Effects of remimazolam on early postoperative cognitive function in elderly patients with hip fracture / 中国临床药理学与治疗学

AIM: To evaluate the effect of remimazolam on early postoperative cognitive function in elderly patients with hip fracture based on a randomized controlled trial. METHODS: A total of 106 elderly patients, aged 65-90 years, ASA grade Ⅱ or III, who underwent hip fracture surgery under combined spinal-epidural anesthesia in the Sixth Affiliated Hospital of Wenzhou Medical University from December 2022 to June 2023 and met the inclusion criteria, were selected and randomized into remimazolam group (group R) and propofol group (group P) according to the random number table, with 53 cases in each group. Patients in group P received a slow intravenous injection of propofol at a dose of 0.3-0.5 mg / kg (injection time of 1min), followed by a pump infusion at 0.5-3 mg · kg

Study on the application value of combined spinal-epidural anesthesia under the assistant of ultrasound localization on patients with lower limb fracture / 中国医学装备

Objective:To explore application value of combined spinal-epidural anesthesia under the assistant of ultrasound location on lower limb fractures.Methods:A total of 80 patients with lower limb fractures who underwent surgical treatment at the 901th Hospital of the PLA Joint Service Support Force from July 2020 to July 2022 were selected,and they were divided into a control group and an observation group according to the random number table method,with 40 cases in each group.The control group received epidural anesthesia under ultrasound,and the observation group received the combined lumbar-epidural anesthesia under ultrasound.The lidocaine dosage,anesthetic block time,anesthesia onset time and dosage of additional analgesic,as well as the changes in vital signs such as diastolic blood pressure(DBP),systolic blood pressure(SBP)and heart rate(HR),between the two groups of patients were compared.In addition,the thrombelastogram,anesthetic effects and occurrence of adverse reactions also were compared between two groups.Results:The lidocaine dosage,anesthetic block time,anesthesia onset time and dosage of additional analgesic of the observation group were significantly higher than those in the control group,and the differences were statistically significant(t=8.657,23.483,12.785,16.600,P<0.05),respectively.There were no statistically significant differences in DBP,SBP,HR,comprehensive coagulation index(CI),reaction time(R),formation time of blood cell agglutination(K)and incidence of adverse reactions between two groups before anesthesia,at the 30th minute after anesthesia and after the end of anesthesia(P>0.05).Compared with α angle before anesthesia and at the 30th minute after anesthesia,the α angles of the two groups increased significantly after anesthesia(t=6.564,5.783,P<0.05),respectively.The mechanical strength(G)of the blood clot and the maximum amplitude(MA)of chromatogram of the observation group were significantly reduced after completed anesthesia,and the differences of them were statistically significant(t=8.480,4.236,P<0.05),respectively.There were no significant differences between G and MA in the control group(P>0.05).The total effective rate of the observation group was 97.50%,which was significantly higher than 80.00% of the control group,and the difference was statistically significant(x2=4.507,P<0.05).Conclusion:The combined spinal-epidural anesthesia under the assistant of ultrasound location can effectively reduce the amount of anesthetics in patients with lower limb fracture,which has fast block and effect.In addition,it has little influence on circulatory function,and it is less likely to form a hypercoagulable state.It has better clinical anesthesia effect.

Application of ropivacaine combination with dexmedetomidine in opioid-free analgesia after cesarean section / 中国药房

OBJECTIVE To investigate the effect of ropivacaine combined with dexmedetomidine on postoperative analgesia in women undergoing cesarean section， and to explore the feasibility of the opioid-free analgesia mode after cesarean section under spinal-epidural anesthesia. METHODS Totally 80 women undergoing cesarean section were randomly divided into observation group （ropivacaine combined with dexmedetomidine for analgesia） and control group （ropivacaine combined with opioid drug sufentanil for analgesia） ， with 40 cases in each group. The exercise and rest score in visual analogue scale （VAS） within 48 hours after operation， the use of analgesia pump （the time of first analgesia pump pressing， the times of analgesia pump pressing within 24 hours and 48 hours after operation）， the time of block （the onset time of spinal anesthesia sensory block， the time to the highest level of spinal anesthesia sensory block， the time of sensory recovery and the time of movement recovery） ， the time of prognosis （the time of gastrointestinal ventilation recovery， the time of getting out of bed and the hospitalization time）， and the incidence of adverse events were compared in 2 groups. RESULTS Finally， 64 parturients （32 in the observation group and 32 in the control group） were involved in the analysis. Compared with the control group， the recovery time of sensation and movement were significantly prolonged， the ventilation time was significantly shortened， and the incidence of nausea， vomiting and abdominal distension was significantly decreased in the observation group （P＜0.05） . There was no significant difference in the other indexes between the two groups （P＞0.05）. CONCLUSIONS Ropivacaine combined with dexmedetomidine under spinal-epidural anesthesia could provide similar analgesic effect as combined with opioids drug sufentanil， shorten the time of gastrointestinal ventilation recovery， and reduce the incidence of nausea，vomiting and abdominal distension， with no increased risk of low blood pressure or urinary retention.

