Combined spinal and epidural anesthesia for cesarean section in a parturient with moyamoya disease

We present the case of a parturient with moyamoya disease admitted to the hospital for elective cesarean section. Combined spinal and epidural technique was chosen because it allows better analgesia than epidural anesthesia and more hemodynamic stability than either general or spinal anesthesia. Ropivacaine was the local anesthetic of choice for the epidural portion because of the wide sensory-motor dissociation, thus preserving adequate respiration in the case of a high block.     

Combined spinal and epidural anesthesia. A review of the method

Combined spinal epidural anaesthesia (CSE) offers the fast and profound neural blockade of spinal anaesthesia, but provides the possibilities of extension of the block and post-operative pain control. On the basis of a historical review, the advantages and drawbacks of CSE are discussed, and purpose-designed needles (Eldor 1 and 2, E-SP, T-A, Braun, Mediziv) are described. The dosage problems inherent in the technique and a possible solution to the "test dose" question are described. In conclusion: CSE is a valuable alternative to established regional anaesthetic techniques. The Mediziv needle offers several advantages, but a comparative study of the different needle types is needed.     

Experimental epidural and conduction anesthesia with azacaine

We present the results of the in vitro action of alpha and gamma interferons and of Intacglobin and Igegam against the 47/93/IPK (Coxsackie A9) strain isolated from the cerebrospinal fluid of a patient with epidemic neuropathy. The in vitro studies showed that the two interferons inhibited the replication of this agent; they also showed the presence of antibodies to it in the Intacglobin and Igegam. The results attained demonstrated that the use of these compounds could be effective for the treatment of this entity.     

硬膜外麻醉与腰硬联合麻醉在剖宫产术中应用效果比较

近年来,剖宫产率呈明显上升趋势,当前我国大部分城市医院剖产率达到40.00%～50.00%.剖宫产术的安全性和术中的并发症越来越受到社会的广泛关注.为比较硬膜外麻醉(CEA)和腰硬联合麻醉(CSEA)在剖宫产术中麻醉效果、不良反应以及对产妇、新生儿的影响.对宜都市妇幼保健院2006年1月-2009年1月剖宫产术的单胎初产妇1600)名采用两种不同的麻醉方法的效果进行比较分析,现报告如下.     

Acquired neuromyotonia in a patient with spinal epidural abscess

We report a case of acquired neuromyotonia in a patient with Staphylococcus aureus septicemia and a spinal epidural abscess. Autoantibodies to voltage-gated potassium channels, which are associated with acquired neuromyotonia, were present during the patient's acute illness but became undetectable on clinical recovery. The spinal epidural abscess may have triggered the production of these specific autoantibodies, resulting in clinically and electromyographically detectable neuromyotonia.     

Advantages of epidural anesthesia in patients with end-stage chronic renal failure

The authors analyze the experience gained in anesthesiological management of 667 surgeries in patients with the end-stage chronic renal failure. 206 patients were operated on under epidural anesthesia and 461 under general anesthesia. The technique of anesthesia, preparation of patients, and the management during and after surgery are described. 63 hemodialysis procedures were performed for 4 h before and 154 for 12 h after surgery. The complications occurring during and after anesthesia by both methods are analyzed. Epidural anesthesia was found to be more safe for patients with the end-stage chronic renal failure. General anesthesia more often led to hemodynamic, respiratory, metabolic disorders, and other hemostasis disturbances.     

Hypertrophic cranial pachymeningitis with spinal epidural granulomatous lesion

A 67-year-old woman with a one-year history of tinnitus and headache had multiple cranial nerve palsies of V, VII, VIII, IX, X, XI and spastic paraparesis. She also had a secretory otitis media. Gd-DTPA-enhanced magnetic resonance imaging (MRI) revealed hypertrophy of the dura of the posterior fossa and spinal epidural mass which extended from C7 to T10. A biopsy of the epidural mass showed chronic granulomatous change. These lesions were completely cured with administration of antibiotics. We believe this case of double-lesion of hypertrophic cranial pachymeningitis and spinal epidural granulomatous lesion originated from a bacterial infection secondary to the secretory otitis media.     

Delayed lumbar epidural hematoma. Discussion of the risk factors: hypertension, anticoagulation and spinal anesthesia]

We report a case of intracystic papillary carcinoma of the breast in a 62-year-old Japanese man, who came to our hospital complaining of a right subareolar mass. Imaging diagnosis was a cyst with an intracystic component. Since repeated aspiration biopsy cytology was interpreted as a borderline lesion, no additional treatment had been given. Because he wanted the removal of the mass 14 months after his first visit, an excisional biopsy was performed under local anesthesia. Pathological examination revealed the intracystic component to be non-invasive papillary carcinoma. Although the incidence of male breast cancer is approximately 1% of all breast cancer, intracystic papillary carcinoma in the male is very rare. From a review of the literature on this disease in Japanese men, an intracystic component can often be demonstrated by ultrasound. However, it is difficult to confirm malignant cells by aspiration biopsy cytology of cyst fluid. Since some cases have a local relapse, excisional biopsy and long-term follow-up are indicated.     

Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease

BACKGROUND: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). METHODS: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38-74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEB1/FVC was 0.52 (range, 0.4-0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. RESULTS: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2-4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including PO2 and pCO2, and no complications occurred either intra- or postoperatively. CONCLUSIONS: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.     

Spinal epidural abscess associated with epidural anesthesia: gadolinium-enhanced magnetic resonance imaging and its usefulness in diagnosis and treatment

A case of spinal epidural abscess following epidural anesthesia is described. Gadolinium-enhanced magnetic resonance images were essential in diagnosis of the abscess without frank pus formation, in defining the extension of the infection, and in assessing the therapeutic effect. The patient was successfully treated non-operatively before neurological symptoms developed and full recovery was achieved.     

CSE vs. augmented epidural anesthesia for cesarean section. Spinal and epidural anesthesia with bupivacaine 0.5% "isobar" require augmentation

Incomplete anaesthesia is a major clinical problem both in single spinal and in single epidural anaesthesia. The clinical efficacy of epidural anaesthesia with augmentation (aEA) and combined epidural and spinal anesthesia (CSE) for cesarean section was investigated in a prospective randomized study on 45 patients. METHODS: Anaesthesia extending up to Th5 was aimed for. Depending on the patient's height, epidural anaesthesia was administered with a dose of 18-22 ml 0.5% bupivacaine and spinal anaesthesia with a dose of 11-15 mg 0.5% bupivacaine. Augmentation was carried out in all cases in epidural anaesthesia, initially with 7.5 ml 1% Lidocaine with epinephrine 1:400,000, raised by 1.5 ml per missing segment. The epidural reinjection in CSE was carried out as necessary with 9.5-15 ml 1% lidocaine with epinephrine, depending on the height and difference from the segment Th5. RESULTS: The extension of anaesthesia achieved in epidural anaesthesia after an initial dose of 101.8 mg bupivacaine and augmenting dose of 99 mg lidocaine reached the segment Th5. The primary spinal anaesthesia dose up to 15 mg corresponding to height led to a segmental extension to a maximum of Th3 under CSE. Augmentation was necessary in 13 patients; in 5 cases because of inadequate extent of anaesthesia and 8 cases because of pain resulting from premature reversion. The augmenting dose required was 13.9 ml. Readiness for operation was attained after 19.8 min (aEA) and after 10.5 min (CSE). No patient required analgesics before delivery. The additional analgesic requirement during operation was 63.6% (aEA) and 39.1% (CSE). Taking into account pain in the area of surgery, the requirement of analgesics was 50% (aEA) vs. 17.4% (CSE). Antiemetics were required in 18.2 (aEA) and in 65.2% (CSE). The systolic blood pressure fell by 17.7% (aEA) and in 30.3% (CSE). The minimum systolic pressure was observed after 13.4 min in aEA, and after 9.5 min in CSE. The APGAR score and the umbilical pH did not show any differences. General anaesthesia was not required in any case.     

Multicomponent intravenous and epidural anesthesia in aorto-coronary bypass surgery

The influence of epidural anesthesia (CEA) on clinical manifestations, cortisole and adrenocorticotropic hormone (ACTH) level, central hemodynamic values during aorto-coronary bypass surgery (ACBS) in 56 patients aged 42-68 years with preserved functional capacity of the myocardium was studied. Catheterisation of the epidural space was carried out in the evening before the operation according to the standard method at the level of T4-T5 with the use of disposable epidural set. During the procedure before perfusion 2% solution of lidocaine 3.8 +/- 0.2 mg/kg was introduced in epidural space (taking into account test-dose) as a bolus in 3-4 motions. The dose of local anesthetics for infusion was selected separately for each individual case with due regard for hemodynamic values. During artificial circulation additionally local anesthetic was introduced as a bolus, the dose being 4.7 +/- 0.8 mg/kg. At the end of the operation morphine (0.061 +/- 0.001 mg/kg) was introduced. It was established that combined application of intravenous and epidural anesthesia represents highly effective method of anesthesia in aorto-coronary bypass surgery. According to clinical course data, cortisone and ACTH blood contents and hemodynamic parameters, EA provides adequate anesthesia, promotes stabilization of hemodynamic values and creates functionally more advantageous conditions for the myocardium in patients with CHD during aorto-coronary bypass operation. Anesthesiologic aid with the use of EA promotes reduction of intravenous anesthetics expenditure, earlier waking up of the patients in postoperative period and decrease in duration of postoperative artificial lung ventilation.