Regional anesthesia in a patient with primary ciliary dyskinesia: A case report.

BACKGROUND: Primary ciliary dyskinesia (PCD) is an inherited autosomal-recessive disorder of impaired mucociliary clearance characterized by chronic respiratory diseases, otolaryngological diseases, central nervous system abnormalities, reproductive system abnormalities, and cardiac function abnormalities. General anesthesia in these patients is associated with a higher incidence of respiratory complications than in patients without the disease. CASE SUMMARY: A 16-year-old male patient was referred to the emergency room complaining of right ankle pain due to distal tibiofibular fracture. Three years prior, he had been diagnosed with PCD. At that time, he had experienced several episodes of pneumonia, sinusitis, and chronic middle ear infections, for which he underwent surgical interventions. At the current admission, he presented with cough and sputum but no other respiratory symptoms. A chest computed tomography scan revealed centrilobular ground-glass opacities in both lower lobes and a calcified nodule in the left lower lobe. For the surgical procedure and postoperative pain management, combined spinal-epidural anesthesia was employed. The patient's postoperative pain score was measured by the numerical rating scale (NRS). On the day of surgery, his NRS was 5 points. By the second postoperative day, the NRS score had decreased to 2-3 points. The epidural catheter was removed on the fourth day following the operation. The patient was subsequently discharged no respiratory complications. CONCLUSION: We performed combined spinal-epidural anesthesia in a patient with PCD. The patient experienced no additional respiratory complications and was discharged with a low NRS score for pain.

Anesthetic dilemmas in an achondroplastic patient undergoing elective cesarean section.

Achondroplasia is a genetic condition characterized by skeletal dysplasia that results in characteristic craniofacial and spinal abnormalities. It is the most common form of short-limbed skeletal dysplasia. Additionally, a pregnant patient who is morbidly obese warrants specific anatomical and physiological considerations, such as a difficult airway with potential hypoxia, full stomach precautions, and a reduced functional residual capacity. Achondroplasia increases the risks of maternal and fetal complications. Although neuraxial techniques are generally preferred for cesarean sections, there is no consensus among patients with achondroplasia. We aimed to discuss the anesthetic challenges in an achondroplastic patient and report our regional anesthesia approach for an elective cesarean section.

Landmark-guided versus Real-time Ultrasound-guided Combined Spinal-epidural Anesthesia Techniques: Paramedian Sagittal Oblique and Transverse Interlaminar Approach.

Background: There are different types of real-time ultrasound (US)-guided combined spinal epidural (CSE) anesthesia techniques. We aimed to investigate the effect of real-time US-guided paramedian sagittal oblique (PSO), transverse interlaminar (TI) approach method, and landmark-guided (LG) CSE anesthesia. Methods: Ninety patients who underwent CSE block were included in the study. Patients were randomized into LG (n = 30), PSO (n = 30), and TI (n = 30) groups. The primary outcome was number of needle manipulations. The secondary outcomes are the number of attempts, needle visibility, procedure time, procedure success rate, catheter placement difficulty, posterior complex distance, and complications. Results: The number of needle manipulations was statistically significantly lower in the LG technique group (P < 0.000). When the number of attempts, the difficulty of catheter placement, and the procedure's success rate were compared between the three groups, we did not find a statistically significant difference (P > 0.05). In addition, when the procedure times were compared, the time measured for the LG group was statistically significantly lower than in the PSO and TI groups (P < 0.000). Conclusion: In the results of this study, the real-time US-guided CSE anesthesia application had a similar success and complication level with LG technique. The LG method had a shorter processing time and fewer needle manipulations.

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

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.

Anesthetic Management of a Cesarean Delivery in a Patient With MYH11 Mutation Who Underwent Aortic Replacement.

We report a case of a pregnant woman with a history of ascending arch replacement for aortic dissection who still had a residual descending aortic dissection. She underwent urgent genetic testing to identify hereditary aortic-related diseases that might be useful in perinatal management. A mutation in the myosin heavy chain gene (MYH11), indicating a high risk of aortic dissection but a low impact on other vascular systems and organs, was identified. Due to concerns about the development of residual aortic dissection, cesarean delivery with combined spinal-epidural anesthesia was selected. Predelivery genetic testing might be useful for perinatal anesthetic management.

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.

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.

Anesthetic management of fetal pulmonary valvuloplasty: A case report.

Anesthesia management of fetal pulmonary valvuloplasty (FPV) is difficult, requiring careful consideration of both the mother and the fetus. Few reports have been published on specific anesthesia implementation and intraoperative management. We report the case of a pregnant woman who was treated with FPV under combined spinal epidural anesthesia (CSEA) with dexmedetomidine in the second trimester of pregnancy. Meanwhile, the application of fetal anesthesia through the umbilical vein was optimal. During the operation, the vital signs of the pregnant woman were stable with no complications and the fetal bradycardia was corrected by intracardiac injection of epinephrine. Four months postoperatively, a boy was born alive by full-term transvaginal delivery. CSEA may be a suitable anesthesia method for FPV surgery. Nevertheless, maternal hemodynamic stability maintenance, effective fetal anesthesia, and timely fetal resuscitation were necessary.

