Loss of resistance to saline reduces responses accompanying spinal needle insertion during institution of 'needle-through-needle' combined spinal-epidural analgesia

Normal saline or air is used to identify loss of resistance during identification of the epidural space for combined spinal-epidural analgesia. Following epidural needle placement using air for loss of resistance, up to 80% of parturients move, grimace, vocalise or experience paraesthesia or dysaesthesia during subsequent dural puncture by a spinal needle. We compared the effects of saline versus air for loss of resistance on the occurrence of these subjective and objective responses during thecal penetration. With institutional approval, 55 parturients presenting for labour analgesia were studied. After infiltration of lignocaine at an L2-L5 vertebral interspace, a 17 gauge Tuohy epidural needle attached to a 5 ml loss of resistance syringe containing either saline or air was inserted and advanced until loss of resistance was identified by injection of 3 to 5 ml of content. During subsequent 'needle-through-needle' insertion of a 27 gauge pencil-point spinal needle through the meninges, all subjective and objective patient responses were recorded, as well as each patient's reply to the question "Did you feel that?". The two groups (n = 28, n = 27) were comparable. In those given saline and air respectively, 5 (18%) and 12 (44%) parturients responded to and/or acknowledged having perceived dural puncture (P < 0.005). Overall, 7 and 31 (P < 0.0005) subjective and objective responses occurred during dural puncture in those given saline and air, respectively. The study found that use of saline to determine loss of resistance is associated with fewer patient responses at the moment of thecal penetration during 'needle-through-needle' placement of the spinal needle at combined spinal-epidural analgesia.     

Epidural anesthesia with lidocaine reduces propofol injection pain

PURPOSE: To determine whether epidural lidocaine reduces the severity of propofol injection pain compared with iv lidocaine. METHODS: A prospective, randomized double-blind clinical study was conducted in 120 female patients scheduled for elective gynecological laparotomy. A lumbar epidural catheter and an iv catheter placed in the cephalic vein of the non-dominant hand were used in all patients. Patients of the control group (Group C) were given epidural normal saline followed by iv normal saline then iv propofol. Patients of Group E were given epidural 2% lidocaine (0.08 mL.cm(-1)) followed by iv normal saline and then propofol. Patients of Group V were given epidural normal saline followed by iv 2% lidocaine (0.05 mL.kg(-1)) then propofol. Pain was scored as no pain=0, minimal pain=1, moderate pain=2, severe pain=3. RESULTS: The pain scores, in group E; 1 (0-2) and group V; 2 (0-2), were significantly lower than in group C; 2 (1-3); median (25th-75th percentile) (P <0.001). There was no difference in pain score between groups E and V The plasma lidocaine concentration 15 min after epidural lidocaine was 2.74 +/- 0.54 microg.ml(-1), compared with 1.54 +/- 0.31 microg.mL(-1) at three minutes after iv lidocaine. CONCLUSION: Epidural and iv lidocaine equally reduced the severity of propofol injection pain despite higher lidocaine plasma concentrations in epidurally administered lidocaine.     

Comparison of sequential combined spinal-epidural anesthesia and spinal anesthesia for cesarean section

AIM: The aim of our study was to prove that by using sequential combined spinal-epidural (CSE) anesthesia it is possible to overcome the limits connected to the use of spinal anesthesia (SA) alone for elective cesarean section. METHODS: We examined 100 women submitted to cesarean section; SA was administered to 50 patients and sequential CSE technique to the other 50. In every woman before execution of the anesthesia we infused 500 mL of a plasma expander and a previous administration of 5 mg of ephedrine. The CSE was executed at the L1-L2 intervertebral space, administering in spinal anesthesia 5 mg of levobupivacaine with 5 _g of sufentanil, and in peridural anesthesia 10-12 mL of levobupivacaine 0.25% according to the patient's height. The peridural catheter for postoperative analgesia was then positioned. In the group of women submitted only to SA, 7.5-8 mg of levobupivacaine was injected, according to the patient's height, in the L1-L2 intervertebral space, with 5 _g of sufentanil. We considered the following adverse effects: hypotension; bradycardia; vomiting; intraoperative discomfort and motor block. RESULTS: The results obtained showed that, with a P < or = 0.05, the incidence of motor block (P < 0.001), discomfort (P < 0.001) and hypotension (P = 0.021) in the SA group is greater than in the CSE group. The difference in the incidence of vomiting (P = 0.147) and bradycardia (P = 0.067) between the 2 groups is not statistically significant. CONCLUSIONS: In our opinion sequential CSE can be considered an important step forward in the regional anesthesia used for elective cesarean section.     

Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia

In this investigation we assessed whether patients receiving spinal anesthesia (SPA) as part of combined spinal-epidural anesthesia (CSE) more often experience relevant hypotension than patients receiving SPA alone. From January 1, 1997, until August 5, 2000, electronic anesthesia records from 1596 patients having received SPA and 1023 patients having received CSE for elective surgery were collected by using a computerized anesthesia record-keeping system. Relevant hypotension was defined as a decrease of mean arterial blood pressure of more than 30% within a 10-min interval and a therapeutic action of the attending anesthesiologist within 20 min after onset. Electronic patient charts were reviewed by using logistic regression with a forward stepwise algorithm to identify independent risk factors that were associated with an increased incidence of hypotension after CSE. Univariate analysis was performed to assess differences in biometric data and relevant risk factors for hypotension between the two procedures. The incidence of relevant hypotension was more frequent with CSE than with SPA alone (10.9% versus 5.0%; P < 0.001). In the multivariate analysis, arterial hypertension (odds ratio, 1.83; 95% confidence interval, 1.21-2.78) and sensory block height >T6 (odds ratio, 2.81; 95% confidence interval, 1.88-4.22) were found to be factors associated with hypotension in the CSE group. Compared with patients receiving SPA alone, patients undergoing CSE had a significantly more frequent prevalence of arterial hypertension and higher sensory block levels (P < 0.01) despite smaller amounts of local anesthetics. In this study, patients receiving CSE had an increased risk for relevant hypotension as compared with patients with SPA alone. Part of this effect seems to be due to the procedure alone and not only because this population is at higher risk. IMPLICATIONS: This study, based on a large number of patients with a retrospective design by using on-line recorded data, suggests that spinal anesthesia as part of combined spinal-epidural anesthesia may more often lead to relevant hypotension than spinal anesthesia alone. Preexisting arterial hypertension and a sensory block height exceeding T6 are major risk factors for the development of this complication.     

不同穿刺体位在腰-硬联合麻醉剖宫产术中的比较

目的比较不同穿刺体位在腰-硬联合麻醉(CSEA)剖宫产术中的效果。方法拟行剖宫产术的足月妊娠产妇90例,随机分为两组,每组45例。选择L3~4椎间隙作为穿刺点。R组右侧穿刺腰麻后保持穿刺体位2 min后左倾30°仰卧至手术开始,L组左侧穿刺腰麻后仰卧位,并调整手术床左倾30°直至手术开始。腰麻药物均为1.0%罗哌卡因1.5 ml+10%葡萄糖0.5 ml。观察腰麻药物注入后15 min内产妇感觉阻滞效应及不良反应情况,记录新生儿Apgar评分,检测脐动脉血p H值。结果 R组产妇最终阻滞平面明显低于L组,达到最终阻滞平面所需时间明显短于L组(P0.05)。R组麻黄碱用量为0(0~6)mg,明显低于L组的6(0~12)mg(P0.05)。R组脐动脉血p H值明显高于L组(P0.05)。两组新生儿Apgar评分差异无统计学意义。结论剖宫产术采用右侧卧位穿刺注药后保持穿刺体位2 min后30°仰卧,其麻醉效果优于左侧卧位穿刺后30°仰卧体位。     

