Epidural nalbuphine versus dexmedetomidine as adjuvants to bupivacaine in lower limb orthopedic surgeries for postoperative analgesia: a randomized controlled trial

BACKGROUND

Administration of adjuvant drugs epidurally in combination with local anesthetics offers new dimensions in the management of postoperative pain. This study aimed to compare the addition of either nalbuphine or dexmedetomidine to epidural bupivacaine for postoperative analgesia in lower limb orthopedic surgeries under combined spinal-epidural anesthesia.

METHODS

This prospective randomized double-blind study included 69 patients scheduled for lower limb orthopedic surgeries. Anesthesia was started with 15 mg hyperbaric bupivacaine 0.5% intrathecally, and then an epidural bolus dose of 12 ml (10 ml 0.25% bupivacaine with 2 ml normal saline in group C, 2 ml (10 mg) nalbuphine in group N or dexmedetomidine 2 ml (100 µg) in group D was administered when sensory regression to T10. Postoperatively, when visual analogue scale (VAS) was ≥ 3, an epidural top-up dose of 8 ml (6 ml 0.25% bupivacaine plus 2 ml normal saline in group C, 2 ml (2 mg) nalbuphine in group N or 20 µg dexmedetomidine (2 ml) in group D was given. The primary outcome was to evaluate the duration of postoperative analgesia and secondary outcomes were any side effects and patient satisfaction.

RESULTS

The onset of epidural analgesia was 17.83 ± 2.53 versus 13.39 ± 1.27 versus 12.17 ± 1.27 min in groups C, N and D, respectively (p value < 0.001). The mean duration of analgesia was 241.3 ± 14.24 versus 318.38 ± 22.54 versus 365.87 ± 18.01 min in groups C, N and D, respectively (p value < 0.001). The mean sedation score was less in group C than group N and D (P < 0.001). The patient satisfaction score showed the lowest degree of satisfaction in group C (p value < 0.001). Top-up doses consumed and total analgesic requirements were lower in groups N and D than in group C. There was a statistically significant difference between the studied groups regarding VAS over time (p value < 0.001), intraoperative bradycardia (p value 0.029), and shivering (p value 0.029).

CONCLUSION

The addition of either nalbuphine or dexmedetomidine to epidural bupivacaine was effective for postoperative analgesia in terms of onset, duration, and patient satisfaction with the superiority of dexmedetomidine over nalbuphine.

TRIAL REGISTRATION

Approval from the research ethics committee of the Faculty of Medicine, Zagazig University was obtained with the reference number (ZU-IRB#:7045-15-8-2021) and it was registered under clinicaltrials.gov (NCT05041270) on registration date 13/09/2021.

Effects of combined spinal-epidural anesthesia on anxiety, labor analgesia and motor blocks in women during natural delivery

BACKGROUND

The background of this study was analgesia in natural delivery. The combined spinal-epidural anesthesia has obvious analgesic effect on the parturients in natural labor, and combined spinal-epidural anesthesia has been widely used in anesthesia for various diseases.

AIM

To study the effects of combined spinal-epidural anesthesia on anxiety, labor analgesia, and motor blocks in parturients during natural delivery.

METHODS

A total of 120 women who gave birth at Changning District Maternal and Child Health Hospital between December 2021 to December 2022 were included; a random number table approach was employed to divide the women into a control group and a joint group, with each group consisting of 60 women. The control group was given epidural anesthesia, while the joint group was given combined spinal-epidural anesthesia. The visual analog scale (VAS) was used to evaluate the degree of maternal pain. Comparisons were made between the two groups’ conditions of childbirth and the duration of labor. Apgar scores were used to evaluate the status of the newborns at birth; Self-rating Anxiety Scale (SAS) and General Self-Efficacy Scale (GSES) scores, umbilical artery blood gas analysis indices and stress indices were compared between the two groups; and the frequencies of motor block and postpartum complications were analyzed.

