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Leighton, Barbara L., Stephen H. Halpern e Donna B. Wilson. "Lumbar Sympathetic Blocks Speed Early and Second Stage Induced Labor in Nulliparous Women". Anesthesiology 90, n.º 4 (1 de abril de 1999): 1039–46. http://dx.doi.org/10.1097/00000542-199904000-00017.
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Background Rapid cervical dilation reportedly accompanies lumbar sympathetic blockade, whereas epidural analgesia is associated with slow labor. The authors compared the effects of initial lumbar sympathetic block with those of epidural analgesia on labor speed and delivery mode in this pilot study. Methods At a hospital not practicing active labor management, full-term nulliparous patients whose labors were induced randomly received initial lumbar sympathetic block or epidural analgesia. The latter patients received 10 ml bupivacaine, 0.125%; 50 microg fentanyl; and 100 microg epinephrine epidurally and sham lumbar sympathetic blocks. Patients to have lumbar sympathetic blocks received 10 ml bupivacaine, 0.5%; 25 microg fentanyl; and 50 microg epinephrine bilaterally and epidural catheters. Subsequently, all patients received epidural analgesia. Results Cervical dilation occurred more quickly (57 vs. 120 min/cm cervical dilation; P = 0.05) during the first 2 h of analgesia in patients having lumbar sympathetic blocks (n = 17) than in patients having epidurals (n = 19). The second stage of labor was briefer in patients having lumbar sympathetic blocks than in those having epidurals (105 vs. 270 min; P < 0.05). Nine patients having lumbar sympathetic block and seven having epidurals delivered spontaneously, whereas seven patients having lumbar sympathetic block and seven having epidurals had instrument-assisted vaginal deliveries. Cesarean delivery for fetal bradycardia occurred in one patient having lumbar sympathetic block. Cesarean delivery for dystocia occurred in five patients having epidurals compared with no patient having lumbar sympathetic block (P = not significant). Visual analog pain scores differed only at 60 min after block. Conclusions Nulliparous parturients having induced labor and receiving initial lumbar sympathetic blocks had faster cervical dilation during the first 2 h of analgesia, shorter second-stage labors, and a trend toward a lower dystocia cesarean delivery rate than did patients having epidural analgesia. The effects of lumbar sympathetic block on labor need to be determined in other patient groups. These results may help define the tocodynamic effects of regional labor analgesia.
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Manchikanti, Laxmaiah. "A Prospective Evaluation of Complications of 10,000 Fluoroscopically Directed Epidural Injections". Pain Physician 2;15, n.º 2;3 (14 de março de 2012): 131–40. http://dx.doi.org/10.36076/ppj.2012/15/131.
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Background: Among the multiple modalities of treatments available in managing chronic spinal pain, including surgery and multiple interventional techniques, epidural injections by various routes, such as interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, and percutaneous adhesiolysis are common. Even though the complications of fluoroscopically directed epidural injections are fewer than blind epidural injections, and have better effectiveness, multiple complications have been reported in scattered case reports, with only minor complications in randomized or non-randomized studies and systematic reviews. Thus, prospective studies with large patient series are essential to determine the types and incidences of complications. Study Design: A prospective, non-randomized study of patients undergoing interventional techniques from May 2008 to December 2009. Setting: A private interventional pain management practice, a specialty referral center in the United States. Objectives: To assess the complication rate of fluoroscopically directed epidural injections. Methods: This study was carried out over a period of 20 months and included over 10,000 procedures: 39% caudal epidurals, 23% cervical interlaminar epidurals, 14% lumbar interlaminar epidurals, 13% lumbar transforaminal epidurals, 8% percutaneous adhesiolysis, and 3% thoracic interlaminar epidural procedures. All of the interventions were performed under fluoroscopic guidance in an ambulatory surgery center by one of 3 physicians. The complications encountered during the procedure and postoperatively were prospectively evaluated. Outcomes Assessment: Measurable outcomes employed were intravascular entry of the needle, profuse bleeding, local hematoma, bruising, dural puncture and headache, nerve root or spinal cord irritation with resultant injury, infectious complications, vasovagal reactions, and facial flushing. Results: Intravascular entry was higher for adhesiolysis (11.6%) and lumbar transforaminal (7.9%) procedures compared to other epidurals which ranged from 0.5% for lumbar, 3.1% for caudal, 4% for thoracic, and 4.1% for cervical epidurals. Dural puncture was observed in a total of 0.5% of the procedures with 1% in the cervical region, 1.3% in the thoracic region, 0.8% with lumbar interlaminar epidurals, and 1.8% with adhesiolysis. Limitations: Limitations of this study include a single-center study even though it included a large number of patients. Conclusion: This study illustrates that major complications are rare and minor side effects are common. Key words: Spinal pain, epidural injections, caudal epidural, interlaminar epidural, transforaminal epidural, percutaneous adhesiolysis, complications, and steroids.
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Tuuli, Methodius, Molly Stout, Candice Woolfolk, Kimberly Roehl, George Macones, Alison Cahill e Adam Lewkowitz. "Epidurals and the Modern Labor Curve: How Epidural Timing Impacts Fetal Station during Active Labor". American Journal of Perinatology 35, n.º 05 (29 de dezembro de 2017): 421–26. http://dx.doi.org/10.1055/s-0037-1617457.
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Objective The objective of this study was to estimate epidural timing's impact on fetal station during active labor. Study Design This secondary analysis of a single-institution prospective cohort study included all term singleton pregnancies, stratified by parity. Those with early epidurals (placed at <6 cm) were compared with those with late epidurals (placed at ≥6 cm). The primary outcome was median fetal station from 6 to 10 cm. Secondary outcomes included rate of prolonged first or second stage of labor (>95%). Multivariable logistic regression adjusted for labor type. Results Among 7,647 women, 3,434 were nulliparous (2,983 with early epidurals and 451 with late epidurals) and 4,213 multiparous (3,141 with early epidurals and 1,072 with late epidurals). Interquartile ranges (IQRs) suggested fetal station at 6 cm was likely lower among those with early epidurals (nulliparous: median head station −1 [IQR: −1 to 0] for early epidural vs. −1 [IQR: −2 to 0] for late epidural, p < 0.01; multiparous: −1 (IQR: −2 to 0] for early epidural vs. −1 [IQR: −3 to −1] for late epidural, p < 0.01). Early epidurals were not associated with increased risk of prolonged first stage, but among nulliparous were associated with decreased risk of prolonged second stage (adjusted odds ratio: 0.66 [95% confidence interval: 0.44–0.99]). Conclusion Early epidurals were associated with lower fetal station in active labor but not prolonged first stage.
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Bernards, Christopher M., Danny D. Shen, Emily S. Sterling, Jason E. Adkins, Linda Risler, Brian Phillips e Wolfgang Ummenhofer. "Epidural, Cerebrospinal Fluid, and Plasma Pharmacokinetics of Epidural Opioids (Part 1)". Anesthesiology 99, n.º 2 (1 de agosto de 2003): 455–65. http://dx.doi.org/10.1097/00000542-200308000-00029.
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Background The pharmacokinetics of epidurally administered drugs has been the subject of many studies, yet drug concentration in the epidural space has never been measured. This study was undertaken to characterize the epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidurally administered opioids on the basis of measurement of drug concentration in each of these compartments after epidural administration. Methods Morphine plus alfentanil, fentanyl, or sufentanil were administered epidurally in anesthetized pigs. Microdialysis was used to sample the epidural space and the cerebrospinal fluid for measurement of opioid concentration over time. Plasma samples were obtained from the central venous plasma and the epidural venous plasma. These data were used to calculate relevant pharmacokinetic parameters, including mean residence time, elimination half-lives, areas under the concentration versus time curves, clearance, and volume of distribution for each opioid in each compartment. Results Some of the more important findings were that the cerebrospinal fluid and plasma pharmacokinetics of the opioids did not parallel their epidural pharmacokinetics and that their hydrophobic character governed multiple aspects of their lumbar epidural pharmacokinetics. Conclusions The findings indicate that the spinal pharmacokinetics of these drugs are complex and, in some ways, counterintuitive. Also, the bioavailability of opioids in the cerebrospinal fluid and epidural space is determined primarily by their hydrophobicity, with less hydrophobic drugs having greater bioavailability.
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McLaren, Steve, Megan Hughes, Catherine Sheehan e Jagdish Sokhi. "A guide to epidural management". British Journal of Hospital Medicine 81, n.º 1 (2 de janeiro de 2020): 1–7. http://dx.doi.org/10.12968/hmed.2019.0174.
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Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. To non-anaesthetists, or those not versed in their usage, epidurals can appear complex and intimidating, and the potential complications, although rare, can be catastrophic if not picked up on in a timely fashion. This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.
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Bernards, Christopher M., Danny D. Shen, Emily S. Sterling, Jason E. Adkins, Linda Risler, Brian Phillips e Wolfgang Ummenhofer. "Epidural, Cerebrospinal Fluid, and Plasma Pharmacokinetics of Epidural Opioids (Part 2)". Anesthesiology 99, n.º 2 (1 de agosto de 2003): 466–75. http://dx.doi.org/10.1097/00000542-200308000-00030.
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Background The ability of epinephrine to improve the efficacy of epidurally administered drugs is assumed to result from local vasoconstriction and a consequent decrease in drug clearance. However, because drug concentration in the epidural space has never been measured, our understanding of the effect of epinephrine on epidural pharmacokinetics is incomplete. This study was designed to characterize the effect of epinephrine on the epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidurally administered opioids. Methods Morphine plus alfentanil, fentanyl, or sufentanil was administered epidurally with and without epinephrine (1:200,000) to pigs. Opioid concentration was subsequently measured in the epidural space, central venous plasma, and epidural venous plasma, and these data were used to calculate relevant pharmacokinetic parameters. Results The pharmacokinetic effects of epinephrine varied by opioid and by sampling site. For example, in the lumbar epidural space, epinephrine increased the mean residence time of morphine but decreased that of fentanyl and sufentanil. Epinephrine had no effect on the terminal elimination half-life of morphine in the epidural space, but it decreased that of fentanyl and sufentanil. In contrast, in the lumbar intrathecal space, epinephrine had no effect on the pharmacokinetics of alfentanil, fentanyl, or sufentanil, but it increased the area under the concentration-time curve of morphine and decreased its elimination half-life. Conclusions The findings indicate that the effects of epinephrine on the spinal pharmacokinetics of these opioids are complex and often antithetical across compartments and opioids. In addition, the data clearly indicate that the pharmacokinetic effects of epinephrine in spinal "compartments" cannot be predicted from measurements of drug concentration in plasma, as has been assumed for decades.
