Anaesthetic Management of Non Traumatic Diaphragmatic Hernia as a Co-existing Disease: Combined Spinal Epidural to Rescue

Diaphragmatic hernia is a congenital or acquired defect in diaphragm, resulting in herniation of abdominal viscera into thoracic cavity. Acquired diaphragmatic hernia are seen mostly in patients with blunt or penetrating abdominal injuries. Nontraumatic acquired diaphragmatic hernias have been reported in literature but are extremely rare. Anaesthetic management of a patient presenting with nontraumatic diaphragmatic hernia as a co-existing disease offer unique challenges and considerations. This report was about the successful anaesthetic management of a 66-years-old male. He had Osteoarthritis (OA) of left knee with long standing massive right diaphragmatic hernia as a co-existing disease. He was scheduled for left Total Knee Replacement (TKR). Combined Spinal Epidural (CSE) with low dose Subarachnoid Block (SAB) was the anaesthetic technique of choice. Femoral sciatic block is an alternate technique of anaesthesia for such patients.

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Postural Stability following Ambulatory Regional Analgesia for Labor

Anesthesiology ◽

10.1097/00000542-200212000-00033 ◽

2002 ◽

Vol 97 (6) ◽

pp. 1576-1581 ◽

Cited By ~ 21

Author(s):

Jeremy Davies ◽

Roshan Fernando ◽

Andrew McLeod ◽

Sonia Verma ◽

Philip Found

Keyword(s):

Epidural Analgesia ◽

Low Dose ◽

Sitting Position ◽

Balance Function ◽

Regional Analgesia ◽

Spinal Injection ◽

Real Time Analysis ◽

Combined Spinal Epidural ◽

Standing Up ◽

Spinal Epidural

Background The safety of mobilization following low-dose regional analgesia in parturients remains controversial. Previous studies have demonstrated preserved balance function despite clinically elicited sensory deficits. The aim of this study was to use the Balance Master 6.1, a device capable of real-time analysis of ambulation, to score the performance of basic maneuvers following initiation of low-dose combined spinal-epidural analgesia in laboring women compared with pregnant and nonpregnant controls. Methods Using the Balance Master, balance function during the performance of several simple tasks, including walking and standing up from a sitting position, was evaluated in a prospective, controlled, observational study with 50 laboring women after combined spinal-epidural analgesia compared with 50 pregnant and 50 nonpregnant controls. Results Nonpregnant women scored significantly better results in 6 of the 13 measured balance function parameters compared with both the combined spinal-epidural and pregnant control groups. Compared with the nonpregnant subjects, the pregnant groups generated less force standing up from the sitting position (P < 0.0001), walked more slowly (P = 0.0067), and took shorter steps (P < 0.0001). They also took longer to step up onto and over a 20-cm-high obstacle (P < 0.0001), and they generated less force while stepping up. Initial spinal analgesia in laboring women did not significantly affect performance in comparison to the pregnant controls. Thirty-four percent of women in the combined spinal-epidural group required supplemental epidural analgesia following the initial spinal injection (n = 17) before testing; they had significantly impaired balance function in four tests compared with those receiving a spinal injection only (n = 33). Conclusions Being pregnant at term significantly affects balance function, although initial low-dose spinal-epidural analgesia does not impair function further. Subsequent supplemental epidural analgesia may have a detrimental effect on balance, but properly designed studies are awaited to confirm this. This study supports the practice of allowing laboring women with initial low-dose spinal-epidural analgesia to ambulate, but indicates that further studies need to be conducted on the effects of subsequent epidural supplementation.

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Low-dose Combined Spinal-Epidural Anesthesia for Cesarean Section in a Patient With Eisenmenger Syndrome

Obstetric Anesthesia Digest ◽

10.1097/01.aoa.0000358441.97830.4c ◽

2009 ◽

Vol 29 (3) ◽

pp. 165-166

Author(s):

M. Parneix ◽

L. Fanou ◽

E. Morau ◽

P. Colson

Keyword(s):

Cesarean Section ◽

Epidural Anesthesia ◽

Low Dose ◽

Eisenmenger Syndrome ◽

Combined Spinal Epidural ◽

Combined Spinal Epidural Anesthesia ◽

Spinal Epidural

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Ultra-Low Dose Combined Spinal-Epidural Anesthesia with Intrathecal Bupivacaine 3.75 mg for Cesarean Delivery: A Randomized Controlled Trial

Obstetric Anesthesia Digest ◽

10.1097/01.aoa.0000288308.34263.ba ◽

2007 ◽

Vol 27 (3) ◽

pp. 166

Author(s):

&NA;

Keyword(s):

Randomized Controlled Trial ◽

Cesarean Delivery ◽

Epidural Anesthesia ◽

Low Dose ◽

Controlled Trial ◽

Randomized Controlled ◽

Combined Spinal Epidural ◽

Combined Spinal Epidural Anesthesia ◽

Spinal Epidural

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Effect of Combined Spinal-Epidural Ambulatory Labor Analgesia on Balance

Anesthesiology ◽

10.1097/00000542-199908000-00018 ◽

1999 ◽

Vol 91 (2) ◽

pp. 436-441 ◽

Cited By ~ 26

Author(s):

Anthony E. Pickering ◽

Martin G. Parry ◽

Basil Ousta ◽

Roshan Fernando

Keyword(s):

Epidural Analgesia ◽

Pregnant Women ◽

Low Dose ◽

Sensory Loss ◽

Balance Function ◽

Regional Analgesia ◽

Dynamic Posturography ◽

Computerized Dynamic Posturography ◽

Combined Spinal Epidural ◽

Spinal Epidural

Background Low-dose combined spinal-epidural analgesia in labor has proved popular with women because lower-limb motor power is preserved, allowing ambulation. However, there has been debate about the safety of allowing women to walk following low-dose regional analgesia because of somatosensory impairment. The authors undertook a prospective controlled observational study using computerized dynamic posturography to examine balance function in pregnant women after combined spinal-epidural analgesia. Methods The authors performed posturographic testing on 44 women in labor after institution of regional analgesia and compared them with a control group of 44 pregnant women. A separate group of six women were tested both before and after combined spinal-epidural analgesia. Results Neurologic examination after regional analgesia showed two parturients (4%) to have motor weakness (excluded from posturography). Four women (9%) had clinical dorsal column sensory loss; these women all completed posturography. The spinal-epidural analgesia group showed a small, statistically significant reduction in one of six posturographic sensory-organization tests; however, this difference was functionally minor. There were no other differences in posturography between the control and spinal-epidural groups. Similar results were found in the paired study, in which there was minimal change in balance function after spinal-epidural analgesia. Conclusions This is the first study to objectively examine the effect of spinal-epidural analgesia on balance function. Using computerized dynamic posturography, the authors were unable to find any functional impairment of balance function after spinal-epidural ambulatory analgesia in women in labor who had no clinical evidence of motor block.

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