•Spinal anaesthesia assessment for caesarean section can be problematic.•Spinal anaesthesia reliably results in significant warming of the feet.•No formal evaluation of skin temperature during ...anaesthesia has been conducted.•Cutaneous temperature shows potential for objective measurement of successful block.
Assessment of adequacy of spinal anaesthesia, prior to obstetric surgery is extremely important but can be problematic because currently available clinical assessment methods are indirect and subjective. As the sympathectomy associated with spinal anaesthesia is known to cause vasodilation and heat redistribution, we sought to assess whether spinal anaesthesia led to significant and consistent cutaneous temperature changes as measured by infrared thermography.
Following ethics committee approval, this observational study was conducted in a tertiary level obstetric centre. Participants included women undergoing elective caesarean section under spinal anaesthesia. Following consent, a Flir T540 infrared camera captured thermographic images over the feet, patella, buttock, iliac crests, xiphisternum and axilla. Temperature was measured prior to spinal needle insertion (T0) and following clinical assessment when the block was deemed adequate.
Thirty patients were included. Baseline temperature varied considerable by site. Spinal anaesthesia altered skin temperature in all areas of interest: right and left hallux (mean of differences (MD) +4.0°C and 5.2°C respectively, P <0.0001), right and left plantar (MD +6.1°C and 6.8°C respectively, P <0.0001), patella (MD −0.33°C, P=0.0445), buttock (MD −0.5°C, P=0.009), iliac crest (MD −0.7°C, P=0.0004), xiphisternum (MD −0.95°C, P <0.0001) and axilla (MD −0.71°C, P=0.0002).
Following spinal anaesthesia thermographic imaging identified different patterns of skin temperature changes, with pronounced temperature increases measured in the feet and cooling of a lesser amplitude in the thoracic and lumbar dermatomes. Infrared thermography has the potential to provide objective measurement of sympathectomy.
Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic ...efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial.
Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 µg (SM) or saline (SS) and a postoperative bilateral TAP block with either bupivacaine (TLA) 2 mg kg−1 or saline (TS).
Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: SMTLA (20 mm)<SMTS (27.5 mm)<SSTS (51.5 mm)<SSTLA (52.0 mm) (P<0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: SMTS (4.0 mg)<SMTLA (5.0 mg)<SSTLA (8.0 mg)<SSTS (12.0 mg) and at 24 h was: SMTLA (5.0 mg)<SMTS (6.0 mg)<SSTS (9.5 mg)<SSTLA (15.0 mg) (P<0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the SMTLA group.
Spinal morphine—but not TAP block—improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg−1 to spinal morphine did not further improve analgesia.
Evaluation of the anterior neck anatomy is used to identify the cricothyroid membrane (CTM) before front of neck airway access. This has been traditionally performed using palpation which results in ...misidentification of the CTM in a high proportion of subjects. The ‘laryngeal handshake’ is currently advocated by the Difficult Airway Society as the method to identify the CTM. We sought to investigate the accuracy of this technique in females.
Five clinicians were asked to identify the CTM using the 'laryngeal handshake' technique in a total of 45 anaesthetised females (Group L) and by conventional palpation in 45 controls (Group P). We measured and analysed the distance to actual CTM using ultrasound, the time to identification, and perceived difficulty using a visual analogue scale.
Successful identification of the CTM occurred in 28/45 (62%) patients in Group L vs 15/45 (33%) in Group P P=0.006; mean difference, 29%; 95% confidence interval (CI), 21–39%. Distance to the CTM (P=0.012) and visual analogue scale (P=0.012) were significantly reduced in Group L. Mean time to CTM identification was greater in Group L at 31 (5.6) s, compared with Group P, which took 18 (5.5) s (P<0.001). The midline was accurately identified more frequently in Group L than in Group P (39/45 vs 28/45, P=0.008).
The ‘laryngeal handshake’ method of palpation is more accurate but takes longer than conventional palpation technique in locating the CTM and the midline. This is of particular relevance if a vertical incision is required to perform front of neck access when anatomy is indistinct.
•Total spinal anaesthesia can occur after any neuraxial technique.•Spinal after epidural is the most common precipitant reported recently.•Total spinal anaesthesia has a good outcome when treated ...promptly.•Poor outcomes were associated with delayed recognition and inadequate resuscitation.
Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments.
We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted.
A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180 min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided.
The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.
•Ultrasonographic assessment of gastric contents was performed.•Assessments were made after a six hour fast at term gestation.•Gastric volumes >1.5 mL/kg were measured in 37% of pregnant women.•High ...gastric volumes were seen in 36% of participants with a grade 1 antrum.
Current fasting guidelines suggest six hours are adequate to minimise the aspiration risk after a light meal consumed by pregnant women undergoing elective caesarean section. We assessed gastric contents in non-labouring pregnant women, using ultrasonographic analysis.
