RESUMEN
BACKGROUND: Hip fracture surgeries in elderly patients often require spinal or general anesthesia, posing risks of severe hypotension and inadequate pain management. The optimal anesthesia type for minimizing these risks remains undetermined. Preliminary studies suggest that a combination of fascia iliaca block (FIB) and low-dose low-specific-gravity spinal anesthesia (LLSA) might offer a solution, but comprehensive evidence is lacking. OBJECTIVES: This study aimed to assess the efficacy of combining FIB with LLSA for reducing severe hypotension and enhancing analgesia during hip fracture surgery in elderly patients. STUDY DESIGN: A prospective, randomized controlled trial was conducted. SETTING: An operating theatre of a tertiary hospital. METHODS: The study comprised 68 patients. They were separated into 2 equal parallel groups 34 patients each: the FIB+LLSA group and the general anesthesia (GA) group. Patients aged 75-96 undergoing primary hip arthroplasty for hip fracture were randomized to receive either FIB+LLSA or GA. The primary outcome was the incidence of severe hypotension; secondary outcomes included postoperative pain, use of rescue analgesia, vasopressor dosage, and complications. RESULTS: We found a significantly lower incidence of severe hypotension in the FIB+LLSA group compared to the GA group (32.4% vs 67.6%). Additionally, postoperative pain scores were significantly lower, and the need for rescue analgesia was reduced in the FIB+LLSA group. Vasopressor use during surgery was also significantly lower in the FIB+LLSA group. The hospital stay was shorter in the FIB+LLSA group, with an average of 5.9 days compared to 6.7 days in the GA group. LIMITATIONS: The study's limitations include its single-center nature, which may limit the generalizability of the findings. Additionally, the inability to conduct a double-blind study could introduce biases, though measures were taken to minimize this. The sample size might not be sufficient to determine the broader implications of LLSA. CONCLUSIONS: Combining FIB with LLSA for elderly patients undergoing hip fracture surgery significantly reduces the incidence of severe intraoperative hypotension and postoperative pain. It also decreases the need for rescue analgesia and shortens hospital stays, suggesting that FIB+LLSA could be a beneficial regional anesthesia technique for elderly hip fracture surgery patients, aligning with enhanced recovery protocols.
Asunto(s)
Anestesia Raquidea , Fracturas de Cadera , Hipotensión , Bloqueo Nervioso , Humanos , Fracturas de Cadera/cirugía , Anciano , Anestesia Raquidea/métodos , Anestesia Raquidea/efectos adversos , Anciano de 80 o más Años , Femenino , Masculino , Bloqueo Nervioso/métodos , Estudios Prospectivos , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Analgesia/métodos , FasciaRESUMEN
BACKGROUND: Cesarean deliveries (CD) are commonly performed using neuraxial anesthesia. The use of neuraxial morphine has proven beneficial in terms of postoperative pain management; however, its effect on postoperative urine retention remains unclear. OBJECTIVES: To determine whether morphine injection into the neuraxis during CD influences postoperative urinary retention rate. METHODS: We conducted a retrospective case-control observational study of patients undergoing CD. We compared patients using morphine injected into the intrathecal or epidural spaces (November 2020 to October 2021) to a historical cohort of patients undergoing CD without morphine (November 2019 to October 2020). The primary outcome was the rate of postoperative overt urinary retention necessitating bladder catheterization. RESULTS: The study group comprised 283 patients, and 313 patients in the control group were eligible for analysis. No differences were found with respect to the baseline demographic and indication for CD. The number of postpartum urinary bladder catheterizations due to urine retention was higher in the study group (5% vs. 1%, P-value = 0.003). No cases of 30-day readmission were recorded. Moreover, patients treated with neuraxial morphine required fewer repeat doses of postoperative anesthesia (oral analgesia 7.4 vs. 10.1, intravenous analgesia 0.29 vs. 0.31, oral opioids 0.06 vs. 3.70, intravenous opioids 0.01 vs. 0.45, P-value < 0.001 for all). CONCLUSIONS: While neuraxial morphine used during CD appears to be safe and effective, the risk of postoperative urinary retention seems to be increased due to its use. Cases of overt urinary retention treated by bladder catheterization does not lead to short-term complications.