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Manchikanti, Laxmaiah. "Assessment of the Growth of Epidural Injections in the Medicare Population from 2000 to 2011". Pain Physician 4;16, n.º 4;7 (14 de julho de 2013): E349—E364. http://dx.doi.org/10.36076/ppj.2013/16/e349.
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Background: Among the many diagnostic and therapeutic interventions available for the management of chronic pain, epidural steroid injections are one of the most commonly used modalities. The explosive growth of this technique is relevant in light of the high cost of health care in the United States and abroad, the previous literature assessing the effectiveness of epidural injections has been sparse with highly variable outcomes based on technique, outcome measures, patient selection, and methodology. However, the recent assessment of fluoroscopically directed epidural injections has shown improved evidence with proper inclusion criteria, methodology, and outcome measures. The exponential growth of epidural injections is illustrated in multiple reports. The present report is an update of the analysis of the growth of epidural injections in the Medicare population from 2000 to 2011 in the United States. Study Design: Analysis of utilization patterns of epidural procedures in the Medicare population in the United States from 2000 to 2011. Objectives: The primary purpose of this assessment was to evaluate the use of all types of epidural injections (i.e., caudal, interlaminar, and transforaminal in the lumbar, cervical, and thoracic regions) with an assessment of specialty and regional characteristics. Methods: This assessment was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master data from 2000 to 2011. Results: Epidural injections in Medicare beneficiaries increased significantly from 2000 to 2011. Overall, epidural injections increased 130% per 100,000 Medicare beneficiaries with an annual increase of 7.5%. The increases per 100,000 Medicare recipients were 123% for cervical/ thoracic interlaminar epidural injections; 25% for lumbar/sacral interlaminar, or caudal epidural injections; 142% for cervical/thoracic transforaminal epidural injections; and 665% for lumbar/ sacral transforaminal epidural injections. The use of epidurals increased 224% in the radiologic specialties (interventional radiology and diagnostic radiology) and 145% in psychiatric settings, whereas and physical medicine and rehabilitation physicians’ use of epidurals increased 520%. Limitations: Study limitations include lack of inclusion of Medicare Advantage patients. In addition, the statewide data is based on claims which may include the contiguous or other states. Conclusions: Epidural injections in Medicare recipients increased significantly. The growth was significant for some specialties (radiology, physical medicine and rehabilitation, and psychiatry) and for certain procedures (lumbosacral transforaminal epidural injections). Key words: Spinal pain, interventional pain management, epidural injections, caudal epidural, lumbar epidural, cervical epidural, cervical transforaminal, lumbar transforaminal
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Stark, Mary Ann. "Exploring Women’s Preferences for Labor Epidural Analgesia". Journal of Perinatal Education 12, n.º 2 (1 de março de 2003): 16–21. http://dx.doi.org/10.1891/1058-1243.12.2.16.
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The purpose of this study was to explore demographic factors related to women’s prenatal preferences for using an epidural during labor. Women recruited from prenatal classes provided data for this descriptive correlational study. Women with the most education, income, and parity indicated greatest preference for epidural analgesia. Thus, these women may be comfortable with the technology and most likely to be willing to pay for epidurals and to select care providers who provide epidural anesthesia. In this sample, prenatal preference for an epidural was not predictive of actual use, although it has been shown to be predictive in previous research.
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Kamiya, Yoshinori, Tatsuaki Kikuchi, Gaku Inagawa, Hiroshi Miyazaki, Masashi Miura, Satoshi Morita e Takahisa Goto. "Lidocaine Concentration in Cerebrospinal Fluid after Epidural Administration". Anesthesiology 110, n.º 5 (1 de maio de 2009): 1127–32. http://dx.doi.org/10.1097/aln.0b013e31819daf15.
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Background In this study, lidocaine concentrations in cerebrospinal fluid (CSF) at different interspaces were measured with or without preceding spinal anesthesia, 10 min after epidural injection of lidocaine, to investigate the effects of preceding meningeal puncture on CSF concentrations of epidurally administered local anesthetic. Methods Sixty patients scheduled to receive combined spinal-epidural anesthesia were randomly allocated to receive either spinal anesthesia first (group CSEA) or epidural lidocaine first (group Epi). Each group was divided into three subgroups in which the site of epidural cannulation and spinal tap were separated by one, three, or five interspaces (sets I, II, and III, respectively). CSF was collected from the L4-L5 interspace 10 min after 10 ml lidocaine, 1%, was administered epidurally. In group Epi, CSF was collected after epidural administration of lidocaine and before spinal anesthesia. In group CSEA, spinal anesthesia was performed at the L3-L4 interspace after epidural cannulation and epidural lidocaine was administered postoperatively, after which CSF was sampled. Results Lidocaine concentrations in CSF were significantly higher with increasing proximity of epidural injection site to CSF collection site in both groups. There were no significant differences in CSF lidocaine concentrations between group CSEA and group Epi in set I, although lidocaine concentrations were significantly higher in group CSEA set II and III patients. Conclusion Lidocaine concentration in CSF was similar with or without preceding meningeal puncture beneath the epidural administration site.
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Davis, Stephanie, e Samuel Hird. "Intermittent epidural boluses vs continuous epidural infusion for labour analgesia: which is superior?" British Journal of Hospital Medicine 82, n.º 5 (2 de maio de 2021): 1–2. http://dx.doi.org/10.12968/hmed.2020.0704.
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Epidurals are considered the gold standard for labour analgesia. The possibility of newer pumps reducing staff workload has reignited interest in the advantages of the intermittent bolus technique, but is this superior to a continuous epidural infusion?
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Mahrose, Ramy, e Mohamed M. Kamal. "Repeated Epidural Anesthesia and Incidence of Unilateral Epidural Block". Open Anesthesia Journal 13, n.º 1 (30 de abril de 2019): 6–11. http://dx.doi.org/10.2174/2589645801913010006.
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Background: Epidural block is today the most common method of pain relief during labor. Nowadays, facing a multiparus parturient requiring epidural for the second or third time is common due to increased frequency of using epidural analgesia during labor. Objectives: Examination of the performance and outcome of women receiving their first versus repeated epidural block. Methods: The study included 140 American Society of Anesthesiologists (ASA) Physical Status II parturients (age range 20 to 40 years) and scheduled for normal vaginal delivery. The parturients were divided randomly into two equal groups. Group (A) in which 70 women primipara subjected to their first epidural block, while group (B) in which 70 women multipara subjected to their repeated epidural block. Our primary outcome of the study is the incidence of a unilateral block and secondary outcomes include Visual Analogue Scale (VAS) before the epidural and 30 minutes after injection of local anesthetic and details of labor as gestation and cervical dilatation. Results: The results showed that there was a statistically significant decrease in the incidence of a unilateral block in the group (A) when compared to the corresponding values in the group (B) (P-value < 0.05). Moreover, group (A) showed a statistically significant decrease in Visual Analogue Scale (VAS) values 30 minutes after the injection of local anesthetic (P-value < 0.05). Conclusion: The conclusion of our study is that there is a higher incidence of unilateral block amongst women receiving their repeated epidurals for labour than those receiving their first epidural block.
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Torre, Abraham Ibarra-de la, Verónica Bautista-Piña e Antonio Avilés-Aguilar. "Hemangioma cavernoso espinal epidural puro". Archivos de Neurociencias 19, n.º 3 (1 de setembro de 2014): 166–68. http://dx.doi.org/10.31157/an.v19i3.52.
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Los hemangiomas espinales epidurales; son entidades raras. La mayoría de estas lesiones afectan los cuerpos vertebrales y tienen extensión ocasional al espacio epidural. La ocurrencia pura (espinal) de hemangioma epidural es poco común, localizados con más frecuencia en nivel torácico, puede presentarse con síntomas sobre raíz nerviosa y/o compresión medular. Presentamos un caso de hemangioma cavernoso espinal epidural puro a nivel lumbar, manifestado con radiculopatía crónica, con mejoría posterior a la resección quirúrgica total.
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Torre, Abraham Ibarra-de la, Verónica Bautista-Piña e Antonio Avilés-Aguilar. "Hemangioma cavernoso espinal epidural puro". Archivos de Neurociencias 19, n.º 3 (1 de setembro de 2014): 166–68. http://dx.doi.org/10.31157/archneurosciencesmex.v19i3.52.
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Los hemangiomas espinales epidurales; son entidades raras. La mayoría de estas lesiones afectan los cuerpos vertebrales y tienen extensión ocasional al espacio epidural. La ocurrencia pura (espinal) de hemangioma epidural es poco común, localizados con más frecuencia en nivel torácico, puede presentarse con síntomas sobre raíz nerviosa y/o compresión medular. Presentamos un caso de hemangioma cavernoso espinal epidural puro a nivel lumbar, manifestado con radiculopatía crónica, con mejoría posterior a la resección quirúrgica total.
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Cook, Fabian Alexander Blyth, Emma Millar, Flora Mclennan, Marc Janssens e Catherine Stretton. "Non-Obstetric Safety of Epidurals (NOSE)". BMJ Open Quality 10, n.º 1 (janeiro de 2021): e000943. http://dx.doi.org/10.1136/bmjoq-2020-000943.
