BACKGROUND: Norepinephrine and phenylephrine are commonly used vasoactive drugs to treat hypotension during the perioperative period. The increased release of endogenous norepinephrine elicits prothrombotic changes, while parturients are generally in a hypercoagulable state. Therefore, this trial aims to investigate whether there is a disparity between equivalent doses of prophylactic norepinephrine infusion and phenylephrine infusion on prothrombotic response in patients undergoing cesarean section under spinal anesthesia.
METHODS: Sixty-six eligible parturients will be recruited for this trial and randomly assigned to the norepinephrine or phenylephrine group. The \"study drug\" will be administered at a rate of 15 ml/h starting from the intrathecal injection. The primary outcome are plasma coagulation factor VIII activity (FVIII: C), fibrinogen, and D-dimer levels. The secondary outcomes include hemodynamic variables and umbilical artery blood pH value.
CONCLUSIONS: Our study is the first trial comparing the effect of norepinephrine and phenylephrine on prothrombotic response in patients undergoing cesarean section under spinal anesthesia. Positive or negative results will all help us better understand the impact of vasoactive drugs on patients. If there are any differences, this trial will provide new evidence for maternal choice of vasoactive medications in the perioperative period.
BACKGROUND: Chinese Clinical Trial Registry ChiCTR2300077164. Registered on 1 November 2023. https://www.chictr.org.cn/ .

BACKGROUND: Spinal anesthesia (SA) is commonly used within the specialties of orthopedic surgery, obstetrics and gynecology, spine surgery, and general surgery, and offers several benefits over general anesthesia (GA). However, SA is used much less frequently in plastic surgery. This review analyzed currently existing data on SA use across various surgical specialties and compared the benefits and complications of SA to those of GA, to assess its utility and potential for more widespread use in plastic surgery.
METHODS: A comprehensive literature review was conducted using the PubMed and Cochrane Library databases to evaluate the utility of SA in plastic surgery. Indications, contraindications, and data on the use of SA across various surgical specialties were reviewed. Benefits, complications, and cost-effectiveness were also assessed. Finally, the utility of SA in plastic surgery was evaluated based on the available literature.
RESULTS: SA has been shown to yield several benefits and fewer risks than GA, including a higher possibility of early discharge, decreased costs, better pain and postoperative nausea and vomiting control, and decreased risk of deep venous thrombosis and pulmonary embolism.
CONCLUSIONS: Although commonly used for procedures across various surgical specialties such as obstetrics and gynecology, urology, and orthopedic surgery, SA is less frequently used within plastic surgery. Plastic surgery procedures that would benefit from the use of SA include those below the umbilicus such as liposuction, lower extremity procedures, and perineal procedures, and owing to its benefits, we recommend that SA be used more often within plastic surgery under appropriate clinical circumstances.

OBJECTIVE: This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients.
METHODS: The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO2 gas pressure, and surgical complications.
RESULTS: BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon\'s work or the course of the operation.
CONCLUSIONS: In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery.
BACKGROUND: ISRCTN38987, 10 December 2019.

BACKGROUND: Phenylephrine infusion is recommended to prevent spinal hypotension during cesarean delivery (CD) but may be associated with dose-dependent side effects. We hypothesized that adding intermittent pneumatic compression (IPC) of the lower legs to a variable-rate phenylephrine infusion will reduce the dose of phenylephrine required during CD.
METHODS: Seventy-six healthy women undergoing elective CD under combined spinal-epidural anesthesia were randomly assigned to IPC or control groups (n = 38 per group). After spinal anesthesia, IPC of the lower legs was initiated in the IPC group, and all women received a phenylephrine infusion starting at 25 μg·min-1 and increasing by 16.7 μg·min-1 for systolic blood pressure (SAP) < 90% baseline. If hypotension (SAP < 80% baseline) occurred, 100 μg phenylephrine bolus was administered. The primary outcome was the dose of phenylephrine per minute.
RESULTS: The dose of phenylephrine per minute (34.4 ± 7.3 μg·min-1 vs. 40.9 ± 9.5 μg·min-1, P = 0.001; mean difference -6.6 μg·min-1, 95% CI -10.5 to -2.7 μg·min-1) and the incidence of hypotension (24% vs. 55%, P = 0.005) were lower in the IPC group than in the control group. There were no significant differences between the two groups in the total dose of phenylephrine (603.2 ± 217.1 μg vs. 706.2 ± 247.5 μg, P = 0.058; mean difference -102.9 μg, 95% CI -209.4 to 3.5 μg), maternal side effects, or neonatal outcomes.
CONCLUSIONS: Intermittent pneumatic compression combined with a variable-rate phenylephrine infusion reduced the phenylephrine dose per minute and the incidence of hypotension during CD under spinal anesthesia.

