Good outcome with conservative treatment of delayed spinal epidural hematoma following combined spinal-epidural anesthesia: a rare case report.

BACKGROUND: Delayed spinal epidural hematoma (SEH) following central neuraxial block (CNB) is a rare but serious complication. The underlying causes of SEH associated with neuraxial anesthesia are still unclear. Furthermore, the decision between surgical intervention and conservative management for SEH remains a complex and unresolved issue. CASE PRESENTATION: We report a case of delayed SEH in a 73-year-old woman who underwent vaginal hysterectomy under combined spinal-epidural anesthesia, with the administration of postoperative anticoagulants to prevent deep vein thrombosis on the 1st postoperative day (POD). She experienced symptoms 56 h after CNB. Magnetic resonance imaging (MRI) revealed a dorsal SEH at the L1-L4 level with compression of the thecal sac. On conservative treatment, full recovery was achieved after six months. CONCLUSIONS: This case reminds anesthesiologists should be alert to the possible occurrence of a delayed SEH following CNB, particularly with the administration of anticoagulants. Immediate neurological evaluation of neurological deficit and MRI are advised. Conservative treatment combined with close and dynamic neurological function monitoring may be feasible for patients with mild or nonprogressive symptoms even spontaneous recovery.

Caudal Neuraxial Blocks for Pain Relief From Pelvic Neuropathy Caused by Extensive Diffuse Large B-cell Lymphoma.

Central neuraxial blocks can be a vital therapeutic tool for neuropathic pain, but they are infrequently implemented for pain management in cancer patients. Upon a literature review, further data on the role or efficacy of central nerve blocks for neuropathic cancer pain would be beneficial. Additionally, evidence-based guidelines and practices are lacking regarding additional interventions for neuropathic pain relief, a common manifestation of cancer burden. Here, we report the case of a 29-year-old male patient who presented in the ED with intractable neuropathic pain from extensive diffuse large B-cell lymphoma. The patient demonstrated left lower extremity pain, fevers, chills, and tenderness with erythema over the site of his port-a-catheter on his chest. The patient was also hypotensive, despite IV fluid resuscitation. Recent imaging showed a hypermetabolic soft tissue mass in the left upper quadrant of the abdomen. There was also extensive cancer spread in the peripheral pelvis, presacral region, and within multiple sacral foramina, with a secondary perineural spread of the tumor. The patient previously positively responded to a caudal nerve block at an outpatient pain clinic. The patient was admitted to the ICU for three days, and following the resolution of sepsis, the patient received caudal and sciatic nerve blocks on admission day 8. Upon further imaging showing metastasis to the brain, the patient was discharged to inpatient hospice on hospitalization day 10 following a palliative conversation with the patient and family.

Assessing the Efficacy of Inferior Vena Cava Collapsibility Index for Predicting Hypotension after Central Neuraxial Block: A Systematic Review and Meta-Analysis.

The use of ultrasonography to predict spinal-induced hypotension (SIH) has gained significant attention. This diagnostic meta-analysis aimed to investigate the reliability of the inferior vena cava collapsibility index (IVCCI) in predicting SIH in patients undergoing various surgeries. Databases, including Embase, Cochrane Library, Medline, and Google Scholar, were screened until 28 July 2023, yielding 12 studies with 1076 patients (age range: 25.6-79 years) undergoing cesarean section (CS) (n = 4) or non-CS surgeries (n = 8). Patients with SIH had a significantly higher IVCCI than those without SIH (mean difference: 11.12%, 95% confidence interval (CI): 7.83-14.41). The pooled incidence rate of SIH was 40.5%. IVCCI demonstrated satisfactory overall diagnostic reliability (sensitivity, 77%; specificity, 82%). The pooled area under the curve (AUC) was 0.85, indicating its high capability to differentiate patients at risk of PSH. The Fagan nomogram plot demonstrated a positive likelihood ratio (PLR) of 4 and a negative likelihood ratio (NLR) of 0.28. The results underscore the robustness and discriminative ability of IVCCI as a predictive tool for SIH. Nevertheless, future investigations should focus on assessing its applicability to high-risk patients and exploring the potential enhancement in patient safety through its incorporation into clinical practice.

Continuous spinal technique in surgery and obstetrics.

Continuous Spinal Anaesthesia (CSA) technique has all the advantages of single-shot spinal anaesthesia with the added benefit of prolonging the duration of anaesthesia. CSA has been used as a primary method of anaesthesia as an alternative to general anaesthesia in high-risk and elderly patients for various elective and emergency surgical procedures involving the abdomen, lower limbs, and vascular surgeries. CSA has also been used in some obstetrics units. Despite its advantages, CSA technique remains underutilised because it is surrounded with myths, mysteries, and controversies concerning neurological, other morbidities and minor technical difficulties. This article includes a description of CSA technique compared to other contemporary central neuraxial blocks. It also discusses the perioperative applications of CSA for different surgical and obstetrics procedures, advantages, disadvantages, complications, problems, and pointers on how to perform the technique safely.

