Pregnancy complicated by severe osteogenesis imperfecta poses a challenge for the anaesthetist: A case report.

Pregnant women with severe osteogenesis imperfecta (OI) are uncommon, and there are limited data regarding anaesthesia for caesarean section in these high-risk individuals. The presence of anatomical and physiological abnormalities can pose technical challenges for the anaesthetist. This report describes the successful implementation of epidural anaesthesia in a parturient with severe OI. To our knowledge, this is the first documented use of ultrasound-assisted neuraxial anaesthesia and wrist blood pressure monitoring in such patients undergoing caesarean section. Understanding the pathophysiological changes associated with OI is crucial for ensuring safe administration of anaesthesia to these women.

Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review.

BACKGROUND: Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments. METHODS: We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted. RESULTS: A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180 min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided. CONCLUSIONS: The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.

Anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo: revisión descriptiva / Neuraxial anaesthesia in patients with cerebrospinal fluid shunts: A descriptive review

La anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo (LCR) se ha asociado clásicamente a un alto riesgo de complicaciones. Con el fin de recabar toda la evidencia disponible, se realizó una búsqueda estructurada de los trabajos publicados en usuarios portadores de estos dispositivos, sometidos a algún tipo de técnica neuroaxial para procedimientos obstétricos o quirúrgicos no relacionados con el mismo, valorando la eficacia de la técnica y las complicaciones perioperatorias. Solo se encontraron series de casos y casos clínicos (n = 72). Se identificó uno de insuficiente cobertura anestésica, que precisó una modificación de la técnica, así como una complicación intraoperatoria con compromiso de seguridad para el sujeto. No se describió ningún caso de infección ni disfunciones posoperatorias del dispositivo relacionadas con el método anestésico. La evidencia hallada es escasa y de baja calidad, lo que no permite establecer conclusiones significativas, aunque los pacientes podrían beneficiarse de una valoración individualizada. (AU)

Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject's safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation. (AU)

Neuraxial Anesthesia for an Open Low Anterior Rectal Resection: Tip the Scales in Patient's Favor.

We present the case of a successful application of combined spinal-epidural anesthesia for a geriatric patient undergoing open cancer surgery. The patient, affected by multiple comorbidities, was proposed for an open anterior rectal resection. The implementation of a tailored protocol, incorporating neuraxial techniques such as epidural and spinal anesthesia, facilitated optimal pain management and expedited postoperative recovery improving perioperative outcomes, and highlighting the potential benefits of such strategies in selected cases.

Neuraxial anaesthesia in patients with cerebrospinal fluid shunts: A descriptive review.

Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject's safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation.

Implementation of Ireland's first state-funded day-case total hip arthroplasty programme.

BACKGROUND: Over the last two decades, many elective procedures have transitioned to day-case surgery thanks to the introduction of 'enhanced recovery' protocols. Only recently has total hip arthroplasty been considered a candidate for day-case surgery, as it was once associated with significant pain, mobility impairment and prolonged postoperative recovery. The National Orthopaedic Hospital Cappagh became the first public hospital in Ireland to set up a day-case total hip arthroplasty service in June 2018, and since then has performed over 109 such cases. AIMS: We outline our day-case total hip arthroplasty pathway, with specific focus on anaesthetic considerations. We report rates of failed discharge and readmission. RESULTS: We achieved successful same-day discharge in 90.8% of our first 109 cases. Readmission rate was 4.6%. CONCLUSION: Our experience of implementing a day-case total hip arthroplasty pathway was highly positive and congruent with expectations from the literature. With appropriate patient selection and education, day-case total hip arthroplasty is not just safe, but of benefit to both patients and healthcare systems.

Intracranial arachnoid cyst in pregnancy: case report, literature review and evaluation of neuraxial anaesthesia risk.

Choosing the type of intrapartum anaesthesia for pregnant women with intracranial arachnoid cysts can be challenging due to a lack of research. We report the intrapartum anaesthetic management of a 25-year-old woman with a known 10 cm arachnoid cyst. By means of a literature review and discussion of safety surrounding neuraxial techniques, this report will help to inform obstetric anaesthesia practice. Overall, in the absence of raised intracranial pressure, neuraxial analgesia and anaesthesia during the intrapartum period appears to be a safe option.

Comparison of Two Different Positions for Ultrasound-Guided Intervertebral Distance Evaluation.

