epidural

The choice of anesthesia for cesarean section should depend on the urgency of the procedure, in addition to the condition of the mother and fetus. It is widely accepted that regional anesthesia for cesarean section is preferable to general anesthesia. Regional techniques have several advantages. They lessen the risk of gastric aspiration, avoid the use of depressant anesthetic drugs and allow the mother to remain awake during delivery. The most common type of regional anesthesia for cesarean section is spinal anesthesia because of its simplicity, cost-effectiveness and speed of onset. It is suitable for cases of an emergent cesarean delivery. Hypotension during spinal anesthesia is a common that is associated with morbidity for both mother and fetus. Epidural anesthesia is preferred when physicians want to minimize the maternal hypotension or when intense motor blockage of the thoracoabdominal segments is not desired. General anesthesia still leads to a higher maternal mortality and should be reserved for absolute emergencies and cases where neuroaxial blockade is contraindicated.

Objective: The primary aim of this study was to measure pressure generated on a Tuohy needle during the epidural procedure in labouring women of varying body mass indices (BMI) with a view of utilising the data for the future development of a high fidelity epidural simulator. High-fidelity epidural simulators have a role in improving training and safety but current simulators lack a realistic experience and can be improved. Methods: This study was approved by the National Research Ethics Service Committee South Central, Portsmouth (REC reference 11/SC/0196). After informed consent epidural needle insertion pressure was measured using a Portex 16-gauge Tuohy needle, loss-of-resistance syringe, a three-way tap, pressure transducer and a custom-designed wireless transmitter. This was performed in four groups of labouring women, stratified according to BMI kg/m2: 18-24.9; 25-34.9; 35-44.9 and >=45. One-way ANOVA was used to compare difference in needle insertion pressure between the BMI groups. A paired t-test was performed between BMI group 18-24.9 and the three other BMI groups. Ultrasound images of the lumbar spine were undertaken prior to the epidural procedure and lumbar magnetic resonance imaging (MRI) was performed within 72h post-delivery. These images will be used in the development of a high fidelity epidural simulator. Results: The mean epidural needle insertion pressure of labouring women with BMI 18-24.9 was 461mmHg; BMI 25-34.9 was 430mmHg; BMI 35-44.9 was 415mmHg and BMI >=45 was 376mmHg, (p=0.52). Conclusion: Although statistically insignificant, the study did show a decreasing trend of epidural insertion pressure with increasing body mass indices.

Objective: The objective of this study was to evaluate the effects of intraoperative epidural anesthesia combined with balanced general anesthesia on intraoperative hemodynamics and fluid requirement, and on postoperative patient outcome. Design: The study design was a retrospective data analysis of patients undergoing open hepatectomy at a single tertiary care center from May, 2013 to June, 2016. Patients undergoing hepatectomies were separated into two groups: patients not receiving epidural local anesthetic intraoperatively (either no epidural or epidural catheter not used intraoperatively) were designated the control group and patients receiving epidural local anesthetic intraoperatively (bolus and/or continuously). Patients were excluded if they underwent laparoscopic or non-elective procedures. Results: 103 patients were included in the data analysis: Control n=14, Epidural = 89 patients. There were no major differences in demographics between groups. Epidural patients did not have higher requirements in intraoperative intravenous fluid administration, blood loss, or vasopressor use compared to control patients. Patients who received epidurals required less intravenous opioids with better post-operative pain scores initially and also on post-operative day 2. There were no differences in length of time to ambulation, or post-operative acute kidney injury amongst groups. Conclusions: This study shows that patients undergoing hepatectomies using combined epidural and general anesthesia: 1) have no increased requirement for intraoperative crystalloid, colloid, or blood component therapy, 2) require lower total intravenous opioid dose, and 3) subjectively report better pain control. Therefore, intraoperative epidural anesthesia combined with general anesthesia may be advantageous for ERAS protocol based oncological procedures.

The lumbar epidural analgesia is commonly used for labour analgesia. The “loss of resistance to air” LORA technique is commonly used for recognition of epidural space. One of the rare complications of this technique is Pneumocephalus (PC). We want to present a case of Pneumocephalus which the mother developed during epidural analgesia in labour. The patient complained of severe headache immediately after attempt at epidural catheter insertion. The symptoms progressively worsened following delivery. A postnatal anaesthetic review was performed and an urgent CT scan of the brain was arranged that showed pneumocephalus. A conservative management pathway was followed with liberal analgesia, oxygen inhalation and keeping the patient mostly in supine position. Her symptoms regressed in severity over the next three days and subsided after one week. We believe that the amount of air used for LORA should be minimized; LORA should not be used after dural puncture and the use of normal saline would alleviate the risk.