Background: Continuous intravenous infusion of remimazolam may be suitable for sedation in patients undergoing regional anaesthesia. However, there have been no studies comparing remimazolam and dexmedetomidine for this purpose. This study compared emergence from sedation between dexmedetomidine and remimazolam following continuous intravenous infusion in patients undergoing spinal anaesthesia. Methods: This double-blinded, randomised controlled trial assessed the sedative effects of dexmedetomidine and remimazolam. Following spinal anaesthesia, patients were sedated using continuous intravenous infusion of either dexmedetomidine (D group) or remimazolam (R group).The D group received dexmedetomidine administered at 6 mL/kg/h (6 µg/kg/h) for 10 minutes, followed by 1 mL/kg/h (1 µg/kg/h). The R group received remimazolam administered at 6 mL/kg/h (6 mg/kg/h) for 10 minutes, followed by 1 mL/kg/h (1 mg/kg/h). Sedation levels were evaluated using the Modified Observer\'s Assessment of Alertness/Sedation (MOAA/S) scale. The time to reach MOAA/S ≤ 3 from the start of drug infusion and the time to reach MOAA/S = 5 from the end of infusion were recorded. Hemodynamic parameters and respiratory rate were also monitored. Results: The R group reached MOAA/S ≤ 3 significantly faster than the D group during induction of sedation (4 ± 1 minutes and 11 ± 3 minutes, respectively, p < 0.001). The R group also reached MOAA/S = 5 significantly faster than the D group during emergence from sedation (11 ± 3 minutes and 16 ± 5 minutes, respectively, p < 0.001). Both groups maintained stable hemodynamic parameters and respiratory rate without any significant differences, although the mean heart rate was significantly lower in the D group than in the R group after the start of infusion. Conclusion: Remimazolam demonstrated significantly faster induction of and emergence from sedation compared to dexmedetomidine, with no significant differences in haemodynamics or respiratory depression.

OBJECTIVE: The purpose of this study was to evaluate the effect of carbohydrate loading prior to the cesarean surgery under spinal anesthesia on thiols and ischemia-modified albumin (IMA) levels.
METHODS: Prospective, randomized placebo-controlled study.
METHODS: Seventy-nine pregnant women planned for cesarean sections under spinal anesthesia at Karaman Training and Research Hospital were randomized into a control group (group C) (n = 42), and an oral carbohydrate preloading group (group OCH) (n = 37). OCH loading requires consuming 400 mL the night before surgery and 200 mL up to 2 hours before anesthesia. Group OCH consumed an oral carbohydrate-rich beverage (Nutricia-Fantomalt), and group C consumed an equal volume of water. This study investigated thiol-disulfide homeostasis after preoperative carbohydrate consumption. Preoperative gastric fluid, volume, antral cross-sectional area, hypotension following the birth, and fetal blood gas parameters were compared across groups.
RESULTS: Thiols and IMA levels did not differ across groups before and after surgery (P > .05). Gastric ultrasonography showed similar antral cross-sectional area and stomach volume between groups (P = .172, P = .128, respectively). When surgery caused hypotension, group OCH received more ephedrine for surgery-induced hypotension, although this difference is not statistically significant (P = .704). A clustered error bar (95% confidence interval) plot with an interpolation line was used for a time-based comparison of mean differences in heart rate and mean arterial pressure between the groups.
CONCLUSIONS: This study supports that mothers\' thiols and IMA levels were unaffected by preoperative OCH loading before cesarean surgery. We did not examine thiol and its derivatives in umbilical cord blood; hence, we can not comment on thiol/disulfide homeostasis levels in neonates.

UNASSIGNED: Spinal anesthesia is commonly performed for cesarean section, however, postdural puncture headache (PDPH) is one of its most common adverse effects. Ondansetron is an antiemetic for cancer treatment and analgesia-induced nausea and vomiting. In this study, the authors aim to evaluate the effect of postoperative ondansetron on PDPH.
UNASSIGNED: In this randomized controlled clinical trial study, 120 pregnant patients are ASA ll, undergoing elective cesarean section, were randomized into two groups (placebo or study). The patients in the study group, immediately after the birth of a baby and 24 h after the operation, received ondansetron 4 mg IV while the placebo group received a placebo. The severity and incidence of headache, postoperative nausea and vomiting, dizziness, neck and lower back pain, and the use of analgesia was assessed in the two groups.
UNASSIGNED: The significant meaning of the time effect (P<0.001) indicated that regardless of the group, for each unit increase in time, the chance of developing a headache increased by 23%, which was statistically significant. Also, the significant meaning of the group effect indicated that regardless of time, patients who did not take indomethacin had ~4.11 times higher chances of developing a headache compared to those who received the medication, which was statistically significant (P=0.004).
UNASSIGNED: The administration of ondansetron significantly reduces the occurrence of postspinal anesthesia headaches and neck pain. There was no significant difference in headache severity between the two study groups.

