Decompressive craniectomies are a neurosurgical operation aimed at normalizing intracranial pressure (ICP). Occasionally, there is delayed replacement of the skull resulting in an acquired skull defect. When managing laboring patients with an acquired skull defect there is often fear associated with traditional labor involving the Valsalva maneuver and with neuraxial anesthesia. These fears typically stem from potential ICP changes and risk of herniation. In reviewing the literature, only 15 cases are described detailing labor management after decompressive craniectomy (DC), mostly with incomplete labor histories. We aim to expand that literature by reporting two cases of safe labor with epidural anesthesia in patients with large skull defects. The first described patient underwent a cranioplasty during pregnancy because of trauma. Later, because of concerns for pre-eclampsia, induction of labor was initiated and she received neuraxial anesthesia via epidural. The patient ultimately underwent cesarean delivery 48 h after induction began due to nonreassuring fetal heart tones. The second patient underwent a cranioplasty because of infection prior to pregnancy. Once in labor, she was cleared by neurosurgery and the anesthesia team placed her epidural. She later underwent an uncomplicated standard vaginal delivery. The existing literature on labor following DC is sparse. Retrospective review of case reports can advance discussion and standardization regarding care for laboring women with a history of DC. We advocate that the Valsalva maneuver and epidural anesthesia is safe for pregnant women who are neurologically asymptomatic.

OBJECTIVE: To compare the speed of achieving painless uterine contractions in parturients undergoing epidural analgesia at different lumbar puncture levels.
METHODS: This study is a randomized controlled trial at a tertiary A hospital with a history of over 80 years in Sichuan Province, China. Parturients aged 22-40 years old scheduled for vaginal delivery under epidural analgesia were recruited. Eligible patients were randomly allocated into lumbar 2-3 (L2-3) or lumbar 3-4 (L3-4) groups. Epidural analgesia was performed through the interspaces according to grouping. The primary outcome was the percentage of painless uterine contractions 15 min after the initiation of analgesia. The secondary outcomes included the percentage of painless status at 5 and 10 min, sensory block plane, motor block evaluation, adverse events of parturients, epidural analgesic consumption, Apgar score, and the parturients\' evaluation of analgesia.
RESULTS: Between April 2023 and August 2023, a total of 150 women were finally recruited, and 136 of them were analyzed (68 in each group). In comparison with the L3-4 groups, there was a significantly larger proportion of painless uterine contractions at 5, 10, and 15 min after analgesia initiation in the L2-3 group (20.6% vs. 7.4%, 52.9% vs. 26.5%, and 80.9% vs. 64.7%, P = .026, .002, and .034, respectively). Similarly, the pain scores were lower in the L2-3 group at 5, 10, and 15 min than that in the L3-4 group (5(4,7) vs. 6(5,7), 3(2,5) vs. 4(3,6), and 2(1,3) vs. 3(2,5), P = .006, .004, and .020, respectively). Furthermore, puncturing through the L2-3 interspace contributed to a higher evaluation of parturients to the analgesia procedure (9(8,9) vs. 8(8,9), P < .001). However, there was no significant difference in sensory block, motor block, or adverse events between the two groups.
CONCLUSIONS: Puncturing through the L2-3 interspace is associated with faster pain relief and a better experience for parturients. These findings present a superior option for anesthesiologists when conducting epidural labor analgesia. Key messages What is already known on this topic?  Epidural analgesia is an effective way to relieve labor pain. What this study adds?  Puncturing via lumbar 2-3 interspace induces more rapid onset of epidural analgesia. How this study might affect research, practice or policy?  Lumbar 2-3 interspace is a superior option in terms of the speed of pain relief and satisfaction of parturients when conducting epidural labor analgesia.

OBJECTIVE: The purpose of this randomized controlled trial was to evaluate whether early urinary catheter removal is feasible during epidural anesthesia during gastrointestinal surgery in male patients at high risk for urinary retention.
METHODS: Male patients who underwent radical surgery for gastric or colon cancer were enrolled in this randomized controlled trial. Patients were randomized 1:1 into 2 groups: the early group, in which the urinary catheter was removed before removal of the epidural catheter on the second or third postoperative day, and the late group, in which the urinary catheter was removed after removal of the epidural catheter. The randomization adjustment factors were age (≥ 65 or < 65 years) and operative site (gastric or colon). The primary endpoint was urinary retention. The secondary endpoints were the incidence of urinary tract infection and length of postoperative hospital stay.
RESULTS: Seventy-three patients were enrolled between March 2020 and February 2024 and assigned to the Early (n = 37) and Late (n = 36) groups. Four patients withdrew their consent after randomization. The intention-to-treat analysis showed that urinary retention occurred in 4 patients (11.1%) in the early group and 1 patient (3.0%) in the late group (P = 0.20). Urinary tract infection occurred in 1 patient (3.0%) in the late group. The median postoperative hospital stay was 9 days in both groups.
CONCLUSIONS: Early urinary catheter removal in male patients undergoing gastrointestinal surgery with epidural anesthesia could increase urinary retention within the expected acceptable range.
BACKGROUND: UMIN000040468, Date of registration: May 21, 2020.

