Regional anesthesia for microvascular surgery: a combination of brachial plexus, spinal, and epidural blocks.

BACKGROUND AND OBJECTIVES: To evaluate the usefulness, safety, and efficacy of the combined plexus brachial, spinal, and epidural blocks in free toe to hand transplantations. DESIGN: Prospective, case series. SETTING: Tampere University Hospital, Finland. PATIENTS: Fifteen adult patients for toe to hand microvascular transplantation under combined regional anesthesia with bupivacaine. INTERVENTIONS: The efficacy of the blocks, complications, and patient satisfaction were recorded in the study form. MEASUREMENTS AND MAIN RESULTS: The duration of operations varied between 8 and 18 hours. No major complications occurred. Vasodilatation in the operated hand was maintained during the entire operation as well as in the postoperative period, and the surgical results were satisfactory. The mean skin temperature was 5 degrees C higher in the blocked extremity compared to the opposite hand. In every patient the skin temperature of the transplant was over 32.4 degrees C after the operation. Blood pressure, heart rate, temperature and oxygen saturation were well maintained during the entire procedure. All patients were satisfied with their anesthesia. Back pain occurred in 11 patients and in two it was considered severe. One patient may have had a systemic toxic reaction (shivering) due to high plasma levels of bupivacaine, but the symptom was transient. CONCLUSION: Combined regional anesthesia is an alternative to general anesthesia in prolonged microsurgical operations and it appears to improve perfusion of the transplanted extremity.

Comparison of Sprotte and Quincke needles with respect to post dural puncture headache and backache.

OBJECTIVE: The objective of this study was to compare 24-gauge Sprotte and 25-gauge Quincke needles with respect to post dural puncture headache and backache. METHODS: Three hundred ASA Physical Status I or II patients scheduled for minor orthopedic or urologic operations under spinal anesthesia were chosen for this randomized, prospective study at a university hospital and a city hospital. Anesthetic technique, intravenous fluids, and postoperative pain therapy were standardized. Patients were randomly divided into three equal groups. Spinal anesthesia was performed with either a 24-gauge Sprotte needle or a 25-gauge Quincke needle with the cutting bevel parallel or perpendicular to the dural fibers. RESULTS: Anesthesia could not be performed in three cases with the Sprotte needle and in one case with the Quincke needle. The most common complications were post dural puncture backache (18.0%), post dural puncture headache (8.2%), and non-postural headache (6.7%). No major complications occurred. The Quincke needle with bevel perpendicular to the dural fibers caused a 17.9% incidence of post dural puncture headache. The Quincke with bevel parallel to the dural fibers and the Sprotte needles caused similar post dural puncture headache rates (4.5% and 2.4%, respectively). Other factors associated with post dural puncture headache were young age, early ambulation, and sedation during spinal anesthesia. There were no significant differences between needles in the incidence of post dural puncture backache. CONCLUSION: Our data indicate that Quincke needles should not be used with the needle bevel inserted perpendicular to the dural fibers. The Sprotte needle does not solve the problem of post dural puncture headache and backache.

Complications during spinal anesthesia: a prospective study.

Complications during spinal anesthesia were studied prospectively in 1881 patients. Twenty-six percent of the patients suffered from one or more complications. The most common complications were hypotension (16.4%) and bradycardia (8.9%). The risk for hypotension was found to be higher with increasing age of patients (p less than 0.005). Higher peak sensory level significantly increased the risk for hypotension (p less than 0.0001), bradycardia (p less than 0.0001) and nausea (p less than 0.0001). Female patients suffered significantly more hypotension (p less than 0.001), nausea (p less than 0.001) and vomiting (p less than 0.001) than males. Cementation of prosthesis and deflation of the leg tourniquet were other risk factors demonstrated in this study.

Incidence and causes of failed spinal anesthetics in a university hospital: a prospective study.

The failure rates associated with spinal anesthesia using bupivacaine and lidocaine were studied prospectively in 1891 patients. The failure rate was 3.1%, with the most common reason for failure an inadequate level of anesthesia for the surgical procedure. Demographic variables showed no significant correlation with the failures. The primary technical reason for failure was use of a low interspace for the administration of the anesthetic agent. All the anesthetic agents used were found reliable in producing spinal anesthesia.

The subjective complications and efficiency of the epidural blood patch in the treatment of postdural puncture headache.

The complications and efficacy of epidural blood patch were studied retrospectively by means of a questionnaire sent to 236 patients. Hospital records were also studied. One-hundred-ninety-six patients returned the questionnaire. No major complications were found. Epidural blood patch was found to be effective; 84.5% of the respondents had complete and permanent recovery from headache in less than 24 hours after a single epidural blood patch. Of those responding, 42.3% were willing to undergo spinal anesthesia in the future, when indicated, only if they could be assured of getting epidural blood patch in the event of a postdural puncture headache.