Epidural infusion of low dose bupivacaine after combined spinal-epidural anesthesia using needle through needle method provided no analgesic effect on postoperative pain after caesarian section

BACKGROUND: In order to evaluate the analgesic efficacy of low dose epidural bupivacaine infusion with and without morphine after caesarean section we performed combined spinal-epidural anesthesia (CSEA) using needle through needle method. Three different epidural analgesic regimens were compared retrospectively. METHODS: The number of analgesic use during 24 hours after operation was compared. Patients were categorized into three groups; group N : intraoperative bolus epidural morphine (2.5 mg) alone, group L : bolus morphine (2.5 mg) plus epidural bupivacaine infusion (32 ml of 0.2% bupivacaine) at a rate of 2.1 ml x hr(-1), group M : bolus morphine (2.4 mg) plus epidural bupivacaine-morphine (33 ml of 0.2% bupivacaine containing morphine 2.3 mg) infusion at a rate of 2.1 ml x hr(-1). Used analgesics included pentazocine 15 mg i.m., diclofenac 25 mg suppo. and loxoprofen 60 mg p.o.. RESULTS: The mean number of analgesic use during the first 24 hours in group M (0.29 +/- 0.46) was significantly smaller than those of group N (0.97 +/- 0.91) and group L (0.84 +/- 0.95). Percentage of patients requiring no analgesic during the first 24 hours was significantly less in group M (70.8%) than in group N (33.4%) and group L (42.1%). CONCLUSIONS: A 2.1 ml x hr(-1) infusion of epidural bupivacaine has no analgesic effect after caesarean section under CSEA using NTN method.     

Comparative study of conventional spinal anesthesia and combined spinal-epidural anesthesia in gynecological surgery]

A prospective study was carried out to compare the qualities of spinal block with those of combined spinal-epidural anaesthesia (CSEA). It included 63 patients, ranked ASA 1 or 2, aged between 35 and 75 years, scheduled for gynaecological surgery due to last more than 2 hours, and randomly allocated to two groups. In the first group (n = 34), spinal anaesthesia was carried out with the patients sitting, in the L3-4 interspace, using 15 mg of hyperbaric bupivacaine with 0.4 mg of adrenaline. In the second group (n = 29), a catheter was inserted in the epidural space through the L2-3 interspace, and spinal anaesthesia carried out as in the first group, using bupivacaine without adrenaline. Once the highest level of analgesia had been reached, aliquots of 0.5% plain bupivacaine were injected through the epidural catheter, until anaesthesia of T5 was obtained. In the spinal group, general anaesthesia was required in 3 cases, as anaesthesia only reached the T12 level in 2 cases, and as surgery lasted longer than the spinal in the third one. In the CSEA group, excellent analgesia was obtained in all patients. Sensory blockade lasted 308 +/- 48 min at the T12 level, versus 162 +/- 51 min in the spinal group (p < 0.025), and 361 +/- 51 min at the L2 level, versus 210 < 44 min in the other group (p < 0.025). "Topping up" was possible with the epidural catheter only, thus raising the level of sensory blockade, making it deeper, and increasing its duration. It avoids the use of general anaesthesia in case of failed spinal blockade.(ABSTRACT TRUNCATED AT 250 WORDS)     

An audit of accidental dural puncture during epidural insertion of a Tuohy needle in obstetric patients