RESULTS

In comparison to the control group, in the joint group, the VAS scores for the first, second, and third stages of labor were lower (P < 0.05). The rates of conversion to cesarean section and postpartum blood loss in the joint group were lower than those in the control group (P < 0.05). No significant differences were observed in the Apgar score, the duration of the first stage of labor, or the total duration of labor between the two groups (P > 0.05). The second and third stages of labor in the joint group were shorter than those in the control group (P < 0.05). When compared to the control group, the postpartum SAS score of the joint group was lower, while the GSES score was greater (P < 0.05). Between the control group and the joint group, the differences observed in pH, arterial carbon dioxide partial pressure, arterial oxygen partial pressure, or arterial hydrogen ion concentration were not significant (P > 0.05). Nitric oxide, cortisol, and adrenaline levels were lower in the joint group than in the control group (P < 0.05). There were no substantial differences in Bromage grade or rate of complications between the two groups (P > 0.05).

CONCLUSION

For parturients during natural delivery, combined spinal-epidural anesthesia can reduce anxiety, provide labor analgesia, shorten labor time, and reduce postoperative stress levels but did not result in a motor block.

Tarlov cyst with self-healing cauda equina syndrome following combined spinal-epidural anesthesia: a case report

BACKGROUND

Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression.

CASE PRESENTATION

A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset.

CONCLUSION

This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required.

Research and application of a teaching platform for combined spinal-epidural anesthesia based on virtual reality and haptic feedback technology

BACKGROUND

Intraspinal anesthesia poses significant teaching challenges and inadequate teaching resources, which ultimately limit students' opportunities for practice. To address this issue, we aimed to develop a virtual platform for combined spinal-epidural anesthesia that merges virtual reality technology with haptic feedback technology, while assessing its educational impact and learning outcomes.

METHODS

We utilized MIMICS, 3Ds MAX, and UNITY 3D software to perform 3D reconstruction based on lumbar CT/MRI data from a standard male volunteer. The haptic coefficients were configured on each layer by 20 experienced anesthesiologists in accordance with the Geomagic Touch X force feedback device. A total of 20 anesthesiology interns completed 30 virtual puncture training sessions. Two experienced anesthetists evaluated the efficacy of the platform and the level of mastery achieved using the Global Rating Scale (GRS) and a Checklist score, respectively. Finally, a questionnaire survey was conducted to gather feedback on the virtual platform.

RESULTS

After the 10th session, the puncture time stabilized at 2.4 min. As the number of sessions increased, the Global Rating Scale (GRS) score stabilized by the 8th session, and the Checklist scores tended to stabilize by the 10th session. Results from questionnaires indicated that over half of the anesthesiology interns (70%) believed that the platform, which exhibited strong repeatability, improved their anatomical recognition and provided a strong sense of breakthrough in identifying the ligamentum flavum. The majority of them (80%) expressed satisfaction with the virtual platform.

CONCLUSIONS

The platform effectively facilitated the acquisition of basic and accurate puncture skills on a virtual patient.

The height of the operating table affects the performance of residents in combined spinal and epidural anesthesia training by affecting the vision of the puncture needle: a randomized controlled trial

BACKGROUND

The present study aimed to evaluate whether the operating table height affected the success rate and incidences of complications of combined spinal-epidural anesthesia administered by residents during training.

METHODS

One-hundred-and-eighty patients were randomly allocated according to landmarks on the resident's body: umbilicus (group U), lowest rib margin (R), and xiphoid process (X). The success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma were recorded.

RESULTS

There were no differences between the three groups in the success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma. However, paresthesia during epidural catheter advancement was more common on the left side (66.7%) than the right side (33.3%) (P = 0.03). In group R, the success rate of epidural anesthesia was higher during the residents' third time (100%) than their first time (50%; P = 0.01). Most residents (83%) preferred the table height at which the needle insertion point was at the level of their lowest rib margin.

CONCLUSIONS

Neither the success nor the complication of combined spinal-epidural anesthesia in lateral decubitus position during residents' training affected by the operating table height. However, paresthesia was more likely to occur on the left side when a stiff catheter was inserted into the epidural space. It may be better to keep the table height at residents' lowest rib margin. It was not just preferred by most of residents but also better for their training of performing epidural anesthesia.

TRIAL REGISTRATION

The trial was registered prior to patient enrollment at Chinese Clinical Trial Registry (NCT: ChiCTR1800016078, Principal investigator: Juan Gu, Date of registration: 9 May 2018). Registry URL http://www.chictr.org.cn.

Failed spinal anesthesia due to accidental dural puncture: a case report

BACKGROUND

We present a case of inadequate spinal anesthesia possibly due to cerebrospinal fluid (CSF) leakage into the epidural space caused by accidental dural puncture (ADP).

