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Objectives: Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy., Methods: A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed RESULTS: Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders., Conclusions: Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products., (Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: To determine whether the appearance of glucose in the fluid spontaneously obtained by the epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence., Patients and Methods: A prospective, observational study was conducted on 34 patients with combined intradural-epidural anaesthesia in whom an epidural catheter was introduced, after locating the epidural space with a saline solution, inserting a spinal needle and injecting hyperbaric bupivacaine. After observing whether any fluid was spontaneously dripping from it, it was determined if this contained glucose. Withdrawal of the needle and washing its lumen with saline solution, it was checked whether there was glucose in washout. The samples were analysed using a glucose meter. When the motor block disappeared a dose of local anaesthetic was administered through the epidural catheter. The relationship of the demographic parameters with the spontaneous dripping of the epidural catheter was evaluated., Results: Spontaneous dripping by the epidural catheter after its insertion was observed in 22 patients. All the samples obtained contained glucose. There was glucose in 9 out of 34 epidural needle wash samples. None of the patients suffered from excessive motor-sensory block. There was a statistically significant relationship between patient age (P<.05) and spontaneous dripping by the catheter (the higher the age, more dripping)., Conclusion: The finding of glucose in the fluid obtained by the epidural catheter is a frequent occurrence and is of no clinical significance. We propose that it could be due to a leak of cerebrospinal fluid by the dural puncture needle during or after the administering of the hyperbaric bupivacaine and the spillage of this into the epidural space., (Copyright © 2010 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.)

Objective: To determine the incidence of paresthesia with different spinal puncture techniques using a 27-gauge Whitacre needle., Material and Methods: Spinal puncture was performed in 224 elective cesarean sections using different techniques in this single-blind, prospective trial. Patients were randomized to 4 groups: group 1, combined epidural and subarachnoid puncture using an introducer needle; group 2, combined epidural and subarachnoid puncture without an introducer; group 3, subarachnoid puncture with an introducer; and group 4, subarachnoid puncture with an introducer to within a few millimeters of the dural sac, at which point the introducer was withdrawn., Results: Paresthesia developed in 23, 11, 16 and 5 patients in groups 1, 2, 3 and 4, respectively. Various nerve roots were affected. In 2 and 11 cases the fourth and fifth lumbar nerve roots were affected; in 29 and 13 cases, the first and second sacral nerve roots were involved. In comparison with group 4, the risk of paresthesia was 7, 2.5 and 4 times greater in groups 1, 2 and 3, respectively., Conclusions: Combined epidural-subarachnoid puncture leads to a higher incidence of paresthesia in comparison with simple spinal puncture, probably because the lumbar puncture is performed on a dural sac that has been previously deformed due to the "tent effect" caused by the epidural needle. Fewer cases of paresthesia occur when the subarachnoid puncture is slow and steady and the introducer needle is withdrawn millimeters before it reaches the dural sac.

Introduction: When low doses of local anesthetic are used in combined spinal-epidural anesthesia for cesarean section, an epidural catheter can be used to enhance a possibly incomplete block or insufficient dose., Objective: To compare the efficacy of spinal 0.5% hyperbaric bupivacaine with fentanyl (20 microg) at a conventional high dose of 0.07 mg cm(-1) (group 1) vs 0.25% levobupivacaine at a low dose of 7.6 mg with fentanyl (20 microg) and epidural volume extension with 6 mL of saline through an epidural catheter (group 2)., Material and Methods: A randomized clinical trial enrolling patients scheduled for elective cesarean section., Results: Sixty-two patients were studied (31 in each group). Characteristics in the groups were comparable at baseline and the maximum level of sensory block achieved was sufficient for all but 1 patient in group 2 who required general anesthesia. The bupivacaine dose in group 1 ranged from 10.5 to 12 mg. The motor block and duration was less intense in group 2 (P<0.0001) and patients in that group could be transferred out of the postanesthetic care unit earlier., Conclusions: The use of low doses of levobupivacaine with an opiate in combination with volume extension through an epidural catheter in the context of combined spinal-epidural anesthesia is a safe, effective technique that may allow the doses and motor block to be reduced when hyperbaric levobupivacaine is administered, without adverse events for patients.

Subdural and epidural hematomas complicating central blocks are rare but serious complications that can lead to permanent neurological deficits. This review discusses cranial and spinal subdural hematomas, including the history of this complication in the literature. Theories to explain the mechanisms by which hematomas are formed are presented and risk factors are analyzed. The associations between such hematomas and the design of the various needles used for lumbar puncture are evaluated and the most common cranial and spinal locations are discussed. The anatomy of tissues that envelop and contain chronic subdural hematomas are described and the various neurological alterations that can develop are mentioned. Finally, diagnostic imaging options and corrective surgical techniques are reviewed.

