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Purpose: The causes of epidural catheter migration beneath the skin have not been previously investigated. We hypothesized that greater subcutaneous fat thickness might be associated with increased catheter migration beneath the skin. Methods: We conducted a retrospective cross-sectional study of patients who had undergone combined general and epidural anesthesia, selecting individuals who received thoracic and abdominal CT scans within the first 5 postoperative days. Needle depth was defined as the distance from the needle tip to the skin surface when the anesthesiologist determined that the needle tip had reached the epidural space. We measured the length of the epidural catheter from the skin surface to the epidural space (catheter length), and subcutaneous fat thickness (fat thickness) using CT imaging. Migration distance was calculated by subtracting needle depth from catheter length. Results: We analyzed 127 patients (72 males), all undergoing epidural catheter insertion in the left lateral decubitus position via a paramedian approach. The median age of the patients was 71 years. Epidural catheters were postoperatively found to substantially curve beneath the skin. Regression analysis revealed no significant influence of fat thickness on catheter length (regression coefficient 0.10, 95% confidence interval [CI]: − 0.17, 0.38). However, it indicated a positive correlation between fat thickness and needle depth (regression coefficient 0.50, 95% CI: 0.30, 0.70), and a negative correlation between fat thickness and migration distance (regression coefficient − 0.40, 95% CI: − 0.65, − 0.14). Conclusion: We found a negative correlation between epidural catheter migration beneath the skin and subcutaneous fat thickness. Anesthesiologists should be aware of the possibility of substantial subcutaneous curving of the catheter, especially in patients with scant subcutaneous fat. [ABSTRACT FROM AUTHOR]

Background: There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case presentation: Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Conclusion: Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery. [ABSTRACT FROM AUTHOR]

Abstract Background There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case presentation Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Conclusion Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

Introduction: Patients with fractured hips almost always have marked pain that results in unfavorable positioning for the central neuraxial block. It was revealed that regional block approaches, including suprainguinal fascia-iliaca compartment block (S-FICB) and pericapsular nerve group (PENG) block, might effectively alleviate pain in patients with hip fractures. This research aimed to evaluate the influence of S-FICB and PENG block on patients positioning during central neuraxial block and compare their analgesic efficacy. Methods: This randomized double-blinded trial included 60 cases aged ≥ 40 years old and ASA I-III with hip fracture with persistent pain and scheduled for surgery under spinal anesthesia (SA). Cases were randomized equally into two groups. Group I (S-FICB) received ultrasound (US) guided S-FICB, and group II (PENG group) received US guided PENG. Both blocks were performed by the same operator using 23 ml of ropivacaine 0.25% + 2 ml (8 mg) of dexamethasone. Results: The ease of spinal positioning (EOSP) score was significantly better in the PENG group than the S-FICB group (p < 0.001). Twenty minutes after blocks, the numeric rating scale (NRS) reduced significantly in PENG than in SFICB groups at rest (p < 0.015) and movement (p < 0.010). The first request for analgesia, NRS in the first 24-hour period postoperatively, and the number of tramadol doses were similar between both groups (p = 0.552) and (p < 0.370), respectively. Conclusions: Although each block provides comparable duration of postoperative analgesia, PENG block achieved more analgesic effect and easier positioning than S-FICB for SA in patients who had hip fractures surgery. [ABSTRACT FROM AUTHOR]

Abstract Background The recent guidelines recommend delaying elective non-neurological surgery after an index stroke, but there is a lack of consensus regarding emergency surgery in patients with a recent stroke. Impaired cerebral autoregulation and altered baroreceptor function elevate the risk of recurrent stroke in this group. Moreover, the impact of anesthesia type (general vs. regional) for non-cardiovascular, non-neurological surgery in patients with an index stroke remains inconclusive. Case presentation A 67-year-old male with an acute mild ischemic stroke underwent emergency surgery for an obstructed right-sided direct inguinal hernia under combined spinal-epidural anesthesia. Pre-operative assessment showed stable hemodynamics, and perioperative measures were taken to ensure stable blood pressure. Neuraxial anesthesia was employed successfully, and the patient remained hemodynamically stable throughout the surgery and postoperative period. No neurological deficits were observed post-surgery, and follow-up up to 3 months revealed no cognitive impairment or neurological decline. Conclusions Neuraxial anesthesia can be considered for patients with acute mild strokes requiring urgent non-neurological surgery, provided they are hemodynamically stable and without coagulopathy. However, the choice of anesthesia should be individualized based on factors such as neurological status, stroke severity, coagulation, and existing disabilities. This case highlights the importance of a personalized approach to anesthesia in emergency surgery for stroke patients.