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 Value of the Optic Nerve Sheath Diameter (ONSD) in Predicting Postdural Puncture Headache (PDPH): A Prospective Observational Study.

BACKGROUND: Postdural puncture headache (PDPH) is one of the serious complications after lumbar puncture, but there is no effective tool to predict it. OBJECTIVES: To explore whether ultrasound measurement of optic nerve sheath diameter (ONSD) as a predictor of PDPH can be a reliable tool supported by reliable protocols and data. STUDY DESIGN: A prospective observational study. SETTING: Department of Anesthesiology. METHODS: This prospective observational study was performed in 156 patients undergoing cesarean section (CS). The patient's ONSD was recorded before anesthesia (T0), 10 minutes after anesthesia (T1), at the end of the operation (T2), at the first postoperative day (T24), at the second postoperative day (T48), and the third postoperative day (T72). During the 3-day follow-up, the patients were evaluated, identified, and divided into a PDPH group and a non-PDPH group. Age, weight, height, ASA, lumbar puncture location, and the number of lumbar puncture attempts were also recorded. We mainly analyzed the changes and differences between the 2 groups of ONSD. RESULTS: Twenty-four patients (15%) developed PDPH. The ONSD was significantly lower in the PDPH group than in the non-PDPH group at T2, T24, T48, and T72. All patients showed a significant reduction in ONSD at T1 compared to T0. Women whose ONSD continued to fall without recovery from T0 to T2 were more likely to experience PDPH (RR 5. 022; 95 CI 3.343 to 7.508). The ONSD at T24 was the best predictor of PDPH (ACU 0. 9787, 95 CI 0.9578 to 0.9996), with a cutoff value of 0.40 cm (sensitivity 92%, specificity 94%). LIMITATIONS: This is a single-center study, and ONSD may vary in different regions or ethnic groups. CONCLUSIONS: We believe that continuous measurements of ONSD may be a useful tool for predicting PDPH.

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.

[Effective Dose of Prophylactic Norepinephrine for Preventing Hypotension under Combined Spinal and Epidural Anesthesia during Cesarean Section in Singleton Versus Twin Pregnancies].

Objective: To determine and compare the 90% effective dose (ED 90) of prophylactic infusion of norepinephrine for preventing hypotension during combined spinal-epidural anesthesia for cesarean section in singleton versus twin pregnancies. Methods: A randomized controlled trial was conducted, enrolling 200 pregnant women, 100 of which were of singleton pregnancies while the other 100 were of twin pregnancies, at West China Second University Hospital, Sichuan University between November 3, 2020 and June 2, 2021. All 200 subjects were to have Cesarean section under combined spinal-epidural anesthesia. By using a random number table, they were randomly assigned to five groups, receiving norepinephrine at the infusion dosage of 0.025, 0.050, 0.075, 0.100, and 0.125 µg/(kg·min), with 20 subjects of singleton pregnancy and 20 subjects of twin pregnancy in each group. Norepinephrine infusion started when the anesthesiologist initiated the spinal anesthetic injection and lasted until the delivery of the fetus. The primary outcome measure was the incidence of maternal hypotension during combined spinal-epidural anesthesia, up until the delivery of the fetus. Survival analysis, with survival being defined as not having hypotension, of the incidence of hypotension among the subjects was conducted. Probit regression was used to determine the ED 90 of norepinephrine, as well as the corresponding 95% confidence interval ( CI), for preventing hypotension during cesarean delivery under combined spinal-epidural anesthesia in women with singleton and twin pregnancies. Results: There was no significant difference in the baseline data or the anesthesia and operation data between pregnant women of singleton pregnancy and those of twin pregnancy ( P>0.05). In singleton pregnant women receiving 0.025, 0.05, 0.075, 0.1 and 0.125 µg/(kg·min) of norepinephrine, the incidence of hypotension was 50% (10/20), 35% (7/20), 20% (4/20), 10% (2/20) and 5% (1/20), respectively. The estimated ED 90 of prophylactic norepinephrine for preventing hypotension during anesthesia was 0.100 (95% CI, 0.082-0.130) µg/(kg·min). In twin pregnant women receiving 0.025, 0.05, 0.075, 0.1 and 0.125 µg/(kg·min) of norepinephrine, the corresponding incidence of hypotension was 60% (12/20), 20% (4/20), 20% (4/20), 10% (2/20) and 5% (1/20). The estimated ED 90 of norepinephrine for preventing hypotension during anesthesia was 0.098 (95% CI, 0.080-0.127) µg/(kg·min). Survival analysis showed significant difference in the incidence of hypotension among the five groups receiving different infusion doses in singleton pregnancy subjects, and the same is true of the twin pregnancy subjects ( P<0.05). The incidence of reactive hypertension increased with increasing dosage of norepinephrine in both singleton pregnancy subjects and twin pregnancy subjects ( P<0.05). There was no significant difference in the incidence of other maternal adverse reaction or in neonatal outcomes in singleton and twin pregnancy subjects receiving different dosage of norepinephrine ( P>0.05). The gestational weeks, weight, and BMI were significantly different ( P<0.05), while the other characteristics, including age and height, were comparable ( P>0.05) between singleton and twin pregnancy subjects receiving norepinephrine at the same dosage. There was no significant difference in the incidence of hypotension, reactive hypertension, bradycardia, nausea and vomiting, and dizziness between singleton and twin pregnancy subjects receiving the same dose ( P>0.05). Survival analysis displayed no significant difference in the incidence of hypotension between singleton and twin pregnancy subjects receiving norepinephrine at the same dosage ( P>0.05). There was no significant difference in the ED 90 of norepinephrine between women with singleton pregnancies and those with twin pregnancies ( P>0.05). Conclusion: There was no significant difference in the ED 90 of norepinephrine for preventing hypotension during combined spinal-epidural anesthesia between women with singleton pregnancy and those with twin pregnancy. Interference of other factors, including gestational age, body mass, and BMI should be considered in clinical practice.