Asunto(s)
Analgésicos Opioides , Cesárea , Morfina , Dolor Postoperatorio , Retención Urinaria , Humanos , Retención Urinaria/etiología , Retención Urinaria/epidemiología , Femenino , Morfina/administración & dosificación , Morfina/efectos adversos , Estudios Retrospectivos , Cesárea/efectos adversos , Cesárea/métodos , Embarazo , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Estudios de Casos y Controles , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/etiología , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Anestesia Epidural/efectos adversos , Anestesia Epidural/métodos , Inyecciones Espinales , Cateterismo Urinario/efectos adversos , Cateterismo Urinario/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
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.
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Anestesia Epidural , Anestesia Raquidea , Tratamiento Conservador , Hematoma Espinal Epidural , Humanos , Femenino , Anciano , Hematoma Espinal Epidural/etiología , Hematoma Espinal Epidural/diagnóstico por imagen , Anestesia Epidural/efectos adversos , Anestesia Raquidea/efectos adversos , Tratamiento Conservador/métodos , Histerectomía Vaginal , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Imagen por Resonancia Magnética , Resultado del TratamientoRESUMEN
INTRODUCTION: Peripheral vasodilation causes a redistribution of body temperature from the core to the periphery, resulting in shivering and hypothermia. These are normal pathological and physiological processes during spinal anaesthesia. Two drugs, norepinephrine and phenylephrine, have peripheral vasoconstrictive effects. It is unclear the effects of norepinephrine and phenylephrine on shivering and hypothermia in patients undergoing caesarean section under spinal anaesthesia. METHODS ANALYSIS: 240 eligible parturients will be recruited for this randomised, double-blind, controlled trial and randomly assigned to either the norepinephrine or phenylephrine groups. The primary outcome will be the incidence of shivering while secondary outcomes will include the severity of shivering, rectal temperature, incidence of hypothermia and umbilical artery blood pH value. ETHICS AND DISSEMINATION: The Institutional Ethics Committee of The Second People's Hospital of Hefei approved the trial protocol (ID: 2023-093). The results will be published in a compliant journal. The original data will be released in December 2029 on the ResMan original data-sharing platform of the China Clinical Trial Registry (http://www.medresman.org.cn). TRIAL REGISTRATION NUMBER: ChiCTR2300077164.
Asunto(s)
Anestesia Raquidea , Cesárea , Hipotermia , Norepinefrina , Fenilefrina , Tiritona , Centros de Atención Terciaria , Humanos , Anestesia Raquidea/métodos , Anestesia Raquidea/efectos adversos , Tiritona/efectos de los fármacos , Cesárea/efectos adversos , Femenino , Método Doble Ciego , Embarazo , Norepinefrina/uso terapéutico , China/epidemiología , Hipotermia/prevención & control , Fenilefrina/uso terapéutico , Adulto , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Vasoconstrictores/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Norepinephrine and phenylephrine are commonly used vasoactive drugs to treat hypotension during the perioperative period. The increased release of endogenous norepinephrine elicits prothrombotic changes, while parturients are generally in a hypercoagulable state. Therefore, this trial aims to investigate whether there is a disparity between equivalent doses of prophylactic norepinephrine infusion and phenylephrine infusion on prothrombotic response in patients undergoing cesarean section under spinal anesthesia. METHODS: Sixty-six eligible parturients will be recruited for this trial and randomly assigned to the norepinephrine or phenylephrine group. The "study drug" will be administered at a rate of 15 ml/h starting from the intrathecal injection. The primary outcome are plasma coagulation factor VIII activity (FVIII: C), fibrinogen, and D-dimer levels. The secondary outcomes include hemodynamic variables and umbilical artery blood pH value. DISCUSSION: Our study is the first trial comparing the effect of norepinephrine and phenylephrine on prothrombotic response in patients undergoing cesarean section under spinal anesthesia. Positive or negative results will all help us better understand the impact of vasoactive drugs on patients. If there are any differences, this trial will provide new evidence for maternal choice of vasoactive medications in the perioperative period. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300077164. Registered on 1 November 2023. https://www.chictr.org.cn/ .
Asunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Norepinefrina , Fenilefrina , Ensayos Clínicos Controlados Aleatorios como Asunto , Vasoconstrictores , Humanos , Cesárea/efectos adversos , Anestesia Raquidea/efectos adversos , Femenino , Norepinefrina/sangre , Método Doble Ciego , Embarazo , Fenilefrina/administración & dosificación , Vasoconstrictores/uso terapéutico , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Adulto , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Factor VIII , Resultado del Tratamiento , Coagulación Sanguínea/efectos de los fármacos , Hemodinámica/efectos de los fármacosRESUMEN
BACKGROUND: Postpartum urinary retention is a common complication following caesarean section, with significant implications for patient comfort and recovery. Combined spinal and epidural anaesthesia is frequently employed for caesarean section, but postpartum urinary retention remains a clinical concern despite its benefits. This study aimed to investigate the effectiveness of hydromorphone hydrochloride combined with bupivacaine for combined spinal and epidural anaesthesia in reducing postpartum urinary retention. METHODS: A retrospective analysis was conducted on patients who received combined spinal and epidural anaesthesia for caesarean section. The control group received bupivacaine, whereas the hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia (HB) group received hydromorphone hydrochloride combined with bupivacaine. Data on demographics, anaesthesia, operative characteristics, postoperative urinary retention and adverse events were collected and analysed. RESULTS: The study enrolled 105 patients, with a control group (n = 51) receiving bupivacaine spinal-epidural anaesthesia and an observation group (n = 54) receiving hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia. The incidence of postoperative urinary retention was significantly lower in the HB group than in the control group (3.70% vs. 17.65%, p = 0.044). Furthermore, the HB group exhibited a shorter time to first voiding after anaesthesia (5.72 ± 1.26 h vs. 6.28 ± 1.35 h, p = 0.029), lower peak postvoid residual volume (168.57 ± 25.09 mL vs. 180.43 ± 30.21 mL, p = 0.032), decreased need for postoperative catheterisation (5.56% vs. 21.57%, p = 0.034) and shorter duration of urinary catheterisation (10.92 ± 2.61 h vs. 12.04 ± 2.87 h, p = 0.039) than the control group. Correlation analysis supported a negative correlation between hydromorphone supplementation and parameters related to postoperative urinary retention. Multivariate regression analysis demonstrated a significant association between the duration of urinary catheterisation and the use of hydromorphone with the occurrence of postoperative urinary retention, providing further insights into the multifactorial nature of this postoperative complication. CONCLUSIONS: The addition of hydromorphone hydrochloride to bupivacaine for combined spinal and epidural anaesthesia was associated with a reduced incidence of postpartum urinary retention and improved postoperative voiding parameters, without significantly increasing the risk of adverse events.
Asunto(s)
Anestesia Epidural , Anestesia Raquidea , Bupivacaína , Hidromorfona , Retención Urinaria , Humanos , Retención Urinaria/prevención & control , Retención Urinaria/etiología , Hidromorfona/administración & dosificación , Hidromorfona/uso terapéutico , Hidromorfona/efectos adversos , Estudios Retrospectivos , Femenino , Anestesia Raquidea/efectos adversos , Bupivacaína/administración & dosificación , Adulto , Anestésicos Locales/administración & dosificación , Cesárea/efectos adversos , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Embarazo , Trastornos Puerperales/prevención & control , Trastornos Puerperales/etiología , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
Background: Fluid loading improves hemodynamic stability and reduces the incidence rate of post-spinal anesthesia hypotension when prophylactic vasopressors are administered. We investigated the impact of different crystalloid coload volumes on the 90% effective dose (ED) of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension in non-hypertensive patients undergoing cesarean section. Methods: Patients were randomly allocated to receive one of the different crystalloid coload volumes (0mL/kg [0mL/kg Group], 5mL kg [5mL/kg Group], and 10mL kg [10mL/kg Group]) in combination with prophylactic norepinephrine infusion immediately after the induction of spinal anesthesia. The prophylactic norepinephrine infusion doses were determined using the up-and-down sequential allocation methodology, with an initial dose of 0.025 µg/kg/min and a gradient of 0.005 µg/kg/min. The primary endpoint was the effective dose at which 90% (ED 90) of patients responded to prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension. Results: The estimated effective dose of norepinephrine infusion, at which 90% (ED 90) of patients responded, was found to be 0.084 (95% CI, 0.070 to 0.86), 0.074 (95% CI, 0.059 to 0.077), and 0.063 (95% CI, 0.053 to 0.064) µg/kg/min in the three groups, respectively. Conclusion: A crystalloid coload of 5 mL/kg or 10 mL/kg, as opposed to the groups receiving 0 mL/kg crystalloid coloads, resulted in a reduction of approximately 11.9% and 25.0%, respectively, in the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean section.
