Administration of Low-dose Hyperbaric Bupivacaine for Spinal Anesthesia in the Setting of Outpatient Arthroplasty.

INTRODUCTION: With the rise of ambulatory surgery centers (ASCs), rapid motor and sensory recovery after anesthesia is crucial. The purpose of this study was to evaluate the safety and efficacy of low-dose single-shot hyperbaric bupivacaine for spinal anesthesia (SA) for patients undergoing outpatient arthroplasty. METHODS: Data were reviewed from a single ASC from 2018 to 2020 for two arthroplasty-trained surgeons for all patients with primary arthroplasties that had administration of low-dose hyperbaric bupivacaine. Data collected from the ASC records were then further evaluated for total spinal block time, length of blockade, time to discharge criteria, visual analog scale (VAS) scores, and time to discharge. RESULTS: Two hundred twenty-seven patients undergoing 244 primary arthroplasties received SA with low-dose hyperbaric bupivacaine. The volume of 0.75% bupivacaine varied: 115 patients received 0.8 mL (6 mg), 111 patients received 1.0 mL (7.5 mg), and 17 patients received 1.2 mL (9 mg). Total SA time averaged 144 minutes with a mean of 30 minutes from post anesthesia care unit arrival to motor recovery. The mean time from post anesthesia care unit arrival to discharge criteria was 89 minutes. The average VAS at discharge was 1.44; the average VAS on POD1 was 3.0. No episodes of urinary retention and no reports of transient neurologic symptoms were noted in the study population. CONCLUSION: Low-dose, single-shot hyperbaric bupivacaine SA is an effective option in the ASC for arthroplasty, providing a fast return of motor function, facilitating rapid discharge, and is safe with a relatively low-risk profile.

Hyperbaric bupivacaine versus prilocaine for spinal anesthesia combined with total intravenous anesthesia during oncological colon surgery in a 23-hour stay enhanced recovery protocol: A non-randomized study.

After the success of the enhanced recovery after surgery protocol, perioperative care has been further optimized in accelerated enhanced recovery pathways (ERPs), where optimal pain management is crucial. Spinal anesthesia was introduced as adjunct to general anesthesia to reduce postoperative pain and facilitate mobility. This study aimed to determine which spinal anesthetic agent provides best pain relief in accelerated ERP for colon carcinoma. This single center study was a secondary analysis conducted among patients included in the aCcelerated 23-Hour erAS care for colon surgEry study who underwent elective laparoscopic colon surgery. The first 30 patients included received total intravenous anesthesia combined with spinal anesthesia with prilocaine, the 30 patients subsequently included received spinal anesthesia with hyperbaric bupivacaine. Primary endpoint of this study was the total amount of morphine milligram equivalents (MMEs) administered during hospital stay. Secondary outcomes were amounts of MMEs administered in the recovery room and surgical ward, pain score using the numeric rating scale, complication rates and length of hospital stay. Compared to prilocaine, the total amount of MMEs administered was significantly lower in the bupivacaine group (n = 60, 16.3 vs 6.3, P = .049). Also, the amount of MMEs administered and median pain scores were significantly lower after intrathecal bupivacaine in the recovery room (MMEs 11.0 vs 0.0, P = .012 and numeric rating scale 2.0 vs 1.5, P = .004). On the surgical ward, median MMEs administered, and pain scores were comparable. Postoperative outcomes were similar in both groups. Spinal anesthesia with hyperbaric bupivacaine was associated with less opioid use and better pain reduction immediately after surgery compared to prilocaine within an accelerated ERP for elective, oncological colon surgery.

My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery.

BACKGROUND: Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anesthesia options for hip fracture surgery and tested its preliminary efficacy and acceptability. METHODS: We developed a 1-page, tabular format, plain-language conversation aid with feedback from anesthesiologists, decision scientists, and community advisors. We conducted an online survey of English-speaking adults aged 50 and older. Participants imagined choosing between spinal and general anesthesia for hip fracture surgery. Before and after viewing the aid, participants answered a series of questions regarding key outcomes, including decisional conflict, knowledge about anesthesia options, and acceptability of the aid. RESULTS: Of 364/409 valid respondents, mean age was 64 (SD 8.9) and 59% were female. The proportion indicating decisional conflict decreased after reviewing the aid (63-34%, P < 0.001). Median knowledge scores increased from 50% correct to 67% correct (P < 0.001). 83% agreed that the aid would help them discuss options and preferences. 76.4% would approve of doctors using it. CONCLUSION: My Anesthesia Choice-Hip Fracture decreased decisional conflict and increased knowledge about anesthesia choices for hip fracture surgery. Respondents assessed it as acceptable for use in clinical settings. PRACTICE IMPLICATIONS: Use of clinical decision aids may increase shared decision-making; further testing is warranted.