Introduction: Back pain is a prevalent global health issue, particularly among women during the postpartum period. Neuraxial anesthesia, commonly used in procedures such as cesarean section, is associated with complications, including postspinal back pain (PSBP). However, limited data exist on its incidence and characteristics, especially within specific demographic groups. This study aimed to examine the prevalence and features of PSBP among women who underwent neuraxial anesthesia for cesarean section in a tertary care center in south India. Materials and Methods: A cross-sectional study was conducted involving 168 women who underwent spinal anesthesia for cesarean section between January 2015 and December 2018. Data were collected through telephone interviews, utilizing a structured proforma covering sociodemographic profiles, pain characteristics, and disability assessment using the Oswestry Disability Scale. Descriptive statistics and chi-squared test were used for data analysis. Results: Among the participants, 40.5% reported experiencing back pain after neuraxial anesthesia, with 39.3% experiencing pain post-delivery and 1.2% since their first delivery. The majority of participants were under 30 years old (78%) and homemakers (92.3%). Severity of back pain varied, with 22.06% classified as mild, 35.29% as moderate, and 42.65% as severe. Statistical analysis revealed a significant association between the number of children and the incidence of back pain (p

Background: The recent guidelines recommend delaying elective non-neurological surgery after an index stroke, but there is a lack of consensus regarding emergency surgery in patients with a recent stroke. Impaired cerebral autoregulation and altered baroreceptor function elevate the risk of recurrent stroke in this group. Moreover, the impact of anesthesia type (general vs. regional) for non-cardiovascular, non-neurological surgery in patients with an index stroke remains inconclusive. Case presentation: A 67-year-old male with an acute mild ischemic stroke underwent emergency surgery for an obstructed right-sided direct inguinal hernia under combined spinal-epidural anesthesia. Pre-operative assessment showed stable hemodynamics, and perioperative measures were taken to ensure stable blood pressure. Neuraxial anesthesia was employed successfully, and the patient remained hemodynamically stable throughout the surgery and postoperative period. No neurological deficits were observed post-surgery, and follow-up up to 3 months revealed no cognitive impairment or neurological decline. Conclusions: Neuraxial anesthesia can be considered for patients with acute mild strokes requiring urgent non-neurological surgery, provided they are hemodynamically stable and without coagulopathy. However, the choice of anesthesia should be individualized based on factors such as neurological status, stroke severity, coagulation, and existing disabilities. This case highlights the importance of a personalized approach to anesthesia in emergency surgery for stroke patients. [ABSTRACT FROM AUTHOR]

Objectives: Commonly, general anesthesia (GA) with endotracheal intubation is the standard anesthesiology approach in gynecological laparoscopic surgery; neuraxial anesthesia (NA) can also be used, but its application is very low and limited to few indications. This study assessed NA feasibility for almost all kinds of gynecologic laparoscopies. Materials and Methods: Data on laparoscopic surgeries performed under NA were collected retrospectively. A total of 76 patients had laparoscopic interventions at the Donatello Clinic in Florence, Italy, between October 2019 and August 2022. Adnexectomies, ovarian cyst enucleations, multiple myomectomies, total hysterectomies, radical hysterectomies with sentinel lymph-node biopsies, and complete excisions of endometriosis and adhesiolysis were performed under regional anesthesia. All procedures but 1 were completed with no change from NA. Results: All cases but 1 were completed under NA. There were (1) spontaneously breathing patients; (2) no pulmonary complications; (3) satisfactory muscle relaxation; (4) fast postoperative bowel function recovery; (5) reduced postoperative pain; (6) reduced postoperative narcotics use; and (6) absence of postoperative nausea and vomiting. Conclusions: These procedures appear to comprise the largest series of complex gynecologic laparoscopies performed under NA reported in the literature. Preliminary data seems to support the concept that this approach might be feasible and safe in selected and motivated patients, but further research is needed to confirm these encouraging data. (J GYNECOL SURG 20XX:000) [ABSTRACT FROM AUTHOR]

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex–race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p < 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p < 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population. [ABSTRACT FROM AUTHOR]