A 69-year-old man with rectal adenocarcinoma and no relevant medical history was scheduled for anterior resection of the tumor under combined anesthesia. The epidural catheter was removed 48 h after surgery. A clinical picture consistent with a diagnosis of epidural hematoma developed gradually and was confirmed by magnetic resonance imaging. The last dose of low molecular weight heparin had been administered 8 h before catheter removal and blood analyses were normal. Recovery was complete following laminectomy and evacuation of the hematoma 31 h after the onset of symptoms. Our analysis of the literature on conditions leading to epidural hematoma after catheter insertion revealed that complications may appear for unknown reasons even when catheter management and thrombolytic prophylaxis are appropriate. Nevertheless, the maneuver for removing an epidural catheter is clearly not risk-free and can cause complications. Monitoring after removal is therefore important if complications are to be detected early.

Objectives: To determine the optimum concentration of bupivacaine administered by continuous epidural infusion, using a Baxter Single Day elastomeric infusor at a rate of 2 ml/h, to treat pain during the first 24 h after lumbar laminectomy., Patients and Methods: Sixty patients undergoing elective repair of a herniated lumbar disk were randomly assigned to three homogeneous groups of 20 each. Group I received epidural infusion of 0.0625% bupivacaine, group II received 0.125% bupivacaine and group III received 0.25% bupivacaine. After surgery each patient was given a 4 mL solution of the local anesthetic being studied, followed by an infusion of the same through an elastomeric infusor at a rate of 2 ml/h throughout the first 24 h after surgery. Ketorolac was delivered through a device for patient controlled analgesia after surgery. Pain was assessed on a visual analog scale (VAS) at rest and during movement. Pain relief was assessed on a simple descriptive scale., Results: Significantly less ketorolac was required during epidural infusion of 0.125% and 0.25% bupivacaine than when the 0.0625% concentration was being infused (29 +/- 16 and 28 +/- 13 mg, respectively, versus 110 +/- 35 mg; p < 0.001). VAS scores were significantly lower during infusion of 0.125% and 0.25% bupivacaine than with 0.0625% bupivacaine. No instances of motor blockade or infection related to catheter insertion were observed in any of the patients., Conclusions: Continuous epidural infusion of 0.125% and 0.25% bupivacaine through an elastomeric infusor gives excellent analgesia during the first 24 h after surgery. Administration of 0.25% bupivacaine is associated with a higher incidence of urinary retention. We therefore think that the most recommendable concentration of bupivacaine for infusion is 0.125%.

Objective: Many publications have linked surgical glove powder to inflammatory reactions of the peritoneum, pleura, pericardium and meninges. Accidental contamination may also increase the likelihood of complications after spinal and epidural anesthesia. We aimed to analyze the morphological characteristics of microscopic particles adhering to surgical gloves and to analyze how likely such particles are to enter the epidural space during catheterization., Material and Method: One hundred epidural catheters were studied in two groups (A and B) of 50. Group A catheters contained stylettes and the distal ends were open (Vygon). Group B catheters contained no stylettes and had closed distal ends and three side openings (Becton Dickinson). Continuous epidural anesthesia was simulated with half the catheters in each group (25) by touching the distal end of each line with the gloves and later inserting the catheter through a Tuohy needle. All catheters--those used in the simulation as well as the untouched ones--were then examined under a scanning electron microscope. The particles on the internal and external surfaces of the gloves had previously been identified under a microscope and analyzed by X-ray diffraction., Results: Gloves: external glove surfaces carried particles measuring between 3 and 4 mu; their morphology was consistent with calcium carbonate. On internal surfaces we found larger particles, between 11 and 14 mu in diameter, shaped differently and of smooth appearance. Analysis of the latter showed them to contain traces of magnesium and to have characteristics consistent with organic molecules. The particles of one surface were never observed on the other. Catheters: the non-manipulated catheters in both groups contained no free particles matching those described above, whereas the outside surfaces of the catheters in contact with gloves contained particles consistent with those of external glove surfaces. The number of particles per square millimeter of surface was 2,598 (95% CI 2,200 to 2,900) in group A catheters and 2,340 (95% CI 2,000 to 2,600) in the group B catheters (p = NS). The differences in the number of particles adhering to catheters touched by gloves and those that had not been manipulated were statistically significant (p < 0.001)., Conclusions: Particles adhering to gloves can be drawn into the epidural space during continuous epidural anesthesia. All unnecessary manipulation should therefore be avoided, and the portion of the catheter to be inserted into the epidural space should not be touched in order to prevent possible nonspecific meningeal inflammatory responses.

Objective: To describe and evaluate anesthetic treatment during single lung transplantation (SLT)., Patients and Methods: This is a retrospective study of patients undergoing SLT during one year of our program's operation. We describe the surgical technique and method of anesthesia, which consisted in combined general and epidural anesthesia. Systemic and pulmonary arterial pressures, heart rate, arterial and mixed venous oxygen saturation were monitored throughout the procedure, along with inspired and expired gases and airway pressure. The following parameters were recorded for the various phases of surgery: cardiac index (CI), right ventricular ejection fraction (REF) and systemic and pulmonary vascular resistances, arterial and mixed venous blood gas readings., Results: Eight SLT were performed during the study period and the survival rate was 100%. PaCO2 and pulmonary artery pressure increased at the start of ventilation of a single lung. These values increased again when the pulmonary artery was clamped. During this period, however, CI and REF held steady and venous oxygen saturation decreased only slightly. Cardiopulmonary bypass was therefore never used. The variables returned to normal upon revascularization of the new lung., Conclusions: In spite of the small series studied, the excellent results obtained lead us to conclude that our method is appropriate and that SLT is a valid therapeutic alternative for our patients.

