Sudha Singh

A prospective, randomized, double-blind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections.

INTRODUCTION:In this prospective, randomized, double-blind study, we compared the effectiveness and time efficiency of perioperative axillary blocks performed via 2 different techniques, 1 involving 2 and the other 4 separate skin punctures. METHODS:One hundred twenty patients undergoing upper limb surgery were randomized to receive either (1) an axillary brachial plexus block involving 2 injections, with 30 mL local anesthetic injected posterior to the axillary artery (with redirection, as needed, to achieve circumferential spread), plus 10 mL local anesthetic to the musculocutaneous nerve, guided by ultrasound (group 1, n = 56); or (2) 4 separate 10-mL injections to the median, ulnar, radial, and musculocutaneous nerves, using a combined ultrasound and neurostimulation technique (group 2, n = 58). All patients received 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine. The primary outcome was the success rate of the block, defined as anesthesia adequate for surgery. Secondary outcomes were the time to administer the block, time to the onset of motor-sensory block, time to surgical readiness, and incidence of adverse events. RESULTS:The 2-injection technique was slightly faster to administer (8 vs 11 minutes, P = 0.003). The mean nerve block score was slightly higher for the 4-injection group at the 10-, 15-, 20-, and 30-minute time points, but the cumulative percentages of blocks having taken effect were not significantly different over these time points, at 0.0%, 5.4%, 12.5%, and 37.5% among those who had received a 2-injection block versus 6.9%, 10.4%, 19.0%, and 48.3%, respectively, with the 4-injection block (P = 0.20). There was no difference in the percentage of patients with complete block by 30 minutes (32.1% vs 37.5%, P = 0.55) or in final block success rates (89.3% vs 87.9%, P = 0.99). CONCLUSIONS:An ultrasound-guided 2-injection axillary block may be as effective as, and more time efficient than, a 4-injection technique.

Pheochromocytoma and pregnancy: a case report and review of anesthetic management

PurposeTo describe a patient diagnosed with pheochromocytoma in the third trimester of pregnancy and discuss the perioperative and anesthetic management.Clinical featuresA 32-yr-old previously healthy woman (gravida 4, para 2) presented to our tertiary care obstetrical hospital at 34 weeks five days gestation with a history of labile blood pressure and severe hypertension. A week prior to admission she began having episodes of severe headache, dizziness, sweating and nausea. On a routine obstetric visit she was noted to be severely hypertensive with a blood pressure of 200/120 mmHg. Biochemical investigations confirmed the diagnosis of pheochromocytoma and magnetic resonance imaging demonstrated a 3 cm × 3 cm right adrenal mass. The patient was invasively monitored in the intensive care unit and treated with alpha-followed by beta-blockade with phenoxybenzamine and metoprolol. A multidisciplinary conference was organized involving endocrinology, anesthesiology, general surgery and obstetrics to determine the most appropriate management of the patient. An uncomplicated laparoscopic adrenalectomy was performed following a period of recovery after an uneventful elective Cesarean delivery.ConclusionsThe primary goals in the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery and definitive surgical treatment. Timing of surgical resection will depend on the gestational age at which diagnosis is made. Cesarean section is the preferred mode of delivery when the tumour is still present. This case illustrates that with antenatal diagnosis, advanced methods of tumour localization, adequate preoperative adrenergic blockade and team planning, pheochromocytoma in pregnancy can be treated successfully.RésuméObjectifPrésenter une patiente chez qui on a découvert un phéochromocytome au troisième trimestre de la grossesse, et son traitement périopératoire et anesthésique.Éléments cliniquesUne femme de 32 ans, antérieurement en bonne santé (G4, P2) s’est présentée à notre hôpital obstétrical de soins tertiaires à 34 semaines et cinq jours de grossesse. Elle avait une histoire de tension artérielle labile et de sévère hypertension. Une semaine avant l’hospitalisation, elle a eu des épisodes de céphalées sévères, étourdissements, transpiration et nausées. Lors d’une visite obstétricale de routine, une tension artérielle de 200/120 mmHg avait indiqué une hypertension importante. Les examens biochimiques ont confirmé le diagnostic de phéochromocytome et l’imagerie par résonance magnétique a montré une masse surrénalienne droite de 3 cm × 3 cm. La patiente, sous monitorage effractifà l’unité des soins intensifs, a reçu des alpha-bloqueurs, puis des bêta-bloqueurs combinés à de la phénoxybenzamine et à du métoprolol. Une réunion des endocrinologue, anesthésiologiste, chirurgien général et obstétricien a permis de déterminer le traitement le plus approprié. Une surrénalectomie laparoscopique sans complications a été exécutée après que la patiente a été remise de la césarienne sans incident réalisée auparavant.ConclusionsLe traitement d’un phéochromocytome pendant la grossesse visent à établir un diagnostic précoce, à empêcher une crise hypertensive pendant l’accouchement et à procéder à l’intervention chirurgicale définitive. Le moment choisi pour la résection dépend de l’âge gestationnel au moment du diagnostic. La césarienne est le mode d’accouchement privilégié lorsque la tumeur est toujours présente. Le cas présent montre que le diagnostic prénatal, des méthodes perfectionnées de localisation de la tumeur, un bloc adrénergique préopératoire adéquat et une planification multidisciplinaire permettent de traiter avec succès un phéochromocytome pendant la grossesse.

