Observational study of continuous spinal anesthesia with the catheter-over-needle technique for cesarean delivery

BackgroundFew studies have assessed the efficacy and safety of continuous spinal anesthesia in obstetrics, although placement of a catheter in the intrathecal space theoretically offers advantages in these patients.MethodsNinety-two women scheduled for elective cesarean delivery using continuous spinal anesthesia with the catheter-over-needle technique (22- or 24-gauge Spinocath^®) were included in the study. The doses of local anesthetic used, hemodynamic variables, use of ephedrine and other drugs, and incidence of complications such as technical failure and postdural puncture headache (PDPH) were recorded.ResultsThe mean (±SD) dose of hyperbaric bupivacaine used was 8.2 ± 1.8 mg. The incidence of hypotension was 30% and the mean total dose of ephedrine was 4 ± 7 mg. The continuous spinal anesthetic technique failed in 18 women (20%). The overall incidence of post-dural-puncture headache was 29%; 18% of patients with post-dural-puncture headache required a blood patch.ConclusionsCompared to previous reports, the incidence of block failure and PDPH in this study was unacceptably high and therefore the risks of the technique appear to outweigh the advantages of continuous spinal anesthesia in obstetric practice.     

Comparação de fentanil e dexmedetomidina como adjuvante à bupivacaína para raquianestesia unilateral em cirurgia de membros inferiores: estudo randômico

Background and objectivesOne of the disadvantages of unilateral spinal anesthesia is the short duration of post‐operative analgesia, which can be addressed by adding adjuvants to local anesthetics. The aim of current study was to compare the effects of adding dexmedetomidine, fentanyl, or saline to bupivacaine on the properties of unilateral spinal anesthesia in patients undergoing calf surgery.MethodsIn this double‐blind clinical trial, 90 patients who underwent elective calf surgery were randomly divided into three groups. The spinal anesthetic rate in each of the three groups was 1 mL bupivacaine 0.5% (5 mg). In groups BD, BF and BS, 5 μg of dexmedetomidine, 25 μg of fentanyl and 0.5 mL saline were added, respectively. The duration of the motor and sensory blocks in both limbs and the rate of pain during 24 h after surgery were calculated. Hemodynamic changes were also measured during anesthesia for up to 90 min.ResultsThe duration of both of motor and sensory block was significantly longer in dependent limb in the BF (96 and 169 min) and BD (92 and 166 min) groups than the BS (84 and 157 min) group. Visual Analog Scale was significantly lower in the two groups of BF (1.4) and BD (1.3), within 24 h after surgery, than the BS (1.6) group.ConclusionsThe addition of fentanyl and dexmedetomidine to bupivacaine in unilateral spinal anesthesia can increase the duration of the motor and sensory block in dependent limb and prolong the duration of postoperative pain. However, fentanyl is more effective than dexmedetomidine.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

Effects of intravenous ondansetron and granisetron on hemodynamic changes and motor and sensory blockade induced by spinal anesthesia in parturients undergoing cesarean section

BackgroundSpinal anesthesia has many advantages for cesarean section parturients, but hypotension is considered the most frequent complication and can be managed by different interventions. One of these interventions is to give a serotonin receptor antagonist prior to spinal anesthesia.ObjectivesTo compare between two serotonin receptor antagonists on the hemodynamics, sensory, and motor blockade induced by intrathecal bupivacaine in parturients undergoing cesarean section.Patients and methodsSixty patients undergoing elective cesarean section under spinal anesthesia by intrathecal bupivacaine were randomly divided into three groups (20 pregnant females of ASA I–II physical status in each group). Group O received intravenous 4 mg ondansetron diluted in 10 ml normal saline and injected over 1 min, 5 min before spinal anesthesia, group G given intravenous 1 mg granisetron by the same route and group S given 10 ml normal saline. Mean arterial blood pressure, heart rate, vasopressor use, sensory, and motor blockade were assessed.ResultsDecreases in mean arterial pressure were significantly lower in group O than groups G and S with lower vasopressor use (P < 0.05), while there was significant faster sensory recovery in group G than groups O and S (P < 0.05). Actually, there were significant decrease in the incidence of nausea in groups O and G than group S (P = 0.008).ConclusionIn parturient females undergoing elective cesarean section, intravenous 4 mg ondansetron before subarachnoid block significantly decreased both the hypotension and the doses of vasopressor used, while intravenous 1 mg granisetron prior to subarachnoid block induced faster sensory recovery compared to both the ondansetron and the saline groups, with no significant differences between the later two groups.     