Pyogenic liver abscess (PLA) is a life-threatening infection that may develop as a result of an underlying hepatobiliary disease. A possible complication of PLA is metastatic spread, resulting in distant seeding of infection in other organs, and occasionally in the epidural space. Spinal epidural abscess (SEA) is a rare infection with severe potential complications. We describe a 71-year-old patient who presented with ascending cholangitis that was complicated by micro PLA, with a subsequent Escherichia coli bacteremia and metastatic SEA. An emergent surgical intervention with laminotomy and drainage of the epidural collection was performed. The patient was treated with a prolonged antibiotic regimen, with uneventful recovery and no neurologic sequelae. To our knowledge, this is the first reported case of a SEA following E. coli PLA.

The transfusion is a normal life-saving procedure conducted commonly by the nurses at the prescription of the attending physician or the emergency physicians. It is generally a safe procedure if guidelines for processing and administering are carefully followed. Blood transfusion is an independent risk factor for morbidity and mortality and major complications arising from transfusion are generally rare. We present a case of a mild case of iatrogenic air embolism exacerbated by pressure infusion for a patient who had undergone an exploratory laparotomy for an iatrogenic fistula repair under epidural anesthesia.

Purpose: The extrusion of implant material is a rare complication but has been reported in several cases following anterior cervical spine surgery. A posterior spontaneous percutaneous rod extrusion after rigid occipitocervical (OC) instrumentation (screw and rod construct) has not been reported yet. The authors discuss potential complications after cervical spine surgery and its clinical management.Methods: This is a case report of a 56-year-old patient after posterior OC spine surgery with initially unobserved implant failure and posterior percutaneous rod extrusion. The implant failure with a missing rod has been documented 4 years later during a routine follow-up visit.Results: At the four-year follow-up, the asymptomatic patient presented with a stable occipitocervical junction and an improved range of motion after generalized sepsis with an epidural spinal abscess, decompression and posterior OC instrumentation. A computed tomography scan of the implant failure of a broken rod was noticed two years postoperatively. The patient failed to return to the clinic. For years postoperatively he returned to the clinic and the broken rod could not be detectable in-situ on the X-rays anymore. Conclusion: The posterior percutaneous rod extrusion following an OC instrumentation not noticed by the patient, is a very rare complication that has not been described in the literature yet. Once seen back in the clinic, the patient unexpectedly reported an improved ROM without neck pain. Usually, revision surgery or implant removal is recommended if an implant failure is documented.

Non-Hodgkin Lymphoma is rarely diagnosed as spinal cord compression syndrome. Caused by an epidural mass, this complication is often encountered in the late stage of the disease. We report two cases presenting symptoms of low thoracic spinal cord compression due to an epidural tumor on the MRI. Possible complications that may occur and how to prevent adverse events during surgery are essential. This case is of special interest for being a low-incidence pathology in a rare location. The case is of high interest because of the importance of resecting the lesion to prevent sequels and the complexity of its management and highlights the importance of considering the diagnosis of this event.

Background: Postoperative Pulmonary Complications (PPCs) escalate mortality, hospitalization, and costs. This study aimed to predict PPCs after curative digestive cancer surgery using thickness fraction (TFdi) determined by ultrasonography. Methods: A prospective study was conducted over a period of 9 months. Diaphragmatic ultrasound was performed pre-surgery and repeated postoperatively (within 24 hours of ICU admission, then day 3). Right and left hemidiaphragm thickness at end-expiration (TEE) and peak-inspiration (TPI) were measured using ultrasonography. The maximal diaphragm thickening fraction during inspiration (TFdi,max) was calculated: TFdi,max = (TPI–TEE)/TEE. Patients were classified into No-PPCs and PPCs groups. Results: 159 patients participated, 55 (34.6%) developed PPCs. ICU stay was longer in PPCs patients with more deaths. TFdi,max decreased postoperatively and remained lower in PPCs patients [44.83% ± 11.07 vs. 31.54% ± 8.45; p < 0.001]. The receiver operating characteristic curve yielded an area under the curve of 0.83 [95% IC: 0.754 – 0.887]. TFdi,max < 37% had 72.7% sensitivity (95% IC: 59.0% – 83.8%) and 80.8% specificity (95% IC: 71.8% – 87.8%), Positive and negative Likelihood Ratios were 3.7 (95% IC: 2.4 – 5.7) and 0.3 (95% IC:0.2 – 0.5), respectively. In multiple logistic regression, preoperative risk factors for PPCs included TFdi,max < 37% [OR: 7.10; 95% CI: 1.71 – 18.60; p < 0.001] and supramesocolic surgery [OR: 9.94; 95% CI: 3.62 – 27.29; p < 0.001]. Epidural administration was protective [OR: 0.21; 95% CI: 0.052 – 0.87; p = 0.031]. Conclusion: A low preoperative TFdi,max identifies high-risk PPCs patients after digestive cancer surgery, aiding targeted preventive strategies like inspiratory muscle preoperative training.