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Objective: Currently, the primary surgical treatment for pseudomyxoma peritonei (PMP) is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The perioperative period is frequently accompanied by severe pain. Erector spinae plane block (ESPB) can enhance analgesia for abdominal surgery. The purpose of this study was to compare the analgesic effects of bilateral multiple-injection ESPB in patients with PMP. Methods: Fifty patients with PMP were randomly divided into two groups: the ESPB combined with general anesthesia group (Group E) and the general anesthesia alone group (Group C). Prior to the induction, patients in Group E underwent ESPB at the T7 and T11 levels. The primary outcome was the visual analog scale (VAS) scores during rest at 6 h post-extubation. Secondary outcomes included intraoperative and postoperative opioid consumption, time for first rescue analgesia, frequency distribution of rescue analgesia, incidence of nausea and vomiting, adverse events associated with ESPB. Results: The Visual Analogue Scale (VAS) scores in Group E were significantly lower compared to Group C at immediate post-extubation (1.6 ± 0.9 vs. 2.4 ± 1.2, P = 0.008), and at 2 (1.9 ± 1.2 vs. 3.2 ± 1.1, P < 0.001), 4 (2.4 ± 1.5 vs. 3.7 ± 1.0, P = 0.001), and 6 h (2.7 ± 1.1 vs. 3.8 ± 1.4, P = 0.004) post-extubation during rest. Similarly, the VAS scores in Group E were significantly lower than those in Group C at immediate post-extubation (3.0 ± 1.4 vs. 4.6 ± 1.2, P < 0.001), and at 2 (3.8 ± 1.7 vs. 4.9 ± 1.4, P = 0.019), 4 (3.5 ± 1.3 vs. 5.3 ± 1.5, P < 0.001), and 6 h (3.9 ± 1.8 vs. 4.9 ± 1.3, P = 0.004) post-extubation during movement. In Group E, the intraoperative remifentanil administration (2319.3 ± 1089.5 vs. 2984.6 ± 796.1, P = 0.017) and the amount of rescue analgesia within 2 h post-extubation (0 vs. 4, P = 0.037) were significantly less than in Group C, and the first rescue analgesia time was shorter as well (231.4 ± 147.5 vs. 668.8 ± 416.7, P < 0.001). Conclusion: Compared to general anesthesia alone, bilateral multiple-injection ESPB with 0.2% ropivacaine can enhance analgesia and reduce opioid administration in patients with PMP. However, the duration of analgesia with ESPB is relatively short due to the low concentration of the local anesthetic used. Trial registration: Chinese Clinical Trial Registry, ChiCTR2300069504, 20/03/2023. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusions This study investigated the relationship between newborn feeding behaviour and feeding type among month‐old babies and explored maternal and neonatal factors associated with breastfeeding rates at 1 month of age.This observational study was conducted in Japan with healthy mothers and full‐term newborns. Newborn feeding behaviours were assessed using the Japanese Infant Breastfeeding Assessment Tool (IBFAT) within approximately 1 day of birth. Obstetric and newborn characteristics, including newborn feeding behaviours, were investigated in relation feeding type (breast milk or mixed milk) at 1 month of age.This study included 176 mother–newborn pairs. IBFAT scores were significantly higher in the breast‐milk group (Median (M) = 10.5, Interquartile Ranges (IQR): 9.0–11.0) than in the mixed‐milk group (M = 10.0, IQR: 7.5–11.0) (P = 0.046). Additionally, the sucking pattern of breastfeeding was showing a greater distribution of higher scores in the breast‐milk group (M = 2.0, IQR: 2.0–2.5) than in the mixed‐milk group (M = 2.0, IQR: 1.5–2.5) (P = 0.015). Compared to mothers who received epidural analgesia or synthetic oxytocin, primiparas who did not receive them were more likely to breastfeed (epidural analgesia: (33.3% vs. 65.8%, P = 0.004); synthetic oxytocin: (42.0% vs. 78.6%, P = 0.018)). For multiparas, Apgar and IBFAT scores were associated with feeding type at 1 month of age.This study found that newborns' effective and sustained sucking within 1 day of birth is an important factor for breastfeeding at 1 month of age. When assessing feeding type, maternal factors such as epidural analgesia should be the focus for primiparas, while neonatal factors such as feeding behaviour should be prioritised for multiparas. [ABSTRACT FROM AUTHOR]

Objective This study aimed to examine the relationship of fetal station in the first stage of labor to labor curves and cesarean delivery rates among women presenting in spontaneous labor. Study Design Labor curves for patients with nonanomalous singletons who presented in spontaneous labor to our hospital's Obstetric Triage Unit with intact membranes from January 1, 2012, to August 31, 2016, were reviewed. Cervical exams and time of exam were obtained for each patient from presentation to triage until delivery. Station for each presentation and cervical dilation was estimated using a random effects model and the slope of cervical station change was calculated to estimate the change in dilation by hour. Perinatal outcomes, including cesarean delivery rates, were examined according to fetal station at initial presentation. Factors known to affect labor curves—epidural analgesia, infant birth weight, maternal habitus, and parity—were also examined. Results There were 8,123 patients presented in spontaneous labor with intact membranes. For patients presenting at 6-cm dilation, the rate of change of labor was significantly different when identified to have a station greater than 0 (+1 and more caudad) when compared with those with −1 and more cephalad station (both p < 0.001). This relationship persisted when analyzed according to epidural analgesia, birth weight, maternal habitus, and parity. The frequency of cesarean delivery was significantly higher for women presenting in spontaneous labor with negative fetal station (p < 0.05). When stratified across all dilation (3–9 cm), this trend remained significant (p < 0.001). Conclusion In the first stage of labor, advanced fetal station was significantly associated with differing rates of labor progression, and positive fetal station was significantly less likely to result in cesarean delivery. Physical examination, including station, remains a critical element in labor management. Key Points Fetal station is important in labor management. Fetal station at initial exam is related to time to delivery. Positive fetal station at initial exam is less likely to result in cesarean delivery. [ABSTRACT FROM AUTHOR]

Purpose: To compare patient-controlled epidural analgesia (PCEA) and epidural morphine (EM) for post-cesarean section analgesia in real-world experience from China. Methods: Parturients receiving one dose of EM (1–2 mg), PCEA, or both EM and PCEA from Peking Union Medical College Hospital were retrospectively recruited. Logistic models were used to identify risk factors. Results: Of 1079 parturients enrolled, 919 (85.2%) parturients received only EM, 105 (9.7%) parturients received PCEA, and 55 (5.1%) parturients received both EM and PCEA. Significantly more parturients from EM group requested supplementary analgesia than those from PCEA and PCEA + EM group (583, 63.4% vs 52, 49.5% vs 25, 45.5%, P = 0.001) with more times of supplementary analgesia (1, IQR: 0–2 vs 0, IQR: 0–1 vs 0, IQR: 0–1 times, P < 0.001) and larger amounts of nonsteroidal anti-inflammatory drugs (NSAIDs) (50, IQR: 0–100 mg vs 0, IQR: 0–50 mg vs 0, IQR: 0–50 mg, P < 0.001). In multivariable Logistic regression for the supplementary analgesia risk, the application of PCEA (OR: 0.557, 95%CI 0.396–0.783, P = 0.001) and the use of NSAIDs intraoperatively (OR: 2.996, 95%CI 1.811–4.957, P < 0.001) were identified as independent predictors. A total of 1040 (96.4%) patients received prophylactic antiemetic therapy during surgery. Only 13 (1.2%) and 7 (0.6%) patients in our cohort requested antiemetic and antipruritic drugs, respectively. Conclusion: The use of PCEA was an independent protective factor for supplementary analgesia during the post-cesarean section. Prophylactic antiemetic therapy may reduce the side effects of post-cesarean analgesia. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study is to examine the analgesic efficacy of varying doses of hydromorphone hydrochloride in conjunction with absorbable gelatin sponge for postoperative pain management in elderly individuals undergoing lumbar fusion surgery. Additionally, the study aims to assess the sustained release analgesic properties of this combination and to determine the optimal dosage of hydromorphone hydrochloride for effective pain relief. Methods: A total of 113 elderly patients (aged ≥ 65 years old) meeting the criteria for 1-2-level posterior lumbar fusion surgery at Ganzhou City People's Hospital between July 2022 and August 2023 were randomly assigned to four groups: group A (0.2 mg hydromorphone hydrochloride 1 ml), group B (0.3 mg hydromorphone hydrochloride 1.5 ml), group C (0.4 mg hydromorphone hydrochloride 2 ml), and group D (0.9% normal saline 2 ml) for standard anesthesia induction and maintenance. Prior to suturing the incision, gelfoam was utilized to administer epidural analgesia to each group. Following the surgical procedure, an intravenous analgesia pump was utilized for pain management. The baseline infusion rate was set at 0.5 ml/h. Patient-controlled analgesia (PCA) was administered at a dose of 2 ml, with a lockout interval of 20 min, allowing the patient to self-administer as needed. Pain relief was assessed using the visual analogue scale (VAS) prior to surgery, as well as at 1 day and 3 days post-operation. The frequency of PCA requests within the initial 48-h postoperative period, the remedial analgesia with dezocine, postoperative adverse reactions, and duration of hospitalization were documented for analysis. Results: The VAS scores of groups B and C were found to be significantly lower than those of group D 1 day after the operation. Additionally, VAS scores at 3 days post-operation, remedial rate of dezocine and PCA follow-up times at 48 h in groups A, B, and C were significantly lower compared to group D (P < 0.001). There was no statistically significant difference between group B and group C in VAS scores at 1 day and 3 days post-operation, as well as PCA follow-up times at 48 h post-operation (P < 0.001). Furthermore, the VAS scores of groups B and C were lower than those of group A at 1 day and 3 days post-operation (P < 0.05). The PCA frequency of group C was also lower than that of group A at 48 h post-operation (P < 0.05). Conclusion: The combination of hydromorphone hydrochloride and absorbable gelatin sponge epidural analgesia has been shown to enhance postoperative pain management. A dosage of 0.4 mg of hydromorphone hydrochloride may be considered an appropriate analgesic dose, as it can provide effective pain relief without eliciting adverse reactions. Trial Registration: ChiCTR.org.cn(ChiCTR2200064863). Registered on October 20, 2022. [ABSTRACT FROM AUTHOR]

