 microg of clonidine, the unilaterality can be achieved and spinal anaesthesia intensified without affecting home-readiness. More vasopressors are needed in the beginning, but after the surgery patients experienced less pain.

Background and Objectives: For completion of perioperative care and for general ethical considerations, any intraoperatively used catheter technique should be utilizable for post-operative pain therapy. Continuous spinal anesthesia (CSA) is an established form of local anesthetic application. However, for its use in post-operative therapy, infusion pumps are required that are technically able to deliver low rates and are distinctive in design to avoid possible pump or medication swaps. Because of a lack of devices specifically designed for CSA, we investigated the potential deployability of infusion pumps for post-operative pain therapy via CSA microcatheters, which were originally designed and approved for different applications., Methods: The accuracy of infusion rates of three different pumps was measured in a liquor model environment. Furthermore, we investigated safety and user-friendliness by interviewing 30 anesthesiologists and 15 pain nurses., Results: Except for the first hour of infusion, all pumps provided comparable and adequate flow profiles. However, interviews revealed significant risk factors for all pumps in terms of swapping devices, lines or medications and misprogramming the units., Discussion: All pumps tested were technically able to deliver accurate flow rates; however, because the non-CSA-specific design involves the risk of medication overdosage and syringe swaps, none of the systems tested can be recommended for routine use in post-operative CSA, irrespective of the fact that it was an off-label application anyway. Therefore, to ensure patient safety, continuous spinal administration of local anesthetics via microcatheters is a questionable method of post-operative pain therapy as long as non-specific pumps are used.

Background and Objective: Hypotension following spinal anaesthesia (SA) is common, especially in the elderly. Elevated sympathetic tone has been shown to correlate with severe hypotension after SA. The aim of this prospective trial was to investigate skin conductance (SC), as a measure of sympathetic tone, to predict hypotension after SA., Methods: After ethical approval and written informed consent, 30 patients undergoing SA were included. Baseline measurements of SC [number of fluctuations per second (reflecting the firing rate of skin sympathetic nerves), area under the curve (AUC) A and B (reflecting the magnitude of the sympathetic impulse)], blood pressure and heart rate were recorded. After administration of SA, all parameters were assessed every 2.5 min for a total of 15 min. Baseline readings of SC were compared with the lowest blood pressure within the study period., Results: Data from 30 subjects [73 (8) years] were analysed. After SA, the mean arterial blood pressure declined an average of 21.3 (11.3) mmHg. A cut-off value of 0.35 microSs for baseline AUC B allowed prediction of more than mild hypotension (>15% from baseline) after SA with a sensitivity of 72.5% and a specificity of 77.5%., Conclusions: AUC B, as a parameter of SC, may predict severe arterial hypotension after SA in the elderly.

We report the case of a woman who received spinal anaesthesia for peripheral vascular surgery of the lower limbs and subsequently developed a spinal subarachnoid haematoma. Interestingly, low back pain was the only symptom of this spinal subarachnoid haemorrhage. During the following days, blood migrated from the spinal haematoma towards the cerebral subarachnoid spaces. The patient presented with stupor, nausea and vomiting that resolved within 2 weeks with conservative treatment.

Background: The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists, are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and pre-eclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today's anesthesiologist., Methods: This is a personal review in which different aspects of obesity in the pregnant woman, that are relevant to the anesthesiologist, are discussed. An overview of maternal and fetal morbidity and physiologic changes associated with pregnancy and obesity is provided and different options for labor analgesia, the anesthetic management for cesarean delivery and potential post-partum complications are discussed in detail., Results and Conclusion: The anesthetic management of the morbidly obese parturient is associated with special hazards. The risk for difficult or failed intubation is exceedingly high. The early placement of an epidural or intrathecal catheter may overcome the need for general anesthesia, however, the high initial failure rate necessitates critical block assessment and catheter replacement when indicated.