Dexmedetomidine is an effective adjuvant to subtenon block in phacoemulsification cataract surgery

BackgroundResearches to find a better adjuvant in regional anesthesia are still continued until now.Dexmedetomidine prolongs anesthesia and analgesia of local anesthetics in various neural blocks as well as the onset of sensory and motor block. The objective of the present study was to evaluate the effect of adding dexmedetomidine to local anesthetics on the sensory and motor block of the subtenon block in patients undergoing phacoemulsification cataract surgery.MethodsSixty patients of American Society of Anaesthesiologists (ASA) grade I–III, aged between 18 and 70 years, scheduled for phacoemulsification cataract surgery were randomly assigned to two equal groups. Group C (control group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine and Group D (dexmedetomidine group) received 2 ml of a mixture of 2% lidocaine and 0.5% bupivacaine plus dexmedetomidine (0.5 μg/kg). Onset and duration of sensory and motor block was recorded. Pain during administration of anesthesia and during surgery was graded using the verbal analogue scale and recorded. Intraocular pressure, hemodynamic, and sedation parameters were recorded before and after surgery.ResultsOnset of both sensory and motor block was significantly decreased in group D (P < 0.001, P = 0.004 respectively), and duration of sensory and motor block was more prolonged in group D than in group C (P < 0.001, P = 0.961). Pain during administration of anesthesia was significantly lower in group I compared with group II, and more patients in group I compared with group II were pain free, without a significant difference between the two groups. Intraocular pressure was significantly decreased in group D (P < 0.001). More sedation score was observed in group D (P = 0.022). Heart rate and mean arterial blood pressure were insignificantly decreased in group D more than in group C.ConclusionDexmedetomidine is a safe and effective adjuvant to subtenon block in phacoemulsification cataract surgery.     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Caffeine,Is it effective for prevention of postdural puncture headache in young adult patients?

Background and objectivesPostdural puncture headache is a relatively common complication in spinal anesthesia, so several kinds of regimens have been suggested for treatment of this problem. The aim of this study was to evaluate the efficacy and safety of prophylactic administration of intravenous caffeine sodium benzoate for prevention of postdural puncture headache (PDPH) in young adult patients received spinal anesthesia.MethodsOne hundred ASA I and II patients undergoing elective knee surgeries either arthroscopy or anterior cruciate ligament reconstruction (ACL reconstruction) were included in this study. Patients were randomized by double-blind, placebo-controlled design to receive intravenously (IV) either 10 mL normal saline as control group (group S) or 10 ml with 500 mg caffeine sodium benzoate (CSB) as caffeine group (group C) during the first 60 min after spinal anesthesia administration. The patient’s electrocardiogram, noninvasive blood pressure, and pulse oximetry were monitored and recorded. The patients’ headaches were evaluated by using the visual analog scale (VAS), and the severity of the headache was classified as follows: no headache = 0, mild headache ⩽3, moderate headache from 4 to 6 and severe headache ⩾7. Analgesic requirements were recorded.ResultsVisual analog scale scores were significantly lower in group C than in group S. The incidence of moderate and severe headache was significantly higher in group S (11 patients) when compared with group C (2 patients). Analgesic demand was significantly lower in group C than in group S.ConclusionIt seems that the incidence of postdural puncture headache decreases in those patients who received caffeine sodium benzoate. The article can potentially help clinicians to use caffeine as an effective drug for prevention of PDPH.     

