Background: Autologous epidural blood patch (AEBP) is effective for post-dural-puncture headache (PDPH). In some cases, repeat procedures are required for complete cure. In rare instances, severe adverse effects can occur. We present a case of neurologically complicated AEBPs, one of which was performed at the interspace of unintentional dural puncture (UDP). Case presentation: A 40-year-old primigravida sustained UDP at the L2-3 interspace during combined spinalepidural anesthesia for a scheduled cesarean section. She developed PDPH and underwent a single AEBP at L3-4. The PDPH recurred and she required another AEBP at L2-3, after which she reported radicular pains. A diagnosis of subdural hematoma and adhesive arachnoiditis was made. Her symptoms partially resolved in the following months. Conclusion: It may be prudent to reconsider the use of repeated AEBP and to avoid the interspace of UDP. A thorough evaluation is warranted to exclude treatable lesions when adverse effects occur.
BackgroundThe Nihon Kohden linear inflationary non-invasive blood pressure (iNIBP) monitoring technology is an oscillometric device that measures blood pressure by detecting oscillations during inflation. Systolic blood pressure can be recorded without overinflating the cuff higher than the true systolic pressure. Thus, total time taken for inflation and deflation is shorter than that by the conventional deflation devices. In this study, the ability of iNIBP to detect maternal hypotension during cesarean section faster than deflationary non-invasive blood pressure (dNIBP) monitoring devices under clinical settings was evaluated prospectively.MethodsA prospective study of singleton planned cesarean sections at a tertiary center was conducted from August 2015 to April 2016. The combined spinal-epidural anesthesia (CSEA) technique through a single puncture was performed for cesarean section at the center where the study was carried out. An iNIBP cuff was placed on the same arm as the intravenous line, and a dNIBP cuff was placed on the other arm. Due to left uterine displacement by approximately 10° tilt of OR table, hypotension in this study was defined as systolic pressure of 107 mmHg or less, when measured in the left arm, which was about 10 cm lower, and pressure of 92 mmHg or less in the right arm which was about 10 cm higher. This setup was done to evaluate which device detected hypotension faster under clinical settings. A two-tailed Z test was performed to statistically analyze the difference between iNIBP and dNIBP measurement results.ResultsOne hundred singleton planned cesarean deliveries under CSEA were included after 36 weeks of gestation. Out of the 100, 76 women (76%) experienced maternal hypotension. Of these, iNIBP detected hypotension faster than dNIBP in 47 cases (61.8%).ConclusionIt was found that iNIBP detected hypotension faster than conventional dNIBP without compromising the reliability of measurement. This may lead to early treatment of maternal hypotension and prevention of adverse events related to the mother and the fetus.
Background and objectives: Palpation has been shown to be rather inaccurate at identifying lumbar interspinous spaces in neuraxial anesthesia. The aim of this study is to assess the accuracy of the determination of the lumbar interspinous spaces by anesthesiologist's palpation using post-operative X-rays in obstetric patients. Methods: We reviewed the anesthetic record and the post-operative abdominal X-rays of the cesarean sections. We indwelled the epidural catheter for post-operative one-shot analgesia. We included combined spinal and epidural anesthesia cases and compared the interspinous level which the anesthesiologist recorded and the epidural catheter insertion level confi rmed by abdominal X-ray for each case. We also evaluated the factors (age, body weight, height, Body Mass Index, gestational age, and the type of surgery [planned / emergency]) leading to misidentifi cation of interspinous level. Results: Nine hundred and sixty seven cesarean sections were performed and a total of 835 cases were evaluated. The levels of the puncture documented by the anesthesiologists were in agreement with the actual catheter insertion levels in 563 (67%) cases. When the anesthesiologists aimed at L2-3 level, we found the catheter insertion at L1-2 in 5 cases (4.9%), none of which had any post-operative neurological defi cits. No variables evaluated were signifi cantly associated with misidentifi cation of interspinous level by the anesthesiologists. Conclusions: There was a discrepancy between the anesthesiologists' estimation by palpation and the actual catheter insertion level shown in X-rays. It seems to be safer to choose the interspinous level L3-4 or lower in spinal anesthesia.
The purpose of this study was to evaluate the role of nitric oxide in the vasodilative effect of dehydroepiandrosterone sulphate (DHEA-S) in term pregnant women. Circulating nitrite, nitrate and oestradiol concentrations were measured on 10 normal full-term pregnant women before (-30 min) and after (10, 30, 60, 90 and 120 min) administration of a 200 mg i.v. dose of DHEA-S dissolved in 20 ml of 5% dextrose (DHEA-S group). Ten normal full-term pregnant women received 20 ml of 5% dextrose as controls (control group). Maternal blood pressure and heart rate were also recorded. The median oestradiol concentration increased significantly after the infusion in DHEA-S group (P < 0.001), whereas there was no significant change in plasma oestradiol in the control group. In the DHEA-S group, plasma circulating nitrate and nitrite increased significantly at 10 and 30 min after DHEA-S administration respectively (P < 0.05). In the control group, there was no change in plasma nitric oxide (NO) metabolites. No change was found in heart rate or mean arterial blood pressure in the control or DHEA-S groups. These results suggest there may be a link between increased NO and increased oestrogen after DHEA-S injection but their peak values did not coincide. Both may be associated with vasodilation in term pregnant women.
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