Effects of Neuraxial Blockade May Be Difficult To Study Using Large Randomized Controlled Trials: The PeriOperative Epidural Trial (POET) Pilot Study

Early randomized controlled trials have suggested that neuraxial blockade may reduce cardiorespiratory complications after non-cardiothoracic surgery, but recent larger trials have been inconclusive. We conducted a pilot study to assess the feasibility of conducting a large multicentre randomized controlled trial in Canada.After Research Ethics Board approvals from the participating institutions, subjects were recruited if they were > or = 45 years old, had an expected hospital stay > or = 48 hours, were undergoing a noncardiothoracic procedure amenable to epidural analgesia, met one of six risk criteria, and did not have contraindications to neuraxial blockade. After informed consent, subjects were randomly allocated to combined epidural analgesia (epidural group) and neuraxial anesthesia, with or without general anesthesia, or intravenous opioid analgesia (IV group) and general anesthesia. The primary outcomes were the rate of recruitment and the percents of eligible patients recruited, crossed over, and followed completely. Feasibility targets were defined a priori. A blinded, independent committee adjudicated the secondary clinical outcomes. Subjects were followed daily while in hospital and then at 30 days after surgery. Analysis was intention-to-treat. Over a 15-month period, the recruitment rate was 0.5+/-0.3 (mean+/-SEM) subjects per week per centre; 112/494 (22.7%) eligible subjects were recruited at four tertiary-care teaching hospitals in Canada. Thirteen (26.5%) of 49 subjects in the epidural group crossed over to the IV group; seven (14.3%) were due to failed or inadequate analgesia or complications from epidural analgesia. Five (9.8%) of 51 subjects in the IV group crossed over to the epidural group but none were due to inadequate analgesia or complications. Ninety-eight (97.0%) of 101 subjects were successfully followed up until 30 days after their surgery.Of the criteria we defined for the feasibility of a full-scale trial, only the follow-up target was met. The other feasibility outcomes did not meet our preset criteria for success. The results suggest that a large multicentre trial may not be a feasible design to study the perioperative effects of neuraxial blockade.ClinicalTrials.gov NCT 0221260 Controlled-Trials.com ISRCTN 35629817

Platelet Counts and Coagulation Tests Prior to Neuraxial Anesthesia in Patients With Preeclampsia: A Retrospective Analysis

This retrospective, descriptive study aimed to assess hematologic testing practices in 100 patients with preeclampsia undergoing neuraxial blockade (NB). Prior to NB, platelet (PLT) count was performed in 61 (98%) of 62 women in labor and in 37 (97%) of 38 women undergoing cesarean delivery (CD). No patients had a pre-NB PLT count 12 hours. The lack of consistency in pre-NB coagulation testing and the variable time intervals between laboratory tests and NB may be due to a lack of consensus among anesthesiologists for determining “safe” hemostatic conditions for NB placement in patients with preeclampsia

Optimal point of insertion of the needle in neuraxial blockade using a midline approach: Study in a geometrical model

Performance of neuraxial blockade using a midline approach can be technically difficult. It is therefore important to optimize factors that are under the influence of the clinician performing the procedure. One of these factors might be the chosen point of insertion of the needle. Surprisingly few data exist on where between the tips of two adjacent spinous processes the needle should be introduced. A geometrical model was adopted to gain more insight into this issue. Spinous processes were represented by parallelograms. The length, the steepness relative to the skin, and the distance between the parallelograms were varied. The influence of the chosen point of insertion of the needle on the range of angles at which the epidural and subarachnoid space could be reached was studied. The optimal point of insertion was defined as the point where this range is the widest. The geometrical model clearly demonstrated, that the range of angles at which the epidural or subarachnoid space can be reached, is dependent on the point of insertion between the tips of the adjacent spinous processes. The steeper the spinous processes run, the more cranial the point of insertion should be. Assuming that the model is representative for patients, the performance of neuraxial blockade using a midline approach might be improved by choosing the optimal point of insertion

WHAT IS YOUR UNDERSTANDING OF SPINAL AND EPIDURAL ATTEMPT?

Background: The practice of spinal and epidural anaesthesia is well established the world over for a number of years. Sighting of spinal or epidural is conducted through various approaches at various levels of the spinal column. The number of attempts has its correlation with the post-spinal and epidural complications.Aim: The aim is to gather information about the understanding among the anaesthetists about the spinal/epidural attempt.Materials and Methods: A pro forma comprising of nine closed-loop questions was distributed to all the participants in the study, and they were requested to fill it anonymously and placed it back in a designated sealed box in anaesthetic  office.Results: A total of 20 pro formas were distributed, and all of them received back with 100% responses. All the participants accepted universally that attempting through another space makes it a second attempt. One of the respondents thought any backward movement means 2nd attempt, the majority of the responders thought it does not count as an attempt. Almost everyone considered another attempt if a needle is completely withdrawn and enters through another puncture site whether through a midline or paramedian approach.Conclusion: Most of the complications after neuraxial blockade are associated with the number of attempts alongside other factors that may play a role. A universal definition of a spinal and epidural attempt may decrease the complications associated with the central neuraxial blockade.Key words: Epidural, single attempt, spina

