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Background This randomized, double-blind study was designed to compare between sequential combined spinal epidural anesthesia versus epidural volume extension in lower limb surgery as regards hemodynamics, sensory, and motor blocks. Methods In this randomized, double-blind, prospective study, 80 patients scheduled for lower limb surgery were divided into two groups: sequential combined spinal epidural (SCSE) group in which small doses of local anesthetic was injected in epidural space after low-dose spinal anesthesia and epidural volume extension (EVE) group in which 10 ml saline was injected in epidural space after low-dose spinal anesthesia. Hemodynamics, anesthesia readiness time, degree of motor block, time to regression of sensory block, and side effects were measured. Results Hemodynamic changes were insignificant. Anesthesia readiness time was significantly faster in EVE group. Motor block and sensory block were better in SCSE. Postoperative bupivacaine consumption was statistically insignificant between the two groups. Conclusion Both SCSE and EVE techniques can preserve hemodynamics after low-dose subarachnoid block and can be used in high-risk elderly patients undergoing orthopedic surgery.

Inadvertent dural puncture with subsequent post-dural puncture headache (PDPH) is the most typical complication of labour epidural analgesia. Subdural hematoma (SDH) is a rare but late neurological complication of this procedure. The intracranial hypotension created by the cerebrospinal fluid (CSF) leakage through the dural defect can lead to the rupture of the bridging veins to produce a subdural hematoma. A change in the character from postural to a non-postural headache is a warning sign of subdural hematoma. We describe a case of post-dural puncture headache followed by the development of cranial SDH in a patient who refused a blood patch and opted for conservative treatment. We conclude that a high index of suspicion must be maintained with a witnessed dural puncture or even without it but having persistent headache, to detect any severe complications like an intracranial subdural hematoma. An epidural blood patch is to be considered when the headache does not subside with conservative management. Early employment of MRI or CT head imaging studies should be considered to exclude, diagnose, or treat any serious complication without unnecessary delay.

Epidural catheters are often used in the provision of surgical anaesthesia and analgesia. These catheters need to be removed after a certain period, but difficulties may be encountered during this process. We present a case of difficult epidural catheter removal in an elderly woman who had undergone surgery for reduction and internal fixation of a comminuted intertrochanteric fracture at the left femur under combined spinal epidural anaesthesia. Anaesthesia was satisfactory during the operation; however, initial attempts to remove the catheter at the end of the procedure was met with significant resistance. Normal saline (5 ml) was injected through the catheter without difficulty, suggesting that the catheter was likely trapped and compressed but not obstructed. A nickel/titanium memory alloy suture was used as a guidewire to remove the catheter without damaging it. This case was analysed subsequently, and the management of future problematic removals is discussed herein. This article aims to raise awareness of, and to explore techniques for managing difficult epidural catheter removal.

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.

Introduction: Spinal anaesthesia is a popular anaesthesia technique for lower limb surgeries. The haemodynamic changes that occur, may be sudden and deleterious, particularly in geriatric patients. Moreover the duration of spinal anaesthesia is limited. Thus, a safer approach of sequential combined spinal epidural (SCSE) anaesthesia is emerging currently. The technique combines benefits of both. Aim: To evaluate the changes in hemodynamic parameters while using SCSE block and spinal anaesthesia for lower limb surgeries. Study Design: A prospective, randomised, double blind study. Materials and Methods: Sixty ASA grade I and II physical status, who underwent lower limb procedures were included in the study. They were divided equally into Group I (spinal) and Group II (SCSE). The haemodynamic parameters in the two groups was observed. Results: From 2 minutes to 20 minutes, there was statistically significant rise in pulse rate in group I, associated with decrease in blood pressure in group I (p value Conclusion: Sequential combined spinal epiduralblock maintains hemodynamic stability with minimal complications as compared to spinal anaesthesia. Key messages: Sequential spinal epidural anaesthesia maintains cardiovascular stability. Keywords: Sequential spinal epidural, Spinal, Haemodynamics, Side effects.

