OBJECTIVE: This study aimed to estimate the median effective dose of intrathecal isobaric ropivacaine without opioid required for adequate cesarean delivery anesthesia after epidural labor analgesia.
METHODS: Patients aged 20-40 years with American Society of Anesthesiology scores of I-II, body mass index ≤ 36, who underwent emergency cesarean delivery after failed vaginal delivery with epidural analgesia of a duration ≤ 6 h were included in the study. After removal of the epidural used for labor analgesia, a new combined spinal epidural was performed, and a dose of intrathecal isobaric ropivacaine without opioid was administered. The dose was determined using up-down methodology, with the starting patient\'s dose set to 12 mg. Adequate anesthesia, defined as a pinprick level no lower than T6 at 5 min after ropivacaine administration, resulted in the next patient receiving a dose of ropivacaine 1 mg higher, and inadequate anesthesia 1 mg lower. The primary outcome was the median (95% confidence interval (CI)) dose of spinal ropivacaine required for adequate cesarean delivery anesthesia.
RESULTS: Of the 46 patients included in the study, 40 were analyzed. The median spinal ropivacaine dose was 8.11 mg (95% CI 7.29-8.93 mg) by the Dixon and Mood method and 8.06 mg (95% CI 6.93-9.00 mg) by isotonic regression. Two patients had high spinal anesthesia.
CONCLUSIONS: Our findings suggest that for 50% of patients undergoing cesarean delivery after failed vaginal delivery with epidural analgesia, an 8-mg spinal dose of isobaric ropivacaine without opioid provides an anesthesia level no lower than T6 at 5 min.

BACKGROUND: Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have described anesthesia methods.
METHODS: We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed.
CONCLUSIONS: Cesarean section was safely performed for a pregnant woman with renal and heart failure using combined spinal and epidural anesthesia.

BACKGROUND: Postpartum urinary retention is a common complication following caesarean section, with significant implications for patient comfort and recovery. Combined spinal and epidural anaesthesia is frequently employed for caesarean section, but postpartum urinary retention remains a clinical concern despite its benefits. This study aimed to investigate the effectiveness of hydromorphone hydrochloride combined with bupivacaine for combined spinal and epidural anaesthesia in reducing postpartum urinary retention.
METHODS: A retrospective analysis was conducted on patients who received combined spinal and epidural anaesthesia for caesarean section. The control group received bupivacaine, whereas the hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia (HB) group received hydromorphone hydrochloride combined with bupivacaine. Data on demographics, anaesthesia, operative characteristics, postoperative urinary retention and adverse events were collected and analysed.
RESULTS: The study enrolled 105 patients, with a control group (n = 51) receiving bupivacaine spinal-epidural anaesthesia and an observation group (n = 54) receiving hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia. The incidence of postoperative urinary retention was significantly lower in the HB group than in the control group (3.70% vs. 17.65%, p = 0.044). Furthermore, the HB group exhibited a shorter time to first voiding after anaesthesia (5.72 ± 1.26 h vs. 6.28 ± 1.35 h, p = 0.029), lower peak postvoid residual volume (168.57 ± 25.09 mL vs. 180.43 ± 30.21 mL, p = 0.032), decreased need for postoperative catheterisation (5.56% vs. 21.57%, p = 0.034) and shorter duration of urinary catheterisation (10.92 ± 2.61 h vs. 12.04 ± 2.87 h, p = 0.039) than the control group. Correlation analysis supported a negative correlation between hydromorphone supplementation and parameters related to postoperative urinary retention. Multivariate regression analysis demonstrated a significant association between the duration of urinary catheterisation and the use of hydromorphone with the occurrence of postoperative urinary retention, providing further insights into the multifactorial nature of this postoperative complication.
CONCLUSIONS: The addition of hydromorphone hydrochloride to bupivacaine for combined spinal and epidural anaesthesia was associated with a reduced incidence of postpartum urinary retention and improved postoperative voiding parameters, without significantly increasing the risk of adverse events.