Perioperative management of geriatric patients for orthopedic surgeries

With increasing life expectancy, the mean age of patient orthopedicians and anesthesiologists have to deal with is increasing. In this review article, we discuss the case management of three centurions aged 110, 105 and 102 years respectively who underwent lower limb orthopedic surgery under nerve block, general anesthesia and neuraxial blockade, and elaborate on the various issues faced perioperatively by the treating team. The challenges and differences faced in perioperative period in geriatric anesthesia were discussed and literature reviewed for the benefit of the operating surgeons

Unilateral radiculopathy away from the puncture site due to adhesive arachnoiditis after spinal anesthesia for an emergent cesarean delivery: a case report

[Background] Adhesive arachnoiditis has been described as a deteriorating neurological complication after neuraxial blockade; however, few pieces of literatures have reported minor cases that resemble peripheral neuropathy. [Case presentation] A 29-year-old nulliparous woman underwent an emergent cesarean delivery under spinal anesthesia at the second and third lumbar interspace (L2/3) without any specific concerns. Subsequently, she developed left L5 and sacral first (S1) radiculopathy that persisted for 2 months. Although the neurological findings more likely indicated peripheral neuropathy, magnetic resonance imaging revealed localized adhesive arachnoiditis at the left L5/S1 level. Her symptoms gradually improved and entirely disappeared within 2 months without any particular treatment. [Conclusion] The neurological symptoms that show a clear tendency to improve spontaneously do not always undergo a detailed workup. Therefore, such minor adhesive arachnoiditis might have occurred more than expected. Imaging such cases might cumulatively further the understanding of its etiology

Comparison of ropivacaine alone or with dexamethasone as an adjuvant for reducing pain during positioning for neuraxial blockade with ultrasound-guided fascia iliaca compartment block

Background: Comparison of ropivacaine alone or with dexamethasone as an adjuvant for reducing pain during positioning for neuraxial blockade with ultrasound-guided fascia iliaca compartment block.Methods: In this double-blinded study, a total of 60 patients between 18 to 80 years of age, undergoing surgery for hip fracture were enrolled. Patients in Group A received 40 ml of 0.25% ropivacaine +2 ml saline and patients in Group B received 40 ml of 0.25% ropivacaine +8 mg dexamethasone. USG guided FICB and postoperative monitoring was done by the chief investigator who was unaware of group allotted and drug administered.Results: There is no significant difference in the heart rate between the two groups after 30 min of the block. The variation of systolic blood pressure of both the group for the first 30 min after giving FICB block was not significant (p>0.05). The absolute value of diastolic blood pressure (DBP) was significantly lower in Group B compared to group A just before the block, a variation of DBP with time was not significant. There was a gradual improvement of pain score from mean 6.7 in Group A and 6.6 in Group B at 0 min to score of 2 at the end of 30 min in both the group. This improvement was achieved earlier in Group B compared to Group A, although the difference was not significant (p>0.05). Vital parameters like HR, SBP, DBP, SpO2 values were similar in both the groups. No patients in either group required any interventions both pre-operatively and pos-operatively. Time of rescue analgesia was noted with the VAS score was significantly more in Group B (p≤0.004). The incidence of hematoma, accidental intravascular injection, convulsion, and paresthesia were nil in both groups.Conclusions: Although both the groups had comfortable and pain-free positioning for administering spinal anaesthesia before surgery. USG guided FICB is easy to perform block and give excellent analgesia for positioning and mobilization of hip fracture patients pre and post-operatively both, and dexamethasone as an adjuvant to 0.25%ropivavaine prolong its local anesthetic effect significantly

Management of bleeding or urgent interventions in patients treated with direct oral anticoagulants : 2017 recommendations for Poland

Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban are mainly used in the prevention of thromboembolic complications in patients with atrial fibrillation (AF) and in the treatment of venous thromboembolism. As compared with vitamin K antagonists (VKAs), they are characterized by at least similar efficacy and better safety profiles, especially with respect to intracranial hemorrhages. Moreover, they are more convenient therapeutic agents. The 2016 European Society of Cardiology guidelines clearly favor DOACs over VKAs in patients with AF. However, DOAC therapy is also associated with the risk of bleeding complications. The aim of this review was to provide recommendations for the management of bleeding complications during DOAC therapy in the Polish setting. The recommendations were based on the most important documents concerning this issue and were developed by representatives of different medical specialties. Experience in managing cases of bleeding on DOAC therapy is still limited. Therefore, we hope that this publication will be helpful in everyday clinical practice and that it will be useful for developing in‑hospital recommendations for the management of patients with DOAC‑related bleeding