Clinical research progress of spinal epidural lipomatosis / 中国修复重建外科杂志

OBJECTIVE@#To review the clinical research progress of spinal epidural lipomatosis (SEL).@*METHODS@#The clinical studies on SEL at home and abroad in recent years were extensively reviewed, and the pathogenesis, clinical and imaging manifestations, and treatment status of SEL were summarized and analyzed.@*RESULTS@#SEL is a disease characterized by compression of the spinal cord and nerve roots due to abnormal accumulation of epidural adipose tissue in the spinal canal. Its prevalence and diagnosis rate are low and the pathogenesis is not fully understood. MRI is the most sensitive and specific diagnostic test for SEL. Surgical decompression and removal of excess adipose tissue are the only options for patients with acute SEL or those who have failed conservative management, and conservative management should be considered for other patients.@*CONCLUSION@#SEL is a rare disease and related research still needs to be improved. In the future, high-quality, multi-center and large-sample studies will be of great significance for evaluating the choice of treatment methods and effectiveness of SEL patients.

Adulto con hematoma medular epidural espontáneo

RESUMEN El hematoma espinal es una entidad clínica poco frecuente. Se necesita de una alta sospecha clínica para su diagnóstico precoz y tratamiento oportuno. Habitualmente se presenta en forma de deterioro neurológico súbito debida a la compresión medular mecánica producida por sangre en el canal medular. Presentamos el caso de un paciente de sexo masculino de 53 años, consumidor de bebidas alcohólicas (ron paraguayo) en forma diaria que presenta un deterioro neurológico brusco comprometiendo miembros superiores e inferiores. Con la resonancia magnética se llega al diagnóstico de hematoma epidural a nivel de C4-C5 y mielopatía compresiva de los segmentos adyacentes.

ABSTRACT The spinal hematoma spinal is a infrequent clinical entity. A high clinical suspicion is needed for early diagnosis and timely treatment. It usually presents as a sudden neurological deterioration due to mechanical spinal cord compression caused by blood in the spinal canal. We present the case of a 53-year-old male patient, a daily consumer of alcoholic beverages (Paraguayan rum) who presented sudden neurological deterioration compromising upper and lower limbs. Magnetic resonance imaging leads to a diagnosis of epidural hematoma at the C4-C5 level and compressive myelopathy of the adjacent segments.

Acupoint Injection Decreases Anesthetic Cosumption during Combined Spinal-Epidural and Patient-Controlled Epidural Labor Analgesia / 中国结合医学杂志

OBJECTIVE@#To explore if acupoint injection can improve analgesic effects or delivery outcomes in parturients who received combined spinal-epidural analgesia (CSEA) and patient-controlled epidural analgesia (PCEA) for labor analgesia.@*METHODS@#A total of 307 participants were prospectively collected from July 2017 to December 2019. The participants were randomized into the combined acupoint injection with CSEA plus PCEA group (AICP group, n=168) and CSEA plus PCEA group (CP group, n=139) for labor analgesia using a random number table. Both groups received CSEA plus PCEA at cervical dilation 3 cm during labor process, and parturients of the AICP group were implemented acupoint injection for which bilateral acupoint of Zusanli (ST 36) and Sanyinjiao (SP 6) were selected in addition. The primary outcome was Visual Analogue Scale (VAS) score, and the secondary outcomes were obstetric outcomes and requirement of anesthetics doses. Safety evaluations were performed after intervention.@*RESULTS@#The VAS scores were significantly lower in the AICP group than in the CP group at 10, 30, 60, and 120 min after labor analgesia (all P<0.05). The latent phase of the AICP group was shorter than that of the CP group (P<0.05). There were less additional anesthetics consumption, lower incidences of uterine atony, fever, pruritus and urinary retention in the AICP group than those in the CP group (all P<0.05).@*CONCLUSION@#Acupoint injection combined CSEA plus PCEA for labor analgesia can decrease the anesthetic consumption, improve analgesic quality, and reduce adverse reactions in the parturients. (Registration No. ChiMCTR-2000003120).