Introduction: postoperative epidural analgesia in open abdominal or thoracic surgery remains the gold standard due to its advantages over intravenous opioid analgesia. However, the success of this technique relies heavily on the correct placement of the catheter in the epidural space. Being a blind, operator-dependent procedure, and in patients with diverse anatomical characteristics, there is a high incidence of placement failure ranging from 12% to 30%. In the immediate postoperative period with residual anesthetic effects, early detection of epidural catheter inefficacy due to misplacement outside the epidural space can be challenging, potentially leading to postoperative pain uncontrolled hours later. Multiple diagnostic methods have been proposed for catheter localization; however, many involve special devices that are costly, invasive, or impractical in the surgical setting like epidurography. Objective: to establish a sequence of steps for the adequate evaluation of the catheter in the epidural space using ultrasound. Material and methods: patients over 18 years of age scheduled for open abdominal or thoracic surgery candidates for thoracic epidural analgesia, who provided consent. Results: a total of 113 patients were included in the study. The mean age of the patients was 55.8 ± 15.2 years, with 50 (44.2%) being 63 (55.8%) female. The ultrasound-guided approach protocol was optimized through measurements with different patients. Conclusions: ultrasound emerges as a recent and promising diagnostic tool for locating the epidural catheter, utilizing both the M-mode and color Doppler mode. This protocol provides a solid foundation for future research, which will be able to analyze the diagnostic accuracy of ultrasound compared to epidurography, as well as evaluate its internal and external validity. [ABSTRACT FROM AUTHOR]

To develop prediction models for intrapartum caesarean section in vaginal breech birth.This single-center cohort-study included 262 nulliparous and 230 multiparous women attempting vaginal breech birth. For both groups, we developed and (internally) validated three models for the prediction of intrapartum cesarean section.The prediction model for nulliparous women (AUC: 0.67) included epidural analgesia (aOR 2.14; p=0.01), maternal height (aOR 0.64 per 10 cm; p=0.08), birthweight ≥3.8 kg (aOR 2.45; p=0.03) and an interaction term describing the effect of OC if birthweight is ≥3.8 kg (aOR 0.24; p=0.04). An alternative model for nulliparous women which, instead of birthweight, included fetal abdominal circumference with a cut-off at 34 cm (aOR 1.93; p=0.04), showed similar performance (AUC: 0.68). The prediction model for multiparous women (AUC: 0.77) included prelabor rupture of membranes (aOR 0.31; p=0.03), epidural analgesia (aOR 2.42; p=0.07), maternal BMI (aOR 2.92 per 10 kg/m2; p=0.01) and maternal age (aOR 3.17 per decade; p=0.06).Our prediction models show the most relevant risk factors associated with intrapartum cesarean section in vaginal breech birth for both nulliparous and multiparous women. Importantly, this study clarifies the role of the OC by showing that this parameter is only associated with intrapartum cesarean section if birthweight is above 3.8 kg (or abdominal circumference is above 34 cm). Conversely, knowing the OC when the birthweight is less than 3.8 kg (or abdominal circumference is less than 34 cm) did not improve prediction of this surgical outcome. [ABSTRACT FROM AUTHOR]

Chloroprocaine and lidocaine bicarbonate are commonly used for epidural anesthesia because of their rapid onset, particularly in the case of conversion from epidural labor analgesia to emergency cesarean section. However, it is unclear whether lidocaine bicarbonate combined with fentanyl has an advantage over chloroprocaine alone in emergency cesarean section. In this study, 102 women who underwent elective cesarean section received 15 mL 3% chloroprocaine and 1 mL saline (CP group) or 15 mL 1.73% lidocaine bicarbonate and 1 mL fentanyl 50 µg (LF group) for epidural anesthesia. Nociceptive block level was assessed by pinprick and recorded every minute. The primary outcome was the onset time to T6 block. The median onset time to T6 analgesia was 10 [10, 10] min in the CP group and 10 [7, 10] min in the LF group (COX model for CP versus LF, HR 0.47, 95% CI 0.23-0.95, p = 0.035). The median onset time to T8 analgesia was 7 [5, 9] min in CP group and 5 [4, 7] min in LF group (COX model for CP versus LF, HR 0.61, 95% CI 0.39-0.95, p = 0.027). The proportion of hypotension episodes occurring before delivery in LF group was lower than that in CP group (p = 0.011). The incidence of block level = T4 after supplemental dosing in the LF group was lower than that in the CP group (p = 0.031). Compared with 3% chloroprocaine, 1.73% lidocaine bicarbonate combined with fentanyl 50 µg has a slightly faster onset time and less hypotension in epidural anesthesia for cesarean section. [ABSTRACT FROM AUTHOR]

Background: Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. Methods: A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. Results: A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). Conclusions: Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance. Trial registration: The study was registered in the Clinical Trials Registry at www.clinicaltrials.gov/, NCT number: NCT06301932. [ABSTRACT FROM AUTHOR]

Shortening analgesic onset has been researched and it has been documented that prewarming epidural medications to body temperature (37°C) prior to administration increases medication efficacy. Our double-blind randomized controlled trial was designed to investigate if a lower degree of prewarming in providers' pockets could achieve similar results without the need of a bedside incubator. A total of 136 parturients were randomized into either the pocket-warmed group or the room temperature group to receive 10 mL of 0.125% bupivacaine with 2 μg/mL fentanyl epidural bolus at either the 27.8 ±1.7°C or 22.1 ±1.0°C temperatures, respectively. Primary outcome, time to analgesic onset (verbal rating scale pain score ≤ 3) was recorded in 0-, 5-, 10-, 15-, 20-, 30-, and 60-minutes intervals. It was observed that the pocket-warming group (n = 64) and room temperature group (n = 72) had no significant difference of analgesic onset time (median 8 vs. 6.2 minutes; p = 0.322). The incidence of adverse events such as hypotension, fever (≥ 38°C), nausea, vomiting, and number of top-off epidural boluses, as well as patient satisfaction rates and mode of delivery, were not significantly different between the groups as well. Further research is warranted to confirm these findings and explore the impact of different temperatures on analgesic onset time as well as the logistical issues associated with their clinical implementations. [ABSTRACT FROM AUTHOR]

