[On the greater probability of hemorrhage in general anesthesia than in spinal anesthesia].
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Anesthesia, Endotracheal↗
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Spinal anesthesia using a continuous spinal catheter for cesarean section in a parturient with prior surgical correction of scoliosis.
This case report demonstrates the successful anesthetic management of cesarean section for a 29-year-old primiparous parturient with a past history of a scoliosis operation at 13 years of age. An Isola hook and screw-rod system had been implanted as posterior spinal instrumentation at the level of T3-L3. We titrated hyperbaric bupivacaine 7 mg combined with fentanyl 15 microg through a continuous spinal catheter, placed with a catheter-over-needle technique in order to avoid unintentional wide spread of anesthetic agents. The anesthetic level was T4 at the start of the operation. Her surgery was carried out without any problems. Headache, as a dural tap-related complication, was not observed. Spinal anesthesia with the titration of anesthetic agents for cesarean section is considered to be one of the choices for a parturient who has had spinal instrumentation.
Adult↗
Extent of hyperbaric spinal anesthesia influences the duration of spinal block.
BACKGROUND: The influence of spread of spinal anesthesia on the duration of spinal blockade has been suggested but never investigated specifically. Because elimination of local anesthetic from subarachnoid space is probably dependent of the surface available for its diffusion and vascular absorption, the current study was designed to evaluate the hypothesis that with a same dose of hyperbaric bupivacaine, a higher anesthetic level would result in a shorter duration of spinal blockade than a lower level. METHODS: Three milliliters (15 mg) of hyperbaric bupivacaine, 0.5%, was injected intrathecally in 40 patients classified as American Society of Anesthesiologists physical status I or H scheduled for lower limb surgery during spinal anesthesia. To obtain significantly different anesthetic levels, the patients were positioned randomly either horizontally or with the torso elevated 30. Regression of sensory level and motor blockade, the appearance of pain at the operative site, and hemodynamic changes were evaluated. RESULTS: The maximum cephalad spread of sensory blockade (expressed as the median with ranges in parentheses) was significantly higher in the horizontal group than in the group with 30-degree elevation of the torso, i.e., T3.5 (T1-T9) versus T10 (T6-L1), with respectively significantly faster regression times (mean ¿ SD) by two segments (216 ¿ 46 mm vs. 253 ¿ 64 mm) and to segment L4 (269 ¿ 53 mm i s. 337 ¿ 58 mm), as well as shorter time to complete motor blockade recovery (173 ¿ 34 mm i s. 233 ¿ 58 mm) and faster appearance of pain at the operative site (221 ¿ 68 mm vs. 271 ¿ 56 mm). CONCLUSION: The results indicate that with the same dose of hyperbaric bupivacaine, the duration of spinal blockade is longer in patients with restricted spread.
Anesthesia, Spinal↗
[Do elevated blood and cerebrospinal fluid glucose levels and other factors modify the density of cerebrospinal fluid and the spread of isobaric spinal anesthesia?].
When isobaric spinal anesthesia is applied the level of analgesia is of special interest. This level is influenced by many factors of varying importance. One major factor is the relation between cerebrospinal fluid (CSF) density and the density of local anesthetic solutions. The density of CSF changes with the concentrations of its constituents, e.g., glucose or protein. Because glucose concentrations in CSF change in parallel with blood glucose levels, this may have effects on CSF density and the spread of spinal anesthesia. In 43 patients in two groups (diabetic n = 32, non-diabetic n = 11) the influence of CSF density on the analgesia level achieved with isobaric spinal anesthesia was investigated with special reference to increased glucose levels in blood and CSF. The influence of body height and weight, age and CSF protein content were also studied. There were no statistically significant correlations between any of these factors and the extension of analgesia. The mean blockade level was 1.6 segments lower in the non-diabetic group: this difference was statistically not significant (P greater than 0.05). Anesthesia spread faster in the diabetic group, but this difference was also not significant (P greater than 0.05). For bupivacaine 0.5% alone a density of 1.0010 g/cc was found, while for bupivacaine 0.5% with epinephrine (1:200,000) the density measured was 1.0022 g/cc. There is no correlation (r2 = 0.083) between CSF glucose concentration and CSF density, other factors such as sodium, chloride or CO2, apparently being more important. With CSF density ranging between 1.000 and 1.003 g/cc there was no correlation with the blockade level (r2 = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
[The influence of small dose intrathecal fentanyl on shivering during transurethral resection of prostate under spinal anesthesia].