Background: Neuraxial placement relies on palpation of anatomical landmarks, sometimes challenging to identify. Ultrasound (US) has helped facilitate those procedure. We wanted to assess efficacy of the US compared to landmark techniques when used by experienced obstetric anesthesiologists. Methods: We conducted a randomized prospective trial of healthy parturients requesting neuraxial labor analgesia. Positive CSF through the 27 G Pencan spinal needle at the first interspace attempted was the primary outcome. Secondary outcomes were the number of attempts and the number of needle adjustments within a space, presence of symmetrical analgesia 2 hours after placement, and need for epidural replacement. The procedures were performed by practitioners experienced in obstetric anesthesia, including obstetric anesthesiology fellows, and attending physicians who received a video training of the US technique prior to the study [1]. Results: Forty-eight patients were randomized to either the US or landmark group. Two patients (one in each group) were excluded from the study due to delivery within 2 hours of CSE (Combined Spinal Epidural) placement. One patient in the landmark group was excluded due to a wet tap. No statistical difference was found regarding positive CSF flow on first attempt at CSE (p = 0.6). All secondary outcomes were statistically insignificant as well: number of spaces attempted (p = 0.71 95% CI –0.30 to 0.21), number of needle adjustments (p = 0.09, 95% CI –0.10 to 1.28), presence of symmetrical anesthesia at 2 hours (p = 1) and need for epidural replacement (p = 0.48). Conclusions: When placed by an experienced obstetric anesthesiology fellow or attending physician, there is no difference in the successful placement of CSE with US versus landmark technique. Key Points Summary Question: Does the use of an US machine (GE Logiq®) by experienced obstetric anesthesiology providers increase the success of neuraxial placement compared to the ‘traditional’ landmark technique. Findings: Our results did not show any statistical difference between the US and the landmark techniques when done by skilled anesthesiologists in term of the number of interspaces attempted, number of adjustments or redirections of the needle in the same interspace, the presence/absence of CSF flow upon dural puncture or the adequacy of the block 2 hours after placement. Meaning: We concluded that the use of US does not confer any benefits for neuraxial placement in this specific subgroup of practitioners.

Tuberous sclerosis (TSC) is a rare disease with multi-systemic involvement, predominantly neurological. Little evidence exists about the anesthetic management of patients with this disorder, particularly in pregnant women. This article discusses a case of a patient with TSC admitted to our hospital for the delivery of a twin gestation. Twenty-four hours after surgery, the patient presented left-side facial-brachial hypoesthesia and headache. A brain CT revealed a right frontal cortical bleeding tumor, which was diagnosed as glioblastoma multiforme. The patient was discharged 15 days after admission and a neurosurgical approach was suggested.

Cesarean deliveries are often performed with a neuraxial anesthetic technique. Fracture of needles used for local anesthetic infiltration is rare. During subcutaneous infiltration of local anesthetic for a combined spinal epidural (CSE) anesthetic technique performed for elective cesarean delivery, a fragment from a fractured 27-gauge local anesthetic needle was retained in the lumbar subcutaneous tissue. CSE anesthesia was then successfully performed at a different spinal interspace, and the patient had an uneventful cesarean delivery. The patient had the needle fragment removed on the first postoperative day by an interventional radiologist who used fluoroscopy to identify the needle location.

Osteogenesis imperfecta (OI) is a rare disabling genetic connective tissue disorder. General anesthesia in these patients is associated with increased risks. Regional anesthesia is favored wherever feasible, but there are limited reports of use of a sole regional technique in OI in pediatric patients. Moreover, combined spinal-epidural anesthesia has never been described previously. We are reporting the use of combined spinal-epidural anesthesia for a prolonged surgery (multiple osteotomies) of lower limbs in a 10-year-old wheelchair-bound child with OI type III. Preoperative counseling, ultrasonography guidance, titrated local anesthetic dosage, and dexmedetomidine sedation helped establish optimum surgical conditions.