Neuraxial opioid-induced pruritus: An update.

Pruritus is a troublesome side-effect of neuraxial (epidural and intrathecal) opioids. Sometimes it may be more unpleasant than pain itself. The prevention and treatment still remains a challenge. A variety of medications with different mechanisms of action have been used for the prevention and treatment of opioid-induced pruritus, with mixed results. The aim of this article is to review the current body of literature and summarize the current understanding of the mechanisms and the pharmacological therapies available to manage opioid-induced pruritus. The literature source of this review was obtained via PubMed, Medline and Cochrane Database of Systematic Reviews until 2012. The search results were limited to the randomized controlled trials, systemic reviews and non-systemic reviews.

Prevention of post‐dural puncture headache in parturients: a systematic review and meta‐analysis

Post‐dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal–epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound‐guided insertion, epidural morphine, Special Sprotte needles, acoustic‐guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta‐analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = −0.48 [95% confidence interval (CI): −0.88 to −0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = −0.44 (95% CI: −0.67 to −0.21)], epidural morphine [one trial, quality score = 4, risk difference = −0.36 (95% CI −0.59 to −0.13)], and cosyntropin [one trial, quality score = 5, risk difference = −0.36 (95% CI −0.55 to −0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well‐conducted, large studies are needed.

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind, dose-comparison, placebo-controlled randomized trial

BACKGROUND The analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery. METHODS Sixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3mg/kg), low-dose ropivacaine (1.5mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10-12mg, fentanyl 10μg and morphine 150μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48h and at 6 and 12weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction. RESULTS There were no differences between groups in the primary outcome. Mean ± SD pain scores (0-10) with movement at 24h were: high-dose ropivacaine 3.6±1.5, low-dose ropivacaine 4.6±2.1 and placebo 4.1±1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6h were lower in the high-dose group 2.0±1.8 compared to the low-dose 3.4±2.7 and placebo groups 4.2±2.0 (P=0.009). Pain scores at 12h were also lower in the high-dose group 2.2±2.0 compared to the low-dose group 4.1±2.7 and placebo group 4.0±1.3 (P=0.011). There was no difference in other outcomes between groups. CONCLUSIONS Neither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12h after cesarean delivery.

Case report : Anesthetic management for sequential Cesarean delivery and laminectomy

