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Knight G, Mushambi M. Anesthetic challenges of pregnant obesity women. Best Pract Res Clin Obstet Gynaecol 2023; 91:102405. [PMID: 37688846 DOI: 10.1016/j.bpobgyn.2023.102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/24/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
Obesity causes significant morbidity and increases the mortality risk for both mother and fetus. With an increasing projected prevalence, it is vital that the obstetric anesthetist is equipped with the knowledge and tools to manage these women. A multi-disciplinary team approach and early planning is required. Neuraxial analgesia for labor helps to negate the need for general anesthesia, which is associated with increased risk in this subset of women. Catheter techniques for neuraxial anesthesia allow for titration, manipulation, and prolongation of the anesthetic block to reduce the risk of conversion to general anesthesia.
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Affiliation(s)
- Georgia Knight
- University Hospitals of Leicester, Infirmary Square, Leicester 0300 3031573, UK.
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Tsao SL, Li WT, Chang LY, Yeh PH, Yeh LT, Liu LJ, Yeh CB. Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1579. [PMID: 37763698 PMCID: PMC10535284 DOI: 10.3390/medicina59091579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.
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Affiliation(s)
- Shao-Lun Tsao
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan City 320, Taiwan
| | - Wen-Tyng Li
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan City 320, Taiwan
| | - Li-Yun Chang
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Pin-Hung Yeh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Liang-Tsai Yeh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ling-Jun Liu
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Statistics, Tung Hai University, Taichung 407, Taiwan
| | - Chao-Bin Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
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Sawasaki F, Takeshita J, Tachibana K. Influence of maternal position during combined spinal-epidural anesthesia for labor analgesia on technical difficulties and complications. J Anesth 2023; 37:426-432. [PMID: 36943474 DOI: 10.1007/s00540-023-03182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE Generally, combined spinal-epidural anesthesia (CSEA) for labor analgesia is performed in the lateral or sitting position; however, only few studies have investigated the effect of maternal position on labor analgesia induction. We aimed to retrospectively assess the influence of maternal position on induction time and complications. METHODS We retrospectively analyzed anesthetic and medical records regarding labor analgesia in 201 parturients treated between January 2019 and November 2019. Patients were classified into 2 groups based on their position (sitting or lateral) during induction. The primary outcome was the time required for CSEA induction. We compared 2 groups on the primary outcome and the occurrences of other complications during CSEA induction using hyperbaric bupivacaine. Moreover, we performed multiple linear regression analysis to identify independent factors associated with induction time. RESULTS There was no significant between-group difference in the time required for induction. Multiple linear regression analysis revealed an independent association of the distance from the skin to the epidural space with the time required for induction. The lateral group had a significantly higher incidence of paresthesia than the sitting group (P = 0.028). The lateral group had a significantly higher ephedrine requirement (P < 0.001) than the sitting group. CONCLUSION Maternal position was not associated with the time required for CSEA induction. However, the sitting group had a lower paresthesia occurrence and ephedrine requirement than the lateral group. Other technical complications were not associated with maternal position during CSEA induction.
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Affiliation(s)
- Fumiya Sawasaki
- Department of Anesthesiology, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan.
- Department of Anesthesiology, Kanazawa Medical University, 1-1 Daigaku, Uchinada-Cho, Kahoku-Gun, Ishikawa, 920-0293, Japan.