In recent years, the dural puncture epidural (DPE) technique has emerged as a novel method of labor analgesia. The DPE technique involves the technical elements of a combined spinal epidural (CSE) technique but avoids the direct administration of intrathecal medications. The underlying mechanism responsible for the unique blockade qualities of the DPE technique is believed to be the translocation of medications from the epidural space into the dural sac; laboratory studies have found a positive correlation between translocation flux and the size of dural perforation. Clinically, earlier and greater sacral spread and dermatomal block symmetry have been observed in obstetric and surgical patients receiving the DPE technique compared to the epidural (EPL) technique. Moreover, the DPE technique appears to have fewer side effects than the CSE technique. The DPE technique appears to offer a paradigm shift in obstetric analgesia and anesthesia, but further investigation is warranted.

BACKGROUND:The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of anal

Background and Aims: Regional analgesia is commonly used for the relief of labour pain, Prolongation of analgesia can be achieved by adjuvant medications. The aim of this randomised controlled trial was to evaluate the efficacy of intrathecal levobupivacaine with dexamethasone for labour analgesia. Methods: A total of 80 females were included in this study, all were primigravidas undergoing vaginal delivery with cervical dilatation ≥4 cm and 50% or more effacement. Forty females were included randomly in either Group L (received intrathecal levobupivacaine 0.25% in 2 mL) or Group LD (received intrathecal levobupivacaine 0.25% combined with dexamethasone 4 mg in 2 mL). The primary outcome was the duration of spinal analgesia. Secondary outcomes included the total dose of epidural local anaesthetic given, time to delivery, neonatal outcome and adverse effects. Results: The duration of spinal analgesia was significantly longer in the LD group compared with L group (80.5 ± 12.4 min vs. 57.1 ± 11.5 min, respectively; P< 0.001). In Group LD compared with Group L, time from spinal analgesia to delivery was significantly lower (317.4 ± 98.9 min vs. 372.4 ± 118.8 min, respectively; P = 0.027), and total epidural levobupivacaine consumption was significantly lower (102.4 ± 34.8 mg vs. 120.1 ± 41.9 mg, respectively; P = 0.027). The two groups were comparable with respect to characteristics of sensory and motor block, haemodynamic parameters, pain scores, neonatal outcome and frequency of adverse effects. Conclusion: Intrathecal dexamethasone plus levobupivacaine prolongs the duration of spinal analgesia during combined spinal-epidural CSE for labour analgesia.

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.

Anterior iliac crest bone grafting is a well-established modality in the treatment of alveolar bone deficiencies. However, this procedure may also have considerable postoperative morbidity which is mostly related to general anesthesia. Postoperative pain-related complications can be managed by neuroaxial blockade techniques which provide adequate surgical analgesia and reduce postoperative pain. This clinical report describes the reconstruction of a severely atrophic maxilla with anterior iliac crest bone grafting using combined spinal epidural anesthesia. Neuroaxial blockade techniques may be a useful alternative to eliminate general anesthesia related challenges of anterior iliac crest bone grafting procedures.

Background To investigate the applicability of the combined spinal-epidural anesthesia (CSEA) method in RIRS for the treatment of kidney stone disease and also to compare with general anesthesia (GA) in terms of their effects on early postoperative pain levels and their cost. Methods A hundred consecutive patients who were scheduled for RIRS were enrolled in this study and were prospectively evaluated according to the anesthesia methods. Patients were divided into 2 groups randomly: the GA (N.=50) and CSEA (N.=50) groups. Five patients were excluded due to patient incompatibility or inadequate anesthesia. The pain levels of patients in the Group 2 were recorded during the operation using the Visual Analog Scale (VAS) at minutes 1, 5, 10, 15, 30 and 60. Peak pain levels within the first 24 hours following the operation were recorded for both groups. Results Ninety five patients in the two groups were determined to be similar in terms of demographic characteristics. The mean VAS score at the postoperative 1st day was found as 1.20±0.9 for Group 1 and 0.82±1.3 for Group 2. No statistically significant differences were identified between the VAS-nram and VAS-ram groups (P=0.450). The total cost of anesthesia medications was similar between the both groups. Conclusions Combined spinal-epidural anesthesia, which produces favorable outcomes in the intraoperative and postoperative periods, will become an alternative to general anesthesia. Also, the costs associated with these two anesthesia methods were calculated, it was found that the total cost of anesthesia medications and materials per operation was similar both methods.