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Anestesia Raquidea , Cesárea , Soluciones Cristaloides , Hipotensión , Norepinefrina , Humanos , Hipotensión/prevención & control , Norepinefrina/administración & dosificación , Femenino , Adulto , Soluciones Cristaloides/administración & dosificación , Anestesia Raquidea/efectos adversos , Embarazo , Infusiones Intravenosas , Relación Dosis-Respuesta a DrogaRESUMEN
To investigate the effect of low-doses esketamine on spinal anesthesia-induced hypotension in women with preoperative anxiety undergoing elective cesarean section, the randomized controlled trial enrolled 120 women aged 18-35 years who preoperative State-Trait Anxiety Inventory State scores > 40, conducted from September 2022 to August 2023 in Xuzhou Central Hospital, China. Women in the esketamine group received a single intravenous injection of 0.2 mg/kg esketamine after sensory block level achieved. The incidence of hypotension in the esketamine group was significantly lower than the control group at T2 (10% [6 of 60]; P < 0.001), T3 (5.0% [3 of 60]; P = 0.007) and T4(5.0% [3 of 60]; P = 0.004). Despite being higher in the esketamine group, the overall rates of hypertension (11.7% [7 of 60]; P = 0.186), tachycardia (23.3% [14 of 60]; P = 0.246), and bradycardia (0.0% [0 of 60]; P = 0.079) were no significantly difference between the two groups. STAI-S scores was significantly lower in the esketamine group (mean [SD] 37.52[7.14]) than in the control group (mean [SD] 41.03[9.66], P = 0.39) in postoperative day 1. Spinal anesthesia combined with intravenous low-doses esketamine infusion can significantly reduce the incidence of hypotension in women with preoperative anxiety undergoing elective cesarean section.
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Anestesia Raquidea , Ansiedad , Cesárea , Procedimientos Quirúrgicos Electivos , Hipotensión , Ketamina , Humanos , Femenino , Ketamina/administración & dosificación , Cesárea/efectos adversos , Adulto , Método Doble Ciego , Embarazo , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Procedimientos Quirúrgicos Electivos/efectos adversos , Adolescente , Adulto Joven , Periodo Preoperatorio , China/epidemiologíaRESUMEN
Background: Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods: 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 µg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 µg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results: The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) µg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) µg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion: The administration of 0.6 µg/kg/min phenylephrine and 0.05 µg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.