PurposeTo describe the anesthetic considerations for a nearterm parturient with progressive cauda equina syndrome who required Cesarean delivery followed immediately by decompression lumbar discectomy and laminectomy in the prone position.Clinical featuresA 33-yr-old woman presented at 35 weeks gestation with severe L5-S1 disc herniation causing motor and sensory neuronal dysfunction in the lower limbs accompanied by bowel and bladder dysfunction. After urgent multidisci-plinary consultations, a decision was made to proceed with general anesthesia for Cesarean delivery in the supine position with left uterine displacement, followed immediately thereafter by L5-S1 discectomy and laminectomy in the prone position. Anesthesia concerns included the risks of hemorrhage from the combined surgeries and upper airway edema from the prone position, and the physiologic changes of pregnancy. The surgeries proceeded without complication, and both mother and baby recovered uneventfully.ConclusionWith a multidisciplinary approach, two surgeries in two different positions with unique anesthetic considerations were performed safely under general anesthesia in advanced pregnancy in a parturient with cauda equina syndrome.RésuméObjectifDécrire les considérations anesthésiques concernant une parturiente presqu’à terme présentant un syndrome de la queue de cheval et nécessitant un accouchement par césarienne immédiatement suivi par une discectomie lombaire de décompression et une laminectomie en position de décubitus ventral.Éléments cliniquesUne femme de 33 ans s’est présentée à 35 semaines de grossesse avec une hernie discale L5-S1 grave causant un dysfonctionnement moteur et sensori-neuronal des membres inférieurs ainsi que des troubles intestinaux et de la vessie. Suite à des consultations multidisciplinaires urgentes, il a été décidé de procéder à une anesthésie générale pour l’accouchement par césarienne en position de décubitus dorsal avec déplacement utérin gauche. La césarienne a été immédiatement suivie par une discectomie L5-S1 et une laminectomie en position de décubitus ventral. Le risque hémorragique des chirurgies combinées, l’œdème des voies aériennes supérieures, ainsi que les changements physiologiques de la grossesse constituent les préoccupations anesthésiques. Les chirurgies se sont déroulées sans complication, et la mère et le bébé se sont rétablis sans difficulté.Conclusionrâce à une approche multidisciplinaire, deux chirurgies en deux positions différentes présentant des considérations anesthésiques spécifiques ont été effectuées en toute sécurité sous anesthésie générale chez une parturiente proche du terme souffrant du syndrome de la queue de cheval.

Ultra low-dose naloxone and tramadol/acetaminophen in elderly patients undergoing joint replacement surgery: a pilot study.

OBJECTIVE A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery. DESIGN Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen-Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 microg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra-articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient-controlled analgesia orders and celecoxib 200 mg twice daily for five days. OUTCOME MEASURES Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty. CONCLUSION Consequently, a randomized, double-blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.

The Efficacy of 2 Doses of Epidural Morphine for Postcesarean Delivery Analgesia: A Randomized Noninferiority Trial

BACKGROUND:A single dose of epidural morphine is effective in reducing pain after cesarean delivery but is associated with adverse effects. In this study, we sought to establish whether half the traditional dose of epidural morphine, when administered as part of a multimodal analgesia regimen after cesarean delivery, was associated with noninferior analgesia and fewer adverse effects. METHODS:Ninety term parturients undergoing cesarean delivery under epidural anesthesia were enrolled in this randomized, double-blinded, noninferiority study. Patients were randomly allocated to receive either 3 mg epidural morphine or, half this dose, 1.5 mg epidural morphine. In addition, subjects received regular systemic ketorolac and acetaminophen. Rescue analgesia (oral oxycodone) was administered for breakthrough pain. The primary outcome was the difference between groups in total opioid consumption (measured in median IV morphine equivalents) within the first 24 hours. A prespecified noninferiority margin of 3.33 mg was used. Secondary outcomes included total opioid consumption from 24 to 48 hours, numerical rating scale pain scores, time to first request for analgesics, overall pain relief, maternal satisfaction, quality of recovery, and adverse effects. RESULTS:Data were analyzed for 87 participants. Noninferiority was demonstrated as the difference in median 24-hour opioid consumption between the 1.5 mg epidural morphine (EM) and 3 mg EM groups was 0 mg (1-sided 95% confidence interval [CI], 2.5 mg), which was less than the prespecified noninferiority margin of 3.33 mg. No significant differences were found between groups in the median 24- to 48-hour opioid consumption or the median total opioid consumption within 48 hours. Pain scores, overall pain relief, and satisfaction at 24 and 48 hours were not significantly different between groups. The 1.5 mg EM group had a lower incidence of moderate and severe pruritus at 6 and 12 hours (relative risk [RR] 0.44, 95% CI, 0.2–0.9 and RR 0.41, 95% CI, 0.2–0.8, respectively) and had less nausea and vomiting at 6 hours (RR 0.22, 95% CI, 0.05–0.9). There was no difference in average pain scores at 12 weeks between the 2 groups. CONCLUSION:When used as part of a multimodal analgesia regimen, 1.5 mg epidural morphine provided noninferior postcesarean analgesia and caused fewer adverse effects compared with 3 mg epidural morphine.