Purpose To evaluate the morbidity of iliac block bone grafting performed under general anesthesia (GA) or combined spinal epidural anesthesia (CSEA). Materials and Methods We implemented a retrospective study including patients who underwent anterior iliac block bone grafting for deficient maxillary alveolar ridges. The anesthetic technique (GA or CSEA) was the primary predictor variable. The outcome variables were pain, gait disturbance, neurosensory disturbance (0 to 5 weeks), vomiting tendency (0 to 7 days), and postoperative hospitalization period (0 to 2 days). Results The sample comprised 22 patients, with 10 in the GA group and 12 in the CSEA group. No surgical complications except sensory disturbance in 2 patients were observed during the study period. Pain during initial healing (P < .001), the gait disturbance rate at 3 weeks after surgery (P = .003), and the vomiting tendency on the day of surgery (P < .001) were significantly higher in the GA group than in the CSEA group; all variables showed significant improvement with time in both groups. The postoperative hospitalization period was also significantly longer for the GA group than for the CSEA group (P

Drug allergies, asthma, and obesity are more common in modern societies, and patients with these problems are often a challenge for anesthetists. Different techniques of regional anesthesia can be beneficial particularly for this group of patients. We present a patient who suffered from all of the above-mentioned conditions and successfully underwent laparoscopic cholecystectomy under thoracic combined spinal-epidural anesthesia. It is still not a popular practice, and we would like to show another indication for using it.

Dr. Ryszard Rodzinski was a Polish surgeon who, in spite of his short life, had a productive career. His most important discovery was a safer method of performing regional anesthesia for abdominal surgery. The first description of combined spinal epidural anesthesia is generally attributed to Soresi in 1937. In the early 20th century, Rodzinski invented a novel technique, "combined lumbosacral anesthesia," which combined lumbar spinal anesthesia and sacral epidural anesthesia. During the 19th Meeting of Polish Surgeons in July 1922 in Warsaw, Rodzinski presented an article entitled "On Combined Lumbosacral Anaesthesia," in which he described this technique used in surgical clinic in Lwow since October 1921. Given this presentation, Rodzinski could be considered to have made the first known presentation of the combined spinal and epidural anesthesia.

Background It is unclear whether recognition of epidural catheter failures is delayed with combined spinal epidural technique (CSE) compared to traditional epidural technique (EPID) when used for labor analgesia. The authors hypothesized that recognition of failed catheters is not delayed by CSE. Methods Anesthetic, obstetric, and quality assurance records from 2,395 labor neuraxial procedures (1,440 CSE and 955 EPID) performed at Forsyth Medical Center (Winston-Salem, North Carolina) between June 30 and December 31, 2012, were retrospectively analyzed. The primary outcome was catheter survival (failure-free) time during labor analgesia. A proportional hazards model with the counting method was used to assess relationships between the techniques and survival (failure-free) time of catheters, while controlling for subjects’ body mass index and providers’ level of training in the final best-fit multivariable regression model. Results Cumulative incidence of epidural catheter failures was 6.6% for CSE and 11.6% for EPID (P = 0.001). In the multivariable regression model, catheters placed with CSE versus epidural were less likely to fail (hazard ratio, 0.58; 95% CI, 0.43 to 0.79; P = 0.0002) for labor analgesia. Among the catheters that failed, there was no overall difference in failure time course between the techniques (hazard ratio, 1.17; 95% CI, 0.89 to 1.54; P = 0.26) even though more failed catheters with CSE (48.4%) than with EPID (30.6%) were recognized within the first 30 min of placement (P = 0.009). Conclusions In this cohort, CSE has a significantly lower risk of overall epidural catheter failures than EPID and does not delay recognition of epidural catheter failures. Choice of CSE versus EPID should be based on overall risk of failure, efficacy, and side effects.