Background: As it was mentioned, the risk of adverse effects and complications is more than what is expected. Hence, the use of epidural analgesia (EA) was decreased in the management of post-operative pain. Hence, there is a need for another pharmacological agent that is more effective. Manly studies reported that buprenorphine transdermal and sublingual both have significant pain relief scores. Aims and Objectives: The present study was undertaken to compare the pain relief scores of epidural midazolam and buprenorphine for post-operative patients. Materials and Methods: A total of 60 male and female participants, within the age group with the American Society of Anesthesiologists grades I and II were recruited. After recruiting, they were randomly divided into two groups. Soon after the surgery, the pain scores were recorded using the Visual Analog Scale. Soon after recording the pain scores, the corresponding drugs were administered to the participants. Epidural midazolam 30 g/kg and buprenorphine 0.15 mg diluted in normal saline were administered to the corresponding groups for 24 h. Results: There is no significant difference in the demographic data of the participants in both groups. There was no significant difference observed between the two groups. Both are equally effective. Nausea and vomiting are the mild side effects observed in the majority of the patients in both groups. Conclusion: In the present study, we have observed similar actions by both drugs in the management of post-operative pain. The study not only adds to the literature about the effectiveness of these drugs but also explains the mild side effects. Hence, the study recommends the use of both these drugs in the management of post-operative pain so that patient satisfaction can be improved and the patient stay at the hospital can be minimized. Further, detailed and multi-center studies are recommended to generalize the results. [ABSTRACT FROM AUTHOR]

Background: We investigated possible parameters that could predict the need for obstetric maneuvers, the duration of the active second stage of labor (i.e., the duration of active pushing), and short‐term neonatal outcome in vaginal breech births. Materials and Methods: We performed a retrospective analysis of 268 successful singleton vaginal breech births in women without previous vaginal births from January 2015 to August 2022. Multivariable regression was used to investigate associations between maternal and fetal characteristics (including antepartum magnetic resonance (MR) pelvimetry) with obstetric maneuvers, the duration of active second stage of labor, pH values, and admission to the neonatal unit. Models for the prediction of obstetric maneuvers were built and internally validated. Results: Obstetric maneuvers were performed in a total of 130 women (48.5%). A total of 32 neonates (11.9%) had to be admitted to the neonatal unit. The intertuberous distance (ITD) (p < 0.001), epidural analgesia (p < 0.001), and birthweight (p = 0.026) were associated with the duration of active second stage of labor. ITD (p = 0.028) and birthweight (p = 0.011) were also independently associated with admission to the neonatal unit, while pH values below 7.10 dropped significantly (p = 0.0034) if ITD was ≥13 cm. Furthermore, ITD (p < 0.001) and biparietal diameter (p = 0.002) were independent predictors for obstetric maneuvers. Conclusions: ITD is independently associated with the duration of active second stage of labor. Thus, it can predict suboptimal birth mechanics in the last stage of birth, which may lead to the need for obstetric maneuvers, lower arterial pH values, and admission to the neonatal unit. Consequently, MR pelvimetry gives additional information for practitioners and birthing people preferring a vaginal breech birth. [ABSTRACT FROM AUTHOR]

Background: It was reported that either shorter programmed intermittent epidural bolus (PIEB) intervals or high-speed bolus can produce more extensive epidural spread. We hypothesized that a combination of shortened time interval and increased speed of epidural bolus might further improve analgesic effect and therefore reduce the hourly volume for epidural labour analgesia. Methods: This double-blind dose-finding study used a biased coin up-and-down sequential allocation method to determine the 90% effective bolus volume of ropivacaine combined with sufentanil while using the push pump at a rate of 400 mL/hr and interval of 30 min to provide effective analgesia without breakthrough pain. We used 0.1% ropivacaine with 0.4 µg/mL sufentanil, with bolus volumes ranging from 3 to 6 mL. The first patient was assigned a volume of 3 mL, and the remaining volumes were assigned according to the biased coin-up-and-down method. Results: The estimated 90% effective volume (EV90) of ropivacaine combined with sufentanil for epidural labour analgesia at a time interval of 30 min was 4.88 mL (95% confidence interval 4.83–5.38). Conclusions: The optimum bolus volume of ropivacaine with sufentanil while using push pump at a time interval of 30 min is approximately 5 mL. It could probably further reduce the hourly bolus volume for epidural labour analgesia. [ABSTRACT FROM AUTHOR]

Introduction: The Skin-to-Epidural Space Distance (SESD) is likely to be different at two different parts of the spine in the same individual and also in the same part of the spine in two different individuals. The knowledge of the expected depth of the epidural space can be very useful in placing the epidural needle appropriately and avoiding unwanted dural puncture. Although many studies have been conducted to study the relation of lumbar SESD with various physical and anthropometric parameters, the literature on thoracic SESD is scant. Aim: To determine the correlation between SESD and Abdominal Girth (AG) in the mid-thoracic, lower thoracic, and lumbar regions of the spine in adult patients scheduled for elective surgical procedures. Materials and Methods: After obtaining Ethics Committee clearance (EC/NIMS/2671/2020, 51st ESGS No: 1082/2020), this prospective observational study was carried out at Nizam's Institute of Medical Sciences, Hyderabad, India, from October 2021 to February 2022. The study recruited 202 patients, and data from 194 patients was analysed. During the preoperative visit, all physical parameters, including AG, were noted. Using an 18G Tuohy needle, the epidural space was identified, and SESD was measured. Its correlation with AG, age, height, weight, and body mass index was studied. The data was analysed using the Statistical Pacakge for Social Sciences Software (SPSS) (2011, IBM, Armonk, NY, United States of America) version 20.0. Results: The mean SESD was 4.7±1.09 cm in the mid-thoracic region, 4.71±0.98 cm in the lower thoracic region, and 4.8±0.82 cm in the lumbar region. The correlation coefficient of SESD with AG was 0.42, 0.44, and 0.78 in the mid-thoracic, lower thoracic, and lumbar regions, respectively, and the significance level was <0.001 in all three regions. Body weight had a good correlation (r-values of 0.56, 0.66, 0.53 in mid-thoracic, lower thoracic, and lumbar areas, respectively, and p-value of <0.001 in all three anatomical regions of the spine) with SESD. All other physical parameters were correlated weakly with SESD. Conclusion: AG has a strong correlation with SESD in the lumbar area but a moderate correlation in the thoracic spine. SESD in the lumbar, mid, and lower thoracic regions have a good correlation with weight. [ABSTRACT FROM AUTHOR]

Background: Regional analgesia is a common and effective form of in‐labour analgesia. However, there are concerns whether it is associated with adverse maternal and neonatal outcomes. Aims: To examine the association between regional analgesia and maternal and neonatal outcomes. Materials and Methods: A retrospective population‐based cohort study of singleton term births in Victoria, Australia, between 2014 and 2020. Women who received regional analgesia were compared with women who did not. Multivariable logistic and linear regressions were used. Results: There were 107 013 women who received regional analgesia and 214 416 women who did not. Compared to women who did not receive regional analgesia, regional analgesia was associated with an increased risk of instrumental birth (adjusted odds ratio (aOR) = 3.59, 95% CI: 3.52–3.67), caesarean section (aOR = 2.30, 95% CI: 2.24–2.35), longer duration of the second stage of labour (β coefficient = 26.6 min, 95% CI: 26.3–27.0), Apgar score below seven at five minutes (aOR = 1.30, 95% CI: 1.21–1.39), need for neonatal resuscitation (aOR = 1.44, 95% CI: 1.40–1.48), need for formula in hospital (aOR = 1.68, 95% CI: 1.65–1.72), and the last feed before discharge not exclusively from the breast (aOR = 1.59, 95% CI: 1.56–1.62). Conclusion: Regional analgesia use in labour was associated with adverse maternal and neonatal outcomes. These findings may add to the risk–benefit discussion regarding regional analgesia for pain relief and highlight the importance of shared decision‐making. Further large prospective studies and randomised controlled trials will be useful. [ABSTRACT FROM AUTHOR]

Background/Aims: A Cochrane review reported that epidural analgesia had no effect on the risk of emergency caesarean section; there was a discrepancy between these findings and the author's clinical observations, prompting the author to evaluate labour outcomes for women with and without epidural analgesia. The aim was to establish whether the author's clinical observations were supported by data. Methods: A retrospective review of the outcomes of 200 labours with and without epidural analgesia was carried out, limited to women the author had personally cared for. A subsequent trust-wide analysis of labours was conducted to explore wider trends in analgesia and emergency caesarean section. Results: In the personal review, epidural analgesia was associated with a more than two-fold increase in risk of emergency caesarean section, regardless of the underlying obstetric risk factors (from 14.7% to 36.4%). A similar trend was found across the trust. Conclusions: Epidural analgesia in labour is associated with increased risk of an emergency caesarean section. Potential reasons for the discrepancy with the Cochrane review findings include differences in anaesthetic practice, timing and dilation at the time of receiving epidural analgesia, and evidence that women taking part in a randomised controlled trial experience better outcomes than those receiving routine care. [ABSTRACT FROM AUTHOR]

