Failed spinal anesthesia for cesarean delivery: prevention, identification and management.

PURPOSE OF REVIEW: There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important. RECENT FINDING: Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery. SUMMARY: Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.

Effects of the Sufentanil and Dexmedetomidine Combination on Spinal Anesthesia in Patients Undergoing Lower Abdominal or Lower Extremity Surgery: A Double-Blind Randomized Controlled Trial.

Background: Intrathecal additive drugs are becoming increasingly common in anesthesia practice. We aimed to evaluate the additive effects of dexmedetomidine on spinal anesthesia with sufentanil in patients undergoing lower abdominal or lower limb surgery. Methods: This double-blind randomized controlled trial was performed in Mashhad, Iran, between 2017 and 2018. Sixty patients undergoing lower abdominal or lower limb surgery were randomly divided to receive 15 mg of bupivacaine and 3 µg of sufentanil (control group; n=30) or 15 mg of bupivacaine, 3 µg of sufentanil, and 10 µg of dexmedetomidine (intervention group; n=30). Outcomes, comprised of the onset and regression of sensory and motor blocks, the duration of analgesia, analgesic use, hemodynamic parameters, and side effects, were assessed. The data were analyzed in the SPSS software (version 22), using different statistical tests. A P value of less than 0.05 was considered significant. Results: The times of sensory and motor blocks reaching T10 and Bromage 3, respectively, were significantly shorter, while the times of sensory and motor regressions to S1 and Bromage 0, correspondingly, were significantly longer in the intervention group than in the control group (P<0.001). Both the frequency (P=0.006) and the dose (P<0.001) of postoperative analgesic use were significantly lower, and the duration of analgesia was significantly longer in the intervention group (P<0.001). The frequency of side effects and changes in hemodynamic parameters had no significant differences between the groups. Conclusion: The sufentanil and dexmedetomidine combination in spinal anesthesia caused the earlier onset and later regression of sensory and motor blocks, longer postoperative analgesia, and lower analgesic use without significant side effects or hemodynamic changes, which appears to be due to the combined effects of sufentanil and dexmedetomidine. Trial Registration Number: IRCT2017082833680N3.

A qualitative study of the operating room experience of patients who underwent surgery under spinal anesthesia: "It was like an adventure".

This study aimed to explore the experiences of the people who underwent orthopedic surgery under spinal anesthesia and to report their feelings and thoughts. The study was carried out using a qualitative approach. Twenty-one patients were interviewed who underwent orthopedic surgery on the first or second postoperative day. Content analysis was performed after the collection of raw data. NVIVO 12 Pro software was used for data analysis. The frequency count (f) and participant codes (P) were used for the presentation of the findings. The themes and frequency counts obtained by analyzing the interviews with the patients were as follows: "Time passed like watching a movie" (f = 213), "Like an adventure" (f = 587), and "See, feel, look" (f = 405). Five of 21 participants (23.8%) stated that they would not recommend spinal anesthesia. The findings generally indicated the anxiety caused by the unknown, fear in the preanesthetic period, operation experienced like an adventure, and a process generally completed with satisfaction.

A Comparison of Spinal Anesthesia Versus Monitored Anesthesia Care With Local Anesthesia in Minimally Invasive Fetal Surgery.