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Epidurals are a useful perioperative procedure for effective analgesia that allow early mobilisation after major surgery and help to minimise postoperative pulmonary, cardiovascular and thromboembolic complications. However, there are potential rare but life-changing complications such as an epidural haematoma. These require a high standard of post-epidural care for prompt recognition and prevention of permanent paralysis. Following a local critical incident of delayed diagnosis of an epidural haematoma in a patient after epidural catheter removal, a multidisciplinary team undertook a Quality Improvement (QI) project to improve epidural safety. To achieve this aim, it is essential that healthcare staff are aware of the early signs of neurological complications during and after epidurals and of what action to take in the event of a developing complication. The application of robust QI methodology has contributed to a sustained improvement in the healthcare staff competence (as measured using a pulse survey) at managing patients who have received perioperative epidurals. This increased from a baseline mean survey score of 38% on three surgical step down wards (general surgery, vascular and gynaecology) to 68% (averaged over the most recent 3 months of the project time frame). Educational interventions alone rarely lead to meaningful and lasting impact for all healthcare staff, due to high turnover of staff and shift working patterns. However, with multiple plan, do, study, act cycles, and a robust QI approach, there was also sustained improvement in process measures, including the occurrence of written handover from high dependency to the step down wards (baseline 33%–71%), ensuring the application of yellow epidural alert wristbands to make these patients readily identifiable (56%–86%), and early signs in improvement in reliability of motor block checks for 24 hours’ post-catheter removal (47%–69%).
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Wahezi, Sayed E. "Hemiparesis and Facial Sensory Loss following Cervical Epidural Steroid Injection". Pain Physician 6;17, n.º 6;12 (14 de dezembro de 2014): E761—E767. http://dx.doi.org/10.36076/ppj.2014/17/e761.
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Interlaminar cervical epidural steroid injections (ic-ESI) are safe and effective treatment options for the management of acute and chronic radiculopathy, spinal stenosis, and other causes of neck pain not responding to more conservative measures. However, the procedure inherently lends itself to possible spinal cord injury (SCI). Though reports of such events have been documented, the clinical presentation of patients with needle puncture SCI varies. In part, this may be due to anatomic considerations, as symptoms may be dependent on the cervical level intruded, as well as the volume and type of injectate used. Many cases go unreported and therefore the true incidence of cord injections during ic-ESI is not known. Cervical epidurals can be performed by the transforaminal or interlaminar approach. It is generally accepted that ic-ESI is safer than transforaminal epidurals. There are numerous reports of arterial invasion or irritation with the latter despite an inherently greater risk of cord puncture with the former. The likelihood of cord interruption rises when ic-ESIs are performed above C6-C7 as there is a relatively slim epidural layer compared to lower cervical epidural zones. Though most cases of devastating outcomes, such as hemiplegia and death, have been reported during cervical transforaminal epidural injections and rarely with ic-ESI, it is important to understand the symptoms and potential pitfalls of performing any cervical epidural injection. Cervical epidural malpractice claims are uncommon, but exceed those of steroid blocks at all the levels combined, demonstrating the need for improved awareness of potential complications in ic-ESI. Here, we will describe an unusual presentation of a spinal cord injection during an ic-ESI procedure. Key words: Cervical epidural, spinal cord, hemiparesis
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Manchikanti, Laxmaiah. "An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018". Pain Physician 2;23, n.º 4;2 (14 de abril de 2020): 111–26. http://dx.doi.org/10.36076/ppj.2020/23/111.
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Background: With increasing costs of health care in the United States, attention is focused on expensive conditions. Musculoskeletal disorders with low back and neck pain account for the third highest amount of various disease categories. Minimally invasive interventional techniques for managing spinal pain, including epidural injections, have been considered to be growing rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis procedures. Objectives: The objectives of this analysis of epidural procedures from 2000 to 2018 are to provide an update on utilization of epidural injections in managing chronic pain in the fee-forservice (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018. Study Design: Utilization patterns and variables of epidural injections in managing chronic spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the United States. Methods: This analysis was performed by utilizing master data from CMS, physician/supplier procedure summary from 2000 to 2018. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Results: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However, from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections, 1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal epidurals, and 3.5% for cervical and thoracic interlaminar epidurals. Limitations: This analysis was limited by noninclusion of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. In addition, utilization data for individual states continues to be sparse and may not be accurate or representative of the population. Conclusions: The declining utilization of epidural injections in all categories with an annual of 2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3% and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural injections. Key words: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns
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Masue, Tatsuhiko, Shuji Dohi, Toshio Asano e Hiroyuki Shimonaka. "Spinal Antinociceptive Effect of Epidural Nonsteroidal Antiinflammatory Drugs on Nitric Oxide-induced Hyperalgesia in Rats". Anesthesiology 91, n.º 1 (1 de julho de 1999): 198–206. http://dx.doi.org/10.1097/00000542-199907000-00028.
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Background Nonsteroidal antiinflammatory drugs (NSAIDs) suppress various hyperalgesia perhaps via inhibition of cyclooxygenase activity at the spinal cord. The present study aimed to examine whether epidural application of NSAIDs affects hyperalgesia induced by nitric oxide. Methods The authors studied the antinociceptive effects of epidurally administered NSAIDs in rats with a chronically in-dwelling epidural catheter by three hyperalgesic models, including nitric oxide-induced hyperalgesia by nitroglycerin (10 microg) or l-arginine (100 microg), and the biphasic response in the formalin test. Results Epidural, but not systemic, nitroglycerin induced hyperalgesia that was completely blocked by methylene blue but not by N(omega)-nitro-L-arginine methyl ester (L-NAME). Epidural l-arginine, but not d-arginine, also induced hyperalgesia that was completely blocked by L-NAME. Epidural S(+)ibuprofen (100-1,000 microg) suppressed the nitroglycerin- and l-arginine-induced thermal hyperalgesia and also the second phase response in the formalin test. Neither systemic S(+)ibuprofen nor epidural R(-)ibuprofen suppressed the hyperalgesia Epidural indomethacin (10-100 microg) or diclofenac (10-1,000 microg) dose-dependently suppressed nitroglycerin-induced thermal hyperalgesia The order of potency for this suppression (ID50 in microg) was indomethacin = didofenac > S(+)ibuprofen > R(-)ibuprofen. Conclusions The antinociceptive action of epidurally administered NSAIDs could be the result of suppression of spinal sensitization, perhaps induced with nitric oxide in the spinal cord. The ID50 values for epidural indomethacin, diclofenac, and S(+)ibuprofen were about 10 times higher than those reported in other studies for intrathecal NSAIDs in hyperalgesia models. (Key words: Cyclooxygenase inhibitors; NO donor; NO precursor; optical isomers; neuroplasticity.)
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Cummings, Kenneth C., Fang Xu, Linda C. Cummings e Gregory S. Cooper. "A Comparison of Epidural Analgesia and Traditional Pain Management Effects on Survival and Cancer Recurrence after Colectomy". Anesthesiology 116, n.º 4 (1 de abril de 2012): 797–806. http://dx.doi.org/10.1097/aln.0b013e31824674f6.
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Background Cancer recurrence after surgery may be affected by immunosuppressive factors such as surgical stress, anesthetic drugs, and opioids. By limiting exposure to these, epidural analgesia may enhance tumor surveillance. This study compared survival and cancer recurrence rates for resection of colorectal cancer between patients who received perioperative epidurals and those who did not. Methods The linked Medicare-Surveillance, Epidemiology, and End Results database was used to identify patients ages 66 yr or older with nonmetastatic colorectal cancer diagnosed between 1996 and 2005 who underwent open colectomy. Recurrence was defined as chemotherapy 16 months or more after surgery and/or radiation 12 months or more after surgery. Patients were followed for at least 4 yr. To account for hospital effects, overall survival was estimated via marginal Cox regression. Recurrence was estimated by conditional logistic regression. Results A cohort of 42,151 patients, of whom 22.9% (n = 9,670) had epidurals at the time of resection, was identified. 5-yr survival was 61% in the epidural group and 55% in the nonepidural group. There was a significant association between epidural use and improved survival (adjusted Cox model hazard ratio = 0.91, 95% CI = [0.87, 0.94]). Adjusting for covariates, there was no significant reduction of recurrence in the epidural group (odds ratio = 1.05, 95% CI = [0.95, 1.15]). Several covariates, including blood transfusion, were predictive of mortality and cancer recurrence. Conclusion This large cohort study found that epidural use is associated with improved survival in patients with nonmetastatic colorectal cancer undergoing resection but does not support an association between epidural use and decreased cancer recurrence.
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Botfield, Claire, e Paul Howell. "The use of spinal anaesthesia in severe pre-eclampsia". Fetal and Maternal Medicine Review 12, n.º 1 (17 de janeiro de 2001): 67–79. http://dx.doi.org/10.1017/s0965539501000146.
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Women with severe pre-eclampsia (PE) commonly require delivery by Caesarean section (CS). Whilst the choice of anaesthetic technique in this group of women has been controversial for a number of years, clinical experience has demonstrated the relative safety and value of well-managed incremental epidural anaesthesia. Several studies attest to the benefits of epidural analgesia in labour and epidural anaesthesia for CS. It is now widely recognised that epidurals provide relatively smooth control of blood pressure, maintain or improve utero-placental perfusion, optimising fetal outcome, and eliminate the airway and haemodynamic problems associated with general anaesthesia. Thus, epidural anaesthesia is the current technique of choice amongst most obstetric anaesthetists for CS in severe PE. Good inter-disciplinary communication between anaesthetic and obstetric staff should allow the need for CS to be anticipated early, and the epidural catheter inserted and topped-up in good time. However, in the case of urgent CS where it is not considered appropriate to wait the time required to produce effective epidural blockade, the choice of technique lies between spinal and general anaesthesia.
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Seidelman, Jessica, Sarah Lewis e Becky Smith. "CAUTIs in Patients With Thoracic Epidurals". Infection Control & Hospital Epidemiology 41, S1 (outubro de 2020): s155. http://dx.doi.org/10.1017/ice.2020.676.