Ultrasound-guided suprainguinal fascia iliaca block to position the patient for neuraxial anaesthesia in acetabular surgery - a randomized controlled pilot study.

INTRODUCTION: Neuraxial anaesthesia is a common choice for most hip and lower limb operations. Pain associated with positioning is often a deterrent, and the vast literature suggests different regional blocks and opioids for these patients. Patients with acetabular fractures may experience increased pain, and thus are more difficult to position for the neuraxial block. We conducted a randomized controlled pilot study to assess and compare the analgesic efficacy of ultrasound-guided suprainguinal fascia iliaca block (SFICB) versus systemic fentanyl to facilitate positioning for combined spinal epidural (CSE) anaesthesia in patients undergoing acetabular fracture surgery. MATERIAL AND METHODS: Twenty patients referred for surgical repair of acetabular fractures were randomly assigned to receive either ultrasound-guided SFICB (group B) or intravenous fentanyl (group F). Changes in visual analogue scale (VAS) scores in supine and sitting position, improvement in sitting angle (SA), positioning quality, rescue analgesic requirement, total opioid consumption, comfort VAS scores, and complications were noted to compare both groups. RESULTS: The post-intervention VAS score in the sitting position was significantly lower in group B than in group F (5.9 ± 2.1 vs. 3.5 ± 1.5, P = 0.01). Group B also had more significant improvement in SA (27.5° (20.75-36.5°), in comparison to group F (10 (5-18.75), P = 0.006). The positioning quality was better in group B, with 70% of patients achieving an optimal position compared to only 10% in group F ( P = 0.02). CONCLUSIONS: Ultrasound-guided SFICB, as compared to systemic fentanyl, provided better analgesia and helped to achieve a better and more comfortable position to perform the neuraxial block.

Ultrasound-guided intersphincteric space block combined with spinal anesthesia for hemorrhoidectomy: a randomized clinical trial.

BACKGROUND: We aimed to compare the analgesic effects and incidence of urinary retention between ultrasound-guided intersphincteric space block combined with low-dose ropivacaine spinal anesthesia and conventional-dose ropivacaine spinal anesthesia post-hemorrhoidectomy. METHODS: Fifty patients aged 20-65 years who underwent elective hemorrhoidectomy were stochastically assigned to one of two groups. Spinal anesthesia was induced with 8 mg ropivacaine, combined with ultrasound-guided intersphincteric space block in the treatment group. Spinal anesthesia was induced with 12 mg ropivacaine in the control group. The primary outcome was the postoperative pain score, measured using the Visual Analog Scale (VAS) at 4, 8, 12, 24, and 48 hours and at the first defecation postoperatively. Secondary outcomes included urinary retention, extent of anal sphincter relaxation, and the time required to lift the lower limbs out of bed postoperatively. RESULTS: The treatment group showed markedly lower VAS scores than those of the control group at 8, 12, 24, and 48 h, and at the first postoperative defecation time (P<0.05). The incidence of urinary retention was considerably lower in the treatment group than in the control group (24% vs. 52%, P=0.04). No remarkable difference in the degree of anal sphincter relaxation was observed between the two groups (P=0.556). The time taken by the treatment group patients to lift their lower limbs off the bed was much shorter than that in the control group (1.3±0.6 h vs. 3.2±1.2 h, P<0.001). CONCLUSIONS: Ultrasound-guided intersphincteric space block combined with low-dose ropivacaine spinal anesthesia provides good anesthesia and analgesia for hemorrhoidectomy.

Efficacy of local infiltration analgesia on recovery after total hip arthroplasty using direct anterior approach under spinal anaesthesia: a randomized, double-blind, placebo-controlled trial.