Background: Surgical resection is a mainstay of treatment in high-risk neuroblastoma (HR-NB), but there exists wide variability in perioperative management practices. The aim of this study was to evaluate two standardized adult perioperative enhanced recovery practices (ERPs) in pediatric patients undergoing open resection of abdominal HR-NB. Methods: All patients with abdominal HR-NB surgically resected at a free-standing children's hospital between 12/2010 and 7/2020 were retrospectively reviewed. Perioperative ERPs of interest included avoidance of routine nasogastric tube (NGT) use and the use of neuraxial anesthesia. Primary outcomes included time to enteral intake, urinary catheter use, opioid utilization, and length of stay (LOS). Results: Overall, 37 children, median age 33 months (IQR: 20-48 months), were identified. Avoidance of an NGT allowed for earlier feeding after surgery (P =.03). Neuraxial anesthesia use more frequently required an indwelling urinary catheter (P <.01) for a longer duration (P =.02), with no difference in total opioid utilization (P =.77) compared to patients without neuraxial anesthesia. Postoperative LOS was unaffected by avoidance of routine NGT use (P =.68) or use of neuraxial anesthesia (P =.89). Conclusion: Children undergoing open resection of abdominal HR-NB initiated diet sooner when an NGT was not left postoperatively, and the need for a urinary catheter was significantly higher in patients who received neuraxial anesthesia. However, these two ERP components did not decrease postoperative LOS. To optimize the postoperative management of NB patients, postoperative NGTs should be avoided, while the benefit of neuraxial anesthesia is less clear as it necessitates the placement of a urinary catheter without decreasing opioid utilization. [ABSTRACT FROM AUTHOR]

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The recent article by Wen et al., published in PLOS ONE, titled “Effects of neuraxial anesthesia in sitting and lateral positions on maternal hemodynamics in cesarean section: A systematic review and meta-analysis,” caught my attention. In their study, the authors observed the effects of neuraxial anesthesia in sitting and lateral positions on maternal hemodynamics during cesarean section. Given the anatomical differences between the left and right sides of the body, which could result in differences in maternal hemodynamics and vasopressor requirements during neuraxial anesthesia for cesarean delivery, I was intrigued by the idea of further dividing the lateral position data from Wen et al.'s study into three subgroups: “left lateral position,” “right lateral position,” and “not mentioned” (where the included original study did not mention the lateral position) for a subgroup analysis. It seems to be more rigorous, the subgroup analysis revealed that the usage rate of ephedrine support was 1.42 times higher for parturients in the right lateral position compared to those in the sitting position. This finding supports our recommendation to distinguish between left and right lateral decubitus positioning in neuraxial anesthesia for cesarean delivery. But in contrast, no significant difference was observed between the sitting and lateral positions in terms of the number of parturients requiring ephedrine in Wen et al.'s. Given the limited research on the right-lateral position and its hemodynamic effects, further studies are needed to explore its clinical applications. Future research should also focus on conducting larger trials with greater sample sizes to evaluate the long-term neonatal outcomes associated with varying maternal positions. Additionally, researchers should conduct subgroup analyses that separate the left- and right-lateral positions to provide clearer guidance for anesthesiologists.

BackgroundIdiopathic intracranial hypertension can lead to dural defects and spontaneous leakage of cerebrospinal fluid (CSF) from the skull base. Skull base CSF leaks are rarely reported in pregnancy but pose unique challenges for obstetricians and anesthesiologists.Case presentationA 31-year-old G4P1021 at 14 weeks developed debilitating headaches and CSF rhinorrhea. Brain imaging revealed a bony defect of the sphenoid sinus with a meningoencephalocele and a partially empty sella, consistent with CSF leakage from a skull base defect. The patient was neurologically stable without signs of meningitis; thus, management was focused on symptomatic alleviation. A planned cesarean section was performed at 38 weeks under spinal anesthesia. The patient had spontaneous marked improvement of her symptoms postpartum.ConclusionPregnancy may exacerbate skull base CSF leaks, requiring careful management with a multidisciplinary team. Neuraxial anesthesia can safely be performed in pregnant individuals with spontaneous skull base CSF leakage, but further studies are needed to determine the safest mode of delivery in these patients.

Purpose of Review: The purpose of this review is to synthesize and examine the literature on the use of neuraxial anesthesia and analgesia during cardiothoracic surgery. As cardiothoracic procedures often require systemic anticoagulation, neuraxial techniques are quite often underutilized due to the theoretical risk of epidural hematoma. In this review, we seek to examine the literature to review the indications and contraindications and to explore if neuraxial anesthesia and analgesia has a role in cardiothoracic surgery. Recent Findings: Neuraxial techniques have multiple advantages during cardiothoracic surgery including coronary vasodilation, decreased sympathetic surge, and a decreased cortisol level leading to overall reduction in stress response. Multiple studies have shown an improvement in pain scores, reduction in pulmonary complications, faster extubation times, with minimal complications when neuraxial techniques are utilized in cardiothoracic surgeries. Summary: Given the numerous advantages and minimal complications of neuraxial techniques in cardiothoracic surgeries, we hope its utilization continues to increase. Moving forward, we hope additional studies continue to reaffirm the benefits of neuraxial anesthesia and analgesia for cardiothoracic surgeries to improve its utilization. [ABSTRACT FROM AUTHOR]

