Helene Finegold

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.

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.

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.

Improved bowel function after gynecological surgery with epidural bupivacaine-fentanyl than bupivacaine-morphine infusion.

Purpose: To compare postoperative gastrointestinal recovery between continuous epidural bupivacaine-fentanyl and bupivacaine-morphine.Methods: In a blinded, randomized, prospective trial, 60 women undergoing surgery for gynecologic cancer were studied. Anesthesia was provided by a combined general/epidural (L2–3 catheter) technique without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.1% with either morphine 0.05 mg·ml−1 (BM) or fentanyl 5 µg·ml−1 (BF). Visual Analogue Scale (VAS) scores for pain at rest and during movement, and the return of bowel function were collected for three days and the duration of hospitalization were noted.Results: On POD-1, 18.5% of patients in the BM group had emesis compared with none in the BF group (P=0.038) and fewer patients in the BM group tolerated clear oral fluids (11.1% BM vs 40.6% BF,P=0.025). These differences became insignificant on POD-2 and 3. Median pain scores were comparable at rest and ranged from 10–20 in the BM group vs 0–20 in the BF group over the three days. Similarly, median pain scores with movement respectively ranged from 20–25 and 20–30 in the BF and BM groups. The mean duration of hospitalization was longer in the BM group (5.7±2.4) vs BF (4.5±1.2 days),P=0.017.Conclusion: Epidural BM and BF provided equally effective postoperative analgesia at rest and during movement. Compared with BM, epidural BF is associated with less emesis and an increased ability to tolerate oral fluids on POD-I and an overall shorter hospital stay.RésuméObjectif: Comparer la récupération gastro-intestinale postopératoire à la suite d’une perfusion péridurale continue avec bupivacaïne et, fentanyl ou morphine.Méthode: L’étude à l’insu, randomisée et prospective a porté sur 60 femmes qui ont subi l’opération d’un cancer gynécologique. Une technique générale/péridurale combinée (cathéter dans l’espace L2–3) sans opioïdes périduraux a permis l’anesthésie. L’analgésie péridurale postopératoire comprenait une perfusion continue de bupivacaïne à 0,1 % avec, soit 0,05mg·ml−1 de morphine (BM), soit 5µg·ml−1 de fentanyl (BF). On a enregistré pendant 3 jrs les scores de douleur au repos et pendant le mouvement à l’échelle visuelle analogique (EVA), et le retour de la fonction intestinale. La durée de l’hospitalisation a été notée.Résultats: Au jour I postopératoire, 18,5 % des patientes du groupe BM avaient des vomissements mais aucune du groupe BF (P=0,038) et peu de patientes du groupe BM ont toléré les liquides oraux clairs (11,1 % BM vs 40,6 % BF,P=0,025). Ces différences n’étaient plus significatives aux jours 2 et 3. Les scores moyens de douleur ont été comparables au repos et allaient de 10–20 pour le groupe BMvs 0–20 pour le groupe BF au cours des trois jours. De même, les scores moyens de douleur au mouvement se retrouvaient respectivement de 20–25 et de 20–30 pour les groupes BF et BM. La durée moyenne d’hospitalisation a été plus longue dans le groupe BM (5,7±2,4) vs le groupe BF (4,5±1,2 jours),P=0,017.Conclusion: L’analgésie péridurale BM et l’analgésie BF ont fourni un soulagement équivalent de la douleur postopératoire au repos et lors de mouvements. L’analgésie avec BF, comparée à l’analgésie avec BM, est associée à moins de vomissement et à une capacité accrue de tolérance aux liquides oraux le premier jour postopératoire ainsi qu’à un séjour hospitalier plus court.