Effect of height versus height/weight-based spinal bupivacaine on maternal hemodynamics for elective cesarean in short stature patients: a randomized clinical trial.

PURPOSE: Doses of spinal bupivacaine adjusted to patient height or height/weight have been shown to provide hemodynamic stability during cesarean section. However, their effects in short stature parturients are unknown. METHODS: In this double-blind, randomized clinical trial, we randomly assigned short parturients (height < 150 cm) undergoing elective cesarean section, to receive doses of intrathecal hyperbaric bupivacaine either height or height/weight-adjusted, in a 1:1 ratio. The primary outcome was post-spinal hypotension (defined as systolic blood pressure [SBP] < 90% of baseline between spinal administration and delivery of the baby). Secondary outcomes included severe post-spinal hypotension (SBP < 80% of baseline), post-delivery hypotension (SBP < 90% and < 80% of baseline), intraoperative bradycardia, nausea and vomiting, shivering, rescue analgesic needed, and spinal block characteristics. RESULTS: A total of 112 patients underwent randomization. Post-spinal hypotension (SBP < 90% of baseline) occurred in 52% of the patients in the height/weight group and in 55% in the height group (difference - 3.5%: 95% confidence interval [CI] - 22 to 14.8, P = 0.705). There was no significant difference between the two groups in the occurrences of post-spinal severe hypotension (SBP < 80% of baseline), post-delivery hypotension, and spinal block characteristics. Six patients (11%) in the height/weight group needed intraoperative rescue analgesic compared to none in the height group (P = 0.027). CONCLUSION: We found that height-based dosing in short parturients provides the optimal trade-off between intraoperative hemodynamic instability and provision of pain-free anesthesia. TRIAL REGISTRATION: clinicaltrial.gov-NCT04082676. https://clinicaltrials.gov/ct2/show/NCT04082676 .

Postdural puncture headache: Revisited.

Postdural puncture headache (PDPH) may develop after an unintended (accidental) dural puncture, after deliberate dural puncture for spinal anaesthesia or during diagnostic dural punctures performed by other medical specialties. PDPH may sometimes be predictable (patient characteristics, inexperienced operator or co-morbidities), is almost never immediately evident during the procedure, and sometimes presents late, after discharge. Specifically, PDPH severely restricts activities of daily living, patients may be bedridden for several days and mothers may have difficulty in breastfeeding. Although an epidural blood patch (EBP) remains the management technique with greatest immediate success, most headaches resolve over time but may cause mild-severe disability. Failure of EBP after the first attempt is not uncommon, and major complications may occur but are rare. In the current review of the literature, we discuss the pathophysiology, diagnosis, prevention and management of PDPH following accidental or intended dural puncture, and present possible therapeutic options for the future.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study.

BACKGROUND: Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. METHODS: In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. RESULTS: In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. CONCLUSIONS: Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. CLINICAL TRIAL REGISTRATION: NCT02362828.

Intrathecal morphine does not prevent chronic postsurgical pain after elective Caesarean delivery: a randomised controlled trial.

BACKGROUND: Morphine is frequently added to spinal anaesthesia for Caesarean delivery. We aimed to determine whether intrathecal morphine for spinal anaesthesia decreases the risk of chronic postsurgical pain (CPSP). METHODS: In this randomised, double-blind, placebo-controlled trial, 290 healthy parturients undergoing elective Caesarean delivery were randomly assigned in a 1:1 ratio to receive either intrathecal morphine 100 µg (n=145) or normal saline (control; n=145) as a part of spinal anaesthesia. Anaesthetic care and postoperative pain management were standardised in all patients. The primary outcome was the incidence of CPSP at 3 months. Secondary outcomes included CPSP at 6 months, pain severity, and pain interference, measured by the Brief Pain Inventory questionnaire using an 11-point numeric rating scale, at 3 and 6 months after the surgery. RESULTS: Two hundred and seventy-six patients completed the 3-month follow-up, 139 in the morphine group and 137 in the placebo group. The incidences of CPSP at 3 months were 19% (27 of 139) in the morphine group and 18% (25 of 137) in the placebo group (odds ratio, 1.08; 95% confidence interval, 0.59-1.97; P=0.803). At 6 months, CPSP was present in 23 of 139 (16%) morphine group patients compared with 19 of 137 (14%) in the placebo group (odds ratio, 1.23; 95% confidence interval, 0.63-2.38; P=0.536). Brief Pain Inventory questionnaire scores for pain severity and pain interference at 3 and 6 months were similar between groups. CONCLUSIONS: Administration of morphine 100 µg as a component of spinal anaesthesia for elective Caesarean delivery failed to reduce the incidence of chronic pain at 3 and 6 months after surgery. CLINICAL TRIAL REGISTRATION: NCT03451695.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study.

BACKGROUND: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. METHODS: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. RESULTS: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. CONCLUSIONS: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

Postcaesarean section analgesia: are opioids still required?

PURPOSE OF REVIEW: The use of opioids for postoperative pain relief after caesarean section is widely spread. Because of unwanted well known side-effects, alternative drugs and methods of pain relief have been introduced, either in addition to or instead of opioids. Can postcaesarean analgesia be achieved these days without opioids? RECENT FINDINGS: Most components of multimodal postcaesarean analgesia have not been studied thoroughly during pregnancy and lactation, and not one or a combination of them has yet proven to be superior to opioids.New applications of local anaesthetics and other drugs, new combinations of existing drugs and new developments in predicting an individual's response to pain provide tools to minimize opioid use for postoperative pain relief in caesarean section. SUMMARY: The dependency on opioids for postcaesarean analgesia is diminishing, but in order to develop effective, well tolerated alternatives, more research is needed.In the meantime, opioids are here to stay.