Objective: During neuraxial anaesthesia, correct patient positioning is key for increased block success and (patient) comfort. The aim of this prospective study was to compare the lateral fetal decubitus (LFD) position with the sitting fetal lotus (SFL) regarding interspinous distance, transverse diameters of paravertebral muscles measured with ultrasonography, and patient comfort. Methods: Fifty adult participants who could sit cross-legged and had no lumbar anomalies were included in our prospective study. In both SFL and LFD positions, measurements were performed with ultrasonography; in the axial plane, interspinous distance at the level of L4-L5, in the sagittal plan, with the probe slightly tilted, subcutaneous tissue-spinous process depth, and transverse diameters of paravertebral muscles were measured. Stretcher, waist position, and abdominal comfort were scored on a scale of 1 (very bad) to 7 (perfect) with a verbal numeric satisfaction scale. Results: Interspinous distance was significantly larger in the SFL position than in the LFD position (P < 0.05). There was no significant difference between the two positions (P > 0.05) regarding patient comfort. Paravertebral muscle diameters were significantly broader in the SFL position than in the LFD position. The diameter of the left paravertebral muscle in the SFL position (45.8±8.8 mm) was larger than that in the LFD position (43±7.8 mm; P < 0.001). The diameter of the right paravertebral muscle in the SFL position was (47±9 mm) larger than that in the LFD position (43.4±7.6 mm; P < 0.001). Conclusion: Although there was no difference regarding the comfort between the two positions, the interspinous distance was larger in the SFL position than in the LFD position.

Effects of early rehabilitation on enhanced recovery after caesarean section.

The objective of this study was to evaluate the impact of improved rehabilitation on the average length of stay after a scheduled caesarean section under neuraxial anaesthesia, it is a descriptive, monocentric study with prospective recruitment. Our protocol was based on neuraxial anaesthesia with intrathecal morphine, multimodal analgesia, with oral analgesics postoperatively, prevention of postoperative nausea and vomiting (PONV), rapid demedicalization, refeeding and mobilisation. We included 99 patients. The mean length of stay (LOS) for the current caesarean section was 1.97 days versus a LOS for previous caesareans of 4.14 days. On the day of discharge, the mean satisfaction with overall management was 8.97+/-1.35. At six weeks, 92.6% wanted to have the same protocol for a future caesarean. Early rehabilitation after caesarean section is quite applicable to the Algerian context. It offers a quick functional recovery with patient satisfaction, as well as a reduction of the length of stay.

L'objectif de ce travail est d'évaluer l'impact de la réhabilitation améliorée sur la durée moyenne de séjour après une césarienne programmée sous anesthésie neuraxiale. C'est une étude descriptive, monocentrique, avec recrutement prospectif. Notre protocole a reposé sur une anesthésie neuraxiale avec morphine intrathécale, une analgésie multimodale, avec des antalgiques par voie orale en postopératoire, une prévention des nausées vomissements postopératoires, une démédicalisation rapide, une réalimentation et une mobilisation rapide. Nous avons inclus 99 patientes. La durée moyenne de séjour (DMS) de la césarienne actuelle était de 1.97 jours vs une DMS des césariennes antérieures de 4.14 jours. Le jour de sortie de l'hôpital, la moyenne de satisfaction de la prise en charge globale était de 8.97+/-1.35. A six semaines, 92.6 % souhaitaient, avoir le même protocole lors d'une prochaine césarienne. La réhabilitation précoce après césarienne est tout à fait applicable au contexte Algérien, elle offre une récupération fonctionnelle rapide avec une satisfaction des patientes, ainsi qu'une réduction de la durée de séjour.

Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS.

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.

Inadequate neuraxial anaesthesia during caesarean delivery: a survey of practitioners.