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Background: The Surgical Care Improvement Project 9 (SCIP 9) mandates the removal of urinary catheters within 48 hours following surgery to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Although patients with thoracic epidurals are not exempt from SCIP 9, these patients may be inherently different from other surgical patients. Early removal of Foley catheters may cause urinary retention and recatheterization, which in turn can lead to CAUTI or urethral trauma. Our hospital’s current policy is to allow Foley catheters to remain in place until the thoracic epidural is removed. The goal of our study was to identify and compare the rate of CAUTI in patients with thoracic epidural catheters to the rate of CAUTI in patients without thoracic epidural catheters Methods: We performed a retrospective cohort study of patients with and without thoracic epidurals who had Foley catheters during hospitalization from July 1, 2017, to May 31, 2019. We used descriptive statistics to compare CAUTI rates based on unit between the 2 groups of patients. Results: We identified 1,834 unique patients with thoracic epidurals and urinary catheters during the study period. We found 4 CAUTIs of 9,896 catheter days (0.4 CAUTIs per 1,000 catheter days) in patients with epidural catheters and 43 CAUTIs of 36,809 catheter days (1.17 CAUTI per 1,000 catheter days) in patients without thoracic epidurals for a rate ratio of 0.346 (95% CI, 0.1242– 0.9639; P < .03). We conducted a sensitivity analysis on a subset of patients admitted under the cardiothoracic service and compared the patients with Foley catheters with and without thoracic epidurals. In this subset, we found 1 CAUTI in 5,890 catheter days (0.17 CAUTI per 1,000 catheter days) in patients with thoracic epidurals and 4 CAUTIs in 9,429 catheter days (0.42 CAUTIs per 1,000 catheter days) in patients without thoracic epidurals), for a rate of 0.4002 (95% CI, 0.0447–3.5808; P < .39). In this subgroup, 7.0% of patients with thoracic epidurals required a second Foley catheter compared to 16.9% of patients without thoracic epidurals who required a second Foley catheter (P < .01). Conclusions: Although patients with thoracic epidurals maintain Foley catheters beyond 48 hours, the CAUTI rate in these patients is lower than in patients without thoracic epidurals. Therefore, removing Foley catheters within 48 hours of surgery in patients with thoracic epidurals may not reduce the risk of CAUTI and, in fact, could be harmful. Further evaluation of confounding variables is warranted.Funding: NoneDisclosures: None
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Ammirati, Mario, e Florence Perino. "Symptomatic air trapped in the spine after lumbar epidural corticosteroid injection". Journal of Neurosurgery: Spine 5, n.º 4 (outubro de 2006): 359–61. http://dx.doi.org/10.3171/spi.2006.5.4.359.
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✓ The authors report the first case involving trapped epidural air in the spine that mimicked a mass lesion and caused neurological symptoms after epidural corticosteroid injection in the lumbar region. New neurological symptoms developed immediately after injection, and magnetic resonance (MR) imaging demonstrated trapped air displacing the dural sac. After the patient underwent conservative treatment, the new symptoms resolved, and follow-up MR imaging and computed tomography demonstrated resorption of the epidural air in the lumbar region. To limit this problem, the clinician should decrease the amount of air injected in the epidural space or substitute nitrous oxide for air when injecting steroid agents epidurally.
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Lucas, T., R. K. Parker, N. R. Connelly, V. Vallurupalli, S. Bhopatkar e S. Dunn. "COMPARISON OF EPIDURAL FENTANYL VERSUS EPIDURAL SUFENTANIL FOR EARLY LABOR AMBULATORY EPIDURALS". Anesthesiology 2000, n.º 4 (1 de abril de 2000): NA. http://dx.doi.org/10.1097/00000542-200004001-00067.
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Ting, Chien-Kun, Mei-Yung Tsou, Pin-Tarng Chen, Kuang-Yi Chang, M. Susan Mandell, Kwok-Hon Chan e Yin Chang. "A New Technique to Assist Epidural Needle Placement". Anesthesiology 112, n.º 5 (1 de maio de 2010): 1128–35. http://dx.doi.org/10.1097/aln.0b013e3181d3d958.
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Background Up to 10% of epidurals fail due to incorrect catheter placement. We describe a novel optical method to assist epidural catheter insertion in a porcine model. Methods Optical emissions were tested on ex vivo tissues from porcine paravertebral tissues to identify optical reflective spectra. The wavelengths of 650 and 532 nm differentiated epidural space from the ligamentum flavum. We then used a hollow stylet that contained optical fibers to place epidural needles in anesthetized pigs. Real-time data were displayed on an oscilloscope and stored for analysis. A total of 50 punctures were done in four laboratory pigs. Data were expressed as mean +/- SD. Results Paired t test shows significant optical differences between the epidural space and the ligamentum flavum at both 650 nm (P < 0.001) and 532 nm (P = 0.014). Mean magnitudes for 650 nm, 532 nm, and their ratio were 3.565 +/- 0.194, 2.542 +/- 0.145, and 0.958 +/- 0.172 at epidural space and 3.842 +/- 0.191, 2.563 +/- 0.131, and 1.228 +/- 0.244 at ligamentum flavum, respectively. There were no differences in the optical characteristics of the ligamentum flavum and epidural space at different levels in the lumbar and thoracic region (two-way ANOVA P > 0.05). Conclusions This is the first study to introduce a new optical method to localize epidural space in a porcine model. Epidural space could be identified by the changes in the reflective pattern of light emitted at 650 nm, which were specific for the ligamentum flavum and dural tissue. Real-time optical information successfully guided a modified Tuohy needle into the epidural space.
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Privado, Marcelo Soares, Adriana Machado Issy, Vera Lucia Lanchote, João Batista Santos Garcia e Rioko Kimiko Sakata. "Epidural versus intravenous fentanyl for postoperative analgesia following orthopedic surgery: randomized controlled trial". Sao Paulo Medical Journal 128, n.º 1 (janeiro de 2010): 5–9. http://dx.doi.org/10.1590/s1516-31802010000100002.
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CONTEXT AND OBJECTIVE: Controversy exists regarding the site of action of fentanyl after epidural injection. The objective of this investigation was to compare the efficacy of epidural and intravenous fentanyl for orthopedic surgery. DESIGN AND SETTING: A randomized double-blind study was performed in Hospital São Paulo. METHODS: During the postoperative period, in the presence of pain, 29 patients were divided into two groups: group 1 (n = 14) received 100 µg of fentanyl epidurally and 2 ml of saline intravenously; group 2 (n = 15) received 5 ml of saline epidurally and 100 µg of fentanyl intravenously. The analgesic supplementation consisted of 40 mg of tenoxicam intravenously and, if necessary, 5 ml of 0.25% bupivacaine epidurally. Pain intensity was evaluated on a numerical scale and plasma concentrations of fentanyl were measured simultaneously. RESULTS: The percentage of patients who required supplementary analgesia with tenoxicam was lower in group 1 (71.4%) than in group 2 (100%): 95% confidence interval (CI) = 0.001-0.4360 (P = 0.001, Fisher's exact test; relative risk, RR = 0.07). Epidural bupivacaine supplementation was also lower in group 1 (14.3%) than in group 2 (53.3%): 95% CI = 0.06-1.05 (P = 0.03, Fisher's exact test; RR = 0.26). There was no difference in pain intensity on the numerical scale. Mean fentanyl plasma concentrations were similar in the two groups. CONCLUSION: Intravenous and epidural fentanyl appear to have similar efficacy for reducing pain according to the numerical scale, but supplementary analgesia was needed less frequently when epidural fentanyl was used. CLINICAL TRIAL REGISTRATION NUMBER: NCT00635986
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Higuchi, Hideyuki, Yushi Adachi e Tomiei Kazama. "Factors Affecting the Spread and Duration of Epidural Anesthesia with Ropivacaine". Anesthesiology 101, n.º 2 (1 de agosto de 2004): 451–60. http://dx.doi.org/10.1097/00000542-200408000-00027.
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Background Epidural anesthesia has an unpredictable extent and duration. Differences in the surface area of the lumbosacral dura, epidural fat volume, and epidural venous plexus velocity might explain the variability in the extent and duration of epidural anesthesia with ropivacaine. Methods Twenty-six healthy patients, aged 18-45 y, undergoing peripheral orthopedic surgery were enrolled. Dural surface area and posterior epidural fat volume were calculated from low thoracic, lumbar, and sacral axial magnetic resonance images obtained at 8-mm increments. Epidural venous plexus velocity at the L3-L4 disk level was derived from phase-contrast magnetic resonance images. The patients received 100 mg ropivacaine (1.0%) epidurally. The spread and duration of sensory anesthesia was assessed by pinprick, and that of motor block was assessed using a modified Bromage scale. Statistical correlation coefficients (rho) between magnetic resonance imaging and epidural anesthesia measurements were assessed by Spearman rank correlation. Stepwise multiple linear regression models were used to select important predictors of measures of epidural anesthesia. Results Dural surface area correlated with peak sensory block level (rho= -0.73, P = 0.0003) and onset time of caudal and cephalad block (rho = 0.62, P = 0.002; rho = -0.63, P = 0.002). Fat volume correlated with the regression to L5-S3 (rho = -0.44.44 to -0.54, P = 0.029 to 0.007). Epidural venous plexus velocity was significantly correlated with the regression to L3 (rho = -0.42, P = 0.038) and L4 (rho = -0.48, P = 0.017). Multiple regression analysis revealed that dural surface area was a significant predictive variable for the peak sensory block level (R = 0.61, P < 0.0001). Conclusions These findings indicate that dural surface area influences the spread of epidural anesthesia with ropivacaine and posterior fat volume influences the duration of epidural anesthesia in healthy patients within a narrow age range. Epidural venous plexus velocity might also influence the duration of epidural anesthesia with ropivacaine.
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Nguyen, Lam D., Anh D. Nguyen, Michaela K. Farber, Chi T. Phan, Luong T. Khuat, Ha T. Nguyen, Tuan M. Dang e Ha T. Ngoc Doan. "Sociodemographic Factors Associated with Request for Labor Epidural Analgesia in a Tertiary Obstetric Hospital in Vietnam". BioMed Research International 2021 (30 de janeiro de 2021): 1–5. http://dx.doi.org/10.1155/2021/8843390.