The use of chemoprophylaxis or not for dvt in spine surgery: a systematic review / O uso da quimioprofilaxia ou não para tvp em cirurgia de coluna: revisão sistemática / El uso de quimioprofilaxis o no para la tvp en la cirugía de columna vertebral: revisión sistemática

ABSTRACT Objective: To compare pharmacological and non-pharmacological prophylaxis in elective spine surgery to determine the risks of DVT, PTE, and epidural hematoma (EH) in both groups, as well as their respective treatment effectiveness. Methods: Systematic review and meta-analysis based on systematically searched articles, using combinations of MeSH terms related to chemoprophylaxis and non-chemoprophylaxis for prevention of deep vein thrombosis and pulmonary embolism in elective spine surgery. Adult patients were eligible for inclusion in the study, except for those with trauma, spinal cord injury, neoplasms, or those using vena cava filters. Results: Five studies were selected for this systematic review and meta-analysis: 3 retrospective studies, 1 prospective study, and 1 case series. Data analysis showed that 4.64% of patients treated with chemoprophylaxis had an unfavorable outcome regarding DVT, while this outcome occurred in 1.14% of patients not treated with chemoprophylaxis (p=0.001). Among patients using chemoprophylaxis, only 0.1% developed epidural hematoma and 0.38% developed PTE. Among those on non-pharmaceutical prophylaxis, 0.04% had EH (p=0.11) and 0.42% had PTE (p=0.45). Conclusions: No benefits were found for chemoprophylaxis as compared to non-chemoprophylaxis in preventing DVT in elective spine surgery, nor was there an increased risk of epidural hematoma or fatal thromboembolic events. Level of evidence III; Therapeutic studies; Investigation of treatment results.

RESUMO Objetivo: Comparar profilaxia farmacológica e não farmacológica em cirurgia eletiva da coluna vertebral, a fim de determinar os riscos de TVP, TEP e hematoma epidural (HE) em ambos os grupos, bem como a respectiva eficácia do tratamento. Métodos: Revisão sistemática e metanálise com base em artigos sistematicamente pesquisados, usando combinações de termos MESH relacionados à quimioprofilaxia e à não quimioprofilaxia para prevenção de trombose venosa profunda e embolia pulmonar em cirurgia eletiva da coluna vertebral. Pacientes adultos foram elegíveis para inclusão no estudo, exceto aqueles com trauma, lesão medular, neoplasias e aqueles que usavam filtros de veia cava. Resultados: Cinco estudos foram incluídos para fazer parte desta revisão sistemática e metanálise: três estudos retrospectivos, um prospectivo e um série de casos. A análise dos dados mostrou que 4,64% dos pacientes tratados com quimioprofilaxia tiveram um resultado desfavorável em relação à TVP, enquanto esse resultado ocorreu em 1,14% dos pacientes não tratados com quimioprofilaxia (p = 0,001). Entre os pacientes em uso de quimioprofilaxia, apenas 0,1% desenvolveram hematoma epidural (HE) e 0,38% desenvolveram TEP. Entre aqueles em profilaxia não medicamentosa, 0,04% apresentaram HE (p = 0,11) e 0,42% tiveram TEP (p = 0,45). Conclusões: Não foram encontrados benefícios para a quimioprofilaxia quando comparada à não quimioprofilaxia na prevenção da TVP em cirurgia eletiva da coluna vertebral, assim como não foi verificado aumento do risco de hematoma epidural ou eventos tromboembólicos fatais. Nível de evidência III; Estudos terapêuticos - Investigação dos resultados do tratamento.