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Anestesia Raquidea , Cesárea , Hipotensión , Norepinefrina , Fenilefrina , Preeclampsia , Humanos , Femenino , Embarazo , Fenilefrina/administración & dosificación , Preeclampsia/tratamiento farmacológico , Anestesia Raquidea/efectos adversos , Hipotensión/prevención & control , Hipotensión/inducido químicamente , Norepinefrina/administración & dosificación , Adulto , Infusiones Intravenosas , Relación Dosis-Respuesta a Droga , Vasoconstrictores/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Adulto JovenRESUMEN
BACKGROUND: The aim of this study was to evaluate the impact of intravenous palonosetron compared to ondansetron on hypotension induced by spinal anesthesia in women undergoing cesarean section. METHODS: Fifty-four women scheduled for elective cesarean section were, randomly allocated to ondansetron group (n = 27) or palonosetron group (n = 27). Ten minutes prior to the administration of spinal anesthesia, participants received an intravenous injection of either ondansetron or palonosetron. A prophylactic phenylephrine infusion was initiated immediately following the intrathecal administration of bupivacaine and fentanyl. The infusion rate was titrated to maintain adequate blood pressure until the time of fetal delivery. The primary outcome was total dose of phenylephrine administered. The secondary outcomes were nausea or vomiting, the need for rescue antiemetics, hypotension, bradycardia, and shivering. Complete response rate, defined as the absence of postoperative nausea and vomiting and no need for additional antiemetics, were assessed for up to 24 hours post-surgery. RESULTS: No significant differences were observed in the total dose of phenylephrine used between the ondansetron and palonosetron groups (387.5 µg [interquartile range, 291.3-507.8 µg versus 428.0 µg [interquartile range, 305.0-507.0 µg], P = 0.42). Complete response rates also showed no significant differences between the groups both within two hours post-spinal anesthesia (88.9% in the ondansetron group versus 100% in the palonosetron group; P = 0.24) and at 24 hours post-surgery (81.5% in the ondansetron group versus 88.8% in the palonosetron group; P = 0.7). In addition, there was no difference in other secondary outcomes. CONCLUSION: Prophylactic administration of palonosetron did not demonstrate a superior effect over ondansetron in mitigating hemodynamic changes or reducing phenylephrine requirements in patients undergoing spinal anesthesia with bupivacaine and fentanyl for cesarean section.
Asunto(s)
Anestesia Raquidea , Cesárea , Hipotensión , Ondansetrón , Palonosetrón , Humanos , Femenino , Anestesia Raquidea/efectos adversos , Cesárea/efectos adversos , Palonosetrón/administración & dosificación , Palonosetrón/uso terapéutico , Adulto , Hipotensión/tratamiento farmacológico , Hipotensión/prevención & control , Hipotensión/etiología , Embarazo , Ondansetrón/administración & dosificación , Ondansetrón/uso terapéutico , Antieméticos/administración & dosificación , Antieméticos/uso terapéutico , Náusea y Vómito Posoperatorios/prevención & control , Náusea y Vómito Posoperatorios/etiología , Fenilefrina/administración & dosificación , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodosRESUMEN
BACKGROUND: Previous findings on the effect of general versus spinal anesthesia on postoperative delirium in elderly people with hip fractures are somewhat controversial. This article included the latest randomized controlled study for meta-analysis to evaluate the effect of general anesthesia (GA) and spinal anesthesia (SA) on delirium after hip fracture surgery in the elderly, so as to guide the clinical. METHODS: Cochrane Library, PubMed, Web Of Science, and Embase were searched from inception up to January 16, 2024. Randomized controlled trial (RCT) was included to evaluate the postoperative results of GA and SA in elderly patients (≥50 years old) undergoing hip fracture surgery. Two researchers independently screened for inclusion in the study and extracted data. Heterogeneity was assessed by the I²and Chi-square tests, and Pâ <â .1 or I² ≥ 50% indicated marked heterogeneity among studies. The Mantel-Haenszel method was used to estimate the combined relative risk ratio (RR) and the corresponding 95% confidence interval (CI) for the binary variables. RESULTS: Nine randomized controlled trials were included. There was no significant difference (RRâ =â 0.93, 95% CIâ =â 0.774-1.111, Pâ >â .05) in the incidence of postoperative delirium between the GA group and the SA group. In intraoperative blood transfusion (RRâ =â 1.0, 95% CIâ =â 0.77-1.28, Zâ =â 0.04, Pâ =â .971), pulmonary embolism (RRâ =â 0.795, 95% CIâ =â 0.332-1.904, Zâ =â 0.59, Pâ =â .606), pneumonia (RRâ =â 1.47, 95% CIâ =â 0.75-2.87, Pâ =â .675), myocardial infarction (RRâ =â 0.97, 95% CIâ =â 0.24-3.86, Zâ =â 0.05, Pâ =â .961), heart failure (RRâ =â 0.80, 95% CIâ =â 0.26-2.42, Zâ =â 0.40, Pâ =â .961), urinary retention (RRâ =â 1.42, 95% CIâ =â 0.77-2.61, Zâ =â 1.11, Pâ =â .267) were similar between the 2 anesthetic techniques. CONCLUSION: There is no significant difference in the effect of GA and SA on postoperative delirium in elderly patients with hip fracture, and their effects on postoperative complications are similar.
