Intrathecal chloroprocaine or hyperbaric prilocaine for ambulatory knee surgery? A prospective randomized study

Purpose The aim of this study was to compare intrathecal 1% chloroprocaine with 2% hyperbaric prilocaine in the setting of ambulatory knee arthroscopy. We hypothesized that complete resolution of the sensory block was faster with chloroprocaine. Methods Eighty patients scheduled for knee arthroscopy were included in this prospective randomized double-blind study. Spinal anesthesia was performed with either chloroprocaine (50 mg) or hyperbaric prilocaine (50 mg). Characteristics of sensory and motor blocks and side effects were recorded. Results Mean time to full sensory block recovery was shorter with chloroprocaine (169 (56.1) min vs 248 (59.4)). The characteristics of the sensory blocks were similar at the T12 dermatome level between the two groups. Differences appeared at T10: the percentage of patients with a sensory block was higher, onset quicker and duration longer with hyperbaric prilocaine. The number of patients with a sensory block at T4 dermatome level in both groups was minimal. Times to full motor recovery were identical in both groups (85 (70–99) vs 86 (76–111) min). Time to spontaneous voiding was shorter with chloroprocaine (203 (57.6) min vs 287.3 (47.2) min). Incidence of side effects was low in both groups. Conclusions When considering the characteristics of the sensory block, the use of chloroprocaine may allow an earlier discharge of patients. Cephalic extension was to a higher dermatomal level and the sensory block at T10 level was of prolonged duration with hyperbaric prilocaine, suggesting that the choice between the two drugs should also be performed based on the level of the sensory block requested by the surgery. This study is registered in the US National Clinical Trials Registry, registration number: NCT030389, the first of February 2017, Retrospectively registered.

The Analysis of Risk Factors to Hypotension Occurring after Caesarean Spinal Anesthesia for Parturients with Scarred Uterus

Background：This study examined the risk factors for hypotension after caesarean spinal anesthesia with low dose of bupivacaine and sulfentanyl in parturients with scarred uterus. Methods：A total of 322 singleton-pregnancy parturients with scarred uterus who had been scheduled for caesarean spinal anesthesia were randomly sampled. The data on the basic information of the parturients, the gestation, the fetus and the anesthesia were recorded and filed according to the clinical questionnaires on hypotension in caesarean section. The parturients whose systolic blood pressure dropped below 90 mmHg or decreased by 20% during the time from the completion of anesthesia until the delivery of infant were classified as Group hypotension (Group H) and the rest were in Group non-hypotension (Group N). This study analyzed the correlation of 39 factors to the occurrence of hypotension, and further analyzed the statistically significant factors through binary classification logistic regression.Results：Of the 322 sampled parturients, 148 parturients suffered hypotension. The incidence of hypotension in this study was 45.96%. The result of univariate analysis showed statistically significant differences in the factors including height (p=0.005), post-pregnancy Body Mass Index (BMI) (p=0.00), fasting time (p=0.031),weight gain in gestation (p=0.000), fundal height (p=0.047), exercise history in gestation (p=0.006) and dermatomal level of analgesia (p=0.000) between the two groups. The variables with statistical significance were analyzed by multivariate logistic regression model. The result showed that BMI in gestation (OR=1.146, 95% CI 1.041-1.262, p <0.05), weight gain in gestation (OR = 1.126, 95% CI 1.060-1.198, p <0.001), exercise history in gestation (OR = 0.399, 95% CI 0.205-0.778, p = 0.007), and dermatomal level of analgesia (OR = 2.248, 95% CI 1.645-3.074, p <0.001) were risk factors for hypotension after caesarean spinal anesthesia in parturients with scarred uterus. Conclusion：The incidence of hypotension after caesarean spinal anesthesia in parturients with scarred uterus was relatively high. The post-pregnancy BMI, weight gain in gestation, exercise history in gestation and dermatomal level of analgesia after anesthesia were risk factors for hypotension after caesarean spinal anesthesia in parturients with scarred uterus. These findings play an important role in predicting the occurrence of hypotension after caesarean spinal anesthesia in parturients with scarred uterus. Trial registration：Chinese Clinical Trial Registry (chiCTR-ROC-17011251)