Defining the role of thoracic spinal anaesthesia in the 21st century: a narrative review.

Since the performance of the first thoracic spinal anaesthetic in early 1908 many anaesthetists have gained interest in this unorthodox neuraxial anaesthetic technique. The main rationale justifying its use is to prevent complications related to general anaesthesia in high-risk patient populations. There is, however, significant debate regarding this practice around the world. The main concerns are fear of iatrogenic injury to the spinal cord, cephalad spread of local anaesthetic causing a complete spinal block, and haemodynamic instability owing to blockade of cardioaccelerator sympathetic fibres. The purpose of this narrative review is to appraise the literature critically regarding thoracic spinal anaesthesia, to synthesise the available information, and to provide a summary of evidence justifying its use in modern anaesthesia.

Central neuraxial analgesia for labor: an update of the literature.

Numerous techniques are in use to provide analgesia for labor, of which central neuraxial block is widely considered superior to non-neuraxial options. Central neuraxial techniques have evolved over many years to provide greater efficacy, safety and maternal satisfaction. This narrative review focuses on the literature relating to central neuraxial labor analgesia from the past 5 years, from November 2010 to October 2015. We discuss the evidence related to the various central neuraxial techniques used, the increasingly widespread use of ultrasound guidance and the evidence surrounding other novel methods of central neuraxial block insertion. The timing of institution of central neuraxial analgesia in labor is considered, as are the advances in maintenance regimens for labor analgesia.

Electrolyte changes: An indirect method to assess irrigation fluid absorption complications during transurethral resection of prostate: A prospective study.

CONTEXT: Fluid absorption is inevitable complication of transuretheral resection of prostate and serum electrolytes changes can indirectly assess the irrigation fluid absorption. AIMS: To monitor the extent of 1.5% glycineirrigation fluid absorption during transurethral resection of prostate (TURP), by measuring the changes of serum sodium and potassium levels peri-operatively. SETTINGS AND DESIGN: This is a randomized prospective cohort observational study. MATERIALS AND METHODS: The 86 male patients of ASA grades I to III in the age group of 50 to 80 years, scheduled for elective TURP surgery under central neuraxial block, were studied. Their preoperative and post-operative serum sodium, potassium and calcium levels were measured. When duration of surgery exceeds 60 min, serum sodium and potassium levels were done intra-operatively with venous blood samples by using blood gas analyser. The height of irrigation fluid column was kept constant at 60 cm. These changes were correlated with the volume of irrigating fluid used, duration of procedure and the volume of prostate gland resected. STATISTICAL ANALYSIS USED: The values of pre and postoperative sodium, potassium and calcium serum levels were compared and statistical significance of the difference in values was assessed using Student's paired t test. RESULTS: Statistically significant reduction of serum sodium levels (hyponatremia) and elevation of serum potassium levels (hyperkalemia) were observed post-operatively, which was directly proportional to volume of irrigating fluid used, duration of procedure and volume of prostate gland resected. No significant changes in serum calcium level were observed. CONCLUSIONS: To measure serum electrolytes changes during TURP surgery, it is simple and economical method for indirect assessment of fluid absorption for early identification of TURP syndrome.

Regional Anaesthesia Techniques for Orthopaedic Surgery.

BACKGROUND: In recent years, there has been a significant resurgence of interest in regional anaesthesia techniques. Despite various advantages, regional anaesthesia is not used to its full potential in orthopaedic surgeries. METHODS: This study was conducted to evaluate the efficacy and safety of regional anaesthesia techniques in 400 consecutive patients, posted for orthopaedic surgeries in a tertiary care centre. Data was analysed for patient profile, type of surgery, nature of anaesthetic technique used, success rate, complications and satisfaction level of patients. RESULT: Age of patients ranged from three months to 92 years with male preponderance (84.5 %). Regional anaesthesia was used in 85% cases. Most frequently used technique for upper limbs was supraclavicular brachial plexus block (12.05 %) followed by interscalene block (5.58 %) and intravenous regional anaesthesia or Bier's block (2.64 %). For lower limbs, subarachnoid block was used in 50 % cases followed by combined spinal-epidural technique (21.47 %) and paravertebral block (4.70 %). Less commonly used techniques like lumbar plexus block, popliteal fossa block, sciatic + femoral nerve blocks were found to be useful but incidence of partial blocks was high. Overall success rate was 96.17 %. In 22.05 % cases supplementation with analgesic / sedative was needed, whereas in 3.82 % cases, technique was converted into general anaesthesia. There was no major complication. Six patients had reversible sensory neuropathy. In 91.64 % cases, satisfaction level was good to excellent. CONCLUSION: Skilfully performed techniques in regional anaesthesia can facilitate excellent surgical anaesthesia and postoperative pain management.