This article discusses the ethical implications of removing Entonox® from labor wards as part of a strategy to mitigate the climate crisis. The authors argue that while the greenhouse gas and ozone-depleting effects of nitrous oxide are well-known, it is premature to remove it without first addressing wastage and exploring alternative strategies. They emphasize the importance of considering patient care, staff safety, and the impact on vulnerable groups when making decisions about sustainability in healthcare. The authors also call for a broader approach to sustainability that goes beyond carbon counting and includes considerations of health inequality and social justice. [Extracted from the article]

Objective Methods Results Conclusion Synopsis To identify the predictive value of the neutrophil‐to‐lymphocyte ratio (NLR) on admission for intrapartum maternal fever in parturients undergoing epidural analgesia (EA).In this retrospective cohort study, propensity score matching (PSM) was applied to address covariates. Univariate and multivariate regression analyses were implemented in sequence to find out the factors influencing intrapartum fever. The receiver operating characteristics curve was applied to determine the area under the curve (AUC) of NLR for intrapartum fever.NLR and duration of EA were independent risk factors for intrapartum fever. The AUC of the combined indicator (NLR + duration of EA) was higher than that of NLR (AUC = 0.583, 95% confidence interval [CI] 0.53–0.64) and duration of EA (AUC = 0.702, 95% CI 0.66–0.75), reaching 0.715 (95% CI 0.67–0.76; p < 0.001). NLR increased predictive performance for intrapartum fever when added to the duration of EA (net reclassification index 0.076, p = 0.022; integrated discrimination improvement 0.020, p = 0.002).NLR has limited predictive power for intrapartum fever. The combination of NLR and duration of epidural analgesia may be considered a promising predictor for intrapartum maternal fever in parturients undergoing epidural analgesia.The neutrophil‐to‐lymphocyte ratio is an accessible predictor for the early identification of parturients at risk of intrapartum fever. [ABSTRACT FROM AUTHOR]

Having epidural analgesia in labour has been associated with a later diagnosis of autism spectrum disorder in the offspring, resulting in concerns about childhood wellbeing. Neurodevelopmental changes are inconsistently reported in the literature, creating challenges in the interpretation of these findings. Here we explore the limitations of the current evidence base, and why findings differ between studies, concluding that the current body of evidence does not support a causal association between use of epidural analgesia in labour and autism spectrum disorder. [ABSTRACT FROM AUTHOR]

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018–2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups. [ABSTRACT FROM AUTHOR]

Recent studies report conflicting results regarding the relationship between labour epidural analgesia (LEA) in mothers and neurodevelopmental disorders in their offspring. We evaluated behavioural and neuropsychological test scores in children of mothers who used LEA. Children enrolled in the Raine Study from Western Australia and delivered vaginally from a singleton pregnancy between 1989 and 1992 were evaluated. Children exposed to LEA were compared with unexposed children. The primary outcome was the parent-reported Child Behaviour Checklist (CBCL) reporting total, internalising, and externalising behavioural problem scores at age 10 yr. Score differences, an increased risk of clinical deficit, and a dose-response based on the duration of LEA exposure were assessed. Secondary outcomes included language, motor function, cognition, and autistic traits. Of 2180 children, 850 (39.0%) were exposed to LEA. After adjustment for covariates, exposed children had minimally increased CBCL total scores (+1.41 points; 95% confidence interval [CI] 0.09 to 2.73; P =0.037), but not internalising (+1.13 points; 95% CI –0.08 to 2.34; P =0.066) or externalising (+1.08 points; 95% CI –0.08 to 2.24; P =0.068) subscale subscores. Increased risk of clinical deficit was not observed for any CBCL score. For secondary outcomes, score differences were inconsistently observed in motor function and cognition. Increased exposure duration was not associated with worse scores in any outcomes. Although LEA exposure was associated with slightly higher total behavioural scores, there was no difference in subscores, increased risk of clinical deficits, or dose–response relationship. These results argue against LEA exposure being associated with consistent, clinically significant neurodevelopmental deficits in children. [ABSTRACT FROM AUTHOR]

Purpose: Although pediatric epidural analgesia is a well-established technique used perioperatively. It is unclear whether a lumbar or caudal epidural is suitable for osteogenesis imperfecta (OI) patients, which may be associated with brittle bones and spine deformity. We conducted a retrospective study to investigate and compare the efficacy of the two continuous epidural techniques in pediatric patients undergoing lower extremity osteotomy surgery using a propensity score-matched analysis (PSMA). Patients and Methods: A total of 274 patients were included. Patients' age, weight, and height were adjusted using PSMA. 90 patients were matched for further analysis, with 45 patients in the lumbar epidural group (Group L) and 45 patients in the caudal epidural group (Group C). Pain scores were categorized into three grades: mild (0– 3), moderate (4– 6), and severe (7– 10), and compared between the two groups. Additionally, operation time, operation site, blood loss, scoliosis, oral analgesic medications, and catheter or nerve-related complications were compared. Results: There were no significant differences in operation time, operation site, scoliosis, and blood loss between the two groups. The percentage of moderate to severe pain during movement was significantly higher in Group L than in Group C, with 37.5% versus 17.5% on the second-day post-operation (P=0.039). However, no statistically significant difference was observed on other days. Additionally, there was no significant difference in oral medication consumption and complications between the two groups. Conclusion: Both lumbar and caudal epidural analgesia can be effectively used postoperatively, and a caudal epidural should be considered where performing a lumbar epidural is challenging in OI pediatric patients. Plain Language Summary: Osteogenesis imperfecta (OI) is a rare genetic disorder that affects the body's connective tissues, particularly the bones and ligaments. It is caused by abnormalities in type I collagen, which leads to skeletal fragility known as "brittle bones". This fragility can cause various issues, including an increased risk of fractures from minor trauma, limb deformities, and unusual fractures such as vertebral compressions. OI patients may also experience spinal manifestations such as scoliosis and kyphosis. Lumbar epidural analgesia has been found to be effective in providing pain relief for surgeries that involve the lower extremities. Additionally, caudal epidural analgesia has also demonstrated its effectiveness in providing postoperative analgesia for surgeries that affect the lower limbs. However, there is still debate about the safety of epidural analgesia in patients with skeletal dysplasias, especially those with OI. Despite this uncertainty, our center, which was supported by the Rare Diseases Public Welfare Organization, has successfully used epidural analgesia since 2015 in the southern part of China for OI surgeries. We conducted a retrospective study to share our experiences of nine years of practice and compare lumbar epidural with caudal epidural using a propensity score matching to balance basic demographics. We also compared the presence of scoliosis. Our findings suggest that both lumbar and caudal epidural analgesia can be safely used in OI patients. In cases where lumbar punctures may pose challenges due to potential spine deformities, the caudal route can be an alternative. [ABSTRACT FROM AUTHOR]

Thailand has reported a high rate of cesarean delivery (45%–55%), prompting global concern about an increase in cesarean delivery rates. Fear of labor pains is one of the most common reasons pregnant women opt for cesarean delivery. Labor pain is associated with cervix dilation and fetal descent into the birth canal, which is exacerbated by ischemic pain caused by uterine contraction. Modern medical and non-medical techniques have demonstrated efficacy in reducing pain and ensuring safety during labor and delivery. Neuraxial labor analgesia is a highly effective medical pain relief method but has no effect on the rate of cesarean or assisted vaginal delivery. Medication administration for pain relief during labor, using a combination of a local anesthetic and an opioid, was observed to be transmitted across the placenta to the fetus, but had no significant effects on fetal outcomes in mothers who chose epidural analgesia. There are several techniques for administering neuraxial labor analgesia that can be customized for each pregnant woman. To achieve the most wonderful feasible labor and delivery experience, effective epidural labor analgesia is a crucial technique for reducing anxiety and suffering about labor pain. It is safe, widely used world-wide, and effective. Implementing a policy to increase public and medical providers awareness and acceptance of labor pain relief, as well as establishing a safe obstetric anesthesia service provided by obstetric anesthesiologists, could improve maternal and neonatal safety while significantly lowering the rate of unnecessary cesarean deliveries. [ABSTRACT FROM AUTHOR]