BACKGROUND: Preoperative anxiety can negatively impact patient outcomes by influencing the intraoperative requirements for anesthetics and analgesics, increasing postoperative pain intensity, and augmenting the need for analgesia. Moreover, it may contribute to higher rates of postoperative morbidity and mortality following certain types of surgery. This study investigates the anxiolytic and sedative properties of sublingual melatonin as a premedication agent in young females undergoing cesarean section under spinal anesthesia.
METHODS: A double-blind, randomized, placebo-controlled trial was conducted in Nasiriyah, Iraq. Eighty females were included, 40 in each group, based on specific inclusion and exclusion criteria. Premedication was administered in the morning, 60 minutes before the procedure. In the melatonin group (M), patients received 10 mg of sublingual melatonin, while the placebo group (P) received placebo premedication. Anxiety and sedation levels were evaluated three times: before taking premedication, five minutes before the insertion of the spinal needle, and one hour postoperatively, using the visual analog scale and Richmond Sedation Scale.
RESULTS: The results show a highly significant P-value regarding anxiety levels between the M Group and P Group (p-value < 0.001). There was a significant difference in the median sedation scores between the studied groups at pre-spinal insertion and postoperatively (p-value < 0.001). The mean heart rate in the M Group was significantly lower than in the P Group (p-value = 0.0019). Significant differences were noted in systolic and diastolic blood pressures between the two groups, measured five minutes before and after spinal needle insertion (p-value < 0.001).
CONCLUSIONS: These findings contribute to understanding the impact of sublingual melatonin as an anxiolytic and sedative premedication agent on patients undergoing elective cesarean sections under spinal anesthesia. Further research is warranted to fully elucidate the benefits and implications of melatonin administration in such procedures.

Ruptured Sinus of Valsalva (RSOV) is a rarely encountered cardiac anomaly that can potentially lead to adverse clinical outcomes. RSOV increases the risk of morbidity during pregnancy due to the physiological changes associated with gestation, that can exacerbate the underlying cardiac pathology. We present the case of a 29-year-old female with an uncorrected RSOV who required an emergency cesarean section for abruptio placenta. The patient underwent the procedure under spinal anesthesia, with careful titration of norepinephrine infusion and close monitoring of hemodynamic parameters using an invasive intra-arterial line. Given the absence of established anesthetic protocols for parturients with RSOV undergoing cesarean delivery, a comprehensive understanding of the complex interaction between the hemodynamic effects of RSOV, pregnancy, and anesthesia is essential. This understanding enables the safe use of spinal anesthesia in urgent situations, leading to favorable patient outcomes.

BACKGROUND: Spinal anesthesia (SA) is used in lumbar surgery, but initial adequate analgesia fails in some patients. In these cases, spinal redosing or conversion to general endotracheal anesthesia is required, both of which are detrimental to the patient experience and surgical workflow.
METHODS: We reviewed cases of lumbar surgery performed under SA from 2017-2021. We identified 12 cases of inadequate first dose and then selected 36 random patients as controls. We used a measurement tool to approximate the volume of the dural sac for each patient using T2-weighted sagittal magnetic resonance imaging sequences.
RESULTS: Patients who had an inadequate first dose of anesthesia had a significantly larger dural sac volume, 22.8 ± 7.9 cm3 in the inadequate dose group and 17.4 ± 4.7 cm3 in controls (P = 0.043). The inadequate dose group was significantly younger, 54.2 ± 8.8 years in failed first dose and 66.4 ± 11.9 years in controls (P = 0.001). The groups did not differ by surgical procedure (P = 0.238), level (P = 0.353), American Society of Anesthesia score (P = 0.546), or comorbidities.
CONCLUSIONS: We found that age, larger height, and dural sac volume are risk factors for an inadequate first dose of SA. The availability of spinal magnetic resonance imaging in patients undergoing spine surgery allows the preoperative measurement of their thecal sac size. In the future, these data may be used to personalize spinal anesthesia dosing on the basis of individual anatomic variables and potentially reduce the incidence of failed spinal anesthesia in spine surgery.