BACKGROUND: Minimally invasive fetal surgery is commonly performed to treat twin-to-twin transfusion syndrome with selective fetoscopic laser photocoagulation and twin-reversed arterial perfusion sequence using radiofrequency ablation. Although an increasing number of centers worldwide are performing these procedures, anesthetic management varies. Both neuraxial anesthesia and monitored anesthesia care with local anesthesia are used at different institutions. We sought to determine the efficacy and outcomes of these 2 anesthetic techniques for fetal procedures at our institution. METHODS: All patients undergoing minimally invasive fetal surgery for twin-to-twin transfusion syndrome or twin-reversed arterial perfusion sequence over a 6-year time period (2011-2016) were reviewed. Patients receiving monitored anesthesia care with local anesthesia were compared with those receiving spinal anesthesia in both selective fetoscopic laser photocoagulation and radiofrequency ablation fetal procedures. The primary outcome examined between the monitored anesthesia care and spinal anesthesia groups was the difference in conversion to general anesthesia using a noninferiority design with a noninferiority margin of 5%. Secondary outcome measures included use of vasopressors, procedure times, intraoperative fluids administered, maternal complications, and unexpected fetal demise within 24 hours of surgery. RESULTS: The difference in failure rate between monitored anesthesia care and spinal was -0.5% (95% CI, -4.8% to 3.7%). Patients receiving monitored anesthesia care plus local anesthesia were significantly less likely to need vasopressors, had a shorter presurgical operating room time, and received less fluid (P < .001). Operative time did not differ significantly. CONCLUSIONS: Monitored anesthesia care plus local anesthesia is a reliable and safe anesthetic choice for minimally invasive fetal surgery. Furthermore, it decreases maternal hemodynamic instability and reduces preincision operating room time.

General versus spinal anesthesia for the elderly hip fractured patient.

PURPOSE OF REVIEW: There is an urge to improve care for patients with hip fracture. The present review will compare the efficacy of spinal versus general anesthesia for patients requiring hip fracture surgery. RECENT FINDINGS: The present review gives an overview with particular emphasis on literature published during the past 24 months. SUMMARY: So far, no clear evidence form randomized trials exists to identify the best anesthesia technique for hip fracture surgery. However, several large-scale pragmatic trials are ongoing and will provide future guidance.

Conventional Landmark-Guided Midline Versus Preprocedure Ultrasound-Guided Paramedian Techniques in Spinal Anesthesia.

BACKGROUND: Multiple passes and attempts while administering spinal anesthesia are associated with a greater incidence of postdural puncture headache, paraesthesia, and spinal hematoma. We hypothesized that the routine use of a preprocedural ultrasound-guided paramedian technique for spinal anesthesia would reduce the number of passes required to achieve entry into the subarachnoid space when compared with the conventional landmark-guided midline approach. METHODS: One hundred consenting patients scheduled for elective total joint replacements (hip and knee) were randomized into group C (conventional) and group P (preprocedural ultrasound-guided paramedian technique) with 50 in each group. The patients were blinded to the study group. All spinal anesthetics were administered by a consultant anesthesiologist. In group C, spinal anesthetic was done via the midline approach using clinically palpated landmarks. In group P, a preprocedural ultrasound scan was used to mark the paramedian insertion site, and spinal anesthetic was performed via the paramedian approach. RESULTS: The average number of passes (defined as the number of forward advancements of the spinal needle in a given interspinous space, i.e., withdrawal and redirection of spinal needle without exiting the skin) in group P was approximately 0.34 times that in group C, a difference that was statistically significant (P = 0.01). Similarly, the average number of attempts (defined as the number of times the spinal needle was withdrawn from the skin and reinserted) in group P was approximately 0.25 times that of group C (P = 0.0021). In group P, on an average, it took 81.5 (99% confidence interval, 68.4-97 seconds) seconds longer to identify the landmarks than in group C (P = 0.0002). All other parameters, including grading of palpated landmarks, time taken for spinal anesthetic injection, periprocedural pain scores, periprocedural patient discomfort visual analog scale score, conversion to general anesthetic, paresthesia, and radicular pain during needle insertion, were similar between the 2 groups. CONCLUSIONS: Routine use of paramedian spinal anesthesia in the orthopedic patient population undergoing joint replacement surgery, guided by preprocedure ultrasound examination, significantly decreases the number of passes and attempts needed to enter the subarachnoid space.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

BACKGROUND: In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. METHODS: This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). RESULTS: Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). CONCLUSIONS: The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

[New short-acting local anaesthetics for spinal anaesthesia - Well-tried substances for ambulatory surgery]. / Neue kurzwirksame Lokalanästhetika in der Spinalanästhesie - Altbewährte Substanzen für ambulante Eingriffe.