The effect of epidural needle type on postdural puncture headache: a randomized trial

PurposeA prospective, randomized trial in labouring parturients was undertaken to assess whether the 18G Special Sprotte™ epidural needle is associated with a lower incidence of accidental dural puncture (ADP) in comparison with the 17G Tuohy needle. A secondary purpose was to determine if the incidence of postdural puncture headache (PDPH ) differed between groups when ADP occurred.MethodsFollowing Institutional Review Board approval 1,077 parturients requesting epidural analgesia at three tertiary obstetrical units were randomized to epidural catheter insertion with a 17G Tuohy or 18G Special Sprotte™ needle. Patients were followed for seven days by a blinded assessor to determine the occurrence of PDPH using standardized criteria. If postural headache or neck ache presented, an ADP was diagnosed even if cerebrospinal fluid (CSF) was not observed at insertion. This subgroup was followed daily to assess headache characteristics and response to blood patch.ResultsSix Tuohy group patients, and two patients in the Sprotte group were excluded. One of the six excluded in the Tuohy group had an ADP. Twenty-eight ADPs occurred, nine unrecognized by CSF visualization (1.8% Tuohy, 3.4% Sprotte, P = 0.12). The incidence of unrecognized ADPs was higher in the Sprotte group (40% Sprotte vs 20% Tuohy, P < 0.05). If ADP occurred, the incidence of PDPH was lower in the Sprotte group (100% Tuohy vs 55% Sprotte, P = 0.025). The ease of use, and user satisfaction were higher in the Tuohy group (84 ± 17.3% Tuohy vs 68.2 ± 25.3% Sprotte, P < 0.001).ConclusionThe incidence of ADP was not reduced with the Special Sprotte™ epidural needle in comparison with the Tuohy needle, but PDPH after ADP occurred less frequently in the Sprotte group.RésuméObjectifUne étude prospective randomisée a été réalisée chez des parturientes en travail pour évaluer si ľaiguille de péridurale 18G Special Sprotte™ est associée à une plus faible incidence de ponction durale accidentelle (PDA) en comparaison de ľaiguille 17G Tuohy. Un second objectif était de déterminer si ľincidence de céphalées post-ponction durale (CPPD) diffère entre les groupes quand survient une PDA.MéthodeSuivant ľapprobation du Comité ďexamen de ľinstitution, 1 077 parturientes nécessitant une analgésie péridurale dans trois unités obstétricales tertiaires ont été réparties en deux groupes pour ľinsertion ďun cathéter péridural ave une aiguille 17G Tuohy ou une 18G Special Sprotte™. Les femmes ont été suivies pendant sept jours par un évaluateur impartial de ľoccurrence de CPPD selon des critères normalisés. Si des céphalées posturales ou des douleurs au cou survenaient, une PDA était diagnostiquée même si le liquide céphalo-rachidien (LCR) n’était pas visible à ľinsertion. Ce sous-groupe a été suivi quotidiennement pour ľévaluation des caractéristiques des céphalées et la réponse à ľadministration épidurale de sang autologue.RésultatsSix patientes du groupe Tuohy et deux du groupe Sprotte ont été exclues. Une des six exclues du groupe Tuohy présentait une PDA. Il y a eu 28 PDA, dont neuf non reconnues par la visualisation du LCR (1.8 % Tuohy, 3.4 % Sprotte, P = 0,12). Ľincidence de PDA non reconnues a été plus élevée dans le groupe Sprotte (40 % Sprotte vs 20 % Tuohy, P < 0,05). Si une PDA survenait, ľincidence de CPPD était plus faible dans le groupe Sprotte (100 % Tuohy vs 55 % Sprotte, P = 0,025). La facilité ďusage et la satisfaction de ľutilisateur ont été plus élevées dans le groupe Tuohy (84 ± 17,3 % Tuohy vs 68,2 ± 25,3 % Sprotte, P < 0,001).ConclusionĽincidence de PDA n’a pas été réduite avec ľusage de ľaiguille de péridurale Special Sprotte™ comparée à ľaiguille Tuohy, mais les CPPD suivant une PDA ont été moins fréquentes dans le groupe Sprotte.