The utilization of local infiltration analgesia (LIA) is a common practice in total hip arthroplasty (THA) procedures to mitigate postoperative pain and diminish the necessity for opioids. However, contemporary literature reports conflicting results. Our working hypothesis was that LIA renders better postoperative VAS-scores and reduces the need for oral analgetics. We performed a randomized, double-blind, placebo-controlled trial aimed at examining the effectiveness of LIA in THA. A total of 90 patients were included for statistical analysis. Our primary endpoint was the Visual Analogue Scale, VAS, (0: no pain, 10: unbearable pain) preoperatively, at the 1st, 2nd, 3rd, 4th and 12th hour postoperative intervals and at discharge. Our secondary endpoints included the postoperative opioid consumption, as well as patient satisfaction at 2 and 6 weeks postoperatively, measured using the Numeric Rating Scale, NRS. LIA has a tendency for superior results regarding VAS- Scores at 3 and 4 hours postoperatively. There were no notable statistical distinctions observed in terms of patients necessitating rescue opioid consumption. Patient satisfaction using the NRS at both the 2-week and 6-week postoperatively did not differ significantly between both groups. The administration of LIA could offer advantages during the initial stages of postoperative recovery, which could be particularly valuable in rapid recovery programs.

Continuing medical education for attending physicians in anesthesia: Feasibility of an innovative blended learning approach.

Continuing medical education plays a pivotal role in fostering and upholding the standard of excellence in medicine. Both SPOC (small private online course) and BOPPPS (bridge-in, learning objective, pretest, participatory learning, posttest, and summary) methodologies are rooted in the same educational and learning theories, emphasizing active student engagement, interaction, and feedback. Using ultrasound-guided spinal anesthesia as an exemplar, we aimed to investigate the feasibility of blended teaching (combination of BOPPPS and SPOC) for anesthesiology clinicians and explore trainees' and trainers' perspectives towards the innovative method. Twenty-seven attending anesthesiologists were randomly divided into experimental group (n = 14, blended teaching method) and control group (n = 13, traditional teaching method). The questionnaire was administered before and a week post-training. Their operative skills (measured by operation time) were assessed. The students' cognitive evaluation of the blended teaching mode was conducted in the experimental group. The experimental group demonstrated notably higher theoretical scores compared to the control group [(46.42 ±â€…5.345) vs (41.92 ±â€…5.219), t = 2.213, P < .05]. The operation time in the experimental group was significantly shorter than that in the control group [(84.79 ±â€…28.450) seconds vs (114.23 ±â€…35.607) seconds, t = -2.383, P < .05]. Most participants preferred blended learning as it was more effective than traditional learning. Suggestions for enhancement included enhanced online interactivity with trainers and the inclusion of case analysis. Integration of blended teaching incorporating BOPPPS and SPOC methodologies holds promise for enhancing the efficiency of skill training among anesthesiologists. Blended learning may become a viable and well-received option among anesthesia clinicians in China.

Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery.

STUDY OBJECTIVE: Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery. DESIGN: Systematic review. SETTINGS: Robot assisted abdominal surgery. PATIENTS: Adults. INTERVENTIONS: Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials. MAIN RESULTS: We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent. CONCLUSIONS: Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

Comparative analysis of combined spinal-epidural anesthesia and general anesthesia in percutaneous nephrolithotomy: a prospective study on surgical team and operating room personnel satisfaction.

OBJECTIVE: We aimed to investigate the efficacy and complications of combined spinalepidural anesthesia and general anesthesia in percutaneous stone surgery prospectively. MATERIALS AND METHODS: The study prospectively included patients who underwent percutaneous nephrolithotomy with general anesthesia (Group.1) or combined spinal-epidural anesthesia (Group.2) at the Department of Urology, Training and Research Hospital, Karabuk University. between December 2018 and December 2019. The effect of the anesthesia technique on the comfort and satisfaction of the operating room personnel, surgeon and anesthesia team were prospectively evaluated and recorded. RESULTS: During the postoperative period, the spinal anesthesia group had a significantly lower visual analog score than the general anesthesia group. No patient in either group required narcotic analgesics during the postoperative period. In terms of overall satisfaction scores, the surgeon performing the surgical procedure had a significantly higher satisfaction score in the general anesthesia group than in the CSEA group. The score was considered good in the general anesthesia group and moderate in the CSEA group. Personnel satisfaction was higher in the patient group that underwent CSEA. In the general anesthesia group, the score was considered to be average. In the CSEA group, the satisfaction score was considered good, with a statistically significant difference (p < 0.05). The anesthesia team's satisfaction score was moderate, with no significant difference between the CSEA and general anesthesia groups (p > 0.05). CONCLUSION: PCNL under CSEA can be performed safely in certain individuals. Different anesthetic techniques may have varied levels of satisfaction among the surgical team.