A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after cesarean section

BackgroundAdding intrathecal opioids to intrathecal local anesthetics to decrease their doses and provide hemodynamic stability are major goals during spinal anesthesia in cesarean section. Different opioids were used to select the one with the longest duration of analgesia and the least side effects. In this study, intrathecal nalbuphine was compared with intrathecal fentanyl as an adjuvant to hyperbaric bupivacaine in cesarean section.Patients and methodsSixty female patients of ASA grades I and II presented for elective cesarean deliveries with spinal anesthesia were randomly allocated to 2 equal groups; Group F: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml fentanyl (25 μg); Group N: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml nalbuphine (0.8 mg). The onset of sensory and complete motor blockade, time of sensory blockade, duration of analgesia and motor blockade, fetal Apgar score, visual analog scale score, oxygen saturation, adverse effects and hemodynamic parameters were recorded intra-operatively and up to 4 h post-operatively. The effective analgesic time was recorded.ResultsThe onset of complete motor block was significantly more rapid in fentanyl group than in nalbuphine group. The duration of post-operative analgesia was more prolonged in nalbuphine group but the difference was insignificant. No significant difference was found between both groups as regards the duration of sensory block, motor block, duration of analgesia, fetal Apgar score, visual analog scale score, hemodynamic parameters and oxygen saturation. Adverse effects were less common in nalbuphine group but the difference was insignificant.ConclusionEither intrathecal nalbuphine 0.8 mg or intrathecal fentanyl 25 μg combined with 10 mg bupivacaine provides good intra-operative and early post-operative analgesia in cesarean section.     

Intrathecal vs intravenous magnesium as an adjuvant to bupivacaine spinal anesthesia for total hip arthroplasty

BackgroundThe aim of this study was to investigate the effect of intravenous infusion vs intrathecal magnesium sulfate during spinal anesthesia on postoperative pain, analgesic consumption, and intraoperative blood loss on patients undergoing total hip arthroplasty surgery.MethodsIn this prospective randomized controlled study, 75 adult patients, ASA physical status I and II scheduled for total hip arthroplasty, were included and randomized into three groups. Patients in Group I (control) received spinal anesthesia with hyperbaric bupivacaine and fentanyl. In Group II (IT Mg), 50 mg of magnesium sulfate was added to bupivacaine and fentanyl. In Group III (IV Mg), after induction of spinal anesthesia as in group I, a bolus dose of i.v. magnesium sulfate 40 mg kg^?1 was injected over 10 min, followed by continuous infusion of 15 mg kg^?1 h^?1 till the end of surgery. Arterial blood pressure, heart rate, electrocardiography, and O₂ saturation were continuously monitored. Onset, duration of sensory and motor block, and postoperative pain scores were assessed. Serum magnesium concentrations were checked before induction of anesthesia, immediately after surgery, at 6 h and 24 h after surgery. Total analgesic consumption and intraoperative blood loss were calculated.ResultsThere were no significant differences between the study groups in terms of onset time and maximum sensory level achieved, as well as onset and duration of motor block. Postoperative pain scores and 24 h analgesic consumption were lower in group II and III with insignificant differences between them. Intraoperative blood loss was significantly lower in group III. Postoperative Mg levels were higher in group III, without significant side effects.ConclusionsBoth i.v. infusion and intrathecal injection of Mg sulfate improved postoperative analgesia after total hip replacement. In addition, i.v. infusion of Mg sulfate reduced intraoperative blood loss.     

Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache

Study ObjectivePostdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment.DesignRetrospective study.SettingBeijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012.PatientsEighty-seven cases undergoing intraspinal anesthesia were assessed.InterventionsOf these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n = 68), receiving continuous epidural pumping of 0.9% NS (150 mL) at a rate of 6 mL/h; the remaining cases were assigned to group B (conservative therapy group, n = 19).MeasurementsAge, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale.Main ResultsOf 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P = .009). In addition, all patients showed PDPH within 3 days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P < .001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH.ConclusionsOur data indicated that application of 6 mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.     