More and more operative procedures are performed in an ambulatory setting. Many patients are denied spinal anaesthesia, although it provides several advantages. Innovative pharmaceutical formulations of well-tried local anaesthetics have created "new" substances that are ideal for ambulatory surgery due to their fast onset, short duration of action, and very low incidence of complications such as transient neurological symptoms (TNS). Both hyperbaric prilocaine 2% and preservative-free chloroprocaine 1% were recently approved for spinal application in Germany. Additional perioperative measures, such as the use of atraumatic, thin spinal needles (25 or 27G), restrictive volume management, and early patient mobilisation, lead to a further reduction of complications. The new S1 guideline of the German Society of Anaesthesiology and Intensive Care Medicine encourages us anaesthetists to use spinal anaesthesia more frequently in an ambulatory setting.

Implementación de un protocolo de anestesia raquídea para reparación de hernia inguinal en lactantes nacidos prematuros: experiencia en el Centro Hospitalario Pereira Rossell / Implementation of a spinal anesthesia protocol to repair inguinal hernia in extremely preterm breastfed babies. Experience conducted at the Pereira Rossel Hospital Center

Introducción: la anestesia raquídea está asociada a una menor incidencia de complicaciones respiratorias y una más rápida recuperación en relación a la anestesia general en lactantes exprematuros (menos de 37 semanas) sometidos a cirugía de reparación de hernia inguinal antes de las 60 semanas. Objetivo: presentar la experiencia de implementación de un protocolo en 15 niños con estas características. Material y método: los pacientes no presentaban comorbilidades, la paraclínica preoperatoria fue normal y la saturación periférica de oxígeno (SpO2) al aire entre 98% y 99%. La punción se realizó con agujas 25G Quincke 2,5 cm de longitud en posición sentada. Se administraron 0,5 ml de bupivacaína, 0,5% hiperbárica. Resultados: la técnica fue exitosa en 11 casos; de los cuatro fracasos, en tres no se accedió al espacio subaracnoideo y en un paciente el tiempo de bloqueo fue insuficiente para finalizar la cirugía requiriendo sedación adicional; promedio de intentos 1,6 ± 0,9 con 66,7% en el primer intento (n = 15); latencia del bloqueo motor 56,7 ± 13,5 seg (n = 12). Para una duración quirúrgica promedio de 46,2 ± 14,8 min, la duración del bloqueo fue de 63,2 ± 8,2 min, lográndose condiciones quirúrgicas adecuadas para finalizar el procedimiento en 11 pacientes. No hubo modificaciones hemodinámicas ni respiratorias significativas, salvo respiración paradojal sin desaturación arterial en dos casos. En sala de recuperación anestésica (SRA) se reinstaló la alimentación habitual junto a la madre, permaneciendo internados 24 horas sin presentar complicaciones. Conclusiones: la evaluación de la aplicación de este protocolo de anestesia raquídea mostró que es seguro, eficaz, y de rápida recuperación en este grupo de pacientes...

Anaesthesia in Ethiopia: providers' perspectives on the current state of the service.

The improvement of surgical and anaesthetic safety in low-resource settings is hampered by a lack of reliable information on the current provision of these services. Ethiopia is one of the world's poorest countries and, despite large amounts of both foreign and domestic investment, still reports some of the worst health outcomes. However, information on anaesthesia and surgical provision is sparse. This work reproduces a questionnaire study, first used in Uganda in 2006, to survey practising anaesthetists regarding the current state of anaesthesia services across Ethiopia. The results indicate that a large proportion of centres remain unable to provide safe general, spinal, paediatric and obstetric anaesthesia, at all levels of hospital and across almost all of the country's regions. In addition to a lack of equipment and pharmaceuticals, anaesthetists report problems with professional recognition and a lack of access to continuing professional development as key barriers to service development.

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials.

CONTEXT AND OBJECTIVE: Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery. DESIGN AND SETTING: Systematic review at Universidade Federal de Alagoas. METHODS: We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included. RESULTS: Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167). CONCLUSION: So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia.

