Transient neurologic symptoms following spinal anesthesia with isobaric mepivacaine: A decade of experience at Toronto Western Hospital

Background: Transient neurologic symptoms (TNSs) can be distressing for patients and providers following uneventful spinal anesthesia. Spinal mepivacaine may be less commonly associated with TNS than lidocaine; however, reported rates of TNS with intrathecal mepivacaine vary considerably. Materials and Methods: We conducted a retrospective cohort study reviewing the internal medical records of surgical patients who underwent mepivacaine spinal anesthesia at Toronto Western Hospital over the last decade to determine the rate of TNS. We defined TNS as new onset back pain that radiated to the buttocks or legs bilaterally. Results: We found one documented occurrence of TNS among a total of 679 mepivacaine spinal anesthetics (0.14%; CI: 0.02–1.04%) that were performed in 654 patients. Conclusion: Our retrospective data suggest that the rate of TNS associated with mepivacaine spinal anesthesia is lower than that previously reported in the literature

Efficiency of spinal anesthesia versus general anesthesia for lumbar spinal surgery: a retrospective analysis of 544 patients.

BACKGROUND: Previous studies have shown varying results in selected outcomes when directly comparing spinal anesthesia to general in lumbar surgery. Some studies have shown reduced surgical time, postoperative pain, time in the postanesthesia care unit (PACU), incidence of urinary retention, postoperative nausea, and more favorable cost-effectiveness with spinal anesthesia. Despite these results, the current literature has also shown contradictory results in between-group comparisons. MATERIALS AND METHODS: A retrospective analysis was performed by querying the electronic medical record database for surgeries performed by a single surgeon between 2007 and 2011 using procedural codes 63030 for diskectomy and 63047 for laminectomy: 544 lumbar laminectomy and diskectomy surgeries were identified, with 183 undergoing general anesthesia and 361 undergoing spinal anesthesia (SA). Linear and multivariate regression analyses were performed to identify differences in blood loss, operative time, time from entering the operating room (OR) until incision, time from bandage placement to exiting the OR, total anesthesia time, PACU time, and total hospital stay. Secondary outcomes of interest included incidence of postoperative spinal hematoma and death, incidence of paraparesis, plegia, post-dural puncture headache, and paresthesia, among the SA patients. RESULTS: SA was associated with significantly lower operative time, blood loss, total anesthesia time, time from entering the OR until incision, time from bandage placement until exiting the OR, and total duration of hospital stay, but a longer stay in the PACU. The SA group experienced one spinal hematoma, which was evacuated without any long-term neurological deficits, and neither group experienced a death. The SA group had no episodes of paraparesis or plegia, post-dural puncture headaches, or episodes of persistent postoperative paresthesia or weakness. CONCLUSION: SA is effective for use in patients undergoing elective lumbar laminectomy and/or diskectomy spinal surgery, and was shown to be the more expedient anesthetic choice in the perioperative setting

EVALUATION OF THE EFFECTS OF ADDING KETAMINE TO MORPHINE IN PCIA AFTER ORTHOPEDIC SURGERY

Background: Midazolam is the only clinically available water – soluble benzodiazepine has been reported to have an antinoceptive effect through neuroaxial pathway . We investigated systematically administrated midazolam on level and duration on motor and sensory block in spinal anesthesia with lidocaine. Methods: After obtaining the approval of the local Ethics committee and with written informed consent and under prospective double blind, randomized study, 36 adult ASA 1&2 patients who were scheduled for elective lower abdomen and lower extremity surgery under spinal anesthesia with 2 ml lidocain 5% were studied. Patients were allocated to two equal groups of receiving midazolam 0.03 mg/kg and fentanyl 1 µg/kg (group 2). Patients were evaluated for level and duration of sensory and motor block. Statistical analysis was performed using the SPSS soft ware. The T test, Chi- square and two way ANOVA were used to data analysis. Results: Sensory block level was T8 and T10 in group 1 and 2 respectively (P=0.02). The duration of sensory block was longer in group 1 (75.1 ± 28 min) than the group 2 (58.8 ± 23.3 min) , but this difference was not statistically significant (P=0.07). Duration of motor block was longer significantly (P=0.01) in group 1 (82.9 ± 27.3 min) than in group 2 (59.1 ± 26.5 min). Conclusion: Intravenous midazolam can improve the level of sensory block and the duration of motor block in spinal anesthesia without farther increasing the preoperatively complications. Key Word: Spinal anesthesia, midazolam, sensory block, motor block

General versus Spinal Anesthesia: Comparison of Complications and Outcomes in Lumbar Laminectomy Surgery