Background and Objectives: Surgical wound analgesia has been analyzed in many studies, but few have focused on its relationship with inflammatory markers. As such, we aimed to determine the influence of analgesic surgical wound infiltration in open colorectal surgery on the seric levels of pro- and anti-inflammatory markers and the associated efficacy in postoperative pain control. Materials and Methods: Forty patients who underwent open colorectal surgery were prospectively randomized: group 0, epidural analgesia; group 1, intravenous analgesia (control), group 2, preincision and prelaparoraphy infiltration; and, group 3, prelaparoraphy infiltration. Wound infiltration was performed with ropivacaine. We analyzed the levels of IL-6 and IL-10 cytokines before and 6 h after surgery and their correlation with pain scores. Results: The postoperative Il-6 levels were significantly lower in group 0 than in the control (p = 0.041). The postoperative Il-10 levels were significantly higher in group 3 (p = 0.029) than in the control. Six hours after the operation, the pain scores were significantly lower in all groups than in the control (p = 0.005, p = 0.022, and p = 0.017 for groups 0, 2, and 3, respectively). Pain scores were significantly correlated with Il-10 levels in group 2 (p = 0.047); in group 3, IL-10 levels directly correlated with those of Il-6 (p = 0.026). Conclusions: The analgetic effect of preincisional and prelaparoraphy analgetic infiltration was efficient. The analgetic infiltration of the surgical wound prior to closure stimulates both the inflammatory activator and regulator interleukins. [ABSTRACT FROM AUTHOR]

AIM OF STUDY. To study the individual structural features of the surface of the lumbar region of the back of patients who underwent catheterization of the epidural space at the lumbar level, and, depending on these features, to determine a group of patients with the possibility of convenient and reliable fixation of the epidural catheter (EC) to the skin with fixing devices and a group of patients who require such fixation will be inconvenient and unreliable and for whom it is better to use subcutaneous tunneling for reliable fixation of the EC, and based on this, determine the absolute and relative indications for this method of fixation. MATERIAL AND METHODS. A study of the surface of the lumbar region of the back was carried out in 600 patients who were on the operating table in a sitting position, while performing neuraxial blockades in the intervertebral spaces L2–L3 and L3–L4. As a result, 4 forms of the back surface were identified: “V” shape, “M” shape, “^” shape and “—” flat shape of the back surface. RESULTS. The overwhelming majority of the studied patients had absolutely convenient (34.2 %) and relatively convenient (53.5 %) places for EC fixation in the area of epidural access. Significantly fewer patients (2 %) had a completely uncomfortable site for EC fixation to the skin using fixation devices, which can be considered an absolute indication for EC fixation by subcutaneous tunneling. CONCLUSION. 1. The absolute indication for fixing an epidural catheter using the subcutaneous tunneling method is the presence of an absolutely uncomfortable fixation site in the area of epidural access in the patient in the form of a combination of a recess greater than 7 mm and a distance from the points of maximum elevation in the specified zone to the right and left of the midline less than the size of the dense adhesive plate of the fixing device (for the Epi-Fix device this is 55 mm). 2. A relative indication for fixing an epidural catheter using the subcutaneous tunneling method is the presence of a relatively inconvenient fixation site in the epidural access area for the patient, regardless of the size of the depression or elevation of the surface shape at the epidural access site and the distance from the points of maximum elevation to the right and left of the larger midline than the size of the dense adhesive plate of the fixing device.

Abstract Background Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. Methods A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. Results A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p

Introduction: The Skin-to-Epidural Space Distance (SESD) is likely to be different at two different parts of the spine in the same individual and also in the same part of the spine in two different individuals. The knowledge of the expected depth of the epidural space can be very useful in placing the epidural needle appropriately and avoiding unwanted dural puncture. Although many studies have been conducted to study the relation of lumbar SESD with various physical and anthropometric parameters, the literature on thoracic SESD is scant. Aim: To determine the correlation between SESD and Abdominal Girth (AG) in the mid-thoracic, lower thoracic, and lumbar regions of the spine in adult patients scheduled for elective surgical procedures. Materials and Methods: After obtaining Ethics Committee clearance (EC/NIMS/2671/2020, 51st ESGS No: 1082/2020), this prospective observational study was carried out at Nizam’s Institute of Medical Sciences, Hyderabad, India, from October 2021 to February 2022. The study recruited 202 patients, and data from 194 patients was analysed. During the preoperative visit, all physical parameters, including AG, were noted. Using an 18G Tuohy needle, the epidural space was identified, and SESD was measured. Its correlation with AG, age, height, weight, and body mass index was studied. The data was analysed using the Statistical Pacakge for Social Sciences Software (SPSS) (2011, IBM, Armonk, NY, United States of America) version 20.0. Results: The mean SESD was 4.7±1.09 cm in the mid-thoracic region, 4.71±0.98 cm in the lower thoracic region, and 4.8±0.82 cm in the lumbar region. The correlation coefficient of SESD with AG was 0.42, 0.44, and 0.78 in the mid-thoracic, lower thoracic, and lumbar regions, respectively, and the significance level was

The most common primary liver tumour in children is hepatoblastoma, which is often diagnosed in the first three years of life. While the majority of hepatoblastomas are sporadic, some associations are reported with genetic disorders like Beckwith-Wiedemann syndrome and familial adenomatous polyposis. The annual incidence of hepatoblastoma in children has gradually increased during the past three decades. Babies born prematurely, weighing

Background: epidural analgesia has emerged as one of the best methods that can be used to reduce labour pain. this study was conducted to assess awareness, attitudes, and practices of pregnant women who visited maternity and antenatal healthcare clinics about epidural analgesia during normal vaginal birth. Methods: this multicentre study was conducted in a cross-sectional design among pregnant women using a pre-tested questionnaire. the study population in this study was pregnant women who visited maternity and antenatal healthcare clinics in Palestine. Results: in this study, a total of 389 pregnant women completed the questionnaire. Of the pregnant women, 381 (97.9%) were aware of the existence of epidural analgesia, 172 (44.2%) had already used epidural analgesia, and 57 (33.1%) experienced complications as a result of epidural analgesia. Of the pregnant women, 308 (79.2%) stated that epidural analgesia should be available during vaginal birth. Of the pregnant women, 243 (62.5%) stated that they would use epidural analgesia if offered for free or covered by insurance. Multivariate logistic regression showed that women who were younger than 32 years, who have used epidural analgesia, and those who stated that epidural analgesia should be available during vaginal birth were 2.78-fold (95% Cl: 1.54-5.04), 4.96-fold (95% Cl: 2.71-9.10), and 13.57-fold (95% Cl: 6.54-28.16) more likely to express willingness to use epidural analgesia, respectively. Conclusions: Pregnant women had high awareness of the existence, moderate knowledge, and positive attitudes towards epidural analgesia for normal vaginal birth. Future studies should focus on educating pregnant women about all approaches that can be used to reduce labour pain including their risks and benefits. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to compare and evaluate the obstetrical differences between three techniques, including the programmed intermittent epidural bolus (PIEB), the patient-controlled epidural analgesia (PCEA), and the continuous epidural analgesia (CEA). Methods: This is a retrospective cohort study that investigates the obstetrical outcomes of 2240 patients who received EA during labor in a tertiary maternal unit over the course of 9 years (2011–2018). The only inclusion criterion was the use of epidural analgesia during childbirth and the only exclusion criteria were multiplets' gestation. Multivariate logistic regression, Kruskal–Wallis test, and the log-rank test were utilized to compare the differences between the three EA techniques in terms of cesarean section rate, the incidence of perineal tears, the use of Oxytocin, the duration of labor, and the incidence of paresthesia. Results: Out of the 2240 included deliveries; 1084 utilized PIEB, 1086 PCEA, and 70 CEA techniques. The incidence of Cesarean section was the highest in the CEA group (45.7%) compared to PIEB (24.8%) and PCEA (24.4%) P < 0.001. A significantly shorter duration of labor (vaginal delivery) was observed in the PCEA group (n: 821, 336.7 min) compared to the PIEB group (n: 814, 368.8 min) P < 0.001. There were no statistically significant differences in the incidence of perineal tears, the need of uterotonics, and the incidence of paresthesia. Conclusion: The results of this study indicate that the PIEB and PCEA techniques are superior to the CEA technique when it comes to analgesia during childbirth. In this study, the PCEA technique seems to be the best-suited technique for childbirth, since it had a significantly shorter duration of labor than the PIEB technique. [ABSTRACT FROM AUTHOR]