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This study is aimed at examining the sociodemographic factors associated with the utilization of labor epidural analgesia at a large obstetric and gynecology hospital in Vietnam. This was a cross-sectional study of women who underwent vaginal delivery in September 2018 at the Hanoi Obstetrics and Gynecology Hospital. The utilization of epidural analgesia during labor was determined. Univariate and multivariate regression models were applied to evaluate the association between patient demographic and socioeconomic factors and request for labor epidural analgesia. A total of 417 women had vaginal deliveries during the study period. 207 women utilized epidural analgesia for pain relief during labor, and 210 did not. Parturients older than 35 years of age (OR 2.84, 95% CI 1.11-8.17), multiparous women (OR 2.8 95% CI 1.85-4.25), women living from an urban area, women with higher income (OR 6.47, 95% CI 2.59-19.23), and women with higher level of education were more likely to utilize labor epidurals. Factors related to a parturient request for epidural analgesia during labor at our tertiary obstetric hospital included age greater than 35 years, multiparity, and high income and education levels. Educational outreach to women about the benefits of epidural analgesia can target women who do not share these demographic characteristics.
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Potdar, Meenoti P., Ajay Tomar e Laxmi Kamat. "Comparison of Ropivacaine with Fentanyl vs Bupivacaine with Fentanyl for Postoperative Epidural Analgesia in Total Knee Arthroplasty: A Prospective, Randomized, Single-blinded Controlled Study". Journal of Research & Innovation in Anesthesia 2, n.º 2 (2017): 51–57. http://dx.doi.org/10.5005/jp-journals-10049-0033.
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ABSTRACT Aim The primary aim of the study was to compare epidural ropivacaine with fentanyl and epidural bupivacaine with fentanyl for postoperative epidural analgesia after total knee arthroplasty (TKA). The secondary objective was to assess the outcomes of passive and active mobilizations postoperatively, requirement of rescue analgesia, and adverse effects, such as nausea vomiting, sedation, numbness, motor weakness, hypotension, and respiratory depression. Materials and methods After obtaining hospital ethics committee approval and written informed consent, 100 patients were randomly allocated to two groups of 50 each. Group B received 0.125% bupivacaine with fentanyl (2 μg/mL) epidurally for postoperative pain relief. Group R received 0.2% ropivacaine with fentanyl (2 μg/mL) epidurally for postoperative pain relief. Patients of American Society of Anesthesiologists (ASA) grades I to II of both sexes undergoing elective TKA and giving written consent were included in the study. Patients with coagulation disorders, history of spine surgery, vertebral deformities, and having contraindications for spinal analgesia were excluded from the study. All patients were preoperatively assessed and clinically evaluated thoroughly. They received conventional combined spinal epidural anesthesia followed by epidural infusion in the postoperative period of ropivacaine fentanyl or bupivacaine fentanyl as per the allocation. The postoperative epidural analgesia was supplemented with intravenous (IV) paracetamol 1 gm TDS, and rescue analgesia, if needed, was given with IV tramadol 50 mg. All patients were monitored for postoperative pain by the visual analog scale (VAS), requirement of rescue analgesia, hemodynamic parameters, sedation scores, and adverse effects. How to cite this article Potdar MP, Tomar A, Kamat L. Comparison of Ropivacaine with Fentanyl vs Bupivacaine with Fentanyl for Postoperative Epidural Analgesia in Total Knee Arthroplasty: A Prospective, Randomized, Single-blinded Controlled Study. Res Inno in Anesth 2017;2(2):51-57.
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KC, NB, S. Rai, P. Chand, A. Joshi e BR Kunwar. "Combined Spinal Epidural Anesthesia for Total Hip Replacement Surgery in Birendra Army Hospital". Medical Journal of Shree Birendra Hospital 10, n.º 1 (16 de julho de 2012): 32–36. http://dx.doi.org/10.3126/mjsbh.v10i1.6447.
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Introduction: Total Hip Replacement surgery is one of the most commonly performed surgeries worldwide. Epidural anaesthesia have shown decrease incidence of DVT in these patient. Hence, combined spinal epidural spinal anesthesia is now a preferred technique over spinal anesthesia alone. We have been practicing combined spinal epidural anesthesia routienely in total joint replacement, but have not analyzed the result. The aim of this study was to analyse various aspect of combined spinal epidura anesthesia. Methods: thirteen cases of ASA I and II who underwent Total Hip Arthroplasty under combined spinal epidural anesthesia were analysed. First epidural was given in space L2-3/L3-4 and patency was confirmed with test dose with InjXylocaine 2% with Adrenaline 3 ml, followed by Spinal anesthesia one space below with Bupivacaine 0.5% 3 ml. Results: Intra operative Mean Blood Pressure had dropped up to 55 mm of Hg.To maintain Blood pressure, Intravenous Fluid was given in average is 2423.077 ml and Vasopressure drug (Mephenteramine Maleate) was given in average of14.769 mg. Dura was accidentally puncture in one patient during epidural insertion and two epidural failed to provide post operative analgesia. Post operative rehabilitation was easy, one one patient developed DVT after 4 weeks of surgery. Conclusion: Combined epidural analgesia effectively manages postoperative pain, allows early ambulation and reduces the risk of deep vein thrombosis and thromboembolism, Although significant drop of Blood pressure was noted in all cases. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6447 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 32-36
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Manchikanti, Laxmaiah. "Analysis of the Growth of Epidural Injections and Costs in the Medicare Population: A Comparative Evaluation of 1997, 2002, and 2006 Data". Pain Physician 3;13, n.º 3;5 (14 de maio de 2010): 199–212. http://dx.doi.org/10.36076/ppj.2010/13/199.
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Background: Interventional techniques for the treatment of spinal techniques are commonly used and are increasing exponentially. Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in interventional pain management. The current literature regarding the effectiveness of epidural injections is sparse with highly variable outcomes based on the technique, outcome measures, patient selection, and methodology. Multiple reports have illustrated the exponential growth of lumbosacral injections with significant geographic variations in the administration of epidural injections in Medicare patients. However, an analysis of the growth of epidural injections and costs in the Medicare population has not been performed with recent data and has not been looked at from an interventional pain management perspective. Study Design: Analysis of epidural injection growth and costs in Medicare’s population 1997, 2002, and 2006. Objectives: The primary purpose of this study was to evaluate the use of all types of epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and thoracic regions), and other epidural procedures, including epidural adhesiolysis. In addition, the purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications from 1997 to 2006. Methods: The Centers for Medicare and Medicaid Services (CMS) 5% national sample carrier claim record data from 1997, 2002, and 2006 was utilized. Outcomes Assessment: Outcome measures included Medicare beneficiaries’ characteristics receiving epidural injections, epidural injections by place of service, type of specialty, reimbursement characteristics, and other variables. Results: Epidural injections increased significantly in Medicare beneficiaries from 1997 to 2006. Patients receiving epidurals increased by 106.3%; visits per 100,000 population increased 102.7%. Hospital outpatient department (HOPD) payments increased significantly; ASC average payments decreased; overall payments increased. The increase in procedures performed by general physicians outpaced that of interventional pain management (IPM) physicians. Limitations: Study limitations include no Medicare Advantage patients; potential documentation, coding, and billing errors. Conclusions: Epidural injections grew significantly. This growth appears to coincide with chronic low back pain growth and other treatments for low back pain. Since many procedures are performed without fluoroscopy, continued growth and inappropriate provision of services might reduce access. Key words: Epidural injections, interventional techniques, interventional pain management, chronic pain, ambulatory surgery center (ASC), hospital outpatient department (HOPD)
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Watts, R. W. "A Five-Year Prospective Analysis of the Efficacy, Safety and Morbidity of Epidural Anaesthesia Performed by a General Practitioner Anaesthetist in an Isolated Rural Hospital". Anaesthesia and Intensive Care 20, n.º 3 (agosto de 1992): 348–53. http://dx.doi.org/10.1177/0310057x9202000314.
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During a five-year period, 324 epidurals were performed by a general practitioner anaesthetist in an isolated rural hospital. Of these 160 were for obstetric purposes, 72% in primagravida patients, the majority in early and established labour (median cervical dilatation of 3.0 cm). The median epidural insertion time was seven minutes: 80% were free of all complications, there were no dural taps and there was a failure rate of 2%. The median visual analogue pain score (VAPS) was 8.3 prior to insertion and at peak of epidural blockade it was reduced to 0.5. Ten per cent of patients had unblocked segments, half of these were corrected and 90% of patients had even blocks. Despite higher pain scores in the 6–10 cm cervical dilatation group, epidural analgesia was just as effective when compared to the 0.5 cm group. Seventy-seven percent of women interviewed the day after delivery were fully satisfied with the epidural: 19% said it was considerable help, 2% some help and 2% said no help at all. During epidural caesarean section (n = 72), 75% of patients were comfortable, 17% had some discomfort and 7% required general or spinal anaesthesia. The incidence of hypotension (systolic blood pressure < 90 mmHg), was 24.6% with a median ephedrine dose of 10 mg; however, with a greater than 20% drop in systolic blood pressure, the dose of ephedrine required to maintain blood pressure increased in a log-dose fashion. For women who received epidurals in labour, the caesarean section rate was 25%, instrumental vaginal delivery 34% and spontaneous vaginal delivery 41%. There were no adverse neonatal outcomes.
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Grouls, R. J. E., T. F. Meert, H. H. M. Korsten, L. J. Hellebrekers e D. D. Breimer. "Epidural and Intrathecal n-Butyl-p-Aminobenzoate Solution in the Rat". Anesthesiology 86, n.º 1 (1 de janeiro de 1997): 181–87. http://dx.doi.org/10.1097/00000542-199701000-00022.