CASE PRESENTATION

A 28-year-old woman with twin pregnancy underwent a cesarean section. She was scheduled to undergo combined spinal-epidural anesthesia (CSEA). Hyperbaric bupivacaine 9 mg with fentanyl 15 μg, with an additional bupivacaine 5 mg was administered from the L3/4 interspace for spinal anesthesia after repeated ADP at T12/L1; however, analgesia level was only up to T12. Insufficient analgesia level would be attributed to leakage of bupivacaine into the epidural space with the CSF via the injured dura. Planned surgery was performed under general anesthesia and completed uneventfully.

CONCLUSION

In spinal anesthesia performed after ADP in pregnant women, the anesthesia level may not increase as expected if there is a large amount of CSF leakage.

Combined spinal-epidural anesthesia with acupoint injection for labor anesthesia reduces IL-1β/IL-10 ratio in maternal peripheral blood, umbilical cord blood and improves the labor outcomes: A prospective randomized controlled trial

BACKGROUND

This study aimed to investigate the effects of combined spinal-epidural anesthesia (CSEA) with acupoint injection (AI) on the maternal-fetal expression of interleukin-1β (IL-1β), interleukin-10 (IL-10), analgesia effect, and labor outcomes.

METHODS

A total of 360 healthy primiparas were randomized into the CSEA+AI group, the CSEA group, the AI group, and the control group (n = 90, each group) according to the labor analgesia methods.

RESULTS

Compared to the CSEA group, the CSEA+AI group had significantly lower visual analog scale (VAS) scores, adverse events, dose of ropivacaine/sufentanil, and shorter labor durations. The IL-1β/IL-10 ratio in maternal peripheral blood and umbilical cord blood was reduced in the CSEA+AI group compared with the CSEA group.

CONCLUSION

The combination of CSEA and AI can reduce the ratio of IL-1β/ IL-10 in maternal peripheral blood and umbilical cord blood, which can effectively relieve labor pain.

Landmark-guided versus modified ultrasound-assisted Paramedian techniques in combined spinal-epidural anesthesia for elderly patients with hip fractures: a randomized controlled trial

Background

Combined spinal-epidural (CSE) anesthesia is considerably challenging for elderly patients with hip fractures due to spine degeneration and limitations in positioning. This study aimed to investigate the ability of a modified preprocedural ultrasound-guided technique to improve the success rate and efficacy of CSE anesthesia for elderly patients with hip fractures.

Methods

This prospective, single-blinded, parallel-group randomized controlled trial included 80 patients (aged ≥65 years) who were scheduled for elective hip fracture surgery with CSE anesthesia. Patients were randomly allocated into landmark group (n = 40) or the ultrasound group (n = 40). The primary outcome was first-pass success rate. Secondary outcomes included first-attempt success rate; number of needle insertion attempts; number of needle passes; locating, puncture, and total time; level of block; procedural adverse reactions and postoperative complications; and patient satisfaction score. Patients were blinded to group allocation.

Results

Eighty patients completed the study and were included in the final analysis. The first-pass success rates for the landmark and ultrasound groups were 20 and 70%, respectively (P < 0.001). The first-attempt success rates in the landmark and ultrasound groups were 42.5 and 85%, respectively (P < 0.001). The median number of attempts was lower in ultrasound-assisted group (1 [1]) than landmark-guided group (2 [1, 2]), P < 0.001). The median number of needle passes was lower in ultrasound group (1 [1, 2]) than in landmark-guided group (3 [2, 4], P < 0.001). The locating time (P < 0.001) and total time (P = 0.001) were longer in the ultrasound group, while puncture time was shorter (P = 0.003). No significant difference was found regarding the incidence of adverse reactions and complications. More patients in the ultrasound group had a high satisfaction score of 4–5 (P = 0.007). Interestingly, subgroup analysis demonstrated benefits for ultrasound in patients with scoliosis.

Conclusions

Modified ultrasound-assisted CSE anesthesia increases first-pass and first-attempt success rates, and reduces needle insertion attempts, passes, and puncture time for elderly patients with hip fracture, especially those with scoliosis. This technique improves patient satisfaction and warrants consideration for application in clinical practice.

Trial registration

Chinese Clinical Trial Register (identifier, ChiCTR1900020819; date of registration, January 20, 2019).