Background: The aim of the present study was to compare placebo, ketamine, granisetron and a combination of ketamine and granisetron in the prevention of shivering caused by regional anaesthesia., Methods: In this prospective, randomized, double-blind study, 160 ASA I and II patients undergoing urological surgery were included. Subarachnoid anaesthesia was performed in all patients with bupivacaine 15 mg. The patients were randomly allocated to receive saline (group P, n= 40), ketamine 0.5 mg (group K, n= 40), granisetron 3 mg (group G, n= 40) or ketamine 0.25 mg + granisetron 1.5 mg (group KG, n= 40). Shivering was graded as 0 = no shivering, 1 = piloerection or peripheral vasoconstriction but no visible shivering, 2 = muscular activity in only one muscle group, 3 = muscular activity in more than one muscle group but not generalized, and 4 = shivering involving the whole body. If 15 min after spinal anaesthesia and concomitant administration of a prophylactic dose of one of the study drugs, the patients shivered according to at least grade 3, the prophylaxis was regarded as ineffective and intravenous (i.v.) pethidine 25 mg was administered., Results: After 15 min, the number of patients with observed shivering was 22 in group P, 6 in group G, 7 in group GK and 0 in group K. The difference between group K and all the other groups was statistically significant (P < 0.0001). The number of patients with a shivering score of 3 was statistically significantly higher in group P compared with the other groups., Conclusion: The prophylactic use of 0.5 mg/kg i.v. ketamine was effective in preventing shivering developed during regional anaesthesia.

Background: After general or epidural anesthesia, clonidine is known to be effective in suppressing established shivering. The aim of this study was to assess the preventive effect of intrathecal clonidine on post-spinal shivering compared with intravenous (i.v.) clonidine., Methods: One hundred and fifty patients scheduled for orthopedic surgery were randomly allocated into three groups to receive either 1 microg/kg clonidine i.v. (IV group) or the same volume of isotonic saline (control and IT groups) at 5 min before spinal anesthesia. Spinal anesthesia was performed with 12-15 mg hyperbaric bupivacaine 0.5% plus either 1 ml of saline (control and IV groups) or 150 microg clonidine (IT group). Shivering was evaluated for a period of 90 min and graded as none, mild, moderate, and severe., Results: Twenty patients (40%) in the control group and 17 patients (34%) in the IT group showed shivering compared with four (8%) in the IV group. Patients with moderate-to-severe shivering were only seen in the control and IT group, and the maximal intensity of shivering was not different between the two groups. Patients in the IV group were significantly more sedated than the other groups., Conclusions: The intrathecal administration of clonidine 150 microg fails to prevent post-spinal shivering; by contrast, we have confirmed that i.v. clonidine 1 microg/kg is an effective method to prevent shivering in patients undergoing spinal anesthesia for orthopedic surgery.

Background: In children, only a few trials have evaluated the use of spinal needles with special tip designs. In this study, we compared the success rate and incidence of post-dural puncture complaints of two small-gauge spinal needle designs used in children undergoing spinal anaesthesia (SA)., Methods: Three hundred and three children aged 9 months to 17 years presenting for subumbilical surgery were randomly assigned to have a 26G Atraucan (n = 156) or 27G Whitacre (n = 147) spinal needle for SA. The number of attempts to obtain successful cerebrospinal fluid (CSF) return and the success rate of SA were recorded. The first week of recovery was recorded by a diary., Results: Both groups had a similar one-attempt success rate: 80% in the Atraucan group and 81% in the Whitacre group. Failure to obtain CSF occurred in one patient in the Atraucan group and in two patients in the Whitacre group. Paraesthesia was observed more commonly in the Whitacre group (10%) than in the Atraucan group (2%) (P = 0.004). The success rate of SA was 96%, with no differences between the two needles; one child was given general anaesthesia and 11 children (3%) a single dose of supplemental analgesia for the skin incision. Forty-one children (15%) developed a headache, 13 of which were classified as post-dural puncture headache (PDPH), seven cases (5%) in the Atraucan group and six (4%) in the Whitacre group; none of the children required a blood patch. Fifteen children (10%) in the Atraucan group and nine (7%) in the Whitacre group developed low back pain. Two children (1%) in the Atraucan group and four (3%) in the Whitacre group developed transient neurological symptoms (TNSs)., Conclusion: Both needles were associated with a high success rate and a low incidence of complaints.

Background: Oral mucosal host defences are altered after anaesthesia and surgery. The effects of endotracheal intubation (ET) and the use of the laryngeal mask airway (LMA) on oral mucosal host defences after minor surgery were compared., Methods: Immunological (immunoglobulin A (IgA), IgG and IgM) and non-immunological (myeloperoxidase, total peroxidase, thiocyanate) oral host defence factors, and amylase and protein concentrations, were measured from saliva pre-operatively and on the first post-operative day in 60 ASA I-II patients undergoing minor surgery. The patients underwent general anaesthesia using oral ET or LMA. Spinal anaesthesia (S) was used as control. Serum IgG, IgM and IgA concentrations were determined., Results: Protein-related salivary secretion of amylase and salivary concentration of IgM showed the only statistically significant overall differences between the groups. By contrast, changes were observed within the ET group in the salivary flow rate, protein concentration, amylase activity and immunological host defence factors. Some changes were also observed in the LMA group, but none in the S group. Most non-immunological test values did not change within any of the groups., Conclusions: ET and LMA induced similar oral mucosal host defence responses. There were, however, observations in this study that indicated a stronger response during ET than when LMA was used.