We report a prospective audit of 100 parturients who experienced accidental dural puncture by a Tuohy needle, while attending a tertiary referral obstetric unit during the period 1993-1999. The post dural puncture headache rate was 81% and the diagnosis of dural puncture was delayed until presentation of the headache in 27% of these cases. The incidence of unrecognised dural puncture was not influenced by the technique used for identification of the epidural space. Intraspinal opioid administration after dural puncture was associated with a significant reduction in the incidence of headache (P < 0.04). There was no association between mode of delivery and post dural puncture headache. Deliberate cannulation of the subarachnoid space with an epidural catheter at the time of dural puncture, for continuous spinal analgesia or anaesthesia, did not affect the incidence of post dural puncture headache but was associated with a significantly reduced rate of epidural blood patch (43% versus 80%, P < 0.01). Of those who developed post dural puncture headache, 48% were classified 'severe' and in 49% the headache presented within 24 h of dural puncture. There was a trend to earlier onset of headache (either immediate or within 24 h) when the epidural identification technique was loss-of-resistance to air rather than saline (54% versus 33%, P = 0.07). Twenty-eight percent of those suffering from post dural puncture headache were treated expectantly and 72% received a therapeutic blood patch. Of seven parturients who received sumatriptan, six found it ineffective and five subsequently received a blood patch.     

The reuse of 29-gauge spinal needles following combined spinal-epidural anesthesia]

The technique of combined spinal epidural anaesthesia (CSE) combines the versatility of spinal with the variability of epidural anaesthesia. Spinal application of the local anaesthetic achieves a fast response, reliable sensorial and motor block at a low dose with little toxicity. The epidural catheter allows for the duration of surgical anaesthesia to be extended and provides analgesia for the postoperative period. As the incidence of post dural puncture headache (PDPH) is inversely related to the size of the spinal needle, PDPH rarely or never occurs when 29 gauge needles are used. In 1775 parturients receiving spinal anaesthesia for caesarean section, Dittmann et al. [4] reported an incidence of PDPH of 1.37% with 29 gauge needles. The 29 gauge needle produced by Becton-Dickinson is the one now most frequently used for this technique. It is recommended that these needles be reused after resterilization. The objective of this study was to examine how clean 29 gauge spinal needles really are after resterilization. MATERIALS AND METHODS. Fifteen needles (29 gauge; Becton-Dickinson) were routinely used for combined spinal epidural anaesthesia. After identification of the epidural space at the L3-4 spinal segment with the 18 gauge Tuohy needle, the 29 gauge needle was advanced through the Tuohy needle. Immediately after use the needles were cleaned, rinsed with 20 ml distilled water, dried with pressurized air and subsequently resterilized in gas. Preparation of the used needles was in accordance with the manufacturer's recommendations ("wash, rinse, dry, sterilize before initial and each subsequent use") and with generally accepted principles [6]. Two needles were additionally cleaned in an ultrasonic bath for 15 min. The needles were examined using a scanning electron microscope. After this analyses, eight needles were sterilized again and then taken for hygienic examination. They were incubated with trypticase soy broth and checked for bacterial growth. RESULTS. Scanning electron microscopy (ScEM) showed organic impurities on all needles. These impurities were equally distributed among all needles. Even the two cleaned in the ultrasonic bath were not free of organic particles. However, no material defects or damage could be seen. Hygienic evaluation proved sterility as no bacterial growth could be detected. CONCLUSION. Owing to the possibility of medico-legal consequences, which sometimes occur a long time after anaesthesia has been given, we think it is unwise to reuse such needles. We hope that disposable and cheap 29 gauge needles will soon become available.     