Shivering during spinal anesthesia is a common complication in patients undergoing transurethral resection of prostate. The high incidence of shivering may be due to decreased core temperature secondary to peripheral vasodilation from sympathetic blockade and/or cold irrigation fluid. Shivering is known to increase O2 consumption, ventilation and cardiac output, which can result in morbidity to patients with limited cardiopulmonary reserves. The aim of this randomized double-blind study was to investigate whether 1.25 micrograms of intrathecal fentanyl administered would influence the incidence and severity of shivering in patients who underwent TURP under spinal anesthesia. In the present study, 79 patients with (n = 41) or without (n = 38) low dose fentanyl were study. The incidence of shivering was 65.8% in control group and 12.2% in the study group. The difference was statistical significance. The shivering grade (1.0 +/- 0 vs 1.76 +/- 0.7) and accumulative shivering scores (2.4 +/- 0.8 vs 12.5 +/- 5.6) were also significantly decreased in the study group (P < 0.05). Obviously, there was no difference in the incidence of pharmacologic side effect. We concluded that low dose intrathecal fentanyl is a god method for decreasing both incidence and severity of shivering during spinal anesthesia.
Aged↗
Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia.
UNLABELLED: 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.
Adult↗
[Behaviorial observation of ropivacaine in continuous spinal anesthesia and Ca2+ content of spinal cord in rats].
OBJECTIVE: To observe the behaviour and Ca2+ content of spinal cord in rats after continuous spinal anesthesia administration of different densities and doses of ropivacaine in SD rats. METHODS: Twenty-four male SD rats weighing 220 approximately 280 g were anesthetized. A polyurethane microspinal catheter was inserted into the lumbar subarachnoid space 8 cm according to the method of Yaksh's. The animals were randomly divided into 4 groups of 6 each: in group N the rats were given normal saline 40 microl intrathecally every one and half hours for 3 times; in group R1, 0.5% ropivacaine was given; in group R2 0.75% ropivacaine and in group R3 1% ropivacaine was given. The activity of rats was observed. After 6 hours rats were perfused with 4% formamint through the ascending aorta. The rats were sacrificed and L1 approximately 2 segment of spinal cord was immediately removed for Ca2+ content examination. RESULTS: A total hind limbs paralysis was seen at 30 seconds and intramuscular strain gradually came back from 30 to 90 minutes after the intrathecal administration of ropivacaine in all rats. The recovery of motor black was remarkably different in group R1, R2, and R3 (P < 0.05). The Ca2+ content of spinal cord was significantly higher in group R3 than that in group R1 and R2 (P < 0.05 ). CONCLUSION: There is no significant change of motor black time and it is related to drug dose for 0.5% , 0.75% and 1% ropivacaine in continuous spinal anesthesia. 1% ropivacaine may increase Ca2+ content in spinal cord.
Amides↗
Ventilatory responses to hypercapnia during tetracaine spinal anesthesia.