Background: Hypotension associated with spinal anesthesia for cesarean section is still a clinical problem. Colloid solutions seem preferable to crystalloid solutions for preloading. In most studies the overall rate of hypotension is reported. Few studies have, however, investigated the maternal and neonatal consequences of different levels of maternal hypotension., Methods: In this randomized, double-blinded study 110 patients presenting for elective cesarean section received either 1000 ml acetated Ringer's solution or 1000 ml 3% dextran 60 solution immediately before spinal anesthesia. The effect on overall hypotension, clinically significant hypotension (hypotension associated with maternal discomfort defined as nausea, retching/vomiting, dizziness or chest symptoms) and severe hypotension (systolic arterial pressure <80 mmHg) was studied., Results: Dextran reduced the incidence of overall hypotension from 85 to 66% (P=0.03), reduced the incidence of clinically significant hypotension from 60 to 30% (P=0.002) and reduced the incidence of severe hypotension from 23 to 3.6% (P=0.004) compared to Ringer's solution. There were neither differences in neonatal outcome between treatment groups nor between neonates grouped after severity of maternal hypotension., Conclusion: Clinically significant hypotension seems to be a more suitable outcome variable than overall hypotension. The protective effect of the colloid solution increased with increased severity of hypotension.

Background: As part of a quality assurance program, we investigated the incidence of postpartum neurologic symptoms in multiparous parturients receiving spinal block for labour analgesia, now in routine use in our labour ward., Methods: Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting spinal analgesia were asked to participate in this prospective study. All parturients received our standard intrathecal analgesia (ITA): 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) using a 27-gauge Quincke-type needle. The patients filled in a questionnaire on the first day after delivery and again upon discharge. Complaints typical of neurologic sequelae were noted and a neurologic examination was performed, if necessary. All patients with postdural puncture headache (PDPH) and transient neurologic symptoms (TNSs) were interviewed by telephone 2 weeks after discharge to determine the course of the symptoms., Results: Two hundred and twelve parturients were included in the study. Eighteen (8.5%) parturients complained of PDPH, the severity of which was mild in eight (4%), moderate in seven (3%), and severe in three (1%) patients, respectively. Fifteen (7%) mothers were treated with analgesics or bedrest only. Three (1%) patients were given an epidural blood patch. The paramedian approach was associated with the development of PDPH (P = 0.04). Transient neurologic symptoms were experienced by nine (4.2%) mothers, lasting 1-3 days, mostly presenting as bilateral pain in the buttocks or thighs. One parturient suffered from paraesthesia of the left foot lasting for 3 days. Forty (19%) mothers complained of non-postural headache and 28 (13%) of new-onset back pain. Three mothers (1%) would not want to receive a further spinal block., Conclusion: Transient neurologic symptoms (TNSs) after spinal block occurred infrequently. The incidence of PDPH was higher than in the obstetric population in general and calls for re-evaluation of our spinal block methods. Despite the occurrence of neurologic sequelae, patient acceptability was high.

Background: Intrathecal analgesia (ITA) is effective in late, rapidly progressing labour. In 1998, our hospital implemented the use of single-shot spinal block for pain relief in multiparous parturients. As part of a quality assurance programme, we assessed the analgesic efficacy, obstetric and neonatal outcomes and maternal satisfaction after this form of analgesia now in routine use in our labour ward., Methods: Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting analgesia were asked to participate in this prospective study. All parturients received our standard ITA: 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) inserted via the L2-3 or L3-4 interspace. Routine monitoring included maternal vital signs, uterine contraction and fetal heart rate tracing. Pain scores (visual analogue scale (VAS) 0-10), sensory levels, motor block, side-effects and maternal satisfaction were recorded. Satisfactory analgesia was defined as a decrease in pain scores to three or less within 20 min after injection. The number of parturients requesting additional analgesia and the duration of spinal block (time from injection until request for additional medication after satisfactory analgesia had worn off) were recorded., Results: Two hundred and nine parturients were included in the study. Satisfactory analgesia was achieved in 153 (73%) parturients. Fifty-five (26%) women requested additional analgesia: 38 (18%) because of unsatisfactory analgesia and 17 (8%) because analgesia ended before delivery. The duration of spinal block was 101 +/- 34 min. Pruritus occurred in 64%, fetal bradycardia in 7% and hypotension in 2% of deliveries. Pain relief was rated excellent by 65%, moderate by 20% and inadequate by 14% of the parturients. One hundred and sixty-nine (81%) women stated that they would like to have spinal analgesia again for pain relief during delivery., Conclusion: The majority of multiparous parturients found ITA adequate for pain relief during delivery. However, modifications are required in terms of improved timing, reliability and duration of analgesia.