Failed spinal anesthesia in addicts: Is it an incidence or coincidence?

BackgroundDrug addiction remarkably increases morbidity and mortality among patients. Several cases of failed spinal anesthesia have been discovered in the clinical practice among addict patients. Different causes of failed spinal blocks have been mentioned in the literature.The aim of the study was to compare the success rate of spinal anesthesia in adult addicts and non-addicts.MethodologyThe study was conducted in Kasr al Ainy teaching hospital, Cairo University, Egypt. One hundred patients aged 20–50, ASA 1-2, both genders, undergoing lower abdominal or limbs surgeries under regional anesthesia, were included in the study. They were divided into 2 equal groups, relative to the addiction history to Marijuana, Cannabis, Tramadol, and Clonazepam. Group [NAD] non-addicts (n = 50); and Group [AD] addicts (n = 50). The success rate, onset, duration of sensory and motor blocks were evaluated. Hemodynamic data were collected, and any complications due to the drugs used or due to spinal anesthesia were recorded.ResultsThe incidence of failure of the spinal anesthesia was higher in Group [AD] (33%) than Group [NAD] (4%), (p < 0.05). There was delay in the onset time and decreased duration of both sensory and motor blocks in the addict groups compared to non-addicts. All previous findings showed statistical significant difference (P < 0.05). Hypotension (p < 0.05) and nausea occurred more in addict groups than in non-addicts. No other complications were encountered in the study.ConclusionThe incidence of failure of the intrathecal anesthesia seemed to be higher in the addict than in non-addict patients. Redo intrathecal injection with a top up 1/2 of the initial dose resulted in success of the block in all failed cases. There was a slower onset and decreased duration of both sensory and motor blocks, with higher incidence of hypotension and nausea more in the addict patients than in non-addicts.     

A randomized comparison of onset of anesthesia between spinal bupivacaine 5 mg with immediate epidural 2% lidocaine 5 mL and bupivacaine 10 mg for cesarean delivery

BackgroundPrevious studies using low-dose spinal anesthesia for cesarean delivery have focused on hypotension and efficacy. This study evaluated whether, using a combined spinal–epidural technique, there was a difference in onset of anesthesia for cesarean delivery between low-dose spinal with an immediate epidural local anesthetic bolus, and conventional-dose spinal anesthesia.MethodsForty healthy term nulliparous women undergoing elective cesarean delivery with a combined spinal–epidural technique were enrolled into this prospective, randomized, double-blind study. Patients were randomly allocated to the low-dose (Group L) or conventional-dose group (Group C). Patients in Group L received intrathecal isobaric bupivacaine 5 mg with sufentanil 2.5 μg followed by epidural 2% lidocaine 5 mL; patients in Group C received intrathecal isobaric bupivacaine 10 mg with sufentanil 2.5 μg followed by epidural saline 5 mL. The onset of anesthesia (defined as the time from spinal injection to a block to T6), incidence of hypotension, maximal sensory block, epidural supplementation and side effects were recorded.ResultsAll blocks reached T6 within 11 min except for one patient in Group L. There were no differences in onset of anesthesia (9.9 ± 3.2 min in Group L vs. 8.5 ± 1.2 min in Group C, P = 0.08), maximal block level and the number of patients who required epidural supplementation in both groups. Hypotension occurred in 8 patients (40%) in Group L and 15 patients (75%) in Group C (P = 0.02).ConclusionsIntrathecal bupivacaine 5 mg with immediate 2% epidural lidocaine 5 mL provided comparable onset and efficacy of anesthesia as bupivacaine 10 mg with immediate epidural normal saline 5 mL for cesarean delivery.     