RESUMEN Objetivo: Comparar la profilaxis farmacológica y no farmacológica en la cirugía de columna electiva para determinar los riesgos de TVP, TEP y hematoma epidural (HE) en ambos grupos, así como la respectiva eficacia del tratamiento. Métodos: Revisión sistemática y metanálisis basados en artículos buscados sistemáticamente, utilizando combinaciones de términos MESH relacionados con quimioprofilaxis y no quimioprofilaxis para la prevención de trombosis venosa profunda y embolia pulmonar en cirugía electiva de columna. Se eligieron pacientes adultos para su inclusión en el estudio, excepto aquellos con traumatismos, lesión medular, neoplasias y aquellos que usan filtros de vena cava. Resultados: Se incluyeron cinco estudios para formar parte de esta revisión sistemática y metanálisis: 3 estudios retrospectivos, 1 prospectivo y 1 serie de casos. El análisis de los datos reveló que el 4,64% de los pacientes tratados con quimioprofilaxis tuvieron un resultado desfavorable con respecto a la TVP, mientras que este resultado se produjo en el 1,14% de los pacientes no tratados con quimioprofilaxis (p = 0,001). Entre los pacientes que recibieron quimioprofilaxis, sólo el 0,1% desarrolló hematoma epidural (HE) y el 0,38% desarrolló TEP. Entre los que recibieron profilaxis no farmacológica, el 0,04% desarrolló HE (p = 0,11) y el 0,42% desarrolló TEP (p = 0,45). Conclusiones: No se encontraron beneficios para la quimioprofilaxis en comparación con la no quimioprofilaxis para prevenir la TVP en la cirugía de columna electiva, así como tampoco un mayor riesgo de hematoma epidural o eventos tromboembólicos fatales. Nivel de evidencia - III; Estudios terapéuticos - Investigación de los resultados del tratamiento.

Anesthetic considerations and postoperative pain management in radical penectomy: Case report / Penectomía radical, consideraciones anestésicas y manejo del dolor postoperatorio: Reporte de un caso

Abstract Radical penectomy (RP) is infrequently performed as it is reserved for specific cases of penile cancer, hence the paucity of reports regarding surgical and anesthetic considerations. Acute postoperative pain, chronic post-surgical pain, concomitant mood disorders as well as a profound impact on the patient's quality of life have been documented. This case is of a patient with diabetes and coronary heart disease, who presented with advanced, over infected penile cancer, depressive disorder and a history of pain of neuropathic characteristics. The patient underwent radical penectomy using a combined spinal-epidural technique for anesthesia. Preoperatively, the patient was treated with pregabalin and magnesium sulphate, and later received a blood transfusion due to intraoperative blood loss. Adequate intra and postoperative analgesia was achieved with L-bupivacaine given through a peridural catheter during one week. Recovery was good, pain was stabilized to preoperative levels and the patient received pharmacological support and follow-up by psychiatry and the pain team.

Resumen La penectomía radical (PR) es una cirugía infrecuente, reservada para casos específicos de cáncer de pene, por lo que hay escasos informes sobre sus consideraciones quirúrgicas y anestésicas. Se ha documentado dolor agudo postoperatorio, dolor crónico posquirúrgico y alteraciones del estado de ánimo concomitantes, así como un profundo impacto en la calidad de vida posterior del paciente. Se presenta el caso de un paciente diabético y cardiópata coronario con cáncer de pene avanzado y sobreinfectado, trastorno depresivo y dolor previo de características neuropáticas, que recibe técnica combinada espinal-peridural para cirugía de penectomía radical. Se le trata también con pregabalina preoperatoria, sulfato de magnesio y transfusión por sangrado quirúrgico. Se otorgó una adecuada analgesia intra y postoperatoria, mediante catéter peridural con L-bupivacaína hasta por una semana. El paciente tuvo una buena recuperación, estabilización del dolor a niveles preoperatorios, controles y apoyo farmacológico por psiquiatría de enlace y equipo del dolor.

