Gordon L. Mandell

Postdural Puncture Headache: A Randomized Comparison of Five Spinal Needles in Obstetric Patients

This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, &khgr;2 analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients. Implications We compared the rates of postdural puncture headache and epidural blood patch (EBP) with five different spinal needles in obstetric patients undergoing cesarean delivery. The least expensive Quincke needle had the highest postdural puncture headache and EBP rates. Patient discomfort as well as the cost of an EBP must be considered when choosing a spinal needle. Our results support using pencil-point spinal needles in obstetric patients.

Effect of Epidural Analgesia with Ambulation on Labor Duration

BackgroundAmbulatory epidural analgesia (AEA) is a popular choice for labor analgesia because ambulation reportedly increases maternal comfort, increases the intensity of uterine contractions, avoids inferior vena cava compression, facilitates fetal head descent, and relaxes the pelvic musculature, all of which can shorten labor. However, the preponderance of evidence suggests that ambulation during labor is not associated with these benefits. The purpose of this study is to determine whether ambulation with AEA decreases labor duration from the time of epidural insertion to complete cervical dilatation. MethodsIn this prospective, randomized study, 160 nulliparous women with AEA were randomly assigned to one of two groups: AEA with ambulation and AEA without ambulation. AEA blocks were initiated with 15–20 ml ropivacaine (0.07%) plus 100 &mgr;g fentanyl, followed by a continuous infusion of 0.07% ropivacaine plus 2 &mgr;g/ml fentanyl at 15–20 ml/h. Maternal measured variables included ambulation time, time from epidural insertion to complete dilatation, stage II duration, pain Visual Analogue Scale scores, and mode of delivery. APGAR scores were recorded at 1 and 5 min. Results are expressed as mean ± SD or median and analyzed using the t test, chi-square, or the Mann–Whitney test at P ≤ 0.05. ResultsThe ambulatory group walked 25.0 ± 23.3 min, sat upright 40.3 ± 29.7 min, or both. Time from epidural insertion to complete dilatation was 240.9 ± 146.1 min in the ambulatory group and 211.9 ± 133.9 min in the nonambulatory group (P = 0.206). ConclusionAmbulatory epidural analgesia with walking or sitting does not shorten labor duration from the time of epidural insertion to complete cervical dilatation.

Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study.

Labor epidural analgesia (LEA) is allegedly associated with maternal fever and an increase in the newborn sepsis work-up (SWU) rate. In this study, we evaluated whether LEA causes an increase in the SWU rate compared with a Control group given parenteral narcotics for labor pain. Maternal and neonatal data were collected prospectively for a continuous quality improvement database. Odds ratios were calculated by using multiple logistic regression for various triggers for SWU in the neonate. Of the 1177 primiparous women and their neonates studied, 922 women received LEA and 255 women received parenteral analgesics. A small but statistically significant increase in maternal and neonatal temperatures occurred in parturients receiving LEA. The SWU rates were 7.5% in the LEA group and 9.4% in the Controls (not significant). Triggers identified for SWU were birth weight (odds ratio = 116, P = 0.000), gestational age (odds ratio = 86.6, P = 0.000), meconium aspiration and respiratory distress requiring intubation (odds ratio = 8.6, P = 0.000), hypothermia at birth (odds ratio = 7.1, P = 0.001), maternal Group B &bgr;-hemolytic streptococcal colonization (odds ratio = 6, P = 0.000), and preeclampsia or hypertension (odds ratio = 3.5, P = 0.03). There was no association between LEA and SWU.

Does Spinal Anesthesia Cause Hearing Loss in the Obstetric Population

Lumbar puncture is believed to cause hypoacousis by causing cerebrospinal fluid leakage in older individuals. We hypothesized that parturients undergoing subarachnoid block (SAB) may experience hearing loss. We evaluated the effects of SAB on hearing in parturients undergoing elective cesarean delivery. We also compared two types of spinal needles: a pencil-point needle (24-gauge Sprotte needle) and a cutting needle (25-gauge Quincke needle). Sixty patients were studied: 20 received lumbar epidural block for labor analgesia (controls), 20 received a SAB with a Sprotte needle, and 20 others received a SAB with a Quincke needle for cesarean delivery. A tone audiometer was used to test for that decibel level at which the patient heard 125-, 250-, 500-, 1000-, 2000-, 4000-, and 8000-Hz frequencies. The hearing test was performed before anesthesia, after delivery, and on the first and second postoperative days. The results were analyzed by using repeated-measures analysis of variance at P < 0.05. No patient from any of the three groups developed a hearing loss either at low or high frequencies. Spinal anesthesia does not lead to significant hearing loss when a pencil- or a cutting-point needle is used in the obstetric population.