Estudio comparativo de diferentes sets de infusión epidural a velocidades máximas para analgesia del parto

IntroductionThe higher injection pressure obtained with epidural boluses give greater anaesthetic spread, and therefore better sensory block.Therefore, it stands to reason that anaesthetic administered at greater injection pressure and a higher flow rate would spread to a higher sensory level.ObjectiveOur aim was to compare the sensory level reached with the high flow. and standard flow set at maximum rates.Material and methodsWe included 73 primiparous women who requested epidural analgesia for labour using programmed intermittent epidural boluses of 0.1% ropivacaine at a flow rate of 10 ml/h and 2 ug/ml fentanyl plus patient-controlled epidural analgesia. The boluses were administered with a standard (250 ml/h) or high-flow (500 ml/h) infusion set, according to the usual clinical practice of each anaesthesiologist. The primary objective was to evaluate the sensory level reached. Secondary objectives were pain on a visual analogue scale, motor block measured on the modified Bromage scale, and anaesthesia consumption in terms of rescue analgesia (patient-controlled epidural analgesia) and anaesthesiologist-administered boluses.ResultsThe median maximum sensory level reached was T9 in the high flow group and T7 in the standard flow group; this difference was statistically significant (p = .0002). There were no significant differences in visual analogue scale, Bromage or rescue analgesia between groups.ConclusionOur results show that the high flow set does not offer benefits. The use of such sets need to be evaluated due to their higher cost.     

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized,double blinded study

PurposeSingle shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.MethodsIn a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5 mg hyperbaric bupivacaine 5 mg/ml (control group), and B0.25 group 3.75 mg hyperbaric bupivacaine 2.5 mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.ResultsAfter exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15 min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6 mg vs. 8.7 mg in the B0.5 group, p < 0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6 ± 23.6 (95% CI 51.7–110.2) min vs. 125.5 ± 37.9 (95% CI 101.7–169.4) min in the B0.5 group, p = 0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.ConclusionLowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.     

Efficacy of preoperative melatonin versus pregabalin on perioperative anxiety and postoperative pain in gynecological surgeries

BackgroundWe compared the efficacy of melatonin and pregabalin on perioperative anxiety and postoperative pain in patients undergoing laparoscopic gynecological surgeries.MethodsIn this randomized double-blind study, 40 patients, 25–35 yr undergoing gynecological surgeries were divided into 2 equal groups to receive either melatonin capsule 6 mg (Group M), or pregabalin capsule 150 mg (Group P) 1 h before induction of general anesthesia. Our primary outcome was preoperative acute anxiety level 1 h after drug administration, 1, 6, and 12 h after operation. The secondary outcomes were postoperative visual analog scale (VAS) for pain, analgesic consumption, sedation level using the inverted observer’s assessment of alertness/sedation scale (OAA/S) scale, and incidence of adverse effects.ResultsThe anxiety scores decreased significantly >50% after premedication in both groups compared to baseline values (p < 0.01) with no statistically significant difference between the two groups (30.4 ± 4.5 in group M versus 31.7 ± 4.2 in group P, p > 0.05). Postoperative VAS for pain, time for first analgesic demand and number of patients requiring postoperative analgesia did not differ between groups, and the sedation score was higher in melatonin group compared to pregabalin group 1 h after drug (3.45 ± 0.7 versus 1.95 ± 0.6, p < 0.001, respectively) and at all the subsequent readings postoperatively with equal incidence of adverse effects in both groups.ConclusionOral melatonin 6 mg or pregabalin 150 mg administered 1 h before operation had reduced perioperative anxiety and postoperative pain in patients undergoing gynecological surgeries, without untoward sedative effects in the pregabalin group compared to melatonin group.     