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials / Anestesia neuroaxial para cirurgia ortopedica: revisao sistematica e metanalise de ensaios clinicos randomizados

CONTEXT AND OBJECTIVE: Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery. DESIGN AND SETTING: Systematic review at Universidade Federal de Alagoas. METHODS: We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included. RESULTS: Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167). CONCLUSION: So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia. .

CONTEXTO E OBJETIVO: Considerando o desfecho de mortalidade, existe controvérsia acerca dos efeitos benéficos da anestesia neuroaxial (AN) para cirurgias ortopédicas. O objetivo do estudo foi comparar efetividade e segurança da AN versus anestesia geral (AG) para cirurgias ortopédicas. TIPO DE ESTUDO E LOCAL: Revisão sistemática na Universidade Federal de Alagoas. MÉTODOS: Buscamos em Cochrane Central Register of Controlled Trials (2012, volume 10), PubMed (1966 até novembro de 2012), Lilacs (1982 até novembro de 2012), SciELO, EMBASE (1974 até novembro de 2012) e listas de referências dos estudos incluídos. Apenas ensaios clínicos randomizados foram incluídos. RESULTADOS: Dentre 5.032 títulos e resumos, 17 estudos foram incluídos. Não houve diferença estatística em mortalidade (diferença de risco, DR: -0,01; intervalo de confiança de 95%, IC: -0,04 a 0.01; n = 1903), em acidente vascular encefálico (DR: 0,02; IC 95%: -0,04 a 0,08; n = 259, em infarto miocárdico (DR: -0.01; IC 95%: -0,04 a 0.02; n = 291), tempo de hospitalização (diferença média, -0,05; IC 95%: -0,69 a 0,58; n = 870), em disfunção cognitiva pós-operatória (DR: 0,00; IC 95%: -0,04 a 0,05; n = 479) e pneumonia (razão de chances, 0,61; IC 95%: 0,25 a 1,49; n = 167). CONCLUSÃO: Até o momento, as evidências são insuficientes nos estudos incluídos para provar que AN é mais efetiva e segura do que AG para cirurgias ortopédicas. Esta revisão sistemática não descartou diferenças clínicas importantes para mortalidade, acidente vascular encefálico, infarto miocárdico, tempo de internação, disfunção cognitiva pós-operatória e pneumonia. .

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

BACKGROUND: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics.

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia. METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant. RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12-4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938-0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001-1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112-90.415], P < 0.001), respectively. CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.

Anestesia geral após falha da raquianestesia para procedimento de urgência em paciente com mucopolissacaridose: relato de caso / General anesthesia after failed spinal block for emergency surgery in a patient with mucopolysaccharidosis: case report

JUSTIFICATIVA E OBJETIVOS: As mucopolissacaridoses são grupo heterogêneo de doenças hereditárias que ocorrem devido à deficiência enzimática lisossomal com acúmulo de mucopolissacárides ácidos nos tecidos. A mortalidade perioperatória é de 20 por cento e deve-se principalmente à dificuldade no manuseio das vias aéreas. O objetivo deste relato foi apresentar a conduta anestésica adotada diante de paciente portador de mucopolissacaridose que se apresentou ao centro cirúrgico para realização de intervenção cirúrgica de urgência. RELATO DO CASO: Paciente de 15 anos, sexo masculino, com diagnóstico de mucopolissacaridose, deu entrada no centro cirúrgico para tratamento de hérnia umbilical encarcerada. Após monitorização, foi submetido à anestesia subaracnóidea com bupivacaína hiperbárica na posição sentada. Após identificar falha na raquianestesia, o paciente foi submetido à anestesia geral. A indução anestésica foi realizada com clonidina, fentanil e propofol por via venosa, seguida de intubação sem intercorrências. Após 45 minutos de procedimento cirúrgico, o paciente foi extubado e encaminhado à sala de recuperação pós-anestésica. Lá permaneceu por 12 horas sob observação, recebendo alta para enfermaria sem ter havido intercorrências durante esse período. CONCLUSÕES: No caso em questão, não houve dificuldade no manuseio das vias aéreas. Entretanto, esse é o principal problema encontrado nesse grupo de pacientes, cabendo ao anestesiologista escolher a melhor técnica para garantir adequado manuseio das vias aéreas.