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan
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Eloy A, Tinoco J, Regufe R, Cortez J, Cordeiro L. Epidural Catheter Migration: A Case Report of a CT Scan Examination. Cureus 2022; 14:e30831. [DOI: 10.7759/cureus.30831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/05/2022] Open
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Pangthipampai P, Sutthibenjakul K. Incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years. J Anaesthesiol Clin Pharmacol 2022; 38:652-657. [PMID: 36778829 PMCID: PMC9912884 DOI: 10.4103/joacp.joacp_253_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 12/30/2022] Open
Abstract
Background and Aims Postoperative pain in pediatric patients is one of most inadequately treated conditions. This study aimed to investigate the incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years at Siriraj Hospital-Thailand's largest national tertiary referral center. Material and Methods This retrospective study included pediatric patients aged 0-8 years who underwent surgery with epidural catheter during January 2015 to January 2020. Patients with missing data were excluded. Records from both the ward staff and the acute pain service were reviewed. All relevant data were extracted until the epidural catheters were removed. Results One hundred and fifty pediatric patients were included. The median age was 29 months and the range varied from 12 days to 98 months on the day of surgery, and 86 (57.3%) were male. The incidence of inadequate epidural analgesia was 32%. Most patients (95.8%) had an unacceptably high pain score within 4 hours after arriving at the ward. Univariate analysis revealed direct epidural placement, the length in epidural space less than 5 cm, and postoperative leakage to be substantially higher in the inadequate pain epidural analgesia group. When those factors were included in multivariate analysis, only length in epidural space less than 5 cm was identified as an independent risk factor. Conclusion The incidence of inadequate epidural analgesia in this pediatric study was 32%. Multivariate analysis showed length of catheter in epidural space less than 5 cm to be the only factor independently associated with inadequate epidural analgesia.
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Affiliation(s)
- Pawinee Pangthipampai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Karuna Sutthibenjakul
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Chau A, Tsen L. Neuraxial labor analgesia: Initiation techniques. Best Pract Res Clin Anaesthesiol 2022; 36:3-15. [PMID: 35659957 DOI: 10.1016/j.bpa.2022.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.
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Affiliation(s)
- Anthony Chau
- BC Women's Hospital, Department of Anesthesia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Lawrence Tsen
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, USA.
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Macpherson D, Quondamatteo F, Broom M. Update on applied epidural anatomy. BJA Educ 2022; 22:182-189. [PMID: 35496647 PMCID: PMC9039569 DOI: 10.1016/j.bjae.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 10/19/2022] Open
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Aditianingsih D, Pryambodho, Anasy N, Tantri AR, Mochtar CA. A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy. BMC Anesthesiol 2019; 19:221. [PMID: 31805855 PMCID: PMC6894195 DOI: 10.1186/s12871-019-0891-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/25/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy. METHODS Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed. RESULT The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group. CONCLUSION The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy. TRIAL REGISTRATION ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.
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Affiliation(s)
- Dita Aditianingsih
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Pryambodho
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Naufal Anasy
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Aida Rosita Tantri
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Chaidir Arif Mochtar
- Department of Urology, Cipto Mangunkusumo General Hospital, Universitas Indonesia, DKI Jakarta, Indonesia
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Matsusaki T, Kaku R, Ono D, Taniguchi A, Morimatsu H. Radio contrast imaging for continuous epidural infusion in humans: a report of three cases. J Pain Res 2019; 12:1077-1082. [PMID: 30988638 PMCID: PMC6438137 DOI: 10.2147/jpr.s193500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
There are no reports of human research on continuous epidural contrast injection, and there are no definite methods to investigate the spread of drugs injected continuously into the epidural space. We investigated the feasibility of continuous epidural contrast injection in patients undergoing computed tomography (CT)-guided therapy. In this study, a combination of a contrast agent mixed with 0.75% ropivacaine was used as the test drug. The main outcome evaluated was the feasibility of continuous epidural contrast imaging by CT scan following epidural injection of a contrast agent with 0.75% ropivacaine. We studied three patients who underwent CT-guided procedures and found that continuous epidural contrast injection was possible without any deleterious effects, such as an allergic reaction. The spread of the contrast agent was not consistent with the level of the clinical analgesic effect. Continuous epidural contrast injection is a feasible procedure. The results of our study might contribute to future research on continuous epidural contrast administration, as well as provide patients with superior analgesia.
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Affiliation(s)
- Takashi Matsusaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan,
| | - Ryuji Kaku
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan,
| | - Daisuke Ono
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan,
| | - Arata Taniguchi
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan,
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan,
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Doodnaught GM, Constant C, Desrochers A, Pang DSJ. Accidental knotting and subsequent removal of a catheter from the epidural space in an adult cow: a case report. Clin Case Rep 2017; 5:2080-2084. [PMID: 29225861 PMCID: PMC5715422 DOI: 10.1002/ccr3.1260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/25/2017] [Accepted: 10/06/2017] [Indexed: 11/23/2022] Open
Abstract
This is the first reported case in the veterinary literature of a knot in an epidural catheter. The report reviews this very rare complication and describes options for investigation and retrieval of catheters entrapped in the epidural space of any species.