硬膜外注气对脊椎-硬膜外联合阻滞时腰穿的影响

Objective To investigate the effect of injection of air into the epidural space on the subarachnoid puncture during the combined spinal-epidural anesthesia (CSEA) .Methods Two hundred and ten ASA Ⅰ or Ⅱ parturients who were at full term with a singleton fetus, aged 20-42 yr, weighing 57-82 kg (height 152-170cm) , undergoing cesarean section under CSEA, were randomly divided into 3 groups ( n = 70 each) : hanging drop technique group (group Ⅰ ) and injection of small volume of air group (group Ⅱ ) and injection of large volume of air group ( group Ⅲ ) . The epidural space was indentified using hanging drop technique in group Ⅰ and using loss of resistance to air technique in Ⅱ and Ⅲ groups. Injection of air was stopped as soon as the clear loss of resistance identified the epidural space in group Ⅱ , whereas all 4 ml of air was injected in group Ⅲ . After the epidural space was confirmed at L3,4 interspace, a 25-gauge spinal needle protruding 14 mm beyond the 18-gauge epidural needle was introduced through the epidural needle. Subarachnoid placement was confirmed by backflow of cerebrospinal fluid (CSF) . If no backflow of CSF was observed, the spinal needle was withdrawn and an epidural catheter was inserted through the epidural needle to perform epidural anesthesia. Successful subarachnoid puncture, failures to observe backflow of CSF and adverse reactions were recorded. Results The three groups were comparable with respect to age, height, body weight and gestation weeks. The success rate of subarachnoid puncture was 91% ,93% and 79% in Ⅰ ,Ⅱ and Ⅲ groups respectively, and it was significantly higher in Ⅰ and Ⅱ groups than in group Ⅲ ( P < 0.05) . There was no significant difference in the success rate of subarachnoid puncture between Ⅰand Ⅱ groups ( P > 0.05) . Bilateral segmental analgesia presented in all cases who received only epidural anesthesia after no backflow of CSF was observed, and the expected analgesia also presented in all cases in whom back flow of CSF was observed. No adverse reactions occurred. Conclusion Injection of air into the epidural space is related to the success of subarachnoid puncture during CSEA and injection of a large volume of air lowers the success rate.     

硬膜外注气对脊椎-硬膜外联合阻滞时腰穿的影响

目的 探讨硬膜外注气对脊椎-硬膜外联合阻滞时腰穿的影响.方法 拟在脊椎-硬膜外联合阻滞下行剖宫产术的足月单胎妊娠患者210例,ASA分级Ⅰ或Ⅱ级,年龄20～42岁,身高152～170 cm,体重57～82 kg,采用随机数字表法,将患者随机分为3组(n=70):悬滴法组(Ⅰ组)、少量注气组(Ⅱ组)和大量注气组(Ⅲ组).Ⅰ组以悬滴法验证硬膜外腔,Ⅱ组和Ⅲ组以注气试验验证硬膜外腔.Ⅱ组注气量以能感觉到阻力消失为准,Ⅲ组注气量为4 ml.置入腰穿针后见脑脊液回流则为腰穿成功.腰穿失败则改行硬膜外麻醉.记录腰穿成功情况、腰穿失败但硬膜外穿刺成功情况及不良反应发生情况.结果 Ⅰ组、Ⅱ组和Ⅲ组腰穿成功率分别为91%、93%和79%,Ⅰ组和Ⅱ组高于Ⅲ组(P<0.05),Ⅰ组和Ⅱ组间差异无统计学意义(P>0.05).所有腰穿失败患者均取得了双侧躯体节段性痛觉消失的硬膜外麻醉效果;所有腰穿成功患者也均取得了预期的麻醉效果.均未见严重不良反应发生.结论 硬膜外注气与脊椎-硬膜外联合阻滞时腰穿成功有关,大量注气可降低腰穿成功机率.