BACKGROUND AND OBJECTIVES: Mucopolysaccharidosis are a group of heterogenous disorders secondary to the deficiency of a lysosomal enzyme, with accumulation of acid mucopolysaccharides in the tissues. It carries a 20 percent perioperative mortality rate due mainly to difficulties on handling the airways. The objective of this report was to present the anesthetic approach of a patient with mucopolysaccharidosis who presented in the operating room for emergency surgery. CASE REPORT: A 15 year-old male patient with a diagnosis of mucopolysaccharidosis was admitted to the operating room for treatment of an incarcerated umbilical hernia. After monitoring, a subarachnoid block with hyperbaric bupivacaine was performed with the patient in the sitting position. After identifying failure of the spinal block it was changed to general anesthesia. Anesthetic induction consisted of intravenous clonidine, fentanyl and propofol, followed by endotracheal intubation without intercurrences. After a 45-minute surgery, the patient was extubated and transferred to the postanesthetic care unit where he remained under observation for 12 hours, being discharged to the regular ward without intercurrences. CONCLUSIONS: In the case presented here we did not have any difficulties handling the airways. However, this is the main problem in this group of patients and it is up to the anesthesiologist to choose the better technique to guarantee adequate handling of the airways.

JUSTIFICATIVA Y OBJETIVOS: Las mucopolisacaridosis son un grupo heterogéneo de enfermedades hereditarias que ocurren debido a la deficiencia enzimática lisosomal con acumulación de muco polisacáridos ácidos en los tejidos. La mortalidad perioperatoria es de un 20 por ciento y se debe principalmente a la dificultad en el manejo de las vías aéreas. El objetivo de este relato fue el de presentar la conducta anestésica adoptada con paciente portador de muco polisacaridosis que se presentó en el centro quirúrgico para la realización de intervención quirúrgica de urgencia. RELATO DEL CASO: Paciente de 15 años, sexo masculino, con diagnóstico de muco polisacaridosis, llegó al centro quirúrgico para tratamiento de hernia umbilical encarcelada. Después de la monitorización, se sometió a la anestesia subaracnoidea con bupivacaina hiperbárica en la posición sentado. Después de identificar la falla en la anestesia raquidea, el paciente fue sometido a la anestesia general. La inducción anestésica fue realizada con clonidina, fentanil y propofol por vía venosa, seguida de intubación sin intercurrencias. Después de 45 minutos de procedimiento quirúrgico, el paciente fue extubado y llevado a recuperación anestésica. Allá estuvo por 12 horas bajo observación, recibiendo alta para enfermería sin haber tenido intercurrencias durante ese período. CONCLUSIONES: En el caso en cuestión, no hubo dificultad en el manejo de las vías aéreas. Sin embargo, ese es el principal problema encontrado en ese grupo de pacientes, cabiéndole al anestesiólogo escoger la mejor técnica para garantizar un adecuado manoseo de las vías aéreas.

Microdiscectomy: spinal anesthesia offers optimal results in general patient population.

Spinal anesthesia provides a safe and highly satisfactory alternative to general anesthesia in patients undergoing limited lumbar surgery. Nevertheless, it is not commonly used for spinal surgery, and in some centers it is not even considered as an option for spinal procedures. This study presents the current anesthetic technique for patients undergoing microdiscectomy and compares the peri- and postoperative outcomes in 76 patients drawn from a case-controlled study group. Patients underwent microdiscectomy for herniated nucleus pulposus under spinal (43 patients) or general anesthesia (33 patients). Patients ranged from 18 to 40 years, and all were anesthesia class 1. Surgical and anesthesia times were longer for the general anesthetic group, as was total anesthetic time. Urinary retention was more common in the general anesthesia group (p = .035). Postanesthetic care unit admission times were significantly shorter among general anesthetic patients compared with spinal anesthetic patients (p < .001). Spinal anesthesia patients required less pain medication and experienced less nausea and emesis. Even among young, medically fit patients, spinal anesthesia provided specific advantages over general anesthesia, including decreased anesthesia time, decreased nausea and antiemetic requirements, reduced analgesic requirements, and a trend toward lower complication rates and shorter hospital stay. Both surgeon and patient satisfaction with this anesthetic approach is high.