Comparison of ropivacaine combined with sufentanil for epidural anesthesia and spinal-epidural anesthesia in labor analgesia

BACKGROUND

To compare the application and efficacy of ropivacaine combined with sufentanil for continuous epidural anesthesia (CEA) and combined spinal-epidural anesthesia (CSEA) in labor analgesia.

METHODS

Three hundred sixty pregnant women requesting labor analgesia from October 2017 to August 2018 were selected retrospectively. According to the anesthetic method, subjects were divided into CSEA group and CEA group. Ropivacaine combined with sufentanil were used in all subjects. The labor time, visual analogue scale (VAS), Apgar score of newborn, adverse pregnancy outcomes and adverse drug reactions were observed.

RESULTS

There was no significant difference in pre-analgesia (T₀) VAS scores between the two groups (P > 0.05). VAS scores of first stage of labor (T₁), second stage of labor (T₂) and third stage of labor (T₃) in CSEA group were significantly lower than CEA group (P < 0.01). The onset time, T₁ and total labor time in CSEA group were significantly shorter than CEA group (P < 0.01). There were no significant differences between T2 and T3 (P > 0.05). There were no significant differences in adverse pregnancy outcomes and Apgar scores at 1, 5 and 10 min after birth between the two groups (P > 0.05). The incidence of adverse drug outcomes in CSEA group was significantly lower than CEA group (P < 0.01). Maternal satisfaction in CSEA group was significantly higher than CEA group (P < 0.01).

CONCLUSION

Considering ropivacaine combined with sufentanil for CSEA achieved a shorter onset time and labor period, significant analgesic effect, lower adverse drug reactions rates and higher subject satisfaction than CEA, it may be worthy of clinical promotion and application.

Comparison of inflationary non-invasive blood pressure (iNIBP) monitoring technology and conventional deflationary non-invasive blood pressure (dNIBP) measurement in detecting hypotension during cesarean section

BACKGROUND

The Nihon Kohden linear inflationary non-invasive blood pressure (iNIBP) monitoring technology is an oscillometric device that measures blood pressure by detecting oscillations during inflation. Systolic blood pressure can be recorded without overinflating the cuff higher than the true systolic pressure. Thus, total time taken for inflation and deflation is shorter than that by the conventional deflation devices. In this study, the ability of iNIBP to detect maternal hypotension during cesarean section faster than deflationary non-invasive blood pressure (dNIBP) monitoring devices under clinical settings was evaluated prospectively.

METHODS

A prospective study of singleton planned cesarean sections at a tertiary center was conducted from August 2015 to April 2016. The combined spinal-epidural anesthesia (CSEA) technique through a single puncture was performed for cesarean section at the center where the study was carried out. An iNIBP cuff was placed on the same arm as the intravenous line, and a dNIBP cuff was placed on the other arm. Due to left uterine displacement by approximately 10° tilt of OR table, hypotension in this study was defined as systolic pressure of 107 mmHg or less, when measured in the left arm, which was about 10 cm lower, and pressure of 92 mmHg or less in the right arm which was about 10 cm higher. This setup was done to evaluate which device detected hypotension faster under clinical settings. A two-tailed Z test was performed to statistically analyze the difference between iNIBP and dNIBP measurement results.

RESULTS

One hundred singleton planned cesarean deliveries under CSEA were included after 36 weeks of gestation. Out of the 100, 76 women (76%) experienced maternal hypotension. Of these, iNIBP detected hypotension faster than dNIBP in 47 cases (61.8%).

CONCLUSION

It was found that iNIBP detected hypotension faster than conventional dNIBP without compromising the reliability of measurement. This may lead to early treatment of maternal hypotension and prevention of adverse events related to the mother and the fetus.

Application of combined spinal-epidural anesthesia during orthopedic surgery for fracture in elderly patients with digestive ulcer

AIM

To observe the clinical effects of combined spinal-epidural anesthesia (CSEA) during orthopedic surgery for fracture in elderly patients with peptic ulcer.

METHODS

From April 2014 to July 2016, 60 elderly patients with peptic ulcer who underwent orthopedic surgery for fracture at our hospital were divided into either a control group (n = 30) or an observation group (n = 30) according to the anesthesia program. The control group underwent continuous epidural anesthesia, and the observation group underwent CSEA. Surgical stress parameters epinephrine, norepinephrine, renin and angiotensin Ⅱ were compared between the two groups.

