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Girard T, Savoldelli GL. Failed spinal anesthesia for cesarean delivery: prevention, identification and management. Curr Opin Anaesthesiol 2024; 37:207-212. [PMID: 38362822 PMCID: PMC11062602 DOI: 10.1097/aco.0000000000001362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important. RECENT FINDING Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery. SUMMARY Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.
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Affiliation(s)
- Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Basel
| | - Georges L. Savoldelli
- Division of Anaesthesia, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine. Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Binyamin Y, Orbach-Zinger S, Ioscovich A, Reina YY, Bichovsky Y, Gruzman I, Zlotnik A, Brotfain E. Incidence and clinical impact of aspiration during cesarean delivery: A multi-center retrospective study. Anaesth Crit Care Pain Med 2024; 43:101347. [PMID: 38278356 DOI: 10.1016/j.accpm.2024.101347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND The risk of aspiration during general anesthesia for cesarean delivery has long been thought to be increased due to factors such as increased intra-abdominal pressures and delayed gastric emptying in pregnant patients. However, recent studies have reported normal gastric emptying in pregnant patients, suggesting that the risk of aspiration may not be as high as previously believed. METHODS We conducted a retrospective study of 48,609 cesarean deliveries, of which 22,690 (46.7%) were performed under general anesthesia at two large tertiary medical centers in Israel. The study aimed to examine the incidence of potentially severe aspiration during cesarean delivery, both under general and neuraxial anesthesia. RESULTS Among the patients included in the study, three were admitted to the intensive care unit due to suspected pulmonary aspiration. Two of these cases occurred during induction of general anesthesia for emergency cesarean delivery associated with difficult intubation and one under deep sedation during spinal anesthesia. The incidence of aspiration during cesarean delivery during general anesthesia in our study was 1 in 11,345 patients, and the incidence of aspiration during neuraxial anesthesia was 1 in 25,929 patients. No deaths due to aspiration were reported during the study period. CONCLUSIONS Our findings provide another contemporary analysis of aspiration rates in obstetric patients, highlighting increased risks during the management of difficult airways during general anesthesia and deep sedation associated with neuraxial anesthesia.
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Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Sharon Orbach-Zinger
- Department of Anaesthesia, Beilinson Hospital, Petach Tikvah, and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Ioscovich
- Department of Anesthesia, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yair Yaish Reina
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoav Bichovsky
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Igor Gruzman
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeny Brotfain
- Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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El-Hajj VG, Ghaith AK, Gharios M, El Naamani K, Atallah E, Glener S, Habashy KJ, Hoang H, Sizdahkhani S, Mouchtouris N, Kaul A, Elmi-Terander A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients. Neurosurgery 2024:00006123-990000000-01067. [PMID: 38391204 DOI: 10.1227/neu.0000000000002887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.
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Affiliation(s)
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karl John Habashy
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Harry Hoang
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Sanchez J, Prabhu R, Guglielminotti J, Landau R. Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration. Anaesth Crit Care Pain Med 2024; 43:101310. [PMID: 37865217 DOI: 10.1016/j.accpm.2023.101310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION The incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. METHODS Between May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. RESULTS Pain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DISCUSSION In our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.
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Affiliation(s)
- Jose Sanchez
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Rohan Prabhu
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA.
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Olmos M, Kanter M, Karimi H, Patel J, Riesenburger R, Kryzanski J. Correlation of thecal sac cross sectional area to total volume. J Clin Neurosci 2024; 119:157-163. [PMID: 38086293 DOI: 10.1016/j.jocn.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Spinal anesthesia (SA) has been increasingly utilized in lumbar surgery due to its various advantages over general anesthesia (GA), however failure of the first dose requiring intraoperative conversion to GA occurs in as many as 3.6% of SA patients. Some studies have reported that a larger thecal sac volume may dilute the anesthetic and play a role in first dose failure. Unfortunately, easy determination of thecal sac volume has not been reported in the literature. Thus, we sought to determine whether cross-sectional area obtained from MRI accurately predicts the volume of the thecal sac. METHODS We conducted a retrospective review of 80 patients who underwent lumbar surgery with spinal anesthesia. T1 and T2-weighted MRI sequences were used to measure thecal sac area at each level between L1-S1. The volume of the thecal sac was calculated using HorosTM. A statistical model was derived relating the area at each level to the thecal sac volume. Of the 80 patients, 20% were reserved and utilized to test the accuracy of the statistical model. RESULTS The area of the thecal sac positively correlated with volume at each lumbar level. The area of the thecal sac at the L4-L5 level most accurately represented total thecal sac volume (R2 = 0.588, RMSE = 2.76). CONCLUSION Cross-sectional area of the L4-L5 spinal level obtained from MRI sequences may be utilized as a proxy for thecal sac volume.
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Affiliation(s)
- Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA.
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