Abstract：

Objective To investigate the effect of injection of air into the epidural space on the subarachnoid puncture during the combined spinal-epidural anesthesia (CSEA) .Methods Two hundred and ten ASA Ⅰ or Ⅱ parturients who were at full term with a singleton fetus, aged 20-42 yr, weighing 57-82 kg (height 152-170cm) , undergoing cesarean section under CSEA, were randomly divided into 3 groups ( n = 70 each) : hanging drop technique group (group Ⅰ ) and injection of small volume of air group (group Ⅱ ) and injection of large volume of air group ( group Ⅲ ) . The epidural space was indentified using hanging drop technique in group Ⅰ and using loss of resistance to air technique in Ⅱ and Ⅲ groups. Injection of air was stopped as soon as the clear loss of resistance identified the epidural space in group Ⅱ , whereas all 4 ml of air was injected in group Ⅲ . After the epidural space was confirmed at L3,4 interspace, a 25-gauge spinal needle protruding 14 mm beyond the 18-gauge epidural needle was introduced through the epidural needle. Subarachnoid placement was confirmed by backflow of cerebrospinal fluid (CSF) . If no backflow of CSF was observed, the spinal needle was withdrawn and an epidural catheter was inserted through the epidural needle to perform epidural anesthesia. Successful subarachnoid puncture, failures to observe backflow of CSF and adverse reactions were recorded. Results The three groups were comparable with respect to age, height, body weight and gestation weeks. The success rate of subarachnoid puncture was 91% ,93% and 79% in Ⅰ ,Ⅱ and Ⅲ groups respectively, and it was significantly higher in Ⅰ and Ⅱ groups than in group Ⅲ ( P < 0.05) . There was no significant difference in the success rate of subarachnoid puncture between Ⅰand Ⅱ groups ( P > 0.05) . Bilateral segmental analgesia presented in all cases who received only epidural anesthesia after no backflow of CSF was observed, and the expected analgesia also presented in all cases in whom back flow of CSF was observed. No adverse reactions occurred. Conclusion Injection of air into the epidural space is related to the success of subarachnoid puncture during CSEA and injection of a large volume of air lowers the success rate.     

硬膜外注气对脊椎-硬膜外联合阻滞时腰穿的影响

Objective To investigate the effect of injection of air into the epidural space on the subarachnoid puncture during the combined spinal-epidural anesthesia (CSEA) .Methods Two hundred and ten ASA Ⅰ or Ⅱ parturients who were at full term with a singleton fetus, aged 20-42 yr, weighing 57-82 kg (height 152-170cm) , undergoing cesarean section under CSEA, were randomly divided into 3 groups ( n = 70 each) : hanging drop technique group (group Ⅰ ) and injection of small volume of air group (group Ⅱ ) and injection of large volume of air group ( group Ⅲ ) . The epidural space was indentified using hanging drop technique in group Ⅰ and using loss of resistance to air technique in Ⅱ and Ⅲ groups. Injection of air was stopped as soon as the clear loss of resistance identified the epidural space in group Ⅱ , whereas all 4 ml of air was injected in group Ⅲ . After the epidural space was confirmed at L3,4 interspace, a 25-gauge spinal needle protruding 14 mm beyond the 18-gauge epidural needle was introduced through the epidural needle. Subarachnoid placement was confirmed by backflow of cerebrospinal fluid (CSF) . If no backflow of CSF was observed, the spinal needle was withdrawn and an epidural catheter was inserted through the epidural needle to perform epidural anesthesia. Successful subarachnoid puncture, failures to observe backflow of CSF and adverse reactions were recorded. Results The three groups were comparable with respect to age, height, body weight and gestation weeks. The success rate of subarachnoid puncture was 91% ,93% and 79% in Ⅰ ,Ⅱ and Ⅲ groups respectively, and it was significantly higher in Ⅰ and Ⅱ groups than in group Ⅲ ( P < 0.05) . There was no significant difference in the success rate of subarachnoid puncture between Ⅰand Ⅱ groups ( P > 0.05) . Bilateral segmental analgesia presented in all cases who received only epidural anesthesia after no backflow of CSF was observed, and the expected analgesia also presented in all cases in whom back flow of CSF was observed. No adverse reactions occurred. Conclusion Injection of air into the epidural space is related to the success of subarachnoid puncture during CSEA and injection of a large volume of air lowers the success rate.     

Evaluation of the effectiveness of spinal anesthesia using lidocaine combined with morphine]

Spinal anesthesia with 2% solution of lidocaine++ in combination with 1-1.5 mg of morphine is more effective as compared with an analogous method of anesthesia without a narcotic analgetic: it considerably increased the quality of the above mentioned analgesia at the expense of an increased blockade of nociceptive reactions and longer duration of the surgical stage of anesthesia and also results in continuous postoperative analgesia.     