The Analysis of Risk Factors to Hypotension Occurring after Caesarean Spinal Anesthesia for Parturients with Scarred Uterus

Background：This study examined the risk factors for hypotension after caesarean spinal anesthesia with low dose of bupivacaine and sulfentanyl in parturients with scarred uterus. Methods：A total of 322 singleton-pregnancy parturients with scarred uterus who had been scheduled for caesarean spinal anesthesia were randomly sampled. The data on the basic information of the parturients, the gestation, the fetus and the anesthesia were recorded and filed according to the clinical questionnaires on hypotension in caesarean section. The parturients whose systolic blood pressure dropped below 90 mmHg or decreased by 20% during the time from the completion of anesthesia until the delivery of infant were classified as Group hypotension (Group H) and the rest were in Group non-hypotension (Group N). This study analyzed the correlation of 39 factors to the occurrence of hypotension, and further analyzed the statistically significant factors through binary classification logistic regression.Results：Of the 322 sampled parturients, 148 parturients suffered hypotension. The incidence of hypotension in this study was 45.96%. The result of univariate analysis showed statistically significant differences in the factors including height (p=0.005), post-pregnancy Body Mass Index (BMI) (p=0.00), fasting time (p=0.031),weight gain in gestation (p=0.000), fundal height (p=0.047), exercise history in gestation (p=0.006) and dermatomal level of analgesia (p=0.000) between the two groups. The variables with statistical significance were analyzed by multivariate logistic regression model. The result showed that BMI in gestation (OR=1.146, 95% CI 1.041-1.262, p <0.05), weight gain in gestation (OR = 1.126, 95% CI 1.060-1.198, p <0.001), exercise history in gestation (OR = 0.399, 95% CI 0.205-0.778, p = 0.007), and dermatomal level of analgesia (OR = 2.248, 95% CI 1.645-3.074, p <0.001) were risk factors for hypotension after caesarean spinal anesthesia in parturients with scarred uterus. Conclusion：The incidence of hypotension after caesarean spinal anesthesia in parturients with scarred uterus was relatively high. The post-pregnancy BMI, weight gain in gestation, exercise history in gestation and dermatomal level of analgesia after anesthesia were risk factors for hypotension after caesarean spinal anesthesia in parturients with scarred uterus. These findings play an important role in predicting the occurrence of hypotension after caesarean spinal anesthesia in parturients with scarred uterus. Trial registration：Chinese Clinical Trial Registry (chiCTR-ROC-17011251)

The Analysis of Risk Factors to Hypotension Occurring after Caesarean Spinal Anesthesia for Parturients with Scarred Uterus

Backgroud：This study aims to discuss the risk factors to hypotension for caesarean parturients with scarred uterus when low dose of bupivacaine and sulfentanyl are used in spinal anesthesia. Methods：A total of 322 singleton-pregnancy parturients with scarred uterus who had been scheduled for caesarean spinal anesthesia were randomly sampled. The data about the basic information of the parturients, the gestation, the fetus and the anesthesia has been recorded and filed according to the clinical questionnaires about hypotension in caesarean section. The parturients whose systolic pressure drops below 90mmHG or decreases by 20% during the time from the completion of anesthesia until the delivery of infant were classified to be Group Hypotension (Group H) and the rest are in Group non-hypotension (Group N). This study analyzes the correlation of 39 factors to the occurrence of hypotension and then further analyzes the statistically significant factors through binary classification logistic regression.Results：Of the 322 sampled parturients, 148 parturients suffered hypotension. The incidence of hypotension in this study is 45.96%. The result of univariate analysis shows that the differences in the factors including height (p=0.005), post-pregnancy Body Mass Index (BMI) (p=0.00), weight gain in gestation (p=0.000), fundal height(p=0.047), fasting time (p=0.031), exercise history in gestation (p=0.006) and dermatomal level of analgesia (p=0.000) between two groups are statistically significant. The variables with statistical significance are analyzed by multivariate logistic regression model. The result shows that BMI in gestation (OR=1.146 95%, CI 1.041-1.262, p <0.05), weight gain in gestation (OR = 1.126 95%, CI 1.060-1.198, p <0.001), exercise history in gestation (OR = 0.399, 95% CI 0.205-0.778, p = 0.007), dermatomal level of analgesia (OR = 2.248, 95% CI 1.645-3.074, p <0.001) are risk factors to hypotension occurrence after caesarean spinal anesthesia for parturients with scarred uterus. Conclusion：The incidence of hypotension occurring after caesarean spinal anesthesia for parturients with scarred uterus is relatively high. Factors including post-pregnancy BMI, weight gain in gestation, exercise history in gestation and dermatomal level of analgesia after anesthesia are risk factors to hypotension occurring after caesarean spinal anesthesia for parturients with scarred uterus. The result plays an important role in predicting the occurrence of hypotension after spinal anesthesia by parturients with scarred uterus in clinic. Trial registration：Chinese Clinical Trial Registry(chiCTR-ROC-17011251)