Background: The perioperative effects of intrathecal and epidural clonidine combined with local anesthetic were evaluated in 60 patients undergoing hip arthroplasty., Methods: This was a double-blinded study and the patients were randomized into three groups, with 20 patients in each group. All patients received spinal anesthesia with 17.5 mg of plain bupivacaine with 15 microg of clonidine (Group BC-RC) or without clonidine (Groups B-R and B-RC). Postoperatively, epidural infusion was administered in the following way: Group B-R-ropivacaine 4 mg h(-1); Groups B-RC and BC-RC: ropivacaine 4 mg h(-1) and clonidine 40 microg h(-1). Sensory block was assessed with light touch, pinprick, transcutaneous electrical stimulation at T12 and L2 dermatomes, and perception of thermal stimuli., Results: The maximal upper level of sensory block measured by pin-prick (T6-T7) did not differ between the groups while the partial sensory block for cold and warmth were increased two dermatomes above pin-prick level in the group with intrathecal clonidine compared to the other two groups (P < 0.05). Duration of anesthesia, analgesia and motor block were longer in Group BC-RC compared to Groups B-R and B-RC (P < 0.02). Postoperatively, both VAS score on movement and PCA-morphine consumption were higher in Group B-R than in Groups B-RC and BC-RC (P < 0.01). The arterial pressure and heart rate in Groups B-RC and BC-RC were significantly lower than in Group B-R at 10-24 and 15-24 h, respectively, after spinal injection., Conclusion: Low-dose intrathecal clonidine provided a better quality of anesthesia and longer-lasting analgesia. Epidural clonidine-ropivacaine infusion resulted in improved postoperative analgesia but was associated with a moderate decrease in blood pressure.

Background: Initial data from 1996 revealed that in contrast to several other countries general anaesthesia was the preferred anaesthetic technique for Caesarean section in Germany. However, anaesthetic practice for Caesarean section has changed during the last decades world-wide. This investigation was performed to obtain more actual data on anaesthetic procedures in obstetric patients in German hospitals., Methods: Questionnaires on the practice of anaesthesia for Caesarean section were mailed to 918 German departments of anaesthesiology. Furthermore, the survey evaluated severe perioperative complications in obstetric patients., Results: The 397 completed replies in this survey represent 41.3% of all German deliveries in 2002. Spinal anaesthesia is now the most common technique (50.5%) for elective Caesarean section. In case of urgent and emergency Caesarean, delivery figures decrease to 34.6% and 4.8%, respectively. Epidural anaesthesia is performed in 21.6% of scheduled and 13.2% and 1.0% of non-scheduled urgent or emergency Caesarean sections, respectively. Four maternal deaths and several non-fatal episodes of gastric content aspiration were reported by the respondents., Conclusions: Compared to data obtained 6 years ago a significant increase in regional anaesthesia for Caesarean section has developed, with spinal anaesthesia being the preferred technique. Surveys can help to initiate discussion and improve current practice of anaesthetic care.

Background: Hip fracture is common in the geriatric population. Patients in this group are often at high risk for perioperative complications from concurrent diseases. Conventional spinal anesthesia can be associated with hypotension but has a better postoperative outcome compared to general anesthesia. We judged that a reduced dose of bupivacaine in combination with sufentanil could give reliable blocks with minimal hypotension., Methods: Fifty elderly patients were randomized into two groups. The study group received spinal anesthesia as a combination of hyperbaric bupivacaine 7.5 mg and sufentanil 5 microg while the control group received hyperbaric bupivacaine 15 mg. The hemodynamic stability of the patients and the quality of the blocks were compared., Results: All patients had adequate duration of reliable blocks. More control group patients than study group patients required ephedrine due to hypotension., Conclusion: A reduced dose of hyperbaric bupivacaine (7.5 mg) in combination with sufentanil (5 microg) provides reliable spinal anesthesia for the repair of hip fracture in aged patients with few events of hypotension and little need for vasopressor support of blood pressure.