Uniport soft-tip, open-ended catheters versus multiport firm-tipped close-ended catheters for epidural labor analgesia: a quality assurance study

STUDY OBJECTIVE To compare a multiport, firm-tipped, close-ended, epidural catheter (Portex catheter) with a uniport, open-ended, soft-tipped, wire-reinforced catheter (Arrow catheter) in obstetric patients. STUDY DESIGN Prospective data collection for intradepartmental quality assurance. SETTING Obstetric unit in a tertiary care maternity hospital. PATIENTS 2612 patients requesting labor analgesia. INTERVENTIONS The Arrow catheter was used in 1,352 women and the Portex catheter in 1,260 women. MEASUREMENTS AND MAIN RESULTS The incidence of unsatisfactory block were 3.3% and 4.4% with the Arrow and Portex catheters, respectively (p = 0.2). The catheter perforated the dura matter in 0.4% of cases with both catheters. The incidence of epidural venipuncture was 1.1% with the Arrow catheter and 5.7% with the Portex catheter (p = 0.0001). Paresthesias occurred in 6% of cases with the Arrow catheter and 11. 2 % of cases with the Portex catheter (p = 0.0001). Epidural catheter reinsertion was required in fewer patients in the Arrow group than in the Portex group (4.8% vs. 7.1%; p = 0.01). CONCLUSIONS In obstetric patients, the softer uniport Arrow catheter produces paresthesias and venipunctures less frequently than the firm multiport Portex catheter.

Comparison of ropivacaine 0.1%-fentanyl and bupivacaine 0.125% — fentanyl infusions for epidural labour analgesia

Purpose: To compare analgesic efficacies of ropivacaine-fentanyl and bupivacaine-fentanyl infusions for labour epidural analgesia.Methods: In this double-blind, randomized study 100, term, nulliparous women were enrolled. Lumbar epidural analgesia (LEA) was started at cervical dilatation <5 cm using either bupivacaine 0.25% followed by bupivacaine 0.125% + 2 µg·ml−1 fentanyl infusion (n=50) or ropivacaine 0.2% followed by ropivacaine 0.1% + 2 µg·ml−1 fentanyl infusion (n=50). Every hour maternal vital signs, visual signs, visual analog scale (VAS) pain score, sensory levels, and motor block (Bromage score) were assessed. Data were expressed as mean ±1 SD and analyzed using Chi -Squared and Mann-Whitney U tests at <0.05.Results: The onset times were 10.62±4.9 and 11.3±4.7 min for the bupivacaine and ropivacaine groups respectively (P=NS). The median VAS scores were not different between the groups at any of the evaluation periods. However, at least 80% of patients in the ropivacaine group had no demonstrable motor block after the first hour compared with only 55% of patients given bupivacaine (P=0.01).Conclusions: Both bupivacaine and ropivacaine produce satisfactory labour analgesia. However, ropivacaine infusion is associated with less motor block throughout the first stage of labour and at 10 cm dilatation.RésuméObjectif: Comparer l’efficacité analgésique des perfusions de ropivacaïne-fentanyl et de bupivacaïne-fentanyl pour l’analgésie péridurale pendant le travail obstétrical.Méthode: Cent femmes nullipares et à terme ont été recrutées pour participer à une étude randomisée et à double insu. L’analgésie préridurale lombaire (APL) a été amorcée quand la dilatation cervicale était <5 cm en utilisant soit de la bupivacaïne à 0,25 % suivie de bupivacaïne à 0,125 % + une perfusion à 2 µg·ml-1 de fentanyl (n=50), soit de la ropivacaïne à 0,2 % suivie de ropivacaïne à 0,1 % + une perfusion à 2 µg·ml-1 de fentanyl (n=50). On a noté à toutes les heures: les signes vitaux de la mère, les scores de douleur à l’échelle visuelle analogique (EVA), les niveaux sensitifs et le bloc moteur (score de Bromage). Les données ont été exprimées en termes de moyenne±un écart type et analysées d’après le test Chi2 et le test U de Mann-Whitney à <0,05.Résultats: Les délais d’installation ont été de 10,62±4,9 et de 11,3±4,7 min pour la bupivacaïne et la ropivacaïne respectivement (P=NS). Les scores moyens de l’EVA n’ont pas affiché de différence intergroupe. Cependant, au moins 80 % des patientes qui ont reçu de la ropivacaïne n’avait pas de bloc moteur vérifiable après la première heur contrairement à 55 % seulement des patientes à qui on a donné de la bupivacaïne (P=0,01).Conclusion: La bupivacaïne et la ropivacaïne produisent une analgésie satisfaisante pendant le travail obstétrical. La perfusion de ropivacaïne est toutefois associée à un bloc moteur moins intense pendant la première phase du travail et à 10 cm de dilatation.

Amniotic fluid embolism with second trimester pregnancy termination: a case report.