Labor Epidural Analgesia to Cesarean Section Anesthetic Conversion Failure: A National Survey

Background. If conversion of labor epidural analgesia to cesarean delivery anesthesia fails, the anesthesiologist can be confronted with a challenging clinical dilemma. Optimal management of a failed epidural top up continues to be debated in the absence of best practice guidelines. Method. All members of the Obstetric Anaesthetists’ Association in the United Kingdom were emailed an online survey in May 2017. It obtained information on factors influencing the decision to utilize an existing labor epidural for cesarean section and, if epidural top up resulted in no objective sensory block, bilateral T10 sensory block, or unilateral T6 sensory block, factors influencing the management and selection of anesthetic technique. Differences in management options between respondents were compared using the chi-squared test. Results. We received 710 survey questionnaires with an overall response rate of 41%. Most respondents (89%) would consider topping up an existing labor epidural for a category-one cesarean section. In evaluating whether or not to top up an existing labor epidural, the factors influencing decision-making were how effective the epidural had been for labor pain (99%), category of cesarean section (73%), and dermatomal level of blockade (61%). In the setting of a failed epidural top up, the most influential factors determining further anesthetic management were the category of cesarean section (92%), dermatomal level of blockade (78%), and the assessment of maternal airway. Spinal anesthesia was commonly preferred if an epidural top up resulted in no objective sensory block (74%), bilateral T10 sensory block (57%), or unilateral T6 sensory block (45%). If the sensory block level was higher or unilateral, then a lower dose of intrathecal local anesthetic was selected and alternative options such as combined-spinal epidural and general anesthesia were increasingly favored. Discussion. Our survey revealed variations in the clinical management of a failed epidural top up for cesarean delivery, suggesting guidelines to aid decision-making are needed.

Comparative Study of Hyperbaric Bupivacaine Plus Ketamine Vs Bupivacaine Plus Fentanyl for Spinal Anaesthesia during Caeserean Section

Background Spinal anesthesia is widely used for caesarean section due to its rapid onset, low failure rate, complete analgesia. Addition of intrathecal ketamine and opioids to local anaesthetics seems to improve the quality of block and prolong the duration of analgesia.Objectives The purpose of this study was to compare the effect of intrathecal ketamine mixed with hyperbaric bupivacaine to intrathecal fentanyl mixed with hyperbaric bupivacaine.Methods One hundred parturients ASA Grade I scheduled for elective or semiurgent caesarean section under spinal anaesthesia were randomly divided into two groups. Group A received 2ml (10 mg) hyperbaric bupivacaine 0.5% plus 25 mg preservative free ketamine. Group B received 2ml (10mg) hyperbaric bupivacaine 0.5% plus 25?g fentanyl. The patients were observed intraoperatively for the onset of sensory block, degree of motor block and total duration of analgesia.Results The time to achieve Bromage scale 3 motor blockade was shorter in Group A than in Group B.(p= 0.445) whereas time to achieve highest dermatomal level of sensory block was shorter in Group A than in Group B (p= 0.143). The duration of spinal analgesia was longer in Group B than in Group A (p= 0.730). The frequency of side effect such as sedation score was higher in Group A compared to Group B (p= 0.048). The incidence of pruritus was significantly higher in Group B compared to Group A (p = 0.000).Conclusion Addition of preservative free ketamine lead to faster onset of sensory and motor blockade, although it did not prolong the duration of spinal analgesia compared to addition of fentanyl in parturients undergoing caesarean section with spinal anaesthesia.Kathmandu Univ Med J 2013; 11(4): 287-291