Effects of intrathecal bupivacaine–fentanyl versus bupivacaine–dexmedetomidine in diabetic surgical patients

BackgroundDiabetes mellitus is the most common endocrine disorder encountered during anesthesia. Experimental researches showed that the functional μ opioid receptors in the dorsal horn of spinal cord in diabetics are either reduced or impaired in their function. This prospective study was postulated to differentiate between the effects of either opioid like fentanyl versus nonopioid like dexmedetomidine agents added to spinal bupivacaine in diabetic patients.MethodsSixty diabetic patients of either sex were submitted for elective lower limb orthopedic surgery. Patients were randomly allocated into three equal groups (each group 20 patient): bupivacaine group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5% plus 0.5 mL of normal saline, bupivacaine–fentanyl group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5% plus 25 μg fentanyl in 0.5 mL of normal saline and bupivacaine–dexmedetomidine group in which patients received 2.5 ml of hyperbaric bupivacaine 0.5%, plus 10 μg dexmedetomidine in 0.5 mL of normal saline. Duration and quality of sensory and motor block were assessed.ResultsThe duration of sensory and motor block as well as duration of effective analgesia was significantly longer in the bupivacaine–dexmedetomidine group as compared with both bupivacaine–fentanyl and control bupivacaine groups.ConclusionAddition of intrathecal dexmedetomidine to heavy bupivacaine 0.5% was more advantageous than fentanyl with special regard to its analgesic properties in diabetic surgical patients.     

A new modality for improving the efficacy of intrathecal injection for cesarean section

BackgroundIntrauterine resuscitation (IUR) is to improve O2 delivery to the placenta and umbilical blood flow, for reversal of foetal hypoxia and acidosis. We evaluated whether maintaining a lateral position after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl improving the efficacy of spinal anaesthesia, IUR and preventing hypotension during cesarean delivery.MethodsOne hundred and seventy two healthy women undergoing elective cesarean delivery were enrolled in a double blind prospective randomized study. Spinal anesthesia was conducted in the right lateral position which maintained for 6 min for all the patients participated in the study, and then the subjects were turned supine. Patients were randomly allocated to two groups: low-dose spinal bupivacaine (LD) group (n = 86) patients received 6 mg of hyperbaric bupivacaine 0.5% and 15 μg of fentanyl, high-dose spinal bupivacaine (HD) group (n = 86) patients received 10 mg of hyperbaric bupivacaine and 15 μg of fentanyl. The incidence of hypotension and nausea, ephedrine requirement, maximal block height, and Apgar score at 1 and 5 min.ResultsThe authors found significant decrease in MAP in the group that was given the high dose of bupivacaine the incidence of hypotension was 80% but the LD spinal bupivacaine group was hemodynamically stable. The lowest blood pressure, boluses of inj. ephedrine used, or nausea were more significant in the HD group than in LD group. Onset of hypotension was more rapid (8 ± 3 vs. 16 ± 6 min, P < 0.001), and the sensory block level was more cephalad in HD group than in LD group (T2 [C8–T5] vs. T4 [T1–T6], P = 0.001). Apgar scores did not differ between the groups.ConclusionMaintaining the lateral position for 6 min after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl resulted in improving the efficacy of spinal anaesthesia, IUR by more gradual and higher cephalad sensory block, without an increase in the incidence of maternal hypotension.     

Postural change from lateral to supine is an important mechanism enhancing cephalic spread after injection of intrathecal 0.5% plain bupivacaine for cesarean section

BackgroundSpinal anesthesia is widely used for cesarean section, but the factors that affect the spread of the block in pregnant patients are still not fully explained. This study was designed to investigate the effect of postural changes on sensory block level.MethodsThirty patients scheduled for elective cesarean section under combined spinal–epidural anesthesia were randomly allocated into three groups. After intrathecal injection of 0.5% plain bupivacaine 7.5 mg, patients in group S were immediately placed in the supine position with left tilt, patients in group L5 were kept lateral for 5 min and then turned to the supine position with left tilt, and patients in group L10 were kept lateral for 10 min and then turned to the supine position with left tilt.ResultsAt 5 min, median cephalad level of sensory block was lower in groups L5 and L10 compared with group S (corrected P<0.001); at 10 min, median cephalad sensory block level was lower in group L10 compared with group S (corrected P<0.001) and group L5 (corrected P<0.001), and lower in group L5 compared with group S (corrected P=0.033); at 15 min, median cephalad level of sensory block was lower in group L10 compared with group S (corrected P=0.003) and group L5 (corrected P=0.015).ConclusionsIn our population, using 0.5% plain bupivacaine 7.5 mg, postural change from the lateral position to the supine position is an important mechanism enhancing cephalic spread of spinal anesthesia during late pregnancy.     

