Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial.

Importance: Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. Objective: To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. Design, Setting, and Participants: This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Interventions: Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. Main Outcomes and Measures: The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Results: Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Conclusions and Relevance: Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery. Trial Registration: ClinicalTrials.gov Identifier: NCT03915574.

ED 90 of Intrathecal Chloroprocaine With Fentanyl for Prophylactic Cervical Cerclage: A Sequential Allocation Biased-Coin Design.

BACKGROUND: Chloroprocaine is a short-acting local anesthetic that has been used for spinal anesthesia in outpatient surgery. There is limited experience with spinal chloroprocaine for prophylactic cervical cerclage placement. We sought to determine the effective dose of intrathecal chloroprocaine for 90% of patients (ED90) undergoing prophylactic cervical cerclage placement. We hypothesized that the ED90 of intrathecal chloroprocaine when combined with 10-ug fentanyl would be between 33 and 54 mg. METHODS: In this prospective 2-center double-blinded study, we enrolled women undergoing prophylactic cervical cerclage placement under combined spinal-epidural anesthesia. A predetermined dose of intrathecal 3% chloroprocaine with fentanyl 10 ug was administered. The initial dose was 45-mg intrathecal chloroprocaine. Subsequent dose adjustments were determined based on the response of the previous subject using an up-down sequential allocation with a biased-coin design. A dose was considered effective if at least a T12 block was achieved, and there was no requirement for epidural activation or intraoperative analgesic supplementation during the procedure. The primary outcome was the ED90 of intrathecal chloroprocaine with fentanyl 10 ug. Secondary outcomes included duration of surgery, anesthetic side effects, time to resolution of motor and sensory block, time to achieve recovery room discharge criteria, and patient satisfaction with anesthetic care. Isotonic regression was used to estimate the ED90. RESULTS: Forty-seven patients were enrolled into the study. Two patients were excluded (1 protocol violation and 1 failed block). In total, 45 patients completed the study. The estimated ED90 (95% confidence interval) for intrathecal chloroprocaine combined with fentanyl 10 ug was 49.5 mg (45.0-50.1 mg). The median (interquartile range [IQR]) duration of surgery was 15 (10-24) minutes. Resolution of the motor (Bromage 0) and sensory block took a median time of 60 (45-90) minutes and 90 (75-105) minutes, respectively. The median time to achieve recovery room discharge criteria was 150 (139-186) minutes. Satisfaction with anesthetic management was high in all patients. There were no reports of postdural puncture headache or transient neurological symptoms postoperatively. CONCLUSIONS: The ED90 of intrathecal chloroprocaine combined with fentanyl 10 ug was 49.5 mg. Intrathecal chloroprocaine was associated with rapid block recovery and high patient satisfaction, which makes it well suited for outpatient obstetric procedures.

Ultrasound-determined landmarks decrease pressure pain at epidural insertion site in immediate post-partum period.

BACKGROUND: Women have blamed epidurals for their post-partum back pain for decades. Survey-based studies have shown similar incidence of chronic back pain between women who delivered with epidurals compared to those who did not. However, epidural insertion site pain has yet to be evaluated by a quantitative measure: pressure pain threshold (PPT). Algometer measured PPT has been shown to be accurate and reproducible in acute, chronic, and postoperative pain studies. This study determines the effect of ultrasound-based landmarks on the PPT at the epidural insertion site in the post-partum period. METHODS: Participants were randomized into either the ultrasound or sham groups. In addition, a non-randomized control group (no epidural) participated. Ultrasound of the lumbar region was used to mark mid intervertebral levels in the US group but not in the sham group. Epidural were placed using the marks in the US group or palpated bony landmarks in the sham group. PPT at each intervertebral space measured before and after the use of epidural. RESULTS: Epidural placement did significantly decreased PPT in US (68%) and US sham (79%) groups and less in the control group (21%). US group showed decreased PPT only at insertion site whereas US sham group also showed decreased PPT at insertion site and adjacent levels. CONCLUSIONS: We showed that epidural placed with ultrasound-determined landmarks not only improves the success of epidural placement but also minimizes the number of intervertebral levels with decreased PPT.

Passive leg raising during pregnancy.

OBJECTIVE: To determine if passive leg raising (PLR) significantly increases cardiac output in a cohort of healthy pregnant women during the third trimester. STUDY DESIGN: Using a noninvasive monitor, baseline hemodynamic measurements for arterial blood pressure, systolic and diastolic blood pressure, heart rate, cardiac output, cardiac index, stroke volume, and systemic vascular resistances were obtained with patients in the semirecumbent position. Measurements were repeated after a 3-minute PLR maneuver in supine, right lateral decubitus, and left lateral decubitus positions. RESULTS: After 10 minutes of bed rest, the cohort's mean baseline heart rate was 80 ± 12 beats/minute. Baseline stroke volume was 98 ± 14 mL, mean cardiac output was 7.8 ± 1.2 L/min, and mean cardiac index was 4.32 ± 0.63 L/min. The baseline systemic vascular resistance value was 893 ± 160 dynes/sec/cm(5). Baseline mean arterial blood pressure was 84 ± 11 mm Hg. Following a PLR maneuver in the supine position, heart rate decreased significantly. No difference was noted in other measurements. Findings were similar with PLR in the left lateral decubitus. PLR in the right lateral decubitus resulted in significantly decreased heart rate, cardiac output, and cardiac index. CONCLUSIONS: PLR did not result in cardiac output recruitment in a cohort of healthy pregnant women during the third trimester.