PurposeDescribe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination.Clinical featuresA 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event.ConclusionsIt is now recognized that the pathophysiological features of AFE are similar to a type-I hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.RésuméObjectifDécrire le diagnostic, les éléments cliniques, la physiopathologie, le traitement et les mesures anesthésiques entourant une embolie amniotique (EA) chez une patiente qui a subi une interruption de grossesse au deuxième trimestre.Éléments cliniquesUne femme de 30 ans, G2 P1, a été admise pour subir une dilatation et une évacuation pour mort fœtale pendant le deuxième trimestre de la grossesse. Hypotension, choc, arrêt respiratoire, dissociation électromécanique, hémorragie, coagulopathie intravasculaire disséminée nécessitant une réanimation cardio-pulmonaire et une transfusion sanguine ont compliqué les soins peropératoires. L’EA a été considérée comme la cause la plus probable de cet événement peropératoire.ConclusionsOn sait maintenant que les caractéristiques physiopathologiques d’une EA sont similaires à une réaction d’hypersensibilité de type I allant d’une réaction bénigne généralisée à l’anaphylaxie et au choc. L’EA présente un taux élevé de morbidité et de mortalité maternelles et fœtales qui nécessitent une identification et un traitement rapides. En cas d’instabilité cardiovasculaire, le traitement de l’EA est semblable à celui de l’anaphylaxie et requiert une hydratation liquide importante, une réanimation cardio-pulmonaire, l’administration de dérivés sanguins et l’usage de vasopresseurs.

Periosteal Entrapment of an Epidural Catheter in the Intrathecal Space

A 25-yr-old woman, 160 cm tall, 113.6 kg, gravida-3, para-0 at 40 wk gestation was admitted in active labor at 3-cm cervical dilation. Her medical history was unremarkable. She elected to receive an epidural for labor analgesia. The patient was placed in the sitting position, and a midline approach was attempted at the L3-4 intervertebral space using the Arrow Flextip kit (Arrow International, Inc., Reading, PA). The 17-gauge Hustead needle was inserted 6 cm to reach the epidural space, but the catheter met resistance and would not pass despite needle rotation, needle repositioning, or dilating the space with saline. A second anesthesiologist attempted a midline insertion at the L2-3 intervertebral space. The Hustead needle was inserted 6 cm to reach the epidural space and the Arrow Flextip catheter was advanced 8 cm into the epidural space. Resistance was encountered when the anesthesiologist attempted to pull the catheter back to the 10-cm mark on the skin surface, which would have left 4 cm of catheter in the epidural space (our standard practice). Further attempts to pull the catheter back were abandoned. The catheter was secured with sterile dressing at 16 cm on the skin surface. After negative aspiration of blood or cerebral spinal fluid from the catheter, a 3-mL test dose of lidocaine 1.5% with 1:200,000 epinephrine was administered. The patient complained of lower motor extremity weakness and numbness. She was placed in the supine position with left uterine displacement. The block rapidly ascended to the T1-2 dermatome level. Her blood pressure decreased from 106/56-mm Hg to 84/44-mm Hg. She received a rapid IV infusion of lactated Ringer’s solution and ephedrine was titrated in 5-mg increments to maintain systolic blood pressure more than 100 mm Hg. During this episode, the fetal heart rate remained more than 135-bpm. Her blood pressure, heart rate, and oxygen saturation were monitored until the block regressed to a T4 level. No further injection of local anesthetic was required while she remained in active labor. Four hours after catheter placement, a cesarean delivery was planned as a result of arrest of cervical dilation. The intrathecal catheter was dosed with 2 mL of hyperbaric spinal bupivacaine 0.75% in divided doses over 10 min. The block reached a T-4 dermatome level bilaterally. The cesarean delivery proceeded uneventfully and a healthy neonate was delivered. Postoperatively, when the patient regained full lower extremity sensation, we unsuccessfully attempted to remove the catheter. All attempts to remove it with the patient’s spine positioned in different degrees of flexion and extension in both sitting and lateral position were futile. Because the catheter was trapped in the intrathecal space, neurosurgical consultation was obtained. A computerized tomography scan of the spine, obtained to determine catheter location and to eliminate nerve entrapment, showed the catheter tip in the intrathecal compartment (Fig. 1). Nerve entrapment was not evident. The catheter appeared to lie in close proximity to the periosteum of the vertebral body (Fig. 2), which was felt to be the source of entrapment. The neurosurgeon extracted the catheter 0.5-cm at a time, holding it with a pair of hemostats and applying gentle traction with another pair placed as close to the skin as possible. The neurosurgeon succeeded in removing the catheter, possibly because the hemostats enabled him to apply a firmer grip and a steady incremental pull. A picture of the removed catheter is shown in Figure 3. The distal 5 cm did not show visible areas of surface damage (Fig. 3). However, the stretched catheter revealed surface damage and disruption of the internal flexometallic ring between 5 and 15 cm (Fig. 3). The patient received IV ceftriaxone and vancomycin. She remained afebrile, and the remainder of her hospital course was uneventful.

Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy.

IMPLICATIONS A single shot spinal anesthetic is not practical in a patient with a lumboperitoneal shunt. Neuraxial block and a blood patch (if necessary) may be performed in a patient on enoxaparin therapy if current guidelines for managing patients on anticoagulant therapy are followed.

Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

STUDY OBJECTIVE To examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients. DESIGN Retrospective cohort study. SETTING Obstetrical unit at a tertiary care referral center. PATIENTS Parturients receiving labor epidural analgesia with recognized unintentional dural puncture. INTERVENTIONS Cases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache. MEASUREMENTS Development of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay. MAIN RESULTS Of the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ± 1.8 vs. No morphine: 7.3 ± 2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ± 2.9 days vs. 3.0 ± 1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96). CONCLUSION In cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.