Responses to dural puncture during institution of combined spinal-epidural analgesia: a comparison of 27 gauge pencil-point and 27 gauge cutting-edge needles

Pencil-point spinal needles are popular for combined spinal-epidural analgesia because they cause less dural puncture headache than cutting-edge spinal needles. However many parturients move, grimace, vocalise or experience paraesthesia or dysaesthesia during dural puncture when performing 'needle through needle' combined spinal-epidural analgesia. We compared dural puncture responses induced by pencil-point and cutting-edge needles (both 27 gauge). With institutional approval, 115 parturients presenting for elective caesarean section or labour analgesia were audited. After lignocaine infiltration, a Tuohy-type needle was inserted to loss of resistance to saline at a mid-lumbar interspace, and either a 27 gauge cutting-edge or 27 gauge pencil-point needle was inserted 'needle through needle' through the dura. During dural penetration, the occurrence of patient movement, grimacing or vocalisation was noted by a blinded observer, as was the patient's response to the question "Did you feel that?" asked by the anaesthetist. The audit comprised two similar groups of patients (caesarean section, n=30; labour analgesia, n=85). In both groups, grimacing and movement during thecal penetration occurred more frequently with pencil-point needles (P < 0.05 and P < 0.025, respectively). Pooled data analysis revealed that pencil-point and cutting-edge needles induced grimacing and movement in 17 (22%) and 2 (5%), spontaneous vocalisation in 4 (5%) and 1 (3%) and was perceived by 13 (17%) and 3 (8%) parturients (P < 0.025, P=NS, P=NS), respectively. Overall, 34 and 6 objective and subjective patient responses (P < 0.005) occurred when inserting these needles, respectively. Dural puncture by a 27 gauge pencil-point needle inserted 'needle through needle' when instituting combined spinal-epidural analgesia induces more iatrogenic responses than a 27 gauge cutting-edge needle.     

Epidural hematoma unrelated to combined spinal-epidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement

Although rare, major complications after spinal and epidural anesthesia do occur. The safety of spinal and epidural anesthesia has been well established. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinal-epidural anesthetic. Most epidural hematomas are spontaneous and idiopathic.     

A single injection of lidocaine as local anesthesia for ultrasound guided needle biopsy of the prostate.

PURPOSE: We evaluated the effectiveness of a single injection of lidocaine on patient tolerance of multiple needle biopsies of the prostate. MATERIALS AND METHODS: In 100 consecutive group 1 patients local anesthesia was achieved by a single bolus injection of 10 ml. lidocaine and multiple prostatic needle biopsies was performed under ultrasound guidance. At the end of the procedure patients were asked to complete a questionnaire regarding the level of pain. Answers were compared with those of 100 group 2 patients who underwent prostatic biopsy before the introduction of local anesthesia. RESULTS: Of the group 1 patients 93% had only slight discomfort during the procedure and 7% required a further 1 cc bolus of lidocaine. In 55% of group 2 patients the level of pain during the procedure was significant but bearable, in 35% it was considered unbearable and in 10% sedation with midazolam was necessary. There was no significant difference in complications in the 2 groups. CONCLUSIONS: A single injection of local anesthesia for prostatic biopsy proved to be efficient, well tolerated by patients and effective for decreasing the pain associated with the procedure.     

腰麻、腰硬联合麻醉、硬膜外麻醉在瘢痕子宫剖宫产手术中的麻醉效果比较

目的 探讨瘢痕子宫产妇剖宫产的麻醉方法.方法 比较腰麻、腰硬联合麻醉、硬膜外麻醉3种麻醉在瘢痕子宫产妇剖宫产手术中的麻醉效果.结果 腰麻、腰硬联合麻醉较硬膜外麻醉起效快、镇痛肌松好,牵拉反应也轻.结论 腰麻、腰硬联合麻醉在瘢痕子宫产妇剖宫产手术中麻醉效果良好.