BACKGROUND: We aimed to determine the knowledge, training, practices and attitudes of obstetric anaesthetic practitioners with regard to failed neuraxial anaesthesia for caesarean delivery. METHOD: We performed a contemporaneous and representative survey in an innovative fashion. We conducted an international cross-sectional study of obstetric anaesthetic practitioners at the Annual Scientific Meeting of the Obstetric Anaesthetists' Association (OAA 2021). Validated survey questions were collected in real time using an audience response system. RESULTS: Of the 426 participants who logged into the survey system, 356 provided responses (4173 responses to 13 questions, across all grades/seniority of practitioner). The number of responses to questions ranged from 81% to 61%. Survey responses suggest that it is routine for respondents to inform patients about the difference between pain and expected intra-operative sensations, (320/327, 97.9%) but less routine to inform patients of the risk of intra-operative pain (204/260, 78.5%), or the possibility of conversion to general anaesthesia. (290/309 93.8%). Only 30% of respondents reported the use of written guidelines for follow-up of patients who experience intra-operative pain under neuraxial anaesthesia, and only 23% reported formal training in management of intra-operative pain under neuraxial anaesthesia. Respondents felt that inadequate block duration, prolonged surgery, and patient anxiety were contributory factors to failed anaesthesia, and the contributory factors differed between grade/seniority of practitioner. Modalities used to test a block were cold, motor block and light touch, with approximately 65% of respondents routinely using three modalities. CONCLUSIONS: Our study survey found that the consent process may not always be adequately comprehensive, and that standardised documentation and testing of the block and focused training may be beneficial to prevent patient dissatisfaction and the chance of litigation.

Thoracic Spinal Anesthesia for Laparoscopic Cholecystectomy: An Observational Feasibility Study.

BACKGROUND: The expanding horizons of the application of Segmental Thoracic Spinal anesthesia in day-to-day anesthesia practice prompted us to perform this study in a large subset of healthy patients with the aim of determining the feasibility, safety, advantages, and complications of this mode of anesthesia. MATERIAL AND METHODS: The prospective observational study was conducted from April 2020 to March 2022, 2.146 patients with symptoms of cholelithiasis and planned for laparoscopic cholecystectomy were included in this study, and 44 patients from this study were excluded due to pre-defined exclusion criteria. The patients belonging to ASA lIl, lV, severe cardiovascular or renal disability, on beta blockers, coagulation anomaly, spinal deformities, or previous spine surgeries were not included in the study. The patients exhibiting allergy to local anesthetics, requiring more than two attempts for the procedure, patchy or inadequate effects after spinal anesthesia, or change in the plan of surgery intraoperatively were also excluded from the study. All other patients were given subarachnoid block at T10-T11 intervertebral space with 26G Quincke needle and Inj. Bupivacaine Heavy (0.5%) 2.4 mL with 5µg of Dexmedetomidine. Intraoperative parameters, number of attempts, the incidence of paresthesia during the procedure intraoperative and postoperative complications, and patient satisfaction were evaluated and recorded. RESULTS: Spinal anesthesia was successful in 2,074 patients and was achieved in a single attempt of procedure in 92% of patients. The incidence of paresthesia during needle insertion was 5.8%. Hypotension was observed in 18% of patients, bradycardia (13%), and nausea (10%) in a few patients, with shoulder tip pain in only 6% of patients. The majority of patients (94%) were "very satisfied" with the procedure. There were no episodes of any adverse event during the postoperative period. CONCLUSION:  Thoracic spinal anesthesia is a regional anesthesia technique practically feasible for healthy patients undergoing laparoscopic cholecystectomy with a manageable incidence of intraoperative complications and no evidence of any neurological complications. It has the advantage of providing manageable hemodynamics, minimal postoperative complication, and an acceptable degree of patient satisfaction.

Major complications following central neuraxial block - A multi-centre observational study in Maharashtra (MGMM CNB Study).

Background and Aims: Major complications of central neuraxial block (CNB) are rare and their incidence in India is not known. This information is essential for explaining risk and medico-legal concerns. The present multi-centre study in Maharashtra was conducted to provide insight into the characteristics of rare complications following this popular anaesthetic technique. Methods: Data were collected from 141 institutes to study the clinical profile of CNB. Incidence of complications like vertebral canal haematoma, abscess, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and drug errors was collected over one year. Complications were reviewed by audit committee to assess causation, severity, and outcome. 'Permanent' injury was defined as death or neurological symptoms persisting for more than six months. Results: Spinal anaesthesia (SA) was the most frequently used CNB in 88.76% patients. Bupivacaine and an adjuvant were used in 92.90% and 26.06% patients, respectively. Eight major complications (four neurological and four cardiac arrests) were reported in patients receiving SA. In seven of eight instances, SA was responsible or contributory for complication. The pessimistic incidence of complications (included cases where CNB was responsible; contribution was likely, unlikely and could not be commented) was 8.69/lakh and optimistic incidence (included cases where CNB was responsible or contribution was likely) was 7.61/lakh. 'Pessimistically' and 'optimistically' there were three deaths including one death due to quadriplegia following epidural haematoma after SA. Five out of eight patients recovered completely (62.5%). As only eight patients had complications of different types, it was difficult to establish statistical correlation of major complications with demographic or clinical parameters. Conclusion: This study was reassuring and suggested that the incidence of major complications following CNB was low in Maharashtra.