Aims: The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR. Methods: Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively. Results: A total of 31 studies were included in the systematic review. Of these, 29 studies entered our meta-analysis, which included 3,273 patients diagnosed with POUR and 11,583 patients without POUR following TJR. The pooled incidence of POUR was 28.06%. Demographic risk factors included male sex (OR 1.81, 95% CI 1.26 to 2.59), increasing age (SMD 0.16, 95% CI 0.04 to 0.27), and American Society of Anesthesiologists grade 3 to 4 (OR 1.39, 95% CI 1.10 to 1.77). Patients with a history of benign prostatic hyperplasia (OR 1.99, 95% CI 1.41 to 2.83) and retention (OR 3.10, 95% CI 1.58 to 6.06) were more likely to develop POUR. Surgery-related risk factors included spinal anaesthesia (OR 1.44, 95% CI 1.19 to 1.74) and postoperative epidural analgesia (OR 2.82, 95% CI 1.65 to 4.82). Total hip arthroplasty was associated with higher odds of POUR compared to total knee arthroplasty (OR 1.10, 95% CI 1.02 to 1.20). Postoperatively, POUR was associated with a longer length of stay (SMD 0.21, 95% CI 0.02 to 0.39). Conclusion: Our meta-analysis demonstrated key risk variables for POUR following TJR, which may assist in identifying at-risk patients and direct patient-centered pathways to minimize this postoperative complication. Cite this article: Bone Jt Open 2024;5(7):601–611.

Abstract National Swedish data shows substantial variation in the use of oxytocin for augmentation of spontaneous labour between obstetric units. This study aimed to investigate if variations in the use of oxytocin augmentation are associated with maternal and infant characteristics or clinical factors. We used a cohort design including women allocated to Robson group 1 (nulliparous women, gestational week ≥ 37 + 0, with singleton births in cephalic presentation and spontaneous onset of labour) and 3 (parous women, gestational week ≥ 37 + 0, with singleton births in cephalic presentation, spontaneous onset of labour, and no previous caesarean birth). Crude and adjusted logistic regression models with marginal standardisation were used to estimate risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) for oxytocin use by obstetric unit. An interaction analysis was performed to investigate the potential modifying effect of epidural. The use of oxytocin varied between 47 and 73% in Robson group 1, and 10% and 33% in Robson group 3. Compared to the remainder of Sweden, the risk of oxytocin augmentation ranged from 13% lower (RD − 13.0, 95% CI − 15.5 to − 10.6) to 14% higher (RD 14.0, 95% CI 12.3–15.8) in Robson group 1, and from 6% lower (RD − 5.6, 95% CI − 6.8 to − 4.5) to 18% higher (RD 17.9, 95% CI 16.5–19.4) in Robson group 3. The most notable differences in risk estimates were observed among women in Robson group 3 with epidural. In conclusion, variations in oxytocin use remained despite adjusting for risk factors. This indicates unjustified differences in use of oxytocin in clinical practice.

Background This study aimed to compare the analgesic effects of programmed intermittent epidural boluses (PIEB) and continuous epidural infusion (CEI) for postoperative analgesia after elective cesarean section (CS). Methods Seventy-four women who underwent elective CS were randomized to receive either PIEB or CEI. The PIEB group received 4 ml-intermittent boluses of 0.11% ropivacaine every hour at a rate of 120 ml/h. The CEI group received a constant rate of 4 ml/h of 0.11% ropivacaine. The primary outcome was the pain score at rest at 36 h after CS. Secondary outcomes included the pain scores during mobilization, time-weighted pain scores, the incidence of motor blockade, and complications-related epidural analgesia during 36 h after CS. Results The pain score at rest at 36 h after CS was significantly lower in the PIEB group compared with that in the CEI group (3.0 vs. 0.0; median difference: 2, 95% CI [1, 2], P < 0.001). The mean time-weighted pain scores at rest and during mobilizations were also significantly lower in the PIEB group than in the CEI group (pain at rest; mean difference [MD]: 37.5, 95% CI [24.6, 50.4], P < 0.001/pain during mobilization; MD: 56.6, 95% CI [39.8, 73.5], P < 0.001). The incidence of motor blockade was significantly reduced in the PIEB group compared with that in the CEI group (P < 0.001). Conclusions PIEB provides superior analgesia with less motor blockade than CEI in postpartum women after CS, without any apparent adverse events.

Abstract Background Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. Case presentation We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. Conclusion Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.

Background: Opioid analgesics with local anesthetics in an epidural route are extremely safe, effective, and reliable methods of post-operative pain relief. Aims and Objectives: The primary objective is to compare the duration of analgesia and pain scoring by visual analog scale. The secondary objective is to monitor sedation, hemodynamic changes, and side effects such as nausea, vomiting, shivering, and pruritus. Materials and Methods: A prospective randomized comparative study of 0.2% ropivacaine with nalbuphine and 0.2% ropivacaine with fentanyl in epidural route for post-operative analgesia in elective lower limb surgeries under spinal anesthesia was carried out in a population of 80 patients. After 1½ h of surgery under spinal anesthesia, patients in group RF received 10 mL of 0.2% ropivacaine with 25 mcg of fentanyl and those in group RN received 10 mL of 0.2% ropivacaine with 2.5 mg of nalbuphine and were observed for the study parameters over time. Results: The mean duration of analgesia was longer in group RN than in group RF (398.45 vs. 222.88 min). The hemodynamic parameters such as heart rate, mean arterial pressure, and respiratory rate were statistically significant from 240 to 480 min which is 4–6 h in group RF and 6–8 h in group RN. 27.5% of patients in group RN attained sedation whereas 7.5% of subjects in group RF had a sedation score of 2 and above at 30 min. The subjects in group RN had a lower visual analog score than group RF. 12% and 4% of patients had vomiting in group RN and group RF, respectively. Conclusion: Epidural nalbuphine in a dose of 2.5 mg with 0.2% ropivacaine provided a longer duration of analgesia with better pain score and more sedation which was advantageous for post-operative patient compliance and satisfaction as compared to 25 mcg of fentanyl with 0.2% ropivacaine.

Background Objectives Search Strategy Selection Criteria Data Collection and Analysis Main Results Conclusion There are conflicting reports on the factors that increase the likelihood of postpartum urinary retention (PUR).We completed an updated systematic review and meta‐analysis to identify the risk factors for PUR.An exhaustive search of the literature was undertaken using multiple databases, including PubMed, Web of Science, the Cochrane Library, and Embase to identify pertinent studies published up until November 4, 2023.Observational studies that provided outcomes to calculate the risk factors for PUR were included.Two investigators separately performed the extraction of pertinent data from the articles. The risk factors for PUR were identified by pooling adjusted and unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). Heterogeneity test, sensitivity analysis, and publication bias assessment were performed.This meta‐analysis included 21 studies with a total of 36 951 participants. Meta‐analysis was performed for 14 risk factors, and eight of these were statistically significant. The risk factors that were identified in this review included instrumental delivery (OR, 2.96 [95% CI, 1.82–4.80]; 95% prediction interval [PI], 0.67–12.98), relatively long duration of labor (OR, 1.04 [95% CI, 1.02–1.06]; 95% PI, 1.00–1.08), episiotomy (OR, 1.56 [95% CI, 1.19–2.06] 95% PI, 0.64–3.83), nulliparity (OR, 1.55 [95% CI, 1.30–1.84]; 95% PI, 0.94–2.77), epidural analgesia (OR, 2.99 [95% CI, 1.78–5.03]; 95% PI, 0.53–16.76), labor augmentation (OR, 2.21 [95% CI, 1.49–3.28]; 95% PI, 0.12–39.26), labor induction (OR, 1.73 [95% CI, 1.12–2.66]; 95% PI, 0.40–7.39), and perineal injury (OR, 2.75 [95% CI, 1.95–3.89]; 95% PI, 1.10–6.92).Instrumental delivery, extended labor duration, episiotomy, nulliparity, epidural analgesia, labor augmentation/induction, and perineal injury are significant risk factors for PUR. The findings could help physicians identify patients at risk in the postpartum setting. [ABSTRACT FROM AUTHOR]