UNASSIGNED: Combined spinal and epidural anesthesia (CSEA) is commonly performed by double space technique (DST) and single space segment technique (SST) or needle-through-needle technique (NNT).
UNASSIGNED: We designed a double-blind randomized controlled study to compare the effect of the double-space technique with that of the single-space technique on time required by the procedure, the number of attempts, and a level of sensory, side effects and cost-effectiveness.
UNASSIGNED: Patients undergoing elective lower abdominal and lower limb surgeries under regional anesthesia were randomized to receive CSEA with either the double-space technique (double group, n = 30) or the single-space technique (single group, n = 30). In the single group, the procedure was performed at the L3-4 interspace using the needle-through-needle technique. In the double group, an epidural catheter was inserted at the L1-2 interspace, and dural puncture was performed at the L3-4 interspace.
UNASSIGNED: The single space (needle-through-needle) technique for CSE takes less time, less number of spinal punctures. There was no difference between the two groups in terms of side effects. Sensory level at T10 on 5 min in group I was 90% and group II was 100% whereas at T8 it was 10% in group I; sensory level at T10, T8 and T6 on 10 min. in group I were 53.3%, 43.3% and 3.3% respectively whereas in group II were 80%, 16.7% and 3.3% respectively; sensory level at T10, T8, T6 and T4 on 15 min. in group I were 6.7%, 43.3%, 50% and 0% respectively whereas in group II were 23.3%, 50%, 23.3% and 3.3% respectively; and sensory level at T4, T6 and T8 on 20 min. in group I were 0%, 73.3% and 26.7% respectively whereas in group II were 16.7%, 33.3% and 50% respectively.
UNASSIGNED: Single-space (needle-through-needle) CSEA takes less time, less number of spinal punctures and results in improved patient satisfaction. There were no differences in intraoperative variables between the DST and SST for CSEA.

UNASSIGNED: Laparoscopic surgeries in gynecologic field have been performed under general anesthesia (GA) due to the respiratory changes caused by pneumoperitoneum and Trendelenburg position. Therefore, this study aimed to compared general anesthesia and combined spinal and epidural anesthesia (CSEA) for gasless laparoscopic surgery in gynecologic field.
UNASSIGNED: We matched patients with type of surgery who underwent gasless single port access (SPA) laparoscopic surgery under general anesthesia and CSEA. The medical records of 90 patients between March 1, 2018 and June 30, 2020 were reviewed. Gasless laparoscopic surgery was performed in all patients with a SPA using a J-shaped retractor.
UNASSIGNED: No significant differences were observed for age, body mass index, parity, and previous abdominal surgery between GA and CSEA groups. During operation under CSEA, six patients (20%) experienced nausea/vomiting. Hypotension (systolic blood pressure < 90 mmHg) was observed in five patients (16.7%). Intravenous analgesics was administrated in four of the patients (13.3%) who suffered from shoulder pain or abdominal discomfort. One patient developed bradycardia. The duration of hospital admission was shorter in the CSEA group than in the GA group (p = 0.014). There was no difference between the groups in terms of surgery type, surgical specific finding, operation time, estimated blood loss, laparotomy conversion rate and use of additional trocar. No major complications such as urologic, bowel, or vessel injuries were found in both groups.
UNASSIGNED: CSEA is a safe and feasible technique for application in nonobese patients undergoing gasless laparoscopic surgery in gynecologic field.

OBJECTIVE: To explore the effect of electroacupuncture on the improvement of insulin resistance after knee joint replacement based on the combined spinal and epidural anesthesia and postoperative epidural analgesia.
METHODS: Eighty patients with insulin resistance but normal blood glucose were randomly divided into a control group and an observation group, 40 cases in each group.Both groups of patients underwent combined spinal and epidural anesthesia and postoperative epidural analgesia for knee arthroplasty. On the basis of the treatment,electroacupuncture (EA) was applied during the operation and within 1 month after the operation in the observation group, and EA was used at Hegu (LI 4), Qihai (CV 6), Zhongwan (CV 12), Pishu (BL 20), Shenshu (BL 23), etc. once every other day. The control group was not treated with electroacupuncture. Fasting blood glucose and fasting insulin were recorded 30 min before surgery (T0), immediately (T1), 1 d (T2), 3 d (T3), 7 d (T4) and 1 month (T5) after surgery, and the insulin resistance (IR) index was calculated.
RESULTS: Compared with those at T0 time point, the IR index of the control group at T1, T3, T4 and T5 time points and the observation group at T1, T4, T5 time points were lower (all P<0.05). Compared with the control group at the same time point, the IR index of the T1 and T5 time points in the observation group was significantly lower (both P<0.05), and it was lower than the insulin resistance standard.
CONCLUSIONS: Combined spinal and epidural anesthesia and postoperative epidural analgesia can improve short-term insulin resistance. Combined with EA, the improvement of insulin resistance is more obviously and longer.