Background and Aims: To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions. Material and Methods: This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions. Results: The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001). Conclusions: There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the impact of anesthesia mode on perinatal outcomes in patients with placenta accreta spectrum (PAS) undergoing cesarean delivery and identified factors associated with adverse perinatal events. Methods: The multicenter retrospective analysis was conducted in patients with PAS who delivered at three medical centers. Patients were classified according to whether they received general anesthesia (GA) or neuraxial anesthesia (NA). We compared the basic clinical characteristics of patients in the pre-propensity score matching (PSM) and post-PSM cohorts and identified factors associated with a high risk of adverse maternal outcomes. Results: This study included a total of 425 patients, with 307 (72.2%) in the GA group and 118 (27.8%) in the NA group. After PSM, 162 patients were identified for analysis. In the post-matched cohort, the NA group exhibited shorter total operation time (P = 0.030) and postoperative length of hospital stay (P = 0.037). Additionally, the NA group experienced lower intraoperative blood loss (P < 0.001) and received fewer units of transfused packed red blood cells (PRBC) (P < 0.001). Multivariate logistic regression analysis indicated that GA (P < 0.001), emergency cesarean delivery (P = 0.010), vascular lacunae within the placenta (P < 0.001), hypervascularity of uterine-placental margin (P = 0.002), hypervascularity of the cervix (P = 0.014), and balloon placement in the abdominal aorta (P < 0.001) were associated with a high risk of adverse maternal events. Conclusion: In comparison to GA, cesarean delivery with NA in PAS patients appears to be associated with reduced intraoperative blood loss, PRBC transfusion, operating duration, and postoperative hospital stay. [ABSTRACT FROM AUTHOR]

Objective: The aim of the article is to assess the impact of retrograde intrarenal surgery under central neuraxial blockade in comparison to general anesthesia (GA). Material and Methodology: This systematic review was conducted following the guidelines set out by the preferred reporting items for systematic reviews and meta-analyses. We conducted a comprehensive search across major electronic databases, including various types of studies such as descriptive studies and full-text literature, all of which were incorporated into the current review from 2018 to 2023. We involved those studies, which included the comparative study of spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal epidural anesthesia with GA. Result: In our meta-analysis of 12 studies, it was found that anesthesia technique significantly affected operation time, with neuraxial anesthesia (NA) showing a mean difference of -2.28 (95% confidence interval (CI): -3.5 to -1.04, P = 0.003) compared to GA. However, there were no significant differences in rates of stone clearance, 24-h pain scores and length of hospital stay among patients administered with NA or GA for retrograde intrarenal surgery (RIRS). Conclusion: On the basis of the outcomes of study, NA can serve as a viable alternative to GA for RIRS. Our analysis reveals no significant differences in rates of stone clearance, operation duration, 24-h pain scores, complication rates, and length of hospital stay between NA in addition to GA in the context of RIRS. This suggests that given the potential economic advantages, NA might be a preferable choice over GA, contingent on patient preferences, baseline characteristics, and stone burden. [ABSTRACT FROM AUTHOR]

Background: Recent advancements in China's perinatal and neonatal intensive care have significantly reduced neonatal mortality, yet preterm births before 32 weeks remain the primary cause of neonatal fatalities and contribute to long-term disabilities. The prognosis of very preterm infants (VPIs) is significantly affected by factors including the intrauterine environment, delivery method and neonatal intensive care. Cesarean section which often used for preterm births has implications that are not fully understood, particularly concerning the type of anesthesia used. This study examines the impact of general anesthesia (GA) during cesarean delivery on VPI outcomes, aiming to identify strategies for mitigating GAassociated risks. Methods: This cohort study analyzed 1,029 VPIs born via cesarean section under 32 weeks' gestation at our single-center from 1 January 2018, to 31 December 2022. Detailed medical records, encompassing perioperative information, maternal data and neonatal outcomes were meticulously examined. The primary aim of this investigation was to compare maternal characteristics and neonatal outcomes between VPIs delivered under GA and neuraxial anesthesia (NA). A significance level of p < 0.05 was established. Results: Of the 1,029 VPIs analyzed, 87.95% (n = 905) were delivered via NA and 12.05% (n = 124) via GA. Mothers with hypertensive pregnancy diseases and emergency operations were more inclined to choose GA. VPIs delivered under GA showed a lower Apgar score at one and 5 minutes (p < 0.01), increased need for tracheal intubation resuscitation (32.2% vs. 12.2%, p < 0.01) and a greater incidence of severe neurological injury (SNI) (14.5% vs. 5%, p < 0.01). Multivariable analysis revealed GA was significantly associated with lower Apgar scores at one (OR 6.321, 95% CI 3.729-10.714; p < 0.01) and 5 minutes (OR 4.535, 95% CI 2.975-6.913; p < 0.01), higher risk of tracheal intubation resuscitation (OR = 3.133, 95% CI = 1.939-5.061; p < 0.01) and SNI (OR = 3.019, 95% CI = 1.615-5.643; p < 0.01). Furthermore, for VPIs delivered under GA, a prolonged interval from skin incision to fetus delivery was associated with a lower 5-min Apgar score (p < 0.01). Conclusion: This study revealed the significant impact of GA on adverse outcomes among VPIs. In cases when GA is required, proactive measures should be instituted for the care of VPIs such as expediting the interval from skin incision to fetal delivery. [ABSTRACT FROM AUTHOR]