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Affiliation(s)
- Graeme M. Doodnaught
- Département de Sciences Cliniques; Faculté de Médecine Vétérinaire; Université de Montréal; Saint-Hyacinthe Quebec Canada
- Groupe de Recherche de Pharmacologie Animale du Québec (GREPAQ); Université de Montréal; Saint-Hyacinthe Quebec Canada
| | - Caroline Constant
- Département de Sciences Cliniques; Faculté de Médecine Vétérinaire; Université de Montréal; Saint-Hyacinthe Quebec Canada
| | - André Desrochers
- Département de Sciences Cliniques; Faculté de Médecine Vétérinaire; Université de Montréal; Saint-Hyacinthe Quebec Canada
| | - Daniel S. J. Pang
- Département de Sciences Cliniques; Faculté de Médecine Vétérinaire; Université de Montréal; Saint-Hyacinthe Quebec Canada
- Groupe de Recherche de Pharmacologie Animale du Québec (GREPAQ); Université de Montréal; Saint-Hyacinthe Quebec Canada
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Lefevre A, Schnepper G. Development of Harlequin Syndrome following placement of thoracic epidural anesthesia in a pediatric patient undergoing Nuss procedure. Clin Case Rep 2017; 5:1523-1525. [PMID: 28878918 PMCID: PMC5582228 DOI: 10.1002/ccr3.1097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 04/12/2017] [Accepted: 04/14/2017] [Indexed: 11/10/2022] Open
Abstract
We report the development of Harlequin Syndrome following thoracic epidural placement in a pediatric patient. Unilateral facial flushing with contralateral pallor and anhidrosis is the clinical presentation. This syndrome is typically benign. When related to regional anesthesia, treatment involves reducing the local anesthetic infusion or stopping it altogether.
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Affiliation(s)
- Ashley Lefevre
- Department of Anesthesiology Children's Healthcare of Atlanta Emory University Atlanta Georgia
| | - Gregory Schnepper
- Department of Anesthesia & Perioperative Medicine Medical University of South Carolina Charleston South Carolina
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Bigwood M, Fox B, Surendran A. Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study. Int J Obstet Anesth 2017; 30:75-76. [PMID: 28108078 DOI: 10.1016/j.ijoa.2016.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/22/2016] [Indexed: 11/27/2022]
Affiliation(s)
- M Bigwood
- Department of Anaesthesia, Queen Elizabeth Hospital, Kings Lynn, UK.
| | - B Fox
- Department of Anaesthesia, Queen Elizabeth Hospital, Kings Lynn, UK
| | - A Surendran
- Department of Anaesthesia, Queen Elizabeth Hospital, Kings Lynn, UK
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Shah R, Butala B, Parikh G, Pargi R. Visible Evidence of Lumbar Epidural Catheter Misplacement-A Critical Incident Case Report. J Clin Diagn Res 2017; 11:UD01-UD02. [PMID: 28274024 DOI: 10.7860/jcdr/2017/24573.9209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 11/08/2016] [Indexed: 11/24/2022]
Abstract
One of the causes of failed epidurals is catheter misplacement. Though various techniques of epidural space identification have been developed, none of them is 100% successful. Here, we present a case of lumbar epidural catheter misplacement in a patient scheduled to undergo right sided open nephrectomy. Catheter was found in the surgical field coming out of psoas major muscle.