Purpose: Preoperative carbohydrate loading (CHO) could improve insulin sensitivity and promoted postoperative recovery under general anesthesia. The aim of this study was to investigate the effects of CHO on gynecological patients. Methods: A group of 58 female patients undergoing surgery were randomized to either fast overnight (the FAST group) or receive 800 ml of CHO the evening before and 400 ml 2 h before anesthesia (the CHO group).The perioperative well-being and the nutritional status, as determined by blood samples for three biochemical assays (the base status, the status after the operation, and the status on the first day after the operation), were recorded. The homeostasis model assessment (HOMA-IR) was used to measure perioperative insulin resistance. The primary endpoint was phantom limb syndrome (PLS) induced by combined spinal and epidural anesthesia (CSEA). Results: The CHO group had significantly lower levels of anxiety (p < 0.01), hunger (p < 0.01), and thirst (p < 0.01); lower incidence of PLS (p < 0.01) and abdominal distention (p < 0.05); earlier occurrence of first flatus (p < 0.01); and fewer hospitalization days (p < 0.01) than patients from the FAST group. Biochemical analysis showed that the levels of interleukin-6 (IL-6) (p < 0.01), C-reactive protein (p < 0.01), cortisol (p < 0.01), glucose (p < 0.01), insulin (p < 0.01), and HOMA-IR (p < 0.01) were lower in the CHO patients. Lactate, pyruvate, and lactate/pyruvate ratios for the CHO patients were also lower than those for the FAST patients. Conclusions: CHO increased perioperative comfort in gynecological patients undergoing CSEA. It also attenuated insulin resistance after the operation and reduced the number of postoperative stress reactions.

暂无摘要。

UNASSIGNED: Chronic subdural hematoma (CSDH) after spinal anesthesia is a rare complication. We experienced a patient who developed CSDH after postdural puncture headache (PDPH) following combined spinal and epidural anesthesia (CSE).
UNASSIGNED: A 38-week-gestation parturient with a history of previous cesarean delivery underwent elective cesarean section under CSE. She had been receiving aspirin therapy for Kawasaki disease for many years. She developed a symptom of PDPH 1 day after the surgery. Fluid administration and analgesics were started. Although the headache was relatively severe and persistent, it suddenly disappeared on the third postoperative day. Aspirin administration was restarted on the third postoperative day, and the patient was discharged 1 week after the surgery. 2 weeks after being discharged, she was readmitted to our hospital for severe headache and was diagnosed as having CSDH. An epidural blood patch was performed, resulting in resolution of the hematoma.
UNASSIGNED: We experienced a case of CSDH after PDPH in a patient who was receiving aspirin therapy. Aspirin therapy should be restarted after confirmation of the absence of headache. We should consider the possibility of unexpected disappearance of PDPH in the postoperative period may be due to the development of CSDH.

A 29-year-old pregnant woman was delivered by cesarean section under a combined spinal-epidural anesthesia. Thirty hours after an uneventful surgery, she complained of weakness in her lower extremities and developed fecal and urinary incontinence. Lumbosacral magnetic resonance imaging showed thickening and clumping of cauda equina nerve roots at L2-3 level, consistent with the diagnosis of arachnoiditis. The patient was included in an intense rehabilitation program with a diagnosis of cauda equina syndrome. Most of the symptoms resolved within a few days, but right side foot drop persisted for 2 years after the procedure. Because there was no other etiologies being noticed, we hypothesized that the hyperbaric bupivacaine neurotoxicity was likely to be the cause for this neurologic deficit.