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Background Epidural administration of an aqueous suspension of n-butyl-p-aminobenzoate (BAB) to humans results in long-lasting sensory blockade without motor block. The dose-response of BAB administered epidurally and intrathecally as a solution was studied in rats to define the local anesthetic properties in an established animal model. Methods The time course of changes in tail withdrawal latency and motor function were determined in rats after epidural or intrathecal administration of solutions of BAB or bupivacaine. The dose-response relation was determined and median effective dose values were calculated. Results After epidural and intrathecal administration of BAB solutions, the onset and duration of the antinociceptive action were comparable to bupivacaine. Median effective dose values for tail-withdrawal latency of 6 s or more were significantly greater for BAB. After both routes of administration, BAB clearly affected motor function. Conclusions When administered epidurally and intrathecally as a solution, BAB is a local anesthetic of relative low potency with onset and duration of action comparable to those of bupivacaine. These findings suggest that the long-lasting action obtained after applying BAB suspension results from the slow dissolution (continuous release) of the solid BAB deposited in the epidural space.
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Kynes, J. Matthew, Matthew S. Shotwell, Camila B. Walters, David P. Bichell, Jason T. Christensen e Stephen R. Hays. "Epidurals for Coarctation Repair in Children Are Associated with Decreased Postoperative Anti-Hypertensive Infusion Requirement as Measured by a Novel Parameter, the Anti-Hypertensive Dosing Index (ADI)". Children 6, n.º 10 (10 de outubro de 2019): 112. http://dx.doi.org/10.3390/children6100112.
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Background: Sympathetically-associated hypertension after coarctation repair is a common problem often requiring anti-hypertensive infusions in an intensive care unit. Epidurals suppress sympathetic output and can reduce blood pressure but have not been studied following coarctation repair in children. We sought to determine whether epidurals for coarctation repair in children were associated with decreased requirement for postoperative anti-hypertensive infusions, if they were associated with changes in hospital course, or with complications. Methods: In this observational retrospective cohort study, we evaluated all patients age 1–18 years undergoing coarctation repair at our institution during a 10-year period and compared the requirement for postoperative anti-hypertensive infusions in patients with and without epidurals using an anti-hypertensive dosing index (ADI) incorporating total dose-hours of all anti-hypertensive infusions (primary outcome). We also assessed intensive care unit (ICU) and hospital length of stay, discharge on oral anti-hypertensive medication, and complications potentially related to epidurals (secondary outcomes). Results: Children undergoing coarctation repair with epidurals had decreased requirements for postoperative anti-hypertensive infusions compared to children without epidurals (cumulative ADI 65.0 [28.5–130.3] v. 157.0 [68.6–214.7], p = 0.021; mean ADI 49.0 [33.3–131.2] v. 163.0 [66.6–209.8], p = 0.01). After multivariable cumulative logit mixed-effects regression analysis, mean ADI was decreased in patients with epidurals throughout the postoperative period (p < 0.001). Patients with epidurals were 1.6 years older and weighed 10.6 kg more than patients without epidurals but were otherwise comparable. Epidural complications included pruritus (three patients), agitation (one patient), somnolence (one patient), and transient orthostatic hypotension (one patient). Duration of intensive care unit admission, duration of hospital stays, and requirement for anti-hypertensive medication at discharge were similar in patients with and without epidurals. Conclusions: This is the first study of children receiving an epidural for surgical repair of aortic coarctation via open thoracotomy. In this small, single-institution, observational retrospective cohort study, epidurals for coarctation repair in children were associated with decreased postoperative anti-hypertensive infusion requirements. Epidurals were not associated with length of ICU or hospital stay, or with discharge on anti-hypertensive medication. No significant epidural complications were noted. Prospective study of larger populations will be necessary to confirm these associations, address causality, verify safety, and assess other effects.
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Samuel C Ojiakor, Afam B Obidike, Kenneth N Okeke, Chioma P Nnamani, Amaka L Obi-Nwosu, Richard O Egeonu, George U Eleje e Chukwuemeka J Ofojebe. "Factors associated with demand for epidural analgesia among women in labor at a tertiary hospital in Nnewi, South-East, NigeriaFactors associated with demand for epidural analgesia among women in labor at a tertiary hospital in Nnewi, South-East, Nigeria". Magna Scientia Advanced Research and Reviews 2, n.º 1 (30 de maio de 2021): 08–013. http://dx.doi.org/10.30574/msarr.2021.2.1.0028.
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Background: Epidural labor analgesia has become prevalent in high income countries, but its use in low and middle income countries such as Nigeria is poorly studied. Objectives: To determine the rate of demand, indications, post-dural puncture headache rate and factors affecting demand for epidural analgesia among women in labor. Method: This was a across sectional analytical study of women in labor who were managed at Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria from 1st January 2017 to 31st December 2017. Data was obtained from women’s case files from Medical record department, labor ward, and Anesthesiology departmental records. Information obtained included total number of deliveries, mode of delivery, those that received epidural: date and time of placement, indication and number of side effects. Univariate analysis models were applied to evaluate the association between patient demographic, socioeconomic factors, clinical and demand for labor epidural analgesia. A p-value of <0.05 was taken as significant. Results: Thirty-six women out of 1,373 women received epidural labor analgesia, giving the epidural labor analgesic rate of 2.6%. The most common indication for epidural labor analgesia was maternal voluntary request which accounted for 24 (66.7%) of the population receiving analgesia. One (2.8%) parturient developed post-dural puncture headache which resolved spontaneously within 24 hours. Parturient who utilized labor epidurals were significantly older than 30 years of age (OR 3.16; 95% CI 1.51-6.62; p=0.002), Multi-parous (OR 26.65; 95% CI 3.64-100.00; p=0.001), and with higher income (OR 9.02; 95% CI 4.38-18.57; p=<0.001), but not with higher level of education (OR 0.56; 95% CI 0.27-1.16; p=0.114). Conclusion: The demand for labor epidural in the study center was low with a demand rate of 2.6% and post-dural puncture headache rate of 2.8%. The significant factors related to a parturient’s request for epidural analgesia during labor included age greater than 30 years, multiparity and higher income. There is a need for an enhanced awareness programs on obstetrics epidural analgesia.
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Debon, Richard, Dominique Chassard, Frédéric Duflo, Emmanuel Boselli, Boris Bryssine e Bernard Allaouchiche. "Chronobiology of Epidural Ropivacaine". Anesthesiology 96, n.º 3 (1 de março de 2002): 542–45. http://dx.doi.org/10.1097/00000542-200203000-00006.
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Background A temporal pattern of the kinetics of local anesthetics is demonstrated in dental and skin anesthesia, with an important variation in the duration of action related to the hour of administration. The aim of this study is to determine whether the hour of injection influences the duration of epidurally administered ropivacaine during labor. Methods One hundred ninety-four women in the first stage of labor were assigned to one of four groups throughout the day period: group 1 (night: from 1:01 to 7:00 am), group 2 (morning: from 7:01 am to 1:00 pm), group 3 (afternoon: from 1:01 to 7:00 pm), and group 4 (evening: from 7:01 pm to 1:00 am). Each patient received 14 ml ropivacaine, 0.17%, epidurally, and analgesia duration was measured. Results Pain assessed by a visual analog score was not differ-ent among groups before the first injection of local anesthetic. Analgesia duration was greater in the diurnal period (group 2: 110 +/- 25 min and group 3: 117 +/- 23 min) compared with the nocturnal period (group 1: 94 +/- 23 min and group 4: 91 +/- 23 min) (P < 0.01). The largest intraday variation of analgesia duration among groups reached 28%. Conclusions Epidural analgesia duration exhibits a temporal pattern with important differences among diurnal and nocturnal phases. The authors emphasize that the lack of consideration of the chronobiologic conditions in epidural analgesia studies may create significant statistical bias. Future studies dealing with epidural local anesthetics should consider the time of drug administration.
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Vialle, Emiliano, Luiz Roberto Vialle e Guillermo Holtmann. "Abcesso epidural pós-traumático". Acta Ortopédica Brasileira 16, n.º 5 (2008): 311–13. http://dx.doi.org/10.1590/s1413-78522008000500012.
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Abcessos epidurais são formas incomuns de infecção na coluna, com complicações graves em decorência de seu difícil diagnóstico e tratamento. Apesar dos avanços em métodos diagnósticos e de tratamento medicamentoso e cirúrgico, a taxa de mortalidade encontrada na literatura varia de 5 a 32%. Os autores apresentam um caso de fratura de coluna torácica, que evoluiu com abcesso epidural, num paciente portador de espondilite anquilosante. Houve déficit neurológico rapidamente progressivo, que regrediu após descompressão de emergência e fixação cirúrgica da fratura. Apesar do curso longo de antibioticoterapia, houve recidiva da infecção, só controlada após remoção do material de síntese. Em casos de fratura de coluna em pacientes imunocomprometidos, a hipótese de abcesso epidural, quando houver dor de difícil controle ou déficit neurológico progressivo, deve ser lembrada.
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Pereira, Carlos Umberto, João Domingos Barbosa Carneiro Leão, Antonio Ribas, Egmond Alves Silva Santos, João Tiago Silva Monteiro e Gustavo Cabral Duarte. "Frontal Epidural Haematoma". JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA 15, n.º 1 (15 de janeiro de 2018): 18–21. http://dx.doi.org/10.22290/jbnc.v15i1.471.
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Background: The epidural haematoma is the most important space-occupying lesion due to head injury with high index of mortality and morbidity when the correct management is not done. Frontal epidural haematoma are considered rare lesions, representing about 10% of the whole epidural haematomas. They are usually unilateral and may present with subacute and chronic evolution in 40% of the cases. Objective: To study thirty cases of frontal epidural haematoma andanalyze the causes, clinical findings, evolution, and outcome. Patients and Methods: Thirty patients presenting with frontal epidure hematomas were retrospectively reviewed. The age ranged from 10 to 32 years old, with a mean of 18 years-old. Main causes were traffic accidents and falls. Results: In therewere 24 male patients and six female cases the haematoma was bilateral. Acute collection occurred in 19 cases, subacute in 5 and chronic in 6 of them. The most important clinical findings were headaches, vomiting and seizures. Skull x-raysdetected fracture in 18 cases and computed tomography was positive in demonstrating the haematoma. In all surgery cases was carried out in 28 patients and two cases had been submitted to conservative treatment. Two patients died in consequence of associated intracerebral and extracerebral lesions. Conclusions: 1) usually frontal epidural haematomas are more frequent in young adults; 2) its evolution is slow, usually subacute or chronic, in the majority of the cases; 3) its clinical findings course with few neurological symptoms and 4) the prognosis is good, except in those cases with multiple intracranial lesions or systemic injury.