General anesthesia using remifentanil for Cesarean delivery in a parturient with Marfan’s syndrome

Purpose: Due to cardiovascular and skeletal abnormalities, anesthetic management of parturients with Marfan’s syndrome can be particularly challenging. Parturients with aortic root dilatation are at risk for aortic dissection. We describe the anesthetic management of a parturient with Marfan’s syndrome and aortic root dilatation, who required general anesthesia for Cesarean delivery.Clinical features: At 26 weeks gestation, a nulliparous woman with Marfan’s syndrome presented to the Anesthesia Clinic. Her history revealed asymptomatic aortic root dilatation of 41 mm, and partial correction of scoliosis with Harrington rods. Her cardiologist advised metoprolol, serial echocardiograms, and Cesarean delivery to decrease the risk of aortic dissection. At a multidisciplinary conference, a decision was made to proceed with Cesarean delivery, at term, at the cardiac surgery centre. After placement of arterial and central lines, general anesthesia was induced with remifentanil, propofol, and succinylcholine. Anesthesia was maintained with N2O, sevoflurane, and remifentanil (0.02–0.08 µgsdkg−1sdmin−1). Transesophageal echocardiography examination confirmed stable aortic root dilatation. The patient remained hemodynamically stable. The baby’s Apgars were 4 and 8, at one and five minutes, respectively. At the end of the procedure, the patient’s trachea was extubated when she was awake. Initial postoperative care was in the intensive care unit. Both mother and baby recovered uneventfully.Conclusions: Peripartum hemodynamic changes can be lifethreatening to the parturient with Marfan’s syndrome and aortic dilatation. Anesthetic goals for delivery included preparation for possible aortic dissection, and avoidance of increased aortic root shear stress, through careful hemodynamic monitoring, and general anesthesia using remifentanil.RésuméObjectif : En raison d’anomalies cardiovasculaires et squelettiques, la prise en charge de l’anesthésie chez les parturientes souffrant du syndrome de Marfan peut être particulièrement exigeante. Les parturientes avec une dilatation de la racine aortique présentent un risque de dissection aortique. Nous décrivons la prise en charge de l’anesthésie pour une parturiente souffrant du syndrome de Marfan et présentant une dilatation de la racine aortique qui a nécessité une anesthésie générale pour un accouchement par césarienne.Éléments cliniques : À 26 semaines de gestation, une nullipare souffrant du syndrome de Marfan s’est présentée à la clinique d’anesthésie. Ses antécédents ont révélé une dilatation asymptomatique de la racine aortique de 41 mm, et une correction partielle de scoliose avec des tiges de Harrington. Son cardiologue a recommandé l’administration de métoprolol, des électrocardiogrammes en série, et un accouchement par césarienne afin de réduire le risque de dissection aortique. Lors d’une conférence pluridisciplinaire, il a été décidé de réaliser l’accouchement par césarienne, à terme, dans le centre de chirurgie cardiaque. Une fois les cathéters artériel et central positionnés, l’anesthésie générale a été induite avec du rémifentanil, du propofol et de la succinylcholine. L’anesthésie a été maintenue avec du N2O, du sévoflurane, et du rémifentanil (0,02–0,08 µg·kg−1sdmin−1). L’examen échocardiographique transoesophagien a confirmé la dilatation de la racine aortique. L’hémodynamie de la patiente est demeurée stable. Les tests d’Apgar réalisés sur le nouveau-né ont donné des scores de 4 et 8 à une et cinq minutes, respectivement. À la fin de l’intervention, la trachée de la patiente a été extubée une fois qu’elle était réveillée. Les premiers soins postopératoires ont été donnés dans l’unité de soins intensifs. La mère et l’enfant ont tous deux récupéré sans complications.Conclusion : Les changements hémodynamiques pendant le péripartum peuvent être fatals pour les parturientes souffrant du syndrome de Marfan avec dilatation aortique. La préparation pour une dissection aortique potentielle et la prévention d’une force de cisaillement accrue sur la racine de l’aorte comptaient parmi les considérations anesthésiques pour l’accouchement. Ces objectifs ont été atteints grâce à un monitorage hémodynamique méticuleux et une anesthésie générale avec du rémifentanil.