The effect of spinal anesthesia with hyperbaric tetracaine with epinephrine on resting ventilation and on ventilatory responsiveness to CO2 rebreathing was studied in 10 unpremedicated patients. Resting end-tidal PCO2 (PETCO2) decreased from 37 +/- 3 mmHg (mean +/- SD) to 34 +/- 2 mmHg after induction of spinal anesthesia (p less than 0.05). Minute ventilation (VE) and occlusion pressure (P0.1) at PETCO2 = 55 mmHg increased during spinal anesthesia from 32.0 +/- 12.9 to 40.2 +/- 17.0 l/min and from 5.0 +/- 1.8 to 8.6 +/- 4.7 cmH2O, respectively. The magnitude of the increase in VE during spinal anesthesia correlated inversely with age. Spinal anesthesia was not associated with significant changes in vital capacity, maximal inspiratory pressure, or the slopes of the lines relating VE or P0.1 to PCO2. These results show increased ventilatory responsiveness to CO2 (a parallel leftward shift of the CO2 response curve) with tetracaine spinal anesthesia.
Adult↗
[Differentiation of brain stem anesthesia from high spinal anesthesia using auditory brain stem response].
A 67-year old woman having intractable chronic postherpetic neuralgia at the neck to forearm for two years was treated with subarachnoid block. Initially, bolus of 1% lidocaine 8 ml, with methylprednisolone acetate 20 mg was injected intrathecally at 6th cervical intervertebral space. The auditory brain stem response (ABR) during high spinal block with intact consciousness was not depressed in its wave height. ABR recorded showed prolongation of latency of 3 and 5 waves and prolongation of 1-3 phase to phase interval without prolongation of 3-5 phase to phase interval. Intrathecal nerve block was then performed with 1% lidocaine 15 ml and methylprednisolone acetate 20 mg, because she complained awareness and shocking sensation with controlled respiration during the first block. She assured that she felt nothing during the second block. The ABR recorded during the second block showed near complete suppression in its height of all waves and prolongation of all wave latencies. During recovery period, 1-3 and 3-5 phase to phase interval prolongation was recorded. One can differentiate brain stem anesthesia from other state that induces unconsciousness after block which is capable of inducing accidental brain stem anesthesia. These two blocks improved activity of daily living of the patient and severity of her pain decreased to 1/5 to 1/10.
Aged↗
The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry.
Studies with modest numbers of patients have suggested that spinal anesthesia in infants is associated with a very infrequent incidence of complications, such as hypoxemia, bradycardia, and postoperative apnea. Although spinal anesthesia would seem to be a logical alternative to general anesthesia for many surgical procedures, it remains an underutilized technique. Since 1978, clinical data concerning all infants undergoing spinal anesthesia at the University of Vermont have been prospectively recorded. In all, 1554 patients have been studied. Anesthesia was performed by anesthesia trainees and attending anesthesiologists. The success rate for LP was 97.4%. An adequate level of spinal anesthesia was achieved in 95.4% of cases. The average time required to induce spinal anesthesia was 10 min. Oxygen hemoglobin desaturation to <90% was observed in 10 patients. Bradycardia (heart rate <100 bpm) occurred in 24 patients (1.6%). This study confirms the infrequent incidence of complications associated with spinal anesthesia in infants. Spinal anesthesia can be performed safely, efficiently, and with the expectation of a high degree of success. Spinal anesthesia should be strongly considered as an alternative to general anesthesia for lower abdominal and lower extremity surgery in infants.
Anesthesia, Spinal↗
[Four cases of diplopia following spinal anesthesia].
Many complications after spinal anesthesia have been reported, but diplopia is rare. We had four cases of diplopia in 794 cases of spinal anesthesia in three years at Nara Medical University Hospital. These 4 cases were not characterized by any major factors including gender, age, or anesthetic choice. However, two of them were accompanied with post-spinal headache. Diplopia in three cases improved spontaneously, but one finally required epidural blood patch for the persistent diplopia. Lack of concern regarding the possibility of post-spinal diplopia among medical staffs might be common because this incidence is really rare. However, we need to know the possibility of this neurological sequel after spinal anesthesia. We would like to propose that the informed consent regarding spinal anesthesia should include the possibility of this complication and anesthesiologists should perform intensive neurological examinations after spinal anesthesia concerning post-spinal diplopia.