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Affiliation(s)
- Rajkiran Shah
- Associate Professor, Department of Anaesthesiology and Critical Care, Smt. K.M. Mehta and Smt.G.R. Doshi Institute of Kidney Diseases and Research Center , Ahmedabad, Gujarat, India
| | - Beena Butala
- Professor and Head, Department of Anaesthesiology and Critical Care, Smt. K.M. Mehta and Smt.G.R. Doshi Institute of Kidney Diseases and Research Center , Ahmedabad, Gujarat, India
| | - Geeta Parikh
- Professor, Department of Anaesthesiology and Critical Care, Smt. K.M. Mehta and Smt.G.R. Doshi Institute of Kidney Diseases and Research Center , Ahmedabad, Gujarat, India
| | - Rajesh Pargi
- Resident, Department of Anaesthesiology and Critical Care, Smt. K.M. Mehta and Smt.G.R. Doshi Institute of Kidney Diseases and Research Center , Ahmedabad, Gujarat, India
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Impact of thoracic epidural catheter threading distance on analgesia during the first 24 hours following thoracotomy: a randomized controlled trial. Can J Anaesth 2016; 63:691-700. [PMID: 26830643 DOI: 10.1007/s12630-016-0585-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 12/04/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE The purpose of this prospective randomized controlled trial was to determine the impact of thoracic epidural catheter threading distance on analgesia quality after thoracotomy. METHODS We randomly assigned 120 elective thoracotomy patients to a thoracic epidural catheter threading distance of 3, 5, or 7 cm (groups 3CM, 5CM, and 7CM, respectively). Epidural bupivacaine 0.1% with fentanyl 2 µg·mL(-1) was administered according to a standardized protocol. Epidural analgesia quality was assessed at 60 min and 24 hr postoperatively for four measures: incidence of non-functioning epidurals; numerical rating score (NRS) < 4 at rest, while coughing, and during wound palpation; cold perception at the wound site; and cumulative dose of analgesic medication used. Our primary hypothesis was that, compared to threading distances of 3 and 5 cm, a threading distance of 7 cm was not inferior at providing an NRS < 4 while coughing at 60 min postoperatively, with a non-inferiority margin of 25% (absolute value) being significant. RESULTS The incidence of NRS < 4 while coughing at 60 min was 74% (29/39) in group 7CM compared with 68% (54/80) in the combined 3CM and 5CM groups (absolute difference 7%; 95% confidence interval -11 to 23; P = 0.29). At both 60 min and 24 hr, differences between groups were similar regarding the number of non-functioning epidurals, NRS < 4, and suppressed cold sensation. Analgesic doses were similar in the three groups. CONCLUSIONS This study found that a thoracic epidural catheter threading distance of 7 cm in the epidural space was not inferior to distances of 3 cm and 5 cm with respect to pain scores at 60 min postoperatively. This study was not powered to examine differences that could have clinical significance that were less than our a priori 25% non-inferiority margin.
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Nightingale CE, Margarson MP, Shearer E, Redman JW, Lucas DN, Cousins JM, Fox WTA, Kennedy NJ, Venn PJ, Skues M, Gabbott D, Misra U, Pandit JJ, Popat MT, Griffiths R. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia 2015; 70:859-76. [PMID: 25950621 PMCID: PMC5029585 DOI: 10.1111/anae.13101] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 12/13/2022]
Abstract
Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.
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Affiliation(s)
| | | | - E Shearer
- Society for Obesity and Bariatric Anaesthesia
| | - J W Redman
- Society for Obesity and Bariatric Anaesthesia
| | - D N Lucas
- Obstetric Anaesthetists' Association
| | - J M Cousins
- Society for Obesity and Bariatric Anaesthesia
| | - W T A Fox
- Society for Obesity and Bariatric Anaesthesia
| | - N J Kennedy
- Society for Obesity and Bariatric Anaesthesia
| | | | - M Skues
- British Association of Day Surgery
| | | | - U Misra
- Obstetric Anaesthetists' Association
| | - J J Pandit
- Association of Anaesthetists of Great Britain & Ireland
| | | | - R Griffiths
- Association of Anaesthetists of Great Britain & Ireland
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Wranicz P, Andersen H, Nordbø A, Kongsgaard UE. Factors influencing the quality of postoperative epidural analgesia: an observational multicenter study. Local Reg Anesth 2014; 7:39-45. [PMID: 25206312 PMCID: PMC4157402 DOI: 10.2147/lra.s67153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Epidural analgesia (EDA) is used widely for postoperative pain treatment. However, studies have reported a failure rate of EDA of up to 30%. We aimed to evaluate the quality of postoperative EDA in patients undergoing a laparotomy in five Norwegian hospitals. Methods This was a multicenter observational study in patients undergoing a laparotomy with epidural-based postoperative analgesia. Data were registered at three time points. Technical aspects, infusion rates, pain intensity, assessment procedures, side effects, and satisfaction of patients and health personnel were recorded. The use of other pain medications and coanalgesics was registered. Results Three hundred and seventeen patients were included. Pain control at rest was satisfactory in 89% of patients at 24 hours and in 91% at 48 hours. Pain control when coughing was satisfactory in 62% at 24 hours and in 59% at 48 hours. The spread of hypoesthesia was consistent for each individual patient but varied between patients. The hypoesthetic area was not associated with pain intensity, and the precision of the EDA insertion point was not associated with the pain score. Few side effects were reported. EDA was regarded as effective and functioning well by 64% of health personnel. Conclusion EDA was an effective method for postoperative pain relief at rest but did not give sufficient pain relief during mobilization. The use of cold stimulation to assess the spread of EDA had limited value as a clinical indicator of the efficacy of postoperative pain control. Validated tools for the control of EDA quality are needed.