Objectives: To evaluate prospectively the advantages and disadvantages of a combined subarachnoid and epidural block with a modified Tuohy needle during hip surgery., Material and Methods: Fifty ASA II-III patients undergoing full hip arthroplasty were studied. The same technique was used with all patients; 2 ml of 0.5% hyperbaric bupivacaine (10 mg) was used for the subarachnoid block. Ten ml of 2% lidocaine (200 mg) was injected by epidural catheter into 25 patients (group I); 5 ml of 0.5% bupivacaine (25 mg) was injected into the others (group II). A Tuohy 17 G needle with a Huber point and supplemental orifice for a 26 G intradural needle was used, along with an epidural catheter. The level of difficulty of the technique was evaluated, as were unusual events, the metameric level of sensory block reached, and intraoperative (hypotension, bradycardia or both) and postoperative (head or lower back pain) complications., Results: The level of difficulty was nil in 60% of the cases, average in 26% and high in 14%. The quality of the motor-sensory blockade was excellent and the thoracic level of sensory blockade (mean +/- SD) was 6.2 +/- 1.4 for group I and 8.2 +/- 1.1 for group II. The difference between the two groups was significant (p < 0.05). Hypotension was found in 6% of all patients, bradycardia in 20% and both in 14%, with no significant differences between the two groups. No case of headache was reported and the level of patient satisfaction with the anesthesia was excellent in 92% of the cases., Conclusions: A combined subarachnoid (10 mg hyperbaric bupivacaine) and epidural (200 mg lidocaine or 25 mg bupivacaine) blockade provides an excellent sensory block with few side effects. The technique facilitates epidural treatment of postoperative pain.

The aim of the present study is to evaluate an electronic detector of negative pressure (Episensor, Palex, Spain) designed for the identification of epidural space. Ninety patients were randomly assigned to two groups: group 1 (n = 47) received epidural anesthesia as perioperative analgesic technique with Episensor method and group 2 (n = 43) received epidural anesthesia with the classic method of loss of resistance with gas mandrin. The following parameters were studied: a) demographic features, b) characteristics of epidural anesthesia, and c) complications occurring during space detection. There were no statistical differences in the analysis of demographic variables neither in the quality of the epidural anesthesia achieved in both groups. With respect to complications, group I presented the highest number of complications although only the lack of detection of epidural space achieved statistical significance (8.5%, p less than 0.05); the incidence was lower than that reported in the literature as physiologically possible in the lumbar epidural segment. We conclude that progressive knowledge of Episensor may decrease the initial incidence of complications with a success rate similar to that of classic techniques of identification of epidural space.

Since the existence of negative pressure in the epidural space was reported, its technique of localization has undergone changes directed to improve objectivity, reliability and safety. The aim of the present study was to evaluate a new electronic divide to localize the epidural space, i.e. the Episensor (Palex, Spain). To this end, 71 patients, both males and females, undergoing elective urological surgery and in whom catheterization of the lumbar epidural space had been planned, were prospectively evaluated and randomly assigned to two homogeneous groups. In group I (n = 35) the epidural space was localized by the classical technique of loss of resistance, while in group II the Episensor was used. In both groups several technical parameters, the qualification of the operator and the complications of the procedure were evaluated. There were no significant differences between both groups regarding the quality of epidural blockade or the subjective technical difficulty of the operator. The incidence of complications of the technique of puncture was significantly higher in group II (p less than 0.05); the most common were dura mater puncture in 13 group II patients and in one group I patient (p less than 0.001). There was no correlation between the qualification of the operator and the development of complications. It was concluded that the use of Episensor to localize lumbar epidural space did not improve the effectiveness of blockade but increased the iatrogenic effects of the puncture. Our lack of experience with this new technique and the low negative pressure of lumbar epidural space might have been the causes of the poor results, that we consider as initial in the evaluation of this new method.

Two types of intradural needles, 25 gauge (Qincke bevel) and 24 gauge (Sprotte type bevel) in 535 intradural anaesthesias were compared. Sprotte type needle is a modification of the Withacre needle. Postspinal total headache had an incidence of 8.9%, being significantly less (p less than 0.01) with the Sprotte needles (4.9 versus 11.8%). Spinal headache were significantly more frequent in women and in patients with an age less than 40 years, and there was no significance between the two needles when patients were older than forty. We conclude that Sprotte bevel needle decreases significatively the incidence of post-puncture headache if the patients are younger than forty, but it is an important fact that the different factors involved: age, sex and needle type, might be taken into account when we need conclusions to be drawn.