Broken spinal needle: case report and review of the literature.

The occurrence of broken spinal and epidural needles has been reported. However, most case reports have focused primarily on prevention rather than on management. A broken spinal needle fragment was left in a patient before it was removed one month later due to back pain.

Blockade of adenosine A2A receptor counteracts neuropeptide-S-induced hyperlocomotion in mice.

Neuropeptide S (NPS) is the endogenous ligand of a G-protein-coupled receptor named as NPSR. Behavioral effects have been recently attributed to NPS, i.e. hyperlocomotion, anxiolysis, and wakefulness. However, little is known about the mechanisms by which NPS evokes such biological actions. The present study aimed to investigate the role played by the adenosine A(2A) and A(1) receptors in hyperlocomotion induced by NPS. Spontaneous locomotion was assessed in an activity cage for 30 min in mice acutely treated with caffeine (a nonselective adenosine receptor antagonist), ZM241385 (a selective A(2A) receptor antagonist), or CPT (a selective A(1) receptor antagonist) before NPS challenge (0.1 nmol, i.c.v.), which induce hyperlocomotion in mice. The pretreatment with caffeine (3 mg/kg, i.p.), in an inactive dose per se, prevented the increase in locomotion evoked by NPS. The co-administration of NPS (0.1 nmol, i.c.v.) and ZM241385 (0.1 pmol, i.c.v.) counteracted hyperlocomotion evoked by NPS. The co-administration of NPS and CPT (0.1 pmol, i.c.v.) slightly facilitated the increase in locomotion evoked by NPS alone. In summary, the pharmacological blockade of A(2A) receptors significantly attenuated the stimulatory effects of NPS. By contrast, the antagonism of A(1) receptors facilitated NPS-induced hyperlocomotion in mice, but we cannot rule out a merely additive effect of two stimulatory systems in the brain. Altogether, this is the first evidence of a putative role played by A(2A) and A(1) receptors in modulating hyperlocomotion induced by NPS.

Análise da fadiga central e seu impacto na qualidade de vida dos pacientes portadores de doenças neuromusculares / Analysis of central fatigue and its impact in the quality of life of patients with neuromuscular diseases

Entende-se por doenças neuromusculares aquelas afecções decorrentes do acometimento primário da unidade motora, sendo que, nas crianças, a maior parte dessas afecções é geneticamente determinada. As doenças neuromusculares levam ao comprometimento progressivo da função pulmonar e motora, levando a alterações significativas destas e acentuando o surgimento da fadiga muscular central. A qualidade de vida é considerada como um importante indicador de prognóstico e de evolução das doenças neuromusculares, a qual é utilizada como forma de avaliar o risco de adoecer, além de indicador válido e importante dos benefícios globais do tratamento do paciente. O estudo teve o propósito de avaliar a fadiga central e seu impacto na qualidade de vida dos pacientes com doenças neuromusculares. Foi realizada uma avaliação contendo itens como idade, tempo de diagnóstico, funcionalidade, espirometria, pressão inspiratória e expiratória máximas, escala de severidade de fadiga, desempenho muscular e questionário de qualidade de vida. Na avaliação da qualidade de vida, notou-se que os pacientes avaliados não apresentavam sintomas de fadiga, mas, sintomas de depressão associados com relatos de insatisfação nos itens sobre relações sociais e meio ambiente. Sugere-se que os profissionais da área da saúde estejam aptos a reconhecer e saber diferenciar os sintomas de fadiga central dos sintomas de depressão, para que possam encaminhar os pacientes, no caso de depressão, também para o serviço psicológico e melhorar a qualidade de vida destes pacientes.

Neuromuscular disorders are understood as diseases affecting the motor unit, and in young children most of these diseases are genetic conditions. Neuromuscular disorder leads to pulmonary and motor function involvement causing central muscular fatigue. The quality of life is considered an important indicator of prognostic and evolution of neuromuscular disorder, and it is used to evaluate the possibility to get ill, and also as an important indicator of patient’s treatment benefits. The study aimed at evaluating central fatigue and its impact in quality of life patients with neuromuscular disorders. It was carried out an evaluation with the following items: age, time of diagnosis, functioning, espirometry, maximal inspiratory and expiratory flow, fatigue severity scale, muscular performance and a questionnaire about quality of life. It was observed that patients did not present symptoms of fatigue but, instead, symptoms of depression as reported in social relationship and environment on quality of life evaluation. We suggest that health professionals should be apt to recognize symptoms of central fatigue in order to differentiating from depression symptoms so that they will be able to conduct patients to the right treatment and improve patients’ quality of life.