Adult↗
Intravenous clonidine prolongs bupivacaine spinal anesthesia.
BACKGROUND: Prolongation of spinal anesthesia by oral clonidine premedication has been known. We hypothesized that intravenous clonidine administered after the spinal block may prolong spinal anesthesia. METHODS: To assess the prolongation of spinal anesthesia by intravenous clonidine, we designed a double-blind, placebo-controlled, prospective study. Patients scheduled for orthopedic surgery received 12 mg of 0.5% hyperbaric bupivacaine and were randomly divided into three groups (n = 26 in each group). In the clonidine 10-min group, 3 microg x kg-1 of clonidine was administered for 10 min immediately after the spinal block. In the clonidine 60-min group, 3 microg x kg-1 of clonidine was administered for 10 min, 50 min after the spinal block. The control group received normal saline. Sensory block was evaluated by pinprick and the duration was defined as the time for sensory block to regress to L1 dermatome. Duration of motor block was defined as the time required for the patient to flex his or her knee. RESULTS: The duration of sensory block was longer in both the clonidine 10-min and clonidine 60-min groups compared with the control group (196 +/- 42 min, 179 +/- 41 min vs. 125 +/- 25 min, P < 0.05). The duration of motor block was longer in the clonidine 10-min group than in the control group (153 +/- 26 min vs. 131 +/- 29 min, P < 0.05). The lowest heart rate and mean blood pressure were not different among groups. CONCLUSIONS: Intravenous clonidine administration within 1 h after the spinal block prolonged bupivacaine spinal anesthesia for approximately 1 h without adverse effects.
Adult↗
Potential neurotoxicity of spinal anesthesia with lidocaine.
Spinal (intrathecal) anesthesia has evolved into a safe, widely accepted method of anesthesia with many advantages. However, the past decade has seen a large number of case reports and incidence studies that implicate the local anesthetic (LA) lidocaine as being more neurotoxic than other commonly used LAs such as bupivacaine and tetracaine, based on patterns of clinical use current at the time of those reports. Available studies suggest a risk of persistent lumbosacral neuropathy after spinal lidocaine by single injection in about 1 in 1300 procedures and a risk as high as about 1 in 200 after continuous spinal anesthesia with lidocaine. While uncommon, this risk is probably an order of magnitude higher than the risk reported for other commonly used LAs or for general anesthesia. Spinal lidocaine is also implicated in the syndrome of transient neurologic symptoms (previously referred to as transient radicular irritation), manifest by pain or dysesthesia in the buttocks or legs after recovery from anesthesia. Although the pain typically resolves within 1 week without lasting sequelae, it can be severe in up to one third of patients with the syndrome. In addition to clinical studies, both whole animal and in vitro studies have shown that lidocaine can be neurotoxic at clinically available concentrations and that lidocaine is more neurotoxic than equipotent concentrations of other commonly used LAs. The mechanism of this neurotoxicity may involve changes in cytoplasmic calcium homeostasis and mitochondrial membrane potential.
Adverse Drug Reaction Reporting Systems↗
Studies of Hemodynamic Changes in Humans Following Induction of Low and High Spinal Anesthesia. I. General Considerations of the Problem. The Changes in Cardiac Output, Brachial Arterial Pressure, Peripheral and Pulmonary Oxygen Contents and Peripheral Blood Flows Induced by Spinal Anesthesia in Humans Not Undergoing Surgery.
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Anesthesia↗
Ventilatory responses to hypercapnia during bupivacaine spinal anesthesia.