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Pedachenko, Eugene G., Mykhaylo V. Khyzhnyak, Olena P. Krasylenko, Yuriy E. Pedachenko, Olexandr F. Tanaseychuk, Volodymyr A. Kramarenko, Andriy M. Furman e Oksana V. Zemskova. "The comparative analysis of MRI data in the early period after lumbar microdiscectomies with epidural injection of polyacrylamide hydrogel". Ukrainian Neurosurgical Journal 27, n.º 2 (27 de junho de 2021): 16–24. http://dx.doi.org/10.25305/unj.223481.
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Objective: To perform a comparative analysis of MRI data obtained in the early postoperative period after repeated lumbar microdiscectomies in patients with and without epidural injection of “Nubiplant” polyacrylamide hydrogel (HG). Material and methods: The MRI data of the lumbar spine in the early postoperative period after repeated removal of herniated disc (on the 3-15th day) in 84 (100%) patients were analyzed: 30 (35,7%) patients were injected intraoperatively epidurally with “Nubiplant” HG to prevent epidural fibrosis (main group (MG) and in 54 (64,3%) patients the HG was not injected (control group (CG). Results: Comparative analysis of MRI data on the 3-15th day after surgery showed that the frequency of epidural edema and hemorrhage signs within the postoperative area in the MG was significantly lower as compared to the CG (p = 0,0444 and p = 0,0288 respectively). To assess the accuracy of the epidural administration of an artificial biopolymer Nubiplant during lumbar microdiscectomy, in the early postoperative period the following MRI criteria could be helpful: i) absence of the dural sac deformation and dislocations of the spinal root; ii) well-defined margin of the adjacent spinal root; iii) homogeneous MRI signals of the Nubiplant zone; iv) absence of Nubiplant areas outside the postoperative area; v) sufficient sectoral coverage of the adjacent root with epidurally administered Nubiplant (optimally >1800). Nubiplant” HG in the patients of the MG was evaluated, and MRI criteria for assessing the correctness of its introduction were proposed. Conclusions: In the early period after repeated lumbar microdiscectomies (on the 3-15th day), intraoperative epidural injection of “Nubiplant” HG was accompanied by a significant decrease of epidural edema and hemorrhage signs within the postoperative area. The proposed criteria of correctness of HG “Nubiplant” introduction allow unifying the approaches in radiological assessment of this patients.
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Kim, Se Hee, e Sang Sik Choi. "Epidural neuroplasty/epidural adhesiolysis". Anesthesia and Pain Medicine 11, n.º 1 (31 de janeiro de 2016): 14–22. http://dx.doi.org/10.17085/apm.2016.11.1.14.
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Kallidaikurichi Srinivasan, Karthikeyan, Anthony Gallagher, Niall O’Brien, Vinod Sudir, Nick Barrett, Raymund O’Connor, Francesca Holt, Peter Lee, Brian O’Donnell e George Shorten. "Proficiency-based progression training: an ‘end to end’ model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study". BMJ Open 8, n.º 10 (outubro de 2018): e020099. http://dx.doi.org/10.1136/bmjopen-2017-020099.
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BackgroundTraining procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training.MethodsDetailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate.ResultsA total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04).ConclusionProcedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.Trial registration numberNCT02179879.NCT02185079; Post-results.
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Calderón Lozano, Marjorie Lisseth, Renato Moreno Gonzales, Dante Segura Pinedo, Gunther Vásquez Rojas e Anibal Arenas Velásquez. "Bolos epidurales intermitentes programados para mantenimiento de la analgesia del trabajo de parto: Estudio observacional, analítico de tipo cohorte". Revista Peruana de Investigación Materno Perinatal 9, n.º 3 (2 de dezembro de 2020): 28–34. http://dx.doi.org/10.33421/inmp.2020194.
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Objetivo: Evaluar la asociación entre analgesia epidural mantenida mediante Bolos epidurales intermitentes programados (BEIP) y las complicaciones materno-perinatales. Materiales y Métodos: Estudio de tipo Cohorte en gestantes entre 18 y 35 años, en trabajo de parto con dilatación cervical de 4 centímetros o más, agrupadas en dos cohortes según administración o no de analgesia epidural: En las gestantes del Grupo A, se administró analgesia epidural en bolo, con mantenimiento mediante BEIP con bupivacaína 0.0625% y fentanilo 25 ug en 10cc cada 60 minutos; en las gestantes del grupo B, no se administró analgesia epidural. Resultados: La duración del periodo de dilatación y expulsivo fue mayor en el grupo que recibió analgesia epidural de (532.91 ± 254 minutos) y de (429.19 ± 311 minutos) en el que no recibió; el tiempo del periodo expulsivo fue (16.97 ± 16 minutos) y (11.76 ± 10 minutos) en el grupo B, (p < 0.05); menor incidencia de desgarros perineales de primer grado en el grupo que recibió analgesia (16.12 % VS 25.35%; p=0.014). No se encontraron diferencias en la vía de culminación del parto, puntuación de APGAR, necesidad de reanimación neonatal e ingreso a Unidad de cuidados intensivos neonatales (UCIN). Conclusiones: Las gestantes que recibieron analgesia epidural mediante BEIP tuvieron una mayor duración del periodo de dilatación y del expulsivo, menor incidencia de desgarros perineales, sin incrementar la morbilidad neonatal.
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Banerjee, Swarna, e Shaswat Kumar Pattnaik. "A COMPARITIVE STUDY BETWEEN EPIDURAL BUTORPHANOL, NALBUPHINE AND FENTANYL FOR POSTOPERATIVE ANALGESIA IN LOWER ABDOMINAL SURGERIES". Asian Journal of Pharmaceutical and Clinical Research 10, n.º 5 (1 de maio de 2017): 383. http://dx.doi.org/10.22159/ajpcr.2017.v10i5.16802.
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Background: Achieving satisfactory post-operative analgesia with neuraxial administration of narcotics has been the subject of much research. The use of epidural opioids had become an increasingly popular technique for management of acute post-operative pain in recent times. This study evaluates post-operative analgesic benefits in patients administered epidural butorphanol, nalbuphine, and fentanyl as adjuvants with local anesthetics postoperatively for surgery under epidural anesthesia.Methods: A total of 75 patients belonging to age groups 18-60 years who were scheduled for surgeries of lower abdomen were randomly divided into groups of 25 each. Epidural technique was adopted for surgery of the lower abdomen for all patients with 0.5% bupivacaine. In the post-operative period, the study drug was given through epidural catheter. Group A received butorphanol 2 mg, Group B received fentanyl 100 μg, and Group C received nalbuphine 10 mg with 0.125% bupivacaine diluted to 10 ml in normal saline each. Onset, duration, quality of analgesia, hemodynamic changes, and side effects – such as sedation, pruritus, nausea, vomiting, respiratory depression, and urinary retention - were recorded and compared.Results: The demographic data were comparable in all three groups. The onset of sensory block was significantly earlier in Group B (fentanyl) than other two groups. Duration was significantly longer in Group A (butorphanol). No serious cardiorespiratory side effects were noted in any of groups.Conclusion: Fentanyl produces the faster onset of analgesia with adverse effects like pruritus. Butorphanol administered epidurally has the advantage of longer duration of analgesia than fentanyl or epidural nalbuphine with side effects such as nausea, vomiting, and sedation.Keywords: Epidural analgesia, Butorphanol, Fentanyl, Nalbuphine.
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Manchikanti, Laxmaiah. "Lumbar Interlaminar Epidural Injections Are Superior to Caudal Epidural Injections in Managing Lumbar Central Spinal Stenosis". Pain Physician 6;17, n.º 6;12 (14 de dezembro de 2014): E691—E672. http://dx.doi.org/10.36076/ppj.2014/17/e691.
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Background: Epidural injections are performed to manage lumbar central spinal stenosis pain utilizing caudal, interlaminar, and transforaminal approaches. The literature on the efficacy of epidural injections in managing lumbar central spinal stenosis pain is sparse; lacking multiple, high quality randomized trials with long-term follow-up. Methods: Two randomized controlled trials of the caudal and lumbar interlaminar approaches that assessed 220 patients with lumbar central spinal stenosis were analyzed. Results: The analysis found efficacy for both caudal and interlaminar approaches in managing chronic pain and disability from central spinal stenosis was demonstrated. In the patients responsive to treatment, those with at least 3 weeks of improvement with the first 2 procedures, 51% reported significant improvement with caudal epidural injections, whereas it was 84% with local anesthetic only with interlaminar epidurals, 57% with caudal and 83% with lumbar interlaminar with local anesthetic with steroid. The response rate was 38% with caudal and 72% with lumbar interlaminar with local anesthetic only and 44% with caudal and 73% with lumbar interlaminar with local anesthetic with steroid when all patients were considered. In the interlaminar approach, results were superior for pain relief and functional status with fewer nonresponsive patients compared to the caudal approach. Limitations: The data was derived from 2 previously published randomized, controlled trials rather than comparing 2 techniques in one randomized controlled trial. Further, the randomized controlled trials were active control trials without a placebo. Conclusions: The results of this assessment showed significant improvement in patients suffering with chronic lumbar spinal stenosis with caudal and interlaminar epidural approaches with local anesthetic only, or with steroids in a long-term followup of up to 2 years, in contemporary interventional pain management setting, with the interlaminar approach providing significantly better results. Key Words: Caudal epidural, lumbar interlaminar, transforaminal epidural, steroids, local anesthetic, central spinal stenosis, radiculitis
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Ladha, Karim S., Elisabetta Patorno, Jun Liu e Brian T. Bateman. "Impact of Perioperative Epidural Placement on Postdischarge Opioid Use in Patients Undergoing Abdominal Surgery". Anesthesiology 124, n.º 2 (1 de fevereiro de 2016): 396–403. http://dx.doi.org/10.1097/aln.0000000000000952.