Asunto(s)
Anestesia General , Anestesia Raquidea , Delirio , Fracturas de Cadera , Complicaciones Posoperatorias , Ensayos Clínicos Controlados Aleatorios como Asunto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Anestesia General/efectos adversos , Anestesia General/métodos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Delirio/etiología , Delirio/epidemiología , Delirio/prevención & control , Delirio del Despertar/epidemiología , Delirio del Despertar/prevención & control , Delirio del Despertar/etiología , Fracturas de Cadera/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Persona de Mediana EdadRESUMEN
BACKGROUND AND OBJECTIVE: Spinal anesthesia remains the preferred mode of anesthesia for preeclamptic patients during cesarean delivery. We investigated the incidence of maternal hypotension under spinal anesthesia during cesarean delivery, by comparing different prophylactic infusion rates of norepinephrine with normal saline. METHODS: We randomly allocated 180 preeclamptic patients (45 in each groups) aged 18-45 scheduled for cesarean delivery to receive one of four prophylactic norepinephrine infusions at doses of 0 (normal saline group), 0.025 (0.025 group), 0.05 (0.05 group), or 0.075 (0.075 group) µg/kg/min following spinal anesthesia. The primary endpoint was the incidence of maternal hypotension (systolic blood pressure < 80% of baseline). RESULTS: The incidence of maternal hypotension was reduced with different prophylactic infusion rates of norepinephrine (26.7%, 15.6%, and 6.7%) compared with normal saline (37.8%) with a significant decreasing trend (p = 0.002). As the infusion doses of norepinephrine increased, there is a significant decreasing trend in deviation of systolic blood pressure control (median performance error; median absolute performance error) from baseline (p < 0.001; p < 0.001) and need for rescue norepinephrine boluses (p = 0.020). The effective dose 50 and effective dose 90 of prophylactic norepinephrine infusion were - 0.018 (95% confidence interval - 0.074, 0.002) µg/kg/min and 0.065 (95% confidence interval 0.048, 0.108) µg/kg/min, respectively. CONCLUSIONS: Prophylactic infusion of norepinephrine, as compared to no preventive measures, can effectively reduce the incidence of maternal hypotension in preeclamptic patients under spinal anesthesia during cesarean delivery, without increasing other adverse events for either the mother or neonate. REGISTRATION: Clinical trials.gov identifier number NCT04556370.
Asunto(s)
Anestesia Raquidea , Cesárea , Relación Dosis-Respuesta a Droga , Hipotensión , Norepinefrina , Preeclampsia , Humanos , Femenino , Embarazo , Norepinefrina/administración & dosificación , Cesárea/métodos , Anestesia Raquidea/métodos , Anestesia Raquidea/efectos adversos , Adulto , Hipotensión/prevención & control , Hipotensión/epidemiología , Hipotensión/etiología , Adulto Joven , Infusiones Intravenosas , Presión Sanguínea/efectos de los fármacos , Adolescente , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Persona de Mediana Edad , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Método Doble CiegoAsunto(s)
Anestesia Raquidea , Cesárea , Hipotensión , Norepinefrina , Ondansetrón , Humanos , Anestesia Raquidea/efectos adversos , Cesárea/efectos adversos , Ondansetrón/administración & dosificación , Hipotensión/prevención & control , Hipotensión/etiología , Femenino , Norepinefrina/administración & dosificación , Embarazo , Relación Dosis-Respuesta a Droga , Ensayos Clínicos Controlados Aleatorios como Asunto , Infusiones IntravenosasRESUMEN
Spinal anaesthesia is considered an effective and safe method for providing pain relief during procedures below the waist. However, in a small subset of patients, life-threatening vasovagal reactions may develop leading to severe bradycardia and hypotension or ultimately asystole and complete circulatory collapse. Early recognition and prompt treatment of this condition can be lifesaving as illustrated in this case report where the patient developed asystole for ten seconds shortly after placing the spinal anaesthetic.