Background: The NOL® system (PMD-200™ Nociception Level Monitor; Medasense Ltd., Ramat Gan, Israel) is used for the real-time detection of physiological nociception in anesthetized patients by assessing the parameters indicative of sympathetic activity, such as photoplethysmography, skin conductance, peripheral temperature, and accelerometry, which are quantified into the NOL®-Index. This index is more sensitive than traditional clinical parameters in estimating pain and stress responses. While its effectiveness in general anesthesia is well documented, its efficacy in epidural anesthesia needs further investigation. Methods: This retrospective study analyzed NOL®-Index dynamics compared to conventional parameters after epidural administration of bupivacaine. Following ethics committee approval, 119 NOL® measurements were retrospectively analyzed after thoracic epidural catheter administration in 40 patients undergoing abdominal and urological surgery. The NOL-Index® was assessed at 0, 1, 3, and 5 min post application and compared to heart rate, blood pressure, and bispectral index dynamics. Results: This study showed a significant decrease in the NOL®-Index post-local-anesthetic administration with better sensitivity than classical clinical parameters (0 min = 38 ± 11; 1 min = 22 ± 13*; 3 min = 17 ± 11*; 5 min = 12 ± 10*). Higher doses of local anesthetics led to a significant, dose-dependent decrease in NOL®-Index (low dose, 5 min = 15 ± 10*; high dose, 5 min = 8 ± 8*). Conclusions: This study is the first to demonstrate the effectiveness of the NOL®-Index in measuring nociceptive effects following epidural administration, highlighting its potential superiority over conventional parameters and its sensitivity to dose variations.

We present a 25-year-old, gravida 2, para 1 woman who developed apparent local anesthetic systemic toxicity (LAST) following activation of an epidural catheter for an urgent cesarean delivery. The patient had a height of 150 cm, weight of 92 kg, body mass index of 41 kg/m2, and calculated ideal body weight of 40 kg. A combined spinal epidural anesthetic was placed and the spinal component did not provide anesthesia to clamping of the abdomen. Subsequently, 300 mg of lidocaine was administered through the epidural catheter in three 5 mL doses over 8 minutes and surgery commenced. Approximately 30 minutes following the final 5 mL dose of epidural lidocaine, the patient had progressive loss of consciousness and was difficult to arouse. A presumptive diagnosis of LAST was made, and 60 mL of 20% intravenous lipid emulsion was administered. The patient\'s mental status improved to baseline within 5 minutes of lipid emulsion administration, and she made a complete recovery. Anesthesiologists should consider using ideal body weight when calculating the maximum dosage of local anesthetics, and LAST should be part of the differential diagnosis when patients have altered mental status in the setting of local anesthetic administration that exceeds recommended dosages.

UNASSIGNED: This study aimed to explore the optimal dose of dexmedetomidine as a 0.59% ropivacaine adjuvant for epidural anesthesia on perioperative hemodynamics and anesthesia efficacy in patients undergoing great saphenous varicose vein surgery.
UNASSIGNED: A total of 90 patients were randomly divided into three groups: 0.25 μg/kg dexmedetomidine combined with 0.59% ropivacaine epidural infusion group (ED1 group), 0.5 μg/kg dexmedetomidine combined with 0.59% ropivacaine epidural infusion group (ED2 group), and 0.75 μg/kg dexmedetomidine combined with 0.59% ropivacaine epidural infusion group (ED3 group). Hemodynamics, anesthesia efficiency, and adverse reactions were recorded.
UNASSIGNED: Compared with the ED1 group, the ED2 group had lower systolic blood pressure at T1-3 (T1, 95%CIs, 6.52-21.93, p < 0.001; T2, 95%CIs, 2.88-18.21, p = 0.004; T3, 95%CIs, 0.49-18.17, p = 0.035), and the diastolic blood pressure at T1-2 was decreased (T1, 95%CIs, 4.55-14.36, p < 0.001; T2, 95%CIs, 0.37-12.17, p = 0.033). Compared with the ED2 group, the ED3 group had higher systolic blood pressure at T1-2 (T1, 95%CIs, 5.90-21.46, p < 0.001; T2, 95%CIs, 2.07-17.55, p = 0.008) and higher diastolic blood pressure at T1-3 (T1, 95%CIs, 2.91-12.81, p = 0.001; T2, 95%CIs, 1.32-13.23, p = 0.011; T3, 95%CIs, 0.14-11.52, p = 0.043). Compared with the ED2 group, the heart rate was significantly decreased at T1-4 in the ED3 group (T1, 95%CIs, 2.25-15.72, p = 0.005; T2, 95%CIs, 2.35-13.82, p = 0.003; T3, 95%CIs, 0.50-9.79, p = 0.025; T4, 95%CIs, 1.46-10.36, p = 0.005). The myocardial oxygen consumption in all three groups was significantly decreased at each time point compared to T0 (p < 0.05 or < 0.001), and no significant between-group differences were detected (P>0.05). Compared with the ED1 group, the anesthesia efficiency of ED2 and ED3 groups was markedly enhanced, but the risk of bradycardia in ED2 and ED3 groups was dramatically increased (6 of 28 [21.4%] vs. 14 of 30 [46.7%] and 14 of 27 [51.9%], p = 0.023), one patient in the ED3 group experienced difficulty urinating, and remaining adverse reactions were mild in all three groups.
UNASSIGNED: A measure of 0.5 μg/kg dexmedetomidine is the optimal dose as a 0.59% ropivacaine adjuvant for epidural anesthesia in patients undergoing great saphenous varicose vein surgery.
UNASSIGNED: http://www.chictr.org.cn/, registration number: ChiCTR2200060619.