Stroke Mimics：report of 3 Cases and Review of Literature / 中风与神经疾病杂志

@#Objective In order to improve the clinicians’ awareness of stroke mimics and to avoid inappropriate therapy，we described the clinical data of 3 patients with stroke mimics and reviewed the literature.Methods We retrospectively gave a description of the medical history，clinical manifestations，imaging data and treatments of three typical cases of stroke mimics from January 2017 to September 2018 in our hospital.Results Case1 The patient complained of inability to speak in the morning and weakness of the right limbs for several hours. Head CT showed old lacunar infarctions.The primary diagnosis was acute ischemic stroke（AIS）. The patient developed with fever and seizures during the following days. The diagnosis of intracranial subdural empyema was confirmed by head MRI and further surgery was performed. The reason why we didn’t make the right diagnosis was that the resident didn’t ask the medical history in detail and we didn’t check the head MRI in time.Case 2 We describe a 70-year-old man who presented to our emergency department（ED）with acute onset of left arm soreness and left leg weakness for 5 hours. The AIS was considered. The patient was admitted to the ward and we knew his first symptom was back pain which lasted about few minutes. Spinal cord MRI revealed spinal epidural hematoma. Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs，mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms，spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a symptom of pain who is a possible candidate for thrombolytic therapy. Case3 The patient admitted to the ward with a seizure，speech disorder and right limbs paralysis for more than 20 hours. The patient’s head MR angiography showed severe stenosis of the left middle cerebral artery. The diagnosis of AIS was made. But the two head MRI being negative for acute ischemic lesion and three dimensional arterial spin-labeled brain perfusion MRI was normal. The diagnosis of AIS was wavering. Within 5 days from the admission，there was almost a complete remission of the neurological findings. The electroencephalogram examination revealed focal abnormalities and Todd’s paralysis was finally confirmed. The neurological deficits during the postictal seizure phase are usually short lasting，but they may last up to days after the convulsion.Conclusion Stroke mimics term is applied in a clinical evaluation，describing those non-vascular conditions that simulate stroke，namely those presenting with an acute neurological deficit.Careful clinical assessment （clinical history and neurological examination）in association with laboratory evaluation is important for depicting the stroke mimics. Brain imaging is essential for the correct diagnosis of AIS and stroke mimic exclusion. With the use of the clinical，laboratory data and magnetic resonance imaging （MRI） evaluation，the misdiagnosis incidence of stroke mimics will decline to lower degree.

Absceso epidural en una paciente obstétrica / Epidural abscess in an obstetric patient

Resumen: El absceso epidural es una complicación rara que puede ser causa de una elevada morbimortalidad, por ello es fundamental el diagnóstico y tratamiento oportunos. Nuestra paciente desarrolló un absceso posterior a un bloqueo epidural para una cesárea, la técnica anestésica se realizó en condiciones de asepsia y antisepsia, y se retiró el catéter al terminar la cirugía; fue dada de alta a las 48 horas. Reingresa a los nueve días por presentar fiebre, dolor en miembro pélvico izquierdo y dehiscencia de herida quirúrgica. La resonancia magnética mostró un absceso epidural en L3-L4. Se realizó laminectomía y el cultivo mostró Escherichia coli, fue manejada con antibióticos intravenosos durante cuatro semanas y se dio de alta sin secuelas neurológicas.

Abstract. Spinal epidural abscess is a rare complication, it can be cause a high morbimortality and the prompt diagnosis and treatment is essential. Our patient present an abscess after epidural block for caesarean section, the anesthetic procedure was in aseptic technique and the catheter was withdrawn after surgery, the patient was discharged after 48 hours. She was readmitted nine days later with fever, left leg pain and wound surgery infection. The magnetic resonance showed a spinal epidural abscess in L3-L4. Underwent laminectomy cultured showed Escherichia coli, she was at hospital by intravenous antibiotic treatment for 4 weeks and she was discharged without neurologic sequelae.

Anaesthesia for Fibroid Surgeries: Experience from A Nigerian Tertiary Institution

Introduction: Worldwide, uterine fibroid is the commonestgynaecological tumour in women. The standard treatment forsymptomatic uterine fibroid is surgery. This is facilitated usinganaesthesia, which could be general or Central neuraxial block(Regional anaesthesia, RA). In Nigeria, most women presentlate with huge fibroids which is a main determinant of themode of anaesthesia. While general anaesthesia (GA) is morecommonly used, it is not without challenges necessitating theincreasing use of Regional anaesthesia (RA) which is thoughtto be more beneficial for the patient. This study seeks to auditthe anaesthetic practice for fibroid surgeries over a five yearperiod in our Institution, assess the role of RA and to generateawareness with a view to increasing its utilization for fibroidsurgeries.Material and methods: The Nurses’ and Doctors ‘theatrerecords were reviewed for Socio demographics, type ofanaesthesia, type of surgery and uterine size.Result: Summary of statistics was done using percentages,means and standard deviation. Categorical variables werecompared using the Chi-square test. A P-value of <0.05 wasconsidered statistically significant. Five hundred and twentyfive (525) surgeries were performed for women with uterinefibroid with an age range of 20-65years.Two hundred andfifteen (215/41%) patients had GA, while 284 (54.1%) hadRA. Twenty six patients (26.4.9%) had spinal anaesthesia thatfailed and had to be converted to GA.Conclusion: There was a yearly increase in the use of RA,and a yearly decline in the use of GA. Regional Anaesthesiais the more commonly used mode of anaesthesia for fibroidsurgeries in our institution.

Delayed Post-operative Spinal Epidural Haematoma after Posterior Spinal Surgery: Report of Two Cases

@#Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.