The selection of anesthetic methods for labor and delivery in individuals with elevated intracranial pressure relies on careful consideration of the risks and benefits. While neuraxial analgesia and anesthesia are favored for healthy individuals, they might not be suitable for individuals with intracranial lesions or a heightened risk of bleeding. Neuraxial block in post-stroke patients raises a concerning question about its safety due to the risk of herniation. The risk of perioperative major vascular events and mortality between general anesthesia and regional anesthesia in post-stroke patients is comparable. However, the neuraxial block shows benefits regarding airway manipulation and lower risk of thromboembolism. A successful and safe neuraxial anesthesia in a pregnant patient with a history of hemorrhagic stroke was presented in this case report.

Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication—noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)—with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS. [ABSTRACT FROM AUTHOR]

Achondroplasia is the most common form of dwarfism, and cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. Given the challenges for both regional and general anesthetic techniques, there is no consensus on the optimal anesthetic management for cesarean delivery in these patients. A search of our electronic medical records for all female patients who had a diagnosis of achondroplasia and had a delivery in our health system from January 1, 2001 through June 16, 2023 was performed. Institutional review board exemption was obtained. We identified seven achondroplastic patients with 12 cesarean deliveries and described their anesthetic management during labor and delivery. Despite the historical preference of general anesthesia in achondroplastic patients due to concerns of unpredictable spinal anatomy and unreliable local anesthetic spread, neuraxial anesthesia was successfully utilized in achondroplastic parturients and is a viable option in carefully selected patients. Reduction of intrathecal local anesthetic dose that minimizes the risk of high spinal and emergent intubation, as well as a titratable neuraxial technique, can be effective in this patient population. [ABSTRACT FROM AUTHOR]

The field of urogynecology has blossomed since its inception to include a broad range of procedures. Various anesthetic methods have evolved in tandem with the diversity of procedures, from office-based procedures under local anesthesia to complex reconstructions under general anesthesia. These anesthetic techniques can provide intraoperative coverage and often postoperative analgesia as well. The push for same-day discharge surgeries and the rise of robotic surgical techniques makes patient selection and optimization even more important in the current practice environment. This review focuses on anesthetic techniques and patient considerations for urogynecologic surgery. (J GYNECOL SURG 39:266) [ABSTRACT FROM AUTHOR]

Background and objective A high rate of preoperative anemia has been observed in patients undergoing knee and hip arthroplasty. The type of anesthesia that patients receive may play a role in preventing or minimizing adverse outcomes in these patients. In this study, we aimed to examine the complication rates in patients with severe anemia undergoing this surgery. In addition, we explore whether neuraxial anesthesia is associated with better outcomes compared to general anesthesia. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) registry was used to extract data related to patients who underwent total hip or knee arthroplasty from 2014 to 2016. Only those patients with a hematocrit level

Introduction. General anesthesia (GA) and spinal anesthesia (SA) are the main techniques applied during total knee arthroplasty (TKA). SA belongs to neuraxial anesthesia (NA) category. Numerous studies have explored benefits of NA in diminishing the complications, among which are pulmonary embolism (PE), urinary tract infection (UTI), and deep vein thrombosis (DVT). Aim. To compare rate of complications of SA and GA in TKA. Materials and methods. This is a retrospective cohort studie conducted on 190 patients who attended Alwasity teaching hospital in Baghdad and underwent TKA. The age ranged from 41 to 75 years and 69% of patients were females. The patients were enrolled into SA group (80 patients) and GA group (110 patients). We reviewed patients’ records and interviewed patients and medically examined them to obtain data on age, sex, body mass index (BMI), comorbidities including diabetes mellitus(DM), hypertension (HT) and other comorbidities. Results: Higher age and BMI were found in SA group. Complications’ incidence in SA group vs. GA group was PE 0.03 vs. 0.09, DVT 0.04 vs. 0.10, Pneumonia 0.04 vs. 0.08, UTI 0.06 vs. 0.23, and ARF 0.03 vs. 0.33, they didn’t differ significantly. Conclusion: SA is a good option for anesthesia in TKA because it wasn’t associated with higher complications rate compared to GA.