Comparative study of epidural morphine and epidural dexmedetomidine used as adjuvant to levobupivacaine in major abdominal surgery

BackgroundA lot of researches have been done to find an adjuvant in regional anesthesia that inhibits pain without any side effects.AimThis study was conducted to evaluate the onset, extent and duration of sensory and motor block, and side effects of morphine and dexmedetomidine when used as adjuvants to levobupivacaine in epidural anesthesia in major abdominal surgery.Materials and methodsA prospective randomized study was conducted on 60 patients classified as American Society of Anesthesiologists status I and status II who underwent abdominal surgery. Patients were randomly allocated into two groups; group I levobupivacaine morphine group (LM), group II: levobupivacaine dexmedetomidine group (LD), comprising of 30 patients each. Group I patients received 20 ml of 0.5% levobupivacaine (150 mg) and 0.005 % morphine. Group II patients received 20 ml of 0.5% levobupivacaine and 1.5 μg/kg dexmedetomidine. The onset, extent and duration of sensory and motor blocks, abdominal muscle relaxation, and side effects were recorded.ResultsThere were no statistically significant differences between the two groups as regards onset of sensory block or sensory level achieved. Time to reach motor block was shorter in the LM group than the LD group. There were no significant differences between the time of total regression of sensory or motor black and abdominal muscle relaxation. As regards side effects, more patients in the LM group suffered from pruritis and more patients suffered from dry mouth in the LD group.ConclusionDexmedetomidine is a good alternative to morphine as an adjuvant to levobupivacaine in epidural anesthesia in major abdominal surgeries.     

Efficacy of prophylactic use of hydrocortisone and low dose ketamine for prevention of shivering during spinal anesthesia

BackgroundSpinal anesthesia is commonly associated with shivering. The aim of this study was to compare the efficacy of i.v. hydrocortisone with i.v. low dose ketamine or placebo for prevention of shivering during spinal anesthesia.MethodIn this prospective, randomized, double-blind study, 90 female patients ASA I–II age 30–60 years old, undergoing posterior vaginal repair surgeries under spinal anesthesia with 3 ml heavy bupivacaine 0.5% (15 mg), patients were randomly allocated into one of three groups, (Group S, n = 30) (control) received saline, (Group K, n = 30) received ketamine 0.25 mg kg^?1 or (Group H, n = 30) received hydrocortisone 2 mg kg^?1, the drugs were given i.v. just after spinal anesthesia with recording of vital signs, and core temperature every 15 min intraoperative and every 10 min in recovery room. The incidence and intensity of shivering, number of patients received meperidine, sensory level, motor block grade, and side effects (hypotension, hypertension, tachycardia, nausea and vomiting, sedation and hallucinations) were also recorded.ResultsIncidence of shivering were significantly reduced in k and H groups being 20% and 23.3% respectively compared to S group (p < 0.05). Patients received meperidine to control shivering were significantly low in Groups K and H compared to group S (p < 0.05), with no difference between Groups K and H.ConclusionsThe prophylactic administration of low dose ketamine (0.25 mg kg^?1) and hydrocortisone (2 mg kg^?1) were comparable in reducing the incidence of shivering and both had significant antishivering effect compared to placebo, in female patients under spinal anesthesia for posterior vaginal repair surgeries.