Comparison of Different Volumes of Normal Saline for Epidural Volume Extension in Combined Spinal Epidural Anesthesia for Lower Abdominal Surgeries

Context: Block augmentation by epidural volume extension has been adequately documented but therehave been not enough studies comparing different volumes of normal saline used in this technique toaugment the level of block achieved. The study compares different volumes of normal saline(5,10 and 20ml) for epidural volume extension in combined spinal epidural anaesthesia for lower abdominal surgeries.120 women, aged between 20-60 years belonging to ASA grade I-II undergoing elective lower abdominalsurgeries were included in this study. The patients were randomly allocated into 3 groups and each groupcomprised of 40 patients. GROUP 1(EVE 5) received 10 mg 0.5% bupivacaine heavy (H) intrathecallywith 5 ml normal saline through the epidural catheter as a part of Epidural volume extension. GROUP 2(EVE10) and GROUP 3 (EVE20) received 10 ml and 20 ml of normal saline as a part of Epidural volumeextension respectively in addition to the intrathecal drug. The patients were assessed for sensory blocklevel to loss of pain from pin prick and for motor block using Bromage scale. Peak sensory block height,highest Bromage score, time taken to achieve maximum sensory and motor block and the time to theirrecovery were recorded.Statstical Analysis. was done using statistical software SSPS version 16.0 andEpi- info version 6.0 .Outcome measures were presented as % for qualitative variables and mean±SD forquantitative variables.Demographic data and duration of surgery were similar in all the groups.Sensoryblock augmentation was found to be significantly higher in the EVE10 and EVE 20 groups. There was nodifference in the peak motor block score between the groups during the study. Time to achieve the blockswere significantly shorter for the 20 ml group than the 10 and 5 ml groups; the latter two being comparable.This was associated with a significantly faster motor recovery to Bromage 0 in groups EVE10 and EVE20.

​Comparative Evaluation Of 0.2% Ropivacaine Versus 0.125% Ropivacaine Under Combined Spinal-Epidural Technique For Labor Analgesia

Background: Both pharmacological and non-pharmacological strategies for pain relief in labor have been tried and tested sincelong. Combined spinal-epidural analgesia (CSEA) satisfies the basic requisites of labor analgesia. Various concentrations oflocal anesthetics along with the addition of opioids can be used. The objective of this study is to compare the quality of laboranalgesia with two different concentrations of ropivacaine (0.2% vs. 0.125%) and assess fetomaternal outcome.Materials and Methods: A total of 60 primipara women with a singleton pregnancy in active labor were given CSEA afterrandomly allocating them in two groups of 30 each. Both Group A and Group B received intrathecal injection of 4 mg (2 ml)0.2% ropivacaine + 25 µg (0.5 ml) fentanyl: Group A - epidural dose of 15 ml of 0.2% ropivacaine solution + 2 µg/ml fentanyland Group B - epidural dose of 15 ml of 0.125% ropivacaine + 2 µg/ml fentanyl. Then, continuous epidural infusion was startedat the rate of 10 ml/h which was continued until the end of delivery.Results: GroupA showed better maintenance of analgesia and better maternal satisfaction while parturients in Group B neededrescue top-up analgesia due to breakthrough pain.Conclusions: It was concluded that ropivacaine in both concentrations (0.2% and 0.125%) with fentanyl is effective forinitiation of labor analgesia. However, quality of analgesia with 0.2% ropivacaine concentration is superior to 0.125%concentration.

Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block / Bloqueio combinado raquiperidural para analgesia de parto. Estudo comparativo com bloqueio peridural contínuo