Abstract Background Neuraxial anesthesia is widely used as the most effective and standard method in obstetric anesthesia. However, there is a concern that neuraxial anesthesia may be technically difficult or ineffective in pregnant women with spinal disease. Therefore, this study aimed to investigate the implementation rate of neuraxial anesthesia among pregnant women with spinal diseases and their success rate at our institution. Methods The subjects of this study were pregnant patients who delivered at Juntendo University Nerima Hospital between April 2017 and December 2020. After obtaining ethics committee approval, data were collected from patients’ medical records. Results Of the 2682 pregnant women who delivered, 1550 underwent preanesthetic evaluation. There were 42 deliveries in 39 pregnant women with spinal diseases (1.7% of all pregnant women and 2.7% of those who underwent preanesthetic evaluation). The diagnoses included adolescent idiopathic scoliosis (51.3%), lumbar disc herniation (23.1%), and others. The mode of delivery was the elective cesarean section in 5 cases, emergent cesarean section in 8 cases, and vaginal delivery in 29 cases. Only one case required general anesthesia. Of the 38 cases of labor analgesia, the neuraxial block was inadequate in 3 cases (7.9%) and technically difficult in 3 cases (7.9%). However, the patients complained of no lower extremity neuropathy, infection, or inadvertent dural puncture. Discussion Neuraxial anesthesia was an option in most cases, even in pregnant women complicated with spinal disease, if an anesthesiologist’s plan before delivery after careful preanesthetic evaluation.

Abstract Background Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity. Methods We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data. Results A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2–7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53–2.24)]. Conclusions No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery. Trial registration 10.17605/OSF.IO/3DJ6C.

Objective: Neuraxial anesthesia (NA) showed to reduce both morbidity and mortality in patients undergoing laparoscopic surgery. We aimed to investigate the use of NA in patients undergoing transperitoneal three-dimensional laparoscopic radical prostatectomy (t-3DLRP) and compare the intraoperative and postoperative outcomes with a control group of patients undergoing t-3DLRP under general anesthesia (GA). Methods: A prospective, double-center, double-surgeon study cohort of 84 consecutive patients undergoing t-3DLRP between June 2019 and June 2021 was analyzed. A study group of 42 patients undergoing t-3DLRP under NA was compared with a control group of 42 patients undergoing t-3DLRP under GA. Results: The two group were similar in all demographic, clinical, and pathological variables. Postoperative blood gas parameters were within physiologic limits in both groups. Muscle relaxation was adequate for surgery during both NA and GA. Median length of stay was 1 day shorter for NA group than GA group (5 days vs. 6 days, p=0.05). t-3DLRP under NA had a statistically lower rate of minor complications (4.8% vs. 19.0%, p=0.03) and less postoperative pain (median numeric rating scale 3 vs. 4, p=0.01) compared to GA. No major complications were observed in both groups. Significantly more patients were willing to undergo a similar intervention under NA than GA (p=0.04). Conclusion: t-3DLRP under NA is a feasible and safe procedure, with less postoperative pain and fewer minor complications than the same procedure under GA. NA allows the maintenance of muscle relaxation and respiratory excursions without interfering with surgery.

The aim of this study is to establish the feasibility of awake laparotomy under neuraxial anesthesia (NA) in a suburban hospital. A retrospective analysis of the results of a consecutive series of 70 patients undergoing awake abdominal surgery under NA at the Department of Surgery of our Hospital from February 11th, 2020 to October 20th, 2021 was conducted. The series includes 43 cases of urgent surgical care (2020) and 27 cases of elective abdominal surgery on frail patients (2021). Seventeen procedures (24.3%) required sedation to better control patient discomfort. Only in 4/70 (5.7%) cases, conversion to general anesthesia (GA) was necessary. Conversion to GA was not related to American Society of Anesthesiology (ASA) score or operative time. Only one of the four cases requiring conversion to GA was admitted to the Intensive Care Unit (ICU) postoperatively. Fifteen patients (21.4%) required postoperative ICU support. A statistically non-significant association was observed between conversion to GA and postoperative ICU admission. The mortality rate was 8.5% (6 patients). Five out of six deaths occurred while in the ICU. All six were frail patients. None of these deaths was related to a complication of NA. Awake laparotomy under NA has confirmed its feasibility and safety in times of scarcity of resources and therapeutic restrictions, even in the most frail patients. We believe that this approach should be considered as an useful asset, especially for suburban hospitals. [ABSTRACT FROM AUTHOR]