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Abstract Background Opioids play a crucial role in providing analgesia throughout the perioperative period; however, patients may become persistent users of these medications months after surgery. Epidurals have been posited to prevent the development of persistent pain, but there are little data on the effect of epidurals on persistent opioid use. Methods This study was conducted using a claims database of a large, nationwide commercial health insurer. Opioid-naive patients who underwent open abdominal surgery from January 2004 to December 2013 were included in the study. Propensity scores for epidural placement were calculated accounting for demographic characteristics, resource utilization, and comorbid conditions (including medical, psychiatric, and pain conditions). Time-to-event analysis was used with the primary outcome defined as 30 days without filling an opioid prescription after discharge. In addition, total morphine equivalents dispensed within 90 days of discharge were also calculated for each patient. Results A total of 6,432 patients were included in the final propensity score–matched cohort. The Cox proportional hazards ratio was 0.96 (95% CI, 0.91 to 1.01; P = 0.0910) for the relation between epidural placement and time till a 30-day gap without filling an opioid prescription. There was no difference in the total morphine equivalents dispensed within 90 days of discharge between the groups (P = 0.7670). Conclusions Epidural placement was not protective against persistent opioid use in a large cohort of opioid-naive patients undergoing abdominal surgery. This finding does not detract from the other potential benefits of epidural placement. More research is needed to understand the mechanism of persistent opioid use after surgery and its prevention.
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Lee, Min Soo, e Ho Sik Moon. "Safety of epidural steroids: a review". Anesthesia and Pain Medicine 16, n.º 1 (31 de janeiro de 2021): 16–27. http://dx.doi.org/10.17085/apm.21002.
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Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.
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Hlinecká, Kristýna, Tereza Bartošová e Jan Bláha. "Epidural fever". Česká gynekologie 86, n.º 5 (22 de outubro de 2021): 355–61. http://dx.doi.org/10.48095/cccg2021355.
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Epidural analgesia (EPA) is the most eff ective method of intrapartum pain relief and is considered to be very safe. Recently, it has been used in up to 34% of parturients with EPA and is also associated with maternal temperature elevations during labor. The mechanism of this epidural-associated fever remains incompletely understood. The most likely etiology seems to be non-infectious infl ammation caused by an epidural catheter. However, some authors deny this association. They theorize it is caused by selection bias only, as EPA is more often required by women with more painful and prolonged or more complicated labor, where temperature elevation is due to other causes. They point out that in some studies, fever was correlated to EPA only with concurrent placental infl ammation. Maternal fever, despite the cause, either infectious or non-infectious origin, carries important clinical and public health implications. Further research that evaluates maternal epidural status and its infl uence on maternal or neonatal fever could improve sepsis evaluation and lead to worldwide decrease of unnecessary antibio tic exposure. Key words: epidural fever – epidural analgesia – thermoregulation
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Tsueda, Kentaro, Phillip J. Mosca, Michael F. Heine, Gary E. Loyd, Deirdre A. E. Durkis, Arthur L. Malkani e Harrell E. Hurst. "Mood during Epidural Patient-controlled Analgesia with Morphine or Fentanyl". Anesthesiology 88, n.º 4 (1 de abril de 1998): 885–91. http://dx.doi.org/10.1097/00000542-199804000-00006.
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Background Mood states during epidural opioids are not known. The authors studied the change in mood during the 48-h period of epidural morphine and epidural fentanyl in 47 patients after elective hip or knee joint arthroplasty. Methods An epidural catheter was inserted at the L2-L3 or L3-L4 interspace. Anesthesia was induced with thiopenthal and maintained with isoflurane and nitrous oxide. One hour before the conclusion of the operation, patients received an epidural bolus injection of 2 mg morphine (n = 23) or 100 microg fentanyl (n = 24), followed by the same opiate (125 microg/ml morphine or 25 microg/ml fentanyl) epidurally delivered by a patient-controlled analgesia (PCA) pump in the postoperative period for 48 h. Mood was assessed using the bipolar form of the Profile of Mood States before operation and 24 h, 48 h, and 72 h after operation. Results There was no significant difference in pain intensity between the groups during epidural PCA. Mood states became more positive over time in the patients who received morphine (P < 0.01 at 48 h) and negative in those who were given fentanyl (P < 0.01 at 24 and 48 h, respectively) compared with those before the operation, and they were more positive in the morphine than in the fentanyl group at 24 h, 48 h (P < 0.05), and 72 h (P < 0.01). Patients in the morphine group were more composed, agreeable, elated, confident, energetic, and clearheaded than were those in the fentanyl group (P < 0.05). There was no correlation between mood scores and pain scores in either group. There was an inverse correlation at 48 h between mood scores and plasma fentanyl concentrations (r = -0.58, P < 0.05). Conclusion Mood states are significantly more positive during epidural morphine PCA than they are during epidural fentanyl PCA.
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Togioka, Brandon M., Katherine M. Seligman, Megan K. Werntz, N. David Yanez, Lorna M. Noles e Miriam M. Treggiari. "Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries". Anesthesiology 131, n.º 4 (1 de outubro de 2019): 840–49. http://dx.doi.org/10.1097/aln.0000000000002868.
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Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. This may represent a healthcare disparity related to a language barrier and inadequate opportunities for labor analgesia education. It was hypothesized that a language-concordant, educational program regarding labor epidurals would improve epidural utilization in two independent cohorts of Hispanic and non-Hispanic women. Methods A randomized controlled trial, blinded to anesthesia, nursing, and obstetric providers, was completed at an academic hospital (February 2015 to February 2017). Two cohorts of Medicaid beneficiaries of Hispanic (English- and/or Spanish-speaking) and non-Hispanic ethnicity were enrolled concurrently. The patients were randomized to routine care alone or routine care and an additional educational program comprised of three components: a video show, corresponding pamphlet, and in-person counseling. The primary endpoint was use of epidural labor analgesia. The secondary endpoint was change in response before and after delivery on common misconceptions based on a 12-point epidural questionnaire. Results Hispanic women randomized to the intervention group were 33% more likely to choose epidural analgesia compared to the routine care group (40 of 50 [80%] vs. 30 of 50 [60%]; risk ratio, 1.33 [95% CI, 1.02 to 1.74]; P = 0.029). For the non-Hispanic cohort, no difference was detected in epidural use between the intervention and routine care groups (41 of 50 [82%] vs. 42 of 49 [86%]; risk ratio, 0.96 [95% CI, 0.80 to 1.14]; P = 0.62), but the study was underpowered to determine a result of no difference. Patients assigned to the intervention had a greater improvement in epidural understanding compared with routine care, among both Hispanic (2.26 vs. 0.74, respectively; difference in change from baseline, 1.52 [95% CI, 0.77 to 2.27]; P < 0.001) and non-Hispanic (1.36 vs. 0.33, respectively; difference in change from baseline, 1.03 [95% CI, 0.23 to 1.75]; P = 0.005) cohorts. There were no adverse events during the trial. Conclusions The educational program increased epidural use among Hispanic women. The educational program reduced misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic cohorts.
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Abdi, Salahadin. "Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review". Pain Physician 1;10, n.º 1;1 (14 de janeiro de 2007): 185–212. http://dx.doi.org/10.36076/ppj.2007/10/185.
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Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing spinal pain. Objective: To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain. Key words: Spinal pain, low back pain, cervicalgia, epidural steroids, interlaminar, caudal, transforaminal, radiculopathy, axial pain, postlaminectomy syndrome, failed back surgery syndrome.
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Ukolov, Konstantin Yur'evich, V. L. Ayzenberg, N. I. Arzhakova, K. Yu Ukolov, V. L. Aizenberg e N. I. Arzhakova. "First Experience in Application of Intraoperative Epidural Morphine Analgesia with Postoperative Ropivacaine Anesthesia in Children with III-IV Degree Scoliotic Deformity". N.N. Priorov Journal of Traumatology and Orthopedics 17, n.º 3 (15 de setembro de 2010): 63–67. http://dx.doi.org/10.17816/vto201017363-67.
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First experience in aplication of intraoperative epidural morphine analgesia with postoperative ropivacaine anesthesia at correction of III-IV degree scoliotic deformity in children (25 patients) is presented. It is shown that epidural morphine analgesia on lumbar level as a component of combined anesthesia provides an adequate analgesia in during operation and creates an analgesic background for postoperative anesthesia with local anesthetics. Intraoperative high catheterization of epidural space by the proposed technique enables to avoid neurologic complications and provides the possibility of effective postoperative anesthesia with ropivacaine infusion within 3 days on the background of prolonged action of epidurally injected morphine. First xperience in application of the suggested technique shows that it is effective enough and helps this group of patients to endure an invasive operation with greater comfort.
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Виноградов, V. Vinogradov, Густоварова, T. Gustovarova, Боженков, K. Bozhenkov, Иванян e A. Ivanyan. "The Effective and Safety Use of the Epidural Analgesia at Vaginal Delivery in the Women with the Uterine Scar". Journal of New Medical Technologies 22, n.º 1 (11 de fevereiro de 2015): 50–56. http://dx.doi.org/10.12737/9077.
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The frequency of the Cesarean section leads to increase number of the patients with the scar on the uterus. In the Clinical hospital № 1 (Smolensk, Russia) the childbirth is carried out through natural birth canal on the women having a reliable scar on the uterus. The analysis of the vaginal delivery and labour outcomes in 69 patients with the scar on the uterus is carried out. The childbirth in 38 patients was conducted with the epidurals, in 31 patients – without this type of anesthesia. The efficiency and safety of the epidural anesthesia are shown. The obtained results confirm that the epidural anesthesia doesn´t complicate the labour, doesn´t increase the hospitalization term, doesn´t influence the bleeding and negative effects on the fetus condition and the newborn assessment according to Apgar score. The possibility of using epidural anesthesia at childbirth on the women with uterine scar during the dystocia is shown.