[Anesthetic support of operations on the hip joint in senile patients].

The impact of spinal anesthesia on a surgical stress response during prosthetic repair of the hip joint was studied in 56 senile patients (mean age 76 +/- 2.1 years). Hemodynamic changes, the time course of fluid distribution in different sectors, the activities of sympathoadrenal, cholinergic, serotoninergic, and histaminergic systems were analyzed. Studies were conducted in 4 steps: before a planned operation, before anesthesia, after the end of surgery, and 24 hours after intervention. The characteristic features of hemodynamic changes were elevated left ventricular filling pressure and high specific peripheral resistance, which was regarded as signs of latent heart failure and age-related vascular tone regulatory changes. Involutional tissue processes in senile patients appeared as decreased water levels in the cellular sector. The patients' sympathoadrenal and enterochromaffin systems were in a state of hypofunction. The adequacy of anesthesia supports no trend in the study neurohumoral regulatory parameters. The low level of hormones and mediators confirms the true depletion of the neurohumoral regulatory system.

[Survey on current practice of regional anaesthesia in Germany, Austria, and Switzerland. Part 2: Use, success rates and techniques]. / Umfrage zur aktuellen Situation der Regionalanästhesie im deutschsprachigen Raum. Teil 2: Anwendung, Erfolgsraten und Techniken.

The current practice of regional anaesthesia in German-speaking countries was investigated in a survey. The second part of the trilogy presents data about its use, success rates, and techniques. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia of which 384 hospitals participated. Peripheral regional anaesthesia is used above all in traumatology and orthopaedics, 45% of the hospitals with paediatric surgery never used neuroaxial blocks. The residents achieved mean success rates of 69.7+/-11.8% for supraclavicular plexus block to 85.5+/-9.0% for spinal anaesthesia, the specialists in anaesthesia 79.2+/-11.3% (supraclavicular plexus block) to 91.0+/-6.8% (spinal anaesthesia). Standards for basic techniques, recording of success rates, and for quality assurance of peripheral nerve blocks should be worked out to improve the application of peripheral regional anaesthesia procedures. In neuroaxial anaesthesia satisfying success rates were reached in German-speaking countries. In paediatric anaesthesia its use still has many opponents.

[Atkinson's retrobulbar anesthesia. A quality control study]. / Die Retrobulbäranästhesie nach Atkinson. Eine Qualitätskontrollstudie.

PURPOSE OF THE STUDY: Recognized local and systemic complications of retrobulbar anaesthesia (RA) are well known. The purpose of this study was to determine which clinical signs predict the success of the RA technique. METHODS: We prospectively investigated 500 consecutive patients scheduled for elective eye surgery for cataracts and for vitreoretinal procedures. Anaesthesia was administered using the Atkinson RA technique while for preoperative quality control, the following parameters were recorded: chemosis, eye motility, preservation of vision, active eyelid movement, and burning caused by disinfection. For analysis, a multidimensional model designed to be useful for forecasting results of the anaesthetic outcome was used. The RA was labeled as a "success" when no supplementary anaesthetics were required. "Partial success" was defined as an incomplete RA with supplementary subconjunctival anaesthetic requirement or an anaesthetic given in the form of eyedrops. In the case of "RA failure", the RA had to be repeated. RESULTS: The success rate for RA was higher for cataract operations than for glaucoma operations. The success rate was not associated with the choice of the local anaesthetic, the application of ocular, compression, or the anaesthetists and surgeons who performed the RA. Burning caused by disinfectant, lid opening and temporal eye motility were found not to be associated with a successful outcome. The presence of chemosis had no influence on the success of anaesthesia. CONCLUSIONS: The results of this study demonstrated that prognostic factors such as defined existing clinical signs, are early predictors of the success of the Atkinson RA.