Defining the role of thoracic spinal anaesthesia in the 21st century: a narrative review.

Since the performance of the first thoracic spinal anaesthetic in early 1908 many anaesthetists have gained interest in this unorthodox neuraxial anaesthetic technique. The main rationale justifying its use is to prevent complications related to general anaesthesia in high-risk patient populations. There is, however, significant debate regarding this practice around the world. The main concerns are fear of iatrogenic injury to the spinal cord, cephalad spread of local anaesthetic causing a complete spinal block, and haemodynamic instability owing to blockade of cardioaccelerator sympathetic fibres. The purpose of this narrative review is to appraise the literature critically regarding thoracic spinal anaesthesia, to synthesise the available information, and to provide a summary of evidence justifying its use in modern anaesthesia.

Spinal versus general anaesthesia in contemporary primary total knee arthroplasties.

AIMS: Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre. METHODS: We retrospectively identified 17,690 primary TKAs (13,297 patients) from 2001 to 2016 using our institutional total joint registry, where 52% had general anaesthesia and 48% had spinal anaesthesia. Baseline characteristics were similar between cohorts with a mean age of 68 years (SD 10), 58% female (n = 7,669), and mean BMI of 32 kg/m2 (SD 7). Pain was evaluated using oral morphine equivalents (OMEs) and numerical pain rating scale (NPRS) data. Complications including 30- and 90-day readmissions were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that included many patient and surgical factors. Mean follow-up was seven years (2 to 18). RESULTS: Patients treated with spinal anaesthesia required fewer postoperative OMEs (p < 0.001) and had lower NPRS scores (p < 0.001). Spinal anaesthesia also had fewer cases of altered mental status (AMS; odds ratio (OR) 1.3; p = 0.044), as well as 30-day (OR 1.4; p < 0.001) and 90-day readmissions (OR 1.5; p < 0.001). General anaesthesia was associated with increased risk of any revision (OR 1.2; p = 0.021) and any reoperation (1.3; p < 0.001). CONCLUSION: In the largest single institutional report to date, we found that spinal anaesthesia was associated with significantly lower OME use, lower risk of AMS, and lower overall 30- and 90-day readmissions following primary TKAs. Additionally, spinal anaesthesia was associated with reduced risk of any revision and any reoperation after accounting for numerous patient and operative factors. When possible and safe, spinal anaesthesia should be considered in primary TKAs.Cite this article: Bone Joint J 2022;104-B(11):1209-1214.

Transnasal sphenopalatine ganglion block for postdural puncture headache in obstetric patients: A Malaysian experience report.

Postdural puncture headache (PDPH) is a common complication among obstetric patients after neuraxial anaesthesia. Conservative management may be associated with compliance issues, whereas the gold standard treatment, the epidural blood patch, is invasive and can result in serious complications. Transnasal sphenopalatine ganglion (SPG) block has recently emerged as a non-invasive treatment modality for PDPH. We describe our experience in performing transnasal SPG block by using modified techniques and different drug regimens at our centre. Dexamethasone was used as an adjuvant in transnasal SPG block for PDPH and has not been reported in other studies. Our first patient showed complete resolution of PDPH, and our second patient had a partially resolved headache subsequently requiring an epidural blood patch.

Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review.

BACKGROUND: Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery. METHODS: This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy. RESULTS: Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017. CONCLUSIONS: Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.

Supraclavicular brachial plexus and paravertebral blocks: novel regional anaesthetic technique for brachioaxillary fistula formation with a synthetic graft.

Vascular access formation surgery for renal replacement therapy can be performed under local, regional or general anaesthesia. Regional anaesthesia may offer several advantages, however the sensory innervation to the upper medial arm can be difficult to adequately block. We describe a novel regional anaesthetic technique using both supraclavicular brachial plexus and paravertebral blocks for a multimorbid 73-year-old woman undergoing brachioaxillary fistula formation with a synthetic graft. An ultrasound-guided supraclavicular brachial plexus block was performed, followed by an ultrasound-guided T2/3 level paravertebral block. Adequate sensory blockade for surgery was achieved. Supplemental local anaesthetic infiltration was not required, and the operation was well tolerated by the patient. We consider this to be a valuable regional anaesthetic technique for vascular access formation surgery involving the upper arm.