Background: The incidence of headache after spinal anaesthesia has varied greatly between studies. We compared the incidence of postoperative headache in general and postdural puncture headache (PDPH) when using 27-gauge (G) (outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory surgery performed under spinal anaesthesia., Methods: In a prospective, randomized study, 676 ASA physical status I-II day-case outpatients were given a spinal anaesthetic through either a 27-G (0.41 mm) Quincke or a 27-G (0.41 mm) Whitacre spinal needle. The incidence of any type of postoperative headache was assessed and the type of headache defined using a standardized questionnaire including PDPH criteria. The severity of the headache was defined using a 100-mm visual analogue scale., Results: For the final analysis, 529 patients were available (259 patients in the Quincke group and 270 patients in the Whitacre group). The overall incidence of postoperative headache was 20.0%, but the incidence of true PDPH was very low (1.51%). The incidence of PDPH in the Quincke group was 2.70%, while in the Whitacre group it was only 0.37% (P < 0.05). The overall incidence of non-dural puncture headache was 18.5% and did not differ between the study groups., Conclusions: True PDPH seldom occurs when a 27-G (0.41 mm) spinal needle is used, although postoperatively a non-specific headache is common. Using the 27-G (0.41 mm) Whitacre spinal needle further reduced the incidence of PDPH. Thus, we recommend routine use of the 27-G (0.41 mm) Whitacre spinal needle when performing spinal anaesthesia.

Background: This study investigated whether addition of 15 microg epinephrine plus 25 microg fentanyl to lidocaine spinal anesthesia for outpatient knee arthroscopy makes it possible to use a subanesthetic lidocaine dose. The aim was to assess the quality of anesthesia and the suitability of this protocol for outpatient knee arthroscopy., Methods: Seventy-five outpatients scheduled for knee arthroscopy were randomly assigned to one of three spinal anesthetic protocols: Group L10F25 received 10 mg of lidocaine plus 25 micro g fentanyl; Group L10F25E15 received 10 mg of lidocaine plus 25 microg fentanyl plus 15 microg epinephrine; and Group L20F25 received 20 microg lidocaine plus 25 microg fentanyl. Tourniquet pain and surgical pain were assessed using a visual analog scale. If spinal anesthesia was inadequate despite supplementary intravenous analgesia and sedation, the patient was converted to general anesthesia. Recovery times and side-effects in the early postoperative period were recorded., Results: The highest level of sensory block was above the T12 dermatome in all patients. Compared with the other groups, significantly more patients in Group L10F25 converted to general anesthesia. Group L10F25 had a significantly higher mean surgical pain score than the other groups. The mean tourniquet pain score was significantly higher in Group L20F25 than Group L10F25E15. Group L10F25E15 had a significantly shorter time to discharge than the other groups. Post-operative nausea and vomiting and drowsiness were more frequent in Group L10F25 than in the other groups., Conclusion: The combination of 10 mg lidocaine and 25 microg fentanyl plus 15 microg epinephrine provides adequate spinal anesthesia and has favorable recovery characteristics for outpatient knee arthroscopy.

Background: In total hip replacement surgery several anesthesiological techniques can be used. In this study we compared continuous spinal anesthesia (CSA) and postoperative analgesia vs. single-shot spinal anesthesia (SPA) and postoperative patient-controlled intravenous analgesia with morphine (SPA)., Methods: In a prospective randomized study, 68 patients, ASA I-III, between 50 and 85 years of age were allocated to these two groups. Quality of analgesia, hemodynamic stability and technical difficulties, as well as incidence of postoperative nausea and vomiting (PONV) and post dural puncture headache (PDPH), were recorded during a 24-h period., Results: Visual analog scale (VAS) scores were significantly lower in the CSA group from 3 h post operation (P < 0.05). Mean arterial pressure dropped by 21 +/- 11 mmHg in the CSA group and 29 +/- 14 in the SPA group during induction (P < 0.05). Technical difficulties and incidence of PDPH were similar in both groups. Postoperative nausea and vomiting was lower in the CSA group (P < 0.05)., Conclusions: Continuous spinal anesthesia/analgesia is a very practicable method providing better postoperative analgesia and better hemodynamic stability during anesthesia induction than SPA followed by morphine PCA analgesia after total hip replacement surgery.