Background: This study was designed to compare the complications and outcomes of lumbar laminectomy surgery performed by general and spinal anesthesia. Methods: In this prospective study, 110 patients with two common degenerative spinal diseases (lumbar discopathy and spinal canal stenosis) were enrolled. All the patients were operated in Bahonar hospital, Kerman City, Iran, via either spinal or general anesthesia by a unique surgeon. Intraoperative and postoperative complications and outcomes were compared between the two groups using descriptive and analytic statistics methods. Results: Surgeon satisfaction of anesthesia, blood loss, and admission time were not statistically significant between the groups. But, postoperative pain at recovery room, and 1, 2, and 12 hours after the operation was significantly higher in general anesthesia compared to lumbar anesthesia. Morphine request was also significantly higher with general anesthesia (P < 0.001). Conclusion: This study demonstrates that general anesthesia has greater pain in comparison with spinal anesthesia that should be considered in degenerative spinal diseases surgeries. Keywords Laminectomy; Lumbar region; surgery; General anesthesia; Spinal anesthesi

Effects of intrathecal opioids use in cesarean section on breastfeeding and newborns’ weight gaining

Objective: To assess the association between intrapartum intrathecal opioid use and breastfeeding and weight gain following cesarean section. Materials and methods: The prospective double-blinded study was conducted on term pregnant women, undergoing elective cesarean section under spinal anesthesia. They divided into two groups. In the first group, intrathecal Morphine was used to achieve analgesia during or after the operation. The remainder divided into two subgroups, those who did not receive any opioid or those received systemic opioids. Following labor breastfeeding accessed in a follow-up, two month latter. Results: There was no difference between the demographic variables of the mothers and newborns APGAR score and weight at the time of birth. Breastfeeding rate was similar in intrathecal group in compare with other patents (P value = 0.518). While, the infants’ weight at the end of second month was lower in spinal opioid group (P value = 0.036). Conclusion: The present study was the first to suggest that spinal (intrathecal) opioids do not have any impact on breastfeeding. However the relationship between spinal anesthesia on weight gaining needs more investigation

The Comparison of General Anesthesia Induced by Thiopental Sodium or Propofol with Spinal Anesthesia on the Apgar Score of Neonates Delivered by Cesarean Section.

Background and Objectives: Regional anesthesia (spinal and epidural) is the method of choice for cesarean surgery, and frequency used during elective cesarean section. In emergent situation, general anesthesia is preferred. The aim of this study was to compare between general anesthesia and spinal anesthesia on neonate's Apgar score delivered by cesarean surgery. Materials and Methods: In a prospective study, 75 patients who were candidate for cesarean section with term fetus were randomly divided into three groups each 25 patients. The first group underwent spinal anesthesia with 5% Lidocaine, second group received general anesthesia with propofol (2mg/Kg) and third one anesthetized generally with thiopental sodium (5mg/kg). Apgar score of neonates were evaluated and recorded in each group at 1,5,10 and 15 minutes after delivery. Data were analyzed with SPSS.13 software by ANOVA test. Results: Average neonatal Apgar's in first minute of delivery in different groups was as the followings: propofol 9.04±1.31, sodium thiopental 8.80±1.41 and spinal anesthesia 9.12±0.93 (P=0.636).The result of apgar score measurements in each group at fifth minutes after delivery was as the following: sodium thiopental 9.72±0.67, propofol 9.44±0.77 and spinal anesthesia 9.68±0.56 (P=0.289). The results of the same measurements at 10th and 15th minutes are as the following succedingly: sodium thiopental: 9.80±0.65, propofol: 10 spinal anesthesia 9.96±0.20 (P=0.166) and sodium thiopental 9.92±0.28, propofol 10, spinal anesthesia 10(P=0.132). Conclusion: General anesthesia with sodium thiopental or propofol and spinal anesthesia didn't have any significant effect on neonatal Apgar

SENSORY REGRESSION TIME FROM SUBARACHNOID BLOCK WITH HYPERBARIC 0.75% BUPIVACAINE IN THE OBESE PATIENT

The purpose of this study was to determine if obese patients have a different sensory regression time from subarachnoid block than non-obese patients using hyperbaric 0.75% bupivacaine. A quasi-experimental design was used. Twenty patients were separated into two groups; one group was classified as obese, and the other group was classified as non-obese. The data consisting of age, height, weight, sex, and surgical procedure were recorded preoperatively. All the patients received hyperbaric 0.75% bupivacaine via subarachnoid puncture. The levels of spinal anesthesia were recorded at the highest level achieved. The injection time was also recorded. When the surgery was completed, the patient was transferred to the recovery room and levels of sensory blockade were checked by pin-prick with an 18-gauge needle every 10 minutes until complete recovery from the spinal anesthesia had been achieved. The hypothesis, there will be no difference in sensory regression time from SAB with hyperbaric 0.75% bupivacaine between obese and non-obese patients, failed to be rejected. No statistically significant difference, using linear regression analysis, was found in mean regression time between groups (obese versus non-obese)

Higher occurrence of nausea and vomiting after total hip arthroplasty using general versus spinal anesthesia: an observational study.