In a prospective study, pregnant women ≥36 weeks’ gestation, without conditions likely to influence gastric emptying, underwent ultrasonographic analysis of their gastric antrum, after six hours of fasting following a standardised light meal. The primary outcome was solid food content in the antrum. Other outcomes included fluid in the supine and right lateral positions, antral cross-sectional area and estimated residual gastric fluid volume. Antral grades were classified: grade 0 = absence of fluid in both supine and right lateral positions: grade 1 = fluid present in the right lateral position only: grade 2 = fluid in both positions.
Complete data were available in 46/51 (90%) women. No woman had solid food visible. Antral grades 0, 1 and 2 were seen in 6 (13%), 36 (78%) and 4 (9%) women respectively. Eighteen of 48 women (37.5%) had a residual volume greater than 1.5 mL/kg. Of those with a grade 1 antrum, 13/36 (36%) had residual volumes in excess of 1.5 mL/kg. For grade 2, this was 4/4 (100%).
Our cohort of pregnant women fasted for six hours had no solid food visible in the antrum, but many had both qualitative and quantitative ultrasonographic evidence of gastric volumes potentially associated with aspiration risk. This suggests that pregnancy-specific fasting guidelines may be required.
A vertical incision is recommended for cricothyroidotomy when the anatomy is impalpable, but no evidence-based guideline exists regarding optimum site or length. The Difficult Airway Society ...guidelines, which are based on expert opinion, recommend an 80–100 mm vertical caudad to cephalad incision in the extended neck position. However, the guidelines do not advise the incision commencement point. We sought to determine the minimum incision length and commencement point above the suprasternal notch required to ensure that the cricothyroid membrane would be accessible within its margins.
We measured using ultrasound, in 80 subjects (40 males and 40 females) without airway pathology, the distance between the suprasternal notch and the cricothyroid membrane, in the neutral and extended neck positions. We assessed the inclusion of the cricothyroid membrane within theoretical incisions of 0–100 mm in length made at 10 mm intervals above the suprasternal notch.
In the 80 subjects, the distance ranged from 27 to 105 mm. Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad. The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch.
An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length.
•After spinal cord de-tethering, the conus may remain at risk of direct needle trauma.•Multidisciplinary evaluation helps prevent serious complications.•Neuroradiology is vital when planning a ...neuraxial block in spinal dysraphism.•Procedural ultrasound helps ensure the proposed interspace is accurately targeted.•Neuraxial anaesthesia is an option in select cases of spinal dysraphism.
Many anaesthetists consider patients with existing neurological deficits, untreated spinal pathology or those having undergone major spinal intervention to be precluded from undergoing neuraxial anaesthesia. While this is partly rooted in fears of litigation there is also a lack of consensus of the best practice in the anaesthetic management of these patients.
We present our management of a parturient who attended our institution, having a number of anaesthetic complexities including a known difficult airway, spinal fusion and persistent spinal cord tethering. She successfully underwent delivery under neuraxial blockade for the delivery of her fourth child.
We believe that by undergoing a thorough multidisciplinary clinical evaluation, including the extensive use of neuroimaging and ultrasound, it may be possible to plan and perform safe neuraxial anaesthesia.
Therapy of acute myeloid leukemia in older persons is associated with poor outcomes because of intolerance to intensive therapy, resistant disease and co-morbidities. This multi-center, randomized, ...open-label, phase II trial compared safety and efficacy of three therapeutic strategies in patients 65 years or over with newly-diagnosed acute myeloid leukemia: 1) continuous high-dose lenalidomide (n=15); 2) sequential azacitidine and lenalidomide (n=39); and 3) azacitidine only (n=34). The efficacy end point was 1-year survival. Median age was 76 years (range 66-87 years). Thirteen subjects (15%) had prior myelodysplastic syndrome and 41 (47%) had adverse cytogenetics. One-year survival was 21% 95% confidence interval (CI): 0, 43% with high-dose lenalidomide, 44% (95%CI: 28, 60%) with sequential azacitidine and lenalidomide, and 52% (95%CI: 35, 70%) with azacitidine only. Lenalidomide at a continuous high-dose schedule was poorly-tolerated resulting in a high rate of early therapy discontinuations. Hazard of death in the first four months was greatest in subjects receiving continuous high-dose lenalidomide; hazards of death thereafter were similar. These data do not favor use of continuous high-dose lenalidomide or sequential azacitidine and lenalidomide over the conventional dose and schedule of azacitidine only in patients aged 65 years or over with newly-diagnosed acute myeloid leukemia. (
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Highlights • Spinal dysraphisms are among the most common neurodevelopmental anomalies. • Bony and neural structures may be anatomically abnormal. • Neuraxial blocks are possible in selected ...patients. • The incidence of complications and failure is relatively high. • Magnetic resonance imaging can clarify anatomical abnormalities and assist decision making regarding neuraxial techniques.
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