Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study.

BACKGROUND: Lumbar epidural analgesia (LEA) is commonly used for labor analgesia but up to 13% of epidural catheters fail and require replacement. Combined spinal-epidural analgesia is associated with a lower catheter failure rate. Few data exist regarding catheter replacement rates after dural-puncture epidural (DPE). We conducted a retrospective analysis comparing catheter failure rates between epidural and DPE techniques. METHODS: This retrospective single-center trial reviewed all labor neuraxial analgesia procedures among 18 726 women across five years, and identified 810 DPE and 2667 LEA procedures. Catheter failure rates, consisting of replacement or requirement of general anesthesia for cesarean delivery, were compared. Propensity score matching was used to balance the groups. RESULTS: Dural-puncture epidural was associated with significantly fewer catheter failures compared with LEA (74/759 vs. 49/759, odds ratio 0.64, 95% CI 0.44 to 0.93, P=0.02). Sensitivity analysis excluding cases of general anesthesia confirmed this relationship. Risk factors identified for catheter failure included age, body mass index, and nulliparity. Dural-puncture epidural was associated with a longer mean time to catheter replacement (918 min vs. 609 min, P=0.04). Kaplan-Meier and Cox multivariate analyses confirmed this relationship. There was no significant difference in the requirement for epidural analgesia supplementation, but DPE required supplementation significantly later than LEA. There was no difference in the rate of headache or epidural blood patch between groups. CONCLUSIONS: Dural-puncture epidural is associated with fewer catheter failures and replacements than LEA, without an increase in the rate of post-dural puncture headache or epidural blood patch.

An evaluation of preoperative anxiety in a population of parents of infants and children undergoing ambulatory surgery.

We attempted to identify specific predictors of preoperative parental anxiety in a population of parents of healthy infants and children undergoing elective, outpatient surgery. We specifically examined the following factors: age of the child, whether or not the child had previous surgery, whether or not the parents' other children had previous surgery, parental gender, highest level of education obtained by the parent, and whether or not there was prior discussion between the parent and anaesthesiologist. In the immediate preoperative period, a questionnaire (State-Trait Anxiety Inventory) was given to all parents of infants and children presenting for elective, outpatient surgery. Six hundred parents of 417 children, aged two months to 16 years (mean = 4.5 years), participated in the study. They included 388 mothers and 212 fathers. Our results indicate that parents are more anxious when their child is less than one year of age and when it is the child's first surgery. When assessed separately by parental gender, both these factors were significant for mothers but not their fathers. We recommend that, although anaesthesiologists generally tailor their preoperative preparation based upon the best needs of their patients and families, they pay special attention to the groups we have identified which are at increased risk for preoperative anxiety.

Of mice and men: an introduction to mouseology or, anal eroticism and Disney.

This essay deals with two important comics, Walt Disney's Mickey Mouse and George Herriman's Krazy Kat, and considers the social, cultural, psychological and symbolic significance of the main characters and their creators. In the discussion of Disney and his work (based, in part on writings about him) it is suggested that he exhibited traits associated with anal eroticism, which raises an interesting question about the popularity of his work with the American public. The two dominant themes found in Krazy Kat are described as "the triumph of illusion over reality" and "anti-authoritarianism." In a comparison of the two characters, it is shown they are polar opposites: Mickey Mouse is sadistic, asexual, and anal while Ignatz Mouse, the hero of Krazy Kat, is playful, sexual, and phallic.