Asunto(s)
Anestesia Raquidea , Paro Cardíaco , Humanos , Anestesia Raquidea/efectos adversos , Bradicardia/diagnóstico , Bradicardia/terapia , Paro Cardíaco/terapia , Síncope Vasovagal/diagnóstico , Síncope Vasovagal/etiologíaRESUMEN
STUDY OBJECTIVE: During cesarean section, hypotension is a frequent side effect of spinal anesthesia. As a sitting or lateral position is required for spinal anesthesia performance, which of these two positions is more likely to cause intraoperative nausea, vomiting, and hypotension is still unknown. This meta-analysis compared the effects of these two positions on maternal hemodynamics and intraoperative nausea and vomiting. DESIGN: Systematic review and meta-analysis. SETTING: Operating room. PATIENTS: This study included 803 patients from 12 randomized controlled trials (RCTs). INTERVENTIONS: Neuraxial anesthesia in sitting position vs. lateral position. MEASUREMENTS: We chose RCTs comparing the effects of spinal anesthesia in the sitting and lateral positions on maternal hemodynamics by thoroughly searching PubMed, Embase, the Cochrane Library, and the Web of Science for articles published from database inception until October 31, 2022. The Cochrane Handbook was used to assess the methodological quality of each RCT; the results were analyzed using RevMan 5.4 software; and the Egger test was used to assess publication bias. MAIN RESULTS: 12 randomised controlled trials with 803 participants were ultimately included in the final analysis. No significant differences were observed between the two positions in terms of the incidence of hypotension(RR, 0.82; 95% CI, 0.58-1.16; P = 0.26; I2 = 66%), lowest systolic blood pressure(MD, -0.81; 95% CI, -7.38-5.75; P = 0.81; I2 = 86%), the dose of ephedrine(MD, -1.19; 95% CI, -4.91-2.52; P = 0.53; I2 = 83%), and number of parturients requiring ephedrine(RR, 0.97; 95% CI, 0.64-1.46; P = 0.88; I2 = 74%). For the incidence of intraoperative nausea and vomiting, there was no statistical difference between the two positions. CONCLUSION: Parturients undergoing elective cesarean section under spinal anesthesia in the sitting or lateral position experienced similar incidence of hypotension, and there were no significant differences between these two positions in terms of the amount of ephedrine administered or the number of patients needing ephedrine. In both positions, the frequency of nausea and vomiting was comparable. The ideal position for anesthesia can be chosen based on the preferences and individual circumstances of the parturient and anesthesiologist.
Asunto(s)
Anestesia Raquidea , Cesárea , Hemodinámica , Humanos , Cesárea/efectos adversos , Femenino , Embarazo , Hemodinámica/efectos de los fármacos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Sedestación , Hipotensión/etiología , Hipotensión/fisiopatología , Ensayos Clínicos Controlados Aleatorios como Asunto , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , PosturaRESUMEN
Background: Ondansetron reduces the median effective dose (ED50) of prophylactic phenylephrine to prevent spinal-induced hypotension (SIH) during cesarean delivery. However, the exact dose response of phenylephrine in combination with prophylactic ondansetron for preventing SIH is unknown. Therefore, this study aimed to determine the dose-response of phenylephrine to prevent SIH in cesarean delivery when 4 mg of ondansetron was used as a preventive method. Methods: A total of 80 parturients were enrolled and divided randomly into four groups (n = 20 in each group) who received either 0.2, 0.3, 0.4, or 0.5 µg/kg/min of prophylactic phenylephrine. Ten minutes before the initiation of spinal induction, 4 mg prophylactic ondansetron was administered. The effective dose of prophylactic phenylephrine was defined as the dose required to prevent hypotension after the period of intrathecal injection and up to neonatal delivery. The ED50 and ED90 of prophylactic phenylephrine and 95% confidence intervals (95% CI) were calculated using probit analysis. Results: The ED50 and ED90 for prophylactic phenylephrine to prevent SIH were 0.25 (95% CI, 0.15 to 0.30), and 0.45 (95% CI, 0.39 to 0.59) µg/kg/min, respectively. No significant differences were observed in the side effects and neonatal outcomes between the four groups. Conclusion: The administration of 4 mg of prophylactic ondansetron was associated with an ED50 of 0.25 (95% CI, 0.15~0.30) and ED90 of 0.45 (95% CI, 0.39~0.59) µg/kg/min for phenylephrine to prevent SIH.