Abstract Introduction: Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia. Methods: Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 cm, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1st and 2nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded. Results: At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5 ± 1.5 min) when compared to GII (11.6 ± 4.6 min) p = 0.01; pain scores in the first and second stages of delivery were lower in GI (0.9 ± 0.3 and 1.8 ± 0.7, respectively) when compared to GII (1.9 ± 0.6 and 2.2 ± 0.5, respectively), with p = 0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p = 0.045) and more frequent use of instrumental (p = 0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p = 0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p = 0.02). Conclusion: The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Resumo Introdução: O bloqueio peridural lombar constitui técnica eficaz e rotineiramente empregada para alívio da dor do parto e o bloqueio combinado raquiperidural tem como benefícios o emprego de doses menores de anestésicos locais e rápido início de analgesia. O objetivo do estudo foi avaliar comparativamente a eficácia e a segurança de duas técnicas anestésicas: bloqueio combinado raquiperidural e peridural contínua em grávidas submetidas à analgesia de parto. Método: Oitenta gestantes, ASA 2 e 3, apresentação cefálica e dilatação cervical entre cinco e seis centímetros, submetidas à analgesia de parto, distribuídas em dois grupos de acordo com a técnica anestésica: técnica combinada raquiperidural (GI) e peridural contínua (GII). Avaliaram-se: intensidade de dor antes do bloqueio; tempo para completa analgesia; grau do bloqueio motor; tempo para dilatação cervical total; duração do 2° estágio do trabalho de parto; intensidade de dor durante o 1° e o 2° estágio do trabalho de parto; tipo de parto; uso de ocitocina durante trabalho de parto; parâmetros cardiocirculatórios, respiratórios e eventos adversos maternos; repercussões neonatais. Resultados: No momento da anestesia a intensidade de dor era semelhante em ambos os grupos. O alívio da dor foi mais rápido no GI (4,5 ± 1,5 min) quando comparado com o GII (11,6 ± 4,6 min) p = 0,01; os escores de dor no primeiro e segundo estágios de parto foram menores no GI (0,9 ± 0,3) e (1,8 ± 0,7) quando comparados com o GII (1,9 ± 0,6) e (2,2 ± 0,5) com p = 0,01 somente no primeiro estágio de trabalho de parto; houve necessidade de complementação com anestésicos locais no GII; partos espontâneos mais frequentes em GI (80% das pacientes) do que em GII (50%) p = 0,045 e instrumentais mais frequentes (p = 0,03) em GII (12 pacientes) quando comparadas com o GI (quatro pacientes); a frequência de partos cesáreos foi significativamente maior (p = 0,02) no Grupo II do que no Grupo I, quatro casos no GI e oito no GII; ausência de alterações cardiocirculatórias e respiratórias maternas e repercussões neonatais; prurido mais frequente no GI (10 pacientes) e (0 paciente no GII) p = 0,02. Conclusão: O bloqueio combinado mostrou-se eficaz com melhor qualidade de analgesia e maior conforto às gestantes, constitui boa opção para a prática de analgesia obstétrica.

Clinical features of spontaneous spinal epidural hematoma / Journal of Rural Medicine

Objective: Spontaneous spinal epidural hematoma is rare and therefore difficult to diagnose. This study evaluated the clinical features of this condition in patients admitted to our hospital.Patients and Methods: We evaluated 12 patients with spontaneous spinal epidural hematoma who were treated at our hospital. We investigated the following variables in these patients: underlying diseases, medications used, initial symptoms, spinal level affected, whether transported to the hospital by ambulance, department where first evaluated, mass lesion on computed tomography with soft tissue window settings, time interval between symptom onset and diagnosis, treatment received, and Frankel classification on arrival and when last observed.Results: Five patients reported the use of antiplatelet or anticoagulant drugs. All patients in this study reported acute onset of severe pain as the initial symptom, and 10 patients reported some degree of paralysis accompanying the pain. With respect to the morbidity level, the cervical region was the most common site of involvement (n=7). Ten patients were transported to the hospital at night via ambulance. Five patients first visited the Department of Internal Medicine. Seven patients presented with a mass lesion on computed tomography with soft tissue window settings. The time interval between symptom onset and diagnosis ranged from 2 hours to 6 days. Three and 9 patients received conservative and surgical treatments, respectively. No patient showed worsening of Frankel classification.Conclusion: Acute onset of severe pain was the most characteristic clinical symptom. Spontaneous spinal epidural hematoma should be included in the differential diagnosis. Computed tomography with soft tissue window settings may rule out cerebrovascular disease and cardiovascular disease, and specifically detect a hematoma. Subsequent magnetic resonance imaging can diagnose a spontaneous spinal epidural hematoma at an early stage.

Epidural hematoma after total knee arthroplasty in a patient receiving rivaroxaban: A case report

Rivaroxaban, a factor Xa inhibitor, is one of the newly developed direct oral anticoagulants (DOAC). In recent times, it has been increasingly used in the prevention of pulmonary embolism in patients undergoing orthopedic surgery. This report describes a case of epidural hematoma in an elderly patient who underwent combined spinal epidural anesthesia for total knee arthroplasty; the patient received rivaroxaban postoperatively for 7 days to prevent pulmonary embolism. Additionally, the epidural hematomas developed on the 5th postoperative day but the patient recovered well with conservative treatment. Although rivaroxaban has a low need for monitoring and is easily administered, the guidelines should be carefully checked for the postoperative administration schedule in patients undergoing regional anesthesia. In addition, rivaroxaban should be used with caution, especially in elderly patients.