Abstract Background Idiopathic intracranial hypertension can lead to dural defects and spontaneous leakage of cerebrospinal fluid (CSF) from the skull base. Skull base CSF leaks are rarely reported in pregnancy but pose unique challenges for obstetricians and anesthesiologists. Case presentation A 31-year-old G4P1021 at 14 weeks developed debilitating headaches and CSF rhinorrhea. Brain imaging revealed a bony defect of the sphenoid sinus with a meningoencephalocele and a partially empty sella, consistent with CSF leakage from a skull base defect. The patient was neurologically stable without signs of meningitis; thus, management was focused on symptomatic alleviation. A planned cesarean section was performed at 38 weeks under spinal anesthesia. The patient had spontaneous marked improvement of her symptoms postpartum. Conclusion Pregnancy may exacerbate skull base CSF leaks, requiring careful management with a multidisciplinary team. Neuraxial anesthesia can safely be performed in pregnant individuals with spontaneous skull base CSF leakage, but further studies are needed to determine the safest mode of delivery in these patients.

The selection of anesthetic methods for labor and delivery in individuals with elevated intracranial pressure relies on careful consideration of the risks and benefits. While neuraxial analgesia and anesthesia are favored for healthy individuals, they might not be suitable for individuals with intracranial lesions or a heightened risk of bleeding. Neuraxial block in poststroke patients raises a concerning question about its safety due to the risk of herniation. The risk of perioperative major vascular events and mortality between general anesthesia and regional anesthesia in post-stroke patients is comparable. However, the neuraxial block shows benefits regarding airway manipulation and lower risk of thromboembolism. A successful and safe neuraxial anesthesia in a pregnant patient with a history of hemorrhagic stroke was presented in this case report. [ABSTRACT FROM AUTHOR]

Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.

BACKGROUND: In scheduled cesarean deliveries, the rate of decrease in the umbilical artery pH is related to the severity of maternal hypotension and the interval from spinal placement to delivery. Base excess values have greater use than umbilical artery pH values to time the duration of fetal acidemia because they demonstrate a linear rather than logarithmic correlation with the degree of acidosis. OBJECTIVE: This study aimed to evaluate the rate of decline in the fetal base excess in scheduled cesarean deliveries that were converted to emergency cesarean delivery owing to fetal bradycardia following spinal anesthesia STUDY DESIGN: All cases of scheduled cesarean deliveries in gestations at >34 weeks’ gestation under spinal anesthesia that were converted to emergency cesarean deliveries owing to fetal bradycardia in the period May 2019 to May 2021 were reviewed. Included were those with (1) a preoperative reactive nonstress test and (2) fetal acidemia (umbilical artery pH

Background: Neuraxial anesthesia is widely used as the most effective and standard method in obstetric anesthesia. However, there is a concern that neuraxial anesthesia may be technically difficult or ineffective in pregnant women with spinal disease. Therefore, this study aimed to investigate the implementation rate of neuraxial anesthesia among pregnant women with spinal diseases and their success rate at our institution. Methods: The subjects of this study were pregnant patients who delivered at Juntendo University Nerima Hospital between April 2017 and December 2020. After obtaining ethics committee approval, data were collected from patients' medical records. Results: Of the 2682 pregnant women who delivered, 1550 underwent preanesthetic evaluation. There were 42 deliveries in 39 pregnant women with spinal diseases (1.7% of all pregnant women and 2.7% of those who underwent preanesthetic evaluation). The diagnoses included adolescent idiopathic scoliosis (51.3%), lumbar disc herniation (23.1%), and others. The mode of delivery was the elective cesarean section in 5 cases, emergent cesarean section in 8 cases, and vaginal delivery in 29 cases. Only one case required general anesthesia. Of the 38 cases of labor analgesia, the neuraxial block was inadequate in 3 cases (7.9%) and technically difficult in 3 cases (7.9%). However, the patients complained of no lower extremity neuropathy, infection, or inadvertent dural puncture. Discussion: Neuraxial anesthesia was an option in most cases, even in pregnant women complicated with spinal disease, if an anesthesiologist's plan before delivery after careful preanesthetic evaluation. [ABSTRACT FROM AUTHOR]

Background: Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity. Methods: We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data. Results: A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2–7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53–2.24)]. Conclusions: No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery. Trial registration: 10.17605/OSF.IO/3DJ6C. [ABSTRACT FROM AUTHOR]

Abstract Background Osler-Weber-Rendu syndrome is characterized by mucocutaneous telangiectasia and arteriovenous malformations in organs. Anesthesia for patients with Osler-Weber-Rendu syndrome is challenging due to complications and physiological changes. Case presentation The case was a 49-year-old female with Osler-Weber-Rendu syndrome, multiple pulmonary arteriovenous malformations and pheochromocytoma who presented for femoral bone head fracture with metastatic adenocarcinoma. The patient was scheduled to undergo bone tumor resection and artificial bone replacement, being positioned laterally with a planned operation duration of 5 h. Anesthesia was managed with spinal and epidural anesthesia, combined with sedation by sevoflurane using a supraglottic airway (SGA) device under spontaneous breathing. Her intraoperative and postoperative courses were uneventful. Conclusion Neuraxial anesthesia combined with general anesthesia using an SGA device to maintain spontaneous ventilation in order to minimize the risk of rupture of pulmonary arteriovenous malformations could be an option.