Comparing quality of recovery and satisfaction between spinal anesthesia and nerve block in orthopedic below-knee surgery: A prospective controlled trial.

BACKGROUND: Postoperative quality of recovery (QoR) and patient satisfaction have gained increasing significance in medical services. This study aimed to compare these 2 parameters between 2 types of regional anesthetics (spinal anesthesia and combined sciatic-femoral nerve block) in orthopedic lower knee surgery. METHODS: A total of 101 patients were classified into 2 groups (combined sciatic-femoral nerve block, group N; spinal anesthesia, group S) according to patient preference. In group N, sciatic and femoral nerve blocks were performed on the popliteal and groin regions, respectively, under ultrasound guidance. Spinal anesthesia was performed in group S. The primary outcomes were QoR and patient satisfaction. QoR was measured using the Korean translation of the QoR-15K. Patient satisfaction was assessed using an 11-point Likert scale (0-10) and a dichotomous question addressing anesthesia preferences for future surgeries. RESULTS: The physical independence of the postoperative QoR-15K was significantly higher in group N than in group S (14.2 vs 12.0, P = .04). On the 11-point Likert scale, group N scored 8.8, and group S scored 7.8 (P = .001). In the dichotomous question, 93.8% of the group N and 52.8% of the group S answered that they would like to choose the same anesthesia method for the next surgery (P < .001). In addition, fewer participants in group N complained of backache than those in group S, and the time to first urination after anesthesia was shorter in group N than in group S (P = .004, <.001, respectively). CONCLUSION: Combined sciatic-femoral nerve block may provide better physical independence and satisfaction than spinal anesthesia in orthopedic below-knee surgeries.

Management of sporadic intracranial vascular malformations in pregnancy: a retrospective analysis.

BACKGROUND: Sporadic intracranial vascular malformations can pose significant risk to parturients, and additional reports of management may inform patient care. Here we describe the peripartum management of parturients with intracranial vascular malformations. METHODS: After Institutional Review Board approval, we performed a retrospective analysis of parturients with a known sporadic intracranial vascular malformation including cavernous malformation, developmental venous anomaly, or arteriovenous malformation who delivered at our institution between 2007 and 2020. RESULTS: We identified 10 parturients (five cavernous malformations, three developmental venous anomalies, and two arteriovenous malformations) with 16 deliveries. Among all deliveries, 13 (81.3%) were cesarean deliveries without trial of labor; 11 of these (84.6%) received a single-shot spinal and two (15.4%) received an epidural for surgical anesthesia. Two deliveries (12.5%) began with attempted trial of labor but ultimately required cesarean delivery for failure to progress; one of these cases received epidural anesthesia and the other received combined spinal-epidural anesthesia. One delivery was via spontaneous vaginal delivery with epidural analgesia. Overall, our study's cesarean delivery rate was 93.8% and spontaneous vaginal delivery rate was 6.2%. Three of 16 pregnancies were complicated by seizure, obstructive hydrocephalus, or intracranial hemorrhage. There were no intensive care unit admissions or maternal deaths. CONCLUSIONS: In our case series of 16 deliveries, there were no complications directly resulting from neuraxial procedures. It remains unclear whether intracranial developmental venous anomalies or unruptured arteriovenous malformations impart increased risk during pregnancy. Antepartum planning with a multidisciplinary team approach enables risk stratification and optimal management.

Observational study of peripheral skin temperature changes following spinal anaesthesia for caesarean birth.