Chronological low field magnetic resonance appearance of canine spinal epidural hemorrhage model

The magnetic resonance (MR) features of spinal epidural hemorrhage depending with the passage of time have a meaning in veterinary medicine. The aim of this study is to propose the characteristic MR image of spinal epidural hemorrhage using a lower field permanent magnet scanner in dogs. A total of 8 clinically normal beagle dogs, weighing about 9 kg, were allocated. After a baseline MR examination, spinal epidural hemorrhage was created. MR scanning was executed on days 1, 2, 3, 4, 5, 10, 15, 20, 25, and 30 using 0.25 Tesla low field MR. Transverse MR images were attained for image examination. T2W, T1W, fluid-attenuated inversion recovery (FLAIR), short tau inversion recovery (STIR), and T2*-GRE sequences were used. Images were compared subjectively for signal transition assessment. Spinal epidural hemorrhage models were produced positively in 8 dogs at the T12 to L2 region. Initially, the spinal cord and epidural lesions were hyper-intense on T2W and T1W images. On T2W, FLAIR and STIR images, the spinal cord lesion was steadily hyperintense. No significant and consistent hypointense signal indicating hemorrhage was seen on T2*-GRE images. This study result suggests that relatively consistent hyperinstensity on T2 and FLAIR is observed for 30 days, meanwhile T2*-GRE imaging is less useful in hemorrhage detection.

Primary Spinal Epidural Non-Hodgkin’s Lymphoma: A case report

Introduction@#Non-Hodgkin’s lymphomas (NHLs) are a varied group of malignancy originating in the lymphatic system. As a subset of lymphomas, primary spinal epidural lymphomas are diagnosed when there are no other recognizable sites of lymphomas at the time of diagnosis. It mimics other spinal diseases making the diagnosis difficult to establish as well as in obtaining tissue diagnosis. We present an atypical case of a 45-year-old female who presented initially with back pain then eventual loss of sensory and motor function of the lower extremities, further work up showed primary spinal epidural NHL.@*Case@#This is a case of a 45-year-old female with chief complaint of back pain. Magnetic resonance imaging (MRI) of the thoracic spine showed nonspecific epidural soft tissue mass at T5 to T6 level compressing the spinal cord. Operative procedure was done with histopathology of the epidural lesion consistent of NHL. Immunohistochemical staining showed CD20 (+), thus a diagnosis of diffuse large B cell lymphoma (DLBCL) was made. Patient underwent six cycles of cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) regimen.@*Conclusion@#Signs and symptoms of primary spinal epidural NHL often overlaps its manifestations with other spinal diseases. A high index of clinical suspicion warrants inclusion of such neoplastic condition in determining the exact and definitive diagnosis of cases manifesting spinal compression.

A Comparative Study Of Combined Spinal Epidural Anaesthesia Versus Epidural Anaesthesia For Elective Caesarean Section

Background and aims This study was done to compare the efficacy of combined spinal epidural(CSEA) anaesthesia with epidural anaesthesia based on the parameters such as onset time,quality of intraoperative analgesia, quality of motor blockade,incidence of hypotension and total local anaesthetic dose requirement Materials and methods– 50 patients undergoing elective LSCS were divided into two groups of 25 each .One group received combined spinal epidural anaesthesia(CSE). The other group received epidural anaesthesia.The combined spinal epidural (CSE) group received 1 ml of 0.5% hyperbaric bupivacaine intrathecally followed by 10 ml of 0.5% plain bupivacaine with adrenaline 5mcg/ml (1 in 2,00,000) epidurally. The epidural group patients received 16 ml of 0.5% plain bupivacaine with adrenaline epidurally. Study parameters were noted. Observation and results In CSE group 72% achieved complete anaesthesia ,while in epidural group only 40% achieved complete anaesthesia which is statistically significant.(p<0.05)Complete motor blockade was achieved in 68% in CSE group and 36% in Epidural group.Incidence of hypotension was similar in both groups.Mean local anaesthetic dose was 55 mg in CSE group compared to 86mg in the epidural group which was statistically significant. Conclusion Combined spinal epidural anaesthesia offers rapid onset of intense neuraxial blockade, better muscle relaxation, better intraoperative analgesia and decrease in the total requirement of local anaesthetic dose when compared with epidural anaesthesia in elective caesarean section.