Ex-utero intrapartum treatment (EXIT) is a rare surgical procedure performed intrapartum in cases of anticipated fetal abnormalities. The most important anesthetic consideration for the EXIT procedure is maintaining fetomaternal circulation during the operation through uterine relaxation with anesthetic gases in general anesthesia or nitroglycerin in regional anesthesia. Two patients were initially scheduled for elective C-sections under neuraxial anesthesia, but due to a premature rupture of the membrane and deceleration of the fetal heart rate, one was carried out as planned, and the other was converted to general anesthesia. In the second case, anesthetic gases were used to achieve uterine relaxation, whereas in the first case, oxytocin was delayed. Mothers were transferred to the low-care ward, whereas infants were transferred to the neonatal intensive care unit and underwent definitive surgery within 1–2 weeks after birth. The EXIT procedure could be used under general and regional anesthesia in elective and emergency settings.

The American Society of Regional Anesthesia and Pain Medicine's guidelines recommend a 1-hour interval after neuraxial anesthesia (NA) before systemic heparinization to mitigate the risk of spinal hematoma (SH). The study authors aimed to characterize the time interval between NA and systemic heparinization in vascular surgery patients (primary outcome). The secondary outcomes included the historic incidence of SH, and risk estimation of the SH formation based on available data. Heparin dose, length of surgery, difficulty and/or the number of NA attempts, and patient demographics were recorded. A retrospective analysis between April 2012 and April 2022. A single (academic) center. Vascular surgery patients. Intravenous heparin administration. All (N = 311) vascular patients were reviewed, of whom 127 (5 femoral-femoral bypass, 67 femoral-popliteal bypass, and 55 endovascular aneurysm repairs [EVAR]) received NA and were included in the final analysis. Patients receiving general anesthesia alone (N = 184) were excluded. Neuraxial anesthesia included spinal (N = 119), epidural (N = 4), or combined spinal-epidural (N = 4) blocks. The average time between NA and heparin administration was 42.8 ± 22.1 minutes, with 83.7% of patients receiving heparin within 1 hour of NA. The time between NA and heparin administration was 40.4 ± 22.3, 50.1 ± 23.4, and 31.3 ± 12.5 minutes for femoral-femoral bypass, femoral-popliteal bypass, and EVAR, respectively. Heparin was administered after 1 hour of NA in 20% of femoral-femoral bypass, 27% of femoral-popliteal bypass, and 3.9% of EVAR patients. No SHs were reported during the study period. The vast majority of vascular surgery patients at the authors' center received heparin within 1 hour of NA. Further studies are required to assess if their findings are consistent in other vascular surgery settings and/or centers. [ABSTRACT FROM AUTHOR]

To determine whether general anesthesia (GA) in conjunction with regional anesthetic (RA) techniques are associated with favorable pulmonary outcomes versus GA alone among patients undergoing lobectomy by either video-assisted thoracoscopic surgery (VATS) or open thoracotomy. A retrospective cohort (2014-2017). The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing lobectomy by either VATS or open thoracotomy. Two groups of patients were identified based on the use of GA alone or GA in conjunction with RA (RA+GA) techniques (either neuraxial or peripheral nerve blocks). Both groups were propensity-matched based on pulmonary risk factors. The authors' primary outcome was composite postoperative pulmonary complication (PPC), including pneumonia, reintubation, and failure to wean from the ventilator. A total of 4,134 VATS (2,067 in GA and 2,067 in RA+GA) and 3,112 thoracotomies (1,556 in GA and 1,556 in RA+GA) were included in the final analysis. Regional anesthetic, as an adjuvant to GA, did not affect the incidence of PPC among patients undergoing lobectomy by VATS (odds ratio [OR] 1.07, 95% CI 0.81-1.43, p = 0.622), as well as in those undergoing lobectomy via thoracotomy (OR 1.19, 95% CI 0.93-1.51, p = 0.174). There was no statistically significant difference between groups in terms of readmission rates, length of stay, and mortality at 30 days. The RA techniques were not associated with a lower incidence of pulmonary complications in lobectomy surgery. Graphical Abstract [Display omitted] [ABSTRACT FROM AUTHOR]