Development and Validation of a Predictive Score and Application of Ultrasound for Difficult Caudal Epidural Blockade in Adult Patients：A Prospective Study

Background: We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verify the role of ultrasound in difficult caudal epidural blockade(CEB).Methods: This study consisted of three phases. First, we prospectively enrolled 202 patients and assessed risk factors to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥ 3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound. Result: The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation of unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), number of the sacral hiatus by palpation ≥ 1 (OR 4.451), and history of difficult CEB (OR 39.282) with higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥ 3, pre-procedure ultrasound scan could reduce the incidence of difficult CEB. Conclusion: This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥ 1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥ 3. 4 Trial registration: No: ChiCTR1800018871, Site url: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4

ESTIMATION OF THE EFFECTIVENESS OF ASSOCIATED ANESTHESIA BASED ON EPIDURAL BLOCKADE IN CESARIAN SECTION IN PATIENTS WITH «EVIDENT» MITRAL STENOSIS

aim. To assess the efficacy and safety of general associated balanced anesthesia based on epidural block during cesarean section in patients with “severe” mitral stenosis.Material and methods. The results of clinical observations, and a complex of clinical, functional and biochemical studies during cesarian section of 26 women aged 18-30 years, with a gestation period of 32-34 weeks had been studied. All patients had «severe» MS (according to A.N. Okorokov, s classifications). Depending on the method of anesthesia all patients were divided into two equal groups Patients of group I (n=13) were operated under conditions of associated balanced anesthesia (CBA) on the basis of epidural blockade (EB) patients of group II (n=13) were operated under conditions of one of the most common variants of multicomponent anesthesia (MCA). The operations were performed in a planned method, their durations made 35-60 minutes. The duration of anesthesia were 50-110 minutesResults. Significant advantages of CBA on the basis of EB became apparent: minimal expense of narcotic preparations and muscular relaxants: rapid rehabilitation of reflex muscular activity, making it possible to carry out extubations of trachea in earlier term: opportunity of using epidural catheter in postoperative period in order to receive prolonged postoperative analgesia. Conclusion. CBA on the basis of EB provides reliable antinociceptive protections of the body from surgical aggression, ensures a smooth course of anesthesia and early postoperative period and therefore has an obvious advantage over the traditional version of GMCA with AVL.K

Comparison of Thoracic Epidural Access with Lateral Decubitus and Shoulder Rotation Positions for Repeat Thoracic Epidural Blockade

Background: Shoulder rotation has been shown to increase the acoustic window of ultrasound for thoracic epidural access. However, this effect of shoulder rotation has not yet been confirmed in clinical practice. Objective: This study aimed to evaluate the effects of shoulder rotation on the thoracic epidural blockade in patients with acute or chronic pain in the thoracic region. Study Design: Prospective crossover trial. Setting: Pain clinic of our university in the Republic of Korea. Methods: Forty patients aged 20 – 80 years with acute or chronic pain in the thoracic region who were scheduled to undergo thoracic epidural blockade more than twice. Interventions: The patients underwent repeated fluoroscopy-guided thoracic epidural blockade via the paramedian approach in the lateral decubitus position either with or without shoulder rotation. The primary outcome measure was the attempt time to the confirmed spread of contrast. The number of attempts, total procedure time, vertical interpedicular distance, contrast spreading length, and complications were compared between the 2 positions. Results: The median attempt times in the lateral decubitus and shoulder rotation positions were 138.8 and 132.5 seconds, respectively, and this difference was significant (P = 0.004). Compared with the lateral decubitus position, the shoulder rotation position was also associated with a significantly lower number of attempts (P = 0.03), shorter total procedure time (P < 0.001), and greater vertical interpedicular and contrast spreading distances (P < 0.001 and P = 0.02, respectively). Limitations: The operator in this study was not blinded to the patient groups. Other researchers observed the operator’s procedure and evaluated and recorded the data in an attempt to overcome this bias. However, it was difficult to completely avoid the bias. Second, epidural blockade was performed at various levels (T3–11), and the anatomical features vary among thoracic spine levels. Conclusions: The study findings demonstrate the clinical benefits of the shoulder rotation position versus the lateral decubitus position in terms of successful epidural access during thoracic epidural blockade using the paramedian approach. Key words: contrast spreading length, fluoroscopy, lateral decubitus position, paramedian approach, shoulder rotation, thoracic epidural blockade, vertical interpedicular distance

Multimodal anesthesia and analgesia at the stages of the perioperative period in children with abdominal surgical pathology

Aim of the study was assess both the effectiveness and safety of anesthetic management and optimizing postoperative anesthesia under conditions of multimodal anesthesia and analgesia during abdominal operations in children. Patients and methods. The authors examined 58 children aged 1 to 17 years with abdominal operations (malformations, diseases, and abdominal organ injuries). To ensure anesthetic protection, patients underwent combined general anesthesia with propofol and fentanil (induction) with inhalation of sevoflurane + propofol intra venous (maintenance) in combination with epidural blockade with bupivacaine. Results. According to surgical intervention, the arrangement of perioperative analgesic protection provided a favorable correction of the hemodynamic status of patients, a decrease in inhalation anesthetic, promoted a smooth course of the postoperative period, a long painless period, an excellent psychoemotional background, and rapid postoperative recovery.

Influence of anesthesia methods on the immune system of patients with oncological diseases of the abdominal organs

Modern anesthesia, based on the use of halogenated hydrocarbons, nitrogen monoxide, or xenon, cannot fully ensure the interruption of nociceptive impulses at the level of the stem and spinal and subcortical formations, which caused vegetative and metabolic signs related to pain. To prevent the negative effects of pain, additional methods are used, including intraoperative analgesia and regional blockades. This study was conducted to assess the effects of various types of anesthesia, including epidural blockade, on the parameters of the immune system in patients with cancer. A total of 438 patients with malignant neoplasms of the abdominal organs were examined. In these patients, levels of cytokines (such as tumor necrosis-alpha and interleukin-6) and T-lymphocytes of various clusters of differentiation in the blood were measured. Impaired cytokine balance in patients with oncological diseases of the abdominal cavity was accompanied by the formation of suppression of cellular immunity in the postoperative period. Measurements revealed immunosuppression that was largely dependent on the type of anesthesia used. Cellular parameters with the greatest relationship with immunity were preserved during combined anesthesia, including epidural blockade.

Protective effect of dexmedetomidine infusion combined with epidural blockade on postoperative complications after surgery: A prospective randomized controlled clinical trial

Objectives This prospective, randomized, controlled study aimed to explore the efficacy of dexmedetomidine combined with epidural blockade on postoperative recovery of elderly patients after radical resection for colorectal cancer. Methods Ninety-six elderly patients who underwent radical resection for colorectal cancer were randomly divided into the following four groups: dexmedetomidine, epidural blockade (ropivacaine), combined (dexmedetomidine + epidural blockade), and control (0.9% saline). The Mini-Mental State Examination (MMSE), Visual Analog Scale (VAS), and Ramsay scores at 48 hours, and time to first activity, length of hospital stay, and postoperative complication rates at 3 months were assessed. Results Twelve hours after surgery, Ramsay scores were higher in the combined compared with the control and epidural blockade groups. Twenty-four hours after surgery, MMSE scores were higher in the combined compared with the other groups. The combined group showed the lowest VAS scores except at 48 hours. Time to first activity and length of hospital stay were significantly shorter in the combined compared with the other groups. There was no difference in total postoperative complication rates among the groups. Conclusions A combination of intraoperative dexmedetomidine infusion and epidural blockade could mitigate pain after surgery, improve cognitive dysfunction in early surgery, and facilitate recovery.