BACKGROUND: Under the assumption that postoperative nausea and vomiting (PONV) may occur after total hip arthroplasty (THA) regardless of the anesthetic technique used, it is not clear whether general (GA) or spinal (SA) anesthesia has higher causal effect on this occurrence. Conflicting results have been reported. METHODS: In this observational study, we selected all elective THA interventions performed in adults between 1999 and 2008 in a Swiss orthopedic clinic under general or spinal anesthesia. To assess the effect of anesthesia type on the occurrence of PONV, we used the propensity score and matching methods, which allowed us to emulate the design and results of an RCT. RESULTS: Among 3922 procedures, 1984 (51 %) patients underwent GA, of which 4.1 % experienced PONV, and 1938 underwent SA, of which 3.5 % experienced PONV. We found that the average treatment effect on the treated, i.e. the effect of anesthesia type for a sample of individuals that actually received spinal anesthesia compared to individuals who received GA, was ATET = 2.00 % [95 % CI, 0.78-3.19 %], which translated into an OR = 1.97 [95 % CI 1.35; 2.87]. CONCLUSION: This suggests that the type of anesthesia is not neutral regarding PONV, general anesthesia being more strongly associated with PONV than spinal anesthesia in orthopedic surgery

Effect of oral tizanidine on prolongation of intrathecal lidocaine

Objective: In order to prolong the duration of intrathecal lidocaine, various drugs are used along with it. Due to the promising effects of tizanidine on central nervous system, it can be assumed that tizanidine can have a positive effect on increasing the anesthesia duration too. Thus, we aimed to investigate the effect of oral tizanidine on the duration of lidocaine spinal anesthesia. Methods: This double blind clinical trial was conducted on 40 male patients waiting for elective leg surgery with the age range of 20-60 years in one of the educational hospitals of Kerman University of Medical Sciences, Iran. We used simple random sampling and our participants were assigned into 2 groups (placebo and oral tizanidine receivers). Spinal anesthesia with 1 mg/kg of hyperbaric lidocaine 5% was performed in both groups. In tizanidine group, patients received 4 mg of oral tizanidine one hour before spinal anesthesia. Sensory block was examined by pin prick test and all anesthetic duration including start block until reduction of sensory level was calculated at 2 lower dermatomes. Results: Findings showed that oral tizanidine compared to placebo can cause a 10-15 minute increase in patients’ lidocaine spinal anesthesia. Therefore, the average anesthesia time for tizanidine group increased meaningfully (P= 0.03). In addition, tizanidine can sedate patients during surgery (P= 0.00) or in recovery (P= 0.003). Conclusion: Based on the results, tizanidine increased the duration of lidocaine so oral tizanidine can be used to prolong the duration of lidocaine spinal anesthesia. Keywords: Tizanidine, Intrathecal lidocaine, Spinal anesthesi

Perioperative and anesthetic deaths: toxicological and medico legal aspects

Background: Anesthesia has become safer during decades, though there is still a preventable mortality; the complexity of medical and surgical interventions, increasingly older and sicker patients, has created a host of new hazards in anesthesiology. In this paper, some of these perioperative (PO) fatal adverse events are investigated in terms of health responsibility. Selective literature research in several data bases, concerning perioperative and anesthetic deaths and medical responsibility, was performed. Main text: A generally accepted definition of the anesthesia and perioperatory-related death still remains one of the major concerns in forensic pathology, and the terms “operative deaths” and “anesthetic deaths” are usually applied inaccurately within the medico-legal literature. Such events involve comprehensively PO fatalities and allow for subtle separation of natural and unnatural death, at least from the prospective of forensic pathology. Iatrogenic deaths in this field can be separated into some major categories, as attributable to previous patient’s unfavorable conditions or depending from surgical procedure per se (such as PO cardiac and cerebrovascular events). In this review, the authors carried out syntheses of specific research areas regarding epidemiology, complications of general and spinal anesthetic, failure in airway management and patient’s circulatory homeostasis, and adverse drugs reactions; analysis considering the challenge of anesthetic-related mortality, epidemiology and classifications, by indicating causal chain of death, in respect of both contributing and associated anesthetic and surgery facts. Conclusions: Perioperative quality control programs and its relevance for medico-legal evaluation are emphasized as, although mortality rates have decreased worldwide over the last decades, however, preventable drug-related deaths still happen. Such fatal events have to be considered within the field of forensic pathology experts, with regard of malpractice claims, to implement a strategy for preventing potentially fatal complications