BACKGROUND: Spinal anaesthesia is widely used in obstetric anaesthesia practice but there is limited knowledge about the development of sympathetic blockade following spinal anaesthesia for caesarean birth. This study investigated the characteristics of sympathetic blockade by measuring peripheral skin temperature changes in the feet of patients given spinal anaesthesia for elective caesarean birth. METHODS: A prospective observational study was conducted involving 60 eligible parturients scheduled for elective caesarean birth with spinal anaesthesia. Skin temperature probes were attached to the dorsum of both feet, and temperature measurements were recorded every minute. The dose of spinal anaesthesia given, and other relevant patient data, were collected. RESULTS: All participants had successful spinal anaesthesia. Following spinal anaesthesia, a sustained rise in skin temperature of both feet was observed, indicating the presence of sympathetic blockade. The maximum rate of temperature increase occurred between 6 and 15 min after the intrathecal injection and plateaued from 22 min after the injection. Control participants did not show any changes in foot temperature. CONCLUSIONS: This study demonstrates that successful spinal anaesthesia for caesarean birth results in a consistent and reliable rise in skin temperature of the feet that is evident after six minutes from intrathecal injection. The observed temperature changes provide indirect objective evidence of bilateral sympathetic blockade. Measurement of feet skin temperatures may serve as an additional objective indicator of successful spinal anaesthesia, along with tests of lower limb motor block and sensory block height. These findings contribute to the understanding of sympathetic blockade during spinal anaesthesia.

A retrospective cohort study of the anesthetic management of postpartum tubal ligation.

BACKGROUND: Neuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks. METHODS: We conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique. RESULTS: The failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures. CONCLUSIONS: Our analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

Bupivacaine-fentanyl isobaric spinal anesthesia reduces the risk of ICU admission in elderly patients undergoing lower limb orthopedic surgery.

BACKGROUND: To evaluate if bupivacaine-fentanyl isobaric spinal anesthesia could reduce the risk of ICU admission compared with general anesthesia in elderly patients undergoing lower limb orthopedic surgery. METHODS: This study comprised a retrospective review of all lower limb orthopedic surgeries performed at our hospital between January 2013 and December 2019. According to anesthesia methods, patients were divided into the spinal anesthesia group (n = 1,728) and the general anesthesia group (n = 188). The primary outcome evaluated was the occurrence of ICU admission. Secondary outcomes included hemodynamic changes, postoperative complications, and mortality. RESULTS: Repeated measure analysis of variance indicated that the difference between the two groups in the systolic blood pressure (SBP) was not significant before anesthesia (T0), immediately after anesthesia (T1), and before leaving the operation room (T8) (P > 0.05), but significant (P < 0.01) from 5 min after anesthesia (T2) to after operation (T7). The proportions of ICU admission (6.4% vs. 23.8%, P < 0.01) and unplanned intubation (0.1% vs. 3.8%, P < 0.01) were significantly lower in the spinal anesthesia group compared with those in the general anesthesia group. Multivariate logistic regression revealed that after controlling for potential confounding factors, the odds of ICU admission for patients in the spinal anesthesia group was 0.240 times (95% CI 0.115-0.498; P < 0.01) than those in the general anesthesia group. CONCLUSIONS: Bupivacaine-fentanyl isobaric spinal anesthesia significantly reduced the risk of ICU admission and unplanned intubation, and provided better intraoperative hemodynamics in elderly patients undergoing lower limb orthopedic surgery. TRIAL REGISTRATION: This study has been registered in the Chinese Clinical Trial Registry (ChiCTR2000033411).

Combined segmental spinal epidural for major spine surgery: a case report.

A woman in her mid-50s, hesitant about general anaesthesia due to a difficult airway, opted for neuraxial anaesthesia for L4 laminectomy with pedicle screw fixation (L3-L5). Preoperatively, she received 150 µg buprenorphine and 1 mg midazolam. In lateral position, a T8-T9 epidural catheter was placed, followed by segmental spinal anaesthesia (2.5 mL 0.5% hyperbaric bupivacaine+30 µg clonidine) at T10-T11. Prone positioning was executed using standard techniques. During the 6-7 hours surgery, three 7 mL epidural top-ups (2% lignocaine epinephrine) were administered at 90 min intervals. Haemodynamics remained stable with 2.5 L crystalloids, 350 mL packed red cells and three ephedrine doses (6 mg each). Sedation included 150 µg buprenorphine and two 1 mg midazolam doses. Postoperatively, she received epidural 0.25% bupivacaine for 2 days, systemic analgesics and was discharged on the sixth day.

Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial.

BACKGROUND: Hypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. METHODS: Term pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. RESULTS: Data from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. CONCLUSION: Omission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.

Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA). METHODS: A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n = 120) or GA (n = 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test. RESULTS: Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P = 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001). CONCLUSIONS: SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.

Non-pharmacological treatments for shivering post neuraxial anaesthesia for caesarean section: a scoping review.

BACKGROUND: Shivering occurs more frequently for women having caesarean section under neuraxial anaesthesia compared to other patient groups and causes an increase in pain and interrupts bonding with her newborn. AIM: This study aimed to report the evidence on non-pharmacological methods to treat shivering, defined as uncontrollable shaking, because of being cold, frightened, or excited, post neuraxial anaesthesia; the use of local anaesthesia inserted around the nerves of the central nervous system such as spinal anaesthesia and epidural in women having a caesarean section. METHODS: A scoping review was conducted using six electronic health databases that were searched with no restrictions placed on language, date, or study type. FINDINGS: Of the 1399 studies identified, following screenings only one study was deemed suitable for inclusion. The study, a randomised controlled trial, compared forced air warming blankets (intervention) with the usual care of warmed cotton blankets (control) and its impact on maternal and newborn outcomes. The only statistically significant difference found was the perceived thermal comfort of the mother. DISCUSSION: Non-pharmacological treatments for shivering are underrepresented in the literature; only one study identified where the impact of active warming was compared to warmed cotton blankets (usual care) for the measures of: oral temperature; degree of shivering; and thermal comfort pain scores. There was a decline in temperature in both groups at odds with some women reporting feeling too warm such that they asked for the active warmer to be turned down. CONCLUSION: Social engagement strategies are interventions that send a signal of safety to the nervous system leading to a sense of calm and wellbeing and have biological plausibility and warrant evaluation. Recommendations for further research: design a robust study to test the effectiveness of social engagement strategies on shivering for women having caesarean section under neuraxial anaesthesia.

Effect of phenylephrine rescue injection on hypotension after spinal anaesthesia for caesarean delivery when guided by both heart rate and SBP during an early warning window: A randomised controlled trial.

BACKGROUND: Spinal anaesthesia is now the most common technique for caesarean delivery. However, because of the intermittent nature of noninvasive blood pressure (NIBP) measurements, maternal blood pressure may become hypotensive between the measurements. There is thus an inbuilt delay before the anaesthesiologist can intervene to counteract the hypotension. Based on the principle that changes in blood pressure can induce compensatory changes in the heart rate (HR), combining the NIBP with real-time HR, we designed two warning windows to predict hypotension and hypertension. OBJECTIVE: To evaluate whether phenylephrine administration guided by these warning windows would help maintain haemodynamic stability. SETTING: A teaching hospital. DESIGN: A randomised controlled trial. PATIENTS: One hundred and ten pregnant women scheduled for elective caesarean delivery were enrolled, from which, after exclusions, 86 were eligible for the study. INTERVENTIONS: All eligible patients received a continuous intravenous infusion of phenylephrine as soon as spinal anaesthesia was initiated. Thereafter, patients were randomly assigned to two groups. In the test group (Win-Group): rescue phenylephrine administration was triggered by an early warning window of HR above 100 beats per minute (bpm) and SBP 90 to 110 mmHg; pausing the infusion phenylephrine was triggered by a HR lower than 60 bpm and SBP greater than 90 mmHg. In the control group, phenylephrine was guided by BP only when it appeared on the monitor: SBP less than 90 mmHg was the trigger for administering rescue phenylephrine; SBP greater than 110 mmHg was the trigger for pausing the phenylephrine infusion. MAIN OUTCOME MEASURES: The primary outcome was incidence of hypotension. Secondary outcomes were the incidence of hypertension and other adverse haemodynamic events. RESULTS: The incidence of hypotension was significantly lower in the Win-Group than in the BP-Group (27.8 vs. 66.7%, P  = 0.001). The minimum SBP was significantly higher in Win-Group than in BP-Group (93.9 ±â€Š9.49 vs. 86.7 ±â€Š11.16 mmHg, P   =  0.004). There was no significant difference in the incidence of hypertension between groups. CONCLUSION: After spinal anaesthesia for caesarean delivery, when phenylephrine infusion is guided by HR along with BP from a warning window it effectively reduces the incidence of hypotension without any significant effect on incidence of hypertension. TRIAL REGISTRATION: Chictr.org.cn; Identifier: ChiCTR 2100041812.