BACKGROUND:The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of anal

The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.

Achondroplasia is one of the commonest forms of dwarfism. A 26-year-old achondroplasic dwarf with vitamin D deficiency was posted for an elective shaft of femur fixation. Owing to her difficult airway and past history of tuberculosis, it was decided upon to operate her under combined spinal and epidural anaesthesia. This case report highlights on the need for real time ultrasound guidance in locating the epidural space and hence aiding in successful placement of the Quincke’s needle and the epidural catheter. The ultrasound is an effective and reliable tool to ascertain the most feasible inter-vertebral space in cases of a difficult spine anatomy.

Uterine rupture rarely occurs during pregnancy, but it is a critical situation if so. It is already known that a history of uterine surgeries, such as cesarean section or myomectomy, is a risk factor for uterine rupture. Currently, the laparoscopic adenomyomectomy is a widely performed procedure, but associated risks have not been defined. We observed a case of spontaneous uterine rupture in a patient during the 35th week of gestation, after a laparoscopic adenomyomectomy. A 42-year-old, gravida 2, para 0 woman became pregnant after a laparoscopic adenomyomectomy and her pregnancy was conventional. At a scheduled date in the 35th week of gestation, after combined spinal epidural anesthesia and frequent uterine contractions, a weak pain suddenly ensued. After 13 minutes of uterine contractions, vaginal bleeding was evident. A cesarean section was performed, and the uterine rupture was found in the scar. After a laparoscopic adenomyomectomy, a pregnant uterus can easily rupture by rather weak and short uterine contractions, and is characterized by vaginal bleeding. When uterine bleeding is observed in pregnant women that have a history of adenomyomectomy, one should consider uterine rupture.

Total paraplegia after epidural or spinal anesthesia is extremely rare. We herein report a case of total paraplegia caused by a giant intradural herniation of a lumbar disk at the L3-L4 level after total hip arthroplasty for coxarthrosis. The patient had no preoperative neurologic abnormalities. Intraoperative anesthetic management involved combined spinal-epidural anesthesia at the L3-L4 level with continuous intravenous propofol administration. Postoperatively, the patient complained of numbness and total paraplegia of the lower extremities. Magnetic resonance imaging showed a giant herniation of a lumbar disk compressing the spinal cord at the L3-L4 level. The intradural herniation was surgically treated, and the patient's symptoms completely resolved.

Anesthesia in a dwarf patient may be challenging as various anatomical anomalies make both general and regional anesthesia difficult. These patients may have atlantoaxial instability, potential for airway obstruction, and associated respiratory problems that may pose problems for general anesthesia. Spinal stenosis, osteophytes, short pedicles, or a small epidural space could complicate regional anesthesia in dwarfs which could lead to difficulties in locating the epidural space and increase the risk of dural puncture. Spinal stenosis may impair cerebrospinal fluid flow such that identification of dural puncture is difficult. This elderly dwarf patient had history of bronchial asthma with restriction of neck extension, managed successfully using combined spinal–epidural anesthesia.

Background Cor triloculare biventriculare accounts for approximately 0.31% of cases of congenital heart disease (CHD). Moreover, people with cor triloculare biventriculare always have shorter life spans, and cases of gestation are rare. There have been various related reports of cor triloculare biventriculare in recent years. Case presentation We described an emergency cesarean section of a 30-year-old, 38-weeks-pregnant woman suffering from cardiac insufficiency and fetal distress. Combined spinal-epidural anesthesia was performed safely, and a male baby was smoothly delivered 10 min after the procedure without any adverse outcome on the mother or newborn. After surgery, we advised that the patient submit to an echocardiogram examination, which revealed the congenital heart disease cor triloculare biventriculare. Conclusions Combined spinal-epidural anesthesia was administered to a patient with cor triloculare biventricularethis with good effect, ensuring the patient’s safety and meeting the need for emergency surgery.