Background: Oesophageal cancer surgery represents a high perioperative risk of complications to patients, such as postoperative pulmonary complications (PPCs). Postoperative analgesia may influence these risks, but the most favourable analgesic technique is debated. This review aims to provide an updated evaluation of whether thoracic epidural analgesia (TEA) has benefits compared to other analgesic techniques in patients undergoing oesophagectomy surgery. Our hypothesis is that TEA reduces pain scores and PPCs compared to intravenous opioid analgesia in patients post-oesophagectomy. Methods: Electronic databases PubMed, Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomised trials of analgesic interventions in patients undergoing oesophagectomy surgery. Only trials including thoracic epidural analgesia compared with other analgesic techniques were included. The primary outcome was a composite of respiratory infection, atelectasis and respiratory failure (PPCs), with pain scores at rest and on movement as secondary outcomes. Data was pooled using random effect models and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs). Results: Data from a total of 741 patients in 10 randomised controlled trials (RCTs) from 1993 to 2023 were included. Nine trials were open surgery, and one trial was laparoscopic. Relative to intravenous opioids, TEA significantly reduced a composite of PPCs (risk ratio (RR) 3.88; 95% confidence interval (CI) 1.98–7.61; n = 222; 3 RCTs) and pain scores (0–100-mm visual analogue scale or VAS) at rest at 24 h (MD 9.02; 95% CI 5.88–12.17; n = 685; 10 RCTs) and 48 h (MD 8.64; 95% CI 5.91–11.37; n = 685; 10 RCTs) and pain scores on movement at 24 h (MD 14.96; 95% CI 5.46–24.46; n = 275; 4 RCTs) and 48 h (MD 16.60; 95% CI 8.72–24.47; n = 275; 4 RCTs). Conclusions: Recent trials of analgesic technique in oesophagectomy surgery are restricted by small sample size and variation of outcome measurement. Despite these limitations, current evidence indicates that thoracic epidural analgesia reduces the risk of PPCs and severe pain, compared to intravenous opioids in patients following oesophageal cancer surgery. Future research should include minimally invasive surgery, non-epidural regional techniques and record morbidity, using core outcome measures with standardised endpoints. Trial registration: Prospectively registered on PROSPERO (CRD42023484720). [ABSTRACT FROM AUTHOR]

Background: Data on the effectiveness of erector spinae plane block (ESPB) for patients undergoing liver surgeries is limited and inconclusive. We hereby aimed to systematically review if ESPB can provide adequate analgesia after liver surgery. Methods: PubMed, CENTRAL, Scopus, Embase, and gray literature were examined up to 25th April 2023 for randomized controlled trials (RCTs) comparing ESPB with control or spinal analgesia. Results: Nine RCTs were included of which three compared ESPB with spinal analgesia. 24-hour opioid consumption did not differ significantly between ESPB vs. control (MD: -35.25 95% CI: -77.01, 6.52 I2 = 99%) or ESPB vs. spinal analgesia (MD: 2.32 95% CI: -6.12, 10.77 I2 = 91%). Comparing pain scores between ESPB and control, a small but significant effect favoring ESPB was noted at 12 h and 48 h, but not at 6–8 h and 24 h. Pain scores did not differ between ESPB and spinal analgesia. The risk of postoperative nausea and vomiting was also not significantly different between ESPB vs. control or spinal analgesia. GRADE assessment shows moderate certainty of evidence. Conclusion: ESPB may not provide any significant postoperative analgesia in liver surgery patients. There was a tendency of reduced opioid consumption with ESPB. Limited data also showed that ESPB and spinal analgesia had no difference in pain scores and 24-hour analgesic consumption. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion The aim of the present study was to investigate the effects of epidural analgesia (EA) administered at cervical dilatation of 1 cm on multiparae who underwent vaginal delivery.This propensity score‐matched retrospective cohort research was conducted between 2021 and 2022. All the singleton multiparae who had previous successful vaginal deliveries and epidural analgesia during this delivery were screened for eligibility. The primary outcome was the effect of EA on the duration of labor. The main secondary outcomes included the incidence of cesarean delivery and umbilical arterial pH.This study incorporated 686 multiparae who were divided into two cohorts: EA 1 (cervical dilatation = 1 cm, n = 166) and EA 2 (cervical dilatation >1 cm, n = 520). In the propensity score‐matched cohort (including 164 women in each group), there were no statistically significant differences in the incidence of cesarean delivery (4 [2.4%] vs 4 [2.4%], P = 1.000), umbilical arterial pH (7.28 ± 0.06 vs 7.28 ± 0.07, P = 0.550) and other secondary outcomes between the two groups. Based on a comparative assessment of the women who delivered vaginally to the Kaplan–Meier curves and propensity score‐matching (including 160 women in each group), there was no statistical significance in the duration of the first, second and third stages of labor (log rank P, P = 0.811; P = 0.413; P = 0.773, respectively).Initiation of epidural analgesia at cervical dilatation of 1 cm in multiparae did not cause adverse effects with regard to the duration of labor, increased cesarean deliveries, and bad neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objectives: At our center, natural home‐like delivery settings have been established in or near conventional labor wards, for the care of pregnant women who prefer little or no medical intervention during labor and birth. We compared obstetrical and neonatal outcomes of women in active spontaneous labor, between those who chose to deliver in a natural‐delivery setup and those who chose a conventional setting. Methods: This retrospective study included low‐risk women who delivered at term between March 1, 2020 and December 31, 2022, in a single tertiary university affiliated medical center. Birth outcomes were compared between 124 women who delivered by natural birth (the study group) and 244 who gave birth in a conventional setting (the control group). Results: No cesarean deliveries were performed in the study group, compared to 18 (7.4%) of the control group, p = 0.004. Intrapartum fever, postpartum hemorrhage, and uterotonic administration were similar between the groups. For the study compared to the control group, breastfeeding was more common (71.3% vs. 12.3%, p < 0.001), analgesia administration within 48 h delivery was lower (4.1% vs. 10.7%, p = 0.033), and maternal and neonatal length of hospitalization were shorter. Of the women initially admitted to the natural‐delivery room, 14 (11.5%) were transferred to a conventional‐delivery room. Conclusions: Birth in a hospital natural‐delivery setting was associated with increased likelihood of vaginal birth, increased immediate breastfeeding and breastfeeding at discharge, and lower postpartum pain. [ABSTRACT FROM AUTHOR]

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Introduction: Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery‐led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital‐based midwifery care. Epidural analgesia and the role of passive descent in midwifery‐led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications. Methods: Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent. Results: Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours. Discussion: Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of a newly developed educational course in terms of improvement in post-test scores in clinical skills assessment of patients with patient-controlled intravenous analgesia (PCIA) and epidural analgesia using the Likert scale among nursing staff working in a tertiary care teaching hospital. Introduction: Nurses require certain clinical skills to assess patient's pain adequately. This can be achieved through regular on-the-job training and educational workshops. This will enhance nurses' clinical practice regarding pain assessment and improve pain treatment and patient satisfaction. Methods: After getting approval from the Institutional Review Committee an education course was developed and implemented. A total of 86 nursing staff attended the course. Teaching methodologies included online lectures, small group tutorials, and hands-on workshops using demonstrations of locally developed videos. Pain assessment skills were assessed at the start of the workshop and the end of the session using PCIA and Epidural Likert scale assessment forms on simulated patients in this experimental, pre-and post- (single-arm) study. Results: Eighty-six participants completed the course, of which 50 (58.1%) were female. In the clinical skill assessment of patients using PCIA, the mean difference in PCIA assessment scores of participants before and after the workshop was 13.88 (90.79%), which was statistically significant (p=<0.001). In the epidural skills assessment, the mean difference in the score of participants before and after the workshop was 15.09 (79.47%), which was statistically significant (p=<0.001). Conclusion: The educational course had a significant impact on increasing the understanding of pain assessment among nursing staff with statistically significant improvement in their clinical skills. [ABSTRACT FROM AUTHOR]

Background: The efficacy of neuraxial analgesia varies with spinal canal pathology. Notably, a secondary epidural catheter has been shown to increase neuraxial labor analgesia in women with spinal lesions. Therefore, we present a case in which catheter withdrawal played a critical role in achieving effective labor analgesia in a woman with epidural adhesions after lumbar discectomy who had inadequate analgesia with two epidural catheters. Case presentation: We encountered a patient with L5 lumbar epidural adhesions who reported pain even after receiving two epidural catheters. The catheters were placed in the L1/2 and L5/S intervertebral spaces. Analgesic effects were exerted when the L5/S catheter was withdrawn by 1 cm, suggesting that the catheter tip was initially placed inside the adhesion. Conclusions: Careful consideration of catheter placement and adjustments by withdrawing the catheter are crucial in managing labor analgesia in patients with known epidural adhesions. [ABSTRACT FROM AUTHOR]