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Affiliation(s)
- Piotr Wranicz
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Hege Andersen
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Arve Nordbø
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ulf E Kongsgaard
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway ; Medical Faculty, Oslo University, Oslo, Norway
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Thangamuthu A, Russell I, Purva M. Epidural failure rate using a standardised definition. Int J Obstet Anesth 2013; 22:310-5. [DOI: 10.1016/j.ijoa.2013.04.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 03/18/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
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SOUVATZIS X, DIAMANTAKI E, KORDA D, DERMITZAKIS E, ZAGANAS I, TZANAKIS NE. Predictors of laterality of motor block during epidural analgesia in a mixed surgical population. Acta Anaesthesiol Scand 2013; 57:126-32. [PMID: 23078544 DOI: 10.1111/j.1399-6576.2012.02786.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Predictors of laterality of motor block during epidural analgesia are currently unknown, as studies so far have yielded conflicting results. We aimed to evaluate predictors of post-operative asymmetric lower extremity motor blockade in a mixed surgical population. METHODS This is a retrospective analysis of 578 consecutive patients with post-operative epidural analgesia for a variety of surgical procedures. A priori determined potential predictors of unilateral motor block were age, gender, body mass index, type of surgical procedure, vertebral level of puncture, catheter insertion depth into the epidural space and concentration of local anaesthetic. Logistic regression analysis was employed for evaluating predictors of laterality. RESULTS Unilateral motor block occurred in 29.2% of the patients. Univariate logistic regression analysis showed that young age, female gender, gynaecologic procedures, a low puncture level, an increased depth of catheter insertion and a high ropivacaine concentration (2 mg/ml vs. less than 2 mg/ml) were significantly associated with increased incidence of laterality. Multivariate analysis revealed that age (OR = 0.73 per decade increase, P = 0.00001), the vertebral level of epidural puncture (OR = 1.37 per lowering vertebral level, P < 0.000001) and the depth of catheter insertion (OR = 1.46 per centimetre deeper, P = 0.001) were independent predictors of unilateral motor block. CONCLUSION These results suggest that young patients with lumbar epidural analgesia or deep catheter insertion should be frequently monitored for the occurrence of laterality of motor block. Also, these results provide support for a prospective study to determine the optimal catheter insertion depth to decrease the risk of unilateral motor block.
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Affiliation(s)
- X. SOUVATZIS
- Department of Anaesthesiology; University Hospital of Heraklion; Heraklion; Crete; Greece
| | - E. DIAMANTAKI
- Department of Anaesthesiology; University Hospital of Heraklion; Heraklion; Crete; Greece
| | - D. KORDA
- Department of Anaesthesiology; University Hospital of Heraklion; Heraklion; Crete; Greece
| | - E. DERMITZAKIS
- Department of Anaesthesiology; University Hospital of Heraklion; Heraklion; Crete; Greece
| | - I. ZAGANAS
- Department of Neurology; University Hospital of Heraklion; Heraklion; Crete; Greece
| | - N. E. TZANAKIS
- Department of Social Medicine, Laboratory of Clinical Epidemiology; Medical School, University of Crete; Heraklion; Greece
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Brummell Z, Khetani H, Seneviratne R. Are anaesthetists sure of the catheter length inserted into the epidural space? Anaesthesia 2012; 67:187-8. [DOI: 10.1111/j.1365-2044.2011.07032.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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