Introduction: Orthopaedic anaesthesia plan requires customization as per patient’s need for safe outcome. Sequential Combined Spinal Epidural Anaesthesia (Sequential CSEA) and Unilateral Single Shot Spinal anaesthesia (Unilateral SA), both have advantages over conventional spinal anaesthesia that they provide longer lasting block with less hypotension. Aim: To compare safety and efficacy of unilateral spinal anaesthesia with sequential combined spinal epidural anaesthesia for lower limb orthopaedic surgery. Materials and Methods: This prospective randomized study was conducted on sixty ASA I-III patients aged 18- 65 years undergoing lower limb orthopaedic surgeries of approximately two hours duration. Sequential CSE group received spinal with 5 mg of 0.5 hyperbaric bupivacaine followed by incremental epidural top up of 2 cc of 0.5% isobaric bupivacaine to achieve and maintain T10 level. In unilateral SA group, unilateral spinal anaesthesia was given with 10 mg of 0.5% hyperbaric bupivacaine. Haemodynamic parameter, anaesthesia readiness time and block characteristics were recorded and results were analysed using unpaired Student's t-test. Results: There was no failure of block, surgical anaesthesia with T10 sensory level and bromage score three motor block was achieved by all patients in both groups. Anaesthesia readiness time was less in unilateral SA (p

BACKGROUND: Augmentation of the level of spinal sensory block after an epidural injection in combined spinal epidural anesthesia may be explained by a dual mechanism: a volume effect due to the compression of the thecal sac and a local anesthetic effect. AIMS: The purpose of our study was to investigate the effect of increasing the dose and volume of epidural injectate in combined spinal epidural technique. SETTINGS AND DESIGN: Prospective randomized controlled and double blind. METHODS AND MATERIAL: Fifty adult patients scheduled for lower limb surgery under combined spinal epidural anesthesia were randomly allocated to one of the five groups comprising 10 patients each. All patients received a combined spinal epidural injection using a needle through needle technique. An intrathecal injection of 10 mg (2ml) of 0.5% hyperbaric bupivacaine was given and an epidural catheter inserted in all the cases. After the maximal level of sensory blockade was attained, an epidural injection was administered according to the designated randomization code. Group I received nothing and served as the control. Groups II, III, IV & V received 20 ml of 0.25% Bupivacaine, 20ml of saline, 10ml of 0.25% Bupivacaine &10ml of saline respectively through the epidural catheter. STATISTICAL ANALYSIS: The observations were analyzed using Chi square and paired t test. RESULTS: Significant rise in the level of sensory analgesia was observed in groups II to V following the epidural injection while no change was observed in the control group. Maximum rise was observed in Group II where the dose as well as volume was maximum. CONCLUSION: We conclude that increasing the dose and volume of injectate increases the effective sensory block when utilizing the epidural volume extension technique; even after maximal sensory blockade of spinal has been achieved.

OBJECTIVES: The present study was planned as a prospective study with the following objectives: 1. To evaluate the efficacy of 0.125% bupivacaine with 20 µg fentanyl in relieving parturition pain with lumbar epidural and combined spinal epidural analgesia. 2. To compare the impact of lumbar epidural and combined spinal epidural technique on maternal satisfaction for pain relief, progress of labor, mode of delivery, neonatal outcome. RESULTS: The two groups were similar with respect to age distribution, height, weight, BMI of the parturients (table 1 & 2). The onset of analgesia was 1.98±0.33 min in group CSE and 5.00±1.64 min in group E (table 3). Peak action of analgesia was 4.15±0.41min in CSE group and 9.87±1.97 min in group E. The onset and peak of analgesia was faster in group CSE and is statistically significant with p