Epidural analgesia alleviates pain during normal labour but women who undergo medical abortion procedures using epidural analgesia continue to express high pain levels. To understand this we assessed if patients undergoing medical abortions, treated with epidural analgesia, use their pain for psychological benefits. This study comprised 105 patients over 13 weeks of gestational age diagnosed with foetal abnormalities after selecting a medical abortion procedure using epidural analgesia. Three questionnaires were handed-out: 1) 'Need for Affect', assessed the motivation to react to emotions; 2) 'Pain-Levels' 3) PANA- 'Positive Affect' (PA), 'Negative Affect' (NA) assessed emotions pre-abortion and post-abortion. Patients with a strong Need for Affect and high Pain-Levels expressed a stronger PA post-abortion (b =.69, se =.11, β =.68, p <.001, 95%CI [.48,.90]). Patients with a strong NA pre-abortion and high Pain-Levels expressed a higher NA post-abortion (b =.48, se =.11, β =.53, p <.001, 95%CI [.26,.70]). Patients with a strong Need for Affect who express a strong PA pre-abortion intensify their pain to fulfill their Need for Affect, which then helps recovery. Patients with a strong NA pre-abortion and high Pain-Levels indicate a less favourable outcome. [ABSTRACT FROM AUTHOR]

Aims: Early mobilisation after periacetabular osteotomy (PAO) represents an important goal after surgery. The purpose of this study was to determine whether the use of epidural aznalgesia (EA) is associated with prolonged immobility and an increased length of stay (LOS) after PAO surgery. Methods: From January 2022 to July 2023, the study included a cohort of 150 PAO procedures all performed by the same surgeon (SSA). Patients were categorized into two distinct groups: those who received epidural analgesia (EA) (79 PAOs) and those who did not receive EA (71 PAOs). "Ready for discharge" was defined as the ability to ascend and descend a standardized flight of stairs independently. Multivariable linear regression was used to identify additional factors influencing LOS after PAO. Results: Patients in the EA group were ready for discharge 5.95 ± 2.09 days after surgery which was significantly longer than in the No EA group´s average of 4.18 days ± 2.5, (p < 0.001). While the reduction in the number of patients experiencing pulmonary embolism in the No EA group did not reach statistical significance, it still demonstrated a relevant decrease from two patients within the EA group (2.53%) to 0 (0%) in the No EA group. The active engagement of the surgeon in mobilising patients led to a substantial reduction in LOS, decreasing it from 5.81 ± 2.18 days to 2.2 ± 0.77 days (p < 0.001). Multivariable analysis revealed five independent factors influencing the LOS following PAO which included absence of EA, surgeon-led mobilisation within 24 h after surgery, postoperative hemoglobin levels, BMI, and prior experience with PAO surgery on the contralateral side. Conclusions: Opting against the use of EA in patients undergoing PAO is advisable, as it will result in extended postoperative immobility and the associated risks. Additionally, the active participation of the surgeon in the mobilisation process is strongly recommended. [ABSTRACT FROM AUTHOR]

Introduction: To evaluate whether epidural analgesia is an independent risk factor for OASIS. Methods: A population-based cohort study including all women who delivered by spontaneous vaginal delivery or by instrumental delivery beyond 24 weeks gestation was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. Women with multiple gestations and those lacking prenatal care were excluded from the analysis. Results: During the study period, 252,542 women delivered at the Soroka University Medical Center and met the inclusion criteria. Of these, 583 (0.23%) were diagnosed with OASIS. Women with OASIS were more likely to be younger, nulliparous, with suspected fetal macrosomia, had higher rates of labor induction and vacuum extraction delivery, higher rates of conceiving after infertility treatments, more advanced gestational age at delivery, higher mean birth weight, higher rates of post-partum hemorrhage and need for blood transfusions. Use of epidural analgesia during pregnancy was significantly high among the OASIS group. Rates of episiotomy were not significantly different between the groups. Using a multimodal logistic regression model, after controlling for vacuum delivery, large for gestational age, nulliparity, gestational age, ethnicity, maternal age, induction of labor, fertility treatments, non-reassuring fetal heart rate and non-progressive second stage of labor, epidural analgesia was found to be significantly associated with OASIS. Conclusion: Epidural analgesia was found to be an independent risk factor for OASIS in our population. [ABSTRACT FROM AUTHOR]

Purpose: Patient harm is often due to medication errors related to neuraxial and peripheral misconnection. We report a case of inadvertent injection of ciprofloxacin into the epidural space and discuss the strategies that could prevent such an incident. Summary: A 74-year-old woman presented a recurrence of an ovarian cancer. The recent discovery of an intrabdominal recurrence on CT-scan led us to propose a new surgical procedure. A thoracic epidural analgesia was performed prior to general anesthesia. Postoperative pain was controlled with patient-controlled epidural analgesia (PCEA) with ropivacaine-epinephrine. During the first night, abdominal pain appeared. During the second day, a nurse discovered that the bag connected to the pump contained ciprofloxacin and not ropivacaine. After aspiration of 2.5 ml sent to laboratory for analysis, the epidural catheter was removed. The investigation revealed the different causes leading to such an error. Three days after, the patient returned home, without any adverse symptoms. Conclusion: This is the first report of the inadvertent administration of ciprofloxacin into the epidural space via a patient-controlled epidural analgesia technique. As there is no effective treatment for such errors, we discuss the neurological risk of ciprofloxacin and prevention strategy mainly based on organizational and human factors. [ABSTRACT FROM AUTHOR]

BACKGROUND: Providing effective health education is essential for patients with cancer-related pain. One solution is leveraging instant messaging tools for teach-back health education. OBJECTIVES: This study investigated the effects of WeChat-based teach-back health education on patients with advanced cancer who underwent patient-controlled intrathecal analgesia implantation and used hydromorphone. METHODS: This retrospective study evaluated 150 hospitalized patients with advanced cancer pain. Patients were classified into a conventional health education group (N = 50) and a teach-back group (N = 100) based on whether they received WeChatbased teach-back health education. Pain was rated using a numeric rating scale, and sleep quality was measured using the Pittsburgh Sleep Quality Index at one, two, and three months postdischarge. FINDINGS: Patients who received remote teachback health education better managed their pain. Data also demonstrated improvements in patients' sleep quality and caregiver satisfaction, and reductions in the occurrence of adverse reactions. [ABSTRACT FROM AUTHOR]

Purpose More literature studies have reported that alfentanil is safe and effective for labor analgesia. However, there is no unified consensus on the optimal dosage of alfentanil used for epidural analgesia. This study explored the concentration at 90% of minimum effective concentration (EC90) of alfentanil combined with 0.075% ropivacaine in patients undergoing epidural labor analgesia to infer reasonable drug compatibility and provide guidance for clinical practice. Methods In this prospective, single-center, double-blind study, a total of 45 singleton term primiparas with vaginal delivery who volunteered for epidural labor analgesia were recruited. The first maternal was administered with 3 μg/mL alfentanil combined with 0.075% ropivacaine with the infusion of 10 mL of the mixture every 50 min at a background dose of 3 mL/h. In the absence of PCEA, a total of 15 mL of the mixture is injected per hour. The subsequent alfentanil concentration was determined on the block efficacy of the previous case, using an up-down sequential allocation with a bias-coin design. 30 min after epidural labor analgesia, the block of patient failed with visual analog score (VAS)>3, the alfentanil concentration was increased in a 0.5 μg/mL gradient for the next patient, while the block was successful with VAS≤3, the alfentanil concentration was remained or decreased in a gradient according to a randomized response list for the next patient. EC90 and 95% confidence interval were calculated by linear interpolation and prediction model with R statistical software. Results In this study, the estimated EC90 of alfentanil was 3.85 μg/mL (95% confidence interval, 3.64-4.28 μg/mL). Conclusion When combined with ropivacaine 0.075%, the EC90 of alfentanil for epidural labor analgesia is 3.85 μg/mL in patients undergoing labor analgesia. [ABSTRACT FROM AUTHOR]