Asunto(s)
Anestesia Raquidea , Cesárea , Relación Dosis-Respuesta a Droga , Hipotensión , Ondansetrón , Fenilefrina , Adulto , Femenino , Humanos , Embarazo , Anestesia Epidural , Anestesia Raquidea/efectos adversos , Hipotensión/prevención & control , Hipotensión/inducido químicamente , Ondansetrón/administración & dosificación , Fenilefrina/administración & dosificaciónRESUMEN
BACKGROUND: Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. CASE PRESENTATION: We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. CONCLUSION: Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.
Asunto(s)
Analgesia Epidural , Artroplastia de Reemplazo de Cadera , Enfisema Mediastínico , Neumorraquis , Humanos , Masculino , Enfisema Mediastínico/etiología , Enfisema Mediastínico/diagnóstico por imagen , Anciano , Analgesia Epidural/efectos adversos , Neumorraquis/etiología , Neumorraquis/diagnóstico por imagen , Artroplastia de Reemplazo de Cadera/efectos adversos , Hemodinámica , Tomografía Computarizada por Rayos X , Anestesia Raquidea/efectos adversosRESUMEN
BACKGROUND: Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments. METHODS: We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted. RESULTS: A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180â¯min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided. CONCLUSIONS: The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.
Asunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Humanos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Femenino , Embarazo , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Bloqueo Nervioso/métodos , Bloqueo Nervioso/efectos adversosRESUMEN
BACKGROUND: The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. METHODS: This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. RESULTS: In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. CONCLUSIONS: Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022. CLINICAL TRIAL REGISTRATION: This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.
Asunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Epinefrina , Hipotensión , Fenilefrina , Vasoconstrictores , Humanos , Femenino , Cesárea/métodos , Anestesia Raquidea/métodos , Anestesia Raquidea/efectos adversos , Embarazo , Fenilefrina/administración & dosificación , Adulto , Hipotensión/prevención & control , Hipotensión/epidemiología , Epinefrina/administración & dosificación , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Infusiones Intravenosas , Recién NacidoRESUMEN
OBJECTIVE: Diabetes mellitus, per se, is a global health concern, which is often accompanied by complications such as diabetic neuropathy. This prospective observational study purposed to assess the durations of spinal sensory block and motor blocks in individuals with and without diabetes mellitus who had undergone spinal anesthesia. METHODS: This study incorporated 80 cases, which were evenly divided into spinal sensory block without diabetes mellitus and spinal sensory block with diabetes mellitus. Various parameters were recorded at different time points, including heart rate, mean arterial blood pressure, SpO2, and spinal block characteristics. Notable measures included maximum spinal sensory block onset time, time to reach the 10th thoracic vertebra (T10), maximal spinal sensory block, time for Bromage scores, and block regression while controlling for age-related variations. RESULTS: Patients in the diabetic group exhibited extended block durations, with significant differences in heart rate noted at specific time points. Regarding the spinal block characteristics, the "maximum onset of SSB" and the "time to reach the T10" were more prolonged in the SSBwDM without significance. Maximum sensory spinal sensory block did not differ. However, some cases in the SSBwDM displayed blocks extending up to the T6. The times to achieve Bromage motor block scores 1-3 were shorter in SSBwDM and lost significance regarding age. Notably, the regression time was longer in SSBwDM, which held significance for both parameters. CONCLUSION: Diabetic cases commonly encounter prolonged block durations post-subarachnoid intervention, potentially linked to nerve sensitivity, age-related changes, and glycemic control. As such, attenuated local doses for diabetic neuropathic cases may enhance early mobilization, attenuate thromboembolic events, and expedite gastrointestinal recovery.