Osteolysis in Lumbar Interbody Fusions: The Role of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2)

ABSTRACT Osteolysis may occur following lumbar interbody fusion procedures in which recombinant human bone morphogenetic protein-2, more commonly known as rhBMP-2, is used. The actual incidence of this process is unknown. Osteolysis results from an osteoclastic, rather than an osteoblastic response to rhBMP-2 and its carrier on trabecular vertebral bone, early in the sequence of bone graft healing. This osteoclastic response may represent an idiosyncratic reaction in those affected. The patient usually does well in the immediate postoperative period with resolution of their preoperative complaints of axial and radicular pain. However, at 4 to 12 weeks following the index surgery, the patient experiences a recurrence of severe back and radicular pain corresponding to the dermatomal level(s) operated upon. Laboratory studies including erythrocyte sedimentation rate, C reactive protein, and cultures are negative for infection. Imaging studies show areas of bone destruction and cyst formation containing fluid. In the majority of post-operative patients with osteolysis, there is an osteoblastic healing response with symptom resolution. Supportive, nonoperative care is usually effective in managing the patient. Nasca RJ. Osteolysis in Lumbar Interbody Fusions: The Role of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2). The Duke Orthop J 2012;2(1):50-54.

Influence of Positioning on Plain Levobupivacaine Spinal Anesthesia in Cesarean Section

Background. The behaviour of isobaric levobupivacaine in relation to gravity when used in obstetric spinal anesthesia is unclear.Methods. 46 women with ASA physical status 1 undergoing cesarean section were randomly allocated to 2 groups. Spinal anesthesia with 12.5 mg levobupivacaine was performed in the sitting position in all women. Those in the first group were placed in the supine position immediately after the injection, while those in the second group were asked to remain seated for 2 minutes before assuming the supine position. The sensory block level, the onset of sensory and motor blocks, the regression of the sensory block for 2 dermatomes of the sensory block, the first request for analgesics, and the regression of motor block were recorded.Results. No differences in onset times, sensory level, or Bromage score were observed between the two groups. The time of first analgesic request was earlier in the seated group (supine131±42 min, seated106±29 min,P=.02).Conclusion. Isobaric levobupivacaine in women at term produces a subarachnoid block the dermatomal level of which does not depend on gravitational forces.

Variety of spinal vascular pathology seen in adult Cobb syndrome

Cobb syndrome is a rare clinical entity that includes the combination of a vascular skin nevus and an angioma in the spinal canal present at identical dermatomal level(s) (cutaneomeningospinal angiomatosis). To date, 38 cases have been reported, only 18 of which are in adults (> 18 years of age). The majority of these cases have been described in the era predating current neuroimaging techniques, and most authors have assumed that each case involves similar vascular pathology. This report highlights 2 patients presenting with similar thoracic cutaneous vascular nevi yet with markedly differing spinal vascular pathology. A 29-year-old man presented with cutaneous hemangioma and a progressive paraparesis and paresthesia of the lower extremities. A 20 × 20–cm port-wine stain over his right upper midback (T6–10) correlated precisely with MR imaging that demonstrated an enhancing epidural mass between T-6 and T-10 causing compression of the cord and cord edema. A 34-year-old man also presented with progressive myelopathy and a 15 × 20–cm port-wine stain within the same dermatomal region as a Type III spinal arteriovenous malformation. Workup for each patient included pre- and postoperative contrast-enhanced MR imaging with vascular sequencing and spinal angiography. The first patient was treated with bilateral laminectomy at the T6–10 levels, with significant postoperative improvement in motor strength. The second patient underwent coil embolization of an intranidal aneurysm, with follow-up embolization 8 years later. Cobb syndrome is an unusual entity in the adult population and should be considered when there is a constellation of cutaneous manifestation and underlying neurological deficit. The vascular skin nevus associated with Cobb syndrome is accompanied by a wide variety of vascular pathologies.