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.

Appropriate Method of Administering Vasopressors for Maternal Hypotension Associated with Combined Spinal Epidural Anesthesia in Elective Cesarean Section: Impact on Postnatal Respiratory Support for Newborns.

Background and Objectives: Vasopressors are used for treating maternal hypotension. However, the appropriate administration method and effects on newborns have not been reported. We evaluated maternal blood pressure fluctuation and neonatal findings in patients who received continuous vasopressor administration during elective cesarean sections and those who received bolus vasopressor administration upon onset of hypotension. Materials and Methods: We retrospectively analyzed the data of 220 patients scheduled for elective cesarean delivery under spinal anesthesia at Mie University Hospital between April 2017 and March 2021. The patients were classified according to the method of vasopressor administration. Maternal information, intraoperative maternal blood pressure fluctuation, and neonatal findings were examined. A multiple regression analysis was performed for the administration of postpartum neonatal respiratory support using maternal background information and other variables related to blood pressure changes as independent variables. Results: The Continuous group and the Bolus group were composed of 98 and 122 patients, respectively. No difference was observed in maternal background information between the groups. Significant changes were noted in several blood pressure parameters between both groups. As for neonatal parameters, newborns of Bolus group patients had lower pO2, 1 min and 5 min Apgar scores, and required more respiratory support than those of Continuous group patients. In the multiple regression analysis, the groups and maternal post-anesthesia diastolic blood pressure variability were considered explanatory variables. Conclusions: Maternal hypotension and the need for neonatal respiratory support associated with anesthesia administration in elective cesarean section may be improved by continuous vasopressor administration upon induction of combined spinal-epidural anesthesia.

Combined spinal-epidural anesthesia with acupoint injection for labor anesthesia reduces IL-1ß/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-1ß (IL-1ß), 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-1ß/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-1ß/ IL-10 in maternal peripheral blood and umbilical cord blood, which can effectively relieve labor pain.

Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery of obese patients: a randomized controlled trial.

BACKGROUND: Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound. METHODS: One hundred obese patients (BMI ≥ 30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First-attempt success rate, the median positioning time and total operation time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, anesthesia adverse reactions, complications after anesthesia, and patients' satisfaction with the epidural puncture were recorded. RESULTS: The first-attempt success rate was significantly different between the two groups [92% (46/50) vs. 76% (38/50), P = 0.029]. The median positioning time and total operation time in the paramedian approach group were higher than those in the median approach group (227.7 s vs. 201.6 s, P = 0.037; 251.3 s vs. 247.4 s, P = 0.145). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs. 12%, P = 0.026), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P = 0.032). CONCLUSION: The ultrasound-guided paramedian approach for CSEA is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction. TRIAL REGISTRATION: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019.

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.

Low-dose spinal and opioid-free anesthesia in patient with Severe Aortic Stenosis and SARS-CoV-2 infection: Case report.

The best anesthesiologic approach to severe AS patient has not been adequately studied in literature. Although the current guidelines have a cautious attitude in this regard, Combined Spinal-Epidural Anesthesia (CSEA) has proved to be a safe technique. Therefore, we would like to provide our experience with a severe AS and COVID-19 patient.

Spinal subdural hematoma and subdural anesthesia following combined spinal-epidural anesthesia: a case report.

BACKGROUND: Subdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal-epidural anesthesia. CASE PRESENTATION: A 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34+ 5 weeks underwent cesarean delivery. Routine combined spinal-epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal. CONCLUSIONS: All anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.