Background: The purpose of the present study is to investigate the anesthetic effect of reduced doses of spinal bupiva caine with epidural top ups in comparison with those of spinal bupivacaine and to determine the adequate doses of drugs used during lower extremity surgeries. Methods: Sixty adult patients were randomized to three different technique groups: S group (10 mg of spinal bupiva caine), SE1 group (7.5 mg of spinal bupivacaine + epidural 1.5% lidocaine 10 ml) or SE2 group (5 mg of spinal bupivacaine + epidural 1.5% lidocaine 10 ml). The level of sensory block, modified Bromage motor scores (MBS), systolic blood pressure and heart rate were recorded for 30 min following anesthesia. Peak sensory block height and MBS, time for sensory regression to L1 and motor recovery to MBS 1, side effects and operator’s satisfaction were noted. Results: The levels of peak sensory block were similar among the groups (P > 0.05). For the SE2 group, the regression to the L1 dermatome was faster (P = 0.004) and the maximum MBS was lower (P = 0.001) than that of the other two groups. Motor block recovery to MBS 1 was faster for the SE1 and SE2 groups than for the S group (P < 0.001). The op erator’s satisfaction scores of the SE2 group were lower than those of the other two groups (P = 0.019). Conclusions: During combined spinal-epidural anesthesia, 7.5 mg of spinal bupivacaine and epidural 1.5% lidocaine 10 ml produced faster motor recovery than did 10 mg of spinal bupivacaine in patients undergoing lower extremity surgeries. (Korean J Anesthesiol 2014; 66: 28-33)

Epidural blood patch is a frequently successful treatment for postdural puncture headache. It is not clear whether a recent epidural blood patch affects subsequent neuraxial analgesia. We describe the case of a patient who received an epidural blood patch for postdural puncture headache and returned 3 days later in active labor, requesting epidural analgesia. The patient successfully received analgesia from a combined spinal epidural without further complications. We discuss the anesthetic considerations for providing neuraxial analgesia after a recent epidural blood patch.

Use of ultrasonography to identify the anatomical structures during central neuraxial blockade is becoming increasingly common. Ultrasound-assistance and its real-time guidance have been used to gauge the depth of the dura-ligamentum-flavum complex. Successful spinal anaesthetic blocks following dry taps have rarely been reported. We report two cases of successful subarachnoid blocks despite dry taps where pre-procedure ultrasonography of the vertebral column helped in decision making process.

Study objective This study evaluated the haemodynamic effects of general anaesthesia versus combined spinal epidural anaesthesia in patients undergoing caesarean section in the presence of mild to moderate pericardial effusion. Design A prospective randomized study. Setting The study setting included a hospital where a surgical team performed elective caesarean section in the presence of mild to moderate pericardial effusion. Patients and interventions Thirty healthy patients were randomly divided into two groups, general anaesthesia (GA) (group I) and combined spinal epidural (CSE) anaesthesia (group II). Measurements and main results Heart rate, central venous pressure, mean arterial blood pressure, and pulmonary capillary wedge pressure were measured 10 min before anaesthesia, after 20 and 30 min of anaesthesia, and 30 min after recovery. Blood loss was significantly lower in group II [465.33 (72.78) ml] as compared to group I [548.20 (22.73) ml]. The pain score in group II was significantly lesser [1.66 (0.72)], than in group I [2.60 (0.73)]. The HR was significantly higher in group I as compared to that in group II at 20 and 30 min after anaesthesia, and 30 min after surgery, being 81.53 (2.72), 94.80 (3.12) and 82.8 (2.85) (beats/min), respectively. However, the CVP was significantly higher in the group I at 20 and 30 min after induction, being 8.40 (0.63) and 7.80 (0.67) (cmH2O) respectively. The MAP was significantly higher in group II than in group I at 20 and 30 min after induction, being 80.86 (1.30) and 81.00 (1.00) (mmHg) respectively. The PCWA was significantly higher in group I compared to group II at 20 and 30 min after induction, being 10.13 (1.35) and 11.80 (0.94) (mmHg), respectively. Conclusion CSE anaesthesia appeared to be more advantageous, in patients undergoing caesarean section with mild to moderate pericardial effusion, with less haemodynamic changes, decreased blood loss, and better postoperative analgesia than general anaesthesia patients.