RESULTS

The onset time of anesthesia, time of sensory block and motor block duration were significantly shorter in the observation group than in the control group (P < 0.05). Analgesia duration was significantly longer in the observation group than in the control group (P < 0.05). The rate of anesthesia-associated adverse reactions was 10.0%, significantly lower than that (20.0%) in the control group (P < 0.05).

CONCLUSION

Compared with continuous epidural anesthesia, the clinical effects of CSEA during orthopedic surgery for fracture in elderly patients with peptic ulcer are better.

Intraoperative conditions and quality of postoperative analgesia after adding dexmedetomidine to epidural bupivacaine and fentanyl in elective cesarean section using combined spinal-epidural anesthesia

This study was designed to evaluate the effect of adding dexmedetomidine to regular mixture of epidural drugs for pregnant women undergoing elective cesarean section with special emphasis on their sedative properties, ability to improve quality of intraoperative, postoperative analgesia, and neonatal outcome.

The comparison of clinically relevant doses of intrathecal ropivacaine and levobupivacaine with fentanyl for labor analgesia

Background

Intrathecal labor analgesia using new local anesthetics such as ropivacaine or levobupivacaine becomes more popular by virtues of their safety and decreased motor weakness. However, the analgesic efficacy of the clinically effective intrathecal doses of these new local anesthetics combined with fentanyl has yet to be determined.

Methods

Sixty parturients who requested neuraxial analgesia in early active labor were randomly assigned to either ropivacaine (group R, n = 30) or levobupivacaine (group L, n = 30) group. Group R received 3 mg of intrathecal ropivacaine and the group L received 3 mg of intrathecal levobupivacaine mixed with 20 µg of fentanyl as part of a combined spinal-epidural (CSE) technique. The associated block parameters, such as pain scores, duration of analgesia, the highest levels of the sensory block and motor block scores 30 mins after the injection were compared between two groups.

Results

Intrathecal ropivacaine offered shorter analgesia (87 ± 41 min vs. 122 ± 56 min, P < 0.05) with lower sensory height (T8.5 vs. T6, P < 0.05) and led to lower incidence of complete analgesia (73 vs. 97%, P < 0.05) compared with intrathecal levobupivacaine. Although motor weakness was comparable in both groups, significantly weak perineal squeezing was noticed in Group L (7 of 30 parturients vs. 16 of 30, P < 0.05).

Conclusions

Clinically relevant doses of intrathecal levobupivacaine in combination with fentanyl as part of a CSE technique provides more effective analgesia than equivalent doses of intrathecal ropivacaine in early labor, but is accompanied by slight motor weakness.

Combined spinal-epidural anesthesia for cesarean section in a patient with Moyamoya disease -A case report-

Moyamoya disease is a rare progressive occlusive disease of the internal carotid arteries. We report a case of combined spinal-epidural anesthesia in a patient with Moyamoya disease presenting for Cesarean section. Hypotension associated with spinal anesthesia for Cesarean section is the most common and serious adverse effect despite the use of uterine displacement and volume preload. We continuously infused phenylephrine and ephedrine to prevent hypotension. The intraoperative hemodynamic state was stable. The patient had no significant postoperative complications.

The effect of different oxygen administration under combined spinal-epidural anesthesia for cesarean section

BACKGROUND

During cesarean section under regional anesthesia, it is current practice to provide the parturient with a source of supplemental oxygen. We compared the effect of high flow oxygen by mask with that of low flow oxygen by nasal prongs.

METHODS

Fifty eight parturients presenting for elective cesarean section under combined spinal-epidural anesthesia were randomly assigned to one of the three groups to be given either oxygen 4 L/min by mask, oxygen 8 L/min by mask or oxygen 2 L/min by nasal prongs. Umbilical arterial and venous blood samples were taken and analysed immediately after delivery.

RESULTS

There were no significant differences in the umbilical arterial or venous pH, partial pressure of oxygen and partial pressure of carbon dioxide among the three groups. In neonatal outcome, there were no differences in Apgar scores.

CONCLUSIONS

It Makes No Differences Whether The Parturients Received Supplemental Oxygen By Nasal Prongs Or Simple Face Mask During Cesarean Section Under Combined Spinal-epidural Anesthesia.