The effect of spinal anesthesia with isobaric 0.5% bupivacaine on ventilatory responsiveness to CO2 rebreathing was studied in ten unpremedicated patients. Minute ventilation (VE) at end-tidal PCO2 = 55 mm Hg increased from 18.7 +/- 6.7 L/min (mean +/- SD) to 22.3 +/- 10.1 L/min after induction of spinal anesthesia (P less than 0.05). Occlusion pressure (P0.1) at PCO2 = 55 mm Hg also increased, from 3.8 +/- 1.5 to 5.0 +/- 1.7 cm H2O (P less than 0.05). Spinal anesthesia was not associated with significant changes in vital capacity, maximal inspiratory pressure, resting end-tidal PCO2, or the slopes or intercepts of the lines relating VE or P0.1 to PCO2. These results show an increased ventilatory responsiveness to CO2 with bupivacaine spinal anesthesia.
Adult↗
Transient radicular irritation followed by meningitis after spinal anesthesia.
Neurotoxicity of spinally administered hyperbaric 5% lidocaine is becoming a serious concern in view of the recent literature. We report a case of probable neurotoxicity of hyperbaric 5% lidocaine, followed by an aseptic meningitis. This case report emphasizes the danger of using hyperbaric 5% lidocaine in a too high dose while performing spinal anesthesia.
Adult↗
[Atypical use of continuous spinal anesthesia sets].
Continuous spinal anesthesia technique with portex sets was used for treatment of neuroinfection. The patients was 43 years old woman with meningitis caused by Cryptococcus sp. suffered from chronic kidney failure, after transplantation and graft removal because of it's rejection. Effectiveness of therapy confirmed high value of CSA not only for pain treatment, but for central nervous system diseases as well.
Adult↗
[Spinal endoscopy in the detection of problems caused by continuous spinal anesthesia].
Continuous spinal anaesthesia has a number of advantages, but there are a number of drawbacks as well: difficulties in threading the catheter, distribution of the local anaesthetics and the development of cauda equina syndrome. Spinaloscopy was done to visualize the fate of catheters during and after their insertion, as well as the distribution of local anaesthetics injected through these fine-bore catheters. METHOD. The studies were conducted in preserved and fresh cadavers donated to the Anatomic Institute for Medical Studies. The spinal column from T12 to S1, together with the back musculature (in order to preserve the normal curvature of the spine) were removed from the cadaver. Spinaloscopy was done with a 4 mm endoscope with a 0 degree optic (Storz, Tutlingen, FRG). All observations were made from the lumbosacral region of the dissected preparation. In this fashion, it was possible to observe the insertion of the spinal needle used to introduce the catheter into the subdural space. The distribution of local anaesthetics injected through a 22-gauge spinal needle or a 28-gauge catheter was shown by injecting 0.5% hyperbaric bupivacaine colored with a small amount of 1% methylene blue. Pictures were taken 15, 30 and 45 s after beginning the injection. RESULTS. Difficulty in threading the catheter: our observations indicate that the difficulty in inserting microbore catheters is most likely due to inserting the needle too far. It is impossible for the catheter to bend and be inserted into the subarachnoid space. In many cases the catheter encountered the anterior wall of the spinal canal and would slide along various structures. Distribution of the drug: the injection is better dispersed with a 22-gauge needle and it completely fills the subarachnoid space. The local anaesthetics injected through the 28-gauge nylon catheter (Kendall Healthcare, Mansfield, Mass.) are distributed in the dependent portions of the spinal canal. If high doses and a high concentration are injected, the distribution pattern may result in an overconcentration in some parts of the subarachnoid space. Possibility of trauma: the catheter stretches around the roots, the potential for trauma is that untoward stress may be applied to the root, either during full insertion of the catheter or during its withdrawal. CONCLUSION. Spinaloscopy was done in a non-fixated anatomic spinal column preparation with a 4 mm 0 degree endoscope (Storz, Tuttlingen, FRG). Based on our observations, we conclude: The catheter should only be inserted 2 cm into the subarachnoid space. This may decrease the risk of malpositioning. After the tip of the catheter has reached the subarachnoid space, the stylet should be with drawn 2 or 3 cm to minimize the risk of nerve injury and/or bleeding.
Anesthesia, Spinal↗