Renal tubular acidosis, associated with hypothyroidism, is rare. We present the case of a woman with known renal tubular acidosis and treated hypothyroidism who underwent emergency cesarean delivery under uneventful combined spinal-epidural anesthesia. The rationale for choosing the anesthetic technique and the potential risks associated with anesthesia and renal tubular acidosis are discussed.

Introduction. In twin pregnancies with a diagnosis of Reversed Arterial Perfusion (TRAP), sequence, is highly recommendedto be managed by fetoscopic fetal surgery through bipolar photocoagulation, in order to improve the prognosis of one ofthe fetuses (pump fetus), in contrast of the other one which is acardiac and / or anencephalic. In this regards anesthesiamanagement has to ensure maternal and fetal safety and provide excellent surgical conditions. Objective. To describe theanesthetic management of a patient diagnosed with TRAP sequence scheduled for bipolar fetoscopic-photocoagulation. Introducción: En los embarazos gemelares con diagnóstico de Secuencia de perfusión arterial reversa (TRAP), serecomienda realizar el tratamiento intra-útero mediante la fotocoagulación bipolar por fetoscopía, con la finalidad de mejorarel pronóstico de uno de los fetos (feto bomba), pues el otro feto es acardio y/o anencefálico, motivo por el cual es necesariauna anestesia que garantice la seguridad materna-fetal y proporcione las condiciones quirúrgicas idóneas.Objetivo: Describirel manejo anestésico de una paciente con diagnóstico de secuencia TRAP programada para fetoscopía-fotocoagulaciónbipolar.

Background and Aims: The use of regional anesthesia for laparoscopic cholecystectomy has been reserved for patients who are at high-risk under general anesthesia (GA). The aim of this study was to assess whether thoracic combined spinal epidural (CSE) anesthesia is a feasible option for American Society of Anesthesiologists (ASA) physical status I and II patients undergoing elective laparoscopic cholecystectomy. Material and Methods: Thirty ASA physical status I and II patients undergoing elective laparoscopic cholecystectomy received thoracic CSE anesthesia at T9-T10 or T10-T11 interspinous space using the midline approach. Two ml of isobaric levobupivacaine 0.5% with 25 μg of fentanyl was given intrathecally. Results: Surgery was conducted successfully in all except one patient. Thoracic CSE was performed at T9-T10 interspace in 25 patients and T10-T11 interspace in five patients. Paresthesia occurred in two patients (6.6%) transiently on Whitacre needle insertion that disappeared spontaneously. Dural puncture on epidural needle insertion occurred in one patient, and intrathecal placement of epidural catheter occurred in one. Ten patients (33%) complained of shoulder pain. Conversion to GA was done in one patient due to severe shoulder pain and anxiety. Hypotension occurred in 11 patients (36%) and all responded to single dose of mephenteramine 6 mg and fluid bolus. Bradycardia occurred in six patients (20%) which was managed in all with a single dose of atropine. Conclusion: Thoracic CSE anesthesia can be used effectively for ASA I and II patients undergoing laparoscopic cholecystectomy with significant postoperative benefits.

A 70-year-old female patient, known case of hypertension and incomplete Left bundle branch block (LBBB), posted for bipolar hemiarthroplasty. A geriatric patient with LBBB and systemic hypertension is a fatal combination; it may precipitate into complete AV dissociation during anaesthesia and surgical stress. We are reporting this interesting case as our patient had developed complete Atrioventricular (AV) dissociation when scheduled earlier for surgery and got postponed. We had given combined spinal epidural anaesthesia and managed successfully without any complication.