Ronald J. Hurley

Cauda Equina Syndrome and Continuous Spinal Anesthesia

In this report, we present pictures produced with a spinal canal model to demonstrate how neural damage might occur with continuous spinal anesthesia. The hypothesis is based on the fact that nerves exposed to large volumes of 5% lidocaine solution may be damaged

Role of needle gauge and tip configuration in the production of lumbar puncture headache

Background and Objectives. Postdural puncture headache (PDPH) is a morbidity that occurs frequently after lumbar puncture. The purpose of this study was to evaluate the role of needle diameter and tip configuration in causing PDPH. The incidence of PDPH was evaluated in parturients because this group of patients is at high risk for developing PDPH and because they often undergo lumbar puncture for spinal anesthesia. Methods. The incidence of PDPH after spinal anesthesia with 26‐ and 27‐gauge Quincke and 25‐gauge Whitacre needles was studied in a series of 4,125 parturients undergoing spinal anesthesia over a 4‐year period. Data were also collected on the incidence of PDPH with 17‐gauge Huber‐tipped Weiss needles in 21,578 parturients receiving lumbar epidural analgesia and/or anesthesia over the same interval. Additionally, the need to treat PDPH with epidural blood patch in all of these patients was studied. Results. The incidence of PDPH was 5.2% with 26‐gauge Quincke needles (1987‐1989), 2.7% with 27‐gauge Quincke needles (1989‐1990), and 1.2% with 25‐gauge Whitacre needles (1990‐1991). During the same periods, the incidence of PDPH with 17‐gauge Weiss needles averaged 1.1%, 1.7% and 1.2%, respectively. As compared with the 26‐gauge Quincke needle, there was a lower incidence of PDPH with the 27‐gauge Quincke (P < .006) and 25‐gauge Whitacre spinal needles (P < .001). The incidence of PDPH with the 25‐gauge Whitacre needle was less than that with the 27‐gauge Quincke needle (P < .05), and it was similar to the overall rate of headache, which occurs occasionally from accidental dural puncture during the performance of lumbar epidural analgesia/anesthesia for labor and cesarean delivery (P = .974). The need for treating PDPH with epidural blood patching was greatest with the 17‐gauge Weiss epidural needle (75.3% of cases), but was similar with the various spinal needles (13‐39%). However, because the Whitacre needle produced the fewest PDPHs, it was associated with the lowest absolute requirement for epidural blood patching. Conclusions. The morbidity associated with lumbar puncture can be decreased by selecting the proper needle gauge and tip configuration. Use of the smallest gauge needle and one that has a noncutting Whitacre tip produces the lowest incidence of PDPH in parturients, a group of patients at increased risk for developing PDPH.

Continuous Spinal Anesthesia with a Microcatheter Technique: Preliminary Experience

This report describes the evolution of the microcatheter, the problems encountered during its initial utilization, the intricacies involved with insertion and removal, and our results with 58 patients

Epidural anesthesia complicated by fluid collection within the spinal cord.

number of neurologic complications of epidural anesthesia have been reported (l), inA cluding direct trauma to the spinal cord or nerve roots, epidural hematoma, epidural abscess, spinal cord infarction, neurotoxicity of injected agents, and arachnoiditis. Neurologic events may also follow epidural anesthesia but be unrelated to the anesthesia; in these cases the surgery, patient positioning, or antecedent medical problems may be implicated. We report a case of epidural anesthesia complicated by back and bilateral leg pain, neurologic deficits, and fluid within the spinal cord.

Pregnancy, labour and delivery in a Jehovah’s Witness with esophageal varices and thrombocytopenia

Purpose: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10 – 61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah’s Witness.Clinical features: A 25-yr-old Jehovah’s Witness parturient with portal hypertension and esophageal varices secondary to crytogenic cirrhosis was referred to our obsetrical unit at eight weeks gestation. In addition she was thrombotyopenic with platelet counts ranging from 42,000–67,000·μl−1. Here esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesaren section which could result in massive hemorrhage, to elective induction of labour wiht an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.Conclusion: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.RésuméObjectif: Un nombre croissant de femmes souffrant de cirrhose deviennent enceintes et mènent leur grossesse à terme. Cependant, la taux de mortalité maternelle demeure élevé (10 – 61%). Le présent article décrit la démarche anesthésique adoptée avec une patiente, Témoin de Jéhovah, qui présente des varices oesophagiennes et une thrombocytopénie.Élements cliniques: Une parturiente de 25 ans, Témoin de Jéhovah, présentant une hypertension portale et des varices œsophagiennes secondaires à une cirrhose nodulaire postnécrotique, a été dirigée vers notre unité obstétricale à 8 sem de gestation. Elle avait aussi une thrombocytopénie, la numération plaquettaire étant de 42,000–67,000·μl−1. Trois fois pendant la grossesse, des bandes prophylactiques ont été posées sur les varices œsophagiennes. Un examen d’IRM, fait à 32 sem de gestation, a montré une tête de Méduse et une varice médiane dominante. Pour cette raison, on a remplacé la césarienne prévue, qui aurait pu provoquer une hémorrhagie massive, par une induction du travil et une expulsion assistée. La patiente refusait toute transfusion de produit sanguin, sauf une hémodilution et une autotransfusion immédiates, au besoin, pendant le travail et l’accouchement. Malgré les préparatifs élaborés en prévision d’un accouchement par voie vaginale, la patiente a connu un travail rapide imprévu. La rachianalgésie a été administrée pour faciliter un accouchement assisté en douceur.Conclusion: Le succès de l’accouchement chez les parturientes atteintes de cirrhose repose sur une démarche multidisciplinaire. L’examen périodique et le bandage des varices œsophagiennes sont recommandés pendant la gorssesse. On devrait considérer sérieusement les bénéfices qu’offre l’anesthésie régionale.

Spinal opioids in the management of obstetric pain.

Spinal opioids have become increasingly popular agents for providing analgesia during labor, augmenting anesthesia during cesarean section, and providing pain relief after operative delivery. The development of spinal opioids in the management of obstetric pain is reviewed.

Continuous Microcatheter Spinal Anesthesia With Subarachnoid Meperidine for Labor and Delivery

The patient was a 28-yr-old, white, gravida 1 para 0, 176.3-cm, 73.8-kg woman who was seen in consultation at 38 wk gestation because of a history of ”allergy to local anesthetics.” She had a history of mild asthma since childhood for which she used a metaproterenol inhaler as necessary, but had never been admitted to a hospital for treatment of asthma. She reported allergies to povidone-iodine solution, tetracycline, erythromycin, lidocaine, and “Novocaine” manifested by rash and urticaria. In addition, she reported an extrapyramidal reaction to proclorperazine. Six months earlier she had suffered an apparent allergic reaction in a dentist’s office when given a maxillary injection of local anesthetic. She developed a rash and hives on her neck, face, arms, and trunk that subsided after several hours. The