OBJECTIVE: To determine the association between timing of indwelling catheter removal and urinary retention after cesarean.
METHODS: Retrospective cohort study.
METHODS: Eight hospitals in suburban, rural, and urban Colorado and Montana.
METHODS: Women who gave birth by cesarean from January 1, 2021, to April 30, 2022 (N = 3,496).
METHODS: We categorized participants who gave birth between January 1, 2021, and June 29, 2021, (before implementation of the Enhanced Recovery After Surgery initiative) into Group A and participants who gave birth between July 1, 2021, and April 30, 2022, (after implementation of the Enhanced Recovery After Surgery initiative) into Group B. We used descriptive statistics to report the proportion of participants in both groups who experienced urinary retention after birth. We performed chi-square tests to determine the association between the time of catheter removal and incidence of urinary retention. We used the Wilcoxon rank sum test to determine the association between length of stay and urinary retention.
RESULTS: Urinary retention rates were 5.8% in Group A and 12.6% in Group B (p < .001). In both groups, participants who received epidural anesthesia experienced significantly more urinary retention than those who received spinal anesthesia (p < .001). Participants who received epidural anesthesia and experienced urinary retention pushed 16.9% longer than those without urinary retention (p < .001). The proportion of participants who experienced urinary retention after catheter removal was 19.4% at 7 hours, 4.6% at 16 hours, and 9.9% at 12 hours after birth. Length of stay was determined to be inconclusive.
CONCLUSIONS: We determined that the optimal time of catheter removal to minimize the rate of urinary retention was 12 to 16 hours after cesarean among women who received morphine sulfate as the spinal anesthesia.

Choloepus didactylus (two-toed sloth) is a Xenarthran mammal whose morphology has so far been little studied. Given the increasing number of sloths requiring clinical and surgical interventions, this lack of clarity regarding anatomical features and landmarks has had a negative impact on veterinary decision-making for this species. We therefore sought to describe the topography of the medullary cone (MC) of Choloepus didactylus in order to provide guidance to qualified professionals on the ideal access for locoregional anesthesia. In evaluating four specimens, radiographs and dissections revealed that Choloepus didactylus has three lumbar vertebrae and five sacral vertebrae. The lumbar intumescence is located between T14 and the cranial half of L2, the medullary cone is located between the caudal half of L2 and L3, with an average length of 2.26 cm, and the cauda equina extends from S1 to S5. Based on these anatomical findings, we propose that the lumbosacral region would be the most suitable target for epidural anesthesia in Choloepus didactylus.

UNASSIGNED: Factor (F)XI deficiency is a rare bleeding disorder with a poor correlation between bleeding tendency and FXI level. Management of pregnant women with FXI deficiency is not clearly established, especially regarding neuraxial analgesia (NA).
UNASSIGNED: A retrospective multicenter observational study was conducted in French hemostasis centers on pregnant women with FXI of <60 IU/dL.
UNASSIGNED: Data to report were (i) FXI levels before pregnancy and at time of delivery, (ii) type of NA and delivery management modalities, and (iii) possible complications related to NA and bleeding complications.
UNASSIGNED: Three hundred fourteen pregnancies in patients with FXI deficiency of <60 IU/dL were reported (from 20 centers); among them, 199 NA procedures have been completed (137 epidurals and 61 spinals, 1 had both). The period of childbirth was mostly from 2014 to 2020 (281/314; 89.5%). Congenital FXI deficiency was established with certainty by investigators in 32.8% patients (n = 103). Previous bleedings were described in 20.4% of the patients (64/314; 45.3% cutaneous, 31.3% gynecologic, and 15.6% postsurgical). Thirteen deliveries had an NA procedure with FXI of <30 IU/dL, 42 with FXI of 30-40 IU/dL, and 118 with FXI of 40-60 IU/dL. Median FXI levels at delivery in the epidural and spinal groups were not significantly different but were significantly lower in the group without NA by medical staff contraindications. There were no complications related to NA. A 17.5% postpartum hemorrhage or excessive postpartum bleeding incidence was reported, which is consistent with previous data.
UNASSIGNED: Our data support the use of a 30 IU/dL FXI threshold for NA, as suggested by the French proposals published in August 2023.

OBJECTIVE: 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).
CONCLUSIONS: 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.